# In Need of a Vent Lecture, Please



## 46Young (May 10, 2009)

Hello all. I've just started a per diem job at a local txp company. One of my former employers used the Bird Avian vents. There was a relationship between inspiration time, tidal volume, and flow. I remember that if the flow is set to high, the vent will cycle must quicker than the selected I-time. Other than that, I can't remember much else, other than "DOPE" for troubleshooting, as I haven't touched a vent in over a year and a half. Would someone be able to give me a quick yet comprehensive prehospital vent refresher? Thanks in advance.


----------



## 46Young (May 10, 2009)

Also, we'll be using either the Autovent 3000, or the Newport HT50. You can find it on the company's site, www.physicians-transport.com


----------



## daedalus (May 10, 2009)

pick up a text on critical care?


----------



## 46Young (May 10, 2009)

Good idea, but I don't know any CC medics at the moment. I'll have to wait until I start ride alongs. I'll ask if I can borrow one from the main office. I would hope that they would have some. They're also in the process of transferring the entire CCEMT-P lecture to MP3 for our listening pleasure.


----------



## VentMedic (May 10, 2009)

46Young said:


> Also, we'll be using either the Autovent 3000, or the Newport HT50. You can find it on the company's site, www.physicians-transport.com


 
For critical care transport?  You've got to be kidding!!

An ATV is not recommended for anything but the living dead as in s/p code to free up your hands.  They definitely should NOT be used on a critically ill patient. 

Autvent 3000
http://www.progressivemed.com/estylez_item.aspx?item=14212

The Newport HT50 should only be used to homecare or long term ventilation in a subacute.   It is not an effective ventilator for CCT.  

Here's your lecture:

http://www.ccmtutorials.com/rs/index.htm




> Would someone be able to give me a quick yet comprehensive prehospital vent refresher?


 
Hopefully you will only use these ventilators (and I use that term very loosely) in prehospital for the living dead and do not attempt to use them on ICU patients.  Also, for transporting ICU patients on ventilators, there is no QUICK vent refresher for someone who has no ICU or Critical Care medicine experience or education.  If you do not understand the basics you will not grasp the many different concepts involved with IFT of critically ill patients.  I also hope you have extensive paralytic and sedation protocols or at least will be taking an RN along with you.


----------



## MasterIntubator (May 10, 2009)

Hey Young.... stop by MWH and get together with some of the resp techs in the ED.  I know many of them, and most are ready and willing on showing you the ropes when they have some downtime.

Especially if you are with PTS... you know.... professional courtesy.

B)


----------



## VentMedic (May 10, 2009)

MasterIntubator said:


> Hey Young.... stop by MWH and get together with some of the resp techs in the ED. I know many of them, and most are ready and willing on showing you the ropes when they have some downtime.
> 
> Especially if you are with PTS... you know.... professional courtesy.
> 
> B)


 
And don't forget to tell them what ventilators you will be using so they can get a good laugh also.


----------



## MasterIntubator (May 10, 2009)

VentMedic said:


> And don't forget to tell them what ventilators you will be using so they can get a good laugh also.



.... I wasn't gonna go there.


----------



## 46Young (May 10, 2009)

VentMedic said:


> For critical care transport?  You've got to be kidding!!
> 
> An ATV is not recommended for anything but the living dead as in s/p code to free up your hands.  They definitely should NOT be used on a critically ill patient.
> 
> ...



Thanks, I knew you'd come through. I remember the ATV form my first job as a basic at a txp company. I remember how the pt would become significantly uncomfortable after being hooked up the the ATV, and would frequently buck the vent. I remember thinking how such a rudimentary piece of equipment could be appropriate for continuation of care. When I promoted to medic at NSUH-LIJ, and we received training on the Bird Avian, it became painfully obvious what a piece of garbage the ATV is. At PTS it is intended for routine txp, not CC. I passed a comment about my prior observations regarding the ATV at the PTS orientation, and the medic dodged the issue. I'm not critical care, but I'll be backing up the CC medics on critical calls. I have experience using RSI as a sole ALS provider when I worked for CCEMS, and PTS has RSI, as well. I've ran enough calls with the CC medic back in NY to be competent in supporting them. I had a solid grasp on the principals of interfacility vent transport. I suppose the company is using the ATV and the Newport to save money. Thanks for the link. I'm sure it will all come back as I read through the material. If I have any further questions, I won't hesitate to ask. We also have a Lt. at Fairfax County FRD who has been a RT for some time. I'll seek his guidance. I just want to competent with vent principles before I'm riding solo.


----------



## VentMedic (May 10, 2009)

MasterIntubator said:


> .... I wasn't gonna go there.


 
There is a good reason why I stated that. 

EMS providers sometimes get stuck with crappy equipment because they have too little knowledge to even know a good ventilator from a bad vent or even what questions to ask. They get sold on words like "easy to use", "operator friendly" and "light weight". 

Choosing a ventilator is like buying a high performance car. Speed, flow, valving, handling, responsiveness and gas mileage are all the things that must also be considered with a ventilator.

Example:

*Performance Comparison of 15 Transport Ventilators*​

http://www.rcjournal.com/contents/06.07/06.07.0740.pdf


----------



## JPINFV (May 10, 2009)

Never mind... you answered it...


----------



## 46Young (May 10, 2009)

MasterIntubator said:


> Hey Young.... stop by MWH and get together with some of the resp techs in the ED.  I know many of them, and most are ready and willing on showing you the ropes when they have some downtime.
> 
> Especially if you are with PTS... you know.... professional courtesy.
> 
> B)



I have an active application at Stafford Hosp. for ER Paramedic. I didn't see anything else in the medicorp system. I applied for the PTS gig to make some side cash, and because I did enjoy interfacility EMS. This place isn't giving me a particularly good vibe, though. Things are hectic at the moment, but I would like to stop by when it's typically slow, to help me get up to speed.


----------



## MasterIntubator (May 10, 2009)

Stafford ER is a new, and they still have bugs to work out.  MWH is where you will get the vent patients anyway. Being a Trauma center ( haa haa ) ... you will have a much better chance playing with folks who know those machines and the physiology inside and out.


----------



## 46Young (May 10, 2009)

MasterIntubator said:


> Stafford ER is a new, and they still have bugs to work out.  MWH is where you will get the vent patients anyway. Being a Trauma center ( haa haa ) ... you will have a much better chance playing with folks who know those machines and the physiology inside and out.



Any openings for ER tech/medic coming up at MWH anytime soon?


----------



## JPINFV (May 10, 2009)

Ok, I retract my last post.


Vent, just curious (since the study you posted was mostly over my head), what's so bad about the HT50? I'm curious because it's what my old company used, but that was mostly for patients going or coming from sub-acute with only an occasional interhospital transport. That said, we also used RTs on all vent transports.


----------



## VentMedic (May 10, 2009)

JPINFV said:


> Ok, I retract my last post.
> 
> 
> Vent, just curious (since the study you posted was mostly over my head), what's so bad about the HT50? I'm curious because it's what my old company used, but that was mostly for patients going or coming from sub-acute with only an occasional interhospital transport. That said, we also used RTs on all vent transports.


 
Flow and demand valve did not meet the patients' needs. We have even tried running the patient in Pressure Control and Pressure Support which have a high initial flow rate but even that didn't work well. Then, there were those little pesky recall notices for equipment failure that got the company a serious FDA letter.


----------



## JPINFV (May 10, 2009)

Thank you!


----------



## VentMedic (May 11, 2009)

Here are more articles to read so you are aware of the many terms used differently.​ 

CLASSIFICATION OF VENTILATOR MODES: UPDATE AND PROPOSAL FOR IMPLEMENTATION

http://www.rcjournal.com/contents/03.07/03.07.0301.pdf​ 
Some new modes:​ 

What Is the Evidence Base for the Newer Ventilation Modes?​ 

http://www.rcjournal.com/contents/07.04/07.04.0742.pdf​ 

Capnographic Waveforms in the Mechanically Ventilated Patient​ 
http://www.rcjournal.com/contents/01.05/01.05.0100.pdf​ 
And of course, the ideal CCT ventilator would have a monitor for waveforms.​ 

Using Ventilator Graphics to Identify Patient-Ventilator Asynchrony​ 

http://www.rcjournal.com/contents/02.05/02.05.0202.pdf​


----------



## Jon (May 11, 2009)

Vent,

I'm curious about this, too... is this documented, or just your experience? The study you posted seemed to judge the HT50 adequate as a transport and EMS/Military vent.


As for the AutoVent... I once had an instructor refer to it as a "timed demand valve"... In some respects, I think he's absolutely right!


And back before I knew any better, I worked for a company that advertised "ventilator transport"... but used Autovent 3000s. Those were some real unhappy patients on those transports. Lots of bucking the "vent" etc.


----------



## VentMedic (May 11, 2009)

Jon said:


> I'm curious about this, too... is this documented, or just your experience? The study you posted seemed to judge the HT50 adequate as a transport and EMS/Military vent.


 
Both. The FDA recalls are very real and many have had the machine shut down at the most inopportune times. 
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRES/res.cfm?ID=54060

The 2 big recalls were in 2004 and 2007. 

One large subacute had 10 out of 50 HT50s malfunction in one week. That was a capital expenditure over $250k that had to be fought for with the company since the facility decided they had enough and wanted to get rid of the Newport. They also had acquired the vents not by choice but by executive decision about finances from their corporate company which "got a good deal". 

We also look at comparison studies such as the one I posted to see if we get similar results. We also have different test lung technology which we use for training on the new ventilators we trial as well as documentation of our findings. RT also has professional forums to which a lot of this data is shared throughout the RT world. 

Another disadvantage for the Newport is its lack of a graphics package which makes it difficult to visually see how patient and machine are struggling especially if the patient is sedated. Even when sedated the ventilator may still be giving the patient asynchronous breaths, inadequate flow, or air trapping. 

The LTV 1200 series with graphics package is still the most versatile and efficient transport ventilator for critically ill adults and children.

quote from the previous link:


> With the Newport HT50 and its nondisposable proprietary
> circuit, intrinsic PEEP developed at higher RR because
> of high expiratory resistance.​





Jon said:


> As for the AutoVent... I once had an instructor refer to it as a "timed demand valve"... In some respects, I think he's absolutely right!


 
That would be my way of describing it also. And, without some measuring device, you truly have no way of knowing the accuracy of delivered volume. I can not emphasize good knowledge of physical assessment for those devices to determine adequate ventilation or unsafe ventilation. It is like using a BVM but without the human hand input for compliance and "alarms".


----------



## VentMedic (May 11, 2009)

Jon said:


> Vent,
> 
> I'm curious about this, too... is this documented, or just your experience? The study you posted seemed to judge the HT50 *adequate* as a transport and EMS/Military vent.


 
The term *adequate* is relative to the patient and the provider.  I could probably transport a patient on an ATV, with me being a very unhappy provider, but I would have to be very pharmacologically proficient to adjust for whatever the situation called for.   Unfortunately, there are many ICU patients that can not tolerate even bagging, which is also not preferred for transport, and require the higher level technology.


----------



## Lunah (May 11, 2009)

We use PTS as our primary transport provider, and most of our crews use a Newport. Sometimes they'll take one of our Versamed iVents, though.

VentMedic, thanks for the links -- I am always looking to learn more about vents. I only have experience with our Versamed, and we don't hold on to vented patients that long in our ED. I work with some former ICU nurses, though, who are amazing with tweaking vent settings.


----------



## VentMedic (May 11, 2009)

Lunah said:


> VentMedic, thanks for the links -- I am always looking to learn more about vents. I only have experience with our Versamed, and we don't hold on to vented patients that long in our ED. I work with some former ICU nurses, though, who are amazing with tweaking vent settings.


 
It is interesting that when working as a Paramedic on CCT or Flight I make ventilator changes under the supervision of an RN. Of course, when I am on CCT, Flight or Specialty as an RRT, that is an entirely different situation.

We also do not loan out any technology unless one of our professionals is accompanying it.


----------



## Lunah (May 11, 2009)

VentMedic said:


> We also do not loan out any technology unless one of our professionals is accompanying it.



We don't do that often -- I work in a freestanding ED, and we only have two iVents to start with, so we don't like NOT having our backup. But our facility is a PTS "station," so at least we know they'll always come back with our stuff, in theory.  We don't usually have an RN to spare to go with, and we don't have RTs in our ED. I wish we did!


----------



## VentMedic (May 11, 2009)

Lunah said:


> We don't do that often -- I work in a freestanding ED, and we only have two iVents to start with, so we don't like NOT having our backup. But our facility is a PTS "station," so at least we know they'll always come back with our stuff, in theory.  We don't usually have an RN to spare to go with, and we don't have RTs in our ED. I wish we did!


 
JCAHO is looking very closely at any ventilator documentation since there have been quite a few Sentinel events cited for them.  As well, some of the largest damage settlements in the medical professions have been for ventilator related injury or death.  Thus, the RT profession is now looking at raising their minimum education to the 4 year degree.  

The other events that have caught the eye of JCAHO and Medicare have been infection related. We now log every patient on each machine for tracking purposes.  Prehospital ventilators, if not filtered correctly, can spread infections  to the patient and the providers.    This has also been the controversy with CPAP and disaster management for disease outbreaks.


----------



## Lunah (May 11, 2009)

Question: do you have experience with the Hi-Lo Evac ET tubes? If so, have you seen them make a difference in vent-acquired pneumonia? Sorry, don't mean to hijack the thread ... if I need to start a new one, just let me know. Still feeling my way around the forum.


----------



## VentMedic (May 11, 2009)

I just hijacked another thread to talk about subglottic suction.  

http://www.emtlife.com/showthread.php?t=12678



Yes, we use the subglottic suction tubes.  We also use the trach tubes with this feature for our head and neck surgery patients that require longer term ventilator management or their TE fistula is problematic.


----------

