# To Vent or Not To Vent



## 18G (Dec 8, 2011)

Quick question: Regarding ventilatory management in an IFT environment where transports range from 45 - >2hrs, do you feel it is vital to have your patient on a ventilator or feel it is sufficient to bag them?

What detriments do you see with bagging a critical patient for this long after they have been stabilized in the ED? I see quite a few but am interested in seeing what everyone else thinks.


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## Sasha (Dec 8, 2011)

What detriments?? If they require bagging chances are there's something pretty serious going on with them, if you're going 45 minutes to two hours you're basically committing yourself to only bagging for that amount of time leaving you kind of useless if something else happens.

Plus I don't like bagging for more than a few minutes... Definitely not going to do it longer than I have too.


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## 18G (Dec 8, 2011)

Sasha said:


> What detriments?? If they require bagging chances are there's something pretty serious going on with them, if you're going 45 minutes to two hours you're basically committing yourself to only bagging for that amount of time leaving you kind of useless if something else happens.
> 
> Plus I don't like bagging for more than a few minutes... Definitely not going to do it longer than I have too.



What I mean by detriments are things that can't be provided (or provided optimally) with just a BVM. 

For one example, patients that are suffering from say massive aspiration, pulmonary edema, near drowning, ARDS, etc, and the associated lung changes like surfactant washout, atelectasis, and increased diffusion distance, are gonna need PEEP without a doubt. In these instances without PEEP, increased ventilatory pressures are going to be needed and gas exchange won't be maximized due to airway collapse and increased pressure required to reexpand the airways. So a BVM is not ideal especially when a PEEP valve isn't even available.

Also, with bagging you run the risk of a provider not concentrating on rate and volume delivered and exposing the patient to episodes of hypercapnia and hypoxia which for a head injury or head bleed can be lethal.


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## usafmedic45 (Dec 8, 2011)

If you can vent them and have a competent provider to run said ventilator and deal with the complications inherent with it, they should be vented simply because it is less likely to produce complications (such as baro- or volutrauma to name the two big ones) than bagging with no practicable feedback in terms of ventilatory rate, tidal volume, airway pressures, PEEP, etc. 



> not concentrating on rate and volume delivered and exposing the patient to episodes of hypercapnia and hypoxia which for a head injury or head bleed can be lethal.



...or hypocapnia and hyperoxia which can be just as dangerous.  The problem with excessive ventilation in head trauma is much more common than hypoventilation.  I can't recall the last time I've seen a tubed head trauma patient come in hypercapnic but I've seen more than my fair share of hypocapnic ones because of overzealous EMS providers.


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## medic417 (Dec 8, 2011)

Vent is the way to go.  If ventmedic was here she could explain more fully the benefits and the risks.  Now when I say vent I mean a real vent not just a lung popper like autovent or similar that try and package all patients into just a couple of settings.


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## 46Young (Dec 8, 2011)

You can kill a pt by overbagging them. Just off the top of my head, if you have a pt in a low flow state such as hypovolemia or septic shock, the venuous return may be as low as 4-6 mmHg. PPV can be as much as 15 mmHg. It is different than when pts inspire, or even hyperventilate, since they create neg. pressure, which aids venuous return and coronary circulation. It is much better to have the pt vented, and have the vent settings/PEEP determined for you beforehand.


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## 46Young (Dec 8, 2011)

medic417 said:


> Vent is the way to go.  If ventmedic was here she could explain more fully the benefits and the risks.  Now when I say vent I mean a real vent not just a lung popper like autovent or similar that try and package all patients into just a couple of settings.



The autovent is barbaric.


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## medic417 (Dec 8, 2011)

46Young said:


> It is much better to have the pt vented, and have the vent settings/PEEP determined for you beforehand.



Negative ghost riders that is a recipe for disaster.  Do your own calculations.  If you can not you should not be in charge of a vent patient.


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## usalsfyre (Dec 8, 2011)

It's very, very difficult to provide consistent ventilations over the length of transport, both in volume, rate and pressure. Too great a variation in any one of these categories may not only cause acid-base disturbance, it may cause mechanical damage to the lung as well. 

Most CCT protocols I'm familiar with call for a ventilator to be used for any transport >10min. That said, the do occasionally fail, meaning it's important your able to provide good ventilations over a period of time.


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## usalsfyre (Dec 8, 2011)

medic417 said:


> Negative ghost riders that is a recipe for disaster.  Do your own calculations.  If you can not you should not be in charge of a vent patient.



Agreed. Matching settings without the ability to troubleshoot (not to mention most transport vents can't deliver the same level of ventilation as an ICU vent, do tweaking may be needed) is bad juju.


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## 46Young (Dec 8, 2011)

medic417 said:


> Negative ghost riders that is a recipe for disaster.  Do your own calculations.  If you can not you should not be in charge of a vent patient.



How many months of education do RT's have that enable them to prescribe vent settings? Most paramedic programs hardly even address vents. Most employers that run vents may give an hour or two inservice on their vent, and that's about it. This is standard for our field.


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## medic417 (Dec 8, 2011)

46Young said:


> How many months of education do RT's have that enable them to prescribe vent settings? Most paramedic programs hardly even address vents. Most employers that run vents may give an hour or two inservice on their vent, and that's about it. This is standard for our field.



If you are not willing to become educated then sadly you should stay with those barbaric lung poppers.  A real vent is a wonderful tool when used properly but can quickly become deadly when handled incorrectly.


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## Smash (Dec 8, 2011)

Definitely a vent.  In my opinion a vent should be mandatory for all patients, IFT or 911.  Fair enough using a bag mask when the tube first goes down but it should be a temporary measure used briefly until the vent is set up.


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## DrankTheKoolaid (Dec 8, 2011)

*re*

Vents are definately the way to go.  Amazing what can be done with them once you learn the various strategies and have working knowledge of the vent you use


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## systemet (Dec 9, 2011)

46Young said:


> How many months of education do RT's have that enable them to prescribe vent settings?



2.5 paramedic program equivalents.


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## MSDeltaFlt (Dec 9, 2011)

Definitely vent them, on proper vent settings for temp corrected ABG's.  Not just for accurate manipulation of PaO2 and PaCO2, but also proper management of intrapulmonary pressures.  Not to mentioned the obvious fact that if your pt needs ventilation odds are they're Going to need hands free for proper critical care throughout the trip.  

What if your pt needs an accurate BP?  Which is at least every 5 min.  What are you going to do?


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## BLS Systems Limited (Dec 9, 2011)

Many hospitals I speak with have been writing policies stating that vent should be used on all transports, regardless of time or distance.  The evidence is very clear that seasoned anaesthetists can't bag with the consistency required.  Yes, people still do despite the studies, but that's just 'cause they are ignoring the data or are lazy.  The main reason many DON'T is lack of equipment, cost and other issues not related to actual patient care.  If you have it handy and management OK's the associated costs, use it.


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## usafmedic45 (Dec 9, 2011)

> If ventmedic was here she could explain more fully the benefits and the risks.



....and what exactly do we need her for?  She'd simply argue that only an RT would fully understand and could handle it, blah, blah, blah.  Let's not give her any provocation to come back under a new alias. 

If you have any specific question MSDeltaFlt and myself are both RTs so no need for the grandiose views of the career field courtesy of everyone's favorite respiratory terrorist.



> > How many months of education do RT's have that enable them to prescribe vent settings?



Basically a full year of clinical experience before they are turned loose.  



> 2.5 paramedic program equivalents.



Nah, remember a third to half of the program is general education and even then a lot of the non-clinical rotation coursework RTs go through is not specific to ventilator management.


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## medic417 (Dec 9, 2011)

usafmedic45 said:


> ....and what exactly do we need her for?  She'd simply argue that only an RT would fully understand and could handle it, blah, blah, blah.  Let's not give her any provocation to come back under a new alias.
> 
> .



Actually she provided many good references and even broke them down to easy to understand points, so easy even a medic mill Paramedic could grasp the points.  After many here were rude she did seem to snap and stop providing the quality material.  If you do not recall those facts well maybe you were one of those threatened by her.  I do wish she would return as her old self, the quality ventmedic.


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## usafmedic45 (Dec 9, 2011)

medic417 said:


> Actually she provided many good references and even broke them down to easy to understand points, so easy even a medic mill Paramedic could grasp the points.  After many here were rude she did seem to snap and stop providing the quality material.  If you do not recall those facts well maybe you were one of those threatened by her.  I do wish she would return as her old self, the quality ventmedic.



She knew her stuff but a lot of the "being rude" was simply those of us who saw that while she was a damn good therapist (and I will defend that aspect of her to my last breath), she suffered from the major problem in respiratory therapy:  The belief that we are somehow better than EMS providers, nurses, docs, etc simply because we have a specialist skill.  

I learned a lot from her and if she could keep the "politics" of the RT profession off this forum and to herself when it's apparent that the few other RTs on the forum didn't want to discuss it, I'd be the first one to welcome her back here.  Despite the attitude, she was the person I went to if I hit the limits of my own knowledge because she has a lot more experience than I do.



> After many here were rude she did seem to snap and stop providing the quality material.



I'll send you a PM about this.  I'm pretty sure it's a TOS violation to discuss what actually happened in public.


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## firecoins (Dec 9, 2011)

I don't see why a patient would not be taken on a vent.  

I use the settings prescribed by MD as required by my protocols. Its not been a problem.


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## 46Young (Dec 10, 2011)

medic417 said:


> If you are not willing to become educated then sadly you should stay with those barbaric lung poppers.  A real vent is a wonderful tool when used properly but can quickly become deadly when handled incorrectly.



On this thread, It was stated that the RT has either 2.5 x the medic's education, or one year's clinical experience before being cut loose to prescribe vent settings. I feel that the paltry amount of education and inservices for medics are inadequate to allow for standing orders for changing vent settings. A couple of paragraphs in a medic text, an hour or two inservice, and four to five vent jobs during orientation is not adequate. 

At my old hospital, we used the hospital's vent settings, and we would put the pt on our vent first thing, before changing drips or anything else. This way, there was some time onscene to see if the pt does well on our vent and at those settings or not. At my current per diem IFT job, we have RT's set up our vents for us, and also ride with us if it's more than a routine vent transfer/discharge.


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## DrankTheKoolaid (Dec 10, 2011)

*re*

Definately agree that we don't receive anywhere near enough training on vent management.  As in like zero....   Unless a provider takes the initiative to become skilled in their use.  And by use I mean setting changes and set up.  For IFT where you just babysit a vent set up by the receiving facility per your protocols is another story, at that point you need to know how to trouble shoot alarms and check a plateau pressure.  I definately fall in the not enough education group, but do also take the initiative to learn.  The various RT forums have been helpful along with Ardsnet.  Unfortunately I've yet to see ventilatory management come into the curriculum changes...............  So until then OJT is best we seem to get.


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## BLS Systems Limited (Dec 10, 2011)

As someone who has been a user and supplier, I would always go to the vendor for support on how to use the device.  Sales is based on building and maintaining relationships, which means they should provide support through post-sales education.  If they don't, they risk being a non-entity the next time a purchase is in the works.  Also, a vendor/supplier HATES having a device not being used or used inadequately such that the device becomes tainted or labeled as being too difficult to use.  Therefore, I would lean on the vendor/supplier to provide as many inservices as possible until you feel comfortable using the device.  Its in their best interests to be there.

My practice is to do an initial inservice, then repeat it later on to capture the "advanced" aspects of the device.  It also corrects any bad practice that crept into "normal" use during initial deployment.


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## socalmedic (Dec 14, 2011)

there are some great youtube lessons about vent management as well as vast resources for continuing education in the area of vent management. one of the things that sets paramedics apart from the rest of the medical community, which may be a bad thing, is the amount of learning we are expected to do OTJ and in our own time outside of formal education. it is your duty to find the information that you do not know and learn it.

start here, the AncientScholar, youtube vids which break down simply the theory and operation concerns of mechanical ventilation.


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## DrankTheKoolaid (Dec 14, 2011)

*re*

Thanks for the youtube link.  Somehow I haven't stumbled across him yet!


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## RocketMedic (Dec 14, 2011)

46Young said:


> The autovent is barbaric.



Barbaric, yes, but it is versatile, and in a setting where you're manpower-limited, having an autovent is far preferable to having to juggle compressions, defibrillation, pharmacology, access, and ventilations with only one or two people.

In my opinion, an IFT patient on a vent should be on a portable ventilator, with the settings re-checked by me, continuous tracking of the patient's oxygenation/tube placement, and continuous capnography. That being said, sometimes we need to use BVMs, which should be monitored to the same standard. 

Can anyone help me with understanding how to set up ventilators? I am familiar with Autovents and the like, but I am kind of lost on the more advanced ones. Pretty much all I know is that we want to see tidal volume appropriate enough to begin to cause chest rise, see appropriate square capnography waveforms, keep end-tidal CO2 between 35 and 45 in most cases, and keep oxygen saturations >95%. I know I'm missing a lot of important stuff, but I can't for the life of me figure it out.


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## socalmedic (Dec 14, 2011)

Rocketmedic40 said:


> Can anyone help me with understanding how to set up ventilators?



see my post above. takes about 3 hours to get through all the vids, but in the end you will feel much more confidant in your abilities. also talk with the RTs and MDs about the topics he goes over.

I watched 2-3 sections per day, took some tidbits to the ED and had the doc and RT further explain them.


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## DrankTheKoolaid (Dec 14, 2011)

*re*

There are multiple strategies of vent setups based on patients.   Check out the various RT forums and more importantly check out Ardsnet for their strategies


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## 18G (Dec 14, 2011)

To help you out more, the basic settings you will be concerned about the most are tidal volume (6-8mL/kg for adult), breaths per min, mode (A/C or SIMV) - volume or pressure, PEEP, I/E ratio, and FiO2.


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## usafmedic45 (Dec 14, 2011)

> but it is versatile,



Compared to what precisely?



> and in a setting where you're manpower-limited, having an autovent is far preferable



...if you don't mind your patient winding up with bilateral chest tubes. LOL


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## usafmedic45 (Dec 14, 2011)

> I am familiar with Autovents and the like, but I am kind of lost on the more advanced ones.



If you'd like, all animosity between the two of us aside, I can try to put you in touch with one of the ventilator sales reps I've met through speaking at conferences and such.  They could likely hook you up with their counterpart in your area.  It's a great way to learn (including CEUs most likely) and chances are good you'll lunch out of the deal.  

If you just have specific questions, you're always welcome to PM me.


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## RocketMedic (Dec 15, 2011)

That would be great. I'd love to learn...and thanks, USAF.


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## RocketMedic (Dec 15, 2011)

18G said:


> To help you out more, the basic settings you will be concerned about the most are tidal volume (6-8mL/kg for adult), breaths per min, mode (A/C or SIMV) - volume or pressure, PEEP, I/E ratio, and FiO2.



That's a lot more complicated then I remember! Back to the books for me. The tidal volume, rate, PEEP, and pressure are familiarish. I/E, FiO2, and mode are strange.


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## DrankTheKoolaid (Dec 15, 2011)

*re*

Oops meant to also note for a crash course go to --- emcrit.com ---and watch his 2 videos on ventilatory management.  The Dr. Wiengart (sp) is very adept at explaining his material in ways that are understandable to all with any kind of advanced medical background


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