Critical thinking: Vent Management

TXmed

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Yep driving pressures are very important because they are responsible for the opening and closing of the alveoli---essentially they are to blame for atelectrauma that leads to acute lung injury. Very much the reason why I advocate for much higher PEEPs in adult patients. I'm not so sure the literature is there for pediatrics; I'll have to do more research. But driving pressures are basically your plateau minus Peep... the degree of opening and shutting of those alveoli.

"A PEEP of 10 is the new PEEP of 5" - some unknown intensivist i heard in a podcast.
 

VentMonkey

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"A PEEP of 10 is the new PEEP of 5" - some unknown intensivist i heard in a podcast.
This seems to be all the rage in the more progressive ICU's (see: pretty much level 1's), I don't know that's it's being widely adopted by prehospital CC providers quite yet, though it certainly makes sense to me for the sicker ARDS cases.
 
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RRTMedic

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"A PEEP of 10 is the new PEEP of 5" - some unknown intensivist i heard in a podcast.

This seems to be all the rage in the more progressive ICU's (see: pretty much level 1's), I don't know that's it's being widely adopted by prehospital CC providers quite yet, though it certainly makes sense to me for the sicker ARDS cases.

Check out the options for PEEP and FIO2 as provided by ARDSNet

peep fio2.JPG
 
OP
RRTMedic

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Our vent doesn't offer patient sizes (impact AEV). a simple answer would be to leave this on adult mode and use A/C pressure control. obviously use pediatric tubing, Maybe cut some off to eliminate more dead space. i am not a pedi transport specialist, but to my understanding they typically are routinely paralyzed for any ventilator operations. adjust the rise time up between 8-10 and the I:E to 1:2. adjust peep in an effort to reduce driving pressure, Driving pressure= Pplat-PEEP, RR 25-30. dont forget that OG tube !!!

@RRTMedic how did i do?

I like it a lot! Yeah it's an unforeseen issue with an LTV that I ran into that's not your typical situation. LESSON LEARNED: do not use the infant mode on the LTV.

I'm not sure if it's standard of care to paralyze most peds vent patients. I know where I worked we never paralyzed unless absolutely necessary (like for HFOV).

Just remember that when using VOLUME CONTROL your vent circuit diameter and length plays a huge role in ventilation; not so much in pressure control (although I have a feeling you may need a longer I.T. if using an adult circuit). But always use a peds circuit if available.

Pressure control is so under utilized. It's a safe mode and I really don't know why it isn't used moreso as an initial mode in adults. I suppose its facility/RT dependent...
 
OP
RRTMedic

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How long are you typically leaving them at higher PEEP's/ FiO2's?

For the prehospital setting I was taught ~10-15 minute increments.

Usually, (if not following the above table) I will wean their FIO2 to 30-40 until I start decreasing their PEEP (unless there is a hemodynamic problem). If an A-line is available, I'll probably get a gas pretty frequently unless their SpO2 stays in the 95-100% range.

I don't have a specific method to it, but my practice has always been to keep the PEEP at its current setting until the FIO2 is AT LEAST <50%.

But alas, another example of anecdotal/provider specific medicine. Not truly evidence based.
 
OP
RRTMedic

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Check out the options for PEEP and FIO2 as provided by ARDSNet

View attachment 3219

The above chart is used to keep their SpO2 within that 88-95% range. The take home message is that you will not hurt a patient with a high level of PEEP. Don't be afraid of high PEEPs. It's not going to cause a pneumothorax and it won't cause barotrauma. It reduces atelectrauma because the alveoli remain open and have less shutting and closing.

AND... I find it strange that texts still remind you to "add PEEP." Shouldn't PEEP be added to everyone? I think so. Just my two cents.
 

VentMonkey

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The above chart is used to keep their SpO2 within that 88-95% range. The take home message is that you will not hurt a patient with a high level of PEEP. Don't be afraid of high PEEPs. It's not going to cause a pneumothorax and it won't cause barotrauma. It reduces atelectrauma because the alveoli remain open and have less shutting and closing.

AND... I find it strange that texts still remind you to "add PEEP." Shouldn't PEEP be added to everyone? I think so. Just my two cents.
I think the "high-PEEP-not-causing-lung-injury" the way it used to may change soon enough, much like the push for the lower Vt's in IBW thanks to such folks as the ARDSnet group.
 
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I think the "high-PEEP-not-causing-lung-injury" the way it used to may change soon enough, much like the push for the lower Vt's in IBW thanks to such folks as the ARDSnet group.

Hmmm... let me post another Critical Care Vent scenario...
 

Midazzled

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Pressure control is so under utilized. It's a safe mode and I really don't know why it isn't used moreso as an initial mode in adults. I suppose its facility/RT dependent...

I would love to see you or ventmonkey, or other knowledgable people start threads that are tutorials on vents. I read alot, and listen to podcasts, but have no way to ask questions when I read instructional stuff. I've actually considered going to RRT school just to be a better medic, but it's a very long waiting list to get in.
 

VentMonkey

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I would love to see you or ventmonkey, or other knowledgable people start threads that are tutorials on vents. I read alot, and listen to podcasts, but have no way to ask questions when I read instructional stuff. I've actually considered going to RRT school just to be a better medic, but it's a very long waiting list to get in.
Why thanks, but by no means do I possess the knowledge of an RRT/ RCP, let alone this guy, Mr. @RRTMedic;).
 
OP
RRTMedic

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Why thanks, but by no means do I possess the knowledge of an RRT/ RCP, let alone this guy, Mr. @RRTMedic;).

Aww thanks... that's flattering but I've just been subject to less than ideal situations and I learn from them...

Vent management is a very very specific skill set. I forgot a lot of stuff because I don't work full time in an ICU anymore. I've had to hit the books again for other critical care stuff.

Example: I really don't know how to set up a transducer. Never had to do it. I can look at a lot of stuff and know what's going on... but there is a good bit of nursing knowledge i need to attain.
 

Carlos Danger

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I think the "high-PEEP-not-causing-lung-injury" the way it used to may change soon enough, much like the push for the lower Vt's in IBW thanks to such folks as the ARDSnet group.
Isn't it already basically like that? I thought ARDSnet basically called for keeping the PEEP as low as you can while still maintaining a good Sp02.
 
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VentMonkey

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Isn't it already basically like that? I thought ARDSnet basically called for keeping the PEEP as low as you an while still maintaining a good Sp02.
Well given some of the conflicting literature I have seen regarding higher peeps and VLI, I think it's par for the course to mention it's like all aspects of medicine, ever-evolving.

I don't know that many critical care programs in the prehospital setting have bought into the higher PEEP strategies not being harmful the way they were previously taught, so perhaps it will shift for the better once others begin to understand he importance of this recruitment strategy.

I still see a lot of "copy and paste", and/ or worrying about baro-/volutrauma etc. in the transport realm.
 
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RRTMedic

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Well given some of the conflicting literature I have seen regarding higher peeps and VLI, I think it's par for the course to mention it's like all aspects of medicine, ever-evolving.

I don't know that many critical care programs in the prehospital setting have bought into the higher PEEP strategies not being harmful the way they were previously taught, so perhaps it will shift for the better once others begin to understand he importance of this recruitment strategy.

I still see a lot of "copy and paste", and/ or worrying about baro-/volutrauma etc. in the transport realm.

My dogma has always been that if you maintain your plateau pressures less than 30 cm of water then peep can only do good :)
 
OP
RRTMedic

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Near Charleston, SC

Oh nice… I went to RT school in North Carolina. Did not have a wait list and the school that I went to was really good have a great reputation… Seems like a lot of people do not want to be RTs
 

Midazzled

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Small world. I went to P-school in NC when I was at Bragg. I am in the group that doesn't want to be an RT, I just want more formal training focused on lungs and airways.
 
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RRTMedic

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Small world. I went to P-school in NC when I was at Bragg. I am in the group that doesn't want to be an RT, I just want more formal training focused on lungs and airways.

I agree. I was miserable doing neb after neb on the floors when I was not assigned ICU. But I loved RT school. Would love to teach formal vent classes one day.
 

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