Critical Vent Management: Oxygenation

[VentMonkey]

I am highly interested in CC and plan on doing a UMBC or Creighton course, hopefully soon.

Feel free to slide me a pm if you have any questions about Creighton's CCP course.

 

[RRTMedic]

So I will go ahead and give you my final vent settings…

PCV
PEEP 18 cmH2O
FIO2 100%
I:E 4:1

Of course there were some RR changes that I can't remember as well as maxing out on our pressure control. This is the type of patient where "permissive hypercapnia" is definitely applicable

 

[VFlutter]

Aw I am late to the party. Awesome case, reexpansion pulmonary edema is interesting. Pretty rare in my experience.

 

[RRTMedic]

Aw I am late to the party. Awesome case, reexpansion pulmonary edema is interesting. Pretty rare in my experience.

Yeah I've only seen it once. Although probably a little too aggressive, indenpendent lung Ventilation would be a great option here as well.

 

[Midazzled]

Feel free to slide me a pm if you have any questions about Creighton's CCP course.

Will do, thanks.

 

[Brandon O]

Pmean should NOT go above 30

You mean the plateau pressure, not the mean, I think. The mean airway pressure is not usually used when evaluating lung protection.

View attachment 3223
No... think "fluffy infiltrates"

When determining the cause of an opacified hemithorax, it's helpful here to note the presence of air bronchograms on the left, as well as a lack of a shifted mediastinum (unlikely in the case of, say, a huge effusion or totally collapsed lung).

So I definitely agree with paralyzingly. Paralyzingly will decrease metabolism due to the muscles not exerting any energy, allowing for less oxygen consumption.

In the above quotes I mentioned that at a PEEP of 12 and a Pressure Control of 15, you probably have a plateau of 25.

How'd you come by that number?

 

[RRTMedic]

How'd you come by that number?

Admittedly, I didn't do the math on it, just relied on experience with ventilating restrictive lungs.

The point isn't necessary the exact numbers but the concept surrounding them. Since the PC is 15 and the Peep is 12, then PIP would be 27. The closer the plateau pressure to the peak, then it suggests a decrease in compliance. In other terms, when there has been a decrease in trans pulmonary pressures, there is often a decrease in compliance. A lung like this suffering from reinflation pulmonary edema isn't going to be very compliant at all.

 

[VentMonkey]

You mean the plateau pressure, not the mean, I think. The mean airway pressure is not usually used when evaluating lung protection.

Cool, thanks.

 

[Carlos Danger]

Admittedly, I didn't do the math on it, just relied on experience with ventilating restrictive lungs.

The point isn't necessary the exact numbers but the concept surrounding them. Since the PC is 15 and the Peep is 12, then PIP would be 27. The closer the plateau pressure to the peak, then it suggests a decrease in compliance. In other terms, when there has been a decrease in trans pulmonary pressures, there is often a decrease in compliance. A lung like this suffering from reinflation pulmonary edema isn't going to be very compliant at all.

Please explain plateau pressure.....

 

[Brandon O]

Admittedly, I didn't do the math on it, just relied on experience with ventilating restrictive lungs.

The point isn't necessary the exact numbers but the concept surrounding them. Since the PC is 15 and the Peep is 12, then PIP would be 27. The closer the plateau pressure to the peak, then it suggests a decrease in compliance. In other terms, when there has been a decrease in trans pulmonary pressures, there is often a decrease in compliance. A lung like this suffering from reinflation pulmonary edema isn't going to be very compliant at all.

True, but you're thinking about it the way you would in a volume-targeted mode (e.g. VC). In PC, in principle, flow should decrease toward zero at the end of the breath, with the result that the peak pressure is actually equal to the plateau pressure.

In reality, if inspiratory time is not set long enough, it often fails to reach zero, leaving some residual gradient between peak and plateau. But that will largely be determined by time.

 

[RRTMedic]

True, but you're thinking about it the way you would in a volume-targeted mode (e.g. VC). In PC, in principle, flow should decrease toward zero at the end of the breath, with the result that the peak pressure is actually equal to the plateau pressure.

In reality, if inspiratory time is not set long enough, it often fails to reach zero, leaving some residual gradient between peak and plateau. But that will largely be determined by time.

Agreed. I think when I posted that number I was trying to get the other to know they had room to increase PEEP...

 

[E tank]

View attachment 3235

Yeah I've only seen it once. Although probably a little too aggressive, indenpendent lung Ventilation would be a great option here as well.

Did you mean to say that was what was going in in the CXR you posted? That sure looks like a L DLT there to me.

 

[RRTMedic]

Did you mean to say that was what was going in in the CXR you posted? That sure looks like a L DLT there to me.

It most certainly does look like a LDLT. Ha! I didn't even notice it when I was looking for CXR that related to the pathology I was referring to. Good eye there, sir, good eye. Although I do feel silly for not seeing the left bronchus obviously intubated.