Small vent story with questions about it.

[Righteous]

I have minimal experience with vents and I'd like to get a grasp on them. Any resources you can recommend?

I'm a paramedic and I was in the process of telling my dispatcher to send someone who knows how to use a vent. An actually has a vent.
As I was explaining the situation to the nurse I noticed the patient was breathing 40 times a minute. Hes sinus tach at 120 and the temp is 102.4 He is hardcore belly breathing and his face starts to grimace. The doctor is called in and they give the guy Vecc, versed, tylenol.

So I'm assuming the patient was breathing over the machine. If nothing was done, would the patient take permanent damage? My line of thinking is that the patient would get tired and the machine would take over the breathing. I understand the underlying problem is still there (probably the fever).

The lack of knowledge is annoying enough for me to put down WoW and go study the topic.

 

[DesertMedic66]

Over breathing the vent can cause respiratory alkalosis. In addition to that when you have a patient who is over breathing the, depending on the vent mode, can lead to breath stacking which can cause barotrauma and/or pneumos. It may also be a sign that your patient is coming out of their sedation which means to need to keep them under because waking up with a tube in your throat is no fun.

 

[hometownmedic5]

When the patient fights the vent, high pressures cause damage to the lungs of a number of flavors.

I don't know anything else about the patients condition or previous treatments, so I can't really comment on the facilitys response. There are times when the correct, or at least the most correct, course of action is to sedate the patient until the problem(in this case, vent alarm) goes away, and there are times when that's the lazy way out. If CMV was the correct vent mode for that patient to be in, then the solution fit the problem; but if that patient should have been in a more active, lung protective vent mode then paralyzing them to stop their inherent respiratory drive and sedating away their consciousness(with no analgesia, GRRR!!!!).

I have not yet worked for a private that took vent training seriously in house. You'll usually get a minimalist on boarding session which might cover such highlights as where the power switch and alarm silence button are(no joke, that was 90% of my first vent training. I quit there less than two weeks later). If you want to be a competent vent medic, you're going to have to get there on your own most likely. Find the local critical care service and see if they offer classes to outside providers. There are many books and websites out there on the topic. Two books I recommend are "The ventilator book" and " A Bedside Guide to mechanical Ventilation". Both are short, basic primers on vent medicine. What the words mean and how to get there. The why needs to come from somewhere else.

 

[E tank]

I'm a paramedic and I was in the process of telling my dispatcher to send someone who knows how to use a vent. An actually has a vent.
As I was explaining the situation to the nurse I noticed the patient was breathing 40 times a minute. Hes sinus tach at 120 and the temp is 102.4 He is hardcore belly breathing and his face starts to grimace. The doctor is called in and they give the guy Vecc, versed, tylenol.

So I'm assuming the patient was breathing over the machine. If nothing was done, would the patient take permanent damage? My line of thinking is that the patient would get tired and the machine would take over the breathing. I understand the underlying problem is still there (probably the fever).

Without knowing what the ventilator settings were and why your patient was intubated, it's really not possible to give a meaningful answer to your questions. But you have the right idea. Managing patients on ventilators is an entire sub-specialty of care and requires formal training and experience.

 

[VFlutter]

Throw them on that CMV transport vent, it will be fine...

Yeah can't really give much input other than good job advocating for the patient and proper transport. Critically ill patients on ventilators need a capable transport ventilator and provider to manage it. Infuriating what some people transport with a CMV vent and minimal education.

The last thing you want to do is paralyze that patient as it sounds like he is pulling a high Minute Ventilation to compensate and his ventilator settings are likely not adequate for his clinical condition.

 

[StCEMT]

Kinda hard to give a great answer with few details, but it doesn't sound like he was sedated well enough at the very least.

Eric Bauer's vent book is one resource I'll throw in that is well worth the read.

 

[Peak]

It's hard to give any kind of insight given the relatively limited history.

Is it possible to request some time shadowing in the ICU or PICU? We host flight nurses and medics from several agencies so that they can get hands on time with the interventions that some of our sickest patients have but they don't see with with any consistency.

 

[E tank]

The last thing you want to do is paralyze that patient as it sounds like he is pulling a high Minute Ventilation to compensate and his ventilator settings are likely not adequate for his clinical condition.

I think you could make an argument for sedating and paralyzing the patient and just give him what he needs with reasonable CMV settings for transport and then just let the receiving CC folks look after the details. Again, speaking in a very generic context.

 

[Carlos Danger]

The last thing you want to do is paralyze that patient as it sounds like he is pulling a high Minute Ventilation to compensate and his ventilator settings are likely not adequate for his clinical condition.

The very first thing you should do with someone who is difficult to ventilate is paralyze them. Then set the minute volume to whatever is appropriate.

Well, maybe not the first thing, but there's no reason to make ventilation difficult or complicated.

I have no idea where the idea that NMB is a bad thing came from - especially for the brief duration of most transports - but it's been around for years, and it needs to die.

 

[VFlutter]

The very first thing you should do with someone who is difficult to ventilate is paralyze them. Then set the minute volume to whatever is appropriate.

Well, maybe not the first thing, but there's no reason to make ventilation difficult or complicated.

I have no idea where the idea that NMB is a bad thing came from - especially for the brief duration of most transports - but it's been around for years, and it needs to die.

Agreed however it is all too common for providers to paralyze the patient without putting any thought into what is an appropriate minute volume. NMB is not a bad thing if you actually appropriately ventilate the patient. But in many cases is the patient truly difficult to ventilate or just asynchronous and tachypneic due to the ventilator settings

 

[Carlos Danger]

Agreed however it is all too common for providers to paralyze the patient without putting any thought into what is an appropriate minute volume. NMB is not a bad thing if you actually appropriately ventilate the patient. But in many cases is the patient truly difficult to ventilate or just asynchronous and tachypneic due to the ventilator settings

True, but the necessity of appropriate ventilation and adequate sedation goes without saying, whether the patient is spontaneously breathing or not. Everyone who uses vents should have a good foundation of ventilatory physiology and mechanical ventilation theory, and understand their specific vent inside and out. We all know that isn't, unfortunately, always the case. That's exactly why I advocate using NMB for transport if even the least bit of challenge is encountered. Any way you look at it, ventilating a completely relaxed patient is easier than ventilating one who is not relaxed. VCV at a rate of 10, Vt 5-6ml/kg, PEEP of 5, i:e time 1:3, Fi02 0.3 and make adjustments from there in a stepwise fashion. Obviously ventilation can sometimes require a more sophisticated approach (I've done transports on bi-level and inverse ratio ventilation in really sick patients with all kinds of lung pathology back when no transport vents had those modes and we had to fly to the main base before heading to the sending facility so our transport RRT's could load up the Servo-i that we had for just such scenarios), but the majority of the time it doesn't, and I don't know why we'd ever want to make it more complicated than it has to be. If we were all truly experts with vent management there'd be no reason to take that simple of an approach, just like if we were all truly experts in airways management there'd be no reason for a lot of the acronyms and tricks and hacks surrounding airway management that you see in the ED and EMS blogs and Foamed world. We're all about optimizing the patient and making things as easy on ourselves as possible when it comes to placing the tube, but that goes right out the window once the tube is in place.

Don't mean to rant, but this one bugs me almost as bad as the "there's no reason to use sux and anyone who does has no idea what they are doing" BS we've been hearing about for a few year now. My whole career I have always heard people say that we should avoid using NMB in ventilated patients during transport at virtually any cost, and that doing so routinely is just bad medicine and the mark of a lazy or unskilled clinician. I've never once heard a good rationale for that position however, and it never made a bit of sense to me. The more time that goes by without seeing a good reason for that approach, and the more experience I gain with mechanical ventilation and NMB's, the more confident I am in saying that it's complete hooey.

 

[Tigger]

Aside from the obvious assessment challenges, what are the disadvantages of continued paralysis in the transport/acute setting?

Our previous medical director mandated that every RSI patient being continually paralyzed with Vec. Our current MD wants "deep sedation" and paralysis "as necessary." Neither even really explained why. I feel like in the mostly hemodynamically stable patient that I can sedate them plenty far enough with fent/versed/ketamine that usually I can easily have our crappy transport vent working. My only backup plan is to continue to sedate aggressively and then add a paralytic if that doesn't work.

 

[StCEMT]

Aside from the obvious assessment challenges, what are the disadvantages of continued paralysis in the transport/acute setting?

Our previous medical director mandated that every RSI patient being continually paralyzed with Vec. Our current MD wants "deep sedation" and paralysis "as necessary." Neither even really explained why. I feel like in the mostly hemodynamically stable patient that I can sedate them plenty far enough with fent/versed/ketamine that usually I can easily have our crappy transport vent working. My only backup plan is to continue to sedate aggressively and then add a paralytic if that doesn't work.

I think the main concern I usually hear is people forgetting sedation since someone is paralyzed and looks ok at a glance.

 

[E tank]

Aside from the obvious assessment challenges, what are the disadvantages of continued paralysis in the transport/acute setting?

Our previous medical director mandated that every RSI patient being continually paralyzed with Vec. Our current MD wants "deep sedation" and paralysis "as necessary." Neither even really explained why. I feel like in the mostly hemodynamically stable patient that I can sedate them plenty far enough with fent/versed/ketamine that usually I can easily have our crappy transport vent working. My only backup plan is to continue to sedate aggressively and then add a paralytic if that doesn't work.

Whatever assessment challenges that paralysis presents, meaningful sedation would present it's own. The issue is that paralysis and appropriate sedation are not mutually exclusive. Sedate appropriately and paralyze. It isn't an either or thing.

 

[Carlos Danger]

Aside from the obvious assessment challenges, what are the disadvantages of continued paralysis in the transport/acute setting?

Are there different assessment challenges between a patient who is paralyzed and one who is deeply sedated?

Our previous medical director mandated that every RSI patient being continually paralyzed with Vec. Our current MD wants "deep sedation" and paralysis "as necessary." Neither even really explained why.

It's quite possible that neither of them really have a good reason. This is probably just how they were trained, or what someone they respect told them should happen. Though neither position is probably supported by any good research, personally I think you can make a really good argument for keeping mechanically ventilated patients paralyzed during transport, and really no argument at all for avoiding it.

I think the main concern I usually hear is people forgetting sedation since someone is paralyzed and looks ok at a glance.

Medication errors do happen. It's an unfortunate reality that they will probably never be 100% eradicated. However, if there is any concern at a given agency for that scenario being other than a highly unlikely and rare event, then I'd say that agency probably has no business using paralytics or sedatives or mechanical ventilators.

 

[Tigger]

I do not understand how providers seem to forget sedation. I understand that it is somewhat more difficult to gauge effect with a paralyzed patient, but to me the operative word is somewhat. If you're RSI/DSIing patients you need to have this ability.

 

[VentMonkey]

Is post-induction sedation not part of enough programs treatment algorithms that even the top "chefs" of said programs can't think enough to sedate post-induction along with long-acting neuromuscular blockade?

I think like most things, the Succs/ Roc debate is slowing losing momentum and most in-hospital providers seem less interested in what was used out in the field, and more interested in perhaps the timing of the longer acting agent(s).

Also, kudos to the OP for admitting he doesn't know what he doesn't know. Hopefully he wasn't scared off because there's quite of bit of useful information in this thread for him...and others.

 

[E tank]

Is post-induction sedation not part of enough programs treatment algorithms that even the top "chefs" of said programs can't think enough to sedate post-induction along with long-acting neuromuscular blockade?

The reality is that some patients don't need or can't tolerate sedation post appropriate hypnotic/relaxant intubation. Categorizing which patients do and which patients don't is a big part of the battle. Folks with a TBI severe enough to require intubation don't need a lot, if any sedation. Folks with CO2's nearing 100 don't need sedation either. If the brain should be working and there isn't severe metabolic derangement, then sedation is required, but that is a judgement call. I suppose the bottom line is, if the patient is hemodynamically tolerant of sedation, erring on the side of caution is an OK course of action.

 

[MSDeltaFlt]

I have minimal experience with vents and I'd like to get a grasp on them. Any resources you can recommend?

I'm a paramedic and I was in the process of telling my dispatcher to send someone who knows how to use a vent. An actually has a vent.
As I was explaining the situation to the nurse I noticed the patient was breathing 40 times a minute. Hes sinus tach at 120 and the temp is 102.4 He is hardcore belly breathing and his face starts to grimace. The doctor is called in and they give the guy Vecc, versed, tylenol.

So I'm assuming the patient was breathing over the machine. If nothing was done, would the patient take permanent damage? My line of thinking is that the patient would get tired and the machine would take over the breathing. I understand the underlying problem is still there (probably the fever).

The lack of knowledge is annoying enough for me to put down WoW and go study the topic.

Occam's razor (or Ockham's razor) is a principle from philosophy. Suppose there exists two explanations for an occurrence. In this case the one that requires the least amount of assumptions is usually correct. Another way of saying it is that the more assumptions you have to make, the more unlikely an explanation.

Tachypnea, tachycardia, fever, and grimacing tell two things. 1. the patient is conscious. 2. the patient is in distress. Why was he hardcore belly breathing? My guess would be that the Succ, or whatever drug they used for induction, wore off. The MD then ordered Norcuron and Versed. Some say to paralyze. Some say not necessarily needed. Depends on clinical presentation and on your Med Control.

You asked if left unchecked would the patient take permanent damage. Yes he could. What kind of damage? Depending on clinical presentation the list can get pretty long of possibilities. Pneumothorax, barotrauma, hypoxia, hypercapnia, hypocapnia, hypertension, hypotension, tachycardia, bradycardia, dysrhythmias, and even cardiac arrest.

Since you mentioned fever, if I were a betting man I'd say the reason he has fever and the reason he was intubated are probably one and the same: Sepsis.

You can never go wrong with sedation. If hypotension is a concern. Follow your protocols for hypotension.

Breathing over the vent will more than likely cause the high pressure alarm to sound. When that happens the tidal volume breath shuts off immediately, whether the lungs are full or not, until the next breath.

When it comes to "breath stacking", the only way to tell if you are breath stacking is if you have Auto-PEEP. Which is any PEEP that is reading higher that the PEEP you currently have dialed in. For example: you dial in a PEEP of 5, yet you're reading a PEEP of 8. Your patient is stacking breaths. If your measured PEEP/total PEEP is reading the exact same amount of PEEP that you set on the vent then you have no Auto-PEEP. If you have no Auto-PEEP then you are not stacking breaths.