8jimi8
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Vent did you mean tidal volume?
What was that device?
- Thread starter Melbourne MICA
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Vent did you mean tidal volume?
Yes.
Here is a list of commonly used pulmonary terms and abbreviations which will be found in some of the articles I post or write about.
http://noairtogo.tripod.com/gloss.htm
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Shishkabob
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Ah, you're no fun Vent 
Thanks for the list.
Thanks for the list.
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8jimi8
CFRN
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Thanks, i didn't realize that VT and TV were the same thing!!
Melbourne MICA
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Not completely daft
So Venty at least in the short term an ETT can "secure" the airway (stating the obvious and paraphrasing the accepted notion) or more correctly prevent significant aspiration from hitting the lung fields.
I have been reading up on cuff pressures and most of the studies I read called for cuff pressures to be measured using a manometer. Even amongst skilled anaesthetists over or under pressure occurred in a surprising percentage of ET placements.
In the field as you know we just inflate the cuff till you hear no leaks. One excellent operator who works on our air wing uses the method whereby rather than just put an arbitrary amount of air via a syringe (which is probably and usually too much) he will put a small amount in, ventilate, add a little more etc until there are no leaks heard.
I like the approach and now use it myself. In the absence of manometers I think this comes closest to providing sufficient pressure to seal the trachea without compromising the perfusion of the tracheal lumen though of course how are we to really know for sure.
In the end however it is clearly a priority to evacuate the stomach with an NG or OG tube and I will certainly give this far more emphasis and a higher place in the chronology of airway management for our tubed Pt's. It makes sense that there can be little passive aspiration if there is nothing or next to nothing in the stomach.
Like I've said before, airway management is a hugely important area for ambos. Keep the great posts on this subject going. All will benefit.
Cheers
MM
So Venty at least in the short term an ETT can "secure" the airway (stating the obvious and paraphrasing the accepted notion) or more correctly prevent significant aspiration from hitting the lung fields.
I have been reading up on cuff pressures and most of the studies I read called for cuff pressures to be measured using a manometer. Even amongst skilled anaesthetists over or under pressure occurred in a surprising percentage of ET placements.
In the field as you know we just inflate the cuff till you hear no leaks. One excellent operator who works on our air wing uses the method whereby rather than just put an arbitrary amount of air via a syringe (which is probably and usually too much) he will put a small amount in, ventilate, add a little more etc until there are no leaks heard.
I like the approach and now use it myself. In the absence of manometers I think this comes closest to providing sufficient pressure to seal the trachea without compromising the perfusion of the tracheal lumen though of course how are we to really know for sure.
In the end however it is clearly a priority to evacuate the stomach with an NG or OG tube and I will certainly give this far more emphasis and a higher place in the chronology of airway management for our tubed Pt's. It makes sense that there can be little passive aspiration if there is nothing or next to nothing in the stomach.
Like I've said before, airway management is a hugely important area for ambos. Keep the great posts on this subject going. All will benefit.
Cheers
MM
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What you described is MLT (Minimal Leak Technique) or MOP (Minimal Occlusion Pressure) which is what RTs do until they can get their gadgets hooked up. A manometer is the best.
Some have a difficult time understanding that it isn't the amount of air placed in the cuff but the fit of the tube in the trachea that varies the pressure. The cuff size will also vary with tube size. And, there are many different cuffs. There is no set recipe or magical number for filling a cuff.
Also, some will claim to see the ETT pass through the cords but what they may not see is the cuff expand and if the tube is just slightly higher than it should be, the cuff will pop back through the cords. If it doesn't go to the esophagus, the cuff may just lie supraglottic giving the provider the false security that the tube is in the correct position. But when the patient arrives at the hospital, when the RT does a MLT, they will realize they can not make a seal with the usual amount of air. Correlating that to the tube marking at the gum or lip line will tell them the tube is misplaced.
The ETT is still a "secure" airway but some will have to remember that it may just slow down the inevitable as secretions will eventually make it to the lungs. Suctioning is not adequately taught in EMT(P) which would also explain why CPAP gets placed on aspirated scrambled eggs and oatmeal each morning by some provider who didn't clear the airway before applying. Usually, one the airway is clear there is not a need for CPAP. However, once CPAP is applied with aspirated secretions, ETI will be needed.
Another little tidbit is we no longer inflate trach cuffs to prevent patients from aspirating when eating. We found they aspirate more by not being able to equalize the pressures within their chest and the cuff may get over inflated and place pressure against the esophagus causing the food to not be swallowing.
The best method for swallowing with a trach, whether on a ventilator or not, is cuff deflated with a Passy-Muir Valve in place which helps to create a relatively normal pressure within the chest.
http://www.passy-muir.com/
Christopher Reeve used this device when he was speaking. It is essentially a one way valve that allows air to enter through the trach but then must exit through the throat and cords.
For nurses and RTs, there are 5 free CEUs on that website.
Some have a difficult time understanding that it isn't the amount of air placed in the cuff but the fit of the tube in the trachea that varies the pressure. The cuff size will also vary with tube size. And, there are many different cuffs. There is no set recipe or magical number for filling a cuff.
Also, some will claim to see the ETT pass through the cords but what they may not see is the cuff expand and if the tube is just slightly higher than it should be, the cuff will pop back through the cords. If it doesn't go to the esophagus, the cuff may just lie supraglottic giving the provider the false security that the tube is in the correct position. But when the patient arrives at the hospital, when the RT does a MLT, they will realize they can not make a seal with the usual amount of air. Correlating that to the tube marking at the gum or lip line will tell them the tube is misplaced.
The ETT is still a "secure" airway but some will have to remember that it may just slow down the inevitable as secretions will eventually make it to the lungs. Suctioning is not adequately taught in EMT(P) which would also explain why CPAP gets placed on aspirated scrambled eggs and oatmeal each morning by some provider who didn't clear the airway before applying. Usually, one the airway is clear there is not a need for CPAP. However, once CPAP is applied with aspirated secretions, ETI will be needed.
Another little tidbit is we no longer inflate trach cuffs to prevent patients from aspirating when eating. We found they aspirate more by not being able to equalize the pressures within their chest and the cuff may get over inflated and place pressure against the esophagus causing the food to not be swallowing.
The best method for swallowing with a trach, whether on a ventilator or not, is cuff deflated with a Passy-Muir Valve in place which helps to create a relatively normal pressure within the chest.
http://www.passy-muir.com/
Christopher Reeve used this device when he was speaking. It is essentially a one way valve that allows air to enter through the trach but then must exit through the throat and cords.
For nurses and RTs, there are 5 free CEUs on that website.
Melbourne MICA
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Suction
I note your point about the almost complete lack of education on suctioning and it is no different here. We have an array of suction tubes in our kit but most of us would miserably fail a pop quiz on their uses and underlying airway pathophysiology specific to their considered use.
Like much of the stuff we carry we could all benefit from some thorough background knowledge on this gear.
I don't come across many trachy pts these days but the info you have given is valuable.
Just on that point do you have tips on pts who have been criked re suctioning, airway pressure issues, ventilation technique etc. It's in our failed intubation drill as it stands but there is little in the way of the technicalities should we have to employ one. We are taught about jet ventilation but not much else.
This will become of greater concern and relevence as there is the possibility of an expansion in our airway management guidelines for paeds in particular the under 12's including RSI, SFI (we can already do this now in some paeds emergency categories) and crike for kids. We already carry paeds LMA's but haven't as yet been updated on the particulars.
There's a fair bit there I realise so just a few basic tips would suffice for now if you feel so inclined. Info at your leasure of course and citations are always a good alternative.
I will keep an eye on the thread or perhaps you might like to start a new one with input from some of the other quality Paras on the forum.
Love your work.
MM
I note your point about the almost complete lack of education on suctioning and it is no different here. We have an array of suction tubes in our kit but most of us would miserably fail a pop quiz on their uses and underlying airway pathophysiology specific to their considered use.
Like much of the stuff we carry we could all benefit from some thorough background knowledge on this gear.
I don't come across many trachy pts these days but the info you have given is valuable.
Just on that point do you have tips on pts who have been criked re suctioning, airway pressure issues, ventilation technique etc. It's in our failed intubation drill as it stands but there is little in the way of the technicalities should we have to employ one. We are taught about jet ventilation but not much else.
This will become of greater concern and relevence as there is the possibility of an expansion in our airway management guidelines for paeds in particular the under 12's including RSI, SFI (we can already do this now in some paeds emergency categories) and crike for kids. We already carry paeds LMA's but haven't as yet been updated on the particulars.
There's a fair bit there I realise so just a few basic tips would suffice for now if you feel so inclined. Info at your leasure of course and citations are always a good alternative.
I will keep an eye on the thread or perhaps you might like to start a new one with input from some of the other quality Paras on the forum.
Love your work.
MM
AnthonyM83
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Could you elaborate on the comment on that few clear the airway before CPAP and that once the airway is clear there usually isn't a need for CPAP?
Are we talking CPAP for an unconscious patient (which I'm not familiar with)?
Or for a CHF'er in pulmonary edema crisis? (In which case, how would I clear an airway to the point they don't need CPAP)
Are we talking CPAP for an unconscious patient (which I'm not familiar with)?
Or for a CHF'er in pulmonary edema crisis? (In which case, how would I clear an airway to the point they don't need CPAP)
I would not put CPAP on an unconscious patient who can not control their own airway.
If the patient appears to have just eaten or was being feel or a misplaced feeding tube, the gurgles and crackles you hear may be aspirated material. A quick NT suction through the nares may stimulate a cough or suction enough stuff to know what you are dealing with. Sometimes the gurgles and crackles disappear. However of course NT suctioning is not without some risks but then again an airway full of secretions or food also presents with some risks.
For inhospital, it is part of our VAP (Ventilator Associated Pneumonia) protocol. We have already banished NTI, except for surgical situations, in our hospitals since the CDC recommendation about 10 - 15 years ago. Sinus infections give rise to PNAs and other systemic infections. Insurers such as Medicare will no longer pay for hospital acquired infections.
http://www.zapvap.com/guidelines.aspx
These same guidelines are now observed by all of our Specialty and hospital based Flight teams (or those with ICU RNs on board) where possible regardless of what county, state or country they are picking up from. But then they are just continuing their practice from the ICUs to transport so it is nothing out of the norm since these protocols and awareness education has been in effect for 10 years at least.
Of course, prehospital EMS will not have access to the meds and intubation assist gadgets the hospital or Specialty teams have so NTI may be your only choice for some situations. The NG may also be better tolerated prehospital due to lack of adequate sedation ability.
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AnthonyM83
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Huh?
Of Michael Jackson? No, dude that paparazzi either got good commission or heck even got a job because of the picture. (There's no way it was EMS..."Hold on guys, I'm gonna stop doing helping so I can take this picture. No one tell".... yeah right)
Hey Vent,
Thanks for the explanation. I think it's amazing that with all the concerns with VAP - and the people making ET tubes that are lined with silver and all the other crazy tech - one simple way was just to put a hole above the pilot balloon to suction the gunk out periodically.
Thanks for the explanation. I think it's amazing that with all the concerns with VAP - and the people making ET tubes that are lined with silver and all the other crazy tech - one simple way was just to put a hole above the pilot balloon to suction the gunk out periodically.
Actually it is hooked up to continuous suction at -20 cm H2O for the duration of the tube.
Silver and copper are both known for their bacterial static properties. Silver trachs have been used for centuries and not the silver lined ETTs are gaining popularity. Copper mesh used to be part of the ventilator humification systems until disposable circuits came along.
Silver coated ETT - hard to miss with the purple although the King Airway looks similar with it dark reddish connector.
http://www.bardmedical.com/products/loadProduct.aspx?prodID=391