EMCrit Lecture – Dominating the Vent: Part I

When I was a resident, every vent lecture either put me to sleep or left me dazed and bewildered. I gave a lecture of that ilk when I started working after fellowship. I had become part of the problem. I decided there must be a way to make vent management more understandable and if not interesting, at least bearable.

This lecture was up on the soon to be defunct EMCrit Lecture site. It offers a path to managing any patient on the ventilator in the ED. I have tried to simplify as much as possible while still maintaining an evidence-based approach.

This is Part I, it deals with the lung injury strategy. Next week, we’ll talk about the strategy for patients with obstructive lung disease.

There are only 4 things you need to remember for a lung injury patient:

Vt (Tidal Volume) = Lung Protection

Flow Rate = Patient Comfort

Resp Rate = Ventilation

FiO2/PEEP = Oxygenation

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  1. mike wansbrough says

    Hi Scott,
    great podcast! However- one suggestion- please make it easier to identify the subjects on the download list. I was trying to find the ‘dominating the vent’ on my iPhone, but was unable to locate it as they are listed by podcast episode number. I then went to this site, but it still doesn’t give me a quick way to find out which ‘podcast episode’ I need to go to. I needed it in a hurry to brush up on some of your points on my way to teaching medics, and it would have been nice to have while driving (I was not organized enough to prepare this podcast for listening the night before!). Thanks, Mike

    • Anand Senthi says

      Hey Mike,
      I agree this website is great but needs a search bar. I get around that by using google to search only within this site. To do that type your google search query as normal then add a space then type “site:emcrit.org” (without the quotation marks)
      you will find the podcast you need
      Very hand trick when website don’t have good search functionality – google search usually is better


  2. says


    Great podcast. Myself and some fellow consultants listened to it and went about playing with our own vent & talking over your fantastic podcasts. As you probably know UK ED consultants do far less of the anaesthetic workup than you.

    One question- we found that setting up for the high flow rates you describe in the injury strategy meant we had really quite fast inspiratory times and high i:e ratios. Classically in the UK the anaesthetists aim for an i:e of 1.5 to 2.

    That gives us, quite low flow rates! Do you run with much higher i:e ratios?

    • says

      in this circumstance, the flow setting is picked by pt demand. The I:E will vary depending on how high we need to go on RR. Honestly never bother to look at I:E on any patient. I manage my asthmatics with flow graphs and on non-obstructive pts, never bother to look.

      thanks for writing!

  3. Jaqueline says

    hello, Thank you for the lecture, I really enjoyed it, I do have a question, at the end of your lecture, when you were doing your summary you said, “co2 its too high go up on your RR, co2 its too low go down on you RR,
    I believe its the other way around, correct me if Im wrong please, “If you increase your RR (hyperventilation) you blow off Co2 so decreases Co2. and if you decreased RR (hypoventilation) you increase you Co2, again, thank you for your lecture,

    Jaqueline Fernandez-Quezada CCRN

      • Jaqueline says

        Yes, I understood wrong, I thought you said IF YOU WANT your Co2 to go high increased the rate, but you actually said if Co2 iTs too high, my bad, we were saying the same thing, sorry. Great presentation 😉

  4. says

    Magnificent web site. Lots of useful info here.
    I’m sending it to a few buddies ans additionally sharing in delicious. And of course, thanks for your effort!

  5. Stacy Turner says

    Hi Scott,
    On our ventilators (PulmonitecSystems LTV1200) we can’t control the inspiratory flow rate, only the inspiratory time. I’m struggling to work out what should this should be set at to be equivalent to an IFR of 60-80L/min. Can you help?

  6. dan says

    Greeat lecture thx. 1 question: why volume controlled? It is afaik almost universally accepted that pressure control is better. I would go with SIMV

    • says

      Dan, To the contrary I think you will have a hard time finding a single article showing that pressure control is better for patient important outcomes. If you find any, do share. SIMV is also a mode with theoretical but no demonstrable patient-important benefits.

      • dan says

        SIMV is actually my favourite. With the volume controlled ventilation you have the disadvantage that once the patient’s compliance gets worse you will have very high pressures. But i guess you are right,in the ED there is always someone there to keep an eye on pressures

  7. Liz K. says

    I can’t THANK YOU enough for this information! Very clear and manageable. Keep up the GREAT work!!!

  8. Nikolay Yusupov says

    Question to you Scott about transition ARDS patients with PEEPS in excess of >10cmH2O (PEEP is between 10-20) from ED ventilator to transport ventilator.

    Would you clamp the ET tube when transitioning to prevent the loss of PEEP in ARDS/Sepsis patients?

    Would you give a dose of a paralytic when your ready to make the transition? So patient does not generate NiF with clamped tube, If so what would you use Sux, Roc?

    Or is it a moot point, and not worry about clamping the tube?

  9. Greg Miller says

    Nice summary, Scott. I listened a while ago and thought I’d add this comment to your ultra-simple method.

    At the risk of simplifying too much,here are 2 quick methods I use for calculating starting tidal volume. It is based on the ARDSNet formula for predicted body weight (PBW) where height is the single variable.

    Males = 50 + 2.3 [height (inches) – 60] Females = 45.5 + 2.3 [height (inches) -60] kg

    None of these numbers will come as a surprise to those who regularly select tidal volume using the recommended formula. Since 6-8 ml/kg creates some leeway, combined with predictable height range, it lends itself to some nice round numbers.

    Method 1 (ultra-simple): Males 500 ml Females 400 ml

    This will provide TVol 6-8 ml/kg based on PBW calculation
    Works for males 5’9″±4″ and females 5’5″±3″
    (Metric: males 175 cm±10 cm, females 165±8cm)

    Method 2 300-400 ml + 15ml/in of height >5 feet for males, subtract 30 ml for females

    300 ml is the base TVol for 50 kg @ 6 ml/kg (60 in height)
    400 ml is the base TVol for 50 kg @ 8 ml/kg (60 in height)
    The extra 15 ml for each in of height equates to ~ 7 ml/kg for incrementally increasing height
    (Metric 300-400ml + 6ml/cm over 150 cm, same 30 ml adjust for females)

    This is a combination of basic algebra and some arbitrary rounding for ease of calculation.
    Works for me; other’s mileage may vary.

  10. says

    Bu sitede Havaland?rma üzerine yap?lan ara?t?rma ve geli?tirme çal??malar? ile mekanikçi arkada?lar güzel ve faydal? bilgilere sahip oluyorlar. Havaland?rma Sistemleri üzerine oldukça tecrübeli arkada?lar?m?z mevcut. Kendilerine buradan çok te?ekkür ediyor ba?ar?lar?n?n devam?n? diliyoruz.


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