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. Right now, the actual knowledge in most of EM on vents is dismal [PMIDs: 27330658 and 25497896]
This lecture 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. In a future episode, 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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First, read my Ventilator Article in the Annals of EM [Managing-Initial-Vent-ED]
Then, print out this Handout for the Dominating the Vent Series
Additional New Information
- American Journal of Respiratory and Critical Care Medicine Vol. 195, No. 4 | Feb 15, 2017 Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure
- LOV-ED Low Ventilation Trial (Ann Emerg Med 2017;70:406)
- Low Tidal Volume in the ED decreases mortality: Lung-Protective Ventilation and Associated Outcomes and Costs Among Patients Receiving Invasive Mechanical Ventilation in the Emergency Department. Chest. 2020 Sep 20;S0012-3692(20)34522-0. doi: 10.1016/j.chest.2020.09.100.Hemodynamic Effects of PEEP
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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… Read more »
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
Cheers
Anand, the search bar on the right toolbar does the same thing without having to type the site name.
ah whoops, I didn’t see it sorry. Usually look for them at top of websites
Mike, you can use the archive link on the top toolbar.
THANKS!!!
Awesome. Very succint.
Hi
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?
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!
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
lost me my friend. If the PaCO2 is too high, you raise the resp rate to make it come down.
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 😉
Jaqueline
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!
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?
I also use this vent (and the newer ReVel) and have wondered the same….I usually set the inspiratory time to 0.8 seconds, but I’m not sure this accomplishes the same thing. Dr. Weingart, any advice?
to get 60 lpm at 500 ml Vt would be 0.5
In volume control, you can mimic increasing flow rate by decreasing I time. In pressure control, go to the extended menu and increase the rise time profile for faster flow. No conflicts.
Greeat lecture thx. 1 question: why volume controlled? It is afaik almost universally accepted that pressure control is better. I would go with SIMV
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.
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
It truly depends on the pt, individualized, whether vol or PC is better.
I can’t THANK YOU enough for this information! Very clear and manageable. Keep up the GREAT work!!!
I have a problem watching the video after minute 4 it stops
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?
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 http://www.ardsnet.org/system/files/Ventilator%20Protocol%20Card.pdf 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… Read more »
v. nice
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.
Dr. Weingart,
Great lecture! I’m curious about something, at the end of your presentation you had mentioned that sedation was a bonus to your patients on an AC/VC setting, the really important part was to have good analgesia. What would your thoughts be on using precedex, or ketamine for the sedative and analgesic properties in conjunction with low dose fentanyl, with the intent being effective pain control with greater anxiety control without the blunt on neuro status found with a drug like propofol for example?
Finally I get it. Thank-you!
hi Scott Appreciate the simple, straight up method that you have outlined for mechanical ventilation in the ED. One comment regarding dead space, a generally accepted belief regarding endotracheal intubation is that when the appropriate size ETT is selected for a patient, that a patient’s anatomical dead space is reduced by 1/2. The addition of the ventilator circuit adds mechanical dead space, from the patient connection to “Y” connector in a dual limb circuit or from the patient connection to the exhalation valve in a single limb circuit; both are designed to minimize the added mechanical dead space when the… Read more »
as always, an incredibly good lecture. i think this is a topic that “frightens” some of us, that unknown magic box that we defer to the RT folk. There is absolutely no reason that we do not understand that magic box , that is breathing for the patient we just resuscitated and worked hard on to keep alive, as well.
Thoughts on that?
https://jamanetwork.com/journals/jama/fullarticle/2710774
you changed my life <3
Hey Scott, This was a great podcast and has really helped me out on managing patients I have intubated on recent shifts I have had. I have two quick questions for you. I had a patient recently who presented with a severe CHF exacerbation. By the time she arrived to the ED she was unresponsive with a spO2 in the 40’s requiring intubation. X-ray showed significant pulmonary edema. She was requiring high PEEP and FiO2 to achieve decent oxygenation. Her tidal volumes we set at 6cc/kg and her Pplat were coming back at 33-35 and her ABG came back with… Read more »
I worked as a Neonatologist 13 years ago and now I will start working in an adult intensive unit in Stockholm due to the Corona situation.
Sorry where is part 2
The objectives of this course are to:
Familiarize clinicians with common terms in mechanical ventilation
Review key principles of pulmonary physiology relevant to mechanical ventilation
Discuss the basic principles of selecting ventilator settings
Develop strategies for caring for ventilated patients with ARDS and obstructive lung disease, as well as COVID-19 specific management
Review the daily assessment of ventilated patients
Provide strategies for evaluating patients for extubation readiness
A learner who understands these concepts will be well-positioned to collaborate with colleagues in Intensive Care and Respiratory Therapy in caring for critically ill, mechanically ventilated patients.
NICE
Nice
It’s very good topic
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
Great
hello everyone
hello everyone
parabéns
Hi Very Nice
Good
Awesome
Thanks for this
Good
Hello everyone, i’m karin from indonesia i’m a nurse. This’s course it’s verry great. I’m enjoy. Thankyou for information.
Good
Good
Good.
Hi
thank you
I’ve always struggled with confidence while using vents which caused me to not use them in the field. Thank you for spelling it out clearly and simply.
AWESOME PRESENTATION REALLY INFORMATIVE THANK YOU