Cite this post as:
Scott Weingart, MD FCCM. Response to Letters on my Mechanical Ventilation Article in the Ann Emerg Med. EMCrit Blog. Published on October 21, 2016. Accessed on April 18th 2024. Available at [https://emcrit.org/emcrit/response-mechanical-ventilation/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: October 21, 2016
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Great lesson in mechanical ventilation in your podcast. Great to hear that somebody thinks at chest compliance too when talking about the driving pressure.
Holy Crap! That’s not a wee by any stretch. For those interested the Gattinoni talk is from the World Sepsis Congress podcasts. Podcast #1 starting at 2 hrs in. The website is http://www.worldsepsiscongress.org/ (currently down). The podcast is still downloadable from iTunes. I would much appreciate folks listening and seeing if I misinterpreted Gattinoni’s discussion. Ok now I have to step carefully. As a practicing ED doc (not intensivist) who is married to one of those AWESOME RTs, I have to echo your sentiment that there is lack of consistency in this profession (probably no more than any other). The… Read more »
thanks for all of that, Mike
Hey Scott, long time listener, first time caller. Love the podcast. I have a few thoughts. You and I profoundly disagree about PRVC, I think, for two key reasons. You’re certainly right in saying that there can be swings in volume, but I think you greatly overstate the magnitude of those swings, especially when using a modern ICU ventilator. These ventilators don’t vary volume breath-to-breath per se, but take a running average of the pressure required to reach the targeted volume over the previous 3 or 5 breaths, so swings due to things like coughing or nursing turns are dampened.… Read more »
Tom,
the problem you mention was also the problem I mentioned–i.e. patient effort will limit the pressure given on subsequent breaths. Our vent doesn’t have a Vt alarm that acts as a limit. In fact I think any vent that puts limits in the alarm section (including the peak pressure alarm/limit for PRVC) is flawed. Any limits should be in the settings screen not in the alarms screen.
PS love the PS you rabblerouser
Hi Scott
I enjoyed this Emcrit Wee. Thank you for posting.
I wanted to ask you about your approach to the trigger sensitivity, which i didn’t hear in the podcast or see mentioned in the Annals article.
If I’m understanding your approach, you’re using an AC(VC) mode which is time and patient triggered for breath delivery.
Do you adjust the trigger on the ventilator and if so, how to you approach it with the particular patient you’re caring for?
Best wishes
Dean
we have flow-trigger on our vent and I rarely find myself adjusting it. the waveforms will give you hints that you need to, but was outside the auspices of the article.
Thanks for your thoughtful responses to my the letter. Your responses show a great deal of class and graciousness that is a model of professionalism instead of the tendency, as you mentioned in your podcast, of LTEs turning into sardonic pissing matches. I chuckled when I opened your website to see Dr. Brower’s discussion with you, specifically that even he doesn’t recommend using it yet. For me, the concept just makes so much physiologic sense, and the data, though retrospective, was so strong that I really am a believer in it to determine whether overdistention or recruitment is occurring. That… Read more »
so glad to have you reading brother! thanks for the Gattinoni reference, I was trying to track it down.
Agree with most of your points – a few notes: 1.) Most of us (of course) aren’t putting an esophageal balloon down to measure transpleural pressure/calculate a true transpulmonary pressure. I have zero evidence for this, but one of my attendings in fellowship told me to keep the Pplat lower than the BMI if the BMI is > 30. I think this is reasonable and easy to apply in most ER settings (I guess unless the BMI is a super high number). 2.) You might already know this (sorry if so), but when the RT uses the term “pressure-targeted” breaths,… Read more »
3. No, not stupid at all. But the gradations of ARDS all have specific meanings. I still prefer the generic term of ALI despite their desire to abolish it, b/c: 1. It allows qualitative description of a clinical scenario 2. the concept of a “syndrome” for clinical disease is an example of all the things we don’t know. Injury I can say for sure, acute I can say for sure. I reserve the ARDS terms when I actually have blood gases and have excluded the other causes of resp. decompensation.