All Things Ventilation, Invasive and Non-invasive

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Permalink Reply by Ronald Taylor on January 4, 2009 at 6:39pm

Totally agree with you Chris on that one

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Permalink Reply by Scot Jones on January 4, 2009 at 10:26pm

Yeah, I'd like to hear more of why you are pushing for more PEEP . . . in the range of 8-12. Do you wean this prior to extubation? How are you determining the exact PEEP? Via an Optimal PEEP maneuver?

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Permalink Reply by Rakan A. Alduwairig on January 5, 2009 at 7:58pm

I'd like to hear more about it also. Scot has an excellent point, are you using Optimal PEEP maneuver to determine the inflation point??

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Permalink Reply by Chris on January 5, 2009 at 9:33pm

In a "normal" lung a peep of 4-6 usually restores a patient to a "normal" FRC. The key word is "normal". Many COPDers normally have an increased FRC. Why wouldn't you restore them to a normal FRC by using a higher peep level? Pt's with a restrictive process also needs higher peep levels to maintain FRC.

When using non-invasive ventilation the ABSOLUTE most important setting is EPAP. Many times if you restore FRC with EPAP 10-15cmh2o you don't even need the IPAP with it's limiting I Time. Many patients fail non-invasive ventilation because lack of operator knowledge.

Many consider peep of 5 cmh2o is the nomal to set on most patients. I say know never less peep of +6 and usually 8-12 is normal. I also don't believe in volume ventilation except if a few cases, such as acute head trauma. Pressure control is the most comfortable for a patient especially when our peep maintains what FRC they find most comfortable. Peep is for ventilation as much as for oxygenation.

We also use APRV ventilation which is all about FRC (phigh) and spontaneous breathing. We also use MMV mode. I do not feel there is any case to use SIMV, an outdated mode of ventilation. My modes are APRV, A/C Pressure control, MMV, CPAP, and in a few cases CMV. As you can tell we use the Drager XL vents.

We don't use any type of optimal peep, we use our graphics, auto peep measurements, and patient response to comfort. A patient on appropriate vent support (mode, Itime, Peep, slope, rate, volume) should not need to be knocked out with sedation.

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Permalink Reply by Chris on November 9, 2009 at 8:54pm

I work at a facility where the RT manages the vent settings. Try different vent settings and if it improves the patient's status on the vent show your MD. Your MD's will have a hard time changing a patient back to a setting that's not working as well.

"FRC is the key"

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Permalink Reply by LS Mullen on January 6, 2009 at 7:33pm

I agree that pt's don't need to be "knocked out" just for mechanical ventilation but having been on the nursing side of the vent...I think it's very important to keep pts comfortable. By using sedation and pain meds (mechanical ventilation/suctioning IS painful) to keep the patient's pain level tolerable and sedation to calm and decrease anxiety it helps us (RTs) accomplish what we need to accomplish. I've recently started working at a hospital where in one ICU they only give PRN pain/sedation meds. I've noticed that with the ups and downs of this practice, the patients stay on the vent longer, have greater comfort issues-tend to fight the vent more, and it is generally more difficult to manage this patient on the vent.
They probably don't realize it but one of the greatest compliments I can pay the nurse is to tell them they have OUR patient "nicely sedated". Not knocked out, just comfortable enough to let us manage the patient's issues.

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Permalink Reply by Chris on January 6, 2009 at 7:55pm

Agreed. My point as far as being knocked out with sedation is, if the vent is not set appropriately more sedation will be needed.

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Permalink Reply by leo lamadrid on October 31, 2009 at 9:15am

can any body help me to explain why a patients when you put to bipap or cpap compare to nasal cannula they have more gud saio2 compare to bipap or cpap.have anybody observed this even you already to to IPAp 19 EPAP of 6 and a 4L of oxygen.

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Permalink Reply by Juan enrique Lee Goic on November 9, 2009 at 3:03am

If I understand your question: Your patient had partial oxygen saturation greater when you put a nasal cannula with 4 liters of O2 (30 to 35% depending on the flow FIO2) than with BiPAP I / E 19 / 6 "What Fio2 scheduled on bipap, you put oxygen in the BiPAP? ... It is possible that the interface has not been adequate and excessive leakage causing discomfort to your patient becomes agitated or upset "a lot of your breathing pattern when you installed the BiPAP?.

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Permalink Reply by abdul majid on October 31, 2009 at 11:30pm

then what about barotrauma/volutrauma/dynamic hyperinflation.hypotension and consequently more worsening??/if u mean to avoid o2 toxicity for first 6 hr is rationale then is reasonable to me.
can u plz put reference of this u wrote.

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