Managing a ventilated patient: vent settings.

I have already shown you a very good short introductory video on using the Oxylog 3000 ventilator.

And now here is something a little more advanced for those of us who are more experienced with managing ventilated patients.

Scott Weingart, an ED Intensivist from New York City and author of the eminent EMcrit has produced a set of 2 videos (also available as podcasts over on his site) on ‘Dominating the Vent’.

For those of you who think you have a fairly good grasp of the basic concepts of ventilation, I strongly recommend you take the time to watch these 2 videos. Like…..do it.

There is also a handout to accompany this lecture which you should download as a pdf and follow along with.

Here is a taster of some of the juicy tips that Scott covers in the first lecture:

• Tidal volume (Vt) should be used to protect the lungs, and NOT to try to alter CO2.
• Initial vent Tidal Volume is 6–8 mls/kg based on predicted body weight. “Injured lungs are baby lungs”
• Initial Vent Resp Rate should be16–18 (18 is better and Scott will tell you why).
• Patient oxygenation is best controlled in response to pt ABG’s via changes to FiO2 and PEEP and the use of a PEEP chart.
• MYTH: High levels of PEEP causes pneumothorax.
• MYTH: high levels of PEEP causes high ICP.
  Do not fear rolling up your patients PEEP
  PEEP of 18–24 are not totally uncommon in this setting.
• Best way of controlling high airway pressures is to measure Plateau pressures (NOT peak pressures).
  If pressure > 30cmH2O, lower the Vt.

Part 1 (Ventilation of the injured lung)

EMCrit Lecture – Dominating the Vent: Part I from Scott from EMCrit on Vimeo.

If you cannot see the player above, here is a link to the video.

Part 2 (Ventilation of the obstructed lung eg Asthma COAD)

Dominating the Vent Part II from Scott from EMCrit on Vimeo.

If you cannot see the player above, here is a link to the video.

And here are some tips from his second vid:

• Vt initially 8mls/kg based on pts predicted body wt.
• FiO2: 40–100%
• PEEP: 0 (or ‘ZEEP’)
• RR: most important setting in the obstructed lung.
  Need to set low (start at 10 BPM and titrate)
• I:E ratio of 1:4 or 1:5.
• If patients are not given time for alveoli to empty before next breath is delivered pressure will build.
• If asthmatic, don’t forget to administer bronchodilators to treat the underlying issue.
• If your patient is crashing the first thing you need to do is disconnect them from the ventilator ( & then bag via bag-vale-mask).

As an important corollary to this information, I would hasten to add that any changes to ventilation settings must be made (at the very least) in close and immediate consultation with the doctor in charge of that patients care.