Manage the Vent Like a Pro

December 10, 2016

Short Attention Span Ventilator Summary

Mechanical Ventilation Made Ridiculously Simple
Scott Weingart published a handy guide to managing the ventilator in a recent Annals of EM review article.  Here are the highlights.

• Lung Protection Strategy – ARDS and Acute Lung Injury

  • Mode: volume-assist control

  • Tidal Volume: 8 mL/kg starting; titrate to 6mL/kg as tolerated (see link below for ARDSnet protocol; use ideal body weight)

  • Flow: inspiratory flow rate at least 60L/min for patient comfort

  • RR: 15-16 breaths/min is a good start but must be titrated based on blood gases (EtCO2 is only a rough guide).

  • PEEP/FiO2: Titrate FiO2 down to 30-40% ASAP and start with PEEP at 5. Use ARDSnet PEEP/FiO2 combinations to achieve SpO2 88-95%. Do NOT aim for 100% because hyperoxia is deleterious.

  • Safety: Check plateau pressure by sedating and pressing the inspiratory hold button at the end of a breath. Goal is <30. If too high, decrease tidal volume 1 mL/kg. Watch blood gases, increase RR prn, and if the lungs are terribly stiff, allow permissive hypercapnea.

• Obstructive Ventilation Strategy – Asthma and COPD

  • “The best ventilatory strategy in the obstructive patient is to avoid intubation altogether.”

  • “The primary goal of the ventilator strategy for obstructive patients is to allow time to exhale.”

  • Mode: volume-assist control

  • Tidal Volume: 8 mL/kg

  • Flow: He recommends against markedly increasing inspiratory flow beyond the usual 60-80 L/min because it causes high peak pressures, alarms, and has only minimal effect on increasing exhalation time.

  • RR: RR is the key driver to allow time to exhale. 8-10 breaths/min is enough. Simply allow permissive hypercapnea. It will probably happen.

  • PEEP/FiO2: Go low. Shoot for FiO2 40% ASAP. He advocates for PEEP at zero the first few hours, then up to 5 later.

  • Peak pressures: Set limits high enough to deliver 8 mL/kg in full. High peak pressures are due to large airway resistance (i.e. bronchospasm) and are not transmitted to the alveoli. If plateau pressures are >30, reduce RR further if you can.

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Do yourself and your patients a service and click the Read icon below to get the full text of this article and read it for yourself.  It is chock full of pearls on ED vent management you absolutely need to know.  This article is gold as is the EMCrit site on mechanical ventilation.

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Citation

Ann Emerg Med. 2016 Nov;68(5):614-617. doi: 10.1016/j.annemergmed.2016.04.059. Epub 2016 Jun 9.

Managing Initial Mechanical Ventilation in the Emergency Department.

Weingart SD1.

Author information:

1Division of Emergency Critical Care, Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, NY.

PMID: 27289336 [PubMed – in process]