HWN Suggests

“It’s Time to Vent”

Emergency medicine places a heavy emphasis on mastery of any difficult airway, however what happens after your respiratory failure patient is successfully intubated? Ventilator management is also a crucial aspect of ER care; understanding how to optimize mechanical ventilation has been shown to decrease ED mortality, duration of ventilation, and hospital stay. Unfortunately, it’s not uncommon for ER physicians to be flummoxed by an alarming vent. Let’s discuss ventilator basics and some fundamental strategies to approach a crashing patient on the ventilator.

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 Managing Initial Mechanical Ventilation in the Emergency Department

The following recommendations, when not specifically referenced, are based on my practice because there is a dearth of trials analyzing most components of ventilator management.

 Mechanical Ventilation Oversimplified

The ventilator: we’ve all learned about it - the lectures, the bed-side demonstrations on those mind-numbingly long ICU rounds. But we were also told, repeatedly, “Don’t touch it!” Unless you are an attending, fellow, or respiratory therapist (RT) of course. So for a lot of us, the ventilator is a black box, mythical and intimidating. In this blog, I hope to demystify ventilators a little so when duty calls, you can set initial settings and make some basic adjustments

 Simplifying Mechanical Ventilation – Part I: Types of Breaths

Instead of going through all the various modes and learning them individually as most ventilator talks do, let’s try something different. Let’s first learn the 3 possible types of breaths your patient can receive on a ventilator and the 2 ways these breaths can be delivered. If you understand these concepts, then you can deconstruct almost any mode of mechanical ventilation and have a clearer understanding of how to use them. There are many modes that exist, but I suggest you learn a few, get to know them well, and when to apply each to your patient.

Articles of Interest

How to dominate the Ventilator

Two Strategies of Ventilation - Injury This strategy is for patients with lung injury and those prone to lung injury. Essentially this means every intubated patient except those with… Obstruction Use this strategy when patients are in the midst of an Asthma/COPD exacerbation.

An Emergency Guide to Mechanical Ventilation

The purpose of this article is by no means meant to qualify or credential you in the use of a mechanical ventilator. The goal is to provide a basic overview and improve your understanding of a mechanical ventilator in order to increase your comfort level in the event you walk into a home and find that your patient is on a ventilator. It should also be noted that this article in no way endorses or promotes the use of any specific brand of ventilator.

Critical Care Alert: Mechanical Ventilator Protocol

Implementing a LPV protocol in the ED is feasible and associated with improved mortality in ARDS patients.

emDOCs Podcast: Episode 48 – Ventilator Management

Managing the ventilator and ensuring appropriate settings are vital; these have a significant impact on patient outcomes.

Mechanical Ventilation Practices in the ED

Take Home Points - Pay attention to tidal volume. Monitor and maintain plateau pressures < 30 cm H2O.

Podcast 816: Ventilator Management in Asthmatics

The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation.

Taking Ownership of the Ventilator – How to Manage and Troubleshoot

The care of critically ill, mechanically ventilated (MV) patients is essential to the practice of emergency medicine. While emergency physicians are experts at securing even the most difficult airways, much less time is spent on learning the intricacies of mechanical ventilation. Increasing emergency department (ED) boarding time has been associated with negative outcomes.

Vent Management on the Run...

We are starting to see improved technology with our transport ventilators. For instance, the Hamilton T-1 ventilator automatically calculates the cc/kg of IBW if the height and sex of the patient is entered. Many teams will also carry a tape measure or utilize other tools and references to help accurately measure the patient’s height and generate an IBW to use to calculate appropriate tidal volumes.

Ventilator Management of Adult Patients in the Emergency Department

This article reviews the most appropriate ventilator settings for a variety of conditions in intubated adult patients presenting to the emergency department, and gives recommendations on monitoring the ventilated patient and making ventilator adjustments.

Your First Shift in the Unit: Demystifying Ventilator Alarms

The goal of this article will be to review the basic concepts of volume and pressure characteristics in mechanically ventilated patient so that you will be able to interpret variations that trigger alarms. After reviewing the fundamentals, the article will review common causes of triggered ventilator alarms and how to troubleshoot these issues.