Good resource/video for ventilator settings?

[as90]

Hi,
I think I am just completely inept to Peak Plateu,PEEP, SIMV, AC, Pressure Control topics, and I need a good visual. Does anyone have any good recommendations? My ICU attending is quite involved with this and he is shocked that the respiratory therapist knows more about this than I do. He makes it a constant point to laugh with nurses at me and I get even more discouraged.

I even have the Marino book but its not good enough.

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[CJack]

No no don't think poorly of yrself, you probs have mad skill. The standard way med school teaches us this stuff (if taught at all) is far from ideal, not usually the most immediately practical hands on applications at yr level (i.e. how to i not kill this patient)

In 3rd year, I found the best sources for stuff like this were often the EM docs. Idk what you're going into, but FOAMed kinda rocks for getting a generally sense of what's new and bubbling up or controversial, a smidge of core content, and not uncommonly, a real solid, practical, break-it-down talk, like this one by Dr. Scott Weingart on Dominating the Vent .

 

[operaman]

I finally learned it by asking every anesthesia resident I worked with. Then I just forced myself to look at and think about the vent settings for every patient of mine. Asked the RTs a lot of questions. Felt like an idiot a LOT. Finally started to figure it out. I'm far from mastery but feel like I have a basic understanding I can build on and could make decisions in a pinch that would be unlikely to kill the patient. There's a lot to it conceptually and there's a lot of terminology and a whole new set of acronyms, so there's a learning curve no matter what you do. Just keep asking questions and trying to get better and accept that you'll still get made fun of. I sure was!

I'm starting another critical care rotation soon and will likely get made fun of again for all the things I've forgotten -- all part of the experience! Feeling like an idiot in the ICU is kinda like being yelled at in the OR: if you don't experience it, you should automatically fail the rotation because you clearly didn't show up.

 

[joeDO2]

I found it helpful to read the chapter on mechanical ventilation in the FCCS textbook. Also take a look at medscape...they have a decent explanation of vent settings.

 

[rwmedic906]

In my former career before medical school, I cant tell you how many times I would tell new employees the most dangerous piece of equipment on our helicopter was the vent. There is a new podcast on the SMACC site about vent management that may be helpful, although I haven't listened to it yet. Ron Wall's "Manual of Emergency Airway Management" has a pretty good section toward the end of the book on basic ventilator management thats easy to understand. I would just try and master some basics like, the difference between peak and plateau pressures, PEEP, and basic modes. The world of ventilator management can get pretty complex so unless you plan on managing vent patients for life, understanding the roles of pressures vs volume ventilation and their effects on different pathologies is probably over kill. Understanding the basic physiologic effects associated with the vent is probably best at this point (i.e. PEEP increases intrathoracic pressures which can decrease B/P, small ETTs should get some pressure support if on any other mode except A/C, etc.) Experience is the greatest teacher with this kind of stuff so you're probably learning a lot more than you think...which in the end is the goal. Good luck!

 

[jdh71]

Hi,
I think I am just completely inept to Peak Plateu,PEEP, SIMV, AC, Pressure Control topics, and I need a good visual. Does anyone have any good recommendations? My ICU attending is quite involved with this and he is shocked that the respiratory therapist knows more about this than I do. He makes it a constant point to laugh with nurses at me and I get even more discouraged.

I even have the Marino book but its not good enough.

He shouldn't be a dick and teach you. And RTs often know as much about a vent as any doc - they run the things.

Maybe a fed key things to remember: in most situations you want a peak pressure less than 40 and a plateau pressure less than 30. Above that you start worrying about giving the patient trauma from the ventilator. As far as modes go you can basically set a pressure or a volume as the independent variable - this will affect the other depending on the mode. Two modes you need to know are "volume control" and "pressure control" - in those modes you set either the volume you deliver or the peak pressure you want. Other modes are more advanced and I won't take time here to explain. You want you tidal volumes in most cases to be 6cc/kg ( I deal body weight for height) and you either dial that in as your volume for volume control or adjust your pressure on pressure control until you can find it. Further nuanced adjustments are beyond the scope of a medical student IMHO. PEEP is just a constant pressure applied to the ventilatory circuit. It's always 5 unless you need more for oxygenation. Times when you decrease the peep below five are outside of medical student need to know. PEEP increases mean airway pressure and by extrapolation mean alveolar pressure and will improve oxygenation. Too much PEEP can interfere with venous return and pulmonary hypertension but you usually need a good amount to see that kind of issue. Increase a patient's minute ventilation for hypercarbia either with rate (your usually choice) or by increasing the volume of each breath.

And that about all I think a medical student really need to know.