Obstructive Physiology: Setting up the ventilator for a patient with severe obstructive physiology like asthma or COPD is almost a completely opposite strategy compared to the patient with severe metabolic acidosis. They both have problems with ventilation (removal of carbon dioxide), but for the patient with obstructive disease it takes a very long time to expire due to inflammation and bronchoconstriction. Instead of setting a high respiratory rate to blow off more CO2 like our severe metabolic acidosis patient, here, you want to set a low respiratory rate to give your patient time to empty more effectively....Read More
Before I set up the ventilator, I consider if my patient has one of the following 3 physiologic processes: severe metabolic acidosis, an obstructive process (Asthma or COPD), or refractory hypoxemia. If my patient doesn't fit into one of these 3 categories then I will default to placing them in the refractory hypoxemia category (Part 5), which is simply a lung protective strategy that will be appropriate for patients. In this part we will discuss setting up your ventilator for the patient with a severe metabolic acidosis....Read More
In part 1, we discussed that the ventilator can deliver 3 types of breaths: controlled, assisted or spontaneous breaths. These breaths can be delivered either by a set pressure or a set tidal volume. Then we closed with a discussion of the common ventilator modes, which is simply just combining all these types of breaths together.
There are many aspects to consider in post-intubation management such as hemodynamic variations, analgesia & sedation, confirmation of the correct position of your endotracheal tube, and setting up the ventilator based on your patients physiology. Too often physicians pay little or no attention to how our amazing respiratory therapists set up the ventilator. Respiratory therapists have expertise in setting up, weaning and trouble-shooting the ventilator, but clinicians need to communicate important clinical physiologic information and their goals for their patient on mechanical ventilation. If you don't feel comfortable setting up the ventilator at this point you at the very least need to communicate with your respiratory therapist when the ventilator is being set up....Read More
Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial....Read More