So at our last webinar (still to be edited due to an unfortunate trolling event), we briefly touched on modes of ventilation but really didn’t delve into it very deeply, so, being fortunate enough to know some really smart people, I figured I might gather up these two for a quick chat. They are both known for no-nonsense, out-of-the-box thinking, paired with solid physiological thinking, which in my mind is the only way to approach complex problems and system failure. Plus, with Rory (@EMnerd) and his powerful nihilistic approach, there would be no chance for a whimsical approach, it would have to have a base in physiology, evidence (bedside or literature) or both!
So just as a little brain teaser, I would like anyone reading to think about how many severe respiratory failure syndromes they are aware of that attack the lungs in a predictable volumetric fashion, where one can say, for instance, that consistently, X% of the parenchyma is affected. Kinda hard, huh? Yet, if asked how best to ventilate these patients, most of us who feel we have a good grasp of severe respiratory failure would answer without thinking twice: “lung protective ventilation: good peep and 4-6 ml/kg.” In a lear, confident tone, most likely as well.
Now I would say that only the first part is correct: lung protective ventilation. As to the second part, it would, to me, only hold true with uniform pathology and uniform patients. But I’ll let Rory rant about that himself, it’s far more entertaining!
So here is our chat.
Hope everyone gets something out of it!
cheers
Philippe
thinking critical care 
Absolutely awesome! Yes, it was THIS that I needed from the previous webinar. Thx for bringing these guys together again. Lots of good info – so much so that I had to listen to it twice! I suggest people listen to this after U have digested EMCRIT’s two episodes on APRV (which includes the one with Habashi).
Hey guys great stuff! Thank you so much. Currenlty using APRV only in a neuro ICU. Agree that sometimes a traditional approach can lead to slower weans and we can lose track of the iatrogenic injuries prolonged ventilation can cause in patients that are weanable by focusing on maintaining and protecting FRC…a forest from the trees problem. Was hoping Rory could comment on his use of higher end expiratory flow percentages approach to Phigh drops. Makes sense to avoid drops in MAP and derecruitment. Specifically how long after the drop do you recalculate your EEF to 75% after they prove they handled the drop with a higher EEF or do you at all? Additionally how are you empirically changing your T low to do this?
Thank you. This APRV is something we all need to explore. Glad to have different modes available in our toolbox.
Thanks for the discussion. As a Respiratory Therapist I’ve used APRV with great success in SICU. However, the MICU side of the house won’t even touch the subject.
Thanks Gerardo. Sadly, that is because of ignorance and the reluctance to adapt one’s understanding of respiratory physiology to the evidence (funky mri, stress risers, etc) and stick to the conventional balloon on a stick combined with one size tried to fit all RCTs. Only education and dedication can improve this. IMO we routinely get away with crappy ventilation because patients heal faster than said ventilation damages their lungs. I APRV-TCAV or CPAP all but the completely healthy lungs (eg overdose, postop). Keep spreading the word!
I really appreciate your reply. I’ll continue to educated and spread the word. Thank you and be safe.