APRV & COVID Respiratory Failure with Spiegel & Farkas. #FOAMed, #FOAMcc

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

3 thoughts on “APRV & COVID Respiratory Failure with Spiegel & Farkas. #FOAMed, #FOAMcc

  1. 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?

  2. Michelle Daryanani

    Thank you. This APRV is something we all need to explore. Glad to have different modes available in our toolbox.

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