Respiratory Physiology with Gary Nieman: The Basis for TCAV(tm) Magic!

So at the last Flipping the Vent course, we had the treat to have guest faculty Dr. Gary Nieman give us a lecture on the basic science and physiology behind the TCAV(TM) method, and it was really fantastic, so I just thought it was worth sharing with everyone.

While no ventilation technique will save every patient with severe lung injury, it is time to forge ahead and take steps towards improving the mortality of ARDS, COVID or otherwise, which has stagnated in the last 15 plus years. While ARMA established that 6 ml/kg was better than 12 ml/kg, it really showed little else. By no means can that data be interpreted as being THE best way to ventilate EACH patient, but only that low VT is better than high VT.

We know that driving pressure correlates with mortality. We know that atelectrauma, more so than volu- or baro-trauma, is the main engine behind VILI. Hence those are the things we should be trying to minimize.

Here is Gary:

Follow the blog for more on resus, POCUS, TCAV and the bleeding edge of acute care!



Flipping the Vent: The APRV-TCAV Course – Next Course May 20th, 2021, 12pm-3pm (Eastern Standard Time).

You must unlearn everything you have learned…

So for me, the first wave (spring 2020 for Montreal) was the early proving grounds for APRV-TCAV in COVID-19 respiratory failure, and now in the second wave, we are fine-tuning the approach. For Rory Spiegel in Washington, the first wave blended smoothly into the second and he has accumulated a ton of COVID APRV TCAV experience. From our experience, steadily growing since last spring, this is the go-to mode for the vast majority of COVID-19 cases requiring mechanical ventilation.

Rory and I have been joined by two other faculty members who are equally passionate about teaching APRV-TCAV, and we will try to get some awesome guest lecturers for each iteration of the course.

Dr. Rory Spiegel, Critical Care & Emergency Medicine, Washington Medical Center, Washington, DC, USA.
Dr. Philippe Rola, Chief of Service, Intensive Care Unit, Santa Cabrini Hospital, Montreal, Canada.
Dr. Benjamin Daxon, Senior Associate Consultant, Associate Program Director, Critical Care Medicine-Anesthesiology Fellowship Department of Anesthesiology & Perioperative Medicine, Mayo Clinic
DRMC EM Residency - Attendings
Dr. Korbin Haycock, Emergency Medicine, Loma Linda University Health Center
Gary F Nieman's lab | State University of New York Upstate Medical  University (SUNY Upstate Medical)
Guest Faculty: Dr. Gary Nieman, Professor, Director, Translational Critical Care Laboratory, Upstate Medical University Department of Surgery

BREAKING NEWS! We are incredibly happy to announce that we will have an amazing guest lecturer for this edition of the APRV-TCAV course, Dr. Gary Nieman, one of the architects of the TCAV methods, and he will be joining us to deliver a lecture on the physiology of the TCAV principles!

At H&R Reloaded, Rory presented “Flipping the Vent,” essentially a conceptual intro to APRV-TCAV, and we ran a small group workshop, which we also did at Haney’s ResusX, which were really enjoyable, and it seems the participants really came away with a lot, but also a lot of questions. So we figured we’d put together a more comprehensive course to give participants a solid base to start using this mode of ventilation.

The first course was essentially held for the Mayo Clinic’s anasthesia/critical care fellows and RTs and included a team from Ireland as well as a handful of individual participants, and was a success. Hence we give it another run!

This course will consist of an online portion (3h core material as well as supplementary material) done at each participant’s convenience, and a live workshop (3h) on the day of the course, but we are adding to the online curriculum, and participants will have ongoing access to the additional material for a year following the course. We are strongly suggesting participants go through at least the core material, because without a reasonable understanding of APRV-TCAV, the workshops will be very difficult to follow and benefit from.

The workshop is the really awesome part of this course, and will mainly feature in-depth case discussions and where we get to the nitty-gritty and review decisions along the course of management of APRV ventilation. This is where the understanding of how to adjust your ventilation as your patient progresses thru different phases of illness, how to escalate or progress to weaning, and how to troubleshoot along the way.

We will finish with an examination to make sure that the concepts have really gotten across.


Coffee or a deep interest in ventilation modes is a must if logging onto this course from Europe – the Q&A piece is in the wee hours!  Attending this course as a group helped us gain confidence to try APRV-TCAV in the difficult to ventilate COVID-19 patient (We have Draeger ventilators but had not used the TCAV version of the mode before with the 75% PEF setting in the “additional settings” part of the vent).  Dr Rola and Dr Spiegel simplified complex concepts. They got us to trouble-shoot problems.  I would recommend this course.” (Dr. Catherine Nix, Anaesthetist-Intensivist)

“Flipping the Vent APRV-TCAV was an excellent introduction to this mode of ventilation, delivered in a practical and useful manner. The rationale is clearly explained at the outset and this is built upon throughout, with discussion around exactly how the ventilator and patient are managed using relevant case scenarios. The expertise of the educators on this course make APRV-TCAV accessible for those unfamiliar with it. I have a better understanding of the practical application of APRV-TCAV having attended this course” Dr Cathal Mac Donncha, Critical Care Fellow.

Registration: due to the rapid sell-out of the last course, we have a long waiting list and we will advise those on it to give them first registration opportunity.

Special Circumstances: we understand that many physicians who may wish to attend and benefit from learning may be in different socio-economic situations, and of registration fee is an issue, please email us at, and we will do our best to accommodate you. Drs. Spiegel and Rola put a high value to knowledge translation and sharing of skills and information.

The Waiting List: please email and let the team you wish to be on the list know in case some spots open up.

Sponsors: we are always looking for sponsors to provide scholarships to physicians or other health care professionals trying to learn. Please contact us if you are able to sponsor one or more!

Schedule (Online module):

Part One – APRV-TCAV Basics (3h) OnLine Module (participants will receive access link with registration)

Core 1: Intro + Physiology

Core 2: Physiological Principles & Literature

Core 3: The Settings

Supplemental: The Low Settings

Supplemental: The Art of the P high

The APRV-TCAV Workshop (3-3.5H)

Part 1: Questions

Part 2: Optimizing & Recruiting (30min)

Part 3: Weaning & Troubleshooting (45min)

Part 4: Exam & Discussion (60min)

With thanks to our sponsors:

COVID-19 Pathophysiology: Are Platelets and Serotonin playing a bigger role than we think? #FOAMed, #FOAMcc

While our general ignorance in medicine has long since stopped surprising me, the COVID-19 pandemic has really highlighted how little we truly know and how unequipped we are to face new diseases. However it has also highlighted an unparalleled degree of collaboration and sharing across the world which has undoubtedly saved many lives.

In this discussion, a very smart and determined friend of mine gives us a masterclass on platelet dysfunction in COVID19 and opens many fascinating potential therapeutic approaches. I think that his outside perspective on the disease – he is a gastroenterologist – gave him a fresh and unbiased approach, and I suspect he is onto something.

Here is the link:

And the passcode: @GJ$7rBs

Since recording this I have had a few more cases where I used ciproheptadine, and must admit there was some apparent benefit. While this cannot be conclusive, I do feel it warrants a trial, given the benign nature of the treatment and the not-so-benign nature of the disease!



Mayo Clinic Critical Care Grand Rounds: Venous Congestion & VExUS. #FOAMed, #FOAMcc

So I was really honoured to have been invited to talk about VExUS for the Mayo Clinic’s CC department. In the last year watching the spread of VExUS has been really rewarding because so far, everyone who has incorporated it into their clinical practice has seen the substantial impact it can have. And it is just the beginning, with exciting new studies in the pipeline and papers about to be published.

Anyhow, the invitation to speak “at” (Zoom of course given that this is COVID times) Mayo represents another step in the spread of precision medicine as applied to venous congestion.

Here is the talk:



H&R Reloaded 2020 Lectures: André Denault and The Fastest Way to Diagnose RV Dysfunction! #FOAMed

Sorry to all for the delay, these last weeks have been busy!  But as promised we are sharing some of the highlights of H&R Reloaded’s lectures, and here is one that should raise a few eyebrows. Andre Denault is one of the few clinicians whose research is groundbreaking, highly clinical and pertinent. Definitely not the kind of research that is done just to show research is being done.

So here Andre brings us something totally new again: Femoral Vein Doppler, which he first presented at H&R Reloaded as The Fastest Way To Diagnose RV Dysfunction!

And here is the paper recently published: Denault Femoral Doppler CCE 2020

More info on our last conference and the link to the rest of the H&R Reloaded lectures can be found here: H&R Reloaded!





The OMI Manifesto: The New Paradigm in Myocardial Infarction – Pendell Meyers. #FOAMed, #HRreloaded

So for all the amazing talks that were had at H&R Reloaded, by far the one that should change the landscape of acute care the most was Pendell’s, that had most participants’ and faculty members’ jaws drop. Not mine of course, because I had seen the pdf of the talk and had a chat with Pendell weeks before, which gave me time to pick it up off the floor.

I grew up in the Q vs Non-Q era, then came the STEMI vs NSTEMI.

It’s time to change.

There will be resistance. There will be inertia. But there’s virtually no way to prevent it. Might as well be ahead of the curve than among the last stragglers still insisting that the ST segment is infaillible.


The OMI Manifesto by Pendell Meyers!




Note that the rest of the H&R Reloaded lectures can be found here: H&R Reloaded OnDemand.








Exploring COVID Theories: Dr. Farid Jalali on 5HT! #FOAMed, #FOAMcc #COVID19

So after chatting a few times, finally got to sit down and discuss Farid’s super interesting theories that certainly seem to tie in many elements of COVID pathology. Just to be clear, this is strictly exploratory and for the purpose of generating discussion and research, and should not form the basis of therapy today, though who knows if it may in the next weeks or days, as several studies are being done around this.

Here is the video!

Here is the audio only:

Please share if you have interesting information around this, and if you are interested, as you heard, Farid has accepted to join in H&R Reloaded’s Virtual Hangout Room on July 31st evening!





Functional Respiratory Imaging: A New Tool? A Chat with Jan De Backer.


Jan de Backer is an aerospace engineer who, in concert with his respirologist father, designed an AI system that, from HRCT, can extract a ton of information about lung parenchymal, airway and vascular structure. With no contrast or anything. Just from a run-of-the-mill CT chest…

In full disclosure, I have (unfortunately!) no connection or interest in Fluidda (  outside of a clinical one.

So I’ve been meaning to speak with Jan whose tweets about functional respiratory imaging (FRI) and the FLUIDDA technology have been really piquing my interest, but its taken me unfortunately too long to do so, but here it is. I think this is fascinating technology, which is currently available to all freely (COVID times and all…), and in my opinion clearly deserves a trial run and some clinical experiences. If you are interested, drop me a line and I will link you up with Jan De Backer.

Here is the vid:


Here is the audio:


So if you are a fan of bedside physiology and personalized medicine, be sure not to miss H&R Reloaded, which will be packed with cutting and bleeding edge talks and faculty – a lot of the stuff we’ve been talking about is not what’s currently being done, or about and I think we just might have to add a talk on FRI…

Bedside Physiology in Septic AKI with Korbin Haycock. #FOAMed, #FOAMcc

So I’ve been meaning to fine tune this concept and really start applying and following more rigorously, so I wanted to see what the only clinician I know of doing it at the bedside was doing in a stepwise fashion.

AKI is one of those things that really, really bugs me. It’s common, it’s serious, impacts mortality in the ICU population, and yet to me, it is usually poorly managed by the vast majority of clinicians, usually by examination of surrogate indices and time-lagging imaging with poor specificity and sensitivity for the actual diagnoses you need to rule in or out, which are pre-renal failure and post-renal failure. With a probe in your hand and a decent understanding of physiology, you can rule both of these categories out in about 30 seconds, add a minute for VEXUS and in a grand total of 90 seconds you are left with either a diagnosis or else  the intrinsic AKI category as the last one standing and it’s time to hunt for offenders.

But that’s not what we’re talking about today, but rather, the fine tuning of macro-hemodynamics in relation to your intra-renal micro-hemodynamics. Fascinating stuff.

Video Link Here!


Audio Only:


Love to hear from anyone trying this!

So you can join us during H&R Reloaded’s Virtual Hangout Room and discuss this and a bunch of other skills or strategies involved in critical care and try to tease out the details from Korbin and the rest of our amazing faculty!





Resus Pet Peeves: The Hemoglobin in Hemorrhagic Shock. #FOAMed

For a little non-COVID #FOAMed, which we still need…

Here’s one that always gets me, that I always try to make sure the residents always understand before they leave our rotation!

I’m pretty sure if you have been fortunate enough to not come across someone doing this, you will – when you do, find a tactful way to share the knowledge!

Oh and don’t forget that H&R Reloaded is on!