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 hospresusconference@gmail.com, 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 hospresusconference@gmail.com 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:

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!