Non-Invasive Estimation of Optimal PEEP

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Non-Invasive Estimation of Optimal PEEP

As a general rule, mechanical ventilation of obese patients is more complex and difficult than in those with a normal body habitus. Obese patients have decreased chest wall compliance due to increased truncal adiposity, amongst other factors. They are also predisposed to other comorbidities that can lead to more involved physiologic challenges.

Critical Care Transport teams commonly transport patients who are intubated and mechanically ventilated. These patients are intubated for a variety of reasons, from altered mental status to hypercapnea to hypoxia. One of the more common challenges we face in our patients who are mechanically ventilated is difficulty with oxygenation – whether the patient is suffering primary or secondary hypoxemic respiratory failure.

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Ventilator Management Simulation Debriefing

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Ventilator Management Simulation Debriefing

Case 1 - "Bucking the Vent"

You have inherited a patient in the VA MICU at signout.  The patient presented with spontaneous bacterial peritonitis and altered mental status and was intubated for airway protection and hypoxic/hypercarbic respiratory failure.  The patient’s altered mental status has resolved but the patient remains intubated waiting for a second large-volume paracentesis that can’t be done over the long weekend at the VA. The RT calls you asking for a one time dose of 5mg Versed, but on a quick glance at the chart, the patient has been getting these Q2 hours for the last several days.  You go to the bedside and find an agitated patient motioning to take out the tube.  “He’s bucking the vent doc!”

Vent settings: AC-VC: TV500  RR12  PEEP8  FiO2 30%

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PEEP PEEP PEEP

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PEEP PEEP PEEP

Ventilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting.   There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here).  Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.

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Sepsis in the Air

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Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

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