This issue includes 4 hours of ACEP/AMA category 1 CME credit.
Authors: Andrea DeGiorgi, BS, RRT and Michael White, MD Peer Reviewers: Peter DeBlieux, MD, Michael F. Murphy, MD and Scott D. Weingart, MD
Publication Date: August 1, 2008
Excerpt from the issue… You realize that it’s been just a little too quite tonight when the radio suddenly cackles to life: “Teenage girl asthma can’t breathe diaphoretic giving nebs No IV 2-minute ETA.” Within minutes, two medics rush in with a diaphoretic cyanotic girl perched forward on her hands. Her pleading glance catches yours as you watch her take her last voluntary breath intubation is obviously required ventilator management is your concern since you realize her life depends on it
As you resuscitate the crashing asthmatic, your 60-year-old male patient on the other side of the curtain, who has been sleeping comfortably, begins to complain that his breathing is getting worse. He is a frequent flyer with a known history of bad emphysema and a worse attitude. He adamantly refuses ‘the mask’ ventilation. You think back about his chest x-ray, which showed extensive bilateral pulmonary infiltrates, and wonder how long your luck can hold up before you need to intervene with him. His voice and attitude sound oddly weak, but you remember that the last time he was intubated he developed a pneumothorax.
Conclustion of the above case study... Case #1: You intubate the young asthmatic and start her on pressure control ventilation. She is adequately sedated and paralyzed as you obtain your initial settings. Because of severe obstruction and prolonged expiratory phase, you have the following settings: FIO2 100% and PCAC to achieve target tidal volume of 400 mL. The inspiratory occlusion maneuver reveals an acceptable plateau pressure of 27 cm H2O. After initial PEEP of 5, the P-flex suggests you set the PEEP at 8 cm H2O. The patient is adequately sedated with ketamine and morphine and therefore tolerates a respiratory rate of 6 breaths per minute and a short inspiratory time with a prolonged expiratory time. With these settings, you get an ABG of pH 7.28, PaO2 85, and PaCO2 of 110. The nurses are uncomfortable and ask to increase the respiratory rate and oxygen. Instead, you recognize the role of permissive hypercapnia and lung protective strategies. The whistling of the continuous nebs comforts you as you arrange an ICU admission.
Case #2: Your frail COPD patient deteriorated soon after you stabilized the asthmatic. You wondered if this man would ever come off the vent as you deftly slid the 8.0 ETT through the cords. After airway stabilization, you set your ventilator as follows: PCAC, FIO2 100%, PIP 22 (corresponds to volumes between 600 cc and 800 cc), PEEP 14 (based on P-flex), sedated with midazolam drips and morphine, short inspiratory time with a prolonged expiratory time, and a respiratory rate of 8. This gives you an ABG of pH 7.40, PaO2 170, and PaCO2 of 30. You ask the respiratory therapist to reduce the FIO2 based on the oxygenation pleth (there is a good wave) and to reduce the PIP. She remarks that the plateau pressures are already below 30, but you explain that the corresponding volumes are a bit too large for a 60 kg man.
About this issue: The goal of this Emergency Medicine Practice issue is to provide an overview of mechanical ventilation in the acute care setting. Basic ventilator technology will be discussed and placed in the context of various disease pathophysiologies with a focus on asthma, emphysema, and acute pulmonary edema.
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