Podcast Episode 21: Optimizing Ventilation
The Special Operations Medical Association Podcast on Prolonged Field Care is back with a new episode on a long awaited topic, traumatic ventilation. We were finally able to corner a real, live anesthesiologist who was actually more than happy to sit down and talk about ventilation after his years of experience working at the heads of thousands of patients. This episode starts right off with a difficult scenario discussion that includes a hypovolemic patient with a GSW to the pelvis, RR 35
As they work to get the patient stabilized, Dr. Kopp recommends an end tidal CO2 Capnograph as the single best patient monitor for this situation.
A SAVE2 vent is discussed along with the ARDSnet recommendations for a lung protective vent strategy including the preferred tidal volume of 6-8ml/kg of ideal bodyweight based on patient height. This is to reduce barotrauma and over-ventilation that can lead to other problems. This begins with attempting to match the patients physiologic respiratory rate to prevent acidosis by giving too few breaths.
The beginning Positive End Expiration Pressure (PEEP) recommendation should start somewhere around 5 to keep alveoli open and recruited, prior to increasing oxygen levels if available.
PIP or Peak Inspiratory Pressure or the maximum pressure of each breath which has a default setting of 30 corresponding with the ARDSnet protocol. For an uninjured patient in the Operating Room, Dr. Kopp would start at 20-22 and then titrate from there.
While we are working on an Airway Clinical Practice Guideline with the Joint Trauma System and Army Institute of Surgical Research, this will go along with our earlier posted PFC WG Airway recommendations (April, 14) until we can get a consensus on the CPG and get it published.
Listen here and then test your knowledge with our 5 question quiz below!
Other Airway Resources:
impact 731 ventilator Cheat Sheet
Old Eagle Impact 752 Ventilator Cheat Sheet (Rule of 5s)
Awake Cricothyroidotomy Checklist
Scott Weingart’s Dominating the Ventilator Handout
Something to consider is the excessively large tidal volumes that the adult-sized BVM compared with a pediatric-sized BVM in an adult patient. We found that EMS providers are able to get closer to lung-protective ventilation with a pediatric BVM rather than an adult BVM, median volumes of 663 vs 981 mLs in intubated patients.
http://www.tandfonline.com/doi/abs/10.1080/10903127.2016.1227003?journalCode=ipec20
https://emcrit.org/racc/hemodynamically-neutral-intubation/
A link to a related podcast above, specifically wondering if the vent used in this podcast could support the settings mentioned toward the end of this podcast. Also wondering if Dr. Kopp’s approach, maintaining patients spontaneous respirations, would change in a patient who may be experiencing a pneumo or tension-pneumothorax?
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