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Who wants to discuss this Pearl: Prone Positioning in Severe ARDS? Do you see these benefits in your patients?
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Mechanical ventilation with obstructive pathology. I came across these settings on an intubated asthmatic. Thoughts?
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Pearl of the Week. Let's discuss!
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Danielle Hardy
May 10
Why not utilize fiberoptic? I’ve actually had patients transferred to our facility with issues after bougie-assisted intubations or bougie-assisted exchanges when an exchange catheter wasn’t used 🤷🏻♀️
There’s a lot more technology available now that can help in these situations. Even in our rural areas, local EMS and critical access centers have access to this technology.
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Severe Obstructive Physiology on the Ventilator: Peak Pressure, ASV, and pH Targets
Severe obstructive physiology on the ventilator is an area I’d like to better understand, especially COPD/asthma patients with high airway resistance, prolonged time constants, dynamic hyperinflation, and auto-PEEP.
A lot of great ventilator discussion focuses on ARDS, PEEP, oxygenation, and synchrony, but I’d love to hear more expert thoughts on the obstructive side.
Specifically, how do you approach high peak pressures in these patients? In volume-targeted modes, especially on transport ventilators like the Hamilton T1, there are times where the pressure limit may need to be raised to deliver an appropriate tidal volume when resistance is very high. My understanding is that the key is not peak pressure alone, but whether plateau pressure/driving pressure, delivered tidal volume, expiratory flow return, auto-PEEP, and hemodynamics suggest unsafe alveolar distension or worsening dynamic hyperinflation.
I’m also curious about ASV in obstructive patients. I realize many clinicians consider ASV controversial or often avoid it…
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brian imdieke
May 01
Thank you all for the discussion. This has been very helpful.
One related question I’ve been thinking through is the rate of correction. In transport, we typically trend VBGs when available, especially pH and pCO₂, and we usually emphasize slow correction rather than trying to normalize CO₂ quickly.
For those managing these patients frequently, do you intentionally avoid rapid PaCO₂ correction in acute-on-chronic obstructive patients, even when airway pressures and auto-PEEP are not the limiting issue? I’m thinking specifically about the risk of overcorrecting a chronically compensated patient into post-hypercapnic alkalosis, versus the need to correct dangerous acidemia.
I realize there may not be a specific “optimal rate,” but I’d be interested in how others think about the practical target: correcting the pH enough to improve physiology without chasing a normal PaCO₂.
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How does your facility bridge the Retention Gap?
Do you rely on once-a-year competencies, or have you implemented 'just-in-time' training or bedside coaching to ensure skills don't fade 6 months after the lab?
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gakuhn53
Apr 30
Although not a core competency, I created "Just-in-time" QR codes for less frequently used device setups, such as NO challenges in our Cath lab. Additionally, I have posted some QR codes in the department that link to soft-skills protocols.
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Choosing PEEP Q&A
Take a look at our latest panel discussion and let's talk about it! This is the place where we can continue the discussion. Feel free to post a question, resource or comment.
T-Roy Whitacre
Apr 13
Not many places have access to it yet, but EIT may help determine benefit earlier.
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In cases of ARDS, we have integrated proning our 'Shock Alert' protocol. Proning is consider once ventilator settings have been optimized without sufficient clinical improvement. If the patient remain unstable or fail to improve after proning, we transition to evaluating the patient for ECMO.