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…

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?

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.

Choosing PEEP Panel Discussion Remix