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#1 SerendepitySaki

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Posted 26 March 2011 - 05:30 PM

Hi Guys,

This is probable not the right thread to start this discussion, but the CCT Experts are here
to take a stab at this..Sean knows me..so I hope everyone understands that this is common problem
that CCT are confronted with.

We are often confronted with Transporting an ICU patient that is on "APRV", and has probable DX of Acute Lung Injury.

They are usually not sedated enough and are actually fighting the vent to a certain degree.

The Transport VENT is an LTV or one of the other ones which CANNOT do APRV..

What is the best Methodology to use at bedside, in placing the patient on the TRANSPORT Vent.?

What ALTERNATIVE mode would you attempt to try th patient on. while still in the ICU?

What THOUGHT process would go into the PLANNING for this particular patient?.

I hope to get everyone involved in this discussion, since one of the purposes of FlightWeb has
been to help share experiences and share EXPERIENTIAL knowledge. (smile)

Thank you

Jkihl
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#2 FloridaMedic

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Posted 26 March 2011 - 06:49 PM

Did you read this thread?

http://www.flightweb...RV&fromsearch=1

I doubt if anyone wants me to retype my lengthy posts again but if you see something you want clarified, let me know or anyone who did some quality posts.

You have to understand what APRV is. This should not be totally experimental since the LTV, transport and APRV have been around for several years. It is a mode used when a patient needs particularly high PEEP and maintain a decent MAP, but whom we do not want to keep paralyzed. The patient will also require a higher flow demand. But, even the LTV may not be able to achieve that so you may have to rething your pharmacology and even consider paralyzing the patient. Also try to make contact with the RN and RRT at the hospital prior to your arrival (we may want to know this before we depart so we can just bring the Servo-i) so they can attempt to "normalize" their tricked out ICU vent into something that resembles the LTV. Some may even put the patient on the LTV for you or have had the patient on the LTV for internal transports and will know what to expect.
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#3 jkihl

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Posted 26 March 2011 - 11:32 PM

Florida Medic,


Thank you for the reply..just for my own info..since I am just starting to know everyone..

You are an RRT are you not?..just from reading your prior posts, you seem to have the experience
you could only gain from being an RRT in Critical Care.

One of the Chronic problems in FightWeb is when someone new like me comes along and you guys have
already addressed a clinical issue, in the past..there seems like there is no mechanism to Search
an index perhaps for the subject.

Perhaps our Resident "CCT Transport Advisor/Educator", (hint Sean) could pmail Rollie and come up with an
idea to index these threads according to subject area..but that is another project.

I will Read the thread and then come back here..Thank you in Advance,

jkihl
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#4 FloridaMedic

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Posted 27 March 2011 - 02:13 AM

Apologies to you jkihl. I didn't mean to sound rude to you but the other thread was still fresh in my memory. I also know the search function on this forum can be a little difficult at times which is why I posted the link.

It is extremely refreshing to see a new member who I hope enjoys education and learning since you know Sean.. After engaging another rather exhausting "don't need no education, can get by on patches and a few things learned on the street (unfortunately, the experience is no longer the same as it was 20 years ago)....
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#5 jkihl

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Posted 27 March 2011 - 05:03 AM

Did you read this thread?

http://www.flightweb...RV&fromsearch=1

I doubt if anyone wants me to retype my lengthy posts again but if you see something you want clarified, let me know or anyone who did some quality posts.

You have to understand what APRV is. This should not be totally experimental since the LTV, transport and APRV have been around for several years. It is a mode used when a patient needs particularly high PEEP and maintain a decent MAP, but whom we do not want to keep paralyzed. The patient will also require a higher flow demand. But, even the LTV may not be able to achieve that so you may have to rething your pharmacology and even consider paralyzing the patient. Also try to make contact with the RN and RRT at the hospital prior to your arrival (we may want to know this before we depart so we can just bring the Servo-i) so they can attempt to "normalize" their tricked out ICU vent into something that resembles the LTV. Some may even put the patient on the LTV for you or have had the patient on the LTV for internal transports and will know what to expect.


Florida Medic..

Some of your Rationale, in contacting the SENDING UNIT prior to our ARRIVAL is exactly what I was trying to
Elicit in the other "Thread", on "STANDARD ORDER SETS". that NO ONE has responded to in the General area. I was hoping to have more input, but perhaps they did not understand my intent. Faxing a pre-designed communication tool, to the ICU staff with our Medical Directors Guidelines attached is IMHO a good way to collaborate ahead of our arrival..if that can be done. I wanted to see of other CCT have done such a thing.

I NEVER switch a patient over to our transport vent without asking that the RRT be at bedside, during the
20 min trial period which I always do, to make sure the patient will tolerate our vent and any changes
we need to make.

John Kihl
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#6 jkihl

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Posted 27 March 2011 - 05:20 AM

Florida Medic,

I re-Read that Thread and yes I had seen that one before..Some of these questions are what
we were addressing during our Vent Workshop. Sean will like to jump in hear, what assessment
tools do you think are important to evaluate and in what particular order, if you were educating
an experienced CCT? in Patient hand-over for a Patient that was on APRV.

We need to make a few assumptions here for academic reasons, but this could be the basis for a
good education program based on Case evaluations.

Sean has talked about doing this in the past.. and it could be fine tuned to the type of Transport
Ventilator that is being used. (in regards to the Case presentation)so the CCT would of course have
to be very well versed in the pro/cons of their vent and its limitations.

I am hoping that the other CCT people will join in this information exchange

Once again, Thank you for your participation

jkihl
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#7 SerendepitySaki

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Posted 27 March 2011 - 07:11 PM

1. agree very much w/ your idea for standard order sets (which, of course, would also allow for free text entry, not only just for additional Rx, but also for anything the sending wanted to communicate directly to the flight team) even when working in the hospitals, if they don't already have them, i push for post-op standard Rx sets, especially if there is a large fellow/resident/etc pool and/or multiple services... bottom line, the more people in the mix, the greater the opportunity for miscommunication... IMHO, standard Rx sets can help alleviate some of that crosstalk, and are a best practice tool for patient centered care....

2. love the 20 minute trial...what are you guys doing blood gas wise?

3. as i mentioned earlier in the case studies forum, running and gunning a lot over the next few weeks... calling me or e-mailing me with your ideas is the best way to facilitate a dialog...
and again, i'm just some geeky guy...nothing special with me....
plenty of folks on here have forgotten more than i'll ever know.... i will definitely give the unit APRV to transport vent standard order set, etc due consideration.... BUT, would very much like to see other folks line-item inputs (and for other "ICU" modes, as well)

4. i try and do as much as possible from a case based perspective... also try and address SPECIFIC equipment/formulary/protocols within the context of those cases... Scenario Based Training with YOUR equipment is the ONLY way to go.... the more you bleed in training, the less you bleed on the battlefield....PERIOD.
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#8 jkihl

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Posted 27 March 2011 - 11:28 PM

1. agree very much w/ your idea for standard order sets (which, of course, would also allow for free text entry, not only just for additional Rx, but also for anything the sending wanted to communicate directly to the flight team) even when working in the hospitals, if they don't already have them, i push for post-op standard Rx sets, especially if there is a large fellow/resident/etc pool and/or multiple services... bottom line, the more people in the mix, the greater the opportunity for miscommunication... IMHO, standard Rx sets can help alleviate some of that crosstalk, and are a best practice tool for patient centered care....

2. love the 20 minute trial...what are you guys doing blood gas wise?

3. as i mentioned earlier in the case studies forum, running and gunning a lot over the next few weeks... calling me or e-mailing me with your ideas is the best way to facilitate a dialog...
and again, i'm just some geeky guy...nothing special with me....
plenty of folks on here have forgotten more than i'll ever know.... i will definitely give the unit APRV to transport vent standard order set, etc due consideration.... BUT, would very much like to see other folks line-item inputs (and for other "ICU" modes, as well)

4. i try and do as much as possible from a case based perspective... also try and address SPECIFIC equipment/formulary/protocols within the context of those cases... Scenario Based Training with YOUR equipment is the ONLY way to go.... the more you bleed in training, the less you bleed on the battlefield....PERIOD.

Sean..

The 20 minute Trial with the Unit RRT at the bedside..(that person knows the Patient, best IMHO from an RC standpoint)and can also make recommendations to the Flight Crew on Vent changes for the Transport Vent.

What would be GREAT..and we Have some excellent people here in this forum who could help to make this work..But I am not sure where in the ON-Line world it would be best to do this..Your last statement on Scenario Based Training..
Perhaps we could get the Clinical Reps from each Vent MFG to participate in an effort to be involved in an on-line, Patient centered effort for CCT training...Like you organized in NC..that would assist with Their products. The
Services that have that particular VENT would then focus their people on the particular scenario's that company
uses and the Clinical reps for that VENT with assist the participants of the case on their products..

BUT the Training would focus around the VENT..that the service uses and we could employ some of the fancy Vent simulators, in the case Scenario's

That would be the first step..

Now I know this would be some work..but it would be a WIN-WIN for everyone if you think about it..it would give
the REPS feedback on their products from REAL world providers. The reps could take the feedback back to their companies R&D for further follow up.

Would allow for Collaboration with other educators in the CCT field..and give other providers an overview of the other vents out their..

We could get some of the other players in RSI and Sedation involved with this discussion..

This has been done by other Special groups in the past..Perhaps getting the RC group who have experience in doing
distant education involved would be a first step.

We would have to have moderators watch things in this particular area..and focus on what the intent is EDUCATION..and to promote SAFETY,TRANSPORT PROFESSIONALISM..

We CANNOT have Personal ATTACKS etc..or people putting any particular product down..BUT stating in a professional way which products have limits etc..from a CLINICAL Sense..

This is the way Motorola and the Cell Device Companies..do..if they want to complain..then private mail or take it
to another venue..

Thank you for all assistance in this area..

jkihl
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#9 jkihl

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Posted 27 March 2011 - 11:38 PM

1. agree very much w/ your idea for standard order sets (which, of course, would also allow for free text entry, not only just for additional Rx, but also for anything the sending wanted to communicate directly to the flight team) even when working in the hospitals, if they don't already have them, i push for post-op standard Rx sets, especially if there is a large fellow/resident/etc pool and/or multiple services... bottom line, the more people in the mix, the greater the opportunity for miscommunication... IMHO, standard Rx sets can help alleviate some of that crosstalk, and are a best practice tool for patient centered care....

2. love the 20 minute trial...what are you guys doing blood gas wise?

3. as i mentioned earlier in the case studies forum, running and gunning a lot over the next few weeks... calling me or e-mailing me with your ideas is the best way to facilitate a dialog...
and again, i'm just some geeky guy...nothing special with me....
plenty of folks on here have forgotten more than i'll ever know.... i will definitely give the unit APRV to transport vent standard order set, etc due consideration.... BUT, would very much like to see other folks line-item inputs (and for other "ICU" modes, as well)

4. i try and do as much as possible from a case based perspective... also try and address SPECIFIC equipment/formulary/protocols within the context of those cases... Scenario Based Training with YOUR equipment is the ONLY way to go.... the more you bleed in training, the less you bleed on the battlefield....PERIOD.

Sean..

The 20 minute Trial with the Unit RRT at the bedside..(that person knows the Patient, best IMHO from an RC standpoint)and can also make recommendations to the Flight Crew on Vent changes for the Transport Vent.

In regards to ABGs would depend on how critical the patient is..I like to see ABG done at least in the prior 8 hours and definite if their were any vent changes, that affected conditions...if anyone else has a different viewpoint Please share...

What would be GREAT..and we Have some excellent people here in this forum who could help to make this work..But I am not sure where in the ON-Line world it would be best to do this..Your last statement on Scenario Based Training..
Perhaps we could get the Clinical Reps from each Vent MFG to participate in an effort to be involved in an on-line, Patient centered effort for CCT training...Like you organized in NC..that would assist with Their products. The
Services that have that particular VENT would then focus their people on the particular scenario's that company
uses and the Clinical reps for that VENT with assist the participants of the case on their products..

BUT the Training would focus around the VENT..that the service uses and we could employ some of the fancy Vent simulators, in the case Scenario's

That would be the first step..

Now I know this would be some work..but it would be a WIN-WIN for everyone if you think about it..it would give
the REPS feedback on their products from REAL world providers. The reps could take the feedback back to their companies R&D for further follow up.

Would allow for Collaboration with other educators in the CCT field..and give other providers an overview of the other vents out their..

We could get some of the other players in RSI and Sedation involved with this discussion..

This has been done by other Special groups in the past..Perhaps getting the RC group who have experience in doing
distant education involved would be a first step.

We would have to have moderators watch things in this particular area..and focus on what the intent is EDUCATION..and to promote SAFETY,TRANSPORT PROFESSIONALISM..

We CANNOT have Personal ATTACKS etc..or people putting any particular product down..BUT stating in a professional way which products have limits etc..from a CLINICAL Sense..

This is the way Motorola and the Cell Device Companies..do..if they want to complain..then private mail or take it
to another venue..

Thank you for all assistance in this area..

jkihl
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#10 SerendepitySaki

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Posted 29 March 2011 - 12:46 AM

are you getting a blood gas during/after the 20 minute trial?
do you carry iStats?
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#11 jkihl

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Posted 29 March 2011 - 04:27 AM

are you getting a blood gas during/after the 20 minute trial?
do you carry iStats?


No Sean, Unfortunately..just hooking up the EtCo2 and pulse ox..most places are just
putting up with us doing this trial..BUT if it looks like we are getting into a problem
then most places do not have a problem with us obtaining ABG..

Their are many places that will only obtain an ABG is they have done a change themselves..

I usually like to have one within the last 8 hours if they have not done one..then I usually
ask that they get one..but it is dependent on how cooperate they are..(the Sending Unit)

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#12 old school

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Posted 29 March 2011 - 05:05 AM

jkihl,


Your question is an excellent one. "How do you mimic APRV/HFOV with an LTV?" comes up pretty regularly in the CCT/HEMS community. And unfortunately, there is no straightforward answer...

Asking that is kind of like asking "the patient is on neosynephrine but we can't use that in transport for some reason....so what else can we use?". The answer depends on many factors. What is the actual problem, do they really need a pressor or an inotrope, what else was tried, could they use volume or PRBC's, etc...

Assuming everything else was tried and the only mode they will oxygenate on is APRV and all you have is an LTV, then quite frankly, you are in a bit of a pickle....

The best you can do is what you are already doing: consult with the referring RRT and intensivist, talk to med control, do a nice long trial, and hope for the best. Paralyzing and using inverse ratios or high PEEPS might get you by with a short transport. You may have to add dopamine if they aren't already on a pressor or inotrope. But as you know there are many factors to consider. If it's a long transport, then it might have to wait until they've stabilized a little.

The bottom line is, that there really is no protocol to recommend for switching from APRV to a conventional mode for transport. You just have to thoroughly understand your options, consider the big picture, and consult with experts if possible.

I work with a couple of excellent RRT's who actually kind of specialize in this very area. They use a Servo i (which does APRV) during these types of transports, but they can probably give you better advice than anyone on what to consider if you have to switch from APRV or HFOV to a conventional mode. I can put you in touch with them if you PM me. Dave Garrard is an excellent source as well - either Sean or I can help you get a hold of him.
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#13 FloridaMedic

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Posted 29 March 2011 - 01:19 PM

SerendepitySaki,

Have you been following the AARC Transport section discussion on teaching non-RRTs?

While RTs are usually very helpful in getting a patient moved to the Paramedics ventilator, there have been times when the something goes very bad in transport and the Paramedics step back saying "they weren't the ones setting up the vent". The same with the RNs/RTs assisting with the medications and IABP.

Since you are now teaching ventilators, what are your concerns? There's a lot of misinformation being presented to those who don't have the foundation and a lot of room for misinterpretation of the general principles taught. This especially occurs when some instructors start over simplifying the material or get cause up in "settings or numbers" when explanations require more time than allowed.
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#14 SerendepitySaki

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Posted 29 March 2011 - 03:42 PM

i have indeed been following that thread with great interest. (I subscribe to transport and neo/pedi and STRONGLY recommend AARC membership to ANYone reading this thread!!!!)

and i very much shy away from the idea that i am teaching vents...maybe i'm splitting hairs, but as my background is more in physiology and basic engineering than respiratory therapy, my material primarily concentrates on approaching from those areas...

basic theory, physics(delta P, gas laws, flow, etc),
physiology (compliance,etc)
patho(age and disease related changes in compliance, etc),
ABGs, capno/pleths, etc
with a little pharm and cert review thrown in...

very very much concur with your assessments of the potential pitfalls, and approach with due caution...very much a work in progress and am very careful to walk that tightrope of not dumbing things down, while not overreaching...truly a challenge.

had seriously thought about shooting you material for input...

as for David Garrard, Old School, you have mail.
(and Jkihl is very familiar with him.)

But, I am familiar with some of the brains you're referring to picking,.... without naming names, perhaps they would like to chime in behind the scenes?
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#15 old school

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Posted 29 March 2011 - 04:29 PM

There's a lot of misinformation being presented to those who don't have the foundation and a lot of room for misinterpretation of the general principles taught. This especially occurs when some instructors start over simplifying the material or get cause up in "settings or numbers" when explanations require more time than allowed.


The above statement is the most important thing to keep in mind.

APRV is an advanced and complex mode, and patients who are on it are very sick and are usually hemodynamically fragile. That is why there's no "best mode" to automatically switch to. Managing these patients takes true expertise. It's like taking a patient requiring high doses of dopamine, and turning the dopamine off for transport....it may be appropriate, but there's no generic protocol for what to do in that situation. You just need to really know what you are doing and really understand whats going on and what the alternatives are.

That type of knowledge only comes with experience, which is why my personal opinion is that these transports really should have an RRT. And it may simply not be possible to do the transport with an LTV.
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#16 SerendepitySaki

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Posted 29 March 2011 - 04:59 PM

i concur 110%... the majority of my ICU pts have been too sick and unstable to transport and true APRV "dependence" is just one more example....

sometimes, there can be no 1/2 ways or "fudging" it... and there are NO absolutes...one pt's transport solution to coming off APRV may not be appropriate to another....

only absolute is to actually understand what is going on with that unique pt and to use the right tool w/ the RIGHT skilled clinician for the job...

and as we have discussed multiple times, the doctor wanting the patient gone does NOT always constitute medical necessity or necessarily what it is best for the patient.... multiple checks in place, but the buck stops with the transport clinician...

pt advocacy first and foremost, it is truly a sacred obligation.....
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#17 jkihl

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Posted 29 March 2011 - 07:56 PM

have indeed been following that thread with great interest. (I subscribe to transport and neo/pedi and STRONGLY recommend AARC membership to ANYone reading this thread!!!!)

''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

Sean,

I went out and DID exactly what you suggested...NOW you have to have READ that THREAD to appreciate my following
comments.

I Consider myself in Learning and EDUCATION MODE ALL THE TIME..because I CARE..about the clients and Patients
that I transport. I have been very HUMBLED by each one of my experiences..and I can say that the people who
have Responded to me in this thread CARE just as much and are true "PROFESSIONAL TRANSPORT CLINICIANS", no matter
what hat they wear.(RRT,RN,EMT-P) with that being SAID..WE STILL ARE CONFRONTED WITH these CLINICAL TRANSPORT issues
in the critical care area.,weather we are the IDEAL practitioner or not.s

IN DEPTH EDUCATION, seems to be the only common denominator that we have in this business.

First let me say "THANK YOU", to OLD SCHOOL and FLORIDA MEDIC..for not being just Lurkers and Just reading as many of
the very experienced practitioners, who hang out here do..I mean on offense in that statement, and may not be political correct.(smile)

READING that Tread in the AARC Transport section, points out a great many issues, in exactly what we have to deal with in the CCT Area.

One of the GIFTS that was given to me..and SEAN you have seen this..is to bring the RIGHT people together to solve
common problems..

I am not sure if I am able to do that in this setting..but will make an effort..for the BENEFIT of our CRITICAL CARE
PATIENTS and CLIENTS.

THIS is NOT going to happen over nite..everyone has LIMITED TIME..and only have so much to give..BUT I THANK YOU to
what TIME, those EXPERIENCED CLINICIANS can GIVE.

I thank the RRT community is off to a good start with their own TRANSPORT SECTION. and maybe we should have a CROSS LINK of some sort between that in this effort..

I am open to IDEAS in this area.

I PERSONAL KNOW some of these dynamic Practitioners and will approach them in the coming weeks to help to address the Education issues..

PLEASE STEER ME IN THE PROPER DIRECTION, I WILL NOT BE OFFENDED if anyone feels that EDUCATION is our only VENUE to address some of these bedside CCT issues in regards to VENT management.

Thank you,

jkihl
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#18 jkihl

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Posted 29 March 2011 - 11:42 PM

Florida Medic,

Also with these type of patients, it makes the graphic package which is available
as an add on to the LTV also needed..and Not all transport vents have that option.

The Education on how to view the flow patterns and Graphics is NOT standard

Critical Care Transport education, but does provide a great deal of information on

how your patient is tolerating changes..IE Altitude/Stressors of Flight etc.

jkihl
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#19 FloridaMedic

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Posted 30 March 2011 - 01:08 AM

I would NOT even consider tranaporting some of the critical patients without a monitor. But, few understand the waveforms and even those on the ETCO2 are not fully understood and under used. Even understanding the numbers on the ETCO2 as they pertain to the patient condition with some saying "don't correlate" and disregard them as being useful.

APRV is not always the scariest situation. The patients who already have had to be paralyzed and maxed on drips on a high PEEP ARDS protocol (and paralyzed in HFOV) are extremely difficult. At least with APRV you still have Diprivan or whatever serious sedation along with paralytics to try. I also would not consider IRV unless the patient could afford the pneumos and you have a very, very reliable monitor and ventilaor. APRV mimics IRV but without the paralytics and spontaneous breathing with PSV allowed on top of the PEEP 1 & 2 levels by way of an active exhalation valve. Essentially we have started exercising the patient while on high levels of pressure. If the patient wears out, we must find something else they will tolerate which might be going back to a high PEEP ARDS protocol with acceptable VTs on VAC or PCV and adequate rate and PEEP. For HFOV, we will look at the MAP and try to get within 3 to 5 cmH2O of it since 3 - 5 above conventional MAP is where we start. Too many get caught up on matching PIP without understanding how flow is obtained on the newer ICU ventilators and rate without understanding the flow capabilities of their machine. For ARDS protocols with high PEEP and rate, you must have enough flow to not go cause inadvertent IRV and must monitor for significant air trapping. Again, a graphic monitor is useful.

Even if a transport ventilator is capable of doing APRV, is it the best mode for the patient in transport. Using the Servo-i, we may sedate and/or paralyze to reduce the stress of the transport. If the patient is stressed and starts reducing VT and overbreathing a decent comfort level, more harm may be done. Some also have attempted to use PSV in an attempt to imitate APRV which is a not appropriate for several reasons and demonstrates a lack of understanding of the spontaneous modes and the many options for each mode especially on an ICU ventilator. Depending on the transport ventilator and the patient, placing a patient on PSV from an ICU ventilator may not even be considered depending on the difficulty we have had finding the right % for sloping the flow and termination. Not many clinicians have even attempted to explore the options on the LTV hidden menu. Although, during a transport may not be the time to try. I have also seen some have a difficult time understanding how to allow a patient talk while on a home or subacute transport. Many have never heard of such a thing. Sometimes it is not only the really sick patients that can present with different or challenging situations.

The more difficult problems will be having a ventilator with a good graphics program to meet flow demand and a suitable PEEP valve.
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#20 FloridaMedic

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Posted 30 March 2011 - 01:31 AM

Now for another issue you might want to add to your list of questions when confirming a transport. What is the liter flow of that nasal cannula? 50? High Flow NC has now become so common it is even on med-surg floors. HFNC can be anywhere from 8 - 70 liters per minute. Some hospitals end up with a BLS crew or an unsuspecting ALS Paramedic who is trying to figure out how many O2 tanks.


Usually it is just understanding the pathophysiology or reasons behind the need for this device. Sometimes it is patient confort for those who don't tolerate BiPAP. Several pulmonary hypertension patients will be on HFNC with or without nitric oxide. Some prefer to take their own nebulized while waiting for another acute situation to resolve. Rarely will intubation resolve the hypoxemis if some of you are thinking you would just tube an awake and alert patient who is otherwise not in extreme distress. This is a situation where the appropriate team with nitric oxide or some nebulized prostacyclin or pulmonary vasodilator.

For other education, I recommend watching the AAP website for conferences such at this to network with pedi/neo professionals.
http://www.aap.org/s...ochure-2010.pdf
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