Airway pressure release ventilation

We are already seeing severe ARDS from these patients infected with COVID-19. There's discussion out there regarding VV-ECMO, proning, and numerous other strategies to help oxygenate and ventilate our patients. There are numerous different modes on the ventilator to help us achieve these goals but I have found none to be more polarizing than airway pressure release ventilation which is also called APRV. On the Servo vents this is called BiVent (just adding to the confusion of terminology).

Since we are in the process of contemplating providing our patients with anti-retrovirals and anti-malarial drugs, I feel that some of us should reach out of our comfort zone and familiarize ourselves with APRV. If I'm being completely honest, I haven't needed this mode of ventilation much since fellowship. I haven't had many patients in whom I have had such a hard time oxygenating them where I have to reach for this mode. I tend to paralyze patients which is definitely NOT recommended in patients with APRV therefore ameliorating the benefit. I am aware of the PETAL study (Early Neuromuscular Blockage in the ARDS, NEJM 5/2019) which did not show a benefit to paralytics, by the way. My experience is therefore limited, thankfully for my patients who haven't needed me to venture down this road.

The data for APRV is not the most robust, but this recently published review this month contains some great tables and recommendations including the indications and contraindications for APRV, how to set up the vent to initiate APRV, how to troubleshoot the vent depending on the different physiological derangements (I find hypercapnia to be the most common of these personally), and lastly how to wean the vent. I feel the authors did a great job and definitely a good resource to have in your article collection. Stay safe everyone!

A hat tip to the authors.

-EJ

Link to Abstract

Link to FULL FREE ARTICLE

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Prone Positioning for ARDS

I am a huge fan of proning patients who are in ARDS. At one point or another I'll cover the data behind proning like the PROSEVA trial (no time today or until at least June). There are a variety of ways to prone patients which reflect the disposable income of the facilities where you work and train. At the 3 institutions were I have worked and the others where I have done moonlighting shifts, we've all used some good ol' fashioned muscles and coordination.

The PDF quoted and linked here was published in December 2019 and is usually very key during flu season. I am not going to comment about the coronavirus but these patients are developing an ARDS-like syndrome where proning may work. I haven't seen any data, though. That being said, having the ability to prone patients and do it well could potentially save lives.

In the paper, they cover pretty much everything I would want them to in a document like this that's beneficial to all. They even discuss chest compressions and defibrillation in these patients, something we all fear.

The PDF is completely free and a direct link. I need to find out the citation for this bad boy. The authors did a great job and a big hat tip to them. There's a really nice safety checklist and nursing checklist included. 

How do you all prone at your institution?

Do you not prone at your shop because of fear of the tube coming out?

Have you ever had to perform CPR on a proned patient?




Link to FULL FREE GUIDELINES


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Spontaneous Breathing Trials: How Does Your Shop Handle This?

There has been quite a bit of variation regarding pressure support trials, spontaneous breathing trials, liberation trials, whatever you want to call it.
I recently looked at the data for my academic curiosity and would like your input as to how you do it at your shop. I’d like to apologize in advance if I don’t write back to each of you in a timely fashion. I’ll try my best.

Here’s how I like to approach it (in the ideal world).
1. Patient isn’t deteriorating and they’ve done well on their spontaneous awakening trial (SAT).
2. RT goes ahead and places them on pressure support (PS or PSV are the lingo)
3. PS for 30 minutes and the RT flips them back into their prior setting on the vent if they don’t fly.
4. If they do fly, I eyeball the patient and have my RT teammate pull the tube.

I usually have HFNC or NIPPV at the bedside in case they have a high likelihood of needing reintubation.

I know many clinicians check ABGs prior to extubating their patients. I very rarely do. I think I’ve checked maybe 2 or 3 prior to extubating in the almost 2.5 years that I’ve been out of training.

A 🎩 tip to the authors.

Let’s reduce the mechanical ventilation days with this! 💪🏼




Link to Abstract

Link to FULL FREE Article

Ouellette DR, Patel S, Girard TD, Morris PE, Schmidt GA, Truwit JD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151:166–180.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Enteral Nutrition: When should we start in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 

A 🎩 tip to the authors! 

- EJ

Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54.