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PRECISION VENT
MANAGEMENT
Sara Crager, MD
Assistant Professor, Division of Critical Care
Department of Anesthesia & Department of Emergency Medicine
University of California Los Angeles
RECURRING
VENTILATOR
CURBSIDE
NEW & IMPROVED ALGORITHM?
QUESTION OUR PREMISES…
Steve Green & David
Schriger
Annals of Emergency Medicine 2017;70(2):158-160
~
“…the illusory sense of
psychological order provided
by a seemingly precise tool”
AND THE
WINNER IS…?
WHAT IS THE RIGHT TOOL?
OPERATOR DEPENDENCE
(The more things that have gone wrong,
the more things that will go wrong…)
MURPHY’S LAW OF
CRITICAL CARE
YOUR CRITICALLY
ILL PATIENT IS A
SNOWFLAKE
QUESTION OUR PREMISES…
MORE ALGORITHMS
NOT NECESSARILY
THE ANSWER?
Albert Einstein
~
“Everything should be
made as simple as
possible, but no simpler”
EXPERTISE-DRIVEN APPROACH
HOPE I’M
FEELING SMART
TODAY…
ORGANIZED CLINICAL
PROBLEM SOLVING
APPROACH
:
Problems
Targets
Problems
Targets Strategies
Problems
Targets Strategies
Problems
The things you
need to fix
Framing the right
question is sometimes
the hardest part
RESPIRATORY FAILURE MASQUERADE
Targets Strategies
Problems
The things you
need to fix
Targets Strategies
Problems
The things you
need to fix
How you know
you’re fixing
the problems
“Measure what is
important, don’t make
important what you can
measure”
Robert McNamara
~
Targets Strategies
Problems
The things you
need to fix
How you know
you’re fixing
the problems
Targets Strategies
Problems
The things you
need to fix
How you know
you’re fixing
the problems
How you go
about fixing
the problems
ORGANIZED CLINICAL
PROBLEM SOLVING
APPROACH
Iterative
Hypothesis
Testing
Iterative
Hypothesis
Testing
Gather
Data
Iterative
Hypothesis
Testing
Gather
Data
Revise
Hypothesis
Iterative
Hypothesis
Testing
Gather
Data
Adjust
Management
Revise
Hypothesis
RINSE AND
REPEAT!
Targets Strategies
Problems
The things you
need to fix
How you know
you’re fixing
the problems
Targets Strategies
Problems
The things you
need to fix
How you know
you’re fixing
the problems
How you go
about fixing
the problems
ORGANIZED PROBLEM
SOLVING APPROACH
TO VENTILATORS
Targets Strategies
Problems
Targets Strategies
Problems
The lungs do
not exist in
a vacuum
Targets Strategies
Problems
Targets Strategies
Problems
Pulmonary
Compliance
Resistance
Recruitment
Pneumothorax
Etc etc etc
Targets Strategies
Problems
Pulmonary
Thoracic
The lungs Live
inside the
Thoracic Cavity
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Positive
Pressure has
hemodynamic
consequences
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Metabolic Acidosis
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
The Injured
brain has
trouble with
autoregulation
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Ventilators are to
lungs as crutches
are to ankles
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygen
Too much
of a good
thing…
HYPOXEMIA
VS
TISSUE HYPOXIA
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
CO2 IS ALL
ABOUT THE
CLINICAL
CONTEXT
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Work of Breathing?
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
HOW BADLY DO
YOU NEED A
MENTAL STATUS?
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
EXPERTISE-DRIVEN APPROACH
You can’t have
everything you
want All at the
same time…
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
PEEP
PEEP Optimization
PREVENT ATELECTRAUMA WHILE
AVOIDING ALVOELAR OVER-DISTENTON
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
PEEP
Minute Ventilation
pH
CO2
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
PEEP
Minute Ventilation
I:E Ratio
I:E RATIO
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
PEEP
Minute Ventilation
I:E Ratio
V-Q Matching
V-Q
MISMATCH
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
CO2
pH
Lung Protection
Mental Status
PEEP
Minute Ventilation
I:E Ratio
V-Q Matching
Synchrony
SLEDGEHAMMER APPROACH
NOT ROUTINELY REQUIRED
PRECISION VENT
MANAGEMENT
ORGANIZED CLINICAL
PROBLEM SOLVING
APPROACH
Targets Strategies
Problems
Pulmonary
Thoracic
Hemodynamic
Metabolic
Neurologic
Oxygenation
pH
CO2
Lung Protection
Mental Status
PEEP
Minute Ventilation
I:E Ratio
V-Q Matching
Synchrony
The End

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Precision vent management | Sara Crager at TBS23