Airway Management in Head Trauma (Scenerio)

[VentMonkey]

To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes. If I showed you the scalars of a PRVC breath you would describe it as a pressure control breath. You wouldn't know it was PRVC unless you knew whether I was fiddling with the inspiratory pressure or the vent was doing it automatically.

Maybe they should have called it VRPC

Maybe, but PRVC just rolls off of the tongue a whole lot easier. Either way, I find it is almost a continuous difference of opinions with what’s called what, and where it fits in when discussing ventilator management and strategies, be it in the respiratory therapy world, or prehospital one. Maybe at the mid-level and intensivist level it’s a tad clearer with better defined guidelines and terminology?

Granted, in the prehospital setting we’re way short on the know how, so perhaps much gets watered down in CC classes and courses to fit the general paramedic populations. I mean who could really learn Vent management in 1-2 days? Thanks for clarifying though.

 

[Brandon O]

Maybe, but PRVC just rolls off of the tongue a whole lot easier. Either way, I find it is almost a continuous difference of opinions with what’s called what, and where it fits in when discussing ventilator management and strategies, be it in the respiratory therapy world, or prehospital one. Maybe at the mid-level and intensivist level it’s a tad clearer with better defined guidelines and terminology?

Granted, in the prehospital setting we’re way short on the know how, so perhaps much gets watered down in CC classes and courses to fit the general paramedic populations. I mean who could really learn Vent management in 1-2 days? Thanks for clarifying though.

If you're thinking that the higher you get, the more people agree, I have some sad news for you.

 

[FiremanMike]

Does he really NEED an invasive airway? Right now? Why? Because he's asleep? He is breathing fine. Isn't gas exchange what matters? What does the research say on the topic of outcomes between TBI patients who are intubated in the field vs. those who are not? Did this very patient not do just fine with NPO's non-invasive management? Don't BLS crews all over the country transport patients just like this every day, and they do just fine?

Like I said before, I'm certainly not going to tell anyone they are wrong for wanting to RSI this guy. It's how I used to practice in the field. It's how we are all trained. It is (arguably) the standard of care. But WHY are we so set on it? WHY do we simply ignore the study upon study that tells us it isn't necessary? Just because it's what our paramedic instructors told us we should do? Because it's what we see the ED docs do? Again, what about all the TBI patients who aren't intubated in the field, and do just fine?

Wanting to intubate is perfectly reasonable, but so it taking a more conservative approach. Aside from dogma, I don't think there is any justification for the idea that an ETT is the only right way to manage a patient who is breathing and oxygenating well.

If I'm being honest, I guess my only real articulable argument for intubating now is that I'd rather do it now while he's oxgenating well and I'm the one making the plans. While it is certainly reasonable and prudent to simply pre-plan the eventual crash intubation, the vast majority of providers will feel that increased stress if/when the patient does crash and will function at a level below their best.

I have grown into the "less is more" approach the older I get, but this patient potential crash just makes me nervous.

 

[Carlos Danger]

To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes.

I think of it as a pressure mode. It's just a pressure mode that targets a set volume instead of a set pressure. What makes it cool is that it manipulates flow rates to try to reach the target volume with the lowest pressure possible. At least that is my understanding of how it works.

 

[Brandon O]

I think of it as a pressure mode. It's just a pressure mode that targets a set volume instead of a set pressure. What makes it cool is that it manipulates flow rates to try to reach the target volume with the lowest pressure possible. At least that is my understanding of how it works.

I would say it manipulates inspiratory pressure to reach target volume. All pressure control manipulates flow (to reach the target pressure); variable flow based upon patient demand is a hallmark of pressure modes.

 

[VentMonkey]

I really should pony up the money for RT school; it’s my most realistically practical option.

 

[NPO]

I really should pony up the money for RT school; it’s my most realistically practical option.

I think that would be great, but I'd hate to see your aptitude wasted somewhere you couldn't stretch your wings.

Where do you think you'd like to work as an RT?
Do many local (to you) hospitals allow the RTs to operate with relative autonomy?

 

[VentMonkey]

I think that would be great, but I'd hate to see your aptitude wasted somewhere you couldn't stretch your wings.

Where do you think you'd like to work as an RT?
Do many local (to you) hospitals allow the RTs to operate with relative autonomy?

Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.

I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.

 

[NPO]

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddps has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.

This is where I think you'd be best used. I know you've expressed interest in fixed wing transport before, and I know of several specialty pediatric transport teams where RTs are quite valuable. Combined with your prehospital and critical care experience, I think you'd be well suited for SCT.

 

[Qulevrius]

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.

If you decide to go through with this, ping me. The wife used to be a NICU/PICU transport coordinator & transport CCRN for a few years, and she still has friends with REACH Air.

 

[Carlos Danger]

I would say it manipulates inspiratory pressure to reach target volume. All pressure control manipulates flow (to reach the target pressure); variable flow based upon patient demand is a hallmark of pressure modes.

This is probably true of all modern ICU vents and even some newer transport vents (neither of which I'm very familiar with anymore) but the "basic" PCV mode uses a flow pattern that decelerates in a linear fashion until the target pressure is reached. Just like volume modes, the vent doesn't vary anything beyond what the operator sets.

PRVC was actually a proprietary term (I forget which manufacturer) and I think it was the first commonly-used mode that would not only change flow rates to meet patient demand by sensing changes in airway resistance at different points of the inspiration cycle, but would also adjust the flow rates at different points to achieve the set vT at the lowest airway pressure possible. Or again, at least that's how I've always understood it.

Of course that's nothing compared to what the newest ICU vents can do, but for us old-timers who don't specialize in ICU ventilation using modern vents and whose original transport ventilator delivered only 100% oxygen and required calculating the flow rate, e-time, and i-time in order to get the tidal volume and respiratory rate you wanted, PRVC was like magic when it first became commonplace. All you have to do is set tidal volume and rate, and the vent will select the appropriate flow and ensure the lowest possible pressure? Sign me up!

 

[Carlos Danger]

Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.

I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.

If you could get into specialty transport as an RRT you might love it for the most part, but I guarantee you'll miss those scene flights.

I too came close to going to school for respiratory therapy, for the same exact reasons that it interests you. At the last minute I decided to enroll in the Excelsior nursing program instead, primarily because it would be easier for me to keep flying FT while going to school.

Unfortunately, after working with many RRT's in the ICU and HEMS, my impression is that the RT field seems to have a problem with career satisfaction. I think that, similar to EMS, many people get into it thinking that the day-to-day is going to be quite different than what it usually turns out being. I haven't known many who were really happy doing what they were doing, aside from the ones that I flew with. I'm sure many do like what they do, but you just have to make sure it's what you want to do.

 

[VFlutter]

Unfortunately, after working with many RRT's in the ICU and HEMS, my impression is that the RT field seems to have a problem with career satisfaction. I think that, similar to EMS, many people get into it thinking that the day-to-day is going to be quite different than what it usually turns out being. I haven't known many who were really happy doing what they were doing, aside from the ones that I flew with. I'm sure many do like what they do, but you just have to make sure it's what you want to do.

This is my experience as well, primarily working with RRTs in the ICU. There is very little autonomy, limited career growth, and monotonous daily work.

 

[FiremanMike]

This is my experience as well, primarily working with RRTs in the ICU. There is very little autonomy, limited career growth, and monotonous daily work.

I've heard the same about perfusionists, which sucks because that would be such a cool job..

 

[Bullets]

Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.

I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.

RN? Perhaps a masters in nursing and become a CRNA? or an NP? NPs are PhDs now, at least in my hospital NPs operate with relative autonomy, primarily in Paeds, Trauma, TICU and NSICU. Or even PA. If you have a bachelors its pretty much the same to a MSN or PA in my area

 

[Brandon O]

This is probably true of all modern ICU vents and even some newer transport vents (neither of which I'm very familiar with anymore) but the "basic" PCV mode uses a flow pattern that decelerates in a linear fashion until the target pressure is reached. Just like volume modes, the vent doesn't vary anything beyond what the operator sets.

I guess I can't speak to all of the older models, but I don't think it's possible to have pressure control without a variable flow.

Here's why: the basic premise of pressure control is that you reach a target pressure and then hold it for a set time. (At least, by convention this is how it works; you could have another universe where it works differently, but this is what people mean when they say "pressure control" these days.) Flow doesn't decelerate until you reach the target pressure; flow decelerates because you've reached the target pressure.

Flow starts out very high in an effort to quickly reach the set pressure (how high is determined by rise time, the only control you have on this), then once you get there, it takes much less flow to maintain that pressure.



But airway pressure depends on the compliance in the airway, and in a patient with any spontaneous work of breathing, compliance depends on their effort. If they do nothing, compliance will be low; if they inspire vigorously, compliance will be high. And they can do both of those things during the same breath if they want.

The vent doesn't know what the patient is doing, but it knows the airway pressure, so if it wants to reach and maintain the target pressure, it has to adjust flow in order to match the patient's attempts to change it.

I don't think it's possible to do this without a variable flow. If the vent cannot adjust flow, it cannot reach the goal pressure; flow is the independent variable here. I suppose you could have a fixed flow (like volume control), and just inspire linearly until you peg the pressure limit, but this would only work in a patient with zero effort (fixed compliance), and would also make it impossible to set your inspiratory time (since the minimum inspiratory time would become determined by flow). Is that how older vents did it?

PRVC was actually a proprietary term (I forget which manufacturer) and I think it was the first commonly-used mode that would not only change flow rates to meet patient demand by sensing changes in airway resistance at different points of the inspiration cycle, but would also adjust the flow rates at different points to achieve the set vT at the lowest airway pressure possible. Or again, at least that's how I've always understood it.

I would say the added variable in PRVC is not flow, but volume. The individual breaths look exactly the same as pressure control breaths. The difference is a BREATH TO BREATH variation in the set pressure.

You give one PC breath at 25 cmH2O. The resulting volume is 350. Your goal was 400.
The next PC breath is therefore at 27 cmH2O. The resulting volume is 370. Still too low.
The next PC breath is 29 cmH2O. The resulting volume is 400. Great, we'll keep this inspiratory pressure until compliance changes.

 

[TXmed]

How well does PRVC work with a patkent with lung etiology. Asthma/COPD or pulmonary contusion ?

 

[Brandon O]

How well does PRVC work with a patkent with lung etiology. Asthma/COPD or pulmonary contusion ?

Works fine. The only time I think it's a poor choice is when patient factors (such as dyssynchrony) create inconsistent compliance; this tends to confuse the vent and result in weird volumes. Or when you really want to tightly control all of your variables, and -- let's say -- directly control the exact minute ventilation to manipulate your acid-base status. Easier done when the vent's not acting like Clippy from Word and trying to be helpful.

 

[E tank]

I've heard the same about perfusionists, which sucks because that would be such a cool job..

Every single perfusionist I've ever met, all pretty smart guys, wouldn't trade their jobs for the world. They do way better than RT's in the accounts receivable department, to be sure.

 

[EpiEMS]

They do way better than RT's in the accounts receivable department, to be sure.

RTs (not the lower-level one, the technician role) median annual wage is $58k. Cardiac techs broadly look to be at $55k, but I see anecdotal evidence for perfusionists being at ~2x RTs...