I just graduated paramedic school, and I have a few questions about ventilators. I work for an emergent/pre-scheduled interfacility transport service that uses the model 754 Impact eagle vent. (We also have autovents.) Our transports range from minutes to 6-10 hours.

One medic who recently completed the CCEMTP UMBC program refuses to use a ventilator because "It can cause ARDS in 10 minutes." He says we need ventilators that can adjust flow.

My questions are:
Why is this so?
Can the eagle vent be adjusted to avoid complications?
Am I better off using a BVM/AMBU to ventilate patients? (This would be my default for short transports)

Eagle vent setting
Mode (A/C, SIMV, CPAP)
Rate (1-100)
Inspiration time (0.1-3 sec)
Tidal Volume
FiO2
Sigh
PEEP
Pressure Plateau

__EDIT__

Flow is just tidal volume over inspiratory time right? (Once you adjust the units)

This message has been edited. Last edited by: David,

David,
I am a veteran of a few out of hospital transports. No disrespect intended, but in the best of circumstance the first item that should be present when an acute patient is being ventilated is a RCP with an in depth understanding of the patient, the ventilator and their interaction. We function in a system that is not quite the best of circumstances. The skills required to be able to assess and act on many of the issues that arise with ventilator patients are developed in the cauldron of day after day of multiple complex vent patient assignment in the ICU. It could take 12 6 hour transports to gain a similar amount of pt/vent management experience that a RCP would gain with what many consider a relatively light 6 vent assignment for 12 hours. Some of the transports I have gone on have been so routine that the patient could have been managed just fine by a CNA, but others have taken every ounce of all of the vent skills and experience I had. I am not against paramedics using vents during transport, but I do have concerns when a paramedic claims such things as using a bag is better than a vent in all cases. I really appreciate your bringing this question here. I expect there are a very large number of vent transports that are putting paramedics at the helm of a pt/vent system. It is very important that questions like this from a paramedic get posted. I'll start with agreeing with your associate. Ventilators can cause ARDS in less than 10 minutes...if they are not set and managed appropriately. If set and managed appropriately they would generally be safer from a lung protective standpoint and in almost all cases better to use for extended transports.

My associate's claim was not that a bag was better than a vent, but that a self filling bag (achieving less than 1.0 FiO2) was better than the eagle vent in most of our transports (10-30 minutes). He will use an Eagle vent on longer transport, but begrudgingly. He wants the company to buy Crossvents. Now that I am responsible for transports of ventilated patients I am trying to figure out what the best thing for my patients is.
So from your advice, following a RT through a busy ICU for a couple of days would be very beneficial. Do you have any insight on the appropriateness of the Eagle Vent for short transports (10-30 min)?

I don't understand the objections to the Eagle Vent. ??

Or why the Crossvent would supposedly be better.

Sure I can imagine that, in some combination of disease/trauma, vent type and settings, one could produce ARDS in ten minutes.

VT of 4 liters maybe. Flow rate 160 L/M

Rate 30 and Peep zero.

In a patient with unilateral severe pulmonary contusion.

I haven't worked at all with an Eagle Vent on a patient. But I did spend some time developing some training materials and competency tools. So I am a bit familiar with the Eagle, though at this time foggy a bit on the details.

I recall at no time being concerned that something was awry with the Eagle.

It sounds like your co-worker has been affected by some marketing propaganda. ?

You can easily setup a patient in ARDSnet settings. And the Plateau Pressure option is akin to Pmax on Evita ventilator---flow controlled ventilation with decelarating flow which "hugs" the inp presssure limit (on Eagle set at 10 below PIP alarm setting).

One more thing. You CAN set the flow rate in the Eagle Vent. You just do it by setting the Insp time and VT. If flow is square wave (constant flow and not ramp) if VT is 600 and Ti is one second then flow will be 60L/M. On other vents you directly set a flow rate and therefore the insp time is also set indirectly in reverse of above...........but then I suppose he would want a vent in which you could set the insp time!


Excuse me for saying this. But it disturbs me that someone with those bizzare concerns is actually in charge of transports. And that you are now in charge and not able to both quickly and easily counter the nonsense.

And I'll bet that it's more likely that manual bagging over 10 minutes could cause ARDS --as opposed to Eagle vent settings based on the ARDSnet guidelines.

My goal is to gain enough knowledge to satisfy my concerns and impart that knowledge to my colleagues. Ventilators are not often taught in paramedic school, but the theory and concepts are. The training on the ventilator is the responsibility of the service.

We are the only ground service in the area that carries vents. We are also the smaller of two competing companies in the city. As a result, the "standard of care" for these transports, in this area, is a bag. Therefore, bagging a patient carries much less legal liability over using the vent. Of course I would much rather be able to accurately adjust PEEP, FIO2, VT, etc..., but if there are questions about the safety of our transport vents, I feel the need to research it to death. I would love to simply shoot down someone whose been doing my job for 20 years, but that doesn't go over well. (Try telling off a senior RT some time and see how that works out.) There is no such thing as "quickly and easily countering" concerns when you've been at the job 1 week vs. 20 years, even if he is wrong.

My co-worker is fairly well respected for his clinical knowledge but, he is prone to idiosyncrasies. My gut feeling is he simple has not been trained adequately on the Eagle Vent. However, I haven't had the chance to sit down and talk at length with him on the matter. As for me, I can fairly easily grasp the concerns here, but this is not like Aunt Betty's waffle recipe. A misunderstanding can cause serious problems. I'm in the undesirable position where several authorities are feeding me contradictory information, and I'm figuring out who is right.

Thanks for the input!

David,

My email is whitnack@pacbell.net

I feel your pain and appreciate the various angles of Catch 22.

At work I have a whole folder with Powerpoints, PDF's, and some competencies I developed on the Eagle. Bear in mind that we have these stockpiled for that Bird Flu/Ebola/Hanta Virus/Influenza/Sarin/Al Queda moment and that I haven't used this vent on a patient. So I am in no way any type of "Eagle Expert". However one of our co-workers is in the Air Force also, uses Eagle and thinks it works great.

Email me and I'll send you what I have.

I would not be so sure about liability being better with bagging. If a patient was transferred from one facility with specific settings, and it ever went to trial.....I can envision someone cross-examing and asking "how can you be sure that your bagging matched the RR 35, VT 380, Peep 16, ..?"....etc.


I would try to pin down from your co-worker what exactly are his problems with the Eagle, as well as why he likes the Crossvent better. It might just be a case of him being trained on a vent where he could directly set flowrate. ?

Mention that this Eagle Ventilator is what is being stockpiled and in wait across the country. If he has a problem with it he should investigate and work it out, writing letters to Congress if need be. Appeal to his sense of patriotism, mom, apple pie, etc. Seriously this could be a way for him to work it out.

Yeah it sounds like when we have an MD we want to convince of something....the trick is in getting them to think it's their idea.

Just to correct the math regarding the flowrate. A flowrate of 60lpm equates to 1.0 liter per second. If you set the Vt to 600 the inspiratory time required to achieve a flowrate of 60lpm is 0.6 seconds not 1.0 second. If the Vt is set to 600 and the insp. time is set to 1.0 seconds the flowrate will be more like 40 lpm (a little bit less if you do the math) in constant (squarewave) flow ventilation. All of this changes when you using modes with decelerating flow.

Seatac

My bad. I think it's 36L/M.

36 divided by 60 is .600. Hey I'm not always in my mental best when posting (not enebriated yet though! )

I made an earlier post, still waiting on approval. Why do some post right away and others take time? Trigger words or phrases to keep spam out?

David,

I did reply to your last post here, but some delay apparently.