Marcus, Thanks again for the reply. I see you are passionate about APRV and that's great. Just yesterday I got a call about a patient with advanced ARDS who wasn't on the ARDSNet protocol. The doc wanted to stop paralytics and try APRV so I sent him that article and guided him through the settings over the phone. I think if your going to do APRV you should do it the way Dr. Habashi describes. Having that info from Shock Trauma is easier than having to gather APRV data from the literature and trying to piece together your own protocol.
I am by no means saying that APRV is a mode that should be used in all clinical scenarios, and I am by no means saying the ARDSnet protocol has no place in the hospital setting. We all have views and opinions that 'sometimes' don't fall in line with the views and opinions of others.
I have used both APRV and the low tidal volume approach; successfully I might add, in the clinical setting. They both have a place, but I prefer the APRV approach......something about patient comfort, but that is just my opinion
You know... Neil McEntyre, MD (not sure about the spelling) said a few years ago at an AARC conference that, all of the new features that come out on these ventilators work as designed; the only problem is, they fail to make a difference in patient outcome.
Other than pressure control, pressure support, continuous flow, flow triggering, and maybe adjustable Rise Time and Flow Termination, most of the newer features haven't impacted patient outcome very much (at least not according to published research).
So, I believe, what this really comes down to is one RT's preference over another's AND how well they like their sales rep. I seriously doubt that any of us RT's have personally used all of the vents on the market - in a clinical situation on a real patient. We have used maybe 1 or 2; they worked, so we feel they are great vents (and because we like the sales rep). I am still using the PB7200 (certainly not by choice) and I get patients weaned off the vent. It is old and outdated technology, and I would love to have more up to date technology, but I am stuck with what I have - which by the way was considered state of the art in the early 1980's.
If I were buying new vents, I'd get the LTV 1000 (Pulmonetic Systems). It is small and lightweight, can be used in the ICU or as a transport, has many of the newer modes and features as the other vents you are talking about, and is quite a bit less expensive than the vents you are talking about. And, no I don't particularly like my sales rep!
What a pitiful argument. Just because you have not had an opportunity to use a modern ventilator you should not discount them outright. Your nostalgia for the 7200s seems to be clouding your judgement. I have also used 7200s in early 90s and yes, they were great back then . 7200 is still a much better vent than LTV 1000 with its slow response, sluggish flow delivery, rudimentary monitoring and high expiratory resistance. In the car terms I would equate it to, "Gee I love my 1972 Buick coz it never caused me any trouble, and as for those newfangled BMWs and Volvos, they are for posers only. If my old faithful ever has to be put down I will get a Hyundai Accent coz it is small, and has an engine and doors just like the BMW!) The Hyundai salesrep has told me that at 55mph it will drive exactly like a BMW!" Sorry to get a little bit steamed under the collar, but the argument of "I still get them weaned" and basing your whole outlook on old evidence of someone who has close ties to PB at the time when PB was struggling to incorporate any new features into their machines (i.e. no R&D for a few years because of cost savings) does not cut it.
quote:
Originally posted by PCMStexas: You know... Neil McEntyre, MD (not sure about the spelling) said a few years ago at an AARC conference that, all of the new features that come out on these ventilators work as designed; the only problem is, they fail to make a difference in patient outcome.
Other than pressure control, pressure support, continuous flow, flow triggering, and maybe adjustable Rise Time and Flow Termination, most of the newer features haven't impacted patient outcome very much (at least not according to published research).
So, I believe, what this really comes down to is one RT's preference over another's AND how well they like their sales rep. I seriously doubt that any of us RT's have personally used all of the vents on the market - in a clinical situation on a real patient. We have used maybe 1 or 2; they worked, so we feel they are great vents (and because we like the sales rep). I am still using the PB7200 (certainly not by choice) and I get patients weaned off the vent. It is old and outdated technology, and I would love to have more up to date technology, but I am stuck with what I have - which by the way was considered state of the art in the early 1980's.
If I were buying new vents, I'd get the LTV 1000 (Pulmonetic Systems). It is small and lightweight, can be used in the ICU or as a transport, has many of the newer modes and features as the other vents you are talking about, and is quite a bit less expensive than the vents you are talking about. And, no I don't particularly like my sales rep!
I just see marketing propaganda on a manufacturer's website. I get most of my evidence from Respiratory Care Journal, New England Journal of Medicine, Critical Care Medicine and other peer reviewed scientific sources.
Was I supposed to be convinced that the features of a particular vent rather than the way the vent is used can improve outcomes? If so, I'm not. And I don't think anyone else should be, either.
Please provide the evidence of how these things quoted below have improved outcomes. The best availabe evidence for improving weaning outcomes is the daily spontaneous breathing trial which can be done with a t-piece. The best available evidence for improving outcomes in ARDS is the ARDSNet protocol which uses plain old volume ventilation.
These things you mention may improve patient-vent synchrony and may reduce sedation use but I don't think you can say they improve outcomes.
otherRT
[QUOTE]Other than pressure control, pressure support, continuous flow, flow triggering, and maybe adjustable Rise Time and Flow Termination, most of the newer features haven't impacted patient outcome very much (at least not according to published research).
To get us at least back on the subject of Vents and not the fight about APRV vs whatever.net. I would like to say this... There are a ton of vents out on the market that do a lot of great things. Every vent that is produced is marketed to be the next best thing. Personally I'm a fan of Drager and just about every product they produce. In saying that there are problems with the technology that they deploy. The only problem so far, and I'm sure others would agree is there flow sensor technology. If you would like to know how to fix those problems I can give you an easy answer. But now is neither the time nor the place. Email me with your questions. Getting back to our subject at hand, new vents can be great to get into your facility and mix things up. Examples would be the LTV's and there line up. LTV makes a great vent if you're only using it for home use on long-term patients or as a transport ventilator (I would limit this to pediatric and adults, not neo's). However, I am not a fan of using this vent in house on critical patient for extended periods of time. Most people fail to realize that LTV has a screen for their vents that nicely mounts to the top of the machine. Wilford Hall Medical Center in San Antonio was using this vent on a trial basis in the Trauma center and strictly on transports services. We found that the vent performed well for our use. They make a great "backpack" for the vent and also some hooks so that you can attach the vent to the bed instead of lying it IN the bed between the patient's legs. GE Healthcare has recently come out with a brand new vent. Currently I am starting up a research project of that mode of ventilation that everyone either love or hates to talk about, APRV. Only my study will be targeting the pediatric and neonate population. Anyway, about the GE, this seems to be a really nice package especially with the 2.2 Software. If any of you have used this in your facility or seen it at a product fair you have probably said to yourself; "Wow the alarms sound like the INO vent that we use for nitric". Well you would be correct. INO and there nitric products are produced for them by GE Healthcare. I am told that by late 2006 to early 2007 the INO nitric delivery system will be available on the GE. So there will be no need to have two different machines in the same room taking up space. Pretty smart if you ask me. The spiro abilities on the GE are pretty cool to work with if you care to dabble into that sort of thing on your patient. Servo has come out with their updates for the Servo-i. New software that takes 15 seconds to set up the vent when you're in the room instead of the eternity (2 min 45 seconds) it use to take. New proximal airway sensors for neonatal use although if I understand without the proxy the ventilator still is accurate within 5 cc. Viasis makes the Avea and another "transport" type ventilator. Myself, personally, I would say stay away for it. I've used it and I'm not found of it. The rep that took care of us was great when we wanted to get the Avea into the facility and let us have it for as long as we wanted. Maybe the dragers have spoiled me, or maybe I just hate troubleshooting vents, but it took myself and three other therapist to fix a leak problem we where having. The leaks originated on the exhalation side of the machine and this is the huge downfall of this vent. When we contacted the rep about the problems we where simply told it was an "education issue" and that we did not have the proper training. So we had him come in, needless to say I guess he wasn't very educated either. It took him an hour to fix the same problem. To finish my rant on this vent (again email me if you have questions I would be glad to answer them) equipment techs hate them... 50% of the RT's I talk to feel the same way. Great color by the way, and like the rep says... "You know they use this vent on Gray's Anatomy?" Now with everything I just said remember this when looking at a new ventilator. Old habits die hard, and Doc's usually have their comfort zones, which are hard to penetrate with new and fresh ideas. I'm sure Dr Habashi and Dr Derdak would say different and I expect this from them. They are great Doc's with a lot of experience. This can be seen with people who continue to try and disprove APRV and it's benefits. No this is not a mode of ventilation that should be used on all patients, but with it comes to IRDS, ARDS, ALI, and other conditions I really don't have time to discuss, I would say it's right up there with HFOV as being the best. (Once again the email thing if you want more info) When looking at the vents ask yourself what you will be using it for. If you not looking to run Heliox, or your facility doesn't use Nitric or even APRV, don't let the reps even talk to you about it. Some people will say, "with our vent you can monitor 350,000 different things", that's great but you will never use it. Most facilities will be lucky to venture out of Volume control and into Pressure mode. I know your not going to use a mode like APRV, ILV, or PRVC+.
