VentWorld    VentWorld    ventworld.infopop.cc  Hop To Forum Categories  RC Professionals    up-to-date ventlation info
Page 1 2 
Go
New
Find
Notify
Tools
Reply
  
up-to-date ventlation info
 Login/Join
 
Member
posted Hide Post
quote:
What is your definition of lung protective ventilation?

Ventilation that attempts to not cause any ventilator induced lung injury due to volutrauma, atelectrauma or biotrauma. An open lung strategy is part of this. I agree you can do this with APRV but it is not necessarily the best mode, that depends on how each mode is individualized to each patient.

I do not find that patients on a low tidal volume strategy (by the way, why is it considered low tidal volume when it is physiologic?) use huge amounts of sedation, we try to keep all our ventilated patients at a RASS of -1 to -2 if possible. But I'm not sure what you consider heavy sedation?

Ever wonder where the old 10-12 ml/kg came from. Well it came from the first big population of patients to ever be ventilated, post-op abdominal surgery patients. Back in the very early ventilator days, they found these patients did best with tidal volumes of 10-12 ml/kg so soon all patients that got ventilated, no matter the reason, began to be ventilated with 10-12 ml/kg and thus began our long love with 10-12 ml/kg.

--


GJ, I think you may have misunderstood me. I'm not suggesting you choose HFOV over APRV. Both have their place.

I just used Dr. McIntyre as an example, he loves HFOV, but he will tell you that even he won't use it until he can no longer provide lung protective ventilation with conventional ventilation, then he will use his beloved HFOV. He does this because, being an evidence based doc, he knows the evidence isn't solid for HFOV in adults and it isn't solid for APRV either.

And I just think that this may be how you could use APRV with your evidence based doc.

I'm not saying APRV can't be used in patients other than ARDS but it seems best suited for patients that require high PEEP levels and hard to recruit lung in the dependent regions of the lung (such as ALI/ARDS).

I use all modalities of ventilation in my practice (CV, APRV, HFOV ...) and I have not found one MODE of ventilation that is best for all or most patients, patients are individuals and we must individualize the ventilator to that patient, no matter what the mode we choose. Whether you use APRV, PC-IRV, a high CPAP, ARDSnet strategy, whatever. They all have their place.

If you really want to tell your evidence based doc how APRV has its place, my suggestion would be to be very light on the technical aspect of it and show how you can physiologically provide a safe and protective way to ventilate the lung in certain patients. You may even suggest that you may be able to use less sedation as an added benefit.

I would love to see a large multicenter trial using APRV, but I would also like to the same with PAV, NAVA and maybe HFOV. And while all 'new' ventilators offer APRV, APRV actually was first used on human patients 20 years ago!

While APRV can be a great mode, just like any ventilator mode, they are great only if used correctly for each individual patient.


Hope this helps and maybe clears things up a bit.

-- JeffD
resptherapy@gmail.com
 
Posts: 11 | Location: Saskatoon, Canada | Registered: November 28, 2006Reply With QuoteReport This Post
Member
Picture of light
posted Hide Post
JeffD,
If your feeling is that you need a multicenter trial to prove a stratagies worth, what are your feelings about the problems with the ARSDnet study?
1) the fact that many of the patients in the "control" arm actually had to have VT increased to fit their "normal" ventilation strategy?
2) or the fact that others have tried to repeat the study and have got different results than the ARDSnet?
3) Or the large number of people that were excluded from the study, how are we supposed to ventilate them?

ARDSnet was a revolutionary study in what and how it went about things, but it is not a end all say all. I believe McIntyre as also said it does not matter what lung protective strategy you use they all have the same mortality rate, so the key is to pick one and go with it.

My issue with ARDSnet is that the physicians in my area read the 6ml/kg part and glazed over the increased PEEP part and since the 6ml/kg is what is talked about some much many forget about the other aspects of the study. APRV has many studies that have looked at it success and if you put the trial together I bet you would have a decent amount of patients. APRV offers too many outside advantages to the patient over ARDSnet for me to support ARDSnet over APRV. Just ask Dr. Habashi (since we were throwing out Doctors names)


Light
 
Posts: 104 | Location: Springfield, MO | Registered: March 08, 2004Reply With QuoteReport This Post
  Powered by Social Strata Page 1 2  
 

VentWorld    VentWorld    ventworld.infopop.cc  Hop To Forum Categories  RC Professionals    up-to-date ventlation info

© Copyright Equipment Simulations LLC, 2000-10. All rights reserved.