Ventilator Jiu-Jitsu

Oct 17, 2024

Brittney Bernadoni, an EM/critical care and flight physician skilled in ARDS and transport ventilation. She explores ventilator jiu-jitsu: choosing modes, low tidal volumes, PEEP strategy, plateau and driving pressures, permissive hypercapnia limits, oxygen targets, mechanical power, and practical tweaks for safe transport. Short, actionable conversations about optimizing lung-protective ventilation in challenging environments.

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ADVICE

Lower Rate For Obstruction And Avoid Excessive Rates

Set respiratory rate to avoid breath stacking; use lower rates for obstructive disease and 16–18 for typical ARDS patients.
Remember higher rate increases lung hits per minute and may increase ventilator‑induced lung injury.

ADVICE

Allow Permissive Hypercapnia Within pH Limits

Allow permissive hypercapnia as long as pH remains >~7.15–7.20; avoid in pregnancy, brain injury, severe right heart failure, and specific toxin overdoses.
Tailor targets: keep lower PaCO2 in those vulnerable populations rather than blanket permissive hypercapnia.

INSIGHT

Eight Is The New Minimum PEEP

Start PEEP at ≥8 cm H2O for most patients and use the ARDSnet low/high PEEP table matched to FiO2.
Favor higher PEEP table for obese patients to counter chest wall and abdominal load.

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In this episode of our series on respiratory critical care called Every Breath They Take, Dr. Lauria is joined by EM/Critical Care and Flight Physician Brittney Bernardoni as they discuss how to grapple with optimizing lung protective ventilation in ARDS.

Lung protective ventilation at 6 cc/kg and maintaining plateau pressures of less than 30 cmH2O have been the cornerstones of invasive respiratory support since the findings of the ARMA trial in 2000. In recent years, some interesting new developments have resulted in changes and improvements in lung protective ventilation strategies. With a particular focus on ventilator "jiu-jitsu," this episode explores the intricate adjustments required to optimize patient care during ARDS management. From ventilator modes and plateau pressure to the impact of PEEP, FiO2, and mechanical power, this episode equips listeners with actionable knowledge for mastering the art of ventilation. Whether in the field or the ICU, the nuanced approaches discussed in this episode will enhance your understanding of optimizing respiratory support in critical patients.

Listen to the episode wherever you get your podcasts or directly on our website at https://flightbridgeed.com/explore. While you're there, explore our award-winning courses that have helped thousands of providers clarify and understand the world of critical care transport and pre-hospital medicine.

Takeaways
• Early care in managing respiratory failure in the transport environment is crucial and can significantly impact patient outcomes.
• Lung protective ventilation with low tidal volumes is the foundation of ARDS management.
• The choice of ventilation mode (volume control or pressure control) depends on the clinician's comfort and ability to titrate the settings, but neither has proved superior.
• Permissive hypercapnia is generally well-tolerated in ARDS patients if the pH exceeds 7.15-7.20.
• The initial PEEP setting should be at least eight - several strategies can be used to guide titration.
• High FiO2 levels can be detrimental to ischemic organs, alveolar patency, and the lung tissue itself. Aiming for a FiO2 of less than or equal to 60% is important.
• Set, check, and change parameters to ensure optimal ventilation!
• Driving pressure may be an important factor in patient outcomes.
• Mean airway pressure and inspiratory time can improve oxygenation and minimize lung damage

References
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