Thursday, December 5, 2013

Why I Do Not use Draeger Ventilator Simulators

I get asked often why do I not use other simulators in my videos.
Specifically the Draeger ventilator simulators.
It is very simple, they cannot perform the functions I need to teach modes of ventilation & pulmonary mechanics as demonstrated in the video. 

Saturday, November 16, 2013

Adaptive Pressure Control Ventilation Video Series

After finishing my videos on the mathematical models of PC-CMV, I decided to create videos on Adaptive Pressure Control (APC) ventilation.

These videos compare and contrast between APC, VC, & PC during changes in pulmonary dynamics & various patient conditions/ interactions.

Tuesday, November 12, 2013

Incorporating Proportional Assist into Ventilator Protocols

Image 1: PAV+ Work of Breathing bar. 

PAV+ may be used for the initial mode of ventilation during the acute phase of mechanical ventilation. However, from my experience I have had the most success and efficiency with PAV+ utilizing the mode to rest patients after a failed spontaneous breathing trial. After reviewing the literature it is still unclear the best way to wean or liberate a patient from PAV+. However, a traditional T-piece trail has been supported by many peer reviewed journals, so at my institution we still use a 30 minute to one hour T-Piece trial to screen patients for extubation.
How to incorporate PAV+

Tuesday, November 5, 2013

The Fastest Ambulance on TED

Whats in your pockets? Are you a Prepper or Macgyver?

In a previous post (The RT Hoarder) I mention that I carry very little on me when I'm at work. 
Yes, I believe in being prepared, however I try to practice the "Macgyver" philosophy [1], versus the "Dooms Day Prepper" mentality [2].

This post presents my Everyday Carry (EDC) [3] from when I first started in the field of respiratory therapy to what I carry now. I will describe "what is in my pockets" and why, also notice the progression throughout the years.

What items do I get rid of & what do I always need to practice the profession?

EDC as a RT student & new graduate.

Saturday, September 7, 2013

High-Fidelity Human Patient Simulators Not Needed: Links to Free Simulators

Image 1 From:

Many academic institutions have or are in the process of implementing high-fidelity human patient simulators to augment didactic teachings. Some centers are even using these simulator labs to decrease/reduce the number of hands-on clinical hours.
Personally, I believe these very high cost simulator labs are a scam and more time should actually be focused at bedside with a dedicated clinical preceptor.

Note- my views are from participating in various curriculum's from the schools with very little resources to highly funded skills labs.

My argument against high-fidelity human patient simulators

1.       Cost- the institution has to invest in space, building a simulation lab, lab equipment overhead cost (e.g. electricity, heating & cooling), and staffing. I believe these funds can be better allocated.

2.        No proof- There is little evidence indicating high fidelity simulator labs provide additional benefits versus cheaper methods of simulation (e.g. role playing, actors, etc). Additionally studies supporting the high fidelity labs have been performed by the labs themselves, so I believe there is some biases here.

3.       Hours- many simulator labs you may only visit a few times a semester. When I was attending graduate school we only went to the simulator lab twice a semester. Conversely, in paramedic school we practiced and went over patient assessment skills in every class. Additionally, with simple simulators I can use these anywhere at any time.

4.       Groups- Usually, the simulation lab is a large group exercise with very little individualized hands on experience.

5.       Scenarios- Usually during your scheduled time your group only participates in one scenario. Conversely, with other simulators you can individually go over multiple scenarios in the same amount of time.

Links to Free Simulators to augment your education (Click Hyperlinks)

1.       Draeger Ventilator & Anesthesia Delivery System Simulators:

2.       Hamilton Medical Ventilators. Note this is just a link to their home page, you need to select a specific product to access the simulator:

4.       Robert Chatburn’s Ventilator simulators. My favorite, true mathematical models great for teaching and understanding modes & the variables which influence mechanical ventilation:'s_Simulators

Monday, August 12, 2013

Waveform of the Week

Waveform of the week 

I posted a patient ventilator asynchrony case on the GMEP Media Gallery.

Here is the link for viewing:

Sunday, August 11, 2013

PC-CMV Relationship of Delivered Minute Ventilation & Set Frequency

Mathematical Review of Pressure Preset Ventilation

Minute ventilation as a function of set frequency with no airflow obstruction. Minute ventilation rises toward a final plateau determined by I-time & resistance. However, compliance determines the rate of the rise of the curves.

Wednesday, August 7, 2013

Relationship of frequency to tidal volume during PC-CMV

Review of Mathematical Principles of Pressure Preset Mechanical Ventilation

This video demonstrates the relationship between set frequency to delivered tidal volume during Pressure control ventilation. Reductions in compliance or increases in frequency decrease delivered VT.

Sunday, July 14, 2013

Don't waste my time! Physician Rounds.

Image from:

Physician rounds, ICU rounds, or multi-disciplinary rounds are very important in the care and treatment of mechanically ventilated patients. It is the only time (usually only once in a 24 hour period) that many specialties can share their concerns, ideas, and goals with the attending intensivist.  The attending physician is very busy, and  responsible for the over-site of many patients, so it is ideal to present your goals during rounds.

I have worked many places and still can't believe how RT's do not attend rounds or do not engage during rounds. These are usually the same RT's that complain that they do not have protocols or that ventilator management is by physician order only. 

"Its your own fault, your NOT allowed to manage the ventilator"

Sunday, July 7, 2013

Why is this patient on mechanical ventilation TODAY?

Photo from:

It is very frustrating when I meet with the ICU staff Respiratory Therapist and ask why is this patient on the ventilator today and I get the following response “they had surgery”, “they coded”, “they had ventilatory failure”, “they have ARDS”, etc. Yet, these events happened hours, days, or even weeks ago, and they are not in the acute stages of their illness anymore.  There is a huge difference between initial indications for mechanical ventilation (MV) versus current goals for MV.

Wednesday, July 3, 2013

The Infectious Disease Post

Before getting into Respiratory Therapy I was thinking about majoring in microbiology, specifically infectious diseases, so I have taken quite a bit of classes on the subject.

These last few months I have took an interest again on the subject, and have spent my down time researching through books, movies, a mobile game, and even a scavenger hunt.

This post is a hybrid part video/ part text so I would recommend watching the video first.
The references from the video are below:

Saturday, June 8, 2013

Wednesday, April 24, 2013

Limits of Pressure-Control Ventilation: a Introduction to the Mid-Frequency Simulator

In respiratory therapy school I was never taught about the various mathematical models of pressure-control ventilation (PC-CMV) and we probably only had a hour lecture on respiratory time constants. In clinical rotations PC-CMV was seldom used and had a bad reputation only being used on the sickest patients. This was due to the practice of utilizing  inverse-ratio ventilation in treating patients with ARDS and  serve hypoxia, which led to the administration of neuro-muscular blocking agents and poor outcomes.

Even today many practitioners are unfamiliar with the most versatile mode of ventilation (PC-CMV) and do not know how to optimize the settings. If one wants to have a understanding of the advance modes of ventilation, PC-CMV is were to start.

Wednesday, March 20, 2013

Assessment of Collateral Circulation of the Hand via Pulse Oximetry

The assessment of collateral circulation of the hand is performed often by surgeons, anesthesiologists, and Respiratory Care Practitioners (Cook, L, 2001; Galvin and Jones, 1989; Gerhring et al, 2002; Raju, 1986; Van de Louw et al, 2001) and Wisely and Cook, 2001). 

Surgeons may use this evaluation before performing a radial artery harvest for coronary artery bypass surgery, Anesthesiologists assess collateral circulation of the hand before arterial cannulation and Respiratory Care Practitioners check the collateral circulation before performing radial artery sticks for blood gas analysis. Each health care professional assesses collateral circulation of the hand for a different reason; however, they all primarily use the same evaluation technique.

Wednesday, February 27, 2013

Using the Quasi-Static Pressure/Volume Curve to Identify Optimal PEEP & Recruitability


In previous post I mention evaluating the static P/V curve to set P-High when using Airway Pressure Release Ventilation (aka. APRV, BiLevel, BiVent) and to set optimal PEEP.

Another advantage of analyzing the static P/V curve is to identify if the patients lungs are recruitable. If they are not recruitable, then they will most likely not respond to higher levels of PEEP or placing them on APRV. 

The above video demonstrates the difference between recruitable & Non-recruitable lungs. 

APRV: Setting P-High Based on the Static Pressure Volume Curve

Setting PEEP

The Constant Low Flow Method: Utilizing the PB840 part two

Identifying Optimal PEEP with the PB840 Ventilator: the Constant Low Flow Method

Friday, February 22, 2013

Obtaining Plateau Pressures Revisited

I receive many questions in regards to plateau pressure.

What is a plateau pressure?

What is the difference between Peak & plateau pressures?

How do I measure/obtain a plateau pressure measurement?

Are my peak & plateau pressures always equal when using pressure control ventilation?

How do I get a plateau pressure when using PRVC, AutoFlow, or VC+?

My new video (above) describes obtaining plateau pressure when using VC-CMV, PC-CMV, & APC (a.k.a. PRVC, AutoFlow, VC+). 

A review of Plateau Pressure

A Problem with Plateau Pressure

Why is my Peak & Plateau Pressures the Same? 

Tuesday, February 19, 2013

Floating Exhalation Valve

What is a floating exhalation valve?

What is the difference between a traditional exhalation valve and a floating one?

How do I know if my ventilator has a floating exhalation valve?

See my new video for answers. 


Sunday, February 10, 2013

APRV Preview Videos

The above video is an example of the content that is in my new course APRV, BiLevel, BiVent the Utilization of Airway Pressure Release Ventilation.

I posted four additional videos from this course on my YouTube page for review. 

Tuesday, February 5, 2013

APRV, BiLevel, BiVent FREE course

My new course is available FREE for the first 10 participants. 

  1. Go to the "COURSES" tab on top of this page.
  2. Click on the link provided.
  3. Use the following coupon code: xab5-1013-sal1-aprv

Sunday, January 20, 2013

Dumbing Down Ventilator Taxonomy

In a recent letter to the editor “Ventilatory modes. What’s in a name?”[1] Authors provide a strong argument for the need to standardize terminology in regards to mechanical ventilation and propose an oversimplified classification system specifically for non-invasive ventilatory devices. I applaud the authors for their call to action; conversely their viewpoint is neither novel nor applicable to ventilator taxonomy.

Thursday, January 17, 2013

FiO2 Titration Augmented by Artificial Intelligence

I have been a Registered Respiratory Therapist for greater than twelve years and have never considered the titration of oxygen a big deal. Furthermore, practicing at > 10 different facilities in eight different States I have never needed to be prompted by a physician or surveillance system to titrate the FiO2 during mechanical. Fortunately, I have only worked at facilities with respiratory care practitioner driven protocols. So when two recent articles were published on the subject within the last month I took notice [1, 2].

Sunday, January 6, 2013

Simplifying Mechanical Ventilation

From Global Nerdy @

In a recent letter to the editor “Ventilatory modes. What’s in a name?”[1] Authors provide a strong argument for the need to standardize terminology in regards to mechanical ventilation and propose an oversimplified classification system specifically for non-invasive ventilatory devices. I applaud the authors for their call to action; conversely their viewpoint is neither novel nor applicable to ventilator taxonomy.