Changing Flow Patterns vs. Changing Ventilator Modes

Figure 1: Various flow patterns within VC-CMVs on the Hamilton G5 Ventilator.

When a device operator thinks about changing the inspiratory flow pattern while administering a Volume-Controlled breathing pattern they do not assume it will change the mode of ventilation. 

However newer software in the Servo-i allows the operator to change the flow pattern 

from the traditional constant flow pattern, to either a fully decelerating  flow pattern (similar to PC-CMV) or to adaptive flow (Fig. 2).  The Adaptive Flow pattern was the default in older software which makes Volume Control a Dual Control mode [1].  The operator now has a choice of using Volume Control as a traditional VC-CMV mode by selecting the square waveform or providing a Dual Control breathing pattern by selecting the Adaptive Flow icon. 

Figure 2: Flow patterns available on the Servo-i, courtesy of Robert Chatburn. 

For more information on flow patterns and Dual Control see the below links.

DUAL CONTROL

Dual Targeting Schemes

FLOW PATTERNS

Flow Patterns & Flow Rates

RELATED POSTS

1. The Volume Control Ventilation Fallacy

    Targeting Schemes

Don't waste my time! Physician Rounds.

Image from: http://house.download-tvshows.com/files/Hugh%20Laurie_1.jpg

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". 

Why is this patient on mechanical ventilation TODAY?

Photo from: http://theprogressivepatient.wordpress.com/2012/04/22/6/

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.

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].

Sun Glasses at Night?

http://en.wikipedia.org/wiki/Sunglasses_at_Night


In his 1984 single “Sunglasses at Night” singer Corey Hart sings about wearing his sun glasses to watch his lover, as she lies and cheats on him or this is what I think the lyrics mean? I’m not one to decipher song lyrics; I just thought it was a pretty catchy tune when it was first released. Wearing sun glasses at night seems pretty idiotic, but what about night shift workers wearing sun glasses?


 

Dead of Night shift

http://en.wikipedia.org/wiki/File:DeadOfNight1.jpg

After six years of being a day walker I have returned to my origin as a night shift healthcare provider. I enjoy the pace and the autonomy of night shift however, it is sometimes torturous. 

I feel like “Walter Craig” in the 1945 British film “Dead of Night”, in which the character experiences a recurring nightmare with the same cast of house guests. Instead of “Pilgrims Farm” I’m stuck in a hospital interacting with it's own recurring cast of personalities; the non-compliant patient, the substance abuse patient, the medical resident who thinks he’s M.D. “House”, the nurses who are fueled on cigarettes & Red Bull.  Yes, I’m dead of night shift; indifferent, cold, and apathetic. Additionally, night shift is slowly killing me.

Night shift work has been associated with a number of maladies including:

Metabolic syndrome [1& 2]

Increased vascular stress [3 & 4]

Induced Apnea [5]

In regards to me it is vitamin D deficiency. Yearly, I have a few blood tests performed to check for abnormal values. Before returning to night shift my previous vitamin D levels were normal, I lived in the Midwest, and had no additional vitamin D supplementation. After starting night shift I began supplementing my vitamin D intake with 1000 micro units/day & I also moved to the east coast (more sun), conversely my results were below normal. I always have these test performed in February, so the amount of sunlight/day/month is not a factor.

[1] Biggi, N. et. Al. (2008). Metabolic Syndrome in Permanent Night Shift Workers. Chronobiol Int.

[2] Pietroiusti, A. et. Al. (2010). Incidence of Metabolic Syndrome Among Night-Shift Healthcare Workers. Occup Environ Med.

[3] Lo, SH. et.al. (2010). Working Night Shift Causes Increased Vascular Stress and Delayed Recovery in Young Women. Chronobiol Int.

[4] McCubbin, JA. et. Al. (2010). Blood Pressure Increases During a Simulated Night Shift in Persons at Risk for Hypertension. Int J Behav Med.

[5] Laudencka, A. et. Al. (2007). Does Night-Shift Work Induce Apnea Events in Obstructive Sleep Apnea Patients? J Physiol Pharmacol.

Oral Exam: 99.9 % Failure Rate Among ICU Nurses

Question 1. What is pictured in image 1?

Image 1

Question 2. What is it used for?

If you answered “Bite Block” you must be an ICU nurse.

 I cannot count how many times nurses have tried to use the “oropharyngeal airway” as a bite block and complain about how the patient is fighting the tube & airway, gagging, and fighting the ventilator.

The next step, they usually heavily sedate or paralyze the patient.

An oropharyngeal airway is to help keep the airway patent (open) & should not be used in the conscious patient with a gag reflex.

Now this is a bite block (image 2), which can be used for that patient biting on an  E.T. tube. 

Image 2 "Bite Block"