RRT needs help. ED attendings giving poor vent settings

[keregg228]

I am currently an RRT Ill be starting an AA program soon. I had a question about the vent settings I have been getting in the ED.

I work at a couple mid sized hospitals throughout MI. I keep getting what I consider to be bad vent settings from the ED attendings (the residents actually have been giving better settings). I am get tidal volumes in the normal range of 6-10 mL for IBW (sometimes on the low end), but the rate and FiO2 are too high. We have an EtCO2 monitor on every tubed patient in the ED (which I compare with the ABG’s) and the vent settings are usually putting the patient’s CO2 between 30-35. This is not always when ICP is an issue. Also EVERY single patient no matter the diagnosis is placed on 100% O2. Every other patient has a pulmonology consult for a bronch b4 they make it to the unit for lobular atelectasis. They have no respiratory disease (most of the time) andhave been admitted for other issues. A lot of these people would be fine on RA or 40%. I understand there are reasons to put a pt on O2 just in case they have a certain dx that hasn’t been confirmed yet, but I don’t feel like every patients needs to be hyperventilated on a high FiO2. They also do not all need to be hyperventilated into hypocapnia. I am concerned that these settings are causing absorption atelectasis and hypocapnia. I have had issues with the ED attendings here before. I had to explain to an ATTENDING what BiPap was. Actually she was so ignorant I spent most of my break giving her a crash course in non invasive ventilation.

Anytime I suggest a vent change they always just agree with me. I only just recently finished my RRT and have not taken my boards yet. These Dr’s are terrifying me.

Should I stop asking for vent settings and just use my own? They always sign off on them. I am sick of seeing entire lungs collapse bc of absorption atelectasis.
Any suggestions?

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[Intensivist]

No you shouldn't. In order to perform certain medical procedures, to practise medicine, you should go to medical school. On the other hand, ER docs, aren't all that much exposed to vent's. Anaesthetist (MD) or any other intensivist should be informed of most of the patients on vents, atleast those who are ventilated b/c of pulmonary issues. While RTs no a lot about vent, they are still technicians, and not a doctors, therefore lack the extensive knowledge of medicine needed to make proper medical decisions.

 

[keregg228]

I am aware I am not a dr. that is why I would like the advice of a Dr. on how to correct this situation.

The ED dr.s at this particular hospital do not have many vents. They also have a lot of young attendings.

This hospital is having a hard time staffing intensivists. In the past they would come to the ED and give new (better) vent settings, but lately they are to short staffed and rarely make it to the ED.

I am concerned about patient safety. Should I start making suggestions to my attending? I feel like this is just as concerning though bc nine times out of ten they will just agree with me with no discussion (and I am not a dr. so I don't feel comfortable giving vent settings on trauma pts/peds).

If I know what unit the patient is going to I could call the intensivist on that unit and try to get vent settings (sometimes they call me and give me new settings, or do you think this would tick off the ED attendings? I think this would be the safest and the best idea I have come up with.

 

[SLUser11]

I am currently an RRT Ill be starting an AA program soon. I had a question about the vent settings I have been getting in the ED.

I work at a couple mid sized hospitals throughout MI. I keep getting what I consider to be bad vent settings from the ED attendings (the residents actually have been giving better settings). I am get tidal volumes in the normal range of 6-10 mL for IBW (sometimes on the low end), but the rate and FiO2 are too high. We have an EtCO2 monitor on every tubed patient in the ED (which I compare with the ABG’s) and the vent settings are usually putting the patient’s CO2 between 30-35. This is not always when ICP is an issue. Also EVERY single patient no matter the diagnosis is placed on 100% O2. Every other patient has a pulmonology consult for a bronch b4 they make it to the unit for lobular atelectasis. They have no respiratory disease (most of the time) andhave been admitted for other issues. A lot of these people would be fine on RA or 40%. I understand there are reasons to put a pt on O2 just in case they have a certain dx that hasn’t been confirmed yet, but I don’t feel like every patients needs to be hyperventilated on a high FiO2. They also do not all need to be hyperventilated into hypocapnia. I am concerned that these settings are causing absorption atelectasis and hypocapnia. I have had issues with the ED attendings here before. I had to explain to an ATTENDING what BiPap was. Actually she was so ignorant I spent most of my break giving her a crash course in non invasive ventilation.

Anytime I suggest a vent change they always just agree with me. I only just recently finished my RRT and have not taken my boards yet. These Dr’s are terrifying me.

Should I stop asking for vent settings and just use my own? They always sign off on them. I am sick of seeing entire lungs collapse bc of absorption atelectasis.
Any suggestions?

I think you are over-reacting big time. What vent rates are they writing for? You didn't include it in your post. Also, the FiO2 of 100% is probably because the ER docs don't want to pick a specific number, so they're leaving it up to the ICU to wean the O2 down. As long as you have a wean order, you can decrease the FiO2 to your heart's content.

ER docs are trained to provide some arbitrary vent settings that will keep the patient stable until the admitting team has a chance to see the patient and write new, more appropriate settings. The same goes for ER (and anesthesia for that matter) where I'm from.

Anyway, your post is loaded with self-righteous nonsense, and I doubt you have a legitimate fear for your patient's outcomes. The fact that you are terrified by relatively benign and common vent settings shows that you are inexperienced.

As far as your last comment, I agree with you that the best thing is to call the intensivist and get settings from them if the ER settings are bad. This is probably what the ER docs want anyway. DO NOT come up with your own settings or you will regret it when the patient crumps.

One final thought: Absorption atelectasis? Are you serious?

 

[poresofkohn]

I think you are over-reacting big time. What vent rates are they writing for? You didn't include it in your post. Also, the FiO2 of 100% is probably because the ER docs don't want to pick a specific number, so they're leaving it up to the ICU to wean the O2 down. As long as you have a wean order, you can decrease the FiO2 to your heart's content.

ER docs are trained to provide some arbitrary vent settings that will keep the patient stable until the admitting team has a chance to see the patient and write new, more appropriate settings. The same goes for ER (and anesthesia for that matter) where I'm from.

Anyway, your post is loaded with self-righteous nonsense, and I doubt you have a legitimate fear for your patient's outcomes. The fact that you are terrified by relatively benign and common vent settings shows that you are inexperienced.

As far as your last comment, I agree with you that the best thing is to call the intensivist and get settings from them if the ER settings are bad. This is probably what the ER docs want anyway. DO NOT come up with your own settings or you will regret it when the patient crumps.

One final thought: Absorption atelectasis? Are you serious?

+1


Let me get this straight......you're terrified with an end tidal of 35 on an intubated Pt?? Cripen hell, I wished I worked in that ED. Some PEEP should aleviate any atelactasis concerns.....absorbtion or otherwise. Who's tubing these Pt's? Perhaps you're "seeing entire lungs collapse" for some other reason.
If you ever find yourself with more pressing issues, get your medical director involved. Thats why we work under physician direction. I run a department in a small rural hospital, our hospitalists are top notch, but not intensivists and were trying to micromanage the vents. After a meeting with them, myself, and my medical director, we got some protocols in place and now they just leave blood gas parameters.



"hyperventilated into hypocapnia"..........Priceless.
Good luck in AA school.

ETA - Sounds like you're not exactly making friends in the ED, if you start making up your own settings without an order (or protocol) you're done for.

 

[keregg228]

35 EtCO2 is not what was terrifying (35 is fine as I am sure you are aware). It was the bad vent orders, and three patients with muti-lobular atelectasis (of about 6 total tubed pts in my last shift none of them had previous lung dz or injury to the chest or airways (none with bronchial intubation), one it was her entire left lung that collapsed) b4 they made it to the floor.

“ETA - Sounds like you're not exactly making friends in the ED, if you start making up your own settings without an order (or protocol) you're done for.”

I had no intentions of writing my own vent orders, but If I make any suggestions (like “the patient’s EtCO2 is 25 can I take the RR down a bit?”) they tell me to just write the vent order and then they promptly sign off on whatever I write without ever speaking to me about it. I think it is dangerous. It’s also only happening at the one hospital with 2-3 young attendings.

Thanks for your advice. Ill start calling the intensivist for vent settings the second I find out where the patient is heading.

 

[SLUser11]

35 EtCO2 is not what was terrifying (35 is fine as I am sure you are aware). It was the bad vent orders, and three patients with muti-lobular atelectasis (of about 6 total tubed pts in my last shift none of them had previous lung dz or injury to the chest or airways (none with bronchial intubation), one it was her entire left lung that collapsed) b4 they made it to the floor.

“ETA - Sounds like you're not exactly making friends in the ED, if you start making up your own settings without an order (or protocol) you're done for.”

I had no intentions of writing my own vent orders, but If I make any suggestions (like “the patient’s EtCO2 is 25 can I take the RR down a bit?”) they tell me to just write the vent order and then they promptly sign off on whatever I write without ever speaking to me about it. I think it is dangerous. It’s also only happening at the one hospital with 2-3 young attendings.

Thanks for your advice. Ill start calling the intensivist for vent settings the second I find out where the patient is heading.

3 out of 6 sounds like a pretty small sample size to make broad generalizations about the incompetence of the ER docs you work with. If you currently have a good relationship with these docs, I would recommend not rocking the boat too much, as it will ruin your relationships and it's unlikely to improve patient care. I would definitely limit the number of "crash course" lectures you give to physicians....not all of them will be very receptive.

I just can't shake the feeling that you've gotten too big for your britches, and if you don't chill out, I'm afraid someone you work with will decide to take you down a peg, which is universally unpleasant. This phenomenon is not limited to RTs, and med students/residents/etc. have all demonstrated this arrogance.

So, what were those vent rates I asked about?

 

[Paseo Del Norte]

Ummm, absorption atelectasis because a patient was placed on an FiO2 of 1.0 following an ER intubation? End tidal CO2's of 25 and PaCO2's of 35 are scary?

From what I gather, the ER is doing exactly what the ER needs to do. You receive an intubated patient who is receiving relatively conservative tidal volumes with "normal" gases. What exactly is the problem? The FiO2 will most likely be titrated down under the ICU intensivist or pulmonologist, so why exactly are you complaining? Certainly not because of a "study" where n=6?

I pretty much have to echo Poresofkohn.

 

[Coastie]

Absorption atelectasis is indeed a theoretical concern, but I'm not sure how clinically significant it is...

http://bja.oxfordjournals.org/content/99/6/769.full

That being said, the ED attendings should know better than to place patients on 100% fio2. Unless necessary, it's just sloppy medicine...

I wouldn't worry about the ETCO2.

The tidal volumes of > 10 cc/kg would be a bit concerning, though. How high are they going?

 

[KYTNOH]

I am currently an RRT Ill be starting an AA program soon. I had a question about the vent settings I have been getting in the ED.

I work at a couple mid sized hospitals throughout MI. I keep getting what I consider to be bad vent settings from the ED attendings (the residents actually have been giving better settings). I am get tidal volumes in the normal range of 6-10 mL for IBW (sometimes on the low end), but the rate and FiO2 are too high. We have an EtCO2 monitor on every tubed patient in the ED (which I compare with the ABG’s) and the vent settings are usually putting the patient’s CO2 between 30-35. This is not always when ICP is an issue. Also EVERY single patient no matter the diagnosis is placed on 100% O2. Every other patient has a pulmonology consult for a bronch b4 they make it to the unit for lobular atelectasis. They have no respiratory disease (most of the time) andhave been admitted for other issues. A lot of these people would be fine on RA or 40%. I understand there are reasons to put a pt on O2 just in case they have a certain dx that hasn’t been confirmed yet, but I don’t feel like every patients needs to be hyperventilated on a high FiO2. They also do not all need to be hyperventilated into hypocapnia. I am concerned that these settings are causing absorption atelectasis and hypocapnia. I have had issues with the ED attendings here before. I had to explain to an ATTENDING what BiPap was. Actually she was so ignorant I spent most of my break giving her a crash course in non invasive ventilation.

Anytime I suggest a vent change they always just agree with me. I only just recently finished my RRT and have not taken my boards yet. These Dr’s are terrifying me.

Should I stop asking for vent settings and just use my own? They always sign off on them. I am sick of seeing entire lungs collapse bc of absorption atelectasis.
Any suggestions?

First off, calm down. You're stressing way too much.

I'm and EM resident who has managed vents in the ER and in the ICUs.

1. Everyone gets started on 100% FiO2 because hypoxia is always worse than normal oxygen levels. As long as you wean your FiO2 in 24-48 hours there is essentially no risk of oxygen toxicity.

2. pCO2 levels of 30-35 aren't bad physiologically. CO2 levels really don't mean much physiologically in the intubated patient anyways as long as they are compensating decently well. The reason we are concerned about CO2 in an intubated patient has to do primarily with pH. If you're going to choose your pH to be either high or low, choose low. Our proteins work much better in an acidotic state than they do in an alkalotic state.

3. Tidal volumes of 6-10 ml/kg of ideal body weight especially if they're on the low end.....That's pretty good. Current recommendations say 5-7ml/kg of ideal body weight to avoid volutrauma.

4. There aren't many people that actually believe in absorption atelectasis. At least in regards to it being clinically relevant. If you're concerned about it just ask to put them on 95%.

The ER is doing exactly what they need to do. And I can tell you that no ER doc in the world is going to complain if you wean their FiO2 to keep sats at 92% or greater.

 

[JackBauERfan]

I am currently an RRT Ill be starting an AA program soon. I had a question about the vent settings I have been getting in the ED.

I work at a couple mid sized hospitals throughout MI. I keep getting what I consider to be bad vent settings from the ED attendings (the residents actually have been giving better settings). I am get tidal volumes in the normal range of 6-10 mL for IBW (sometimes on the low end), but the rate and FiO2 are too high. We have an EtCO2 monitor on every tubed patient in the ED (which I compare with the ABG’s) and the vent settings are usually putting the patient’s CO2 between 30-35. This is not always when ICP is an issue. Also EVERY single patient no matter the diagnosis is placed on 100% O2. Every other patient has a pulmonology consult for a bronch b4 they make it to the unit for lobular atelectasis. They have no respiratory disease (most of the time) andhave been admitted for other issues. A lot of these people would be fine on RA or 40%. I understand there are reasons to put a pt on O2 just in case they have a certain dx that hasn’t been confirmed yet, but I don’t feel like every patients needs to be hyperventilated on a high FiO2. They also do not all need to be hyperventilated into hypocapnia. I am concerned that these settings are causing absorption atelectasis and hypocapnia. I have had issues with the ED attendings here before. I had to explain to an ATTENDING what BiPap was. Actually she was so ignorant I spent most of my break giving her a crash course in non invasive ventilation.

Anytime I suggest a vent change they always just agree with me. I only just recently finished my RRT and have not taken my boards yet. These Dr’s are terrifying me.

Should I stop asking for vent settings and just use my own? They always sign off on them. I am sick of seeing entire lungs collapse bc of absorption atelectasis.
Any suggestions?

Wow I haven't posted in a long time but this one sparked my interest ha.

I'm an EM person, doing a critical care fellowship. You are off on a few things.

First of all, you still haven't answered SLuser about rate. I have always been under the impression that a rate of 12 is ok, but it really does depend on what you want for the CO2. You really can't go wrong with this initially unless you have a situation like copd/asthma exacerbation where you want to keep the rate maybe even below 10, or salicylate tox where you may want to keep above 25. But in general, unless you start following CO2 levels, you can do pretty much anywhere between 10-20 and be find. I know some docs who beleive that you have to be at 16-18 to make up for CO2 production...

You're right FiO2 should be titrated to less than 60% pretty much as soon as you can. I personally intubate, then sit there and start titrating down while the residents are getting ng tube, resus patient, all the other things that are involved with emergency care. Sometimes I can't get it down but most of the time within 5 minutes of intubating i'm down to 40% fiO2 +/- Peep. There have been studies done showing PO2 levels greater than 300 on admission to ICU might be as bad as PO2's less than 60. Generally its thought a PO2 greater than 60 is ok.

I dont think anyone will argue with you if you titrate it down to keep sats greater than 90% (some say 93% because there is a possible 3-5% range for accurate spO2 monitoring).

Absorbtion atelectasis, I'm not even going to mention.

Left lung opacified? are you sure it wasnt' in the right mainstem? sounds odd for one lung to be bad unless it was a bad pneumonia to start with, not just from whatever absorbtion atelectasis process.

Dont' worry even if you think most ED docs are 'just signing off on whatever you change' they are prob checking without you knowing. Also, they assume you did some training and are not going to do something stupid like put a rate of 40, or tidal volume of 2000 mL. I actually dont' trust anyone so rarely sign of on stuff like that, but once I know a respiratory tech, I do listen to them a good bit since it is kind of what they do.

Tidal volume of 6-8 mL/kg is what is recommended, and most studies show less is better. in the Ardsnet, they even go to 4mL/kg so I'm not sure hwat you are worried about. Back in the old days (i guess like 10 years ago), 10-12 was standard, but that has pretty much fallen out of favor.

Ok, so don't worry., you are not the ED doc, and you are not killing the patients.

 

[Hernandez]

1. Everyone gets started on 100% FiO2 because hypoxia is always worse than normal oxygen levels.

why? i see this all the time in hypercarbic respiratory failure PTs from the ED, if oxygenation isn't an issue, why go over board and start on 100%?

3. Tidal volumes of 6-10 ml/kg of ideal body weight especially if they're on the low end.....That's pretty good. Current recommendations say 5-7ml/kg of ideal body weight to avoid volutrauma.

who's recommendations and for what conditions?

 

[Paseo Del Norte]

why? i see this all the time in hypercarbic respiratory failure PTs from the ED, if oxygenation isn't an issue, why go over board and start on 100%?



who's recommendations and for what conditions?

ARDS net appears to have been the initial driving force behind lower Vt ventilation. They published a paper comparing 12 ml/kg to 6 ml/kg Vt's. There was fairly significant evidence that lower Vt's were helpful in managing ARDS patients. The ventilator protocol card that can be downloaded from their site recommends starting around 8 ml/kg of IBW then decreasing by 1ml/kg based on static pressures (Pplat). I believe they recommend going as low as 4 ml/kg if needed.

Of course, this is specific to ARDS and ALI patients. I believe they look at the PF ratio and radiographic findings as inclusion criteria for lower Vt ventilation strategies. Over the years, this lower Vt concept seems to have evolved into the concept of "lung protective" ventilation strategies and is being used on patients with "normal" lungs. I cannot quote any literature about low Vt's and patients without ARDS, but it does seem intuitive that you would want to avoid high volumes and pressures in patients with healthy or relatively healthy lungs.

 

[Hernandez]

ARDS net appears to have been the initial driving force behind lower Vt ventilation. They published a paper comparing 12 ml/kg to 6 ml/kg Vt's. There was fairly significant evidence that lower Vt's were helpful in managing ARDS patients. The ventilator protocol card that can be downloaded from their site recommends starting around 8 ml/kg of IBW then decreasing by 1ml/kg based on static pressures (Pplat). I believe they recommend going as low as 4 ml/kg if needed.

Of course, this is specific to ARDS and ALI patients. I believe they look at the PF ratio and radiographic findings as inclusion criteria for lower Vt ventilation strategies. Over the years, this lower Vt concept seems to have evolved into the concept of "lung protective" ventilation strategies and is being used on patients with "normal" lungs. I cannot quote any literature about low Vt's and patients without ARDS, but it does seem intuitive that you would want to avoid high volumes and pressures in patients with healthy or relatively healthy lungs.

my question was somewhat rhetorical as im a pulm-cc fellow, im aware of the data and the reasoning, but I am unaware of any recommendations for 5-7ml/kg TV in a non-ARDS pt by any ATS/ACCP or other organizations. the actual recommendation is what i would like to see,

and the lung protective strategies only applies if you think that volume is the sole determining factor in barotrauma. I fall into the pressure-induced trauma not the valu-trauma group as tht makes more sense to me as compliance is a major factor in determining how much pressure a set TV will require to generate. and using less than 6mL/kg in a non-ARDS PT very well can leave you with a dyschronous pt on the vent.

 

[Paseo Del Norte]

my question was somewhat rhetorical as im a pulm-cc fellow, im aware of the data and the reasoning, but I am unaware of any recommendations for 5-7ml/kg TV in a non-ARDS pt by any ATS/ACCP or other organizations. the actual recommendation is what i would like to see,

and the lung protective strategies only applies if you think that volume is the sole determining factor in barotrauma. I fall into the pressure-induced trauma not the valu-trauma group as tht makes more sense to me as compliance is a major factor in determining how much pressure a set TV will require to generate. and using less than 6mL/kg in a non-ARDS PT very well can leave you with a dyschronous pt on the vent.

I agree and I am unaware of any evidence supporting very low Vt's in patients without said issues. However, it seems that I've seen a fair number of people apply this concept to patients without said issues in the name of "lung protection." I had a protocol where I work that allowed us to use lower than 6 ml/kg and it was recently updated to ensure that we were only using less than 6 ml/kg with patients that meet specific criteria as there were some people who ended up on incredibly low Vt's, and we are cut off at 5 unless we have orders to go lower. In all honesty, I typically match the sending facilitie's settings if they seem fairly reasonable. I guess that's why I replied to this thread, because the settings the OP described do not seem unreasonable for a newly intubated ER patient.

I would think you would still want to be reasonable with with volumes and static pressures, but would question using very low volumes on patients with healthy lungs.

As I recall, the OP was not concerned with Vt's and I think he said the ER Docs were going with 6-10?

 

[Intensivist]

Anyone involved in CC should know much about ARDSnet therefore, no need to explain it on here.
Liberal volumes are OK for a patient with healthly lungs for a while, after you're confirmed that there is no pathology. But using these same volumes long term will cause you ALI and maybe ARDS.

 

[michigangirl]

keregg228-- First off, I want to say your heart is in the right place even if your reasoning isn't completely correct. And for the first few posters that were completely rude-- this RT is simply coming here for some help and to find out what they can do better because they have concerns-- why do we have to go and get all offensive? How can someone who just admitted they just finished their RT training be too big for their britches? They are simply stating that based on their current knowledge base they are concerned and are looking to "experts" for advice-- and apparently some of these "experts" are residents.

It's not unreasonable to start off on 100% WITH the caveat that you have weaning parameters that enable you to wean quickly based on sats and/or blood gases. Also, depending on a patients baseline CO2, it might not be acceptable to hyperventilate to a rate that creates a CO2 so low that might affect other physiologic parameters, i.e. if the patient is a COPD'er whose CO2 is usually 55, it's not acceptable to drop it to 35 once intubated-- this is too far to the left of the patient's autoregulation curve. The ETCO2 may not be an appropriate indicator of the actual arterial CO2, which complicates management in the ED even more, and brings in the need for blood gases. So if the ED physicians are swamped or you need extra guidance, then it's completely appropriate to discuss with the accepting ICU docs-- this is a complex discussion that I could write paragraphs about, but bottom line-- if it's a healthy person with normal lungs, 100% and 10 cc/kg volumes aren't going to be harmful in the short term until they get to the ICU. It's the patients with multiple comorbidities that vent management gets tricky and may need to be stepped up to the next level.

I appreciate you being proactive and voicing your concerns. You don't have to rock the boat to do the right thing-- simply call the appropriate people if you need help and learn along the way and you'll be fine.