Emily Damuth, MD

Preventing ventilator-induce lung injury (VILI): Optimizing PEEP titration in ARDS

Lung-protective mechanical ventilation with low tidal volume and restricted plateau pressure improves survival in ARDS. However, the optimal approach to PEEP titration to minimize VILI is still debated. Should oxygenation, lung compliance, driving pressure or transpulmonary pressure guide adjustment of PEEP in ARDS?

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Leave the sedation alone! Diagnosis and management of patient-ventilator asynchrony

Patient-ventilator asynchrony is underrecognized yet associated with increased mortality, ICU length of stay and duration of mechanical ventilation in critical illness. How do you diagnose and treat it? Hint: the answer is rarely deep sedation or paralysis!

 

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Management of status epilepticus

A 72-year-old man develops generalized tonic-clonic activity at home. He receives lorazepam 4 mg intravenously during the 7-minute transport to the ED. He continues to have witnessed convulsions on your examination. Point-of-care glucose is normal. After supporting his airway, breathing and circulation, what medication should be administered second line for status epilepticus (SE)? 

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#Name that Mode…and a ventilator alarm is firing!

An 82-year-old woman is mechanically ventilated for acute respiratory failure following acute intracerebral hemorrhage. Her FiO2 has been 30% with an arterial blood gas showing adequate ventilation and oxygenation for the last 24 hours (7.43/37/89/25). Suddenly, the ventilator alarms for low exhaled tidal volume. On bedside evaluation, her SpO2 is 84%, respiratory rate 20 breaths per minute, HR 124 beats per minute and blood pressure 105/65 mm Hg. Her ventilator graphics before and after the alarm are depicted below. What mode of mechanical ventilation is she receiving and what triggered the alarm? 

 

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Deviation from Standard ACLS: Esmolol for Refractory VF/VT

You have a patient in cardiac arrest getting high quality CPR with an initial rhythm of pulseless VT that has been defibrillated three times and received a total of 3 mg of epinephrine and a loading dose of 300 mg of amiodarone. As you continue ACLS, the patient remains in VT. Are there alternative treatments to consider? 

 

 

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Tracheostomy Emergencies

A 44-year-old man with a history of cardiac arrest complicated by hypoxic-ischemic encephalopathy presents to the ED in respiratory distress. He underwent tracheostomy 2 weeks ago for acute respiratory failure and was subsequently weaned to trach collar. He developed acute onset of respiratory distress at rehab this morning and now presents to the ED with acute hypoxic respiratory failure. On exam, he is hypertensive (169/88), tachycardic (HR 178), tachypneic with respirations assisted with bag-valve mask (BVM) ventilation and hypoxemic (SpO2 87%). What is your approach to the management of tracheostomy emergencies?

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Mechanical Ventilation Alarms: High Airway Pressure

You are called to the bedside of a mechanically ventilated patient for an alarm that is being triggered on the ventilator. In red and blinking you see “Airway pressure high.” What’s your next move?

 

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Ventilator graphic analysis: Obstructive lung disease

Analyzing ventilator waveforms in a patient with acute respiratory failure is as essential as monitoring the telemetry of a patient with suspected cardiac dysrhythmia. What life-threatening complication is demonstrated in the ventilator graphics? 

 

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Pressure regulated volume control (PRVC): Is it a “volume control” or “pressure control” breath?

Dr. Phil Dellinger, master of mechanical ventilation, breaks down Pressure Regulated Volume Control (PRVC) by discussing the breath type delivered in this mode of mechanical ventilation.  

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