Vent question/concerns

[larocca465]

Most of my experience is on a 911 unit.....I am fairly new to the inter-facility thing and noticed recently I have developed a fear of vent patients. Would anyone be able to give me some insigt on portable vents used in transports?

[Timmy]

Insight ay? Well it pumps air into the patient

Nahh, I’m not sure what you mean? I hate vents to! My mum recently had some surgery done on her hand and the bloke next to us was on a vent, I hated it! The noise is horrible! The machine is so big and has so many buttons, screens, noises ect…

When I did my EMT course they sorta touched on vents but didn’t really explain it in much detail. It was a little red box with a little screen and a hose. They pretty much said the IC medic intubated the patient, they’d calibrate to how ever much 02 the patient needed and the only time we could touch it was if they arrested, then we have permission to rip off the hose and clip on a BVM.

[VentMedic]

What is your background for education and certifications?

Which ventilator are you using?

Here's a starter for some basics.

http://www.ccmtutorials.com/rs/index.htm

There are many different transport ventilators (at least 12 popular ones come to my mind now) in the field from the very simple to the complex. Knowing your equipment VERY WELL with the help of the ventilator rep and/or a Respiratory Therapist would be a good start.

Just getting the "just turn this knob and that knob" lesson from someone else who only has a tiny bit of knowledge doesn't always work if you don't understand why you're turning those knobs and the possible consequences. Integrating patient and machine can be difficult at times. That is why there are many different ICU machines and each have many different modes.

Knowledge and hands on practice will ease your fears somewhat.

Volunteer at a sub-acute facility for a couple shifts. (Sub-acute as in a ventilator nursing home) You'll learn airway maintenance and clearance as well as moving patients from point A to B like into the showers with their ventilators. Not the same as critical care but it will get you comfortable with several different portable ventilators and airways. In each facility, you'll find about 40 - 60 ventilator patients to check out. Each patient will have a different reason for being on the ventilator and can be high maintenance for the RT staff. There's a good possibility that these sub-acute patients will be your patients somewhere down the line also depending on the type of service you are with.

Critical care experience will teach you more about the pharmacological and hemodynamic aspects of the ventilator patient.

And don't forget the filters to protect the ventilator and yourself from exposure to the microbes of the pulmonary system.

[RedZone]

I try to learn about things. It's in my nature. When I have a question, I find someone qualified and ask them. But, if your service is like the ones I've worked with, they'll offer you little training. Here's a few pointers:

First off, ALWAYS carry an ambu-bag with you.

You probably won't have to worry about prescribing any settings. You're transferring a patient and maintaining them on their prescription. Always get a verbal report of the patient's vent settings, preferably from the respiratory therapist.

ALWAYS carry an ambu-bag with you.

If you notice mild signs of hypoxia or a dropping oxygen sat, increase the FiO2

ALWAYS carry an ambu-bag with you

Keep the connection between patient and vent visibile. That is, don't cover the trach with a blanket. The vent tubing likes to pop off a lot, so you'll have to replace it. You'll get used to hearing the sound of air leaking, and the vent will "Low Pressure" alarm.

ALWAYS carry an ambu-bag with you

High Pressure usually means the patient coughed. If it's consistent, suction the trach.

ALWAYS carry an ambu-bag with you

And, what's the big deal? No reason to be scared at all. If anything goes wrong, all you have to do is bag the patient. You did carry an ambu-bag with you, right?

As far as all the settings.... yes, take the time to learn about them all. And since you're going to become familiar with respiratory therapists, don't ever be afraid to ask them questions... they know a hell of a lot.

[JPINFV]

You probably won't have to worry about prescribing any settings. You're transferring a patient and maintaining them on their prescription. Always get a verbal report of the patient's vent settings, preferably from the respiratory therapist.

Wow, so wrong for so many reasons. I've done my fair share of vent transports with RTs as a basic [if the patient's on a vent, my company sends a RT, even if an RN is going] where settings were changed. It's been as simple increasing the ventilation rate because the patient stopped triggering the vent for what ever reason (it was set to 6/min when we arrived) to completely changing the vent settings to help stabilize a patient for transport post surgery. Each vent is different and not every patient will tolerate every machine the same.

[Dustdevil]

Wow, so wrong for so many reasons. I've done my fair share of vent transports with RTs as a basic [if the patient's on a vent, my company sends a RT, even if an RN is going] where settings were changed.

I think his point was that, if those settings are changed, it will not be you -- the EMT -- who is responsible for changing them. It will be the RRT. The most you are going to have to do is to bag this patient while the RT troubleshoots a crapped out machine, or maybe help him set up to suction.

[larocca465]

We use the LTV 950, normally a RT doesn not accompany us nor does a RN, just the medic and myself.

Thanks for the adivce so far, I will try to get some time on a vent care center nearby- that is a great idea. As a basic I know vent operation is'nt my responsibilty, but I like atleast knowing the basics of it and at my service getting guidence or answers is harder then pulling teeth from a live wallrus.

[chbare]

This is a very complex subject. I find that it is difficult to simply go with the hospital settings. The additional stimulation and stress of the prehospital environment will usually require additional sedation, analgesia, vent changes, and perhaps neuromuscular blockade.

I cannot comment on the specifics of the LTV, as I use the Crossvent 4. I would urge you to obtain as much additional education on vent management as possible.

Things to consider with ventilators include:

Type of ventilation: Volume vs Pressure

The mode: SIMV, IMV, PS, etc.

Tidal Volume: usually calculated at 6-8ml/kg of lean body weight. May vary and lower tidal volumes may be used in specific conditions such as ARDS.

Rate: Will vary according to the patient condition.

Flow: Flow of oxygen/air, generally adults are most comfortable when the flow is around 40 lpm, but this will vary according to patient condition. A down and dirty basic calculation is to add 6lpm per every 100ml of tidal volume.

FIO2: Will vary according to patient condition.

Peak Pressure: indicator of airway pressures and resistance. Generally I try to keep below 35, very high pressures can result from disease or equipment issues such as a kinked tube or obstruction. Always ensure proper connection to tubes and vent with very low pressures.

Plateau pressures: Indicator of actual pressures in the lower lung tissue and indicator of specific types of air flow through passages. ( Turbulent, etc) This is a very important indicator of pulmonary damage and the development of ARDS. Try to keep below 30 if possible.

PEEP: Positive pressure at the end of exhalation, used in a variety of conditions and can assist with oxygenation and recruitment of alveoli.

I:E Ratio: I: amount of time spent inhaling, E; amount of time exhaling. Generally we allow for more time to exhale. If you look at a regular breath, one inhalation and exhalation. The amount of time inhaling would be similar to the I time, while the time it takes to exhale would be similar to the E time. Generally, we shoot for 1:2-1:3.

Many complications and pitfalls exist with ventilator management. In addition, this all must be taken into consideration along with your patient assessment, end tidal CO2 management, labs, and vital signs.

This topic is too complicated to adequately discuss on this forum. I have given you a few basic concepts to study and hopefully if you can understand these with additional education, you will begin to put the pieces of this complex puzzle together.

Take care,

chbare.

[tniuqs]

Most of my experience is on a 911 unit.....I am fairly new to the inter-facility thing and noticed recently I have developed a fear of vent patients. Would anyone be able to give me some insigt on portable vents used in transports?

Well I think that FEAR of the unknown is a GOOD Thing!

The reason there is this specialty area.... the so called RRT is for very good reason, Ventilation can be quite a complex area this on top of all the "flavours" of Ventilators as well, how the Vents work is as important as the interactions of pulmonary patho.

oh yes ALWAYS carry an ambu-bag with you.

Get as much training as you can, as questions of the toothless walrus, if they are good at what they do, they will want to educated you.

ps an educated hand is very important as well.

cheers

[RedZone]

Wow, so wrong for so many reasons. I've done my fair share of vent transports with RTs as a basic [if the patient's on a vent, my company sends a RT, even if an RN is going] where settings were changed. It's been as simple increasing the ventilation rate because the patient stopped triggering the vent for what ever reason (it was set to 6/min when we arrived) to completely changing the vent settings to help stabilize a patient for transport post surgery. Each vent is different and not every patient will tolerate every machine the same.

You're talking about a much different scope of practice. An RT has a hell of a lot more training than a medic does. A medic might get a one hour lecture on how to operate a vent, an RT will have a few years. An experienced interfacility medic will be able to "tweak" settings, but generally that's probably pushing on a fine line of stepping outside of our scope.

I am also not referring to medics who have taken advanced critical care programs. But not all regions utilize this level of training.

Also, medics don't stabilize patients for transport, we either stabilize as first line of care (pre-hospital), transport to facilities for stabilization (e.g. - pt unable to be stabilized without specialty care), or transport already stabilized patients. Patients becoming unstable during transport would probably fall under the pre-hospital care category. Post-op stabilization... outside of a medic's scope.