EMerging Insights is a new educational series that is intended to increase the breadth of knowledge and exposure to medical literature for our residents. It is intended to be a brief update about new and interesting emergency medicine literature, as well as summarize foundational trials/studies that will help residents hone their skills and remain up-to-date in the ever-changing landscape of medicine.
This series is designed to take journal articles and present the information in a simplified, distilled format. Additionally, related clinical pears are to help with clinical practice, reiterating knowledge to perform evidence based medicine.
This first article is not novel, complex, or even lengthy. It is a clinical management piece. However, it is regarding a topic that many are unsure about, but is at the foundation of emergency medicine practice; right next to intubation. Literally.
Managing Initial Mechanical Ventilation in the Emergency Department
TLDR:
Almost always employ a lung protective strategy to reduce barotrauma and volutrauma. This means low tidal volumes. Tidal volumes are set using the patient’s IDEAL body weight. You can start at 8mL/kg. Inspiratory flow is for the patient's comfort, and can be started at 60 L/min. Respiratory rate is titrated to the illness/acid-base status and PEEP/O2 are adjusted for oxygenation. FiO2 can be titrated down to 30-40% with a PEEP of 5 after intubation.
The only patient’s which need to stray from the lung protective strategy are asthmatics/COPD. Here, we want to avoid air trapping and barotrauma. Ideally, avoiding intubation is the best course of action, however, alternate ventilator management is needed if intubation is required. The change is in the respiratory rate setting, starting at 8-10 breaths/min and titrated. Increased expiratory time will result in hypercapnia, to be permissive in these patients.
VENTILATION = RR and I/E time, titrating to pH and PaCO2
OXYGENATION = PEEP and O2, titrating to SpO2 and PaO2
FYI: A great tool and resource is your EMRA Ventilator Management Card!