Thank you 👋 for the encouragement. I would love to expand the channel by having other clinicians discuss various topics. [email protected] Please let me know if you ever want to join a livestream and chat. You can pass my email around if ever someone would like to present something on my channel they can.

We don't have HFOV, but I'm working on it. I also need to convince my boss to have esophageal balloons for those rare cases (7 Liter + fluid) with obviously insanely high pleural pressures. If the EIT is saying 48 cmH20, P-HIGH is optimal, I would like that variable added to the clinical picture. Thinking a Plateau below 30 cmH20 is always safe with these patients increases mortality, but without EIT or pleural pressure, we are flying the plane blind. I had a case with a P-High of 45 cmh20 being optimal. It opened this severely collapsed lung (baby lung). Patient 7+ liters. Went to OR and eventually was 12 + liters. They called, and I said increase P-high further because volume was down to 125 ml. Instead, they were scared and lowered P-low for more of a deltaP. That increased volume for 1 hour, then lung closed never to open again. The transpulmonary pressure was not taken into consideration. The increased P-high would not have been transmitted to overdistention, in my opinion. The atelectrauma is the real killer, in my opinion. Anyways, this was a crazy case where family was pushing to continue treatment instead of letting go.

This is the only darn thing that's missing. The PulmoVista 500 has an esophageal ballon module that they are making to add to the electrical impedance tomography device. I don't know if it's on the market yet. I am working on getting this in our ICU also. Thanks for commenting 🙂

You set the T-High lower, creating more releases that will be equivalent to setting an RR. So, set the desired minute ventilation and adjust when you get your blood gas.

The orange indicates a loss in compliance compared to your reference when looking at regional compliance. You're always comparing a reference and control. Blue means that compliance is improving. There are % values that indicate the degree compliance change.

Here is a video that will explain the basic panels of the PulmoVista 500 so you know what you're looking at. kzbin.info/www/bejne/rnSamn96i82fZpo Make sure to subscribe and press notifications. I will be starting live streams on this channel where I can answer questions in real time. I can also invite people onto the stream to chat also. I do that on my other channel, and it's awesome

You set it on conventional with the protective lung strategy. The optimal PEEP in ACVC will give you the best Pdrive (delta P), and from that, you use the Pplat as a good "starting" point for Phigh setting. It's just gives you a good starting point.

It's because APRV can feel foreign to new users. So, helping to decide a good starting point, Pplat from ACVC with optimal PEEP, lowest Pdrive & 6 to 8 ml/kg VT........whatever the Pplat is try starting there. From that initial setting, you adjust. I could start doing a livestream where we can all discuss these topics and other topics on mechanical ventilation.

Hi 👋 Thanks for visiting my small channel. The 75% of peak expiratory flow for setting T-low is using (TCAV) TIME CONTROLLED ADAPTIVE VENTILATION. The P-low is set at zero. Breath is stopped when expiratory flow reaches 75% of PEF. This purposely causes auto peep which is your measured Plow found by expi. Pause. Dr. Nader Habashi developed the TCAV protocols. Many published articles on APRV/TCAV. Here are some really cool Drager sponsored lectures where they go into details about the APRV/TCAV. 75% calculation creates the most stable alveolar network. So it's not my professional opinion I shared. It's the official way APRV is utilized when using TCAV. kzbin.info/www/bejne/aoHJp4GeiM98iKM kzbin.info/www/bejne/iKnUgYBmZ5qcqNE kzbin.info/www/bejne/Y4urh3uMfdCfjNE

@@pulmovista500guidedaprv2 I am familiar w the TCAV Method. In fact when I came across it I became more convinced that APRV could be a useful mode. Without TCAV there are too many variables. The Habashi group sold me. Now I'm trying to sell others on it.

@@steves8860 same here. We are in the same TCAV cult. I am anxious for there to be a large scale RCT study with TCAV versus ARDnet now that we have a consistent way of using APRV. Especially with PulmoVista 500 comparing traditional to APRV you clearly see the difference. I personally love the mode.

I would like to do a livestream on my channel with you and talk about our experience using APRV and discuss any other topics related to mechanical ventilation. Would you be interested ?

And esens should not, and didn't seem to, matter if the PSV is set to 0. But I'm checking on that as well.

Yes rise time is very important. I When I first started I figured getting back to Phigh quickly made sense. However atleast with the Drager V500 adding a slope from 0.00 to 0.30 added sometime 150 ml + to the release TV. I posted 2 quick videos I made in French for an RT that worked in another hospital cause we use it often where I work. The videos are far from complete. It was just a quick setup of the TCAV method. kzbin.info/www/bejne/raLZkJiXh5qXotU This is my APRV setup video. Most of the cases I post are cases from my ICU where we used APRV and had PulmoVista 500 to guide management. I say all the time in my other videos about adding a slope.

@@steves8860 I use APRV with V500 because it has auto release that decides the Tlow by adjusting expiratory flow termination %. Super user friendly. I don't like the PB980 Bilevel. It's not user friendly and over complicates things. Since drager APRV is configured better we rarely use PB980. We will swap vents if we have the option. You ever used the PulmoVista 500?

@@pulmovista500guidedaprv2 @PulmoVista 500 Guided APRV @PulmoVista 500 Guided APRV I don't know if I've used it. Have used some Drager for some study using intermittent PEEP sighs. Curious how well the auto set release works though. If it simply uses the "point" at the beginning of T low as it's reference, then I would be concerned since the point may be overshooting. The Habashi videos show not to use the point, but to look at the slope and intersect that to the beginning of the time low flow.

@@pulmovista500guidedaprv2 Interesting Is a slope of 0.0 to 0.3 faster or slower than, let's say, 0.7 on a Drager? As you know the rise on PB is in % and lower number is slower. How about the Drager?

You are 100% correct and I agree with you. Thank you for brining this to my attention. I have edited this part of the video out. When this video was made I only used APRV with V500 and always used the auto release which gives us the option to use (expiratory term %) and set it at 75%. Machine does the calculation and adjustments automatically. I have used it for an additional 2 years and with various vents like PB 980 and set the P-low at zero. Thanks for watching the video, visiting my channel and giving important feedback. Greatly appreciated

As PEEP increases so does intrathoracic pressure which can potentially decrease central venous pressure especially with those already hemodynamically unstable or those with hypovelemia which can potentially reduce cardiac output. However not using optimal PEEP puts the lung at risk of increased stress do to less alveolar surface area secondary to atelectasis. Alveolar derecruitment also increases strain to adjacent alveoli do to alveolar interdependence. Alveoli support each other and when alveoli collapse or cyclical opening and closing occurs healthy alveoli beside the collapses one become unstable are at risk of overdistention (strain). Derecruitment also increases pulmonary vascular resistance which transmits to the right side of the heart and can drop central venous return creating hypotension. Usually if your successful in finding optimal Peep and not going higher than what is optimal blood pressure is not an issue. If we correct the transpulmonary gradient we are doing something beneficial. A morbidly obese patient lying on there back creating excessive pleural pressures collapsing the lung will also have negative hemodynamic effects. Quite often a overweight patient ready to be extubated will often have an optimal Peep requirement of 8 to 10 cmh20. While the average patient is 6 to 8 from the EIT's I've done over the years.

👍💪

Thanks for visiting my small channel. MRI imaging has shown that even people that had zero symptoms with C19 showed some damage in the lungs.

Yes!!! One of my videos is a wonderful example of using ACPC then APRV and finally APRV in Prone position all guide by EIT. The result was spectacular !!!! This has been extremely successful in many of our cases. I am going to be doing a EIT presentation on this channel (Respiratory Coach)next Monday 5PM eastern time zone on ZOOM live. It will eventually be posted on my channel and His. Here is the link kzbin.info kzbin.info/www/bejne/d4XKc6Jon65msMk 👆👆👆👆👆👆👆 Above is the video I mentioned. Please check it out and let me know. Send me your contacts if you like [email protected] I'll send you the ZOOM link. If not I'll post the ZOOM link here. Please share my channel if you can. Thanks again for visiting my tiny channel

@@pulmovista500guidedaprv2 I’ll be sure to check in Monday, then. Traveling in Oklahoma right now, but hopefully I’ll land someday in a facility with resources to explore with this and other equipment. Thank you for the links!

I have many videos published in English also. I do a few French ones cause I live in Canada, Quebec which is French. So I'm getting comments asking for French videos. Go check out my other videos which are English and subscribe please 😊

I'll definitely do the audio of the French videos in English eventually when time permits.

It really should be an official teaching. I teach it to the students during there rotations. I figured a quick video was worth it. Thanks so much visiting my small channel. 😊👍

This better not be a trick question 😉 If the ventilation is poor on the right side turning the pt right side down will increase perfusion to right side, worsening the V/Q. If you put left side down where ventilation is good then perfusion will increase on left side cause of gravity and improve V/Q.

Welcome to the Matrix Neo 😎😉

Yes Casper the friendly Ghost is super annoying and he isn't even friendly to be honest

Thanks Bruce 😊

Most of my videos are PulmoVista and I often explain the screens. So by watching them you kinda start understanding more and more. It is electrical Impedance Tomography. It uses a 16 electrode belt that goes around the chest. About 2 inches below the armpit (between the 4th and 5th intercostal). It sends electrical current across at 50 Hz or 50 frames per sec and measures the impedance (resistance to the current). More air in lungs = more impedance, less air less Impedance. So through impedance measurements the Tomography makes an image of the distribution of ventilation. It's the same view as a CT. Scan. Caudal to cranial. So the bottom would be the dorsal/posterior and the top is ventral where the sternum is. The PulmoVista can show the distribution of ventilation, measures regional compliances, measures end expiratory lung volume to measure recruitment and derecruitment. It also measures end inspiratory volume. It also has diagnostics that allow you to do PEEP studies to find optimal PEEP. Check out my other videos 😊

@@pulmovista500guidedaprv2 Thank You very much

@@andyspark5192 If you search Drager PulmoVista 500 on youtube you will also have a wide array of lectures on PulmoVista. What's cool about mine is that they are at the patient bedside and not just a power point presentation. Are you a healthcare professional? Thanks for visiting my channel. Hope to see you again

@@pulmovista500guidedaprv2 I don't work in the medical field, but i like science and i like to learn new stuff. You mentioned this channel on your keto-channel. If you come across some German words and need help to understand them, then i can help you with that.

Thanks!!!

Crap. Ya that was a mistake. Said it backwards. Hopefully people got what I was trying to say. Thanks for letting me know

@@pulmovista500guidedaprv2 lol! I am sure others were quicker on the uptake than I was! I am a NICU RT and we don’t use this mode. I know they use it in our adult ICU, so I thought I would check it out. Great in service, overall.

@@deendrew36 To bad I can't edit it and fix the mistake. I'm in Canada, Quebec. Where are you at ?

@@pulmovista500guidedaprv2 I am in Ottawa! We are neighbours!

@@deendrew36 Ha ha. Cool 👍😎 Small world.

We use early APRV instead of rescue when nothing else works. We set everything with PulmoVista 500 electrical Impedance Tomography. If traditional modes with PulmoVista show better results we use traditional modes. If APRV shows better results we use it. We use the TCAV method outlined by Dr. Nader Habashi. TCAV is time controlled adaptive ventilation. We limit the expiratory phase from Phigh to Plow by stopping the release phase when the expiratory flow descends to 75% of the peak expiratory flow. This would be equivalent to APRV optimal peep. The Drager vent uses auto release which does the 75% for us automatically. Phigh is usually set where Pplat is. This is a good starting point. The Plow and Tlow are created with the 75% auto release (exp. Termination). If the patient need alot of support we use a short Thigh and the breathing profile is similar to ACPC however you don't have a trigger which really helps with synchrony. When Vt get to high we wean the Phigh to respect the 6 ml/kg to 8ml/kg. For sure we will use the lower TV of 5 ml/kg or even 4 ml/kg if needed.👍 We still respect the drive pressure targets below 15 cmh20. With APRV you start with a short Thigh and as the blood gas C02 clearance is adequate we slowly stretch the Thigh to optimize diffusion. So you start with a ACPC profile and as you stretch the Thigh you encourage more spontaneous breathing on the Phigh (which is a CPAP level). That's why Drager vent mode is called PC-APRV. Small Thigh =ACPC with no trigger. Longer Thigh begins to look like traditional APRV taking advantage of lung diffusion. We use PulmoVista 500 electrical inpedance Tomography to set traditional modes and well as APRV so we have regional compliance data as well as end expiratory volume trends and end Insp. Volune trends. If the patient is recruitable or higher peeps are optimal APRV works very well cause recruitment is pressure over time. If you can stretch the Thigh you increase time and often need less pressure for recruitment. Hard to explain with a text. Please search APRV, TCAV, DR. NADER HABASHI, Drager

We meet again 😎🤠

Wow. Thank you so much for the kind words. More APRV case studies to come. Most of my other videos are APRV case studies and combining the mode with Electrical Impedance Tomography (PulmoVista 500) from Drager company. kzbin.info/www/bejne/f6S1kIFtrb2sh7c ☝️☝️☝️☝️ Another good APRV video. Make sure to add a slope if setting is available which will increase tidal volume. The video shows the changes in VT just by manipulating the slope. Look up TCAV with Dr. Nader Habashi. TCAV stands for (Time Controlled Adaptive Ventilation ) and is how we should use APRV. Thanks again for the encouragement. What medical profession are you?;

@@pulmovista500guidedaprv2 thats very interesting! I’ll read more abt it before i watchh ur video so i can have an idea 👍🏼

The video can be viewed first. It explains from A to Z. Let me know what you think and please ask me any additional questions. I'd be glad to respond

From my experience with Covid ICU patients all of them have high Respiratory Rates and minute ventilation averaging around 13 l/min. The high Respiratory drive is do to the refractory hypoxemia. We set optimal peep with PulmoVista 500 Peep trial and evaluate trends in end Insp. Lung impedance and end exp. lung Impedance. You can always add a resp rate to equal patients drive and make sure pressure support is optimal however they usually maintain a very high Respiratory drive. If there is substantial WOB on NIV then intubation might be the next step. If the Sp02 is 75% on NIV and unable to increase then intubation is necessary even if we know vented pts do poorly. That being said allowing the patient to struggle causes patient induced lung injury. This is why electrical Impedance Tomography is vital for an individualized ventilation approach to fine tune settings for each unique lung

Thank you. 🙏😊