Respiratory Therapy - ARDS and Driving Pressure

[@user-bx8lf7mp4n]

I wanna be like you someday , I'm in my last year and you make me wanna study more and practice more and more , thank you 🙏

[@RespiratoryCoach]

Just when I get the greatest compliment ever, you come in with this one. Thank you for your kind words. Keep up the strong work!

[@mahienaslewegena1292]

Thank you so much , great explanation,, we need one like you every school …

[@stephgoodrow864]

I second that

[@juancardec3849]

Thank you so much. Im only a nurse but I hear these terms thrown around every so often but didnt understand them. I hope I can provide better care to my patients and at least understand better the plan of care for ARDS patients.

[@RespiratoryCoach]

Awesome! Always love to get comments from my RN comrades!! Thanks for watching, Juan!!

[@Reefahholic]

Great video. Covid changed the game. Covid redefined ARDS. I have pt's who have very high pip's & plat's and even when switched over to PC the pip's and plat's may drop initially, but as the disease progresses you can no longer ventilate at lower 4-6 mL/Kg volumes with higher rates. You're maxed on pressure and RR to keep them from being hypercarbic, your maxed on peep because the pt's are so hypoxic. Plat's are running well over 30....(40's, 50's). Pip's are high (50's, 60's). Once I see plat's getting over 45...then you're at risk for Pneumothorax or Pneumomediastinum. Cardiac output is suffering due to high peep levels. Can you imagine trying to manage a vent when the rate is already maxed at 35bpm. You can't increase pressure, because they have a pneumothorax or bilateral pneumo's and your pip's, plat's, and MAP are already sky high. You can't reduce peep because they fall below SpO2 of 88% or PaO2 of 55-80. You're basically screwed. My game plan for the last two years is to find the optimal peep level and keep it as low as possible. Try to ventilate between 4-6 mL/kg. Keep rates high (35bpm max) and pressures as low as possible. I try to keep the Plat's under 40, and Pip's under 40-50. Their lung compliance is so jacked. Then add PRONING on top of that and guess what happens to your pressures and compliance. Raw has not been to big of an issue with most pt's unless they're asthmatic or similar. But despite all this....most pt's are even on Flolan. Also...guess what happens when you need to change filters or suction every 4 hrs. Yep...they DErecruit. Sure sure...you can clap the tube..super fun doing that for 16 filter changes Q4 hrs. I work in TMC downtown Houston, TX. Now in Clear Lake fighting Delta variant.

[@wsolis07]

What a pleasant surprise to meet you today at the PSRC conference! Keep up the good work. I’ll keep sharing this info with my colleagues.

[@RespiratoryCoach]

Awesome! It was so nice meeting you. Thanks for the support!

[@jessaemerson8359]

ICU nurse here. Thank you!! You’re awesome and such a great teacher! I love your passion for your field. Keep it up.

[@angelaloredo3337]

I just want to stay: THANK YOU !!! I APPRECIATE THIS SO MUCH

[@CamilaDeAvila-n6z]

can you please share that ARDS study you are referring to on the video?? thank you!!

[@oliviamfragoso]

Professors at Collin College Mckinney did teach us thankfully❤

[@RespiratoryCoach]

@@oliviamfragoso Big shoutout to Collin College! Love the faculty over there!

[@فطومالموسوي-ع4غ]

what the lung protection protocol that we use to reduce pco2 or acidosis ?

[@jackiep8792]

Does the ARDS protocol call for you to monitor driving pressure

[@RespiratoryCoach]

Great question. The original ARDSnet Protocol (2000) does not mention driving pressure as a value to monitor. The metanalysis from 2015, performed by the researchers of the ARDSnet protocol, revealed the value of driving pressure. Thanks for watching and commenting.

[@CarlosArias-m3d]

Can we use pressure gradient to calculate the empty volume of lungs to give the right tidal volume? Or calculate empty lung volume with static compliance? So, instead of guessing on how many kg per litter we can actually give the right vt to the empty space in lungs?

[@roxanamanaila5875]

Hei, coach! Can you do a video with how to best manage ARDS în the context of the COVID-19 pandemic? Thanks to your videos, i am able to manage the situation, as i am normally a resident în nephrology! Many thanks!

[@RespiratoryCoach]

I haven't seen any research that suggests anything different than the original ARDS.net protocol. I think we're all figuring this out together.

[@greenforestacres8901]

So let’s pretend I have a patient who’s plat is 40, and peep is 14, if I increase the peep the plat will go up as well. So won’t driving pressure stay the same? Pt is already at 35 bpm and I can’t drop pressure control because abg shows high co2 with ph of 7.15. In order to normalize this driving pressure I have to drop their volumes via PC, but then their ph is already low, so I can’t drop their PC. I guess I’m missing something because I can’t see how I can make this persons driving pressure within normal limits.

[@RespiratoryCoach]

Great question, Veronica. Very valid points. First thing, in PC the set delta P is the set driving pressure because pressure is set and held. To your other point about increasing PEEP and that will increase Pplat. In theory, by increasing PEEP you searching for optimal PEEP. Once optimal PEEP is found you should see an increase in compliance, which explains why we see better or same plateau pressures despite increasing PEEP, which yields lower driving pressures. Hope that helps and thanks for watching!!

[@JustinJayBeats]

Whats up coach, I recently passed my board exams a couple weeks ago! And I have to thank you because I would watch your videos every morning before clinicals.. Here's a question that I always get 2 different answers to from different rt's. Do we keep the patient sedated in the bilevel mode? And also, I forgot how to determine the t-low.. so was wondering if you can go over how to determine the t-high n low

[@RespiratoryCoach]

That's awesome! Congratulations! I have an answer to your question coming soon. Thanks for watching and for commenting. I'm happy for you passing your boards.

[@JustinJayBeats]

@@RespiratoryCoach looking forward to it coach! Can you include one more argument as well. The talk whether to use peep or not in this bilevel mode and its reasonings

[@eduardonava1291]

Please go over Equation of motion

[@RespiratoryCoach]

Hey Eduardo! I don't want to, but I will! LOL You're on the list. Thanks again for watching and commenting.

[@jagadeeswararao4996]

Good explanation sir

[@roshu4557]

So driving pressure is jst p plat -peep? Or something else

[@RespiratoryCoach]

That's correct, Roshan. Plateau minus Peep equals driving pressure.

[@trevorog1212]

What is the difference between Mean airway pressure and driving pressure? I feel like RTs at clinical don't know the answer to either of these points. Thanks

[@johannkainz8688]

Hello from Austria, Coach :-) If you are on PCV (such as because of worsening oxygenation-problems - utelizing a greater Pmean to recruite some lung areas), you can`t use Amatos driving pressure concept? Or is there any benefit on this theory in PCV? In other words, can i use the driving pressure concept in PCV or is it useless to think on it.... in my home country we generally prefere PCV... Thanks for commenting, you realy do a great job!!

[@mondego]

In pcv if you make a insp hold you will have the real plat... So can get the driving pressure, right?

[@RespiratoryCoach]

I think the thing to understand here is that a plateau pressure in PCV is not the same as plateau pressure in VC. They are both plateau pressures, defined by the cessation of insp flow. However, in VC a volume is held and pressure drops to plateau, where in PC the insp pressure is held, therefore you don't see that drop to plateau. This makes the plateau pressure in PC essentially useless in assessing static compliance, because it can not be discerned from an airway resistance problem.

[@pawansingh1642]

Sir i want to know swan ganz and pa pressure wedge...plz make on vedio

[@RespiratoryCoach]

Hey Pawan! Thanks again for watching and commenting. I have your question on the list.

[@roshu4557]

Suppose p plat is 28 and peep is 10 so driving pressure will be 18?

[@RespiratoryCoach]

💯

[@CarlosArias-m3d]

How ever, I've noticed some people are using too low of tidal volumes. They are not considering mechanical and dead space. They are giving puffs to adults and that is not ventilating!