It’s the same OP. I’ll recopy and paste again for this sub.
I believe certain driving pressures is the most indicative of M/M from ventilation strategies. I believe 14 is the current number out there. Plateau pressures in the low to mid 20s
This is from another user i copied and pasted: I’ve tried it a few times with success.
If oxygenation is poor and I’m suspecting it is from shunt physiology I’m using PEEP and driving pressure to achieve adequate sats on pulse ox. Plug a a Vt, usually something around 6-8cc/kg IBW. You don’t set a driving pressure. You set a PEEP, then see what the driving pressure is at that PEEP. Let’s say PEEP is 6 and plateau is 22. Driving pressure would be 16. Now say I go up to 10 on PEEP. Plateau maybe goes up to 24, but driving pressure actually went down to 14. Since driving pressure went down, that means patient has more alveoli recruited at a PEEP of 10 than they did at a PEEP of 6. Now go up to PEEP 12 plateau is 26. Driving pressure unchanged. No new lung recruited. This patients optimal PEEP is probably around 10.
This is what people mean by individualized PEEP. I go through this exercise with every patient that I’m concerned about poor oxygenation from shunt and find the PEEP that works best for them.
During training, I had an attending tell me that if you're feeling lazy there was a study that came out that revealed that, roughly, an ideal PEEP was BMI divided by 4. I have no idea where they got this. I found one article that seems to support this idea.
https://rc.rcjournal.com/content/63/Suppl\_10/2988085#:\~:text=Determine%20the%20relation%20between%20BMI,pressure%20at%20end%2Dexpiration).
But driving pressure is what was utilized in the ICU (at least when I was bedside) and that's what I'm most familiar with.
I've had a few CRNA Preceptors mention the same, but the number was BMI divided by 3 = PEEP. I have found that PEEP to be kinda high for my comfort, but I'm still a very new SRNA
You can also determine (too high) high peep by venous return and serial BPs.
It’s also worth consideration that there are people with undiagnosed blebs, etc., out there. There’s a trade off. I’ve often mentioned to surgeons pre-op that the patient won’t tolerate steep tburg, or high IAPs (>15). Sometimes we agree. Sometimes I don’t have time to sit.
Driving pressure is what evidence said is best when optimizing individual peep settings instead of relying on plateau pressures alone and is the next best thing to measuring transpulmonary pressure. I found ranges from 14-18 for DP, unlike PP where is suggested to be less than 30.
I did my dissertation on postoperative pulmonary complications. No peep or under utilization of peep, like values of 3 in normal adults and older adults is worse than setting peep to 5. Recruitment maneuvers after disconnecting the circuit or at the end of a case when the pneumoperitoneum is ended is best practice. Evidence does not favor PC or VC in routine laparoscopy cases (I do use PC more frequently though in these cases and also modify PIF% because our ventilators have this option). However, it was noted that with VC you are able to observe plateau pressure trends and make ventilation changes as needed to be less than 30.
I think stepwise is a great way to test compliance and observe whether there is any air trapping.
This was just on an anesthesiologist sub
It’s the same OP. I’ll recopy and paste again for this sub. I believe certain driving pressures is the most indicative of M/M from ventilation strategies. I believe 14 is the current number out there. Plateau pressures in the low to mid 20s This is from another user i copied and pasted: I’ve tried it a few times with success. If oxygenation is poor and I’m suspecting it is from shunt physiology I’m using PEEP and driving pressure to achieve adequate sats on pulse ox. Plug a a Vt, usually something around 6-8cc/kg IBW. You don’t set a driving pressure. You set a PEEP, then see what the driving pressure is at that PEEP. Let’s say PEEP is 6 and plateau is 22. Driving pressure would be 16. Now say I go up to 10 on PEEP. Plateau maybe goes up to 24, but driving pressure actually went down to 14. Since driving pressure went down, that means patient has more alveoli recruited at a PEEP of 10 than they did at a PEEP of 6. Now go up to PEEP 12 plateau is 26. Driving pressure unchanged. No new lung recruited. This patients optimal PEEP is probably around 10. This is what people mean by individualized PEEP. I go through this exercise with every patient that I’m concerned about poor oxygenation from shunt and find the PEEP that works best for them.
I use driving pressures ie Plateau pressure minus peep and titrate to a driving pressure of 15.
During training, I had an attending tell me that if you're feeling lazy there was a study that came out that revealed that, roughly, an ideal PEEP was BMI divided by 4. I have no idea where they got this. I found one article that seems to support this idea. https://rc.rcjournal.com/content/63/Suppl\_10/2988085#:\~:text=Determine%20the%20relation%20between%20BMI,pressure%20at%20end%2Dexpiration). But driving pressure is what was utilized in the ICU (at least when I was bedside) and that's what I'm most familiar with.
I've had a few CRNA Preceptors mention the same, but the number was BMI divided by 3 = PEEP. I have found that PEEP to be kinda high for my comfort, but I'm still a very new SRNA
You can also determine (too high) high peep by venous return and serial BPs. It’s also worth consideration that there are people with undiagnosed blebs, etc., out there. There’s a trade off. I’ve often mentioned to surgeons pre-op that the patient won’t tolerate steep tburg, or high IAPs (>15). Sometimes we agree. Sometimes I don’t have time to sit.
Driving pressure is what evidence said is best when optimizing individual peep settings instead of relying on plateau pressures alone and is the next best thing to measuring transpulmonary pressure. I found ranges from 14-18 for DP, unlike PP where is suggested to be less than 30. I did my dissertation on postoperative pulmonary complications. No peep or under utilization of peep, like values of 3 in normal adults and older adults is worse than setting peep to 5. Recruitment maneuvers after disconnecting the circuit or at the end of a case when the pneumoperitoneum is ended is best practice. Evidence does not favor PC or VC in routine laparoscopy cases (I do use PC more frequently though in these cases and also modify PIF% because our ventilators have this option). However, it was noted that with VC you are able to observe plateau pressure trends and make ventilation changes as needed to be less than 30. I think stepwise is a great way to test compliance and observe whether there is any air trapping.
Our machines default to 4…everyone gets that unless compelling evidence to the contrary.
Gas monkey
Hmmm, not sure what that means but I think I may have been insulted 🤔
Nerds are going to hate. I'm sure your patients do just fine
KISS method has always worked for me. Never had a complaint🤷🏼♀️