You are so awesome. Please don’t stop making these videos. I’ve been following you as a student and continue to watch as a working RT. Your videos have been so helpful!
Actually before I really didn't know about driving pressure, what that is and the significance of it. Now I understand the value of this in ARDS net protocol. Thanks a lot.
Coach! I can agree with you on this one too! I watched that same lecture 6 months ago and I feel like we should be going off of driving pressures especially knowing the data behind it. Thanks for the explanation!
this was such a useful video for me..taking care of my mother on home NIV.. tried avaps ..but looks like its tidal volume based pressure delivery approach can be suboptimal too.
looks like increasing peep with higher plateau improves mortality because it opens alveoli more therefore improving ventilation of gases across the lung alveolar membrane. I guess that's why PRV helps stiff lungs. It keeps the alveoli open to improve gas exchange, which is the main function of the lungs! Hum?!
So! depending on lung condition; and if the lungs are stiff as in ARDS, we can change driving pressure by increasing Peep; for better ventilations, get that Driving Pressure and Static Cl numbers and calculate Vt? But! I think only getting the numbers on Volume ventilation and applying it on Volume or Pressure and when ventilating keep an eye on the Plateau Pressure trend to watch for improvement and deterioration?
Thank you for this education. I have two questions: 1: Which modes of ventilation allow us to measure driving pressure? 2: Can you please show us [maybe in a video] how to measure driving pressure in APRV mode? Thank you in advance.
Hi bro For the first question, a mode of volume controlled is used in order to measure DP .. because the calculation needs a specific set of tidal volume, while you can't do this in pressure control mode because the volume is variable regarding the specific amount of pressure you're delivering. For the second question, as long as APRV is a spontaneous mode of mechanical ventilation, then the volume is variable regarding how much the pt. takes breath in , which will directly affect your DP reading I hope I could answer you, best regards
@@fuadfayyah1387 The problem then becomes: Should we always use VC on ARDS patients? The vast majority of our new crop of ARDS patients [ you know who I'm talking about] do not tolerate VC. And therefore, we cannot guarantee good lung protective ventilation. As such, I opt for APRV for most of our patients.
@@Shak-MD Well I'm also experiencing the same issue with covid ARDS patients .. theoretically if you used pressure control mode it would be more of not damaging the lungs because you're delivering a specific amount of pressure regardless to the volume given, and also it would be more beneficial in getting better oxygnation status because MAP would be increased But then I realized that almost all protocols for ARDS is based of volume setting, such as the ARDSNET and DP protocols .. which needs you to measure Pplat, Cstat .. exc. so you can adjust settings and deliver almost the optimal required setting for such case For APRV, it's really a very good mode for primarily hypoxic patients (type I respiratory failure), which would be beneficial in optimizing the oxygnation status primarily .. specially those patients present with ARDS If I could help with APRV, you should watch the previous video for Respiratory Coach about APRV, it's really clear and understandable learning video in order to correctly understand and adjust your settings By the way, good discussion to have .. cheers mate 👍👍
Wouldn’t driving pressure be= Pplat decided by auto peep + peep? Taking into account the total PEEP. This is seen while using the esophageal balloon monitoring.
Hey coach could you make a video of Weaning or improving pt w/ trachs. Method for speaking valve, capping. I'm new rt only about 2 years experience and 1 year was icu hospital work which I felt like a slave passing nebs and charting vents. I now work at long term facility which is better one on one w/ pts ..vented and non vented. I just want to help these pts the best I can. Thank you so much for all ur videos .
So, driving pressure multiplied by static compliance will give me my optimal tidal volume? Would you please explain that process? You've been such a help to me in my journey so far. Thank you.
Thank you so much for bringing this topic to light within our Respiratory Therapist community! I always watch for the driving pressure and present it on rounds during vent changes. The providers don't understand it though. I will try to explain it as this video or just send this video to them lol.
There is no difference in referencing "Driving Pressure" or "tidal volume". The effect on the patient by limiting tidal volume or driving pressure is the same to limit distention of the alveoli and lungs. If using "Driving Pressure" as a ventilator goal separated from a tidal volume to patient IBW can be a useful way to have clinicians use lower tidal volumes that is fine. But let us be clear, it is the lower tidal volume and limiting distending pressures on the lungs that is the clinical advantage to the patient. You should also consider limiting flow and shearing forces on the lungs.
But! To decrease Driving P with a stiff lung, we can increase peep to deliver a proper Vt and to decrease Driving pressure! Right? ...according to the bars shown earlier!
Looks like driving pressure is related to pressure gradient. If so, then a ventilator giving us a pressure gradient can help us ventilate better. I remember using a Drager ventilator which on the first 6 breaths can figure out the pressure gradient to set a proper flow. So, if vents can figure out the pressure gradient and the flow, then we can get the right VT, get a Cstat, and have a Driving Pressure measurement?
I have a pratical question since I am a technician. Would it help to reverse mortality to purposely puncture the lungs and place chest tubes on a patient with ARDS where ventilation pressures are high, even while using PRV..pressure release ventilation? using the chest tubes sort-of -like a pressure relief mechanism to prevent barotrauma and blood pressure/heart issues? In order to possibly save a life or to give more options or opportunity for survival?.....and also consider adding surfactant? Hm!? I wonder?!
So. Does that mean that as soon as we place a pt on a vent we are to find what's the mean airway pressure with static complaince to set the right peep and the right vt?
Hi Olivia.....Vt = Driving Pressure X Cstat. Once you know your static compliance you can multiply by your desired driving pressure and that will yield your target tidal volume.
Can you explain why it appears as is some pts can go above the set PIP on pressure control? For example if the total pip is set to be 25 (20+5) I see total pip displays on as 28 on the servo while the pt is triggering breaths on the vent?
Many thanks for this awesome informative video! So! Would it be pk to initially set a pt on an approximate Vt, low peep and on volume ventilation, then get a plateau pressure, then calculate driving pressure then ventilate according to driving pressure? So I would use the formula you mentioned: vt/Cstat. and monitor that driving pressure as a trend to see pt's progress? Also having in mind pt's lung condition getting better or worse? What's a normal driving pressure?
Just curious, I have been strictly monitoring Driving pressure for 2 years now and have came up empty handed that it has created any benefit to mortality? Have you had similar findings? I actually found that identifying optimal PEEP and leaving it there with a very gradual wean has proven better outcomes than following driving pressure. I would love any current studies or findings you have that show results either way. Thank you!
Yes you can, as long as your flow waveform reaches baseline. There’s no more flow. That’s your pressure at end inspiration. That will be your plateau pressure.
As always, great video! But crossing out ibw... thats a long shot I believe.. ibw is such an easy way to initiate a vent, then after I think we can work it to change to the correct driving pressure... so I think only after we initiate with ibw, correct driving pressure will be superior. Lolol
Hey Jesse! I agree 100% that IBW still has a place in MV as a starting point for setting Vt. Thanks for contributing to the conversation. I think your thoughts are spot on.
Hey man... Highly appreciate it.... 👍👍👍 Can you drop the link to the paper you used in the description or pinned comment.. ? PS. Also I think it's a good practice for ur oncoming videos... ☺️☺️
Absolutely and done! Thought I had already done that, but apparently not. Thanks for asking! Here's the link as well...www.nejm.org/doi/full/10.1056/nejmsa1410639
You are so awesome. Please don’t stop making these videos. I’ve been following you as a student and continue to watch as a working RT. Your videos have been so helpful!
Hi Nancy! Thank you for continuing to watch.
me too
I don’t think I’ve ever seen those 3 graphs with plateau pressures and peep levels explained as “cleanly”, as clearly as you did. Awesome!
Amazing lecture ! You have an incredible gift of explaining highly complex concepts and breaking them down to simple easy explanations. Bless you.
Actually before I really didn't know about driving pressure, what that is and the significance of it. Now I understand the value of this in ARDS net protocol. Thanks a lot.
driving pressures simplified. Appreciate the quality of your content🙏🏽
Thank you!!! I appreciate you watching and commenting!!
That was an empirical explanation.
Great performance coach. 👍
Glad you liked it! Thanks for watching and kindly commenting!!
Thank you for the clean and crisp explanation… lots of Love from India….
This is an amazing video Coach! Another reason to do best PEEP.
Coach! I can agree with you on this one too! I watched that same lecture 6 months ago and I feel like we should be going off of driving pressures especially knowing the data behind it. Thanks for the explanation!
What's up, Jake! Hope you and your precious family are enjoying the holiday season!! Appreciate your presence on the channel!
@@RespiratoryCoach Thanks brotha! We definitely are. I hope your family is also enjoying the holiday season. I will always be a fan of what you do!
Thank you very much, I hope this can be utilized more for all pt. with pulmonary complications related to lung injury and decreased compliance.
this was such a useful video for me..taking care of my mother on home NIV.. tried avaps ..but looks like its tidal volume based pressure delivery approach can be suboptimal too.
thank you coach! glad to see you post some useful videos online again! keep it going and i will stay tuned!
Thank you again for your great explanation
You are so welcome, Deb! Thanks for watching and commenting.
Excellent presentation! Gives us a lot to think about!
Always amazing .. thank you coach !! ❤️
Thank you, Fuad, for watching and kindly commenting! I appreciate you!
looks like increasing peep with higher plateau improves mortality because it opens alveoli more therefore improving ventilation of gases across the lung alveolar membrane. I guess that's why PRV helps stiff lungs. It keeps the alveoli open to improve gas exchange, which is the main function of the lungs! Hum?!
Can you explain to us how to calculate or to know our Optimal peep?
Thank you 😊,
please puplish more content about driving pressure
Can you give us optimal number for driving pressure as a guide
So! depending on lung condition; and if the lungs are stiff as in ARDS, we can change driving pressure by increasing Peep; for better ventilations, get that Driving Pressure and Static Cl numbers and calculate Vt? But! I think only getting the numbers on Volume ventilation and applying it on Volume or Pressure and when ventilating keep an eye on the Plateau Pressure trend to watch for improvement and deterioration?
Thank you for this education. I have two questions:
1: Which modes of ventilation allow us to measure driving pressure?
2: Can you please show us [maybe in a video] how to measure driving pressure in APRV mode?
Thank you in advance.
Hi bro
For the first question, a mode of volume controlled is used in order to measure DP .. because the calculation needs a specific set of tidal volume, while you can't do this in pressure control mode because the volume is variable regarding the specific amount of pressure you're delivering.
For the second question, as long as APRV is a spontaneous mode of mechanical ventilation, then the volume is variable regarding how much the pt. takes breath in , which will directly affect your DP reading
I hope I could answer you, best regards
@@fuadfayyah1387 The problem then becomes: Should we always use VC on ARDS patients? The vast majority of our new crop of ARDS patients [ you know who I'm talking about] do not tolerate VC. And therefore, we cannot guarantee good lung protective ventilation. As such, I opt for APRV for most of our patients.
@@Shak-MD
Well I'm also experiencing the same issue with covid ARDS patients .. theoretically if you used pressure control mode it would be more of not damaging the lungs because you're delivering a specific amount of pressure regardless to the volume given, and also it would be more beneficial in getting better oxygnation status because MAP would be increased
But then I realized that almost all protocols for ARDS is based of volume setting, such as the ARDSNET and DP protocols .. which needs you to measure Pplat, Cstat .. exc. so you can adjust settings and deliver almost the optimal required setting for such case
For APRV, it's really a very good mode for primarily hypoxic patients (type I respiratory failure), which would be beneficial in optimizing the oxygnation status primarily .. specially those patients present with ARDS
If I could help with APRV, you should watch the previous video for Respiratory Coach about APRV, it's really clear and understandable learning video in order to correctly understand and adjust your settings
By the way, good discussion to have .. cheers mate 👍👍
@@fuadfayyah1387 no need to use VC or PC when you have PRVC
@@fuadfayyah1387 u can measure it simply by Pplat-peep , u can do it both in VC and PC
Wouldn’t driving pressure be= Pplat decided by auto peep + peep? Taking into account the total PEEP. This is seen while using the esophageal balloon monitoring.
Hey coach could you make a video of Weaning or improving pt w/ trachs. Method for speaking valve, capping. I'm new rt only about 2 years experience and 1 year was icu hospital work which I felt like a slave passing nebs and charting vents. I now work at long term facility which is better one on one w/ pts ..vented and non vented. I just want to help these pts the best I can. Thank you so much for all ur videos .
Good explanation
This is amazing
Glad you enjoyed it! Thanks for watching Ahmed!
Beautifully explained, thank you!
So we can reduce the driving pressure by increasing PEEP, and ideally driving pressure should be kept ≤15 cmH20 ?
Absolutely! When optimized PEEP can improve lung compliance which can decrease driving pressure.
Love the evidence
So, driving pressure multiplied by static compliance will give me my optimal tidal volume? Would you please explain that process? You've been such a help to me in my journey so far. Thank you.
How do you know when you have the correct peep and Vt for to avoid lung injuries?
Thank you so much for bringing this topic to light within our Respiratory Therapist community! I always watch for the driving pressure and present it on rounds during vent changes. The providers don't understand it though. I will try to explain it as this video or just send this video to them lol.
You are very welcome, Olivia! Share the word however you can! Thanks for watching and kindly commenting!!
Awesome! thanks!
There is no difference in referencing "Driving Pressure" or "tidal volume". The effect on the patient by limiting tidal volume or driving pressure is the same to limit distention of the alveoli and lungs. If using "Driving Pressure" as a ventilator goal separated from a tidal volume to patient IBW can be a useful way to have clinicians use lower tidal volumes that is fine. But let us be clear, it is the lower tidal volume and limiting distending pressures on the lungs that is the clinical advantage to the patient. You should also consider limiting flow and shearing forces on the lungs.
Hey, Allan. Thanks for watching and taking the time to contribute to the conversation. I appreciate you.
But! To decrease Driving P with a stiff lung, we can increase peep to deliver a proper Vt and to decrease Driving pressure! Right? ...according to the bars shown earlier!
hi Coach can you help me getting some TMC practice questions
Looks like driving pressure is related to pressure gradient. If so, then a ventilator giving us a pressure gradient can help us ventilate better. I remember using a Drager ventilator which on the first 6 breaths can figure out the pressure gradient to set a proper flow.
So, if vents can figure out the pressure gradient and the flow, then we can get the right VT, get a Cstat, and have a Driving Pressure measurement?
I have a pratical question since I am a technician. Would it help to reverse mortality to purposely puncture the lungs and place chest tubes on a patient with ARDS where ventilation pressures are high, even while using PRV..pressure release ventilation? using the chest tubes sort-of -like a pressure relief mechanism to prevent barotrauma and blood pressure/heart issues? In order to possibly save a life or to give more options or opportunity for survival?.....and also consider adding surfactant? Hm!? I wonder?!
how do we determine driving pressure before placing pt on a vent? We will still need a formula for tidal volume to initiate mechanical ventilation
So, if I solve for vt then I'll get the right vt for the driving presume, so to get the optimum peep, I can get an idea on the PV loop for COP.
100% Carlos!!
So. Does that mean that as soon as we place a pt on a vent we are to find what's the mean airway pressure with static complaince to set the right peep and the right vt?
Awesome! So what's a normal driving pressure?
What is the formula to obtain the appropriate tidal volume from the known data?
Hi Olivia.....Vt = Driving Pressure X Cstat. Once you know your static compliance you can multiply by your desired driving pressure and that will yield your target tidal volume.
This is great thanks
How would you assure that you dont have ateletatic issues with volumes that are too low…meaning less than 4-6ml per kg?
Can you explain why it appears as is some pts can go above the set PIP on pressure control?
For example if the total pip is set to be 25 (20+5) I see total pip displays on as 28 on the servo while the pt is triggering breaths on the vent?
Can you please explain strain index
Brilliant!
Many thanks for this awesome informative video!
So! Would it be pk to initially set a pt on an approximate Vt, low peep and on volume ventilation, then get a plateau pressure, then calculate driving pressure then ventilate according to driving pressure? So I would use the formula you mentioned: vt/Cstat. and monitor that driving pressure as a trend to see pt's progress? Also having in mind pt's lung condition getting better or worse?
What's a normal driving pressure?
Just curious, I have been strictly monitoring Driving pressure for 2 years now and have came up empty handed that it has created any benefit to mortality? Have you had similar findings? I actually found that identifying optimal PEEP and leaving it there with a very gradual wean has proven better outcomes than following driving pressure. I would love any current studies or findings you have that show results either way. Thank you!
thankyou very helpful
Thank you🎉
Awesome!!!!!
Wil driving pressure be on nbrc
Ammmmazing
Can you get a true plateau pressure in PRVC?
Yes you can, as long as your flow waveform reaches baseline. There’s no more flow. That’s your pressure at end inspiration. That will be your plateau pressure.
As always, great video! But crossing out ibw... thats a long shot I believe.. ibw is such an easy way to initiate a vent, then after I think we can work it to change to the correct driving pressure... so I think only after we initiate with ibw, correct driving pressure will be superior. Lolol
Hey Jesse! I agree 100% that IBW still has a place in MV as a starting point for setting Vt. Thanks for contributing to the conversation. I think your thoughts are spot on.
keep feedn me!
Hey man... Highly appreciate it.... 👍👍👍 Can you drop the link to the paper you used in the description or pinned comment.. ? PS. Also I think it's a good practice for ur oncoming videos... ☺️☺️
Absolutely and done! Thought I had already done that, but apparently not. Thanks for asking! Here's the link as well...www.nejm.org/doi/full/10.1056/nejmsa1410639
❤🎉