ED Ventilator Settings

Quality Control editors at work.

Quality Control editors at work.

All excited for intubation but forget to optimize the ventilatory settings?

Important for those that are not rapidly taken away to the ICU.

Ventilation
Tidal Volumes: low tidal volumes 6 ml/kg (ideal body weight) even without acute lung injury is even beneficial.  Study by Determann et al. 2010 Critical Care.  Looked at 150 patients, randomized trial of 10 vs 6 ml/kg.  Development of Acute lung injury in 13.5 in the 10 ml/kg group and 2.6 in the 6 ml/kg group.  Stopped early because of difference.
Respiratory Rate: Minute ventilation is RRxTV.  You want a MV of 5-6L/min in a normal patient, but if need to increase for metabolic derrangement may need much higher.  Permissive hypercapnea is okay in those with ARDS.  Caution in those with brain injury and severe metabolic acidosis.  Don’t go higher than RR of 35.  Keep ph>7.15, as done in ARDSnet. Continue reading

Angioedema Disposition

Angioedema is anatomically limited, non-pitting edema that occurs in 10% of Americans, with men=women

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Who should be admitted, and to where?

  • Retrospective 10 year review of 93 episodes of angioedema from Boston Medical Center
  • 39% of the cases were from ACEI, 19% from food, 11% antibiotics, 9% multiple agents, and 33% unknown cause
  • Voice change, hoarseness, stridor, SOB were associated with need for airway intervention
  • 31% of patients had facial rash, facial edema or lip edema (stage 1); 5% had soft palate edema (stage 2)
  • 32% had tongue edema (stage 3) and 31 % had laryngeal edema (stage 4)
  • Need for intervention:
    • Stage 1, facial: 0 ICU, 0 intervention
    • Stage 2, soft palate: 0 ICU, 0 intervention
    • Stage 3, lingual edema: 26% outpatient, 7% floor, 67% ICU, 7% intervention.  DIFFUSE TONGUE worse than anterior/lateral tongue.
    • Stage 4, laryngeal: 100% ICU, 24% intervention

Bottom line: ADMIT diffuse tongue and laryngeal edema, voice change, hoarseness, stridor, or SOB to the ICU due to a combined 31% incidence of airway intervention. Consider early intubation.

Ishoo E. Predicting airway risk in angioedema: Staging system based on presentation.  Head and Neck Surgery 1999.