Thank you putting this video out, it could not be a better explanation along with part 1 and 2. I always enjoy and learn a lot from your videos. When I read it does not make sense but when I watch your videos it does help me correlate with what I read. Thank you !
Great video. I already had a pretty good understanding of this but it's been a while, so I wanted to refresh before my upcoming boards. This was explained so well and I always appreciate your inspirational viewpoints you share with up and coming RRTs to be the best that we can be. Thank you!
Cool, Randa. Glad it reinforced your knowledge. We can all use that occasionally. Best wishes on your upcoming boards. Thanks for watching and commenting!
First of All thank you for your continued sharing of your years experience as a Respiratory Therapist, I wish I had found your vids from the beginning of my training, you’ve helped me so much. Here is my question : to do the Optimal peep study looks as though it takes time and ABGS which requires orders to perform and to fit in the work loads which I’ve experienced with my preceptors. I totally get the value of this optimization therefore can you give me a feel of flow with the timing within that workload. I believe I’ve also seen Peep optimization quickly using a flow loop.
Hi, Jodie! I'm glad you find the videos beneficial, and thank you for watching and commenting. Before I answer your question, when you say "preceptors", I assume you are in orientation now? Also, in regards to workloads, what does your average daily workload consist of? I probably know the answer to that last question, but I don't want to assume in my response to your original question. Look forward to hearing back from you. Thank you again!
Respiratory Coach Hi. I am not in clinicals due to Covid and have been through two rotations. Mornings consisted of setting up meds to be delivered. Spontaneous breathing trials. Bronchial hygienes, dressing g changes. Any stat needs. Broncoscopys. Then set next round. Optimal peep for patient benefit should be mandatory for ventilation/ perfusion
Got it, Jodie. So you're still in school now. Just wanted to clarify if this was new grad orientation preceptors or clinical preceptors. As I write this I realize they might end up being the same people. Anyhow, finding time for peep studies is definitely a challenge. I think the key is the priority placed on the value of peep studies. For example, some RTs say, "We don't have time for that because we have 22 first round nebs to get done." What they're really saying is that those 22 first round nebs are a higher priority than maximizing the benefits of peep for their critically ill patients. When the truth is that most likely only 2 of those 22 first round nebs are actually indicated and actually benefit the patient in a manner that will improve outcomes. How many treatments have you given to patients with clear breath sounds, no distress and no documented flow obstruction responsive to bronchodilator therapy? Please don't misunderstand what I'm saying. Bronchodilator therapy is important, but only for those that truly need it and respond to it. You mention other things, such as SBTs, bronchs, etc....now those are definitely therapies that directly impact outcomes, and will pose time constraints in regards to performing peep studies. I would recommend peep studies be performed on nights or during a time of the day that is typically less chaotic. Of course, this will vary per facility. At the end of the day, as respiratory therapists, we have to ask ourselves what are the true priorities when it comes to maximizing outcomes for our patients. Finding each patient's exact optimal peep level, instead of everyone being on 5, 8, 10, 12, MAYBE 15, seems to me to be more valuable and beneficial than routine vent checks and an abundance of nebs. I'm sure there's research out there that supports this statement, as well as research that opposes it. Not sure if this is what you are seeing in your rotations or not, but my years of experience have lead me to the conclusion that we, as a profession, have become more task oriented (nebs, o2 checks, vent checks) and productivity focused, as opposed to individualized patient outcomes focused. I feel very passionate about the fact that we leave so much of our clinical skills and expertise on the table, and end up losing those skills in the end, if we're not aware of it happening. This is why I take the time to interact with students from all over. Be aware of this! Do not allow your excited, critical thinking RT self to be reprogrammed into a mindless, task oriented Respiratory Therapist. I don't think I answered your question, but I do hope I provided with some value.
Respiratory Coach Hi I do not believe at all that it should be an end of day or oh it’s quiet let’s do a peep study. From your lecture I believe I should be a critical component of patient care and outcome. As a Respiratory Therapist I imagine there will be practioner leeway in delivery of morning meds within the scope of time and during One’s shift provided we can train our new habits to perform as such. Thanks again see you on the Tube!
I like the way you think and I agree. Optimizing peep should not be minimized to when it's quiet or convenient. I hope you didn't think that's what I was saying when I stated, "less chaotic times." Keep up the strong work, Jodie, and best wishes as you continue through school!!! Don't be a stranger.
Hey Matthew. I probably do not have one specific to I time and Rise time in conjunction with waveform feedback. I do have this one in regards to I time and Rise time. ua-cam.com/video/aYUhHoKoODs/v-deo.html I'll put it on the list to incorporate waveform feedback. Thanks for asking and watching.
@@RespiratoryCoach Thanks! One more question if you don't mind me asking: In AC-VC mode, if you set a specific tidal volume, is it normal to see varying volumes estimated on the vent? On the Trilogy 100 if I plug in let's say Vt 500ml, rate 12, the volume reported seems to vary within maybe + or - 50ml. But when you read a lot of scholarly articles about AC mode, it says it delivers the specific Vt on every single breath. I've seen other vents with varying Vt as well even in AC mode. Thanks man love your content!!!
@@matty00926 Not completely sure on this but does the trilogy 100 ask you to learn a vent circuit? It may not be compensating for compressible vol loss. Or maybe its a equipment issues and its not flow sensing properly. Just tossing out some ideas, good luck!
Thank you for another awesome video! Just one logistical question. As swan-gantz catheter is being put in less and less nowadays, where would you get mixed venous blood from? Would obtaining sample from central line(let's say it's in internal jugular site)be acceptable?
Hey Alex. Yes, central venous. It's definitely the next best thing to a true mixed venous sample which we know comes from the pulmonary artery. You might see it stated as PcvO2 and ScvO2 (central venous oxygen saturation) as opposed to PvO2 and SvO2 (mixed venous oxygen saturation), in order to note the difference. Great question and I hope this helps. Thanks for watching Alex!
Thanks! Great video! So many options to evaluate optimal PEEP. I just would explain differently why PvO2 is getting lower with supraoptimal PEEP. Indeed it is because CO drops down, so we can say that blood moves slower through the tissues and cells have time to extract more oxygen from it. Otherwise I love your explanations. Wish you a good health so you could continue making more of clear and helpful videos :)
I hope you don't mind yet another clarifying question. How would SpO2 respond in these incremental steps? Would it increase incrementally until optimal peep is reached and then decrease? If so, how big of a drop would you expect clinically?
when you start increasing PEEP, you would see decrease in EtCO2 then sudden increase once you go past optimal PEEP? or is it you would start seeing increase in EtCO2 then sudden decrease in EtCO2 past optimal PEEP?
Once you past the point of optimal peep you will see a decrease in your ETCO2. This is due to the negative cardiac effects of peep. Decreased venous return = decreased pulmonary blood flow = ventilation in excess of perfusion = an increased in V/Q ratio = deadspace ventilation. So, you will see a decrease in ETCO2 once you pass optimal peep. Hope this helps and thanks for watching!!!
Great thought, Brian. I can't think of way pressors would increase PEEP. Doesn't mean the answer is no, I'm just not aware of this concept affecting peep. Send me an email if you would like to continue this conversation. I'd like to hear your thoughts on this concept. respiratorycoach@gmail.com
Your explanation is better than any book... thanks a lot👍👍👍
Thank you for that kind comment. I try!!!
You give me a better understanding of issues. Please keep on your smooth teaching methods.
LOL....The older I get the harder it gets to stay smoothe, but I'll do my best! Thanks for watching!!
What can we do it is the mission of humanity to ease other people's life in our best understanding of things with our best
Fantastic explanation. Easy to follow and deeply appreciated that you take the time to share all your knowledge. Look forward to many more videos.
Thanks, Jay. Always appreciate you watching and your comments.
Your channel was the fastest subscribe I've ever made. Thanks for your great lessons!
Hey Jake! You're very welcome. Thank you for the quick sub and for watching!!!
Thank you putting this video out, it could not be a better explanation along with part 1 and 2. I always enjoy and learn a lot from your videos. When I read it does not make sense but when I watch your videos it does help me correlate with what I read. Thank you !
I love your videos!!! I can’t stop watching!
YOU ARE THE BOMB!!! Love you. THANKS for helping me digest this.
Great video. I already had a pretty good understanding of this but it's been a while, so I wanted to refresh before my upcoming boards. This was explained so well and I always appreciate your inspirational viewpoints you share with up and coming RRTs to be the best that we can be. Thank you!
Cool, Randa. Glad it reinforced your knowledge. We can all use that occasionally. Best wishes on your upcoming boards. Thanks for watching and commenting!
Great and well explained coach love it. can't wait for another video 😍
Take care and stay healthy coach.
You too, Adz. Always appreciate your comments.
You hit the word GUESSING. So true.
Hello, Liz. Good to see another comment from you. Hope all is well.
Hi Coach! Talking from Brazil. It would be great if you made a video about the ideal peep and pressure vs. volume curve. Best wishes
First of All thank you for your continued sharing of your years experience as a Respiratory Therapist, I wish I had found your vids from the beginning of my training, you’ve helped me so much.
Here is my question : to do the Optimal peep study looks as though it takes time and ABGS which requires orders to perform and to fit in the work loads which I’ve experienced with my preceptors.
I totally get the value of this optimization therefore can you give me a feel of flow with the timing within that workload.
I believe I’ve also seen Peep optimization quickly using a flow loop.
Hi, Jodie! I'm glad you find the videos beneficial, and thank you for watching and commenting. Before I answer your question, when you say "preceptors", I assume you are in orientation now? Also, in regards to workloads, what does your average daily workload consist of? I probably know the answer to that last question, but I don't want to assume in my response to your original question. Look forward to hearing back from you. Thank you again!
Respiratory Coach
Hi. I am not in clinicals due to Covid and have been through two rotations.
Mornings consisted of setting up meds to be delivered. Spontaneous breathing trials. Bronchial hygienes, dressing g changes. Any stat needs. Broncoscopys. Then set next round. Optimal peep for patient benefit should be mandatory for ventilation/ perfusion
Got it, Jodie. So you're still in school now. Just wanted to clarify if this was new grad orientation preceptors or clinical preceptors. As I write this I realize they might end up being the same people. Anyhow, finding time for peep studies is definitely a challenge. I think the key is the priority placed on the value of peep studies. For example, some RTs say, "We don't have time for that because we have 22 first round nebs to get done." What they're really saying is that those 22 first round nebs are a higher priority than maximizing the benefits of peep for their critically ill patients. When the truth is that most likely only 2 of those 22 first round nebs are actually indicated and actually benefit the patient in a manner that will improve outcomes. How many treatments have you given to patients with clear breath sounds, no distress and no documented flow obstruction responsive to bronchodilator therapy? Please don't misunderstand what I'm saying. Bronchodilator therapy is important, but only for those that truly need it and respond to it. You mention other things, such as SBTs, bronchs, etc....now those are definitely therapies that directly impact outcomes, and will pose time constraints in regards to performing peep studies. I would recommend peep studies be performed on nights or during a time of the day that is typically less chaotic. Of course, this will vary per facility. At the end of the day, as respiratory therapists, we have to ask ourselves what are the true priorities when it comes to maximizing outcomes for our patients. Finding each patient's exact optimal peep level, instead of everyone being on 5, 8, 10, 12, MAYBE 15, seems to me to be more valuable and beneficial than routine vent checks and an abundance of nebs. I'm sure there's research out there that supports this statement, as well as research that opposes it. Not sure if this is what you are seeing in your rotations or not, but my years of experience have lead me to the conclusion that we, as a profession, have become more task oriented (nebs, o2 checks, vent checks) and productivity focused, as opposed to individualized patient outcomes focused. I feel very passionate about the fact that we leave so much of our clinical skills and expertise on the table, and end up losing those skills in the end, if we're not aware of it happening. This is why I take the time to interact with students from all over. Be aware of this! Do not allow your excited, critical thinking RT self to be reprogrammed into a mindless, task oriented Respiratory Therapist. I don't think I answered your question, but I do hope I provided with some value.
Respiratory Coach
Hi
I do not believe at all that it should be an end of day or oh it’s quiet let’s do a peep study. From your lecture I believe I should be a critical component of patient care and outcome.
As a Respiratory Therapist I imagine there will be practioner leeway in delivery of morning meds within the scope of time and during One’s shift provided we can train our new habits to perform as such. Thanks again see you on the Tube!
I like the way you think and I agree. Optimizing peep should not be minimized to when it's quiet or convenient. I hope you didn't think that's what I was saying when I stated, "less chaotic times." Keep up the strong work, Jodie, and best wishes as you continue through school!!! Don't be a stranger.
Thank you Coach!
Love and Respect Sir ❤️
So you don’t look at stroke volume but you look at CO instead?🤔
Thanks Respiratory Coach
You are very welcome, Karen. Thank you for watching and commenting.
Do you have a video on how to determine and set an appropriate inspiratory rise time and I-Time in PC mode based on waveform feedback?
Hey Matthew. I probably do not have one specific to I time and Rise time in conjunction with waveform feedback. I do have this one in regards to I time and Rise time. ua-cam.com/video/aYUhHoKoODs/v-deo.html
I'll put it on the list to incorporate waveform feedback. Thanks for asking and watching.
@@RespiratoryCoach Thanks! One more question if you don't mind me asking: In AC-VC mode, if you set a specific tidal volume, is it normal to see varying volumes estimated on the vent? On the Trilogy 100 if I plug in let's say Vt 500ml, rate 12, the volume reported seems to vary within maybe + or - 50ml. But when you read a lot of scholarly articles about AC mode, it says it delivers the specific Vt on every single breath. I've seen other vents with varying Vt as well even in AC mode. Thanks man love your content!!!
@@matty00926 Not completely sure on this but does the trilogy 100 ask you to learn a vent circuit? It may not be compensating for compressible vol loss. Or maybe its a equipment issues and its not flow sensing properly. Just tossing out some ideas, good luck!
Thank you for another awesome video! Just one logistical question. As swan-gantz catheter is being put in less and less nowadays, where would you get mixed venous blood from? Would obtaining sample from central line(let's say it's in internal jugular site)be acceptable?
Hey Alex. Yes, central venous. It's definitely the next best thing to a true mixed venous sample which we know comes from the pulmonary artery. You might see it stated as PcvO2 and ScvO2 (central venous oxygen saturation) as opposed to PvO2 and SvO2 (mixed venous oxygen saturation), in order to note the difference. Great question and I hope this helps. Thanks for watching Alex!
Thanks! Great video! So many options to evaluate optimal PEEP. I just would explain differently why PvO2 is getting lower with supraoptimal PEEP. Indeed it is because CO drops down, so we can say that blood moves slower through the tissues and cells have time to extract more oxygen from it.
Otherwise I love your explanations. Wish you a good health so you could continue making more of clear and helpful videos :)
Hi, Yulia. Thanks for that contribution. I appreciate you watching and your input.
I hope you don't mind yet another clarifying question. How would SpO2 respond in these incremental steps? Would it increase incrementally until optimal peep is reached and then decrease? If so, how big of a drop would you expect clinically?
also, what about PaO2 changes? would it drop once you go past optimal peep as well?
when you start increasing PEEP, you would see decrease in EtCO2 then sudden increase once you go past optimal PEEP?
or is it you would start seeing increase in EtCO2 then sudden decrease in EtCO2 past optimal PEEP?
Once you past the point of optimal peep you will see a decrease in your ETCO2. This is due to the negative cardiac effects of peep. Decreased venous return = decreased pulmonary blood flow = ventilation in excess of perfusion = an increased in V/Q ratio = deadspace ventilation. So, you will see a decrease in ETCO2 once you pass optimal peep. Hope this helps and thanks for watching!!!
@@RespiratoryCoach Thank you for your reply! You are awesome!
Hey! Is there equation to calculate the best PEEP, or we adapt it just by monitoring the steps you talked about?
Well explained Thank you!
Thank you, Abdi. I appreciate you watching and commenting.
Could you make a video explaining extrinsic peep, intrinsic peep and auto-peep
Got it on the list. Thanks for watching and requesting, Summer.
If the patient is on pressors, can we augment peep with the pressor? Will this be beneficial or detrimental over time?
Great thought, Brian. I can't think of way pressors would increase PEEP. Doesn't mean the answer is no, I'm just not aware of this concept affecting peep. Send me an email if you would like to continue this conversation. I'd like to hear your thoughts on this concept. respiratorycoach@gmail.com
Thank you a lot
You are so nice. Always saying thank you! I thank you for always watching and kindly commenting!
Thanks man...
You got it, Gnokhi!!!!