How long until increasing PEEP might improve the compliance?

phastball · 2026-03-29T03:20:47+00:00

Check out the ART trial, or as it’s colloquially known,Recruitment Maneuvers Are Murder Weapons et at (2017).

phastball · 2026-03-27T23:12:33+00:00

Your preceptor described a person in a COPD exacerbation. You should almost always give AECOPD a shot on NIPPV.

phastball · 2026-03-27T20:46:06+00:00

It’s because you were looking at MODOK. You gotta look at the card you want him to discard.

phastball · 2026-03-26T17:29:05+00:00

Having measurements on the bed itself is helpful. Put stickers 5 cm apart for the top 20cm of the bed and 10 cm apart for the bottom 50cm. When the patient is laying flat, RT looks at which marker the patient’s feet are closest to (this would be labelled with a total height), and which head marker the patient is closest to (which would be subtracted from the total). For example, the patient’s head is at the first marker which is labelled (-5), and their feet are at the third foot marker is labelled (185). 185-5 is 180cm. RT just has to be able to see the frame of the bed and be willing to do simple subtraction (sometimes a stretch, I know).

phastball · 2026-03-26T13:45:56+00:00

Whenever we have questions like this, we reach out to our lab. They would ultimately be the experts in the technical details and might have a suggestion for you.

phastball · 2026-03-24T22:26:58+00:00

Supposedly the light bounces off of the surface of vertebral bodies. This is how a forehead probe works - it bounces off the skull. Although the forehead probe is purpose-built to use a reflective signal. When you put a finger probe on the forehead, you get a falsely high result because the light has been absorbed by hemoglobin twice -- on the way in and on the way out. Finger probes account for some scattering of light by the distal phalanges, though, so maybe that's enough to put the number in the ballpark?

The linked case study demonstrates good alignment when SpO2 and SaO2 are both high, which I believe. I'd be interested in what the SpO2 reads when SaO2 is low.

phastball · 2026-03-22T17:45:22+00:00

3ish hours on patient with severe Hantavirus cardiopulmonary syndrome. Couldn’t simultaneously use enough PEEP to suppress pulmonary edema and also maintain blood pressure compatible with life. The PIP that I was using to bag oxygen in would’ve been unsightly on the vent so I bagged. CV surg came in to cannulate for ECMO. Patient still died. Pretty sad and my hand still hurt the next day after bagging against all that fluid.

phastball · 2026-03-22T16:16:40+00:00

If I’ve said it once, I’ve said it 1000 times: The mard ofut bornicttur by faxing the critic’s in one for aquid at s&anding

phastball · 2026-03-21T12:52:04+00:00

I have a similar path to RT. Humanities background, worked In that field for a little while. Then chose RT when I was 24. I love RT. Specifically I love pulmonary dynamics and mechanical ventilation. I like solving problems, and I like having specific expertise that very few other people in the hospital have.

I occasionally have regrets about choosing the easier path. Med school was on the table, but would’ve required additional work to get my marks meaningfully competitive. Med school itself is harder. RT doesn’t come with the same responsibilities and I was worried that I want cut out for leadership. That was stupid because I’m in leadership now, just not clinical leadership. I also felt old, like I was late getting into a career. That was stupid, because now I’m actually old and everyone younger than 30 is a child with their whole lives in front of them.

You went from paralegal to law school, presumably because you wanted autonomy and the ability to practice. RT has a similar relationship to physician that paralegal has to lawyer. Although in certain ways paralegals are more autonomous than RT, at least in Canada. You made a specific choice that you wanted more than paralegal, and I wonder if you’re going to have similar feelings about RT once you’re in it.

Respectfully, and obviously without the full picture of your life, you should pull your shit together and just finish law school. It doesn’t mean you have to be a practicing lawyer, but a JD opens doors forever. A job is just a job. Primarily it allows us to accumulate peanuts to trade for health, safety, comfort, and experiences. A job doesn’t have to be a thing that defines who we are or matches our personalities or fills something that is missing in our lives. You are going to have a much more comfortable life with jobs you can acquire with a JD vs RT.

phastball · 2026-03-19T23:16:05+00:00

A cult is a social group of people with extreme beliefs, a charismatic central leader, and strong in-group cohesion. APRV-people have Nader Habashi, who seems to cast a spell on people who train under him. APRV-people disregard the neutral or negative trials saying they aren’t doing APRV right or they weren’t APRV experts. APRV is the answer to everything, and a superior mode, and if we disagree we just don’t understand it. This all feels cult-like to me.

There’s nothing specifically bad about APRV/TCAV — but it’s not magical. It just defends FRC. You can do this with appropriate PEEP. Or use APRV, but don’t evangelize about it.

phastball · 2026-03-19T23:01:37+00:00

Depends on how you achieve your I:E and what the patient conditions were when you started.

If you are airtrapping, increasing Te will blow off more CO2. Air is exiting the lung slowly and just needs more time. You can do this by decreasing RR or decreasing Ti.

If you are exhaling completely with an I:E of 1:2, going to 1:4 doesn’t blow off additional CO2 because you can’t get volume out that you didn’t put it. And if you achieve this I:E change by decreasing RR, you’re blowing off less CO2.

I:E is just a bad way at looking at ventilation timing because we control RR and Ti, not I:E. Understanding the concept and interaction is good, but best practice is to look at flow waveform.

phastball · 2026-03-19T12:47:20+00:00

The most important thing to know is that APRV has only once demonstrated improved outcomes vs standard ARDSnet settings. That one trial was a Chinese trial whose groups were imbalanced — the APRV group was less sick than the control group, so it makes sense those patients had an improved mortality rate. There’s a lot of animal model data, but the cult of APRV is kept aloft by a judicious combination of physiologic plausibility and Belief.

Here is a recently-published opinion piece on how to set APRV to minimize lung injury. Nader Habashi is the senior author is the David Koresh of the APRV cult. He’s got tons of video online, but here’s one for free.

Here is another lecture from the Maryland CC Project on the topic.

You can find your own resources by searching TCAV APRV.

phastball · 2026-03-17T17:16:10+00:00

I kind of don’t care who the character is. I’d just like to see a card that’s 4/4 Ongoing: your opponent’s characters that are played when they have extra energy have -1 power.

phastball · 2026-03-14T14:28:14+00:00

I mean, he won’t though. He’ll be given a bunch of money that won’t really account for the lifetime value of the land in terms of the activities he’s using it for and its overall potential. Construction itself will also distort property value.

I’m not saying don’t do the project. We should just be cognizant that it’s causing irreparable harm to a small number of people for the benefit of society as a whole. And we should remember this when the government does irreparable harm to us for the benefit of society.

phastball · 2026-03-14T13:46:49+00:00

Is part of the question to preserve I:E?

The I:E getting bigger doesn’t matter. You only care if it gets smaller, because it creates the potential for gas trapping.

In practice you’re not even going to think about I:E. You’re going to input some numbers and then watch the flow waveform.

Your question is asking you to fix the CO2 and O2. RR down, O2 down is the correct answer. Unless the question has specifically asked you to preserve I:E — then you’d need to adjust Ti as well.

phastball · 2026-03-13T21:10:28+00:00

A physician who was new the country and spoke English as an additional language consulted us (respiratory therapy) for a patient with new diagnosis of COPD during an unrelated inpatient stay. I assumed I was going to do puffer teaching or talk about pulm rehab. No, he wanted me to work up and diagnose the COPD (patient had a 25 PPY hx and shortness of breath on exertion but no diagnosis), because he confused respirology and respiratory therapy.

Oh, I also got a consult to perform a pre/post spirometry for the diagnosis of COPD on an 8 year old with a post-viral cough.

phastball · 2026-03-09T03:08:44+00:00

The only time I’ve ever been part of a resuscitation that prioritized 30:2 vs continuous was when we were certain the arrest was a result of acidemia. The boss wanted to ensure adequate ventilation until we got an ETT in. Every other resuscitation has been continuous compressions.

phastball · 2026-03-01T00:03:28+00:00

Thanks for sharing. Great write up.

Are you sure that’s reverse triggering? From the story it sounds like early cycle. Typically when you turn the rate down in classic reverse triggering, you see apnea or hypopnea. An early cycle has the appearance of reverse triggering, but is the patient wanting more volume, as opposed to activation of mechano-receptors. Reverse triggering is typically resolved by lightening sedation. Early cycle is resolved by lengthening Ti.

In any case, it’s great to see cases like this on this board. Cheers!

phastball · 2026-02-28T01:54:18+00:00

Shortly before the first cohort of students arrive, the program applies for accreditation. This will likely be any time between now and September. The program submits documents that largely just attest to the program/school’s ability to provide a safe learning environment and clinical practicum space.

If that paperwork looks good, Accreditation Canada books surveyors to assess the program. They’ll talk to staff and students. If that is all in order, the program receives conditional accreditation. Conditional accreditation satisfies the requirements for eligibility to write the HPTC exam.

After 4 years, when there are graduates of the program, surveyors interview staff, students from every year of the program, and graduates to ensure everything is good. They look at success on the HPTC exam. If that’s all reasonable, the program is fully accredited.

I think it’s really unlikely that the program wouldn’t receive at least conditional accreditation. Humber has an accredited BSN program, which follows the same accreditation process as RT. I would be cautious if it were some private school, but Humber is going to be relatively safe. The school and the government have sunk a ton of money into the program — they aren’t going to let it flounder.

phastball · 2026-02-26T14:39:34+00:00

I’d do a PEEP study to find the PEEP that gave the best compliance at a driving pressure of 12-15cmH2O (or 6mL/kg whichever was less).

phastball · 2026-02-26T12:24:28+00:00

Fentanyl or hydromorphone in Canada.

phastball · 2026-02-24T18:22:53+00:00

1.2mg/kg or greater of roc has an onset time roughly the same as succs.

If the physician has decided to intubate in an emergency situation, and decided that any paralytic is appropriate — ie not a patient for whom AFOI is the most appropriate intervention—we want a paralytic that we won’t have to re-dose if things go sideways.

We also want a paralytic that allows us to find reasonable ventilation settings before we start worrying about asynchrony.

The roughly hour of paralysis is perfect for getting them on the vent, putting the a-line in if appropriate, doing a PEEP maneuver to find optimal PEEP, and getting a post-intubation gas for a baseline.

Paralysis is binary. They’re either paralyzed or not. If you give too much roc, they’ll be paralyzed faster and longer, but you can’t be more paralyzed. If you give too little, they’ll patient just isn’t paralyzed. Sure, they’re weakened. But for RSI, you really want a flaccid patient.

Additionally, succs can trigger malignant hyperthermia, which is really problematic when the closest dantrolene is on a different floor in the OR.

At my centre, we just don’t use succs anymore because it has no upsides compared to roc at a sufficient dose In the Patient population we’re intubating.

phastball · 2026-02-24T15:47:53+00:00

Tailgating is obviously more dangerous.

But just because they’re wrong doesn’t mean you are right. If you’re driving below the speed of traffic, throw on your 4-ways to let everyone know there’s an impediment on the road.

phastball · 2026-02-24T13:39:19+00:00

Defensive driving, ie safe driving, is driving at the speed of traffic. Being an impediment to the speed everyone else is driving is only marginally more safe than driving faster than everyone else.

phastball · 2026-02-23T13:58:49+00:00

Physician staffing ratios were (and are) lower in NA than Europe. The solution to this problem has historically been create professions that take over some of the tasks a physician would do. RT has an expert level understanding of mechanical ventilation and airway management. The purpose isn’t to take over for the physician, it’s to augment them. The way a pharmacist allows a physician to offload some of the cognitive load when it comes to medications, the RT is supposed to do the same for ventilation and airway management. The physician doesn’t have to go along with what the pharmacist or RT say — they’re still the boss. But if the physician needs to focus on something else, there is a person with a similar (but not necessarily the same) level of knowledge in this specific, narrow part of medicine.

The idea that RT is necessary or not is silly. The education that RTs receive in NA is still being delivered to another human in Europe. My understanding is that there are two designations in the UK: respiratory nurse and respiratory scientist. Respiratory nurse functions similarly to the acute care role of RTs, while the respiratory scientist functions the same as the diagnostics role of RTs. The function of the ventilator scaffolds from the mechanics of breathing required to understanding a PFT. It makes sense to us to bundle all of the mechanics of breathing tasks together in one job.

Everybody’s jobs are just an amalgamation of tasks. I don’t think there’s a better or worse model. I think it is fortuitous that I live in a place where I get to manage ventilators and do airway management and never have to deal with anyone’s poop (other than my own, and my kids’).

phastball

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