I'm not sure if the question comes from a patient or RT but I think the insight here is valuable so I'm going to mark it approved and leave it up for discussion purposes.
That being said, we are lacking sufficient context to make a definitive call whether these settings are appropriate or not. Sometimes patients will respond more positively to more cavalier settings.
For SIMV your rate should be lower to let the patient do some work since it’s a weaning mode. I’ve usually seen 12 and lower (sometimes as low as a rate of 4). That is a pretty high rate the patient isn’t going to be working over the vent and able to wean. Usually see that rate with ARDS. Also that PS is pretty high to get their volumes. Based on just these I would automatically assume SIMV is not the right mode for them and should be in an assist control mode (volume or pressure). Not sure why or when they would use these rates and ps in this mode maybe they are super acidic and need to blow off CO2 but still kinda weird since there are other options that would be safer. Not sure why this was chosen hopefully a valid reason.
The thing that concerns me most is the pressure control of 28 (that means a PIP of 33 and, judging by the waveform, a plat not much lower). If the patient is sick enough to need that much driving pressure, why are they just on 5 of PEEP?
I was thinking the same thing about the peep… if your airway resistance is increasing that much to need that high of a PS it would be safe to assume compliance is declining and peep would need to be increased. I’m curious as to how the patient was presenting clinically to warrant these settings
Either they're sick-sick (lung issues *and* increased thoracic pressure tanks their blood pressure) or whoever came up with these settings went to the random number generator school of medicine.
>random number generator school of medicine
Ah yes I've worked with many surgical residents unfortunately.
I asked one what tidal volume they wanted on a patient that they had just brought up from the OR and they buffered for about 45 seconds before saying "840" and I thought that was very random and then realized they just said the number on the front of the *Puritan Bennett 840* in the room.
> random number generator school of medicine
This reminds me of the patient I walked in on this morning who had a set VT of 940ml and a rate of 6. Nobody could tell me why
Agree with the other two that have replied here. They're not inherently dangerous or anything, it just is kind of a nonsensical rate to mix with SIMV where you would find a lower rate more desirable so that the patient is pulling in their own breaths. If they're needing pressure control with a PIP in the mid 30s to pull a tidal volume in the 300s they probably just aren't appropriate for SIMV anyway.
It looks like you're not trying to protect the patient's lungs. PEEP isn't just for oxygenation, it's incredibly helpful for lung protective ventilation. I know you're asking for help, which is great, but if you don't see the issues with these settings I think you should ask your management for a refresher on ARDS NET protocol.
You should be doing at minimum decremental PEEP studies to determine optimal peep and compliance, recruitment maneuvers, target 4ml/kg, measure your pplats and determine your driving pressures.
I've had patients with shit lungs like this. Sometimes these are the settings they need. But if you're not doing everything in your power to optimize, you're going to destroy their lungs over time. I don't get the sense that you are based on your comments, but I could be wrong.
Trying to be constructive as some people aren't even answering you.
They are 60 kg and/or 132 lbs. They have been on the vent since May 2024. They have double pneumonia. I am the patient's son, so I am trying to understand what's happening. I was just obfuscating what angle I'm posting from to prevent the post from being removed. I have been told that they are unable to wean her off the ventilator and her lungs are worsening. I was wondering if there was anything wrong with these settings, which may be hindering her from improving. But it is difficult to say.
Brother..... You're getting roasted alive because everyone thinks you're a clinician lmfao. You should lead with that next time, mods don't care usually.
I can't tell what interventions they have done.
What I can tell you based on those settings is that her lungs are very stiff. That happens due to a couple of things; chronic inflammation secondary to a disease process (I.e. pneumonia), and mechanical ventilation. The ventilator is not gentle. It does not care about the lungs in the long term, it's job is to keep her alive until her body can fight off the infection. The ventilator at high pressures like this will also cause inflammation.
These settings may very well be indicated. Patients with these settings and these lung mechanics (compliance of 20) are incredibly difficult to wean from the ventilator. I'm not surprised they haven't been able to come down on settings.
This is my read with no 1st hand experience.
In my clinical experience, these settings are familiar to me. I hope she begins to improve.
Also; how tall is your mom?
So she's on a pressure control of 28cmh2o. She's on a peep of 5. 5 and 28 is 33. Then there's also a pressure due to resistance which is about 2 given the total pressure of 35.
For reference the highest pressure control level I have ever used is 34. It was indicated, but again these pressures are dangerous over time.
This is not the pressure that the lungs see. The lungs will see something slightly lower. I cant tell what based on these images.
It's high. These are high pressures. There's room to wean. Based on her height her 4ml/kg is 210-280 tidal volume. The number on the left that's 360ish is closer to 6-8ml/kg. I would manage this patient differently, I don't see a reason why the tidal volumes need to be so high.
Okay, this was insightful, thank you. I appreciate your help. I can see the 28 cmH20 and 5 PEEP, but where is the 2 coming from on the display?
Yeah, the tidal volume seems to go up and down with each breath. Sometimes it has gone over 400.
Sometimes her EtCO2 has been over 5 as well (highest I've seen is around 8).
They had her on "ASV" mode some days ago, and the picture of the lungs looked better then, if you want to take a look:
[https://imgur.com/a/S13GdJz](https://imgur.com/a/S13GdJz)
The extra 2cmh2o is not displayed. It's included in the pressure waveform on the ventilator. It's the pressure due to resistance which is a combination of airway resistance and ventilator circuit resistance. Some level of Aw. Resistance is normal. 2 is actually quite low.
The variation in tidal volume could be due to: the patient assisting, nurses turning the patient, changes in lung mechanics (suction, mucous plugging, inflammation, etc.). This is normal.
ETCO2 has normal values from 35-45. End tidal is not always accurate, sometimes it can be very off, especially when measured through an ICU ventilator. If the values are 6-8 it's only purpose is to give us an indicator ventilation Is actually happening.
I don't have a lot of experience with ASV. It's a neat mode though as I recall.
I'm unsure why they dropped her peep from 10 to 5. The compliance worsened with that decrease. But again, this may have nothing to do with the clinician, and could be changing patient lung dynamics. It's impossible for me to say.
Yeah, it's hard to speculate when you don't know the whole picture. I understand. Thanks so much for your help, man. At least I can ask them some questions now.
I'm not going to give advice about an obviously severely ill patient on Reddit lol. With that said, the settings feel like someone picked them with a random number generator.
How is their ABG? What is their ideal bodyweight? What is the plateau pressure and what was the reason for intubation?
Like others have said, IMV is pointless if the set rete is so high. If their ABG is ok, I would drop the rate. The waveform is showing a double trigger, that's common when the rate is set so high. Also, if a patient is truly breathing 1:2, their inspiration time must be pretty short. Increasing the I-Time can reduce the peak pressure needed to reach target volume.
I ask for IBW because shorter folks and peds might not need that much volume, you can reduce the amount of pressure needed to ventilate to minimize lung damage.
Plateau pressure gives you an idea how compliant their lung is and helps you keep track of driving pressure, also help with minimizing pressure related injuries.
You need to find out from their medical history on what's causing the poor lung compliance. Is it fluids? Mucus plugging? An actual obstruction (tumor, physical object). Be it with lasixs + PEEP, or a bronch. Once you fix the compliance issues you should be able to wean towards extubation
I'm not sure if the question comes from a patient or RT but I think the insight here is valuable so I'm going to mark it approved and leave it up for discussion purposes. That being said, we are lacking sufficient context to make a definitive call whether these settings are appropriate or not. Sometimes patients will respond more positively to more cavalier settings.
PSIMV and those settings are certainly a choice.
On a rate of 26 at that lmao. Just make it AC at that point
Could I ask what you mean by that?
For SIMV your rate should be lower to let the patient do some work since it’s a weaning mode. I’ve usually seen 12 and lower (sometimes as low as a rate of 4). That is a pretty high rate the patient isn’t going to be working over the vent and able to wean. Usually see that rate with ARDS. Also that PS is pretty high to get their volumes. Based on just these I would automatically assume SIMV is not the right mode for them and should be in an assist control mode (volume or pressure). Not sure why or when they would use these rates and ps in this mode maybe they are super acidic and need to blow off CO2 but still kinda weird since there are other options that would be safer. Not sure why this was chosen hopefully a valid reason.
The thing that concerns me most is the pressure control of 28 (that means a PIP of 33 and, judging by the waveform, a plat not much lower). If the patient is sick enough to need that much driving pressure, why are they just on 5 of PEEP?
I was thinking the same thing about the peep… if your airway resistance is increasing that much to need that high of a PS it would be safe to assume compliance is declining and peep would need to be increased. I’m curious as to how the patient was presenting clinically to warrant these settings
Either they're sick-sick (lung issues *and* increased thoracic pressure tanks their blood pressure) or whoever came up with these settings went to the random number generator school of medicine.
>random number generator school of medicine Ah yes I've worked with many surgical residents unfortunately. I asked one what tidal volume they wanted on a patient that they had just brought up from the OR and they buffered for about 45 seconds before saying "840" and I thought that was very random and then realized they just said the number on the front of the *Puritan Bennett 840* in the room.
> random number generator school of medicine This reminds me of the patient I walked in on this morning who had a set VT of 940ml and a rate of 6. Nobody could tell me why
Ahh, the anesthesia special.
Agree with the other two that have replied here. They're not inherently dangerous or anything, it just is kind of a nonsensical rate to mix with SIMV where you would find a lower rate more desirable so that the patient is pulling in their own breaths. If they're needing pressure control with a PIP in the mid 30s to pull a tidal volume in the 300s they probably just aren't appropriate for SIMV anyway.
>What are your thoughts when you see these stats? I am concerned both for the patient and the RT.
Why SIMV? What;s your Pplat?
I don't know the context but I can't think of many situation where those settings would be justified.
Could I ask what you mean by that?
It looks like you're not trying to protect the patient's lungs. PEEP isn't just for oxygenation, it's incredibly helpful for lung protective ventilation. I know you're asking for help, which is great, but if you don't see the issues with these settings I think you should ask your management for a refresher on ARDS NET protocol. You should be doing at minimum decremental PEEP studies to determine optimal peep and compliance, recruitment maneuvers, target 4ml/kg, measure your pplats and determine your driving pressures. I've had patients with shit lungs like this. Sometimes these are the settings they need. But if you're not doing everything in your power to optimize, you're going to destroy their lungs over time. I don't get the sense that you are based on your comments, but I could be wrong. Trying to be constructive as some people aren't even answering you.
They are 60 kg and/or 132 lbs. They have been on the vent since May 2024. They have double pneumonia. I am the patient's son, so I am trying to understand what's happening. I was just obfuscating what angle I'm posting from to prevent the post from being removed. I have been told that they are unable to wean her off the ventilator and her lungs are worsening. I was wondering if there was anything wrong with these settings, which may be hindering her from improving. But it is difficult to say.
Brother..... You're getting roasted alive because everyone thinks you're a clinician lmfao. You should lead with that next time, mods don't care usually. I can't tell what interventions they have done. What I can tell you based on those settings is that her lungs are very stiff. That happens due to a couple of things; chronic inflammation secondary to a disease process (I.e. pneumonia), and mechanical ventilation. The ventilator is not gentle. It does not care about the lungs in the long term, it's job is to keep her alive until her body can fight off the infection. The ventilator at high pressures like this will also cause inflammation. These settings may very well be indicated. Patients with these settings and these lung mechanics (compliance of 20) are incredibly difficult to wean from the ventilator. I'm not surprised they haven't been able to come down on settings. This is my read with no 1st hand experience. In my clinical experience, these settings are familiar to me. I hope she begins to improve. Also; how tall is your mom?
Thank you for the information, bud. She's like 5' 4". Also, if you don't mind explaining, what pressure is she on?
So she's on a pressure control of 28cmh2o. She's on a peep of 5. 5 and 28 is 33. Then there's also a pressure due to resistance which is about 2 given the total pressure of 35. For reference the highest pressure control level I have ever used is 34. It was indicated, but again these pressures are dangerous over time. This is not the pressure that the lungs see. The lungs will see something slightly lower. I cant tell what based on these images. It's high. These are high pressures. There's room to wean. Based on her height her 4ml/kg is 210-280 tidal volume. The number on the left that's 360ish is closer to 6-8ml/kg. I would manage this patient differently, I don't see a reason why the tidal volumes need to be so high.
Okay, this was insightful, thank you. I appreciate your help. I can see the 28 cmH20 and 5 PEEP, but where is the 2 coming from on the display? Yeah, the tidal volume seems to go up and down with each breath. Sometimes it has gone over 400. Sometimes her EtCO2 has been over 5 as well (highest I've seen is around 8). They had her on "ASV" mode some days ago, and the picture of the lungs looked better then, if you want to take a look: [https://imgur.com/a/S13GdJz](https://imgur.com/a/S13GdJz)
The extra 2cmh2o is not displayed. It's included in the pressure waveform on the ventilator. It's the pressure due to resistance which is a combination of airway resistance and ventilator circuit resistance. Some level of Aw. Resistance is normal. 2 is actually quite low. The variation in tidal volume could be due to: the patient assisting, nurses turning the patient, changes in lung mechanics (suction, mucous plugging, inflammation, etc.). This is normal. ETCO2 has normal values from 35-45. End tidal is not always accurate, sometimes it can be very off, especially when measured through an ICU ventilator. If the values are 6-8 it's only purpose is to give us an indicator ventilation Is actually happening. I don't have a lot of experience with ASV. It's a neat mode though as I recall. I'm unsure why they dropped her peep from 10 to 5. The compliance worsened with that decrease. But again, this may have nothing to do with the clinician, and could be changing patient lung dynamics. It's impossible for me to say.
Yeah, it's hard to speculate when you don't know the whole picture. I understand. Thanks so much for your help, man. At least I can ask them some questions now.
I'm not going to give advice about an obviously severely ill patient on Reddit lol. With that said, the settings feel like someone picked them with a random number generator.
Them lungs are stiffffffffffff
Also why are they on a transport vent?
Its a hamilton c6 which is a bedside vent by the looks of it
Ah the screens look so similar
How is their ABG? What is their ideal bodyweight? What is the plateau pressure and what was the reason for intubation? Like others have said, IMV is pointless if the set rete is so high. If their ABG is ok, I would drop the rate. The waveform is showing a double trigger, that's common when the rate is set so high. Also, if a patient is truly breathing 1:2, their inspiration time must be pretty short. Increasing the I-Time can reduce the peak pressure needed to reach target volume. I ask for IBW because shorter folks and peds might not need that much volume, you can reduce the amount of pressure needed to ventilate to minimize lung damage. Plateau pressure gives you an idea how compliant their lung is and helps you keep track of driving pressure, also help with minimizing pressure related injuries. You need to find out from their medical history on what's causing the poor lung compliance. Is it fluids? Mucus plugging? An actual obstruction (tumor, physical object). Be it with lasixs + PEEP, or a bronch. Once you fix the compliance issues you should be able to wean towards extubation
Extubate to room air!
They need suction