BlogBloghttp://www.thomaspiraino.ca/blog/2012-05-26T02:25:46ZSquarespaceIf you can't explain it simply...http://www.thomaspiraino.ca/blog/2012/5/26/if-you-cant-explain-it-simply.htmlThomas Piraino2012-05-26T02:24:44Z2012-05-26T02:24:44Z

]]>Free Webinar from CareFusionhttp://www.thomaspiraino.ca/blog/2012/5/3/free-webinar-from-carefusion.htmlThomas Piraino2012-05-03T15:39:25Z2012-05-03T15:39:25ZMore information and to register click HERE

Course overview

Mechanical ventilation in the intensive care unit (ICU) is usually guided by arterial blood gases, and the parameters used to maintain these blood gases are limited by standards for lung protective ventilation. Airway pressures and tidal volume are minimized for lung protection despite evidence that they may be inadequate surrogates for lung stress and strain. Transpulmonary Pressure (Ptp) represents true lung pressure and physiologically, is ≥ 0 cmH2O at end-exhalation. 

Learn about the clinical aspects of Ptp from Tom Piraino, RRT, and how the CareFusion AVEA® ventilator can help optimize mechanical ventilation through:

  • Clinical measurement of Ptp
  • Effects of elevated pleural pressures on ventilation
  • Optimal PEEP setting
]]>Webinar Preparationhttp://www.thomaspiraino.ca/blog/2012/2/27/webinar-preparation.htmlThomas Piraino2012-02-28T01:29:08Z2012-02-28T01:29:08Z

Two things required. Computer and coffee.

Actually 3 things....sleeping children.

]]>Exciting Projecthttp://www.thomaspiraino.ca/blog/2012/2/3/exciting-project.htmlThomas Piraino2012-02-04T04:35:31Z2012-02-04T04:35:31ZOver the past 2 years I have thought of writing a critical care mechanical ventilation handbook.  I know there are a few on the market, but I think I have something new to offer.  I have a different idea of what a mechanical ventilation handbook should look like.

Tonight I began writing an interactive mechanical ventilation textbook for the iPad/iPhone/iPod touch.  It will be available in the iBooks store once it is completed.  It will focus on the simplest explanation of mechanical ventilation combined with interactive images and videos.

I have laid out the chapters and what each will focus on, written a brief introduction, and I have an idea for the title.

My goal is to have completed this year.

I hope you'll like it, which means I hope you'll download it. :-).  

]]>Design Tweakshttp://www.thomaspiraino.ca/blog/2012/1/27/design-tweaks.htmlThomas Piraino2012-01-27T06:08:47Z2012-01-27T06:08:47ZI made some design tweaks over at Respiratory Resource.  I also did away with the multiple discussion forums and replaced them with a general Practice Forum.  Hopefully this will encourage members and visitors to post!

]]>Non-Invasive Ventilation and Community Acquired Pneumoniahttp://www.thomaspiraino.ca/blog/2012/1/8/non-invasive-ventilation-and-community-acquired-pneumonia.htmlThomas Piraino2012-01-09T01:36:43Z2012-01-09T01:36:43ZWhen I graduated Respiratory Therapy in 2003 I remember having a preconceived notion that non-invasive positive pressure ventilation (NIPPV) should NOT be used with patients admitted with pneumonia. Whether it was something I was specifically taught or something that I learned during my clinical placement, it seemed to be consistent with other RTs I started working with as a staff RT.

It was many years later I learned that a study published the year I graduated (2003) by Ferrer et al. showed that the use of NIPPV in patients with acute hypoxic respiratory failure (COPD patients excluded) prevented intubation, reduced the incidence of septic-shock, and improved survival when compared with high-concentration oxygen therapy. However, there was another study by Confalonieri et al. that did not show any benefit (or harm) to using NIPPV with patients without COPD.

So why did there still appear to be such a hard stance against using NIPPV with pneumonia patients?

There is this strong belief that NIPPV will effect the ability to cough and clear secretions, and this may true with a mask strapped tightly to their face (makes sense), but conversely so does being intubated. Intubation requires heavy sedation and can be much less comfortable for a patient than a properly fit mask.

Perhaps the fear of NIPPV with pneumonia patients stems from a bad experience with someone who had pneumonia that escalated to primary ARDS with bilateral infiltrates and severe hypoxemia. Although there are no RCTs specifically designed to determine the effectiveness of NIPPV with ARDS patients, in this study by Ferrer et al. the multivariate analysis of the risk factors for intubation showed an odds ratio of 28.5 (p = 0.003). If you patient has developed ARDS the likelihood of them needing intubation is very high.

In summary, if you are called to see a pneumonia patient with SpO2 <90% on an FiO2 of 0.50 (the inclusion criteria for this study) there may be a benefit to using NIPPV. There is not strong enough evidence to support its exclusive use in these patients (because of conflicting results of other studies). However, it appears that the use of NIPPV does not cause harm. There is also an increased use of high-flow nasal canula with patients, further study is needed to determine it's true benefit with these patients other than comfort.

Keep in mind that a failure to improve within 1 hour of NIPPV (resp rate, pH, PaO2, PaCO2, etc.) is a strong predictor of failure.

Side note: There was no mention in this study as to whether humidification was used with the NIPPV patients, or the control group.

References:
Ferrer M, Esquinas A, Leon M, Gonzalez G, Alarcon A, Torres A. Noninvasive ventilation in severe acute hypoxemic respiratory fail- ure: a randomized clinical trial. Am J Respir Crit Care Med 2003; 168(12):1438-1444.

Confalonieri M, Potena A, Carbone G, Porta RD, Tolley EA, Meduri GU. Acute respiratory failure in patients with severe community- acquired pneumonia. A prospective randomized evaluation of non- invasive ventilation. Am J Respir Crit Care Med 1999;160(5 Pt 1):1585-1591.
]]>Ready, Set, Go!http://www.thomaspiraino.ca/blog/2012/1/6/ready-set-go.htmlThomas Piraino2012-01-06T05:18:23Z2012-01-06T05:18:23ZA New Year, A New Initiativehttp://www.thomaspiraino.ca/blog/2012/1/1/a-new-year-a-new-initiative.htmlThomas Piraino2012-01-02T01:15:18Z2012-01-02T01:15:18ZI decided to start a personal website this year, but not for the purpose of showcasing personal things (i.e. family, friends, or things I find funny...I have a website for that already).  This website instead will serve as a personal professional website where I can write about things, exciting or not, that are occuring in my professional life.  Much like LinkedIn, but one that I control the design, layout, and content much easier.  

This site can also serve as a means to increase consultation oportunities and perhaps even website development oppourtunities.

Currently this site is under construction, so if you found it good for you, keep checking back for updates!

]]>Should we worry about tidal volume when plateau pressure is low?http://www.thomaspiraino.ca/blog/2011/12/15/should-we-worry-about-tidal-volume-when-plateau-pressure-is.htmlThomas Piraino2011-12-16T02:24:18Z2011-12-16T02:24:18ZSome clinicians may feel that tidal volume isn't really an issue when plateau pressure is at a safe level (< 30 cm H2O).  In a paper by Hager et al. published in 2005 in the AJRCCM journal data from the ARDSNet study was seperated into quartiles of plateau pressure.  It showed that higher plateau pressures had higher mortality, even with 6 ml/kg.  

Patient's with low AND high tidal volume that had plateau pressures in the 1st quartile all had plateau pressures < 30 cm H2O (99 and 100 patients respectively).  

The absolute risk reduction (ARR) was determined and showed an ARR of 9.4% would be achieved by decreasing tidal volume to 6 ml/kg from 12 ml/kg.

So does tidal volume matter when plateau pressures are within safe limits?  Yes.

 

]]>Time to develop VILIhttp://www.thomaspiraino.ca/blog/2011/12/7/time-to-develop-vili.htmlThomas Piraino2011-12-07T19:50:31Z2011-12-07T19:50:31ZThere was an interesting study published this month (last month online) that analyzed the time it took to develop ventilator induced lung injury (VILI) in healthy mammals.  The interesting points made were that tidal volume and pressure did not correlate with how long it took to develop VILI (r2 = 0.25).  One might think that if you applied excessive tidal volume to a mammal that you would cause VILI.  However, lung strain did correlate (r2 = 0.85).  Larger mammals took much longer to develop VILI if the lung strain was low (below 2).  

 

Why is this important?  
We spend a lot of time focusing on tidal volume and pressure to try and prevent VILI, but it seems to be a poor indicator of whether or not it will occur.  The reason perhaps is that none of our ventilator parameters we monitor represents the actual inflation pressure of the lung, transpulmonary pressure.  Lung stress takes this into account.

 

 

 

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