Mechanical ventilation and flail chest

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Perfectly appropriate mode of ventilation for the patient population you
describe, but I would not catagorize APRV as an "advanced" mode of
ventilation. Basically CPAP with short interruptions.

We have used APRV for some time now, and use it for most "recruitable"
processes causing refractory hypoxemia in our surgical/trauma patient
population. It has not caught on as much in our medical population. I
believe that this is mostly because of the different characteristics between
primary and secondary ARDS, and how they react to mean airway pressure
changes.

Keith

On Sat, Oct 31, 2009 at 7:51 PM, Sise, Michael (MD) <
Sise.Mike at scrippshealth.org> wrote:

> Colleagues,
>
> We've used APRV in most settings that require advanced ventilator
> management with quite a bit of success - including chest wall trauma with
> flail and underlying contusion. I'm very interested to know how many of you
> have experience with APRV to the point that you have become comfortable with
> it as your choice for advanced ventilator management. We had a steep
> learning curve when we first adopted it 5 years ago. My new colleague (15
> months now), Steve Shackford, has been on that curve with us and his initial
> discomfort it reminiscent of my own experience.
>
> Mike Sise
> San Diego
>
> ________________________________
>
> From: Ante Coric [mailto:ante.coric85 at gmail.com]
> Sent: Sat 10/31/2009 3:43 PM
>  To: Trauma-List [TRAUMA.ORG <http://trauma.org/>]
> Subject: Re: Mechanical ventilation and flail chest
>
>
>
> sedated first, agree, but considering ventilating mode itself, l would
> prefer straightforward approach, CMV, usually pressure control, tidal
> volume
> being 8-10ml/kg but if patient is asking for more give more if plataue
> pressure below 25 cm water. depending on sedation level inspiratory time 1
> sec or less, minimum FiO2.
> Ante
>
> 2009/10/31 Ronald Simon <Traumamd at nyc.rr.com>
>
> > I wonder if you could accomplish this with APRV and not have to paralyze
> > your patient.
> > Ron Simon
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org [mailto:
> > trauma-list-bounces at trauma.org]
> > On Behalf Of jduchesn at tulane.edu
> > Sent: Saturday, October 31, 2009 1:44 PM
> > To: Trauma-List [TRAUMA.ORG <http://trauma.org/>]
> > Subject: Re: Mechanical ventilation and flail chest
> >
> > Dear Matthieu:
> > I have my own bias on what works for lung contusion with severe chest
> wall
> > injury (flail chest) and ARDS net is not the answer.
> > I like to use damage control ventilation using pressure control at low
> rate
> > with a 1 to 1 I:E ratioa. This works great in opening your FRC. I
> identify
> > the best PEEP and then add Pressure above PEEP to give you a Plateau at
> 33.
> > For this maneuver the patient needs to be paralyzed and sedated in order
> to
> > achieve the best recruitment.
> > I use this damage control ventilation mode for the first 72 hours and
> > although I don't have our own data yet the CXR difference is dramatic.
> > Good Luck
> > Duchesne
> > CharityOne-New Orleans
> > Sent via BlackBerry by AT&T
> >
> > -----Original Message-----
> > From: Matthieu G. <mat.genz at gmail.com>
> > Date: Sat, 31 Oct 2009 18:13:49
> > To: Trauma-List [TRAUMA.ORG <http://trauma.org/>]<trauma-list at trauma.org
> >
> > Subject: Mechanical ventilation and flail chest
> >
> > Dear list members,
> >
> > do you use a specific mechanical ventilation strategy for patient with
> > flail chest and underlying lung contusions, besides the lung
> > protective approach for patient with ALI/ARDS? For example, Moore's
> > Trauma textbook advocates the use of volume controlled over pressure-
> > supported mode, the rationale being that even the modest negative
> > pressures needed to trigger the ventilator cycle may destabilize the
> > chest wall.
> >
> > Thank you for your input.
> >
> > Matthieu Gensburger
> >
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