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S1E10 - Don’t Hold Your Breath – Mechanical Ventilation 101 (Part 2)
166 Plays1 month ago
In this second installment of our two-part series, our trio of veterinary anesthesiologists takes a deep breath and dives into the more complex issues of mechanical ventilation. We turn up the pressure and tackle the trickier side of mechanical ventilation. Whether you’re new to the concept or need a refresher, this episode will help you breathe easier about ventilator basics—without leaving you gasping for air from information overload!
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Transcript
Intro
Exploring European Cuisine and Culture
00:00:42
Gianluca Bini
Yeah.
00:00:42
Annatasha
It's 100% hot.
00:00:42
Ryan Bailey
so yeah i will say, i wish I was recently in Europe, France specifically, and I am shocked the number of hot dogs that are on menus everywhere.
00:00:44
Gianluca Bini
i
00:00:58
Gianluca Bini
yeah
00:00:59
Ryan Bailey
Like...
00:00:59
Annatasha
Have you been to Germany or Austria?
00:01:00
Annatasha
Because it's a real sausage culture.
00:01:02
Ryan Bailey
Sure, but, like, they said hot dog. Not, like, Xiao Chen or whatever.
00:01:06
Annatasha
Hmm.
00:01:09
Ryan Bailey
Like, hot dog would be in French.
00:01:14
Annatasha
Chien chaud.
00:01:15
Ryan Bailey
out That's much better. Yeah, they were everywhere. I had two hot dogs within the first two days and I was like, okay, they're too common. I'm going to have slow it down or I'm going to die. What's up?
00:01:29
Gianluca Bini
Worthy or not worthy?
00:01:32
Ryan Bailey
what's up
00:01:32
Gianluca Bini
Were they worthy or not worthy?
00:01:34
Ryan Bailey
I mean, the first one was i have to i still have yet to write my reviews. i've been you know i was busy eating French food and being in France and all that and learning at the World Congress of Veterinary Anesthesia.
00:01:47
Annatasha
Did you say flirting?
00:01:48
Ryan Bailey
Learning.
00:01:49
Annatasha
Oh, I thought you said flirting.
00:01:49
Gianluca Bini
I told you.
00:01:51
Annatasha
And i said well, that's very French of you, but also weren't you with your wife?
00:01:55
Ryan Bailey
yeah I was the only person I was forwarding with, in fact. She does not attend the conference, though. Uh, so the first hot dog I had stuffed in a baguette.
00:02:07
Ryan Bailey
It was,
00:02:08
Annatasha
It's so good, right?
00:02:09
Gianluca Bini
co you
00:02:10
Annatasha
We
Ventilation Techniques in Anesthesia
00:02:10
Annatasha
told you to get that. Yeah. Like,
00:02:12
Ryan Bailey
and it was the first one and it was awesome.
00:02:14
Ryan Bailey
And then we went to very historic cocktail bar called Harry's New York bar invented many of the classic cocktails we think of. They also had a hot dog.
00:02:25
Annatasha
Bellini was invented at Harry's in Venice.
00:02:27
Ryan Bailey
I did not understand this situation. were given a hot dog. I can't remember what toppings it had Maybe a mustard.
00:02:37
Annatasha
You went to Harry's in Paris and you got a hot dog?
00:02:40
Ryan Bailey
Hell yeah. also got a bova Boulevardier.
00:02:44
Gianluca Bini
Thank you.
00:02:45
Ryan Bailey
And it comes out with a cup, like a pint glass filled with relish.
00:02:54
Annatasha
Okay.
00:02:56
Ryan Bailey
Yeah, I don't know who's eating that much relish, but it was a pint glass of it. it was a one hot dog.
00:03:00
Annatasha
Well, this is a great segue to the fact that Gianluca is really not a big fan of pickles because, of course, relish is just chopped up pickles.
00:03:07
Ryan Bailey
but
00:03:11
Annatasha
And I just, is it pickled cucumber specifically or is it all pickled things?
00:03:16
Gianluca Bini
The cucumber specifically, yeah. i I like giardiniera. In Italy, giardiniera is not spicy. So we do eat giardiniera a lot as an appetizer usually.
00:03:28
Gianluca Bini
It's together with like cheeses a meat and and there is giardiniera in it, but it's not spicy at all.
00:03:29
Ryan Bailey
Oh,
00:03:35
Gianluca Bini
We have pickled mushrooms, we have pickled a bunch of stuff. It's just the cucumber here, it seems like at least in the US, When you ask for peacock, it's straight up cucumber, which, you know, it's not really appealing, but there is stuff.
00:03:48
Ryan Bailey
oh yeah
00:03:53
Gianluca Bini
It's it's good. So
00:03:55
Annatasha
i I love a pickle. I love pickled anything, like beets and turnips and carrots and beans. Like, yeah.
00:04:02
Gianluca Bini
going back to Paris, though.
00:04:03
Ryan Bailey
Yeah.
00:04:03
Gianluca Bini
So hear
00:04:05
Annatasha
You're just like totally like, you know what? That's how I feel about pickles. Moving on.
00:04:07
Gianluca Bini
did you know? Well, I have two questions for Ryan, right? Like i haven't seen him in a couple of weeks.
00:04:10
Ryan Bailey
yeah Yeah.
00:04:13
Gianluca Bini
So
00:04:13
Ryan Bailey
and
00:04:15
Gianluca Bini
Did you go to the Louvre?
00:04:17
Ryan Bailey
I did not. We walked to the area. We walked to the building.
00:04:22
Gianluca Bini
Fucking Ryan. Okay.
00:04:23
Ryan Bailey
i mean,
00:04:24
Gianluca Bini
okay
00:04:25
Annatasha
It's no big deal.
00:04:25
Gianluca Bini
okay
00:04:25
Annatasha
It's only one of the greatest art collections in the entire
00:04:27
Ryan Bailey
Sure, sure. im I don't doubt it. I will say i am glad we didn't go. It would have been madhouse. Paris was overall a madhouse, and there was no way we were going to be able to go on a day where it wasn't just going to be fighting crowds the entire time.
00:04:47
Ryan Bailey
like it was we definitely went in the high season, so that would have...
00:04:52
Gianluca Bini
The best way to go to a Louvre is like the day after Christmas.
00:04:55
Ryan Bailey
Yeah, like that would be...
00:04:56
Gianluca Bini
There's nobody.
00:04:57
Ryan Bailey
Yeah, yeah there was there were people everywhere at all the things.
00:04:58
Gianluca Bini
Nobody done that. Nobody.
00:05:05
Ryan Bailey
It was... Yeah, like we we went into Notre Dame. Actually, we went into Notre Dame literally after Macron
00:05:17
Ryan Bailey
reopened the towers or whatever, I guess.
00:05:19
Annatasha
Yes. He re-pressin the rebuild. Yeah.
00:05:23
Ryan Bailey
Yeah, so, like, we saw his motorcade, like, leaving as we were walking up, and, like, people were, like, going crazy. But it was...
00:05:32
Gianluca Bini
you saw Notre Dame 2.0.
00:05:34
Ryan Bailey
Yes.
00:05:35
Annatasha
Yeah.
00:05:35
Ryan Bailey
Yeah, so I saw Notre Dame 2.0.
00:05:37
Gianluca Bini
Nice. And then have you been to the La Dure?
00:05:41
Ryan Bailey
I did not go to La Durée either.
00:05:44
Gianluca Bini
you go You go to Paris and you don't eat fucking macarons.
00:05:47
Ryan Bailey
i did even I did eat macarons. I will also say macarons are not really my jam. I appreciate them as like a item, but like they are not a I'm not ever seeking out a macaron. They look absolutely gorgeous. I'm not going to lie.
00:06:03
Ryan Bailey
But I'm just like, yeah, I don't, I like, i read there are many other desserts I'd rather eat for sure.
00:06:11
Ryan Bailey
That's, that's my problem with them.
00:06:11
Gianluca Bini
Okay.
00:06:13
Ryan Bailey
That's my problem with them.
00:06:14
Gianluca Bini
Okay.
00:06:15
Ryan Bailey
But i did I did not go. We did have some really good mackerel ones while we were in Strasbourg though. And we had a bunch of different flavors and they're all really solid.
00:06:23
Gianluca Bini
First off, who the fuck goes to Strasburg?
00:06:27
Ryan Bailey
We needed a day trip from Paris and that's what worked out for the train schedules. It was really nice. It was very cute. it was a cute little town yeah.
00:06:34
Annatasha
It kind looks like a Grimm's fairytale town.
00:06:35
Gianluca Bini
Yeah. Yeah,
00:06:37
Ryan Bailey
yeah Yeah, and we saw the astrological clock, which is absolutely wild. It's crazy. It's like this clock that was invented a long time ago, and it like can predict the religious holidays and the rotation of the Earth and the axis of the moon and all. like it's All the things it does is like truly wild, so that was...
00:07:00
Gianluca Bini
yeah you should see the one in Prague. That one is really cool.
00:07:03
Ryan Bailey
I didn't see, I saw the church where it is when I was in Prague, but we didn't pay to see the clock.
00:07:09
Gianluca Bini
So wait, wait, wait. on So every time you go to a city, you basically skip everything you should actually see or do from that city and you do something else.
00:07:20
Ryan Bailey
I mean, I am really there to
00:07:21
Annatasha
Yeah, what do you us to eat hot dogs? Like what's that's the problem?
00:07:26
Ryan Bailey
Yeah, I'm there to like eat the food,
Challenges in Exotic Species Ventilation
00:07:28
Ryan Bailey
drink the drinks. I have a, I have like a pretty hard limit of like one, like big historic thing per day, 0.5 to one per day.
00:07:40
Ryan Bailey
And I'm more than happy to just like hang at like a Parisian cafe and just like drink wine or spritzes and just like watch the Parisian life and just watch what they're doing.
00:07:46
Gianluca Bini
Sure.
00:07:50
Ryan Bailey
And just like, that's like, what?
00:07:52
Gianluca Bini
sure
00:07:52
Annatasha
What are you, 85? What are 85? but eighty five
00:07:56
Ryan Bailey
I mean, Venice was my favorite place to go. We went to the same Chiquetti spot every single day. it was this one guy and he was German. Apparently we found out because we went every day and we'd like talk to him and like the little bit of language we could share.
00:08:12
Ryan Bailey
And we ate the same Chiquetti and we drank the same spritzes and the same red wine. And it was just like the greatest. Yeah.
00:08:21
Gianluca Bini
Magic.
00:08:22
Ryan Bailey
Yeah.
00:08:22
Annatasha
I just booked Venice for February, actually, because I've always when I was recently getting through my near death medical scare, i just started booking on my bucket list trips because I was like, just never know.
00:08:33
Gianluca Bini
What if I actually die?
00:08:33
Annatasha
Never know when you're going to get taken out by Giordia.
00:08:35
Ryan Bailey
and
00:08:36
Annatasha
And so I booked the carnival. I've always wanted to go to the I've always wanted to go to the carnival.
00:08:39
Ryan Bailey
Well, I'll show you where the little Chiquetti spot we went to.
00:08:43
Annatasha
And I was like, well, if I survive Giordia, I'm going to have to go.
00:08:48
Gianluca Bini
Fair.
00:08:48
Ryan Bailey
oh I'll show you the Chiquetti spot we went to, Artel, and you can just post up there all the time.
00:08:53
Annatasha
No problem.
00:08:53
Gianluca Bini
All right, ventilation.
00:08:54
Annatasha
Ventilation.
00:08:56
Ryan Bailey
Anyway, ventilation. all right.
00:08:58
Gianluca Bini
Now that you've entered about Paris,
00:09:00
Ryan Bailey
Yes. Ha ha. oh see I want to, so I did have a couple, there were obviously topics we didn't get to.
00:09:11
Ryan Bailey
So we'll start with the kind of ventilation adjacent a little bit, but still ventilation for sure. How do you feel and what do you do and are you routinely looking at systolic pulse therapy?
00:09:25
Ryan Bailey
uh systolic pressure variation pathismographic variability index pulse pressure variability and then like are you routinely looking that on cases you have on the ventilator and then how do you like adjust or approach that and then how do you take into account the variance in tidal volume that you're probably working with relative to what's actually described
00:09:31
Gianluca Bini
Did
00:09:52
Annatasha
what is this? What is this? and at Like an exam essay question?
00:09:55
Ryan Bailey
I
00:09:58
Gianluca Bini
did Chachi me this?
00:09:59
Annatasha
I almost started taking notes. Like I was like, I'm not going to remember all this, right? Yeah. like
00:10:03
Ryan Bailey
i mean, I just, I think it's a, it's a big topic. Like, I think it's a important thing. Like, you know, we, we aren't ever really working at the described pressures where the human papers really wrote it up.
00:10:17
Ryan Bailey
So I always wonder, like, what is the merit of intervening based on That.
00:10:26
Gianluca Bini
Yeah. So you're saying that basically because we never reach high enough pressures, what we're seeing, if we do see s SPV or PBV whether we actually believe it or not?
00:10:43
Ryan Bailey
Well, that like the original human stuff was in much lower tidal volumes and much lower pressures. And on a clinical case, we we
00:10:51
Gianluca Bini
Got
Anesthetic Choices and Patient Outcomes
00:10:54
Ryan Bailey
generally can't do that.
00:10:55
Ryan Bailey
We can't do the same lower pressure, lower tidal volume because our patients will be massively hypercapnic, blah, blah, blah.
00:11:02
Gianluca Bini
it. Right. so if we
00:11:02
Ryan Bailey
Yeah.
00:11:04
Ryan Bailey
Yeah.
00:11:04
Gianluca Bini
But if it happens a high, so, you know,
00:11:08
Gianluca Bini
they needed that low enough sorry but that you know low enough pressure in order to generate that PPV or s SPV.
00:11:11
Ryan Bailey
Yeah.
00:11:17
Ryan Bailey
Yeah.
00:11:18
Gianluca Bini
Now, even if you're not using the lower pressure and you're using a higher pressure,
00:11:24
Ryan Bailey
yeah
00:11:26
Gianluca Bini
that still occurs. So why wouldn't you believe that?
00:11:28
Ryan Bailey
Oh, yeah. My question is, like, i guess the way I interpret it that when they were noting it at the lower pressures, that's where the therapeutics were beneficial. The interventions, the fluid boluses, et cetera, were beneficial.
00:11:44
Gianluca Bini
gotcha
00:11:44
Ryan Bailey
In a clinical case, we're already above the pressures and volumes they were working with. And we know that as you increase volume and pressure, you generally do increase the likelihood of seeing systolic and pulse pressure variability, even in healthy patients who are adequately volume loaded. Like you pressurize a dog's lungs to 20 and you're going to drop the pulse trace no matter what, even though dog's totally fine.
00:12:10
Ryan Bailey
So like, I guess it's to say that in a clinical case, we're probably, I mean, I for one, I'm going to look at that. I'm going to look at the peak pressure I'm achieving.
00:12:22
Ryan Bailey
If I'm at 14 and I'm getting some pulse pressure variability, I'm probably not going to be as excitable as if I'm on the lower end 10, I'm and I'm getting pulse pressure variability, then I'm going to be a little bit more like, oh, I think this dog is volume underloaded. This cat is volume underloaded.
00:12:40
Ryan Bailey
Even though I know that, you know, the original evidence, we we probably are going to tend to over-treat our patients.
00:12:48
Annatasha
This is the longest question we've ever been asked.
00:12:51
Ryan Bailey
Well, you're smart, so...
00:12:55
Annatasha
Meany, you first.
00:12:57
Gianluca Bini
Yeah, no, I mean, I get what you're saying. I'm very, very cautious with fluid bonuses anyway, right?
00:13:03
Ryan Bailey
What's wrong?
00:13:05
Gianluca Bini
a And probably most of us are, right? Like, you know, we don't, we, okay. Do
00:13:15
Annatasha
We're the three bears. Ryan is the least, I'm the middle, and you're the most. let Let me just paint this out for the listeners.
00:13:21
Gianluca Bini
you?
00:13:22
Annatasha
like
00:13:23
Gianluca Bini
Okay. I forget about the daily way.
00:13:30
Annatasha
Okay.
00:13:32
Gianluca Bini
The Davis way, Ryan. I forget about that.
00:13:34
Ryan Bailey
Exactly.
00:13:35
Gianluca Bini
Yeah, right.
00:13:35
Ryan Bailey
Exactly.
00:13:36
Gianluca Bini
It's drowning in fluids.
00:13:38
Ryan Bailey
that
00:13:38
Gianluca Bini
Anyway. We're
00:13:40
Annatasha
Guys, we haven't been sued yet by Davis.
00:13:44
Gianluca Bini
totally going to get sued at some point.
00:13:45
Ryan Bailey
As we learn from surviving sepsis, it's some fluids, some vasopressors. It's not all of one or all the other. there' There's room for all of it.
00:13:54
Gianluca Bini
Agreed. Agreed. Agreed. Now,
00:13:58
Annatasha
I mean, I watch all those things, Bailey, right?
00:13:58
Ryan Bailey
You know? Yeah.
00:13:58
Gianluca Bini
no
00:14:00
Annatasha
Like I watch the PLF and I watch pulse pressure variation and, and, you know, I sort of have this bedside, you know, rule of thumb, which is if I can visualize it from across the OR, then chances are you are probably volume deplete.
00:14:02
Ryan Bailey
Yeah.
00:14:02
Gianluca Bini
Yeah. Right.
00:14:03
Ryan Bailey
yes
00:14:14
Gianluca Bini
yeah
00:14:15
Annatasha
However, I think it's important to see, like, I could chase that volume and you might not be a fluid responder, in which case then I'm actually becoming more detrimental.
00:14:20
Ryan Bailey
but For sure.
00:14:24
Annatasha
So again, it's a picture of full context, right?
00:14:25
Ryan Bailey
What's that? Right.
00:14:26
Annatasha
Like it's, You know, are you hypotensive and tachycardic and you have pulse pressure variation? And I can see it from across the province.
00:14:32
Ryan Bailey
Okay.
00:14:33
Annatasha
You know, I probably will give you fluid, right? But at the same time, I also take into consideration, what's your hematocrit doing? What are your electrolytes doing?
00:14:39
Gianluca Bini
Yeah.
00:14:40
Annatasha
What's your base excess? What's your lactate? Like, I'm looking at everything and trying to make completely arbitrary decisions.
00:14:46
Ryan Bailey
Yeah.
00:14:47
Gianluca Bini
Yeah. Same, same. You know, I think it's, you make a good point. You know, you need to look at the full picture. You can just, you can just get that and that's it. But, you know, having some pulse pressure variation and your patient's blood pressure is normal and harsher is normal. Like who the fuck cares?
00:15:07
Ryan Bailey
i So maybe this is a better way to ask this question is when you are not overseeing the case and someone comes up to you and they say, hey the dog has post-pressure variation, blah, blah, blah. Do you want me to do something about it? Or like they're all fussed off about it.
00:15:25
Ryan Bailey
And.
00:15:25
Gianluca Bini
The next question is, what's the blood pressure?
00:15:28
Ryan Bailey
right And then you walk in the room and they're hitting, you know, a peak inspiratory pressure of like 15. fifteen And you're like, well, maybe let's back down the ventilation a little bit. Or like, maybe let's take the tidal volume down a little bit here. And like, let's see if that pulse pressure variation persists and things like that.
00:15:46
Ryan Bailey
feel like some people... it you know, it becomes a hot thing every once in a while, like this pulse pressure variation or systolic pressure variation. People get all excited about it and then they, you know, want to use it and do something with it.
00:16:00
Ryan Bailey
And then, you know, it's just part of.
00:16:02
Annatasha
It's great time to say, don't treat the numbers of the machine, treat the patient.
00:16:02
Ryan Bailey
totally. Yeah. Yeah. And.
00:16:06
Gianluca Bini
Yeah.
Advanced Ventilation Strategies
00:16:07
Gianluca Bini
Yeah. You can just look at the monitor and, you know that's, it's, yeah, we can't, I can't stress that enough, you know, like, you know, we always tell our students, I don't, you know, you need to look at the whole picture.
00:16:10
Ryan Bailey
yeah
00:16:18
Ryan Bailey
and
00:16:22
Gianluca Bini
You can just focus on these few numbers that you have in front of you. Right.
00:16:26
Ryan Bailey
And now with all the monitoring equipment too, like, especially as we get more and more of these like higher end human monitors make into the veterinary side, you know, they're having SPI or like PVI right on the, right on the monitor next to the pulse ox. They've got PPV right there on the monitor next to the blood pressure, like the art line trace. So you're getting all that information.
00:16:48
Annatasha
I think you make a good point, Ryan, about though, like, do you change your ventilation parameters based on that?
00:16:55
Annatasha
And I tend to agree with you. Like, I i think my level of concern changes more rapidly or more acutely when you're at a low tidal volume or a low PIP and you've got, like, marked variation versus, you know, if I –
00:17:11
Ryan Bailey
yeah
00:17:14
Annatasha
and doing something a little wild and crazy. and And, you know, like, you know, you have pressures at a 20, 25, 30. thirty
00:17:26
Ryan Bailey
Your peeps all dialed up.
00:17:28
Annatasha
Yeah, like, yes. So I think you make a good point. I think that, you know, looking at the picture of the patient, you know, are you driving a very small positive pressure?
00:17:34
Gianluca Bini
you
00:17:38
Annatasha
into the thoracic cavity and you're having a marked variation and the patient is hypotensive and the patient maybe is tachycardic and maybe it has blanched mucous membranes from, you know, peripheral vasoconstriction because you're shunting to central compartment. I don't know.
00:17:53
Annatasha
What's its temperature? You know, and like I said, looking at the blood work because, I mean, If I have a hematocrit of 75, probably going to give a fluid bolus.
00:17:59
Ryan Bailey
Yeah. Right.
00:18:00
Annatasha
If I have a hematocrit of 10, probably not going to give a fluid bolus.
00:18:03
Ryan Bailey
yeah
00:18:04
Annatasha
So like I said, you know, it it changes the level of like alarm or, you know, how more, you know, how aggressively am I going to intervene at this point?
00:18:14
Gianluca Bini
Yeah.
00:18:15
Annatasha
But I think that's a very good point. Like, you know, when are you seeing this variation on that spectrum of ventilation needs to be considered?
00:18:19
Ryan Bailey
i
00:18:22
Ryan Bailey
Totally. Yeah. And that's that's the thing I do oftentimes is where I see it and I know we're already working at higher pressures, I'm often going try and dial back my ventilation settings a little bit in terms of volume or pressure or both. I mean, they kind of both go in tandem, but bring those down and then see, is it still as marked as it was before or has it kind of returned to like,
00:18:47
Ryan Bailey
And, you know, I'll be honest, I'm good. It's for me, it's the eye test, you know, it's me looking at the trace and seeing what happens to the trace. I'm not.
00:18:57
Annatasha
I'm not measuring like the actual like peak variability, and like integrating a function, like, you know, great, but I'm not doing that.
00:18:57
Ryan Bailey
Yeah. Yeah. Yeah. Right. yeah
00:19:05
Annatasha
But like I said, if I can see it across the OR, then I think it's probably going to be greater than 13%. And it's probably significant. My other like really like fast bedside thing is like, if you're not doing a great, you know, job at ventilating and we do convert you to the ventilator and after, you know, two or three best, you're cutely dropped hypotensively.
00:19:23
Ryan Bailey
Oh my gosh, yeah.
00:19:23
Annatasha
That makes me go, oh, you probably need a little bit of volume there, or you need a little bit of vasoconstriction, right? Or a little bit of both.
00:19:29
Ryan Bailey
Yeah. Yeah.
00:19:30
Annatasha
So yeah, so if you acutely switch to positive pressure ventilation, and you see cardiovascular collapse as a consequence, that's a great like indication for me that one, we should probably stop mechanical ventilation while we too sort out cardiovascular stability.
00:19:37
Ryan Bailey
Yeah.
00:19:44
Annatasha
So
00:19:45
Gianluca Bini
Right. I mean, so, and then getting to your point, right? So
00:19:50
Gianluca Bini
i rarely have to ventilate to the high pressure.
00:19:54
Ryan Bailey
Oh, yeah.
00:19:55
Gianluca Bini
right? Like 15, it's rare, right? Like usually, unless there is, you know, if you have like pneumothorax or if you have chylothorax or anything that's like co occupying space in there, sure.
00:20:08
Gianluca Bini
But even in older patients, like you rarely hit 15, right? Like,
00:20:12
Ryan Bailey
Yeah, for sure.
00:20:12
Annatasha
Don't forget I'm doing, I do horses. So that, that comes into my conversation.
00:20:14
Gianluca Bini
yeah, sure, sure. Of course, of course, a large animal, different beast, literally.
00:20:18
Annatasha
Yeah, yeah, yeah.
00:20:24
Ryan Bailey
Right.
00:20:24
Annatasha
and
00:20:26
Annatasha
We are such dorks.
00:20:28
Ryan Bailey
Okay.
00:20:32
Gianluca Bini
So, okay.
00:20:35
Gianluca Bini
So, yeah, you you would back down your ventilation, of course, and then you go up in your respirator, right?
00:20:44
Ryan Bailey
right
00:20:45
Gianluca Bini
And so, and and now I have a question for you. So, At what point do you think that increasing the respiration becomes inefficient?
00:21:00
Ryan Bailey
I mean, like,
00:21:01
Gianluca Bini
Because over a certain number of breaths per minute, it becomes inefficient, right? Like it becomes too short.
00:21:07
Ryan Bailey
yeah. Oh, yeah. I mean, for me, well, I guess...
00:21:11
Gianluca Bini
Do you have a number?
00:21:13
Ryan Bailey
Generally. Yeah. And, and I think it probably varies ventilator to ventilator. So like on the Hallowells, like the, the Hallowells that everyone has, i don't know. I think it's 20 to 25. Like, I don't think you are, I mean, it, to me, it's also the closer you get to one to one IE ratio.
00:21:31
Ryan Bailey
So the closer you are one to one, I find in the veterinary species, you're not giving enough times to fill the lungs and you're not,
00:21:41
Ryan Bailey
getting good like good sampling of your alveoli and good you know accurate representation of co2 and then you're making bad decisions and you're chasing your tail it's a whole thing but i find the halo well for me it's like 20 to 25 is where it gets real cagey
00:21:58
Gianluca Bini
One of my mentors said but above 16 in dogs.
00:22:02
Ryan Bailey
interesting yeah
00:22:03
Gianluca Bini
I couldn't find a reference for it anywhere. but a lot of this stuff, there is no reference, right? Like this is stuff that's been passed down, you know?
00:22:11
Ryan Bailey
Yeah.
00:22:12
Gianluca Bini
And so I don't know.
00:22:12
Ryan Bailey
I always think it's like 30 because at 30, you're about one-to-one IE ratio because 30 breaths per minute, you have to spend one time inhaling, one time exhaling.
00:22:18
Gianluca Bini
Right.
00:22:24
Ryan Bailey
So the closer you get there.
00:22:24
Gianluca Bini
Right. But 15, it's one to two.
00:22:27
Ryan Bailey
Yeah. Yeah.
00:22:28
Gianluca Bini
So 16, it's kind of there.
00:22:31
Ryan Bailey
Maybe that's why. yeah Maybe that was the rationale.
00:22:33
Gianluca Bini
It's kind of there.
00:22:33
Ryan Bailey
Yeah.
00:22:35
Gianluca Bini
Yeah. I don't know. I mean, do you do you know about any of this, Tasha? Do you have a number in your...
00:22:43
Annatasha
I don't have a number. no
00:22:45
Ryan Bailey
I mean, I'm always on the low rate, right? I'm always dialing it back. You know, if the, we started 20 to 25, I'm always, which is such a funny thing. I've got another point about that, but it's such a funny thing.
00:22:58
Ryan Bailey
You know, if we started 20, 25 and the patient's not, you know, getting capture or whatever, I usually tend to back them down rate wise pretty quick and try and up their volume.
00:23:08
Ryan Bailey
I don't overventilate or I go really aggressive and I dial up their volume really aggressively and try and get it. drop their co2 in a matter of minutes and then get them converted but one thing i was we i have heard taught and i've said it myself is like when you're dealing with an exotic species and you have never ventilated them before and you want to start them on the ventilator what is a good approach to that i know
00:23:33
Annatasha
Like anyone knows the answer to that.
00:23:35
Ryan Bailey
I know. And one thing that kind of always gets talked about is like, well, take their resting respiratory rate when they're hanging out on your physical exam and use that as your starting parameter.
00:23:48
Ryan Bailey
You're never going to start.
00:23:49
Annatasha
sleep parameters, right? Like there's sleep parameters.
00:23:51
Ryan Bailey
and I mean, yeah, that's a good point. and You would never get one to sleep because they're not to
00:23:54
Annatasha
If, if they sleep, like, I mean, if it's, like, if it's a shark, I don't know.
00:23:58
Ryan Bailey
Yeah. Let's not talk about fish. but like, like weakness. but like you would never ventilate a dog at like 32 breaths per minute. That would bonkers.
00:24:13
Ryan Bailey
The ventilator would probably just like jump off the
00:24:15
Annatasha
And I think you would kill a reptile doing that. Like, I just, i like, yeah, I i mean, i don't have a great answer for this.
00:24:18
Ryan Bailey
but
00:24:24
Annatasha
All I can do is conjecture based on, like, my loosey-goosey physiology for the exotic groupings or the geni. But, yeah, I mean, I think it's better to start more conservatively and then respond accordingly. But, I mean, have no idea. I mean, fuck, I'm
00:24:43
Ryan Bailey
and Anyway, that was... yeah
00:24:46
Annatasha
Half of them, like some of them don't have diaphragms and some of them have half a diaphragm. And I'm like, I don't know. You know, and they oxygenate at expiration and inspiration or they have hypoxic drives.
00:24:53
Gianluca Bini
so
00:24:57
Annatasha
And it's just like, I don't really think that there's probably more than a handful of people in the world who really know what they're doing in this.
00:25:04
Ryan Bailey
That's true. That's very true.
00:25:05
Gianluca Bini
That's true.
00:25:05
Annatasha
Yeah. Like maybe not to talk it, but like but other than that, it's pretty much guesswork.
00:25:07
Gianluca Bini
So...
00:25:11
Annatasha
Like I once had to ventilate a budgie. And, you know, that was wild.
00:25:14
Gianluca Bini
Oh, my God.
00:25:17
Ryan Bailey
Couldn't you just like that?
00:25:18
Annatasha
yeah little like My tiny little bellies, my tiny little circle circuit.
00:25:18
Ryan Bailey
I
00:25:21
Annatasha
It was quite cute, actually. i felt like I Barbie anesthesia.
00:25:22
Gianluca Bini
So...
00:25:24
Annatasha
But, yeah, I mean, that was a that was like beep, beep, beep, beep. Like it was fast respirate. But.
00:25:30
Ryan Bailey
bet.
00:25:32
Gianluca Bini
Okay, so I have another question for you. This is probably a little bit more advanced, but so then,
00:25:42
Annatasha
really than making up exotics?
00:25:43
Ryan Bailey
Do you think we can handle on it?
00:25:46
Gianluca Bini
I don't know. But so, you know, let's say you have a patient with pulmonary hypertension, right?
00:25:56
Annatasha
Yes.
00:25:57
Gianluca Bini
What are your, okay, don't get too excited, guys. The fuck?
00:26:01
Annatasha
Pulmonary hypertension is not my favorite thing to anesthetize.
00:26:05
Gianluca Bini
It's nobody's favorite thing to anesthetize.
00:26:07
Annatasha
Oh, good. I thought it was just the cheese stands alone, but I'm glad everyone else hates it too. So that's
00:26:11
Gianluca Bini
no Nobody likes it. And those are usually the patients that do die.
00:26:13
Ryan Bailey
Yeah.
00:26:15
Ryan Bailey
Yeah.
00:26:16
Gianluca Bini
Right? so what are your goals? What do you do?
00:26:21
Ryan Bailey
Drop their CO2.
00:26:22
Gianluca Bini
Okay.
00:26:23
Ryan Bailey
Actionate them.
00:26:24
Gianluca Bini
But how do you do that? Like, do you... Okay.
00:26:26
Ryan Bailey
Carefully. Excellent
00:26:30
Annatasha
This is like having a conversation with my dad.
00:26:30
Ryan Bailey
question. Thank you so much.
00:26:32
Annatasha
Like it's super annoying.
00:26:35
Gianluca Bini
Okay. So, but how do you do it? Like, do you, do you have a specific ventilation modality that you prefer? do you target like, you know, high respirate, low volume? What do you, what what what do you do, Ryan?
00:26:47
Gianluca Bini
Yeah.
00:26:48
Ryan Bailey
I
00:26:49
Annatasha
Yeah, Ryan, what do you do?
00:26:49
Ryan Bailey
yeah yeah right
00:26:50
Gianluca Bini
What do you do?
00:26:52
Annatasha
Yeah, let's go hot dog guy.
00:26:52
Ryan Bailey
but feel that, and some people back me up on some other people I've discussed pulmonary hypertension with, because when you look up veterinary pulmonary hypertension, it's like yeah big old goose egg for the amount of literature we have on management of anesthetized patients with pulmonary hypertension.
00:27:13
Annatasha
I think I have like maybe three overviews in my cache.
00:27:16
Ryan Bailey
Yeah, yeah it's it's just not a topic we write about a lot. And I think it's in part because a lot of our patients have pH and they do fine and I don't know why. And then you have that one that like you anesthetize and immediately become cyanotic and dies.
00:27:36
Ryan Bailey
And you're just like, uh...
00:27:39
Annatasha
Maybe we should ask cardiology how to do the anesthesia.
00:27:42
Ryan Bailey
It happened to me, and I had to use a... I had to get a bucket of water and stick the hose in there to create peat because I didn't have a peat valve where I was working at the time, and I saved that dog's life. Thanks, Dr. Brosnan, for teaching me how to make a peat valve with a bucket and water.
00:27:59
Ryan Bailey
Because that's what it is.
00:28:02
Ryan Bailey
Yeah, it was kind of crazy. So...
00:28:06
Ryan Bailey
so
00:28:06
Annatasha
I mean, my i mean mike my goal with marked pulmonary, like you said, I think most of them, like mild or undetected or whatever, are probably going to rock it quite well. But I try to be very simple when I do these cases and not make my life harder by trying to be cool or fancy or rebellious.
00:28:14
Ryan Bailey
Yeah.
00:28:19
Ryan Bailey
Yeah.
00:28:26
Annatasha
And, you know, in my head, the golden rule is don't let the PVR increase anymore and don't let the SVR drop anymore.
00:28:35
Ryan Bailey
Yep.
00:28:35
Annatasha
And then my differentials for those are the usual things that kill you under anesthesia anyway, right? Like hypercapnia, acidemia, hypoxemia, right?
00:28:41
Ryan Bailey
Yep.
00:28:43
Annatasha
So, you know, I'm trying to use pretty straightforward enough.
00:28:45
Gianluca Bini
do you know Do you send your patients on with sildenafil?
00:28:51
Annatasha
Yeah.
00:28:51
Gianluca Bini
If you know, you know, you have an angle that tells you, hey, you know, there is pH severe, moderate to severe, what would you do? Do you suggest a few days of sildenafil beforehand?
00:29:07
Annatasha
Yeah, usually if I can get it on board beforehand.
00:29:10
Ryan Bailey
Yeah.
00:29:10
Ryan Bailey
Yeah.
00:29:12
Annatasha
I will actually. Do I send them home per se, like assuming that they live?
00:29:20
Annatasha
like really think I can't really think of an instance where i specifically have done that.
00:29:24
Gianluca Bini
Okay. Oh.
00:29:25
Ryan Bailey
I guess, so to the to your ventilation question, i think this is a case where the little bit fancier modes are really going to help you. So I feel like this is a patient where if they come in, they have pH, we get them anesthetized, either c o two is really high or they're hypoxemic at induction, but they still have a respiratory drive.
00:29:35
Annatasha
Thank you.
00:29:47
Ryan Bailey
This is one where I would probably try like a PSV to start. because you're gonna you're gonna follow the patience pattern. and so you're gonna synchronize a little bit more nicely that would That would be what I would personally try in these guys to – like if if, for instance, I was had the nice ventilator I do now and I had PSV on it and I was anesthetizing this dog that became cyanotic immediately after induction even though I used like a fairly reasonable induction plan and I couldn't get him out of cyanosis without super aggressive ventilation strategies.
00:30:26
Ryan Bailey
I feel like this is one where I would love to have some PSV and been able to kind of dial in the pressure settings to kind of help as the dog breathes, like we're helping him a little bit more with every breath.
00:30:32
Gianluca Bini
Oh yeah.
00:30:36
Ryan Bailey
So I think that's, that's probably what I would try initial. Yeah.
00:30:42
Annatasha
Yeah, I mean, i mean i don't disagree.
00:30:42
Ryan Bailey
Yeah.
00:30:44
Annatasha
And I also think too, like I tend to be more conservative with it because, you know, peeps going to make it worse to the right side of the heart and high tidal volumes and high plateau pressures, like all of that's going to hammer the right side of the heart.
00:30:47
Ryan Bailey
yeah
00:30:59
Gianluca Bini
oh yeah
00:30:59
Annatasha
And that's really what kills you, right? Is if you go into suicidal right ventricle mode. So again, this is one of those things where I'm like, I start conservatively and see how the patient responds and I try to keep my parameters within normal limits and, you know, rub my lucky rabbit's foot and hope for the best.
00:31:22
Gianluca Bini
So,
00:31:23
Ryan Bailey
How about you, Beanie? What are you doing? Do you have a favorite strategy for these?
00:31:26
Gianluca Bini
yeah, no, I think, I think it's, you know, a combination of what you guys mentioned. I think, you know, they, definitely being aggressive for the beginning, it's probably not great.
00:31:39
Gianluca Bini
at some point you need to sometimes, right? Like depends on the patient. you know, I wish we had some of the you know tools that they have in humans, right?
00:31:50
Gianluca Bini
Like to vasodilate a little bit, like nitric oxide.
00:31:53
Ryan Bailey
and was going to ask you to about the inhaled basal dilators. Yeah.
00:31:57
Gianluca Bini
Yeah, the nitric oxide stuff, that would be nice, but like, you know, we could do that.
00:32:00
Annatasha
Well, we have beta blockers, right? Like I do my intratracheal sylbutanol puffing.
00:32:04
Ryan Bailey
Yeah. Yeah.
00:32:06
Gianluca Bini
Yeah.
00:32:08
Annatasha
I'll do that. But yeah, I don't obviously have nitric oxide.
00:32:11
Gianluca Bini
Yeah, that would be nice.
00:32:12
Annatasha
Make them a little septic. It'll kick up the nitric oxide levels.
00:32:18
Annatasha
Woo! Do not listen to me, anybody.
00:32:20
Gianluca Bini
No,
00:32:21
Annatasha
Again, disclaimer, do not take my advice. Yeah.
00:32:26
Gianluca Bini
no, I agree.
00:32:26
Ryan Bailey
Yeah.
00:32:26
Gianluca Bini
agree with you. Like, I mean, it would be nice. It's just that the the cost, it's cost prohibitive.
00:32:30
Ryan Bailey
Yeah. Ooh.
00:32:31
Gianluca Bini
You know, that's, yeah. Do you have a specific inalien that you like with those, you know, with the whole idea about, you know, epoxy pulmonary vasoconstriction and hollyalens how inalien, how inalien is like affected, right?
00:32:46
Gianluca Bini
Like, versus like, so,
00:32:47
Ryan Bailey
How
00:32:48
Annatasha
I try to keep these guys off the inhalants, actually.
00:32:50
Ryan Bailey
about no inhalants? Yeah.
00:32:53
Gianluca Bini
Yeah.
00:32:53
Annatasha
Right? Because you either have to have like such a low percentage of one of them to avoid hypoxic pulmonary vasoconstriction, but then you're also going to get dose-dependent hypotension. So I'm mean doing exactly what you don't want to do. So I run those on Teva.
00:33:08
Annatasha
Oh, there's brownie.
00:33:09
Gianluca Bini
Yeah.
00:33:10
Annatasha
Yeah.
00:33:10
Gianluca Bini
Do you do Proboful or a fax event?
00:33:17
Annatasha
Does it matter?
00:33:19
Ryan Bailey
but
00:33:20
Gianluca Bini
doesn Well, I mean, there was a recent post on the Navas Facebook page
00:33:28
Gianluca Bini
that made some pretty, don't know, like audacious stuff.
00:33:36
Annatasha
Made a lot of people clench, although just as a casual reminder, it was just an infographic and data can be interpreted subjectively even at the best of times. And it, it did not in any way give a people any sort of preferred option. I mean, you know what I mean? But, yeah, no, propofol or alfaxilone, I mean, it a cat or a dog?
00:34:02
Annatasha
how long are we going to be under? Those are probably more my considerations than necessarily what I think, is going to happen either, you know, with HPV or with cardiovascular, what have you, that's probably more of what I'm considering.
00:34:12
Gianluca Bini
right No,
00:34:13
Annatasha
Like, how long are we going to be down and what's my recovery going to be like? and that kind of stuff, the more practical components.
00:34:18
Ryan Bailey
Yeah. And the size of the patient, right? Like if you're with a big dog, you're probably just going use Probofol because...
00:34:22
Annatasha
Yep.
00:34:26
Ryan Bailey
it's easier to get a lot more of it than it is to get a lot more alfaxilin.
00:34:30
Gianluca Bini
hard.
00:34:31
Ryan Bailey
Like you buy a 100 mil vial of propofol and that can last you all day in the case versus 10 vials of alfaxilin.
00:34:38
Gianluca Bini
yeah
00:34:39
Annatasha
Oh, you can get those like 500 mils or like liter bottles of propofol that they use in human medicine, right? They just spike them like a bag and they run them when they do like burn Teva and then, cause they always run burn victims on Teva, right?
00:34:48
Gianluca Bini
Love that. Yeah.
00:34:52
Annatasha
And they, and they do actually use propofol in those cases, which is like maybe a good point, right? Like why are the, we should ask Mika, the human anesthesiologist at our next talk, like why is, you know, propofol,
00:35:05
Annatasha
Teva, I mean, I understand obviously the lungs have been burned and what have you, but, you know, like why aren't you doing fentanyl ketamine or why aren't you doing key to fall or that kind of stuff?
00:35:11
Ryan Bailey
I'm
00:35:12
Annatasha
so I think that might be a cool question for her, like, you know, smoke inhalation and burn victims.
00:35:16
Gianluca Bini
yeah
00:35:17
Annatasha
And, but yeah, you can actually just get like a huge, it looks like a high bottle of hypertonic saline, except it's purple fall and you spike it.
00:35:21
Gianluca Bini
no
00:35:23
Annatasha
Yeah.
00:35:23
Ryan Bailey
not seeing one that big.
00:35:26
Gianluca Bini
Nice.
00:35:26
Annatasha
Yeah.
00:35:27
Ryan Bailey
Like one day. Okay.
00:35:28
Annatasha
day
00:35:29
Gianluca Bini
One day.
00:35:31
Ryan Bailey
One of my favorite ventilation topics.
00:35:32
Gianluca Bini
Okay.
00:35:38
Ryan Bailey
Handbag.
00:35:38
Annatasha
Wait, what our are ours or you're about to broach yours?
00:35:42
Ryan Bailey
I'm about to broach one of my least favorite topics in the entire ventilation world.
00:35:47
Annatasha
wow
00:35:51
Ryan Bailey
and it's it's about handbagging.
00:35:54
Annatasha
Oh, I totally thought you were going to say it spirometry.
00:35:57
Ryan Bailey
No.
00:35:59
Gianluca Bini
Thank
00:35:59
Ryan Bailey
I love swarming. think it's great. I'm just not... I don't do it every day now, so I'm not as good at it. So I can't...
00:36:04
Annatasha
assisted ventilation using the reservoir or re-breathing back.
00:36:07
Ryan Bailey
Yes.
00:36:07
Annatasha
or an Ambu bag,
00:36:09
Ryan Bailey
Yeah. I hate it. I think it is dog shit. And I think it is and incredibly, when we have machines that do the job literally infinitesimally better than us, I think it is detrimental to be used regularly.
00:36:32
Annatasha
So you're saying like, you're saying like bagging the patient, not just once or twice.
00:36:35
Ryan Bailey
ye Nope.
00:36:37
Annatasha
You mean like bagging the patient in lieu of putting it on a ventilator.
00:36:41
Ryan Bailey
Yep.
00:36:42
Gianluca Bini
okay
00:36:42
Annatasha
Why would you do that? Do I look like I want to get some sort of weird wrist cramp? Like, no.
00:36:46
Ryan Bailey
I mean, I i know people who have, you know, said you need to know how to do this and be and do this and this is the way we're going to do this.
00:36:57
Ryan Bailey
Yeah. And i think you end up, it's, it never, in my hands, I can never get CO2 where I want it. I can never get a good waveform.
00:37:11
Ryan Bailey
It's all like, and I, trust me, I try a lot of different ways. You tend to just overventilate them so rapidly. Their CO2 just like falls, like just stone to the earth.
00:37:19
Gianluca Bini
Thank you.
00:37:23
Annatasha
Well, it begs the question, actually, like if you are going to hand ventilate or what have you, I mean, Carrie Craig at Davis, actually, I remember i was listening to her round once with the students and she actually said like, how much do you need to ventilate?
00:37:28
Ryan Bailey
Yeah.
00:37:35
Annatasha
How do you make that decision? Right. And like one of the students to think like, you know, is there a set number of times per minute or are you being driven by SpO2? Are you being driven by ETCO2?
00:37:46
Annatasha
But yeah, I mean, I can understand because there might not be places where you have access to a ventilator. So that could be
00:37:52
Ryan Bailey
I understand that situation.
00:37:53
Annatasha
Yeah. And like, or if you were to do, for example, like field anesthesia in a traumatic war zone where they everything is portable in hand, I get that.
00:37:58
Ryan Bailey
Yes. first
00:38:03
Ryan Bailey
i yeah
00:38:03
Annatasha
But if I have access to a ventilator, why, you know, the only, you know, here's a scenario where I would do that, where I want to feel the compliance of the chest myself.
00:38:15
Ryan Bailey
Okay, sure. We're talking like continuous, like 10 minutes, 20 minutes, hour.
00:38:20
Gianluca Bini
Thank you.
00:38:20
Ryan Bailey
Yeah.
00:38:21
Annatasha
If you have like a tension pneumothorax or you think you have a tension pneumothorax, I usually give them like a breath because I will probably have bagged them at the start for like your endotracheal tube leak check thing.
00:38:32
Annatasha
And I can tell you off that one or two bags that I give them whether or not they have the actual tension pneumothorax.
00:38:38
Ryan Bailey
yeah
00:38:38
Annatasha
So that's probably the only time or like if if I want to really have primary control over ventilation because you're in a crisis and you can't,
00:38:46
Ryan Bailey
Right.
00:38:47
Annatasha
up and down with the ventilator. So you end up going back and forth.
00:38:50
Ryan Bailey
Yeah.
00:38:50
Annatasha
and you know So maybe I only breathe once a minute. Maybe I want to breathe twice a minute. It gives me more flexibility in that way. But like for routine, big youre like I don't understand why anyone would do that.
00:38:57
Ryan Bailey
Right.
00:39:01
Ryan Bailey
Okay.
00:39:02
Gianluca Bini
No, that makes that makes sense.
00:39:03
Annatasha
Beanie?
00:39:04
Gianluca Bini
oh I don't think anybody, if you have a ventilator, you
00:39:09
Annatasha
The cat's done.
00:39:11
Gianluca Bini
have a ventilator, use the ventilator, right? But I mean, there is clinics out there that do not have a ventilator.
00:39:18
Ryan Bailey
Yeah.
00:39:19
Gianluca Bini
And sometimes, you know, they have cases where they do need to handbag. And at that point, that's what you do. But if you do have a ventilator, you know probably you should ventilate with it.
00:39:33
Ryan Bailey
i
00:39:34
Ryan Bailey
feel like I come from the, like, you have that patient. The the ones i experience it with a lot, other than where, like, it's a teaching thing. Like, oh, if you've got a ventilator, like, you've always got a ventilator with you. And they, like, hold their hands up. It's like, yeah, I get it. But, like, it sucks. And it's, like, the worst one. Like, it's worse than a Hallowell, which is saying a lot.
00:39:54
Ryan Bailey
But, like... But, like, you've got those patients, you try to get them on the ventilator, and they won't synchronize. And you're like, I'm going to do it by hand. And, like, some of those guys, you can kind of, like, create a system where you're ventilating them by hand, and you can, like, get their – and, like, I don't know if it's the way you drive the breath because – The Hallowell only drives the breath one way versus like the newer machines. You could have variable ways that the flow goes in. So you can try different ventilation strategies. You know, you can like slam the bag real fast. You can like slow push and hold. Yeah, I don't know. I hate handbagging. It's my nightmare and it's never fun for me.
00:40:34
Annatasha
Maybe your hands are just all like clawed up from all the hot dogs and that's what
00:40:37
Ryan Bailey
it it's Yeah, it's probably something with all the sodium that is in the hot dogs. I'm just like, yeah, it's hard because I'm always like just punching at the back like this.
00:40:45
Gianluca Bini
Maybe you're just stuck with it, Ryan.
00:40:47
Ryan Bailey
I mean, I can't. That's also what I wanted to see. Are you getting like great waveform traces and like the CO2 stays exactly where you want to when you breathe for that? Yeah, exactly.
00:40:57
Gianluca Bini
no Okay.
00:40:57
Ryan Bailey
Yeah. I mean, i also once had to handbag a cow. That was a nightmare.
00:41:01
Annatasha
Oh, no. I've actually had to do that, too, in a cow specifically. And it's basically like, you've got two minutes before I'm, like, fatigued and we're, like, we're done here.
00:41:08
Ryan Bailey
yeah
00:41:09
Annatasha
Like, that's crazy.
00:41:10
Ryan Bailey
It's like a whole body. You're like...
00:41:12
Annatasha
No. Like, you cling on to it like you're climbing, like, a coconut, like a palm tree.
00:41:12
Ryan Bailey
The
00:41:15
Annatasha
Like, you're just, you know, and it's just no.
00:41:22
Ryan Bailey
Okay.
00:41:23
Gianluca Bini
You guys are nuts.
00:41:25
Annatasha
Okay.
00:41:26
Ryan Bailey
Okay. Where... So, hypercapnia. Everyone loves it. Everyone loves the permissive hypercapnia stuff. Where... So in and the average healthy patient where you've chosen to ventilate them, where are you starting for permissive hypercapnia?
00:41:44
Ryan Bailey
How high? And what patients are you actually going to be like targeting that permissive hypercapnia? Okay.
00:41:49
Gianluca Bini
55 is my limit 60 if it's you know occasionally depends on the patient
00:41:51
Ryan Bailey
Yeah.
00:41:57
Ryan Bailey
Yeah.
00:41:58
Gianluca Bini
oh I don't use permissive epichapnea just as a mean of, you know, yeah, sure, it benefits with your sympathetic tone and it increases potentially little bit your vasoconstriction and it gives, well, not really, like whatever.
00:42:07
Ryan Bailey
Yeah. Yeah.
00:42:15
Gianluca Bini
It increases your blood pressure a little bit.
00:42:17
Ryan Bailey
yeah yeah
00:42:19
Gianluca Bini
But also it doesn't decrease your preload. Right? Like, you know, that's the other deal. Like, I don't want to be ventilating something and then i take away the sympathetic tone simulation, but also I'm reducing the preload a little bit, right?
00:42:34
Gianluca Bini
Because every time you breathe with positive pressure, unfortunately you do squeeze the vena cave a little bit, right?
00:42:40
Ryan Bailey
Yeah.
00:42:40
Gianluca Bini
And so like, I think it's more like, it's not just, you know, permissive cappnea so that I get that sympathetic stone simulation, but also like, I don't really want to be, i don't want to be shooting myself on the foot.
00:42:54
Ryan Bailey
Right. Yeah.
00:42:56
Gianluca Bini
So, and the other side of thing is also, you know, sometimes less is more.
00:43:03
Ryan Bailey
Yeah.
00:43:04
Gianluca Bini
Right. So,
00:43:06
Annatasha
I don't disagree. I mean, assuming like otherwise healthy, like I don't really get that worked up till around 55, 60, especially after induction where I'm trying to build CO2.
00:43:14
Ryan Bailey
Yeah.
00:43:17
Annatasha
So you take a breath.
00:43:17
Gianluca Bini
No.
00:43:18
Ryan Bailey
Right. Yeah.
00:43:19
Annatasha
i Do I treat vasodilation with permissive hypercapnia?
00:43:24
Ryan Bailey
Right.
00:43:24
Annatasha
No.
00:43:25
Ryan Bailey
Yeah.
00:43:25
Gianluca Bini
know
00:43:26
Annatasha
But I really don't start getting my knickers in a twist until I think you're going to start to drive pH down and affect myocardial contraction, which is somewhere in the 60s. Like I don't have an absolute cutoff per se, but if I have a blood gas to hand and I'm like, oh, you're 7.2 and, you know, then I'm going to be like, all right, like we should probably do something.
00:43:40
Ryan Bailey
Yeah.
00:43:43
Annatasha
But yeah, it's, it's, but yeah it's hard it's not hard and fast but like once you start sitting in the 60s on paco2 you know i'm probably gonna faff abound with a couple of things
00:43:55
Gianluca Bini
Yeah.
00:43:56
Ryan Bailey
All right, so speaking of increasing CO2, what is your kind of average strategy to wean your patients off the vent?
00:44:07
Gianluca Bini
Turn it off.
00:44:10
Gianluca Bini
Wait till it breathes.
00:44:12
Annatasha
Yeah, i mean if you if you've been down a long time and you're on like you're still metabolizing your way through high doses of respiratory depressants, so let's say you've been on fentanyl 20 for like eight hours,
00:44:12
Ryan Bailey
Wow. Wow, all right.
00:44:25
Ryan Bailey
Right. right
00:44:27
Gianluca Bini
Who the fuck keeps it at 20 for eight hours?
00:44:27
Annatasha
i
00:44:30
Annatasha
Okay, well, maybe that's a bad example. But anyway, but yeah, like I'm just saying like it depends on what drugs you're on and where we are with weaning that too. But, you know, sometimes I just turn it off and sometimes I slowly turn down like respirate per se and let them start to breathe. And once they were starting to breathe on their own appropriately, like I just turn it off because I don't like it when they breathe against the ventilator.
00:44:50
Ryan Bailey
Mm-hmm.
00:44:50
Annatasha
But yeah, I am... And sometimes you have those patients where you're just like, I mean, I had a patient just actually yesterday, Sunday, like healthy dog, foreign body, had it on Siva fluorine.
00:45:02
Annatasha
And that dog just didn't didn't read the medical textbook. It did take a hot minute to wake up. And I was like, what are you doing?
00:45:06
Ryan Bailey
and
00:45:07
Annatasha
like And I never had it on the ventilator for the whole procedure. And even though it was on Sivo, it just kind of kept sleeping on through. And I was like, chippy chop, like Tasha wants to go home. It's a Sunday.
00:45:17
Ryan Bailey
you Come on.
00:45:19
Annatasha
Yep, chippy chop. But yeah, sometimes like I just turn it off and sometimes I'll wean, rest down and see whether or not they can start to breathe on their own. Otherwise, you do that thing where like you turn it off and they're like apneic and they're not actually breathing off the inhaling.
00:45:30
Gianluca Bini
Thank you. here
00:45:32
Ryan Bailey
right. Yeah.
00:45:33
Annatasha
And then you flip it back on, you know, and'll be and then you do that like on and off for a while. And so if the patient's be responding like that, then I tend to set a lower rate. and keep them so because i you know i'm doing other stuff like you know i'm disconnecting them and i want to move them and we're cleaning the incisional say and pulling the art line and all that kind of stuff so
00:45:46
Ryan Bailey
Yeah.
00:45:49
Ryan Bailey
Right.
00:45:51
Gianluca Bini
So here is my thought, right? So otherwise, I'll be patient, right? You have a pulse ox that tells you whether your patient hemoglobin is saturated or not, right?
00:46:01
Annatasha
yep
00:46:03
Ryan Bailey
Right. Yeah.
00:46:05
Gianluca Bini
We do know that the respiratory drive, the main drive CO2, right?
00:46:09
Ryan Bailey
Yes.
00:46:09
Gianluca Bini
There are other things as well, you know, when you become severely epoxic, blah, blah, blah, that, you know, affects it too.
00:46:14
Ryan Bailey
All right.
00:46:16
Gianluca Bini
But the main thing is CO2.
00:46:18
Ryan Bailey
Yeah.
00:46:18
Gianluca Bini
So, and if you breathe for them, they will the CO2 will never accumulate enough to start triggering their brainstem, right?
00:46:26
Ryan Bailey
Right.
00:46:27
Gianluca Bini
And so and that's so so that's what I do.
00:46:27
Ryan Bailey
For sure.
00:46:29
Gianluca Bini
i could just turn it off, wait for that CO2 to build up. I look at the pulse ox. If the pulse ox is fine, I don't give a breath.
00:46:36
Annatasha
Thank you.
00:46:37
Gianluca Bini
If I do need to give a breath, I will. But like, it doesn't matter.
00:46:42
Ryan Bailey
So I guess.
00:46:44
Gianluca Bini
and And most people are like, yeah, give a breath a minute. And then you look at the clock. A minute is a terribly long time. Like, you know, nobody actually does wait a minute.
00:46:52
Ryan Bailey
Oh, I know. I know.
00:46:53
Gianluca Bini
you know?
00:46:53
Ryan Bailey
It's great. And for people to wait a minute with the patient apneic, have like slap their hands at least five times.
00:46:58
Gianluca Bini
Oh, yeah. And...
00:46:59
Ryan Bailey
They'll be like, oh, I'm like, no, leave alone.
00:47:01
Gianluca Bini
Now, the only exception I have is patients with potential endocrinial disease. And those I do go in CMV. I use CMV in those patients.
00:47:13
Gianluca Bini
And actually, you know, the practices they use are services when, and they do brain patients at times. I'm like, you need to have a machine with CMV because that's, to me, one of the best ways to wear win them off, right?
00:47:24
Ryan Bailey
Yeah.
00:47:32
Gianluca Bini
Everything else, it doesn't matter. And the only reason why it matters in these intracranial patients is because, you know, if you have too high of a rise in CO2, that's going to base with a later brain capillaries and increase intracranial pressure and kill them.
00:47:34
Ryan Bailey
Yeah.
00:47:43
Ryan Bailey
Yeah.
00:47:47
Gianluca Bini
And I've seen most of the the patients that I've seen dying with intracranial disease are always in recovery.
00:47:47
Ryan Bailey
yeah
00:47:56
Ryan Bailey
Oh, for sure.
00:47:56
Gianluca Bini
Always. 100%.
00:47:59
Ryan Bailey
Yeah, so that's, I guess, what I was... That's part of what I was getting at It's interesting that you're both in the cold turkey strategy versus the, like... I tend to go for the no more inhalant, continue ventilation, drive out all the CO2, drive out all the inhalant as fast as I possibly can, and then try and cold turkey them there.
00:48:10
Gianluca Bini
oh
00:48:22
Ryan Bailey
I don't have a good way to describe it other than I call it the fast way. And that's what I use for most of my patients. As long as I'm not doing, you know, if they're not being transported from one place to another, like we're just done with the case, I usually just crack off the inhalant, let the ventilator keep firing, get that ISO down as low as I can possibly go.
00:48:39
Gianluca Bini
Thank you.
00:48:42
Ryan Bailey
Usually 0.3 is the magic number. And then I'll, you know, turn the ventilator off and see if the patient has decided to breathe breathe or if they've hopefully like bucked the vent one time during that cycle i've usually turned it off by then which i guess is like is that good or bad i don't know bucking the vent they do it all the time you know when you at least get them started you have to fight them a little bit so it's not the end of the world but like yeah there is that one drawback to that and then
00:48:56
Annatasha
Thank you.
00:49:09
Ryan Bailey
The other question I had is when are you weaning your patients?
00:49:11
Gianluca Bini
They're done.
00:49:13
Ryan Bailey
Like where are those specific patients? So intracranial pressure patients, I totally agree. I'm going to wean them. because like that's where the disaster happens is you let their co2 spike up and their brain herniates because i also like to i don't know if it's like weaning per se but i do like to do a little double check in any of the like cervical lesion patients just to make sure that they're able to maintain a semi-normal co2 before we go to wake them up not like
00:49:26
Gianluca Bini
that
00:49:44
Ryan Bailey
it's It's not like we wean them so much as like I make sure that when they do breathe that it's like a normal breath on the waveform and that the CO2 fits with like a normal size breath for that patient.
00:49:57
Ryan Bailey
And then the patients where I've used paralytics, I like to obviously make sure the patients are breathing. Yeah.
00:50:05
Gianluca Bini
Yeah.
00:50:06
Ryan Bailey
where they're, you know, again, they're not being weaned per se. i don't know where we, i think the true, the only real weaning cases are those ICP cases, like you said.
00:50:14
Annatasha
Thank you.
00:50:17
Ryan Bailey
but those are the only ones I could think of where I'm going to like specifically target a different way to get them out off the ventilator. Yeah.
00:50:26
Gianluca Bini
And I tend to reverse some of those patients too. Like, you know, the intracranial patients, I try to like, I'm more proactive in reversing opioids, reverse like, you know, or at least trying to minimize the respiratory side effects from them, right?
00:50:29
Ryan Bailey
Yeah.
00:50:47
Gianluca Bini
I have this feeling that TNL and the doses we give
00:50:52
Ryan Bailey
Yes.
00:50:54
Gianluca Bini
unless you overdose them, they're not super respiratory depressant or compared to the rest of the drugs we have. Right?
00:51:01
Ryan Bailey
OK.
00:51:01
Gianluca Bini
Like I think that opioids do a way worse job at it. I think of course, probably for a vaccine, they do a way worse job at it.
00:51:08
Ryan Bailey
Yeah.
00:51:09
Ryan Bailey
yeah
00:51:09
Gianluca Bini
don't know. I don't think they're the worst drugs that we have out there for respiratory depression. I think they're... That's why they called Turkey probably from me and Tasha. You know, that's that's where that comes from.
00:51:21
Gianluca Bini
Like, I don't think that the Nielans, that's the huge role there. Yeah.
00:51:25
Ryan Bailey
Yeah. Makes sense.
00:51:28
Gianluca Bini
Yeah.
00:51:28
Ryan Bailey
I just kind of wanted to know. How about you, Bartell? When are you weaning your patients?
00:51:36
Annatasha
when I remember.
00:51:42
Gianluca Bini
Thank you.
00:51:43
Annatasha
I mean, i mean, I don't run a lot of primary cases. Right. So, and, and if I do have like multiple cases down, like I can't always be there at the moment where I think like, you know, closure is complete or whatever, you know, and it's a lot of texting back and forth or walkie talkies and, and, but you know, when am I weaning?
00:51:46
Ryan Bailey
Sure. Sure.
00:52:01
Annatasha
probably when I start turning down my CRIs, I start to wean everything collectively. So I step down everything to try and expedite recovery.
00:52:06
Ryan Bailey
Hmm. just
00:52:09
Annatasha
yeah, I, I'm pretty impatient actually about recovery because, uh, you know, i got to get the horses up. I got to get these subject patients like stabilizing. And also I got to turn over to the other case.
00:52:19
Annatasha
So like I got a 20 minute cutoff for anesthesia recovery before I'm starting to get like
00:52:20
Ryan Bailey
Right.
00:52:24
Annatasha
sing in my ethyl merman broadway voice and reverse drugs so yeah i i don't have a particular cutoff but i as soon as i start stepping everything else down i'm going to step the ventilation down with it too obviously unless they have some sort of other type of physiological compromise but
00:52:38
Ryan Bailey
Yeah. Right.
00:52:41
Annatasha
you yeah you also have that thing too where it's like there's so much like kerfuffle afterwards like you know
00:52:41
Ryan Bailey
How about
00:52:46
Annatasha
We need post-op rods.
00:52:46
Ryan Bailey
Oh, yeah.
00:52:47
Annatasha
Can you put an NG tube in? And does anyone want to do you, Kevin?
00:52:48
Ryan Bailey
Right.
00:52:51
Annatasha
You know, so and you're just like, how much longer is this?
00:52:51
Ryan Bailey
Yeah.
00:52:54
Annatasha
It's going to go on. That's also a factor sometimes so because sometimes I'm like wrapping it up and then they're like, oh, actually, you know what?
00:52:55
Ryan Bailey
Yeah.
00:53:00
Annatasha
Let's go back to CT. And you're like, go right? So anyway, that also happens very frequently.
00:53:08
Ryan Bailey
so in regards to those icp cases what is your ventilation strategy and approach are you like right off the bat by the book
00:53:18
Gianluca Bini
28 to 35. twenty eight thirty five and direct
00:53:21
Annatasha
I tend to stay at the like the lower end of the end-tidal CO2 range. I know that there's really not a lot of evidence about prophylactic hypocapnia in terms of preventing herniation.
00:53:32
Gianluca Bini
Thank
00:53:33
Annatasha
It really is more of a reaction to... a herni herniation event per se. But my theory is, is that it's easier for me to jump you from 30 down to 20 than it is for me to jump you from 55 to 20.
00:53:45
Ryan Bailey
right
00:53:46
Annatasha
So I err on the side of the low end of of the end tidal CO2 for mechanical ventilation so that if I do have to intervene, I can do it more quickly and and without making wildly aberrant changes in pH, which I also don't think helps.
00:53:47
Ryan Bailey
Yeah.
00:53:59
Ryan Bailey
Right.
00:54:01
Annatasha
the cerebrum. So yeah, so my my strategy is I do tend to ventilate them from the get go.
00:54:01
Ryan Bailey
OK.
00:54:07
Ryan Bailey
Mm-hmm.
00:54:07
Annatasha
And I do tend to want to drive their PaCO2 to that lower end, because like I said, I could sit you at 20 the whole time. but It's actually not that great for your brain, because you know, around 18, you start to hit cerebral ischemia.
00:54:17
Ryan Bailey
Right, right.
00:54:19
Annatasha
So the goal is, is to optimize cerebral perfusion. And if they have an adverse reaction, then to intervene. But like I said,
00:54:26
Ryan Bailey
Yeah.
00:54:27
Annatasha
i and I drive at the lower end so that my intervention is is easier to achieve.
00:54:32
Gianluca Bini
yeah I usually do 28 to 35, something like that. the Depends where you read for cerebral experience. Some places say even 24. So
00:54:40
Ryan Bailey
yeah So are you Right off the bat, patient's down, get them on the vent, immediately drop their CO2.
00:54:46
Gianluca Bini
yeah. Yeah.
00:54:50
Gianluca Bini
Preset the vent, hook them up, flip the switch, be good.
00:54:54
Ryan Bailey
Are you getting a blood gas on these patients then? Routinely?
00:54:59
Gianluca Bini
You should.
00:54:59
Annatasha
Yes.
00:55:00
Ryan Bailey
yeah
00:55:02
Gianluca Bini
the answer is no, though, like practically no.
00:55:03
Ryan Bailey
just Bartell mentioned and just wanted to ask about it because it is, you know, there are obviously patients out there where the gradient is greater than five. And so that, you know, I just wondered what you're.
00:55:12
Gianluca Bini
of
00:55:15
Gianluca Bini
Although there is evidence where if you start ventilation from the get-go, you can minimize that gap.
00:55:23
Ryan Bailey
That's true.
00:55:25
Annatasha
Yeah. And I mean, all my MRIs have an art line anyway, because I don't have very useful oscillometric in the MRI. So if I have the art line and I think that you're going to be physiologically aberrant, I do take my blood gas sample as my baseline and see what's see what's up.
00:55:37
Gianluca Bini
yeah
00:55:38
Ryan Bailey
Yes. Yes.
00:55:42
Ryan Bailey
Yes.
00:55:44
Ryan Bailey
yeah
00:55:45
Annatasha
like you know Especially if they do have like high intracranial pressure and then they're in that
00:55:50
Annatasha
Like Cushing's triad, actually the first change is the change in breathing, and most people don't pick up on that clinically. And so might I anticipate that you're likely going to have weird PaO2 and PaCO2, and I want to know what's up before I start doing crazy ventilation things.
00:55:58
Ryan Bailey
yeah
00:56:04
Gianluca Bini
Yeah. Yeah.
00:56:09
Ryan Bailey
makes sense.
00:56:10
Gianluca Bini
Yeah, makes sense.