We have a two part special with Sam Ireland from FOAMfrat. He is a critical care paramedic in Wisconsin and a brilliant mind including with ventilation. Sam agreed to come on to talk both about impending and acute ventilatory failure. Stay tuned next week for the second part of his talk.
This post we talk about impending ventilatory failure which is less severe than acute ventilatory failure. Sam breaks down both portions as a definition and the management of the condition. Here are the key points, but please listen to the podcast for full details.
Definition: These patients are in respiratory distress with a high minute volume, high respiratory rate, low tidal volume (not moving dead space to clear CO2), and generally a PCO2 >50 with blood gases that does not look terrible. Management: The patients in impending ventilatory failure need to have their CO2 blown off. To do this, we need a high Delta pressure (pressure difference between IPAP and EPAP). This means that we may start with an IPAP of 10 and EPAP of 5 but if we increase we may want to make a larger separation of those two numbers such as IPAP of 20 and EPAP of 10. What we do not want to do is titrate without increasing the Delta pressure such as IPAP of 15 and EPAP of 10 then increasing to IPAP of 20 and EPAP of 15. The difference between those two numbers stays 5. If we work to improve our Delta pressure, we want to increase the difference of those two numbers. Additionally, we need to address any underlying hypoxemia by increasing the FiO2 in these patients. As a side note, if you still want to understand bi-level ventilation (commonly called BiPAP) better Sam has a podcast on that, too! His friend, Tyler Christifulli, has a podcast on optimizing PEEP and an interview with Josh Dillman on NPPV tips. Check them out and master these skills. Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere. 
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