Ventilator Management

Maximizing Outcomes In Caring For Asthma, COPD, And Pulmonary Edema

DeGiorgi, Andrea BS, RRT
White, Michael MD
DeBlieux, Peter MD
Murphy, Michael F. MD
Weingart, Scott D. MD

Authors
Andrea DeGiorgi, BS, RRT Respiratory Care Practitioner, Carolinas Medical Center, NC
Michael White, MD Director, Department of Emergency Medicine, Shands Lake Shore Hospital, Lake City, FL
Peer Reviewers
Peter DeBlieux, MD Professor of Clinical Medicine, LSU Health Science Center; Director of EM Services, University Hospital, New Orleans, LA
Michael F. Murphy, MD Professor and Chair, Department of Anesthesia; Professor Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
Scott D. Weingart, MD Assistant Professor, Director, Division of Emergency Department Critical Care, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY

Emergency Medicine Practice 10(8):p 1-19, August 2008.

You realize that it's been just a little too quite tonight when the radio suddenly cackles to life: “Teenage girl … asthma … can't breathe … diaphoretic … giving nebs … No IV … 2-minute ETA.” Within minutes, two medics rush in with a diaphoretic cyanotic girl perched forward on her hands. Her pleading glance catches yours as you watch her take her last voluntary breath; intubation is obviously required … ventilator management is your concern since you realize her life depends on it ….

As you resuscitate the crashing asthmatic, your 60-year-old male patient on the other side of the curtain, who has been sleeping comfortably, begins to complain that his breathing is getting worse. He is a frequent flyer with a known history of bad emphysema and a worse attitude. He adamantly refuses ‘the mask’ ventilation. You think back about his chest x-ray, which showed extensive bilateral pulmonary infiltrates, and wonder how long your luck can hold up before you need to intervene with him. His voice and attitude sound oddly weak, but you remember that the last time he was intubated he developed a pneumothorax ….

Just as you ponder these thoughts, a seasoned pair of medics burst into the ED. The hiss of nebs can be heard under the rushing sound of high pressure CPAP. “Sorry Doc, tried to raise you on the radio but no one answered. This lady is sick and not moving much air. We got her on CPAP at 20, 100%, but we're not making much progress; heart rate of 170 and can't get her sats higher than 60%. She's got CHF. Had no time to intubate.” Just then their short, morbidly obese, pale, diaphoretic patient rips her CPAP mask aside and screams, “I … can't … breathe.” Her eyes then roll back, and she begins to have a hypoxic seizure.