I find this discussion off center from the ventilator strategy I used to achieve very good results. First of all, higher driving pressures indicate stiffer, sicker lungs, so higher mortality rates should be expected. Second, I always aimed for a respiratory rate of 26 or less to achieve better outcomes. Increased RR requires decreased inspiratory times (less time for gas exchange at the alveolar level). I don't subscribe to the notion that an increase of a couple of cm/H20 of driving pressure will hurt outcomes. In so many of the discussions on VILI, the mode of ventilation is omitted, but it is important. Volume assist control is damaging. I never use it, because it often leads to respiratory rates of 30 or more. I always start my patients on SIMV(PRVC) with 10 pressure support and 5 PEEP. I want an inspiratory time of about 1.2 seconds. Longer I-time, lower flow rate, softer tidal volume, no VILI.
Indeed, your approach to ventilator management has its merits, especially given your focus on individualized care and specific ventilation modes. However, the video's emphasis on driving pressure also offers some valuable insights: 1. The video's approach is grounded in post-hoc analyses of various randomized trials, suggesting an evidence-based methodology. This could be particularly useful for less experienced clinicians or in settings where specialized expertise is limited. 2. Driving pressure is a single, easily measurable variable that can be universally applied. This simplicity could be advantageous in various clinical settings. 3. The video highlights the correlation between high driving pressure levels and increased mortality during controlled ventilation. This offers a straightforward method to assess lung stress and the risk of Ventilator-Induced Lung Injury (VILI). 4. While the video focuses on driving pressure, it also acknowledges the importance of individualized care. Driving pressure can be a helpful guide for setting tidal volume according to individual lung sizes, potentially leading to better outcomes. 5. The video is open to the evolution of this approach, acknowledging that more research is needed. This suggests a willingness to adapt based on new evidence. 6. Lastly, the video provides a comprehensive overview of how driving pressure can be managed in different patient scenarios, making it a versatile tool for clinicians. Your approach and the video's recommendations aim for better patient outcomes, each with advantages and limitations. What works best could depend on various factors, including patient condition, available resources, and clinician expertise.
