Thread by @NidaQadirMD

Why do I hate hearing “the patient was bucking the vent”?

Mainly because it’s usually followed by “so we increased sedation.”

✅ Read on to learn what to say & do instead to better help your patient 🧵

#MedTwitter #NurseTwitter #MedEd

https://twitter.com/NidaQadirMD/status/1622264076322893824

What do people mean when they say this? Usually that the patient is on a vent & looks uncomfortable. Common but non-specific.

➡️ What I hear: the patient is on a vent & looks uncomfortable AND I’m not sure why

➡️ What I think of: buck teeth and/or a horse doing this

What can make vented patients feel (or appear) uncomfortable? Lots of things, but broadly:

➡️ Vent dyssynchrony

➡️ Something non-vent related (ie pain, anxiety)

➡️ Delirium

Sedation is not the 1st line treatment for any of these. If sedation has already been reflexively given, it becomes harder to sort out what was actually needed 🫤🫠

Vent dyssynchrony = a mismatch between what the vent is doing vs. what the patient needs

For the most part, this is caused by:

➡️ Inability to trigger the vent

➡️ Inadequate inspiratory flow

➡️ Timing or duration of either inhalation or exhalation

🚫 Ventilator dyssynchrony is NOT “overbreathing the vent”

🚫 “Overbreathing the vent” is term that is often used incorrectly

✅ Overbreathing = breathing above the set rate on a controlled vent mode. This is usually not a bad thing.

How do you recognize vent dyssynchrony? Waveform analysis

That’s a topic for a whole other thread, but I posted a few images below

Manage it by:
1️⃣ Recognizing the type of dyssynchrony
2️⃣ Adjusting the vent accordingly
3️⃣ Increase sedation ONLY IF vent adjustments aren’t enough

Management of non-vent-related agitation of course consists of addressing the cause (ie pain meds for pain).

Communication can definitely be difficult, so the biggest challenge here is often figuring out what the issue is. Be up to that challenge - your patients will thank you.

Management of delirium should start w/ non-pharmacological methods, such as:

➡️Reorientation
➡️Ensuring adequate sleep
➡️Providing glasses & hearing aides when needed
➡️Minimizing deliriogenic meds

Sedation may ultimately be needed, but make sure you’ve done these things first

Why does this matter?

😵 Because oversedation is not benign. It’s associated with:

⬆️Mortality
⬆️Vent days
⬆️ICU days
⬆️Delirium

🧠 Delirium also is more than just a nuisance - it’s associated with:

⬆️Mortality
⬆️Hospital days
⬇️Global cognition & executive function @ 1 year

Your goal is an awake & calm patient (RASS = 0 to -1). If someone is more sedated than that, there should be a good reason (ie need for paralytics, agitated delirium not responsive to non-pharm measures, etc)

So coming back to “bucking the vent” - knowing the specifics of the “bucking” helps us avoid oversedation & improve patient care 😀

So next time you see someone “bucking the vent,” ask yourself the following:

✅ Is it agitation or vent dyssynchrony?
✅ If it’s agitation, what might be causing it?
✅ If it’s vent dyssynchrony, what kind of dyssynchrony is it?

Then you can formulate the most appropriate plan

Thanks for reading! If you found this useful, please retweet the thread.

https://twitter.com/NidaQadirMD/status/1622604832136904707