150 episodes

Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.

Critical Care Scenarios Brandon Oto, PA-C, FCCM and Bryan Boling, DNP, ACNP, FCCM

    • Health & Fitness
    • 4.6 • 207 Ratings

Join us as we talk through clinical cases in the ICU setting, illustrating important points of diagnosis, treatment, and management of the critically ill patient, all in a casual, "talk through" verbal scenario format.

    Episode 75: Automatic tube compensation, with Ben Fabry

    Episode 75: Automatic tube compensation, with Ben Fabry

    We discuss the principles and application of automatic tube compensation (ATC) on modern ventilators, with its creator Ben Fabry. Dr. Fabry is a professor and chair of biophysics at University of Erlangen-Nuremberg, originally trained as an electrical engineer, who originally developed ATC as part of his PhD program.







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    Takeaway lessons









    * ATC, originally called “electronic extubation,” is meant to normalize or eliminate the resistance to flow created by the endotracheal tube. Since this resistance is always present, yet is dynamic and varies by flow (and tube size), it creates a continuous confounding variable, making the displayed pressure on the ventilator a measurement not of tracheal pressure, but of another, largely meaningless pressure (the pressure outside the patient).







    * ATC works by increasing airway pressure during spontaneous inspiration to eliminate the pressure gradient created by the tube at the current flow, and reducing it during expiration to reverse the effect.







    * While ATC can be used in any mode, it is mostly meant for pressure support or other spontaneous modes. It has no real role in volume control. In pressure control, it has little meaningful impact during inspiration, although it will reduce the airway pressure below the set PEEP during expiration, which may help facilitate expiration.







    * The original ATC test ventilator could drop pressure below atmospheric pressure during expiration, but this feature is not possible on modern ventilators, so the lowest possible pressure during ATC is zero (probably not quite even, that due to expiratory valve resistance). Some modern vents will not drop pressure during expiration at all.







    * In principal, actual tracheal pressure could be measured by a separate monitoring lumen. In practice, this is dangerous, as the lumen could be occluded by mucus, so the resistance constant is instead applied mathematically. The modifiers were derived empirically by testing a variety of tubes at different flow rates.







    * ATC will generally ask for the tube size. Length has some effect but a fairly trivial one, as resistance is mostly influenced by turbulence, which is mainly a product of diameter. Resistance is not a constant, but increases with (roughly) the square of the flow of gas.







    * A swivel connector on the ETT outlet adds about 1 cm H2O of resistance. An HME adds about 3 cm H2O.







    * Changes in gas composition at different FiO2 changes resistance trivially, although a mix like Heliox would change it significantly, and would make the internal calculations incorrect.







    * No fixed single pressure support value can accurately match tube resistance, due to its dynamic nature during and between breaths, even if you were willing to set the sort of pressure needed—which might be 50+ cm H2O in a strongly breathing patient.







    * The main downside of ATC is that modern ventilators don’t do it very well—they can only vary flow so quickly, so when there are brisk changes in pressure, they fail to match it. They usually can match only about 50% of tube resistance, with the worst at the start of a breath as they lag behind the initial drop in pressure. (You can appreciate this by seeing the airway pressure drop below the set PEEP.) Response is even less in some of the current generation of vents with radial blowers and slower valves







    * Quality check your ATC by watching the tracheal pressure—the vent will display this ...

    • 56 min
    TIRBO 61: How to use POCUS (our expert consensus)

    TIRBO 61: How to use POCUS (our expert consensus)

    Brandon summarizes his recent publication describing best practices for performing POCUS. Read the paper open access at POCUS Journal.







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    • 23 min
    Episode 74: Obstructive shock, with Sarah Lorenzini (Nurses’ Podcrawl 2024)

    Episode 74: Obstructive shock, with Sarah Lorenzini (Nurses’ Podcrawl 2024)

    Our collaboration with Sarah Lorenzini of the Rapid Response RN podcast, discussing a case and general principles for diagnosing and managing obstructive shock. Check out the other episodes on shock in the Nurses’ Podcrawl 2024!







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    • 49 min
    Lightning rounds 40: Critical care medicine fellowships with Nicholas Ghionni

    Lightning rounds 40: Critical care medicine fellowships with Nicholas Ghionni

    We chat about pulmonary/critical care medicine fellowship with recent graduate Nicholas Ghionni (@pulmtoilet), a first-year attending at the MedStar Baltimore Hospital system. He completed PCCM fellowship at MedStar Washington Hospital Center where he also served as chief fellow.







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    • 39 min
    TIRBO 60: They don’t care about you

    TIRBO 60: They don’t care about you

    The difference between people and institutions.







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    • 13 min
    Episode 73: POCUS for nephrology, with Abhilash Koratala

    Episode 73: POCUS for nephrology, with Abhilash Koratala

    We discuss the role of point-of-care ultrasound in evaluating the patient with kidney injury and assessing volume status, with Abhilash Koratala (@nephroP), nephrologist, Director of Clinical Imaging for Nephrology at the Medical College of Wisconsin, and champion of nephrology-focused ultrasound.







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    Takeaway lessons









    * A quick kidney and bladder ultrasound to rule out urinary obstruction is appropriate for most significant AKIs, maybe even if it was done previously (as obstruction can develop at any time).







    * Ultrasound of the lungs and IVC help establish the presence of elevated filling pressures; if present, the VEXUS scan can be performed to establish the presence of venous congestion that might be contributing to kidney injury.







    * Pulmonary edema as evidenced by B-lines establishes that the patient is not fluid tolerant, and suggests that further volume loading may be harmful. It increases the chance that AKI is due to congestive nephropathy as well, although each can also occur in isolation (and of course AKI can be a cause, leading to volume retention and then pulmonary edema).







    * Abhilash does an 8-zone lung exam (2 anterior and 2 lateral zones on each side), which is plenty for cardiogenic pulmonary edema. He does not really count B-lines; if he sees B-lines in more than one dependent zone, he takes it as evidence the patient could be decongested.







    * IVC is a reasonable method of estimating RAP; it is not reliable to gauge fluid responsiveness or other questions. The internal jugular vein is a good fallback if the IVC is untenable or seems unreliable, such as if bandages limit access, or the presence of cirrhosis (which alters local vasculature in unpredictable ways). Look for the highest point of distention and measure roughly from the sternal angle, adding it to the right atrial depth to approximate the CVP (usually ~5 cm although this is not very reliable).







    * A non-plethoric IVC and absence of B-lines suggests a fluid tolerant patient. He uses the ACE guidelines of IVC >2.1 and 50% collapse with deep inspiration (sniff) to equate RAP ~15 mmHg.







    * In the presence of elevated RAP, VEXUS helps determine whether that change is likely to be affecting organ perfusion by altering flow characteristics. Higher VEXUS scores are well-associated with risk of AKI.







    * High RAP with a low VEXUS suggests that congestive nephropathy is not actively worsening renal function, whereas a higher VEXUS suggests the opposite. Serial VEXUS scans help track the progress of decongestion to dial in a patient to an optimal fluid balance.







    * VEXUS is a right-sided heart parameter, so the state of the left heart’s filling may differ somewhat (e.g. as evidenced by lung markers like pulmonary edema—so track your B-lines too!). It is probably more precise and reliable than other markers like peripheral edema.







    * Right and left heart filling should generally be well-linked. Venous congestion and elevated RAP usually indicate a well-filled LA as well, unless the lungs are acting as a significant resistor. If major PH is present, consider introducing measures like pulmonary vasodilators instead of further fluid loading; overdistending the RV will not help the LV.







    * Although portal vein pulsatility can usually move towards normal after optimal decongestion, hepatic vein waveforms may remain abnormal in some patients with TR, PH, etc.

    • 53 min

Customer Reviews

4.6 out of 5
207 Ratings

207 Ratings

Methriln ,

Great podcast

Loved working with these guys. always super informative in person and love the podcast

Maria Jean McCarthy ,

Review of “Nurses are from Venus”

Nurses are humans trying to use critical thinking to better the patient’s outcome , not just machines implementing tasks … loved a lot of your episodes except “Nurses are from Venus “. Your voice speaks more than your words … nauseating. If a nurse is listening to this podcast it’s because we care about the patho , the reasons, not just following the order as they appear. Hard not to care about the reasons for doing each thing you do and the outcome when you spend your whole day with a critical kid and their family.

NicACarr ,

Bedside Nurse Finds Value

As a bedside PCU/ICU RN, I find these episodes so informative, so relevant and applicable, and a great benefit to the nursing community! I recommend them to my friends to listen to. I find the perspective of both hosts to be so valuable to helping me understand so much of what is not communicated between the “MD” team and the “nursing team”. This podcast honestly pushes me to critically think while making my practice better!

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