Switching to the bag on emergence...

[appcan]

With a bunch of the attendings that I've worked with, there's this preference to switch from PSV to the bag when the patient begins to react to the tube or even earlier during emergence with the idea that it's more comfortable for the patient with less bucking. I can't say I've noticed a particular difference since it seems like all of these patients inevitably end up reacting to the tube rather than what mode ventilation is being used. I've seen patients emerge calmly or with considerable coughing/bucking with both strategies with otherwise similar anesthetics. It seems like all I'm doing by switching to the bag is increasing their work of breathing and probably atelectasis which in my opinion would just increase their distress rather than calm them. I understand that in the ICU, doing spontaneous breathing trials on T piece is relatively common and can demonstrate if the patient can tolerate the absence of positive pressure ventilation (e.g. someone at risk for or with a component of pulmonary edema). However, in the perioperative ambulatory setting, is there really any benefit in switching to the bag from PSV on emergence?

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[Guillemot]

Manual can increase atelectasis (as detailed in a recent publication in Anesthesia). In my experience it can decrease coughing sometimes also. Some ventilators such as Perseus allow for CPAP. Thinking about it, it might be less stimulating than PSV while also decreasing atelectasis, but I dont know that for sure.

Manual with the pop off at 5-10cm of water at high flows is probably somewhat close to PSV with PEEP and no actual pressure support if the breathing pattern is regular, but probably differs more if the pt is coughing as it would be trying to apply PEEP to an irregular pattern.

 

[jwk]

Manual can increase atelectasis (as detailed in a recent publication in Anesthesia). In my experience it can decrease coughing sometimes also. Some ventilators such as Perseus allow for CPAP. Thinking about it, it might be less stimulating than PSV while also decreasing atelectasis, but I dont know that for sure.

Manual with the pop off at 5-10cm of water at high flows is probably somewhat close to PSV with PEEP and no actual pressure support if the breathing pattern is regular, but probably differs more if the pt is coughing as it would be trying to apply PEEP to an irregular pattern.

Just read that article today. Interesting.

 

[MirrorTodd]

With a bunch of the attendings that I've worked with, there's this preference to switch from PSV to the bag when the patient begins to react to the tube or even earlier during emergence with the idea that it's more comfortable for the patient with less bucking. I can't say I've noticed a particular difference since it seems like all of these patients inevitably end up reacting to the tube rather than what mode ventilation is being used. I've seen patients emerge calmly or with considerable coughing/bucking with both strategies with otherwise similar anesthetics. It seems like all I'm doing by switching to the bag is increasing their work of breathing and probably atelectasis which in my opinion would just increase their distress rather than calm them. I understand that in the ICU, doing spontaneous breathing trials on T piece is relatively common and can demonstrate if the patient can tolerate the absence of positive pressure ventilation (e.g. someone at risk for or with a component of pulmonary edema). However, in the perioperative ambulatory setting, is there really any benefit in switching to the bag from PSV on emergence?

Biggest benefit is if they are pulling lowish tidal volumes on psv, you can see what they pull on spontaneous ventilation. Adequate tidal volumes are one of the extubation criteria if we're getting into the semantics of it all.

 

[GassYous]

I just blow off the gas with the vent, leave 'em paralyzed until the gas is close to being off. Reverse, switch to bag and when their tidal volumes are good enough then pull the tube. No bucking.

You can extubate on ps no problem. They do it all the time in the icu. The comfy patients have had enough opioids most likely. Just don't mess with the patient during emergence. But as a resident try different things and you'll see what you get comfortable with.

 

[thinkorswim]

I don’t think it makes a difference. I will always try for manual first but will turn it to PSV if tidal volumes are too low or ETCO2 is too high.

The bucking and coughing have more to do with the anesthetic than the ventilator. Narcotic, propofol and/or lidocaine can all help with that. I’m personally a fan of nitrous oxide and narcotic for super smooth extubations, but everyone has their own way of skinning the cat.

 

[GassYous]

I don’t think it makes a difference. I will always try for manual first but will turn it to PSV if tidal volumes are too low or ETCO2 is too high.

The bucking and coughing have more to do with the anesthetic than the ventilator. Narcotic, propofol and/or lidocaine can all help with that. I’m personally a fan of nitrous oxide and narcotic for super smooth extubations, but everyone has their own way of skinning the cat.

I stopped using nitrous due to environmental concerns and found out that I don't need it at all

 

[deleted875186]

Bucking is sometimes part of emergence. Use opioids if you need to stop it, they are the most reliable. Patients don’t remember bucking in emergence, I generally don’t care about it unless you need to avoid hypertension or cough for some medical reason. Or if it’s a big muscular dude, then I am very concerned with bucking. I think it’s mostly ego of the anesthesiologist to want to make things look smooth 100% of the time.

 

[deleted875186]

For what it’s worth, I also leave on full vent support and full blast to get the gas off and reverse, observe spontaneous breathing, pull tube. Fastest and easiest. None of this wean nonsense, the patient had normal lungs when we put them on the vent in the begining.

 

[Hoya11]

With a bunch of the attendings that I've worked with, there's this preference to switch from PSV to the bag when the patient begins to react to the tube or even earlier during emergence with the idea that it's more comfortable for the patient with less bucking. I can't say I've noticed a particular difference since it seems like all of these patients inevitably end up reacting to the tube rather than what mode ventilation is being used. I've seen patients emerge calmly or with considerable coughing/bucking with both strategies with otherwise similar anesthetics. It seems like all I'm doing by switching to the bag is increasing their work of breathing and probably atelectasis which in my opinion would just increase their distress rather than calm them. I understand that in the ICU, doing spontaneous breathing trials on T piece is relatively common and can demonstrate if the patient can tolerate the absence of positive pressure ventilation (e.g. someone at risk for or with a component of pulmonary edema). However, in the perioperative ambulatory setting, is there really any benefit in switching to the bag from PSV on emergence?

you get the patient breathing truly on their own - thats the benefit.

you get them used to already taking big negative pressure breaths, so when the tube comes out they are already in rhythm for success.

i was trained to never extubate off PSV.

i will sometimes use PSV or VC or PC to blow off the gas, but at least the last 0.6 or so of sevo i have them breathing completely unassisted.

try getting them back breathing on their own when they are somewhat deep - that leads to smooth breathing pattern.

when you go from manual breathing without support, and extubate, the patient has to adjust to breathing without the tube.

when you go from PSV and extubate, the patient has to adjust to breathing without the tube AND without the support.

also on manual you can see the patients "true" rate and titrate opioids more effectively.

 

[psychbender]

Who the hell uses a t-piece in the unit when weaning?

 

[patriot6]

With a bunch of the attendings that I've worked with, there's this preference to switch from PSV to the bag when the patient begins to react to the tube or even earlier during emergence with the idea that it's more comfortable for the patient with less bucking. I can't say I've noticed a particular difference since it seems like all of these patients inevitably end up reacting to the tube rather than what mode ventilation is being used. I've seen patients emerge calmly or with considerable coughing/bucking with both strategies with otherwise similar anesthetics. It seems like all I'm doing by switching to the bag is increasing their work of breathing and probably atelectasis which in my opinion would just increase their distress rather than calm them. I understand that in the ICU, doing spontaneous breathing trials on T piece is relatively common and can demonstrate if the patient can tolerate the absence of positive pressure ventilation (e.g. someone at risk for or with a component of pulmonary edema). However, in the perioperative ambulatory setting, is there really any benefit in switching to the bag from PSV on emergence?

I switch to manual once patient is close to extubating. It's like taking the plane off auto-pilot as you approach the runway. Nothing can replace the feel of how well your patient is ventilating with the bag in your hand. Turn the APL and support in sync if your patient needs support.

 

[GassYous]

I switch to manual once patient is close to extubating. It's like taking the plane off auto-pilot as you approach the runway. Nothing can replace the feel of how well your patient is ventilating with the bag in your hand. Turn the APL and support in sync if your patient needs support.

I don't even know what the bag feels like anymore. Tube without bagging, distube without bagging.

 

[Radetzky]

With a bunch of the attendings that I've worked with, there's this preference to switch from PSV to the bag when the patient begins to react to the tube or even earlier during emergence with the idea that it's more comfortable for the patient with less bucking. I can't say I've noticed a particular difference since it seems like all of these patients inevitably end up reacting to the tube rather than what mode ventilation is being used. I've seen patients emerge calmly or with considerable coughing/bucking with both strategies with otherwise similar anesthetics. It seems like all I'm doing by switching to the bag is increasing their work of breathing and probably atelectasis which in my opinion would just increase their distress rather than calm them. I understand that in the ICU, doing spontaneous breathing trials on T piece is relatively common and can demonstrate if the patient can tolerate the absence of positive pressure ventilation (e.g. someone at risk for or with a component of pulmonary edema). However, in the perioperative ambulatory setting, is there really any benefit in switching to the bag from PSV on emergence?

T piece trial is what’s written in the textbooks but i extubate 95% of patients in the ICU off of PSV. The exception is those who have been tubed for ages and have other factors making risk of failure high.

No reason to prove that someone can breathe unsupported through a straw in order to prove they can breathe from the atmosphere

 

[vector2]

T piece trial is what’s written in the textbooks

We've known since Girard et al in 2008 that there's no difference between T piece, CPAP, or PSV when doing an SBT of the same duration. And in this 2019 RCT in JAMA 30 min of PSV was superior to 2 hr of T piece. And "There are no differences in the rate of successful extubation between 2-hour PSV and 2-hour T-piece ventilation, between T-piece ventilation for 30 minutes vs 2 hours, or between PSV for 30 minutes vs 2 hours."

Long story short, T piece is mostly a waste of time and does nothing but unnecessarily fatigue the pt.


In the OR I still put pts on the bag before pulling, though.

 

[deleted880510]

do ya'll want the patient to follow commands (open eyes, squeeze hand, etc) prior to pulling out the tube?

 

[anbuitachi]

I don't even know what the bag feels like anymore. Tube without bagging, distube without bagging.

agree

do ya'll want the patient to follow commands (open eyes, squeeze hand, etc) prior to pulling out the tube?

not really. just pull the tube not in stage 2

 

[coffeebythelake]

do ya'll want the patient to follow commands (open eyes, squeeze hand, etc) prior to pulling out the tube?

Not for most cases. I want them breathing spontaneously well and showing some basic signs that would indicate they are not in stage 2.