WhiteBoard Medicine

Mechanical Ventilation Basics - Waveforms/Scalars (Press, Flow, Volume) + Loops | Clinical Medicine

Ventilator waveforms, also known as scalars, and loops can be tricky topics to grasp. In this video we introduce the pressure, flow, and volume waveforms/scalars. We discuss their normal shapes, including how their shapes may change when the ventilator is in volume control versus pressure control. We correlate different parts of their shapes to what is happening physiologically or on the ventilator. We then go into how these shapes may change with different respiratory changes or ventilator adjustments. After that, we discuss the pressure:volume and flow:volume loops. Again, going into their normal shapes, including the lower and upper inflection points, and how these shapes may change depending on what respiratory abnormality is occurring.
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YouTube Video:
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Mechanical Ventilation Advanced - Auto PEEP, Breath Stacking, Air Trapping | Clinical Medicine

In this podcast we dive into the topic of AutoPEEP, also known as breath stacking or air trapping or intrinsic PEEP as related to mechanical ventilation. Better understand these complex but important concepts!
Mechanism of Auto PEEP
Causes of Auto PEEP
Complications of Auto PEEP
Diagnosis, Management, and Scalars
Auto PEEP occurs when a patient on mechanical ventilation does not have enough time to fully expire their tidal volume before the ventilator gives another breath. This leads to a small amount of tidal volume being retained in the lungs with each breath and over time this builds up creating Auto PEEP. The breaths are "stacking" on top of each out or the air is being "trapped" in the lungs creating intrinsic PEEP! (see what I did there?)
Auto PEEP can occur for a number of reasons. The most common include a high minute ventilation. If you are administering huge tidal volumes or if you have set the respiratory rate quite high, sometimes a patient will not have enough time to fully expire each breath. Lung compliance contributes and more commonly when a patient has high airway resistance, such as with COPD or asthma.
Auto PEEP can cause hypotension as the intrathoracic pressures increases decreasing venous return. It also can cause ventilator induced lung injury, patient ventilator dyssynchrony, and increased dead space ventilation.
It is most formally diagnosed with an expiratory hold maneuver, but you can look at the pressure, flow, and volume scalars to assist in diagnosis. It also tends to cause a high plateau pressure. Manage it by treating the underlying illness, increasing the amount of a time a patient has to expire, and if it gets severe disconnecting the patient from the ventilator.
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YouTube Video:
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CPAP, BPAP, AVAPS - Introduction to Non-Invasive Ventilation Strategies | Clinical Medicine

Non-invasive ventilation strategies are used both at home and in the hospital. In this video we discuss the three most common strategies - CPAP (continuous positive airway pressure), BPAP or BiPAP (bilevel positive airway pressure), and AVAPS (average volume assured pressure support). These strategies can be used for both Type 1 (low oxygen or hypoxemia) and Type 2 (high carbon dioxide or hypercapnia) Respiratory Failure. There are multiple different mask types, including nasal, nasal pillows, and full face mask.
We discuss how each of these strategies works from a physiologic standpoint. We then dive into the different settings and how to adjust/program them, including EPAP, IPAP, FiO2, Tidal Volume, Tmin, Tmax, Respiratory Rate, and more! Lastly, we dive into the different indications, such as obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), heart failure (HF), neuromuscular diseases (NMD), obesity hypoventilation syndromes (OHS), and more. We finish out by discussing the contraindications, both absolute and relative.
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The Brain Eating Parasite And Another Death - Naegleria Fowleri | Public Health

Marburg Virus is now responsible for two recent outbreaks and the CDC put out a statement warning healthcare providers to be on alert. Here, we do a deep dive on Marburg Virus.
New Headlines And Relation To Ebola
Viral Structure And Properties
Marburg Virus Disease, Incubation, Symptoms
Zoonotic Transmission To Humans
Human To Human Transmission And Prevention
Treatment, Vaccines, Previous Outbreaks
Current Outbreaks, Should We Be Worried?
Marburg Virus is from the same viral family as Ebola virus, the Filoviridae. It causes Marburg Virus Disease (MVD), one of the viral hemorrhagic fevers. We discuss the symptoms and incubation period of Marburg Virus. How it is transmitted both between bats and humans, as well as human to human transmission. We touch on prevention strategies and treatment possibilities. And finally we dive into the history of the virus, previous outbreaks, and the current outbreaks. Should we be worried?
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YouTube Video:
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The Brain Eating Parasite And Another Death - Naegleria Fowleri | Public Health

Naegleria fowleri has been labeled the brain eating parasite, and for good reason. With a 97% mortality rate, it unfortunately burrows into the brain digesting brain tissue and causing widespread inflammation.
Naegleria fowleri is a parasitic amoeba found in warm, fresh water. If it enters a human or animal nose, it can burrow into the olfactory nerves traveling to the brain where it causes primary amebic meningoencephalitis.
This is how it got the nickname "brain eating parasite." Although incredibly rare with only 157 cases in the USA since the 1960s, it is almost universally fatal with only 4 known survivors. It has been found on almost every continent worldwide.
Its symptoms are similar to meningitis from other causes including nausea, vomiting, headache, fevers and eventually seizures, confusion, coma, and death. Treatment is with a cocktail of medications and aggressive early management of brain swelling, or cerebral edema.
Amebic Meningoencephalitis, Brain Invasion, Pathophysiology
Florida Case, Total Cases, Geographic Locations, Mortality Rate
Symptoms
Treatment Of Parasite And Brain Swelling
Pictures And Stages
Preventing 
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YouTube Video:
https://www.youtube.com/watch?v=OdrLMKonm8E 

Mechanical Ventilation Advanced - Ventilator Dyssynchrony - Double Triggering | Clinical Medicine

Ventilator dyssynchrony can be a very challenging subject to recognize and manage. In this podcast we try to pull back the veil on one of the types of ventilator dyssynchrony called Double Triggering (Premature Cycling, Breath Stacking, Short Cycling). How to identify it on waveforms/scalars and manage it!
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YouTube Video:
https://www.youtube.com/watch?v=_NKwOVPGrMk 
 

Hyperglycemic Crises Advanced - Comparison of DKA and HHS | Clinical Medicine

Advanced discussion on the differences between Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar States (HHS). Both of these conditions can be life threatening and it is critical we identify and manage them appropriately! They share a large degree of pathophysiology, but also have very distinct differences that we can understand through their distinct pathophysiologic differences.
In this podcast, we will dive into the pathophysiology, symptoms and signs, and management principles side-by-side between DKA and HHS.
Pathophysiology Shared and Distinct Between DKA and HHS
Signs and Symptoms of DKA and HHS
General Management Principles for DKA and HHS
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YouTube Video:
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Shock Basics - Understanding Distributive, Hypovolemic, Cardiogenic, Obstructive | Clinical Medicine

Shock can be a very complex topic. We often break it down into four general shock states - distributive, hypovolemic, cardiogenic, and obstructive. We use a framework that breaks down oxygen delivery and oxygen consumption as a way to better understand the differences in these four shock states and also the ways in which we can treat them.
Introduction to 4 Shock States
Distributive Shock, Causes, Pathophysiology, Compensation, Treatment
Hypovolemic Shock, Causes, Pathophysiology, Compensation, Treatment
Cardiogenic Shock, Causes, Pathophysiology, Compensation, Treatment
Obstructive Shock, Causes, Pathophysiology, Compensation, Treatment
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Shock Basics - Four Main Shock States, Oxygen Delivery, Oxygen Consumption | Clinical Medicine

Understanding shock states, particularly distributive, hypovolemic, cardiogenic, and obstructive, can be quite challenging. In this podcast of our, we talk about shock using the oxygen consumption and oxygen delivery equations to better understand how to differentiate and manage these shock states.
Defining Shock, Tissue Hypoxia
Oxygen Delivery, Cardiac Output, Arterial Oxygen Content
Cardiac Output, Heart Rate, Stroke Volume
Arterial Oxygen Content, Hemoglobin, Oxygen Saturation, Dissolved Oxygen
Stroke Volume, Preload, Contractility, Afterload
Equation for Oxygen Content
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YouTube Video:
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CPAP Basics - How It Works, Types of Masks, Hospital vs Home Settings | Clinical Medicine

CPAP is a type of breathing machine support known as non-invasive positive pressure ventilation. It stands for continuous positive airway pressure. Many patients use CPAP machines at home, especially while they sleep, for conditions such as obstructive sleep apnea, obesity hypoventilation syndrome, COPD, heart failure, and many more. We also use CPAP in the hospital for acute illnesses like COPD and Heart Failure. In this podcast we dive into the following and more!
Uses, Medical Conditions
How It Works, Machine Parts
Types of Masks (Nasal, Full Face, Nasal Pillow)
Home and Hospital Settings (EPAP, FiO2, RR)
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YouTube Video:
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