ETD HKL SPLIT DUO-MECHANICAL VENTILATION

This method of mechanical ventilation is a mitigation strategy to accommodate a sudden large influx of patient’s surge in need to support
mechanical ventilation in disaster incidence and only to be considered as a last resort once all available resources have been exhausted, goals of
care and options for palliation have been discussed with family , and the probability of survival is reasonable if shared ventilation is provided.

Patient Selection
•Similar ABW & lung mechanics (PEEP & FiO2 requirements)
•DO NOT use it for obstructive/ restrictive lungs
•Hemodynamically stable
•Non-respiratory infected patients.

Initial FiO2 and PEEP requirements may be similar, but the

lungs may recover at different rates.

Adjustments of the setting must be tailored to each individual

lungs.

Equipment
•Viral filters and one-way valve connectors to prevent cross
contamination
•ETCO2 monitoring placed in-line-> helps to monitor
ventilation efficacy
•Consider to add inline PEEP valve in patient with different
requirement

Why use pressure mode in multiple patient

Ventilator Setting ventilation using one ventilator?

Parameter Recommended Range Parameter Recommended Range Volume-mode Pressure-mode

Mode CMV/ PCV RR 12-30 per min
ventilation ventilation

TV 6-8ml/kg iTime 0.6-1.0s Guaranteed TV, however Guaranteed limitation of

multiple patients the Ppeak-> control over
IP 30cmH20 FiO2 21-100% provide no control over the maximal airway
the TV of any patient. pressure & the driving P.
PEEP 5-16cmH20 Driving P 5-18cmH20

Increase the ventilator Lack of control over Lack of control over TV

Low volume alarm. Set trigger threshold to Ppeak -> No control on but can be compensated
Alarm based on VTe of the Trigger lock out the ventilator the maximal airway with above lung-
least compliant lung. to prevent triggering of pressure. protective mechanism.
breaths.

Possible deleterious Possible deleterious

interactions between interactions between
Monitoring patients: patients can be avoided.

•Patients must remain sedated +/- paralyzed during shared Example: Example:
ventilation. • Patient 1 has a • Patient 1 has a
•Target pH 7.25-7.45: If one patient is markedly acidemic and kinked ETT-> kinked ETT->
other is alkalemia; treat acidemia with conventional Reduction in TV due Reduction in TV due
ventilator changes while alkalemia by adding dead space to to increase in to increase in airway
ventilator circuit (to induced hypercapnia). airway R. R.
• Patient 2 will • Patient 2 will not be
•Patients cannot be weaned from shared ventilation and must
receive larger TV-> affected.
be transferred to a single ventilator when available.
Risk of volutrauma.

Pearls & Pitfalls

1. Risk of inadequate ventilation: TV will be difficult to track & optimize, while FiO2, RR and I:E ratio cannot be individualized.
2. Risk of hypercapnia-> connections and tubing will increase dead space.
3. Risk of cross contamination.
4. The alarms systems are limited since the ventilator is reading combined VTe thus delaying recognition of events like obstruction of ETT
(hence it is important to carefully set the tidal volume alarm).
5. Requirement for monitoring of patients, which may be difficult given the shortage of staff with ventilation expertise.
6. Prolonged ICU stay and risk of ICU AW– patient’s withdrawal due to high requirements of sedation+ paralytics.

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