Explore every episode of the podcast The Peak Inspiration Podcast

🫁 MAKE THE DRIVING PRESSURE < 15

We all hear it: “Keep driving pressure <15.”

Cool… HOW?

There’s no driving pressure button on the ventilator.

In this webinar, we break down the physiology and the practical bedside approach to actually lowering driving pressure—using tidal volume, PEEP, recruitment, compliance, ventilator modes, and waveform interpretation.

The goal isn’t just to memorize DP <15. It’s to understand WHY the driving pressure is high and what you can actually do about it.

🎥 Full webinar + slides available on Patreon:

Patreon.com/cw/Pulmtoilet

Click the link for your specialty to sign up and get a free month!!!!!

Attending

CRNA

APPs/PharmD/Rehab Services

RTs/RNs/Medics/Flight

All Trainees and First Responders

Critical access healthcare workers

I go over 4 waveforms sent to me from followers! They quite bad so take a listen and let me know what you think!

Only 2/4 are here-- go to my patreon (@pulmtoilet) for the full 4 waveforms and the accompanying PDF to download and annoate along!

https://www.patreon.com/Pulmtoilet/posts/waveform-video-2-167832507?utm_medium=clipboard_copy&utm_source=copyLink&utm_campaign=postshare_creator&utm_content=join_link

Bridging the Gap in Critical Care Education

In this episode, I sit down with Karen Battistoni, a CVICU educator from the Texas Medical Center, to discuss one of the biggest challenges in critical care: the gap between classroom education and bedside practice.

We explore why many clinicians feel underprepared for complex ICU patients, how social media has become a powerful educational tool, and why teaching practical physiology matters. Karen also shares her perspective on fast-track cardiac surgery protocols, emphasizing that patient assessment and clinical judgment should always come before rigid protocol adherence.

Finally, we discuss the importance of collaboration between nurses, respiratory therapists, and physicians, and how shared decision-making leads to better patient outcomes.

Key takeaways:

• Practical education is essential for building ICU confidence.

• Protocols should support—not replace—clinical judgment.

• Teamwork is critical for delivering high-quality patient care.

Whether you're a nurse, RT, APP, resident, fellow, or attending, this conversation offers practical insights you can apply at the bedside.

In this episode, I break down the same framework I teach in my Ventilator Dyssynchrony Bootcamp.

Rather than memorizing a long list of named dyssynchronies, I focus on understanding what a normal breath should look like first.

From there, we compare expectation to reality and systematically work through each phase of the breath—trigger, flow, cycle, and expiration—to identify where the patient and ventilator have fallen out of sync.

This approach helps make waveform interpretation more intuitive, more reproducible, and ultimately more useful at the bedside for anyone caring for mechanically ventilated patients!

A clip of my webinar that I did on PRVC and why adaptive modes are generally bad in the ICU.

Want full webinar? Email ME!

pulmcritnick@gmail.com

Running back my talk from ResusX about ventilating severe acidosis!

I try to approach this from a pragmatic perspective! Nothing will work great so just do the least bad thing!!

We all know SIMV sucks, but what exactly is the difference between SIMV and AC?

My thoughts on a waveform question from April 17 on my Instagram @pulmtoilet !!!

Go check it out !

In this episode of Peak Inspiration, we’re bringing you a high-yield excerpt from the Pressure Control Part 2 webinar, focused on one of the most practical skills in mechanical ventilation—recognizing abnormal waveforms.

We break down how to interpret pressure, flow, and volume waveforms through the lens of the equation of motion, helping you pinpoint whether the issue lies in resistance, compliance, or patient effort. Instead of memorizing patterns, this episode teaches you how to think through the waveform so you can quickly identify what’s wrong at the bedside.

If you’ve ever looked at a ventilator and felt like something was off but couldn’t quite explain why, this episode will sharpen that instinct and give you a framework you can apply immediately.

When the ventilator triggers a breath the patient didn't ask for, something has gone wrong. In this episode we dig into autotrigger: why it happens, how to spot it at the bedside, and the cascade of harm it can set off when it goes unrecognized.

Then we turn to one of the most underused numbers on the ventilator screen: the airway occlusion pressure (P0.1). This 100-millisecond window into the respiratory drive tells you things that tidal volume and respiratory rate simply can't — how hard the brainstem is working before flow has even begun. We break down the physiology behind it, walk through how to measure and interpret it, and explore how P0.1 can serve as both a trigger-sensitivity troubleshooting tool and a real-time gauge of patient effort and diaphragm load.

Along the way we tackle practical questions: what P0.1 thresholds should raise concern, how autotrigger and elevated drive interact with patient-ventilator asynchrony, and when you should let the number change your clinical decisions. Whether you're a fellow just getting comfortable with modes and waveforms or an experienced intensivist looking for a sharper framework, this episode gives you a cleaner mental model for one of ventilation's trickier corners.

Intro to mechanical ventilation is out now.

This is a true starting point. No fluff, no overcomplication just the fundamentals you actually need when you’re at the bedside making decisions.

We break down
What each ventilator setting actually does
How to choose initial settings without guessing
Volume vs pressure modes in a way that finally clicks
How to recognize when things are going wrong early

You can find the full episode for FREE on YouTube, Spotify, and Apple Podcasts

Search “The Peak Inspiration” or find it through @pulmtoilet

If you watch or listen, I’d genuinely like to hear what you think.
What made sense, what didn’t, and what you want covered next.

Sepsis care keeps evolving but not always in ways that feel clean or universally agreed upon.

In this episode, I break down the latest Surviving Sepsis Campaign guidelines what actually changed, what didn’t, and what matters at the bedside when the patient in front of you is crashing.

We focus on two of the most debated areas right now:

• Prehospital antibiotics: Are we truly helping patients or just moving the needle earlier without improving outcomes
• Blood cultures before antibiotics: Dogma vs reality when time, access, and patient stability are working against you

This isn’t a guideline summary. It’s a practical discussion about where the evidence is strong, where it’s weak, and where clinicians are still forced to make judgment calls in real time.

If you’ve ever wondered whether you’re practicing evidence-based medicine or just following momentum, this episode is for you.

My approach to ventilating severe metabolic acidosis! Often needing to balance harm of the acidosis with harm of the ventilator and creating a balance of these 2 forces while we fix the underlying pathophysiology!

Spontaneous Breathing Trials aren’t just a checkbox before extubation.

They’re one of the most nuanced and most misunderstood checklists in critical care.

In this episode, we unpack why SBTs are not simply “pass or fail.”

A patient can “pass” the numbers and still fail at the bedside. They can “fail” and still be extubatable.

We dive into:

• Why the RSBI isn’t about extubatability
• How anxiety, pain, sedation washout, and cardiac function distort the data
• The hidden hemodynamics of liberation
• Why diaphragm performance matters more than a single respiratory rate
• And how over-reliance on protocol can blind us to physiology

Because at the end of the day, extubation is not decided by a spreadsheet. It’s decided at the bedside.

By watching the patient. By reading subtle cues. By integrating ventilator data with work of breathing, mental status, secretion burden, airway protection, and trajectory.

SBTs are a test of physiology — but they’re also a test of clinical judgment.

Dont fall into the trap of : "better luck tomorrow"

#floatingventguy

IG: @pulmtoilet

If your PEEP strategy is:
“ARDSnet table + hope for the best”
…it’s time for an upgrade.
This webinar walks through how to personalize PEEP in ARDS using compliance, stress index, PV curves, and bedside clues you can use on your next shift.

#floatingventguy

Podcast I did with Escola de Intensiva about vent management in the obese ARDS patient and COPD!

First 45 min of the PC webinar!!!

Response to a reel that Kali Dayton posted about a nurse who is burned out in the ICU due to poor A-F bundle implementation.

TLDR: We need to do better

Triggering the ventilator is how the ventilator knows to go from expiration to inspiration.

Theres a few ways we can trigger the breath and some dssynchronies associated with it.

In this episode, I go over these concepts!

Positive Pressure & the Failing Heart 

Positive pressure ventilation is one of the most powerful tools we use at the bedside.

In this episode, I sit down with critical care cardiologist Willard Appelfeld, MD to unpack how positive pressure ventilation interacts with the failing heart. We break down preload, afterload, venous return, RV–LV interactions, and why CPAP, BiPAP, and invasive ventilation can dramatically improve patients with acute decompensated heart failure.

We move beyond dogma and into physiology—connecting ventilator settings to pulmonary edema. If you’ve ever wondered why positive NIPPV settings to flash pulmonary edema and how PPV affects the RV and LV.

 Cardiac mechanics Positive pressure as therapy Real ICU decision-making

When we are aiming for a lung protective strategy, it's important to note what exactly we mean when we say lung protective. Its also important that we follow the ventilator waveforms to ensure we are protecting the lungs with the settings we provide. You can call a vent strategy lung protective… but the alveoli will be the judge. We dive into the importance of reading waveforms and being able to spot if we are violating our goals.

This is a small sample of the APRV webinar I did on December 9th !

Reach out to me on Instagram, @pulmtoilet, or pulmcritnick@gmail.com for more information !!

Whether you're a seasoned intensivist or just beginning to decode ventilator waveforms, this case-driven episode will give you the confidence to recognize and reverse auto-PEEP before it snowballs into hemodynamic collapse????

Ashley and I go over some ventilator questions that were sent in by you ! We take a deeper look into some settings, what about the managment of the ventilator is most challenging, and how we can all work better together to deliver the best patient care in the setting of invasive mechanical ventilation !

Ever stared at a ventilator screen and felt like it was speaking another language? You’re not alone. In this episode of The Peak Inspiration, we break down the mystery behind every number, waveform, and alarm flashing on that monitor.

We’ll cover what each parameter means, how to find what you need to report on rounds or to an attendings, and a little known secret of the alarms that is often overlooked!!!

In this episode, we go over the fundamentals of autopeep starting with the basics including the mathematical fundamentals that underpin this concept

We start off The Peak Inspiration Podcast with "how do we breath".

A quick primer on negative pressure breathing, which is where we will build to positive pressure breathing and the mechanical ventilator!