Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Mechanical ventilation is a life-saving intervention for respiratory failure and constitutes a cornerstone of the therapeutic toolkit we utilize in critical care medicine today.
Speaker: Over the years, as technology evolves, the number of mechanical ventilation modes and ventilator capabilities has grown at a staggering rate.
Speaker: The question is, are you leveraging technology to its fullest capacity to provide optimal mechanical ventilation support to your patients?
Speaker: I would probably think that the answer is perhaps not so much.
Speaker: Today, we will discuss a more rational approach to mechanical ventilation, helping clinicians better understand and apply the ever-growing complexity of ventilators at the bedside.
Speaker: Our guest is Dr. Eduardo Mireles Cabo de Vila, director of the Medical Intensive Care Unit and the Simulation and Advanced Skills Center at the Cleveland Clinic.
Speaker: In addition, Dr. Moreles Cabo de Vila is the vice chair of the Division of Critical Care Medicine in the Department of Pulmonary and Critical Care Medicine in the Integrated Hospital Care Institute at the Cleveland Clinic.
Speaker: An accomplished clinician, educator, and researcher who had a tremendous focus and passion for mechanical ventilation.
Speaker: Eduardo, welcome back to Critical Matters.
Speaker: Thank you, Sergio.
Speaker: Thank you for the invitation.
Speaker: Very happy to be here.
Speaker: And I love this topic, Eduardo, because it's something that is part of our daily world in the ICU.
Speaker: Yet when you start peeling the layers of the onion, there's so much we could do better and so much that we need to learn that sometimes I think that we're not really aware of all these complexities.
Speaker: and just talk about ventilators the same way we talked about them when we were in training.
Speaker: So I'm really excited to talk with you about this and try to maybe provide our listeners with a better view of how to provide goal-directed mechanical ventilation.
Speaker: So my first question to you is, why should intensivists and APPs in the ICU care about the topic of goal-directed mechanical ventilations?
Speaker: Thank you, Sergio.
Speaker: This is probably the most important part of why would we care about changing our practice and doing this?
Speaker: The first one is that this is what defines us as intensivists, the type of technology that we use for years.
Speaker: Being on the mechanical ventilator is what equates to us in the ICU.
Speaker: And putting a patient on the mechanical ventilator has multiple implications in their life.
Speaker: The way that you optimize and adjust the ventilator for these patients has bearings on their outcomes.
Speaker: And we have seen this through the literature, the landmark paper of just turning down the knob and decreasing the tidal volume had an effect on the survival of these patients.
Speaker: So I think that the act of us optimizing that interaction with the ventilator in terms of decreasing sedation, making the patient being able to move and to be interactive with the family is key.
Speaker: But at the same time, how to maintain and keep their lives through the process and make it the best interaction possible.
Speaker: So all of these things, one, it defines us as clinicians is part of what the critical care intensive is most dominate.
Speaker: And number two, it definitely affects the outcomes of our patients.
Speaker: Perfect.
Speaker: And one of the conversations that we were having before we started recording was on technology and its application at the bedside.
Speaker: And I know that this is an area that within this topic has been of great interest for you and you've done a lot of work.
Speaker: But before we dive into a little bit more details,
Speaker: Could you give us kind of a historical maybe perspective of where we started with ventilators?
Speaker: Initially, there was only a couple of modes available and where we are today in terms of the complexity of this technology landscape.
Speaker: Absolutely.
Speaker: So if you think back not that far in time, and we go to the 1970s,
Speaker: and you grab the first book of respiratory therapy equipment, you'll see that there are three modes only described on that book.
Speaker: Just three modes of mechanical ventilation.
Speaker: Assist, control, and assist control.
Speaker: That's what it had been described.
Speaker: There were a large amount of brands and manufacturers, but only three modes.
Speaker: From there, decade by decade, with the advent of obviously advances in technology, but also the integration of computers into the mechanical ventilator, the number of modes has exploded.
Speaker: We have a database that helps us put all the modes that we have available by the FDA approved in the U.S. And the last count that we did for all those modes was 795.
Speaker: And so just to put it into context, when I came in to do my fellowship,
Speaker: the ventilator that I was using was a Puritan Bennett 7200 and that ventilator had, what, five modes?
Speaker: By the time that I finished in 2008, the ventilator that I was using was another Puritan Bennett at that time and it had now 14 modes.
Speaker: So in just a number of years, the availability for me to use more modes was there.
Speaker: Now the last ventilator that we analyzed, now that we do courses around the country, many institutions have these types of ventilators.
Speaker: One of them has 72 modes of mechanical ventilation.
Speaker: So the complexity and the availability of features on the ventilators has just exploded because we have the ability.
Speaker: And that's what made it so complex.
Speaker: And so we have a lot of technological features to help our patients, too many modes, and we don't know what each one of them does.
Speaker: And I think that the first step, I mean, in your journey of trying to really get to a more...
Speaker: efficient and optimal use of the available technology for our patients in this area was to start creating a taxonomy or a ventology, right?
Speaker: Can you maybe explain first what this is in general terms, maybe using in the example of drugs that we use in the ICU or drugs that we use in medicine?
Speaker: Absolutely.
Speaker: So, I mean, the seminal work started in the 1990s with work by my mentor and partner, Rob Chatburn, who started describing how a mechanical ventilator, a mode, existed and what were the parts of a mode of mechanical ventilation.
Speaker: And from there, the evolution was to start trying to say, well, what actually does each mode has?
Speaker: What does it do?
Speaker: And this created, evolved in 2012, a paper that essentially just summarizes all the work on the taxonomy, talking about three characteristics that every mode has.
Speaker: And that helps us explain how the technology acts and what it would do on a patient and in the respiratory system.
Speaker: So this was essential.
Speaker: for us to understand what was the universe, what was out there and what do the ventilators do.
Speaker: But let me take a step back and think a little bit on an analogy that makes sense to understand what we have to do with the ventilators, which is with medications.
Speaker: If you go out right now to any of the pharmacy and in the over-the-counter section, you will find that when you want the medication for pain,
Speaker: or for a headache, you will find several brands out there with commercial names, each one better than the other, Headaches Away or Maximum Strength Headache Prevention or whatnot.
Speaker: But we know that when you read the label and that attracts you to the medication, that you can see always what are actually the components, the medications that are inside that medication.
Speaker: So you could grab three of those medications for pain and actually see what the ingredients are.
Speaker: And you would realize that some of them would have three medications.
Speaker: So it could have acetaminophen, aspirin, caffeine.
Speaker: Another one could have just two.
Speaker: So acetaminophen and caffeine.
Speaker: Another one is mainly only acetaminophen.
Speaker: So even though they have very fancy names, we have a method, a mechanism with generic names of knowing exactly what each one of those headache medications have.
Speaker: And this is actually the way that we practice in the majority of the hospitals.
Speaker: Imagine the complexity of trying to put just the commercial names for the medications that we're giving in each one of our patients.
Speaker: It becomes very hard.
Speaker: So our medical records and the way that we document use the generic names for each one of these.
Speaker: So you need to have a way to classify all these commercial names that are out there
Speaker: with a system that all of us understand.
Speaker: And that's something that was lacking and it continues to lack.
Speaker: Actually, if you grab a ventilator, you will not see the generic name.
Speaker: You would see only the commercial name.
Speaker: And that generates confusion amongst the user because the names, the commercial names don't mean exactly what the ventilator is going to do.
Speaker: So that's the first part.
Speaker: The second part that you need to put here is understanding how the mechanical ventilators work.
Speaker: So one of the items when we think about the taxonomy is that if you think about words that we use or interactions that we describe with the ventilator, we usually use
Speaker: What I say that it's a mandatory breath or a spontaneous breath may be something different for you or for your listeners.
Speaker: When I say spontaneous breath, you may think about the breath that is triggered by the patient, even though it's cycled by the ventilator.
Speaker: So we need to standardize that nomenclature and create some rules around what we mean when we say things so that then we know what the technology is doing and we can use that to classify the modes.
Speaker: And this is similar to when you are talking about the drug, about what a caplet or a tablet does or a liquid form does.
Speaker: I mean, these are very standardized design words of what each one does.
Speaker: And the final part of this, what we call ventology or understanding what the ventilator does is to have a standard in taxonomy and nomenclature of how those interactions happen between the patient
Speaker: and the ventilator.
Speaker: Similarly, when I give a medication to a patient that you have to know the pharmacokinetics and pharmacodynamics, the same way we have to have a standard way of describing those interactions between the patient and the ventilator.
Speaker: All of these we do actually today, but we do it with different words.
Speaker: And so when I grab an article today and I try to compare it to another article, you will say that you use this mode.
Speaker: And the way that you describe volume control may have not been volume control because you're using the commercial name.
Speaker: You may refer to the interaction with the ventilator as a filter.
Speaker: false trigger or as a mis-trigger.
Speaker: And those words, as you're trying to come to terms, are very confusing for all the people.
Speaker: So we need to standardize.
Speaker: So that's the basis for this work, Sergio.
Speaker: Excellent.
Speaker: So basically, really what you've worked on, and we'll talk a little bit about it, is not only a taxonomy of modes, which is basically trying to accomplish what we accomplish with generic names and medications, right?
Speaker: A more unified and descriptive name that actually, if I use a taxonomy and I describe something, everybody should understand what that really means, and we're all talking about the same thing.
Speaker: And the other thing that you mentioned, which I think is also important, and maybe that's a discussion for another day, Eduardo, is that when we talk about patient ventilator asynchrony, we might be describing different problems with different words, and that you've also created a taxonomy
Speaker: or a language that can describe those patient-ventilator interactions in a better way in terms of making sure that we are reporting on the same things, that we're treating the same things.
Speaker: And that also, I think, helps, I mean, bring some clarity to this complexity.
Speaker: So let's dive a little bit into the taxonomy of mechanical ventilation modes, what you call ventology.
Speaker: What are the basic components of all mechanical ventilation modes?
Speaker: Where do we start?
Speaker: So it's actually relatively simple.
Speaker: All of them have three components and sometimes when we see these you may see the complexity rather than the simplicity.
Speaker: And the simplicity is that in terms of control variable, control variable is how we control inspiration during mechanical ventilation.
Speaker: And we use the equation of motion to define this, and that's actually how the ventilators work.
Speaker: And you can only control either the pressure or the volume.
Speaker: You cannot control both at the same time.
Speaker: And so because of that, you can only have either pressure control or volume control as what you're controlling during inspiration.
Speaker: So that's the first component.
Speaker: The second component is the breadth sequence.
Speaker: And the breath sequence, this is where the definition of what's a mandatory and a spontaneous breath stand.
Speaker: And a mandatory breath is when you control either the trigger or the cycle of the breath.
Speaker: If any of those are controlled, that's a mandatory breath.
Speaker: And then if it's a spontaneous breath, then the patient determines
Speaker: the trigger and the cycle or the characteristics of the respiratory system determine the cycle.
Speaker: And so there can be just those two types of breaths.
Speaker: And so if you think about that, if all your breaths are mandatory, then that's continuous mandatory ventilation.
Speaker: that's the sequence.
Speaker: If all of them are spontaneous, then it's continuous spontaneous ventilation.
Speaker: And then if there's a mix of both in which there's mandatory and the spontaneous, that's called IMB or intermittent mandatory ventilation.
Speaker: So there's only those three bread sequences.
Speaker: It's important to highlight that actually within these bread sequences, an area that we talk now a fair amount about is the IMB.
Speaker: And IMB,
Speaker: has also evolved through time, such that the studies that came decades ago about the interaction of how to wean patients and how to use IMB used the primordial type of IMB, which is type 1, in which essentially you set a mandatory rate and the ventilator will deliver it regardless of what the patient is doing.
Speaker: There's a type 2 that we've described, which is essentially whenever the patient starts breathing spontaneously, the mandatory is shut off.
Speaker: And there's a third in which the mandatory breaths will continue mixed with the spontaneous until you reach a minimum minute ventilation that you have set.
Speaker: And the fourth one is an odd one in which it just happens in certain modes when there's a very high respiratory drive, the mode changes from mandatory to spontaneous.
Speaker: And so those are the breadth sequences.
Speaker: And you can see as I talk about this how there's some technological developments that now you as a clinician can start thinking, oh, that may be good for this patient or this may be good for this type of patient that you could be applying.
Speaker: And the last component, which is the targeting scheme, and targeting scheme is the engineering term for essentially the programming that we put on the computer on the ventilator.
Speaker: And we have described seven targeting schemes, which go from very basic, and the most basic is you setting all the parameters.
Speaker: So you say, how much is the tidal volume, how long is it going to last, the inspiration and the rate and whatnot.
Speaker: to the most automation, which is using tools of artificial intelligence, we call that intelligent targeting, in which you essentially have programmed
Speaker: the ventilator with rules.
Speaker: And those rules may be to protect the lung or to wean the patient or to react to hypoxemia or to hypoventilation.
Speaker: And the ventilator then adjusts the settings to achieve the goal.
Speaker: So if you mix these three components,
Speaker: you're going to end up with a mode of mechanical ventilation.
Speaker: And to summarize all of this that we said, we use the TAG.
Speaker: The TAG stands for Taxonomic Attribution Group, but essentially it's a TAG.
Speaker: It's kind of cute that it matches what a TAG would be on clothing, but essentially it's five letters.
Speaker: that you have together that tells you what the mode does.
Speaker: And rapidly you can identify that.
Speaker: So you can be on PC, CSV, S, and now you know it's pressure control, all the breaths are spontaneous, and it's a set point targeting.
Speaker: So that's how we created this tag that helps us classify all those modes that we have now identified as available out there.
Speaker: And I think that I want to just clarify a couple of things.
Speaker: Obviously, this is a fascinating discussion, Eduardo, but just to make sure that all our listeners are on the same page, when we talk about triggering, we're talking about what initiates the breath, right, the inspiration, and cycling is what ends that inspiration and starts expiration.
Speaker: So I think that is important.
Speaker: And also, I wanted to...
Speaker: to ask you the whole idea then if you use the tags I would imagine that we really don't have 700 plus modes of mechanical ventilation is that correct that's absolutely right actually it's very impressive how you can then reduce the number of modes that you have and so when we
Speaker: We tagged all these modes.
Speaker: It went down from... One thing that we realized is that there's modes that have the same name and have different tags.
Speaker: So you may have a volume control that you think is volume control, but those other things.
Speaker: So that's on the side.
Speaker: But we went down from 795 to 500 modes, 540 modes.
Speaker: commercial names.
Speaker: And then when we use the tags, we can bring them down to 46 tags, which is much more manageable than trying to know 795.
Speaker: So yeah, 46 tags to describe all those modes that are available right now.
Speaker: Perfect.
Speaker: And the last question I have in terms of taxonomy is, are there any particular lessons that you have learned through this journey and process of organizing modes via tags?
Speaker: Yes.
Speaker: So I'll give you three of my favorite ones.
Speaker: The first one is commercial names are meaningless.
Speaker: I'm sorry about that, some of them sound really cool and I like, and I mentioned them, but I'll give you an example.
Speaker: And again, this is,
Speaker: I have nothing against any manufacturer of ventilators or any mode in particular, but one of the names that is meaningless is, for example, pressure-regulated volume control.
Speaker: This causes a lot of confusion in our learners because they think that they are controlling volume because the title of the mode is volume control when actually what you're controlling is pressure.
Speaker: So that's one of the insights.
Speaker: The second one is
Speaker: And this becomes more evident if your hospital is similar to mine, in which I don't have only one platform of ventilators.
Speaker: I have several, and you may be changing a patient from one ventilator to another through their journey on the hospital, or simply you are implementing a protocol
Speaker: and you want to use a particular mode, you will realize that they may have the same commercial name but different tag.
Speaker: And one of those is volume control.
Speaker: So here, in my practice, the tag could go volume control CMBS.
Speaker: to volume control IMB4DD, to volume control CMBD.
Speaker: So I know I said a lot of words, but these are three different tags.
Speaker: That means that the ventilator will react differently to the patient interaction because it's not what you think that it is with the classic volume control as we refer, which would be volume control CMB, continuous mandatory ventilation set point.
Speaker: And the last one is when we start organizing all these modes and the technology that is available and we were able to see the universe, is that we realized that there were some modes that make no sense.
Speaker: And I'll give you, this happens because we have technology and they give us options.
Speaker: And now you have in your ventilator a button that you can press.
Speaker: And when you press it, it changes what the mode does.
Speaker: And so one of those examples is if you have somebody on volume control, CMBS, and you press a button that's called adaptive tube compensation, that's a, I mean, I'm not gonna get into the details about adaptive tube compensation, but that has a very specific indication.
Speaker: And when you mix it with volume control, it loses all logic.
Speaker: So the mode exists, but it doesn't have an application currently for what we would use it.
Speaker: That's the beauty about being able to classify modes and understand what's the universe and what you have available at your bedside, and then you know what you can use and how you should use it.
Speaker: And I think that the taxonomy obviously has a descriptive value because by applying the appropriate tag, I think the clinician has a much better understanding of what the mode actually is meant to do and what are the variables that you have to control.
Speaker: But also, like you said, Eduardo, it's trying to organize complexity into a more manageable and effective way of making a difference for our patients.
Speaker: So before we go on and talk about the goals of mechanical ventilation, which is, I think, what is most important for clinicians to start with, could you tell us how do we compare modes?
Speaker: What are the ways that we can actually compare these modes?
Speaker: And I love when people say something like X mode is better for ARDS.
Speaker: Based on what?
Speaker: Yeah, and that has been...
Speaker: one of the challenges, so your insight is key here, is how do you stand in front of a patient and say, which mode is gonna be better for this patient?
Speaker: And the ability to do this has to come from understanding what the mode does and what you're trying to achieve for the patient.
Speaker: So if we take a step back, when you are in front of a patient, for example, with the ARDS,
Speaker: you're trying to achieve certain features with the mode.
Speaker: And those come from your clinical goals.
Speaker: And so you may come to the bedside and say, I want to protect the lung, and so I want to achieve this amount of tidal volume, and I want to achieve this rate and this minute ventilation.
Speaker: And you will program it in the ventilator, and if the patient is passive,
Speaker: you're going to compare one mode versus the other, and they're probably going to do exactly about the same if you put the same variables.
Speaker: There may be some changes in the amount of flow and whatnot, but it's going to be, you're going to have to determine what your outcome is that you're trying to look.
Speaker: And it has to make sense with the goal that you are trying to achieve.
Speaker: So the goal of trying to say, well, this mode is better than other, may be at a very discreet level, which is, for example, achieving oxygenation or achieving higher mean airway pressure.
Speaker: But in terms of longer outcomes, it's going to be very hard.
Speaker: And I'll speak more about that when we talk about the goals of mechanical ventilation, or perhaps this is the time to do it, which is, if you think about this, you don't ventilate a patient.
Speaker: You don't ventilate a patient
Speaker: all the time on the same mode.
Speaker: You change from one mode to another mode to another mode.
Speaker: So trying to ascertain that one mode is going to be better in all the patient outcomes when you have contaminated with different interactions with other ventilators, and there's so many other interactions that will come, sedation, medication, timing of
Speaker: fluids, de-resuscitation, it's going to be very hard to come to identify that the mode was actually the one that changed the outcome of the patient just because of all those confounders.
Speaker: And the fact that we changed so much from mode to mode.
Speaker: The second is that sometimes, because we don't know actually what the mode does, we end up comparing modes that have technological features for comfort with modes that have technological features for safety.
Speaker: And that is also kind of an unfair comparison, because one will be better for synchrony and work of breathing, the other one will be better for
Speaker: safety in terms of maintaining gas exchange or mineral pressure or protecting the lung.
Speaker: So that's why I think that trying to say that a mode is better from clinical evidence is going to be very difficult.
Speaker: So what is left for us is to take a step back and compare the modes about how they achieve their goals
Speaker: how they achieve goals of mechanical ventilation based on their technological features.
Speaker: So if you ask me, Eduardo, what's the best mode for a patient that is paralyzed in which I want to control everything on the patient, I want to have absolute control, I would say, well, the mode for that is volume control because you have absolutely control on all of this or pressure control.
Speaker: You can control everything.
Speaker: At the same time, you could say, well, what mode would be the best for safety in general?
Speaker: And then you would go back and look at features on the ventilator that achieve that.
Speaker: And you could say, well, this mode has automatic features that can protect the lung.
Speaker: For example, I have programmed it so that it never gives tidal volumes above this number.
Speaker: or that if the pressure goes above this number, we get concerned, or to prevent auto PIP, or to prevent hypoventilation.
Speaker: And that would be actually a feature that you would like for that mode.
Speaker: So I think that as we start understanding and classifying the modes better,
Speaker: you can see the technological features that each mode has, and that's how we compare them to say this mode serves that goal of mechanical ventilation better than others.
Speaker: I hope that framed it well, Sergio.
Speaker: No, I definitely think that that's a good framework, and we can dive a little bit more into the goals of mechanical ventilation.
Speaker: And you did talk about them, but just to make sure that everybody is very clear, the way I'm interpreting this, Eduardo, is that really we start at the bedside as clinicians with defining what is my goal of mechanical ventilation for this individual patient.
Speaker: And once we identify that goal, we can then try to fit the
Speaker: the best available mode based on our theoretical and performance data, right, for that mode into achieving that goal.
Speaker: And that really is the way that we should think about this.
Speaker: And what it would ultimately lend to is two things that I think are very powerful.
Speaker: One is the recognition that a single patient with a diagnosis of ARDS will have different goals through their hospital stay.
Speaker: And the second is that two different patients in the ICU with different disease process would also have different goals.
Speaker: Is that correct?
Speaker: Absolutely.
Speaker: And, and, and that's, that's actually the, the perfect segue to understand the goals of mechanical ventilation.
Speaker: And we have divided them into three.
Speaker: So it's either your goal is safety, your goal is comfort, or your goal is liberation.
Speaker: And, uh,
Speaker: As you think about safety, the clinical objectives of safety is to maintain gas exchange and to prevent ventilator-induced lung injury.
Speaker: So when I'm thinking about my goal for this patient today is safety, that's what I have in mind.
Speaker: The classic patient for that is a patient that I just intubated, a patient on day one of ARDS that is flaring, that all the inflammatory markers are out there, the gas exchange is terrible.
Speaker: My goal there is to maintain gas exchange and prevent lung injury.
Speaker: The second goal is comfort.
Speaker: And when you think about comfort, you're thinking about synchrony, meaning that the patient and the ventilator start and end the breath at the same time.
Speaker: And I think about work of breathing.
Speaker: And the work of breathing has to do with what your goal is and having a balanced work of breathing.
Speaker: As you can imagine, the ventilator can give you a lot of support, medium support or no support at all.
Speaker: And you want to have a match of what you're trying to achieve for the patient and a balanced work of breathing, that they get enough that you think that it's clinically appropriate.
Speaker: So that's when I think of comfort, the types of patient is a patient that I'm waking up from mechanical ventilation, a patient that is not ready to be extubated, but it's awake and interactive.
Speaker: That's a patient that I want to have the goal of comfort.
Speaker: And then there's the goal of liberation.
Speaker: And the goal of liberation has a kind of a bimoral phase.
Speaker: The first one is we always, when I think about liberation, is these patients that have gone through
Speaker: in the ICU in which you have not been able to liberate.
Speaker: They have either a difficult wean or a prolonged weaning
Speaker: And you want technology that essentially would minimize the length of mechanical ventilation.
Speaker: And the optimal there would be things that make the patient start regaining spontaneous breathing and to test them for spontaneous breathing.
Speaker: And the perfect would be that it would advise you, hey, I'm ready to, this patient is ready to breathe unassisted.
Speaker: This doesn't take away the protocolization that we need to have for spontaneous breathing trials.
Speaker: And as you well know, Sergio, there's patients that we intubate because they had flare, they are in ARDS.
Speaker: The next day you come, you wake them up, the gas exchange has improved, they're ready to come off.
Speaker: you do a spontaneous breathing trial, even though your goal is still safety and you still have gas exchange issues, they pass the SBT, you as a clinician will decide if you want to extubate the patient or not, and it may be that they go just straight to high flow nasal cannula or whatever you want.
Speaker: And so it doesn't take away that we do a spontaneous breathing trial intermittently throughout this, but there's patients in which the goal, the predominant goal becomes liberation.
Speaker: And so
Speaker: As we think about these three goals, I have to emphasize that at any given time, you have to have just one of those as a main goal.
Speaker: You can have secondary, but you cannot have the three of them.
Speaker: You have to think, when you change your mind from thinking, oh, I want the three things at the same time, it makes it easier for you to select what you're going to do for the patient.
Speaker: So I have patients that have ARDS, they are day three, they are on 40% FiO2, but they are still, they did not pass their SBT.
Speaker: For those patients, my number one goal becomes comfort, but secondarily to that is safety.
Speaker: So that doesn't mean that I'm going to let them breathe at 10, 15 cc per kilo, but
Speaker: If it's not appropriate, I would say, okay, let's use a mode that will help me maintain the tidal volume where I want it, but allow the patient to breathe unassisted.
Speaker: And that may be volume support.
Speaker: And so the patient triggers and cycles the breath, and the machine will adapt and give the tidal volume that we set as a target for them.
Speaker: So that's how we think about these goals to select then the mode of mechanical ventilation.
Speaker: So in summary, really, I mean, three things to focus on, which are safety, comfort, and liberation, and trying to identify where in their journey is the patient.
Speaker: And it doesn't mean that you're not attending to other things, but there can only be one priority, right?
Speaker: This is the priority, which means I'm going to choose the mode in order to achieve this particular goal the best.
Speaker: Is that the way to think about it?
Speaker: Yeah, absolutely.
Speaker: And the, I mean, I'll, I'll,
Speaker: This actually helps at the bedside into making decisions for what you're doing for the patient.
Speaker: This is a common item that I find as we go to the bedside.
Speaker: And I'll give you an example of our classic ARDS patient.
Speaker: Day one, you intubate them.
Speaker: The goal is safety.
Speaker: So the selection of the mode at that time are modes that are going to be focusing on maintaining gas exchange and where we can
Speaker: have settings that will be lung safe, lung protective, right?
Speaker: But the next day, as the patient is waking up, it's now time for doing SAT.
Speaker: And let's say that your practice uses volume control.
Speaker: And we all that have practice in an ICU, now you have a patient that is going to go, that is going to be woken up.
Speaker: You're going to stop sedation and...
Speaker: As the patient wakes up, the respiratory drive stops being numbed by those medications.
Speaker: The patient becomes aware, starts breathing.
Speaker: And I'm sure all you and all your listeners have seen patients that they wake up when they're in volume control.
Speaker: And the interaction with the ventilator, although sometimes it's decent, many times leads to double trigger.
Speaker: It leads to severe interactions with the ventilator where there's a lot of work shifting and the patient is fighting the ventilator.
Speaker: And that may have...
Speaker: consequences on the care of the patient, depending on the practice where you are.
Speaker: And it may be that the immediate reaction from nursing, based on the way that your protocol is designed, is to sedate that patient again.
Speaker: And so a patient that could potentially have been breathing on their own, they failed because they started fighting the ventilator, they became tachycardic, hypertensive, they went sedated again.
Speaker: So at that moment, when I'm doing an SAT, my goal for that patient has changed.
Speaker: And I'm going to change to a goal that is now going to be still safety, but I'm going to put in the secondary comfort.
Speaker: And that means that I'm gonna choose a mode that will allow the patient to have more freedom as they are waking up.
Speaker: And that means that you choose a mode now that will have the ability to free the flow or that will allow the patient to switch from a mandatory mode to spontaneous automatically without having to have the RT at the bedside, having to come and press the button.
Speaker: And those modes exist and you can then choose
Speaker: That mode, the patient has their SAT, their SVT, or just the SAT, and then you come at the bedside and assess and say, oh, this patient is awake, it's interactive, it's not fighting the ventilator, let's do a spontaneous breathing trial for this patient.
Speaker: Or not ready, let's move back to comfort, let's resedate because it's not safe for the patient.
Speaker: That changed the whole trajectory of that patient at that moment of time.
Speaker: And so that's the importance of thinking about goals.
Speaker: And I'll give you the last example related to ARDS and related to COVID because it's dear and near to our hearts.
Speaker: A common thing that we saw was that patients would go in prolonged days of mechanical ventilation and then we would wake them up.
Speaker: And it was really hard to deal with them because of the interaction with the ventilator.
Speaker: They had very high respiratory drives.
Speaker: The inflammation in the lung was high, but they had been several days and you wanted to start waking and having interactions.
Speaker: And one of the challenges is that they take some time once that you stop the medication to come back to a regular rhythm or to get rid of the reverse trigger or get out of those pathways.
Speaker: And there may be modes that you could choose at that time that would have helped avoid the resedation of these patients.
Speaker: So in general, our aim, and when we think about goal-directed therapy, you will realize that if you go to safety, you are gonna choose modes that have a lot of manual settings and automation to maintain safety.
Speaker: But when we go to comfort,
Speaker: We want to deal with synchrony and deal with work of breathing with the ventilator, not with sedation.
Speaker: and that changes the view of the team of how to deal with these patients.
Speaker: It's not just the ventilator.
Speaker: My mantra to them is a patient's synchrony issue is if your goal is comfort, should be dealt with the mode of mechanical ventilation, not with sedation.
Speaker: I mean, I know that this is not a dogma, but it's a 80-20.
Speaker: The majority of patients
Speaker: If they're having a poor interaction and your goal is comfort, should be managed with the ventilator mode.
Speaker: The problem is the ventilator mode.
Speaker: And some of them will need sedation, not the other way around in which you sedate for synchrony when your goal is comfort.
Speaker: Which is extremely common, I would say.
Speaker: We see asynchrony and the reaction is to sedate.
Speaker: And in some instances, even going further than that and sedating and applying neuromuscular blockers, which would be appropriate if your goal was safety, but not for comfort.
Speaker: This is a great discussion.
Speaker: And it's fascinating because using, obviously, the tags that you have worked on, you could go through the same example and maybe start with somebody who's on volume control, continuous mechanical ventilation with a set point, right, targeting, who then wakes up and you may move them to a pressure control now,
Speaker: with maybe one of the new IMV, IMV type two, right?
Speaker: That allows them to maybe get more comfortable.
Speaker: And then if they fail repeated SPTs, you might now move to a third mode that has adaptive targeting schemes that allows them to really try to get them off the ventilator.
Speaker: And I think it's something that most clinicians and most of our listeners, I would imagine, are not applying.
Speaker: And I think that
Speaker: Two things that, at least in my practice, this conversation is going to change significantly is one is thinking of the different
Speaker: parts of a journey in a patient stay in the ICU.
Speaker: And being very clear, today my goal is either safety, comfort, or liberation, right?
Speaker: And that itself should prompt the right questions with our team of what's the best mode that we have available on our ventilators to achieve that.
Speaker: And then the second part that I think is very powerful, what you said, Eduardo, and I think especially post-COVID when I think our sedation and neuromuscular blocker conduct went back a couple of decades, right, is that we should probably first try to approach a patient who's not in synchrony or is having asynchrony with event with mode changes and
Speaker: not with extra sedation, which I think is the knee-jerk reaction and all too common with probably not good consequences for our patients.
Speaker: Absolutely.
Speaker: And I would say that the other part that I would highlight here, and this is an exercise that I would
Speaker: that we did over here, and it was a healthy exercise, which was we grabbed all our ventilators, and obviously we have a lot of modes available with all the platforms that we have.
Speaker: And then we said, if you are on X ventilator, what would be the best modes that we would select for achieving this goal?
Speaker: So safety, for comfort, for liberation in our unit.
Speaker: with the platforms that we have.
Speaker: That doesn't mean that, I mean, we rarely change a patient from one ventilator to the other, except if the technology that it's in the other ventilator will serve much better the goal for that given patient.
Speaker: But that makes you now choose rationally some of the technologies that you have available and decrease the amount of work for our respiratory therapists, for our nursing, and for you as a clinician, because, uh,
Speaker: Well, that's very important in general terms, but I would also say that it's impossible to have a respiratory therapy at the bedside all the time.
Speaker: I do a common comment that I said is, well, Eduardo, I can ventilate anybody with volume control or pressure control or pressure support.
Speaker: And I agree.
Speaker: If you sit at the bedside of a patient, you will be able to adjust parameters to achieve probably a pretty good outcome in general in terms of ventilation.
Speaker: But that means that you're going to be sitting there and that the patient is not going to change afterwards when you leave.
Speaker: And as you and I know, and all the listeners, there is nothing constant with our patients in general, unless they're paralyzed.
Speaker: And even when they're paralyzed, they change.
Speaker: There's a lot of movement through these patients.
Speaker: As we're moving in general in our lives towards automation, there are some features that will make it safer for the patient that are available on our ventilator to deliver support that I would welcome because that means let's work for my RT and then my RT can do other things on other patients that need it.
Speaker: For example, walking somebody across the unit.
Speaker: You need an RT there and while the RT is walking with the patient or transporting a patient
Speaker: you need to ensure that the patients that are there are going to be able to continue to have a high quality delivery of mechanical ventilation.
Speaker: Absolutely.
Speaker: Well, as we try to wrap this up in terms of the practical application, making the complex simpler at the bedside, but more importantly, having a rational way of trying to optimize the support for our patients.
Speaker: Because I think a lot of people fall in love with a mode and just basically...
Speaker: say that's the mode for everything, right?
Speaker: And that is not very rational or evidence-based.
Speaker: You did mention, Eduardo, that realistically with so many modes, head-to-head comparisons, A, is not feasible from a research perspective, but B, would probably not be scientifically sound because we should be comparing modes for specific goals, right?
Speaker: Not just in general in different stages of diseases.
Speaker: But how do you practice?
Speaker: How do you do this at the Cleveland Clinic?
Speaker: How do you help your fellows do this in a practical way?
Speaker: So it's been a journey, Sergio.
Speaker: I would say that one of the big parts of what we work over here is how to implement
Speaker: what we speak about.
Speaker: And implementation is from literature to bedside takes time.
Speaker: And a lot of what we have worked on is how do we ensure that our teams understand what we're talking about, that everybody speaks the same language and that the literature gets to the bedside.
Speaker: And obviously there's protocolization that has occurred.
Speaker: But we started this journey, I mean, 15 years ago, we started working on how to train and how to work through this.
Speaker: And part of the items that we realized, and this is in a way of saying it's the road, and there's a lot of lessons to learn about the road that we have crossed.
Speaker: The first is I started...
Speaker: training with Rob, Chadbourne, all our fellows.
Speaker: That was our first target group.
Speaker: And actually that led to a lot of changes on the way that we practice mechanical ventilation because the fellows drove a lot of the change.
Speaker: But that caused also our respiratory therapists to sometimes not understand what we were doing and the staff much less, right?
Speaker: Because we had been trained on the time of
Speaker: volume control, pressure support and whatnot.
Speaker: And so you were like, what is happening here?
Speaker: What are these nomenclature stuff?
Speaker: So we realized that we had made a mistake by just doing that, that we were not thinking about the team.
Speaker: We were not thinking about how to train and move everybody across the spectrum and getting them to adopt this.
Speaker: So then we started training our respiratory therapists, and I've been lucky to have excellent support from leadership and our respiratory therapy leadership with Umur Hatipoglu, helping us ensure that this became part of the expectations and competencies that our respiratory therapists had to have.
Speaker: And then also training our staff and getting our staff to understand where we're going and getting their perspective.
Speaker: Because there's a lot of experience that you can hear, learn and understand where and how do you make it easy.
Speaker: Because it was complex and we wanted to make it easy.
Speaker: So there was a big movement towards education.
Speaker: There was also a big movement to change education.
Speaker: the availability of how you document.
Speaker: And this was a big item for us, which was changing the EMR.
Speaker: So in Epic, we interacted and changed all the modes.
Speaker: Now have, just as the medications have in parentheses, they have the tag.
Speaker: So now you know what actually that commercial name is.
Speaker: So if you're changing a patient from one ventilator to the other, and it's a different name,
Speaker: they're going to have the same tag or the same modal, or at least you will know what is happening.
Speaker: The third one has been
Speaker: to implement it into our, to doing rounds around with the respiratory therapy and our fellows and ensure that there's a continuity of management and the language is being told.
Speaker: So really a long road, but that's how we have implemented it.
Speaker: Is it 100%?
Speaker: There is still...
Speaker: stuff that we have to start moving through.
Speaker: But we follow this in a type of continuous improvement project to implement it better and make it happen at the website.
Speaker: But over the last years, I would tell you, Sergio, that the
Speaker: use of technology has improved within the unit.
Speaker: And although we have not reported this, I think that in experience we have seen a reduction in the amount of sedation and paralysis that we were using to manage some of these patients because the technology is now available for us to, well, this was available, but now we're using it for some of these groups of patients.
Speaker: that we needed to be thinking in a different way than what we were thinking.
Speaker: Absolutely.
Speaker: And I think that a lot of our listeners might say, well, I'm not at the Cleveland Clinic with all the resources available.
Speaker: But I think it starts by clarity of mind and by thinking at the bedside with each one of our intubated, mechanically ventilated patients, what is my goal today?
Speaker: Am I trying to achieve safety?
Speaker: Am I trying to achieve comfort?
Speaker: Am I trying to liberate?
Speaker: And at that point, I think that can raise the appropriate questions with our RT colleagues in terms of with the ventilator we have, which would be a mode that would help us achieve those goals in the best way possible.
Speaker: So I think that itself, I think, can be a transforming implementation or transforming habit for our practices.
Speaker: As we close, I would like to ask you a little bit more about your efforts on education, because I think that you obviously have done a lot of education for your team at Cleveland Clinic, but my understanding is that there's education available for people outside of Cleveland Clinic that goes along the lines of everything that we talked.
Speaker: Absolutely, Sergio, and thank you.
Speaker: We have created a course, which is called the SEBA course, which is Standardized Education for Ventilatory Assistance.
Speaker: And the SEVA course goes from the need to train everybody, to retrain everybody on a standardized language, standardized nomenclature, and how the ventilators work.
Speaker: And so it has, we have expanded outside of the Cleveland Clinic over the last year, or last year's program.
Speaker: with people that were interested on it.
Speaker: So now we have an online platform in which you can do online modules, which are the same exact online modules that we do here at the clinic to train our team in general.
Speaker: So we have two sets of online modules that you go through.
Speaker: And then we have a series of
Speaker: courses that are live courses and we have been doing the live courses across the US and in Mexico and hopefully soon in Europe in which we
Speaker: essentially go and go through the different steps of how to essentially learn the taxonomy, learn how to choose a goal, learn to read waveforms and learn to read patient ventricular interactions.
Speaker: And at the end, there's a checklist that we call the goal-directed
Speaker: mechanical ventilation management, which you go through all these steps and it asks at the end, is the mode serving the goal that you want?
Speaker: And if not, what are you going to change?
Speaker: And so it helps you really, it's a method to start thinking in order and using the technology to solve the patient problem
Speaker: as we need.
Speaker: We have other modules that we also have that the next module after SEVA method is called SEVA OptiVent, which essentially we train on how to use protocols.
Speaker: It's very interesting Sergio that
Speaker: You know, we have all these protocols that come out, but very little training on actually how to implement it, right?
Speaker: So they tell you this is the steps that you have to follow, but you don't go into detail on to them.
Speaker: So we created this course in which we train
Speaker: with simulation, either by computer simulation or with patient simulation, how to apply this in the different stages according to our goal, safety, comfort and liberation.
Speaker: And we do this for ARDS as well as for obstructive lung disease.
Speaker: If you can manage those two, you can manage essentially any patient on mechanical ventilation.
Speaker: And then the third level is learning how to monitor patients.
Speaker: And we reserve this to the end rather than to the beginning like in other courses because we think that this is not for everybody, but it's for some patients that you may need to know how to measure muscle pressure, how to measure a PV curve, how to do a recruitment maneuver, how to do electrical diaphragm surgery.
Speaker: activity.
Speaker: And so that's how we have focus and it just drives you through all these steps.
Speaker: So we have opened up and our goal is to start doing this outside and to have more people get into the SEBA.
Speaker: And essentially, and I'll say this, this course, we have been running it now for the last 10 years.
Speaker: It has evolved.
Speaker: Every year we improve a little bit because of feedback and input from our teams.
Speaker: from people that say, Eduardo, this needs to change, this needs to improve.
Speaker: Rob is a machine and our team over here that we have all working together to create this product that would be standardized for all of us to speak the same language.
Speaker: And the goal is essentially that then we can do, if we speak the same language and we write the same way,
Speaker: then it's easier for us to report our outcomes, to compare our modes, to compare our protocols when we're speaking the same way.
Speaker: Awesome.
Speaker: And we will definitely link in the show notes information to the SEVA website.
Speaker: And again, I think for those interested in really bringing this to an institution, learning more, I think a great venue.
Speaker: I talk with a lot of Gen Z colleagues or I guess Gen Z, they're not physicians yet, but Gen Z people always tell me that there's an app for everything, right?
Speaker: When I talk about a new product, I say, oh, there's an app for that.
Speaker: Is there an app for this?
Speaker: Yes, we have created an app that's called the Ventilator Mode Map, and I'll give you the links to share with your team.
Speaker: But this one is actually that database that will tell you about the 795 modes.
Speaker: We have created an app that is free for anybody, there's both in Android and the iOS system.
Speaker: And essentially for all the modes that are FDA approved, all the ventilator manufacturers, you will find there the tags for each one of your modes.
Speaker: And so if you just have to sit down, grab whatever ventilator you have available, you'll find that you just have to put the manufacturer, then the ventilator model, and then you can see all the modes and what's available.
Speaker: And actually, it has a cool feature that if you're in one ventilator and you want to see what other ventilators have that mode available, it will tell you what other modes have the same tag out there.
Speaker: So all free.
Speaker: Awesome.
Speaker: Well, Eduardo, this has really been a very educational conversation for me, for sure.
Speaker: And I hope I'm sure it will also have been for our audience.
Speaker: The idea in medicine, I believe, is not to have the right answers, but to always have the right questions.
Speaker: And I think there's a lot of questions that we can pose ourselves at the bedside when we have a mechanically ventilated patient.
Speaker: of what we're trying to achieve and how we can use technology to do it a little bit better.
Speaker: And I really appreciate all the efforts you and your group have done to bring a more rational approach to such a complex and evolving area that is so integral to what we do every day in the ICU.
Speaker: So you've been on the podcast before, so you know that we like to close with a couple questions that are unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: Yeah, absolutely.
Speaker: So the first question, Eduardo, is about books.
Speaker: Is there a book or books that you have gifted often to other people or that have had a particular influence on your way of thinking?
Speaker: Well, I will call out, since I shared last time the book that I shared very often, I will tell you a book that I read recently that really, really struck a chord with me, which was Solito by Javier Zamora.
Speaker: which is about this, the history of immigrating and going through all the way through Central America, Mexico and crossing over to the United States.
Speaker: And it's fantastic.
Speaker: It really resounded on me, not just because of the grit that this Javier had, but also the humanity that you see all the characters and how you
Speaker: are easy to judge some people and rapidly you realize that they still have good and that we're better than we think sometimes.
Speaker: It highlights Latino culture, which is huge, and a lot of hope on us, on humans in general.
Speaker: So I really love that book by...
Speaker: Awesome.
Speaker: And I've heard about this book, but I have not read it, but I definitely will pick it up.
Speaker: So we will definitely add links in the show notes.
Speaker: And like you said, it reminds me of a conversation we had with Wes Ely on the podcast where a phrase that either a colleague or a patient gave him once, he really brings to the
Speaker: to presence every time he's with a patient, which says in Spanish says, cada persona es un mundo, which means every person's a world.
Speaker: And I think that is true for our patients, for our colleagues.
Speaker: And maybe if we were more curious instead of judgmental, I think we would all be in a much better place.
Speaker: But it sounds like this story really shows a whole world of a person who came through this journey.
Speaker: So thanks for sharing that, Eduardo.
Speaker: The second question is about failure.
Speaker: I think that in medicine, we have grown up in this culture of genius and failure is not an option.
Speaker: Failure is always bad.
Speaker: And I think that we really learn through failure.
Speaker: So I try to normalize for my teams and my family that we should embrace failure.
Speaker: We should learn from failure and we should definitely become better because of it.
Speaker: Do you have a favorite failure or a failure you want to share that has taught you a lot?
Speaker: I have several, but I thought about one that makes me laugh, but it highlights and related to technology since this, we were talking a lot about technology and intelligence and using technology for improving our life.
Speaker: And when I arrived to the US and I was starting to write my first papers,
Speaker: I used, as many have, the word to write the articles.
Speaker: And I remember I was already in, I don't know how many papers I had submitted by that time.
Speaker: And I remember one of my peers came to me and said, Eduardo, I want to let you know that I really enjoy what you're writing, but you are writing
Speaker: instead of assess, you're writing asses.
Speaker: Because the darn word was not under, with the red squiggly line, it was not highlighting that I was missing an S. So I was essentially writing all the time asses instead of asses in my papers.
Speaker: And so that's a failure of technology to not understand context, right?
Speaker: And that can happen with any technology that we use.
Speaker: And it's a simple but a message of saying, A, even though we have great technology, you still have to, there has to be the human factor, the rational factor, the education factor of knowing what you're doing and reading this with care.
Speaker: And two, don't trust completely the automation because you may make an ass out of yourself.
Speaker: I love that.
Speaker: That's perfect.
Speaker: So to finish, Eduardo, what would you want every listener, intensivist, clinician who's listening to us today to know?
Speaker: Could be a quote, a fact, or just a parting thought.
Speaker: Well, one of my common statements is if you don't have a diagnosis, there's no prognosis.
Speaker: And ARDS is not a diagnosis.
Speaker: It's a syndrome.
Speaker: So if you tell me the patient has ARDS, fair, but tell me why.
Speaker: Because then if you tell me why, I can treat it and I can tell you how you're going to do afterwards.
Speaker: So no diagnosis, no prognosis, Sergio.
Speaker: That's my parting thought.
Speaker: I think that's perfect place to stop.
Speaker: I love it.
Speaker: And Eduardo, as always, a pleasure.
Speaker: I learned so much by talking with you and really want to thank you for being so generous with your time, but also with all the efforts that you have done over your career to advance, I mean, critical care in particular, the topic that we talked about today, which is mechanical ventilation.
Speaker: So hope to have you back soon and I look forward to seeing you in person shortly.
Speaker: Thank you, Sergio.
Speaker: And as always, it's a pleasure talking to you.
Speaker: And the way that you summarize and get the point across is fantastic.
Speaker: I really appreciate you and the invitation to be with you.
Speaker: Looking forward to more.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
