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Liberation From Mechanical Ventilation
10 Plays5 years ago
In this episode of Critical Matters, we will discuss mechanical ventilation.
Our guest is Dr. Eduardo Mireles-Cabodevila, a practicing pulmonary critical care physician and Director of the Medical Intensive Care Unit at the Cleveland Clinic. His areas of clinical interest are critical care medicine, application of mechanical ventilation, acute and chronic respiratory failure, and extracorporeal life support. Our conversation covers general concepts related to liberation from mechanical ventilation, weaning from mechanical ventilation, and also examines how these concepts may apply to COVID-19 patients.
Additional Resources:
Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation: https://pubmed.ncbi.nlm.nih.gov/27818331/
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests: https://pubmed.ncbi.nlm.nih.gov/27762595/
Tracheostomy in the COVID-19 Era: Global and Multidisciplinary Guidance: https://pubmed.ncbi.nlm.nih.gov/32422180/
Lung Ultrasound Allows the Diagnosis of Weaning-Induced Pulmonary Edema: https://pubmed.ncbi.nlm.nih.gov/30863935/
Previous episode of Critical Matters on Prolonged Mechanical Ventilation: https://critical-matters/outliers-and-super-users:-targeting-prolonged-use-of-mv-in-the-icu
Books Mentioned in this Episode:
William Osler: A Life in Medicine by Michael Bliss: https://www.amazon.com/William-Osler
Recommended
Transcript
Podcast Introduction
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Mechanical Ventilation Challenges
00:00:32
Speaker
Mechanical ventilation is a life-saving intervention frequently utilized in the intensive care unit.
00:00:38
Speaker
Because it is associated with complications, patients should be liberated from the ventilator as soon as their underlying condition has improved to the point where they no longer require mechanical ventilator support and they are able to safely breathe on their own.
00:00:52
Speaker
Duration of mechanical ventilation is a commonly followed quality metric in many intensive care units.
00:00:58
Speaker
In today's episode of the podcast, we will discuss general concepts related to liberation from mechanical ventilation, weaning from mechanical ventilation, and also examine how these concepts may apply to COVID-19 patients.
Guest Introduction: Dr. Eduardo Mireles
00:01:12
Speaker
Our guest is Dr. Eduardo Mireles Cabo de Vila.
00:01:15
Speaker
Dr. Mireles Cabo de Vila is a practicing pulmonary critical care physician and director of the medical intensive care unit at the Cleveland Clinic.
00:01:23
Speaker
His areas of clinical interest include critical care medicine,
00:01:26
Speaker
application of mechanical ventilation, acute and chronic respiratory failure, and extracorporeal life support.
00:01:33
Speaker
He has a special interest in education and critical care, and is specific on the use of stimulation to enhance and accelerate learning.
00:01:42
Speaker
Dr. Mireles Cabo de Villa is also the medical director of the Simulation and Advanced Skills Center.
00:01:48
Speaker
He has developed, along with his critical care simulation team, several courses and devices to enhance the training of healthcare providers
00:01:56
Speaker
at the clinic and elsewhere.
00:01:58
Speaker
He's an accomplished clinician, researcher, and educator.
00:02:01
Speaker
We are truly honored and fortunate to have him on the podcast.
00:02:04
Speaker
Eduardo, welcome to Critical Matters.
00:02:08
Speaker
Thank you, Sergio.
00:02:08
Speaker
Nice to be here.
00:02:11
Speaker
We were talking before we started recording on the last time that we saw each other back in February at SECM Annual Congress, and it really feels that it's been decades ago
00:02:24
Speaker
So much has happened since, and I hope things are good in Cleveland.
00:02:27
Speaker
So how are things down there?
00:02:31
Speaker
They are much better.
00:02:33
Speaker
It has been a long year, no doubt, Sergio, but now we are preparing for a presidential debate tomorrow for October.
00:02:41
Speaker
We're vaccinating everybody, and we are ready to work.
00:02:46
Speaker
Excellent.
00:02:47
Speaker
So let's dive into the topic that we have at hand today.
00:02:50
Speaker
I would like to start with just some concepts and definitions to introduce the audience to what we're talking about today.
Liberation vs. Weaning Terminology
00:02:56
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And what I wanted to ask you first, the difference between liberation versus weaning from mechanical ventilation, are they different?
00:03:04
Speaker
Can they be used interchangeably?
00:03:06
Speaker
Does it really matter at the end?
00:03:09
Speaker
Well, I think that words do matter.
00:03:11
Speaker
And so I prefer the term liberation because it talks about removal of support, the whole process that occurs.
00:03:20
Speaker
I think weaning, as the word states, focuses on a gradual decrease of support, which is a historical wording.
00:03:29
Speaker
And I think that the association with gradual decrease of support may point towards things that we are not doing necessarily all the time.
00:03:39
Speaker
So in general, I would say that when you talk about liberation and weaning in the literature, you're going to see that they use them interchangeable.
00:03:46
Speaker
But more and more, the word being used is now liberation.
00:03:51
Speaker
And I think it also speaks to the fact that the vast majority of patients are liberated quite quickly, but there's a small subset that can be very difficult.
00:04:01
Speaker
And a lot of what we're going to talk about today is going to focus on those patients as well.
00:04:06
Speaker
That's correct.
00:04:07
Speaker
Majority of the patients will be extubated on the first attempt of the ventilator without any gradual decrease in support.
00:04:16
Speaker
And majority of them, as we'll talk about this, just need a test, the spontaneous breathing trial.
00:04:23
Speaker
And from there, they go on to be liberated without any weaning, as the word means.
00:04:31
Speaker
Excellent.
Weaning Classifications and Outcomes
00:04:32
Speaker
The second thing I wanted to ask you was about the concept of simple liberation versus difficult weaning versus prolonged weaning or liberation.
00:04:41
Speaker
Are these terms that are commonly agreed upon, or do they mean different things to different clinicians?
00:04:48
Speaker
Well, I think that one of the challenges that occurred when you read the literature on winning and liberation is the multiple words and terms that are used.
00:05:02
Speaker
And in 2007, in the sixth international conference, a group of experts got together and came up with this classification, which I think,
00:05:15
Speaker
although at that time it was created by consensus, now after several publications, it does correlate with practice.
00:05:23
Speaker
So the terms matter in this situation, and they correlate well with outcomes.
00:05:29
Speaker
So, for example, simple weaning is the extubation at the first try.
00:05:34
Speaker
So you do as continuous brain trial, the patient gets extubated after he passes it.
00:05:40
Speaker
The term difficult weaning refers to those patients that require up to three
00:05:45
Speaker
spontaneous breathing trials or less than seven days of mechanical ventilation.
00:05:52
Speaker
And then the term prolonged weaning is aligned with those that have more than three spontaneous breathing trials that they need to get extubated or more than seven days on mechanical ventilation trying to extubate them.
00:06:08
Speaker
So I think that it helps to know
00:06:11
Speaker
what is happening in your unit or in the literature that is being presented with certain interventions that we will talk about.
00:06:18
Speaker
So I think that overall, we should be using those terms at this time in our publications and to refer about our patients.
00:06:29
Speaker
And I think, correct me if I'm wrong, Eduardo, but I believe it was the WIND study that actually looked at these and made some propositions.
00:06:37
Speaker
But
00:06:38
Speaker
it showed that these three categories or these categories are also associated with outcomes and that they can tell you, I mean, in a higher risk patient populations based on what's going on with their time on mechanical ventilation.
00:06:53
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Absolutely.
00:06:54
Speaker
This has been now repeated in a couple of trials in which you can see the
00:07:03
Speaker
mortality, the length of mechanical ventilation and length of ICU stay increasing as you move from one category to the other.
00:07:13
Speaker
And you can also see the incidence of prolonged or difficult weaning according to the population.
00:07:24
Speaker
And so I think that absolutely this is now has been replicated in a couple of studies
00:07:31
Speaker
and it does correlate absolutely with outcomes.
Resource Consumption in Weaning Challenges
00:07:35
Speaker
Another aspect that I want to get your thoughts on related to these three classifications is an observation that I'm sure a lot of our audience who follow these metrics for duration of mechanical ventilation have seen if they look at their data, and that is that difficult weaning patients and prolonged weaning patients, so more than three attempts, seven or more days in the last category, are a smaller subset of patients
00:08:01
Speaker
yet they represent an enormous amount of the total time on mechanical ventilation in a given unit.
00:08:07
Speaker
So they're really super users and consume an enormous amount of resources.
00:08:12
Speaker
That's correct.
00:08:16
Speaker
The amount of time that they spend on mechanical ventilation, length of stay in the ICU, if you compare on the Peรฑuela study in 2011, they were, if you're a simple wean in six days,
00:08:30
Speaker
difficult weaning nine, but if your prolonged weaning is 18 days and longer.
00:08:35
Speaker
And so these are patients that occupy one of the resources in the ICU that needs to be addressed.
00:08:46
Speaker
And so in every single ICU, I would say length of mechanical ventilation is a key metric about the interventions that we can do to shorten them.
00:08:57
Speaker
And I actually think that that's a really meaningful metric because it talks about several interventions that you can do to shorten mechanical ventilation that go from sedation practices, mobility, use and protocolization of spontaneous breathing trials and awakening trials and whatnot.
00:09:21
Speaker
So I think it's meaningful to try to shorten that
00:09:27
Speaker
amount of time by intervention.
Extubation Failure Metrics
00:09:31
Speaker
I wanted to ask you the next kind of category of terms relate to failure and failure to wean, failed extubation.
00:09:40
Speaker
What do those terms mean to you and what do they mean in the literature?
00:09:44
Speaker
Yeah, the extubation failure had variable
00:09:53
Speaker
definitions through the literature, but I think that more commonly now, we use reintubation at 48 hours, so within 48 hours after extubating a patient.
00:10:05
Speaker
And I think that that's pretty operationally efficient for us to recognize those patients, both in studies and in practice.
00:10:16
Speaker
The second one, which is prolonged mechanical ventilation, has a long story,
00:10:22
Speaker
of how we came to those more than 21 days of mechanical ventilation to be the definition.
00:10:27
Speaker
But it all started in 1992 when they were doing one of these CPT codes and they had an advisory committee to create the code.
00:10:36
Speaker
But actually, it pans out very well with the patients that have prolonged mechanical ventilation that the literature describes.
00:10:45
Speaker
In general, all the series of patients that have had prolonged weaning
00:10:50
Speaker
and that go on to have prolonged mechanical ventilation have more than 21 days on mechanical ventilation.
00:10:56
Speaker
So I think that those two are now pretty well established and accepted.
00:11:03
Speaker
I want to probe a little bit more in the failed extubation concept because you mentioned that if somebody gets extubated and they get re-intubated within 48 hours, we would call it obviously a failed extubation.
00:11:17
Speaker
But I do believe that
00:11:19
Speaker
there's a misconception among many clinicians that a reintubation rate of 0% is phenomenal.
00:11:27
Speaker
And I think that there's probably a sweet spot because if you have no reintubations, perhaps you're not being as aggressive.
00:11:33
Speaker
Could you comment on that, Eduardo?
00:11:37
Speaker
Absolutely.
00:11:38
Speaker
That's another metric that we follow, which is how many patients should be
00:11:46
Speaker
failing extubation so that you know that you're being active enough to get them off the ventilator.
00:11:54
Speaker
Because if you have a zero, that means that you went really conservative and had patients on mechanical ventilation for a longer period of time, and you didn't allow them to spontaneously breathe.
00:12:07
Speaker
So the number ranges, and as the literature goes forward, it's around 5% to 10%.
00:12:13
Speaker
I've seen as high as 14%.
00:12:17
Speaker
But it's another metric that we keep an eye on to be sure that we're not using the gestalt.
00:12:26
Speaker
So actually, this is an important thing that came from literature was that as the protocol started to get implemented for spontaneous breathing trial, what we knew is that we usually underestimate the readiness of patients.
00:12:44
Speaker
So
00:12:46
Speaker
we may not extubate patients just by looking at them just from their clinical characteristics, not test them.
00:12:53
Speaker
And many of them, up to 85% on some literature, were ready to be extubated.
00:12:59
Speaker
And it always comes to us, Sergio, is the events in which patients get self-extubated,
00:13:06
Speaker
and then half of them do not get reintubated, right?
00:13:11
Speaker
So it tells you, well, this patient should have been extubated before he did it on his own, and talks about that readiness to be extubated and how to be a little more aggressive rather than conservative on how to get them off the mechanical ventilator.
00:13:28
Speaker
And I think that those are very important points that are worth reemphasizing.
00:13:32
Speaker
And point number one, like you said, is that
00:13:35
Speaker
I guess it's a systematic bias that we have, but we tend to underestimate the ability of our intubated patients to breathe spontaneously
Evidence-Based Liberation Practices
00:13:43
Speaker
on their own.
00:13:43
Speaker
So we tend to keep them a little bit longer and we'll talk about what are the mechanisms that we can implement to try to overcome that bias.
00:13:51
Speaker
And the other thing that you mentioned, Eduardo, which I think is worth repeating is that you follow metrics of quality.
00:13:57
Speaker
You need obviously more than one metric to make sure that you
00:14:01
Speaker
are doing the right thing.
00:14:02
Speaker
So if you follow duration of mechanical ventilation as you implement protocols and you modify the behavior of your team, you would like to see that number go down.
00:14:11
Speaker
But you also don't want to make sure that you stay within a target with your re-intubations because if you are zero, it means you're too conservative.
00:14:20
Speaker
If you are 50%, it means that perhaps you're a little bit too liberal and that poses a safety threat to our patients.
00:14:29
Speaker
Absolutely.
00:14:30
Speaker
Is there any increased morbidity documented with patients who fail in extubation and need to be re-intubated?
00:14:38
Speaker
Yeah, and that's the challenge.
00:14:41
Speaker
It's always one of these thoughts that keeps crossing through your mind is, well, if I keep them intubated, I expose them to a set of risks from sedation, immobility, prolonged stay,
00:14:57
Speaker
I mean, all the things that imply with doing that.
00:14:59
Speaker
And on the other side is, well, if I extubate this patient and he has to be reintubated, that's associated with increased mortality and morbidity.
00:15:10
Speaker
And so that makes you think about this and try to test the patient and be sure that you're doing this the best way that you can.
00:15:23
Speaker
because obviously it does have consequences when you fail and the patients get re-intubated.
00:15:31
Speaker
Absolutely.
00:15:33
Speaker
I would like to move on and talk more about evidence-based liberation in adult critical care patients from mechanical ventilation.
00:15:41
Speaker
And perhaps what we could do, Eduardo, is if we could start with a brief narrative of what your current practice is at the Cleveland Clinic, and then we can maybe dissect that and go a little bit deeper into what are the individual components and what the literature says or doesn't say in terms of what's best practice.
00:16:01
Speaker
Absolutely.
00:16:02
Speaker
I think that the, as I think about the practice that we have,
00:16:08
Speaker
I always start by the fact that what you want to do is that you want to use a protocol that is run by our respiratory therapist.
00:16:17
Speaker
That's what we do.
00:16:18
Speaker
And the whole rationale for this, we're going to talk more about it, but essentially they are at the bedside.
00:16:24
Speaker
They do the assessment, and they go on to move the protocol all the way to the moment that they say this patient is ready to be extubated.
00:16:33
Speaker
And so what do we do?
00:16:35
Speaker
We have a WIMP.
00:16:36
Speaker
screening screening screening
00:17:05
Speaker
essential for us and the ones that were being used the most.
00:17:09
Speaker
And then we did a sensitivity analysis and saw that the others were not changing the patients that we should be choosing.
00:17:16
Speaker
So that made us use less steps.
00:17:20
Speaker
After that, if the patient passes what we call the windscreen, those patients go on to have a spontaneous breathing trial in which they undergo a pressure support trial of eight or five
00:17:34
Speaker
professional support over five OPEP.
00:17:37
Speaker
And then if they pass that after half an hour, they have an extubation screen.
00:17:42
Speaker
And during that extubation screen, essentially the amount of secretions, do they have a cough leak and their level of interaction.
00:17:51
Speaker
And if they pass the extubation screen, then they get extubated.
00:17:57
Speaker
And so that's the series
Spontaneous Breathing Trials (SBTs)
00:18:00
Speaker
of steps.
00:18:00
Speaker
We used to have an intermediate step in which we were
00:18:04
Speaker
measuring certain values like the RSVI and minute ventilation and whatnot.
00:18:12
Speaker
And we just took that off from the protocol.
00:18:15
Speaker
We thought that just having the spontaneous breathing trial passed or failed was a way to get more patients to have the spontaneous breathing trial and extubated when they need it.
00:18:29
Speaker
That's phenomenal.
00:18:30
Speaker
So let's dissect that a little bit more.
00:18:31
Speaker
And the first thing you mentioned
00:18:33
Speaker
was the weaning screening or weaning readiness assessment.
00:18:37
Speaker
So that is done by protocol by the respiratory therapy colleague.
00:18:43
Speaker
And like you said, what you've learned over the years is that less is better, right?
00:18:48
Speaker
Less is more.
00:18:49
Speaker
So you really focus on just, I presume, a couple of key components.
00:18:52
Speaker
Could you share some of those key components with us, Eduardo?
00:18:56
Speaker
Absolutely.
00:18:58
Speaker
And this is some key word that I heard from my
00:19:03
Speaker
one of my peers, which is the more steps in a process, the higher the chance of error or failure you will have.
00:19:11
Speaker
And I think about that a lot because we try to designate all these protocols and you keep putting stuff on and it just makes it harder for them to get to the end of the process.
00:19:23
Speaker
So what we have right now, the patient has to be able to breathe spontaneously, so to trigger the breath.
00:19:30
Speaker
His FiO2 has to be less or equal to 40%.
00:19:36
Speaker
The pH has to be above 7.3.
00:19:39
Speaker
And the PEEP has to be less than 8 and a respiratory rate less than 35.
00:19:46
Speaker
And if they are on pressers, it has to be less than 5 micrograms per minute of leave of it.
00:19:51
Speaker
That's what we have said.
00:19:53
Speaker
If it's higher than that, then they have to interact with the clinicians.
00:19:58
Speaker
and we decide if it's good or not to put the patient on a spontaneous breathing trial.
00:20:05
Speaker
But it's a team decision at that moment.
00:20:10
Speaker
And if they pass that, so what it means really is that they are ready for a spontaneous breathing trial, so that's really what you're assessing for.
00:20:18
Speaker
And a lot of places, I think, would still use an RSPI for that, but you really feel that you just moved to the SPT at that point.
00:20:28
Speaker
Yes, we just โ there were several reasons for that.
00:20:35
Speaker
Some of them have to do with workflows and amount of work that the respiratory therapist has to do because if you want to do the appropriate RSVI, you would have to disconnect him, put the right spirometer, measure the respiratory rate, and do the calculations.
00:20:52
Speaker
Based on the fact that if you leave them on the ventilator or try to do it with the machine, you get different values.
00:20:59
Speaker
the sensitivity and specificity were different.
00:21:02
Speaker
And we thought that at the end of the story, the thing that was most important for us was whether they passed or not the spontaneous breathing trial.
00:21:13
Speaker
Were they able to breathe spontaneously?
00:21:15
Speaker
And if they were, unless there wasn't any contraindication to it, we would extubate these patients.
00:21:23
Speaker
Excellent.
00:21:24
Speaker
So let's dive into the spontaneous breathing trial, the SPT itself.
00:21:28
Speaker
And I think that, again, it's a very simple concept, but the devil's in the details.
Pressure Support in SBTs
00:21:33
Speaker
And there's obviously been discussion in the literature and there's been recommendations based on the available evidence for some aspects of the SBT.
00:21:42
Speaker
But the first question relates, and you did answer, but I just want you to maybe tell us a little bit more the rationale behind it, is the use of pressure augmentation for the SBT versus what originally was described as a trait color
00:21:55
Speaker
or a T-piece without any pressure augmentation.
00:22:00
Speaker
Yes, absolutely.
00:22:02
Speaker
And this has been a real interesting story because the main issue is when you're going to do a spontaneous breathing trial, what you're doing is you're testing, testing the ability of the patient to breathe without assistance.
00:22:22
Speaker
And so the fact that they have a
00:22:25
Speaker
endotracheal tube increases the resistive load that the patient's respiratory muscles has to be exposed to.
00:22:35
Speaker
So the question was, well, if you do a pressure support or pressure-augmented spontaneous breathing trial, you are decreasing or compensating for the resistive load that the patient would have.
00:22:54
Speaker
And
00:22:55
Speaker
If you do it without it, then the patient is breathing with an even higher respiratory load than if the tube was coming out.
00:23:04
Speaker
And so the issue here is if you augment the pressure or the effort for the patient, then you may be hiding patients that will fail.
00:23:18
Speaker
And I will comment a little bit more here because the issue is, and you may have seen this here in which
00:23:25
Speaker
you come to the bedside and they're doing a spontaneous screening trial and they use a pressure augmentation they're using 10 or 9 or 8 or 5 and and the question is well all of them have different support level for that resistive load and in some of them you're even supporting the elastic load not only the resistive so you may be hiding patients that are going to really fail and and they would be at higher risk now
00:23:53
Speaker
I think that that was our issue.
00:23:55
Speaker
It's easier to do, without a doubt, a pressure support trial because you don't have to disconnect the patient.
00:24:00
Speaker
It's easier for the RTs just to, and you have the monitoring from the ventilator.
00:24:04
Speaker
The patient stops breathing, it kicks in.
00:24:07
Speaker
So there's operational things that makes it easier.
00:24:09
Speaker
And it was not until recently that this trial was done, even though they compared extremes of the process, the T2 trial versus the pressure support, that
00:24:22
Speaker
there was actually more patients being extubated with the pressure support without an increase in the number of patients that got re-intubated, which was very interesting to us.
00:24:36
Speaker
And perhaps there's nuances in that study, but it just talked about that fear that we had for that group of patients.
00:24:43
Speaker
And we'll talk about some other subgroup of patients in which I think that TPs may be a better option for them.
Weaning-Induced Pulmonary Edema Management
00:24:52
Speaker
And it feels like the last, at least, ATS, ACCP recommendations talked about this, and I think for a lot of things that you articulated, and based on what we know, really recommend that we do it for support five to eight seems to be the best approach at this moment.
00:25:09
Speaker
But you did mention that in some instances, you might want to move to a TPS.
00:25:13
Speaker
Could you tell us a little bit more about that?
00:25:16
Speaker
Yes, I think that there's a couple of
00:25:21
Speaker
practices that you may be thinking at times, which is in some patients that have, in which the pressure may hide failure from water shifts.
00:25:36
Speaker
And so these are usually the pressures that have, the patients that have volume overload of pulmonary edema or cardiac dysfunction, in which the breathing trial with
00:25:51
Speaker
some support in the area with positive pressure may hide and then when they get extubated then they are exposed to this situation.
00:26:00
Speaker
So getting them off to a pee piece to see if that highlights or unmasks the presence of water and respiratory failure may be a situation in which I would use a pee piece trial.
00:26:18
Speaker
There is very exciting new literature coming from France on this weaning-induced pulmonary edema, which essentially doing testing the patients for preload responsiveness to try to unmask this group of patients.
00:26:36
Speaker
And that may be another way rather than using a TPS for these patients and to protocolize the care for them.
00:26:46
Speaker
So how would you, so are you doing a true volume responsive, not a bolus test, but more kind of a, how do you, how would you implement that?
00:26:56
Speaker
Could you share that with that a little bit more?
00:26:58
Speaker
Yes.
00:26:59
Speaker
And this is the group from Javier Monette and Tabul and Dres, which essentially have done in patients pretty invasive patients.
00:27:13
Speaker
monitoring on patients that failed their spontaneous breathing trial.
00:27:17
Speaker
And then what they have done is that actually, and there's different monitoring ways that they have done it, which are pretty interesting.
00:27:27
Speaker
But one of them, which I think that probably is the most easy to implement, is to, in patients that failed their spontaneous breathing trial, then to do a passive leg raise.
00:27:39
Speaker
And if the patients have a negative
00:27:43
Speaker
uh passive leg raise so the cardiac index doesn't change under those circumstances you can do this non-invasive echo or whatever uh those patients uh may need uh correlated with patients that had um a work that were that were failing due to uh uh weaning induced pulmonary edema and so the numbers that they they're reporting are pretty high around
00:28:09
Speaker
uh from go they range on the literature from 20 to 60 percent 67 percent and so on those patients that that do have uh these events of uh winning induced pulmonary edema uh perhaps the therapy for them is to uh to give them diuretic and to reduce the fluids and uh there have done other things that i thought that were pretty interesting is uh to measure
00:28:36
Speaker
the plasma protein before and after, which I think that it's operationally not feasible, but it increases because of the water going into the lung as well as the hemoglobin.
00:28:46
Speaker
And they also have done ultrasounds before and after counting the B lines also with relatively good performance.
00:28:56
Speaker
So I think that this is an area that needs further exploration, but it has caught my attention because you can
00:29:04
Speaker
think about it, how you would make it part of your protocol for those that have failed, so they have gone into the difficult wean situation.
00:29:15
Speaker
Those patients may be patients that we should be focusing on seeing if this is volume, cardiac dysfunction, and whatnot.
00:29:24
Speaker
Absolutely.
00:29:25
Speaker
And I think I was going to ask you, Eduardo, related to another population that I have observed a
00:29:34
Speaker
empirically or anecdotally, but I really have never seen any literature that I think a TP sometimes might benefit.
00:29:41
Speaker
It's a very similar rationale.
00:29:43
Speaker
I've had a series of, I recall, young patients with intra thoracic cancer, lymphomas and others that seem to respond, their airway seems to respond very well to a little bit of positive pressure, but when they lose that positive pressure, they have airway collapse and have issues.
00:30:04
Speaker
And a lot of times those are patients that look great on pressure support, SPT, and then you extubate them and you get into trouble.
00:30:11
Speaker
Is that something that has been reported or that you have observed as well?
00:30:16
Speaker
I have observed that.
00:30:17
Speaker
Actually, this week, well, last week, we had a similar patient with an intrathoracic mass, and the exact same thing occurred.
00:30:27
Speaker
The clinician at the bedside said he passed the spontaneous breathing trial.
00:30:30
Speaker
He was extubated, failed.
00:30:32
Speaker
re-intubated, and so we did a TP trial just to reassess that.
00:30:37
Speaker
And so I have not seen particularly that reported, but I can relate very clearly with your point.
00:30:47
Speaker
Also, the patients with excessive dynamic collapse, which you may be then under those circumstances considering, well, how do I extubate him to CPAP considering the situations?
00:30:59
Speaker
So really good point.
00:31:01
Speaker
Absolutely.
00:31:02
Speaker
The other question I had regarding the SPT is the timing of the day and the frequency.
00:31:09
Speaker
One of the problems that I have encountered in a community practice is that if the SPT is done by the night shift, a lot of times when we're rounding, nobody really knows exactly what happened and it's a failed SPT, but you really don't know if they failed, should do it again, is the patient now sedated?
00:31:25
Speaker
Is that something that you guys have wired down at your practice?
00:31:31
Speaker
Yes, and I think that there's a lot of room for
Role of Protocolized Care
00:31:36
Speaker
improvement.
00:31:36
Speaker
And I'll put it this way.
00:31:39
Speaker
We are once a day, spontaneous breathing trial, unless the team comes to the conclusion that this patient needs another one.
00:31:48
Speaker
And sometimes it's because you come in the morning, they are doing the SAT, and they're completely snowed.
00:31:52
Speaker
You say, you know, that doesn't even count weights.
00:31:55
Speaker
Let's do it later on.
00:31:59
Speaker
I think that some of the automated systems of mechanical ventilation and some of those trials essentially extubated at any time that the machine said the patient passed the spontaneous brain trial and came out.
00:32:15
Speaker
Now, there's some literature saying that if you extubate them at night, the mortality may be higher on those groups of patients.
00:32:23
Speaker
However, I think that this is all related to
00:32:25
Speaker
the site where you work and how you make the operations occur.
00:32:30
Speaker
And the point is going towards, you have a patient that is on mechanical ventilation, and as that patient is on mechanical ventilation, he should be assessed the moment that he's ready to get off the ventilator.
00:32:45
Speaker
And the system, the hospital system and the ICU should be designed in a way that you can ensure that you make that a safe event.
00:32:55
Speaker
for that patient when you extubate him.
00:32:57
Speaker
So, that's in our to-do things for our practice, but at this time, we're once a day or more if needed, but guided by a clinician.
00:33:10
Speaker
Excellent.
00:33:11
Speaker
And I wanted to ask you a little bit about kind of the evidence behind protocols, and you talked about that a little bit.
00:33:18
Speaker
Obviously, we have protocols for sedation or daily assessment of sedation.
00:33:24
Speaker
awakening.
00:33:25
Speaker
We have protocols for weaning and liberation from mechanical ventilation for who's ready for SPT.
00:33:31
Speaker
And also now people are including protocols for early mobility and other interventions within the A to F bundles.
00:33:37
Speaker
Could you comment on where that stands and what should be the current practice based on the evidence?
00:33:44
Speaker
Well, yeah, I think that the, there is no doubt in my mind that the way that we need to
00:33:52
Speaker
manage is by protocols.
00:33:55
Speaker
There are several reasons to ensure that you are creating protocols for management of these type of evidence-based practice in which you want to ensure that these interventions are being applied.
00:34:09
Speaker
And it has to do with the environment and how we as humans practice
00:34:17
Speaker
I think that we are in an era of information overload.
00:34:20
Speaker
You're at the bedside and you're getting messages from everywhere in which this should not be something that is dependent on the performance of the team at the bedside.
00:34:30
Speaker
It should be dependent on the performance of the protocol by a team member continuously at the bedside.
00:34:37
Speaker
I think that the other reason for ensuring that we're doing protocols in our practice
00:34:42
Speaker
is that it's very hard for us to detect associations with when the output is rare.
00:34:48
Speaker
So as you're trying to improve the practice in your own ICU, you need to be sure that what you're doing and getting data back from that.
00:34:59
Speaker
And if it's left to the variability of other practitioners, it really creates, it's very difficult to know what you're doing.
00:35:09
Speaker
I think that there's also an issue which is related to the variability on levels of experience and turnover in the population that are at the bedside.
00:35:21
Speaker
And at least in our ICU, we have residents and we have fellows and we have advanced practice providers with a lot of movement.
00:35:29
Speaker
And you have to ensure that you create a protocol that speaks to the environment where you are.
00:35:37
Speaker
There's also, and we talked a little bit about that, the desire of inertia on beliefs on our providers.
00:35:44
Speaker
And so I think that at some point you have to make a commitment on certain actions to your ICU that have some degree of evidence.
00:35:55
Speaker
It's always very easy to destroy articles and to find flaws on what they did, but you have to choose something and apply it in order.
00:36:05
Speaker
So
00:36:06
Speaker
As I read from the first key article by Wes Sely on the application of the spontaneous breathing trial by their respiratory therapists onwards, I think that we just continue to see this through time.
00:36:25
Speaker
If you leave it to our own device, you're not going to necessarily perform as good as you could if you establish a protocol.
00:36:33
Speaker
that's where I would say that we stand right now.
00:36:37
Speaker
And from there you can build up what should be on that protocol, right?
00:36:42
Speaker
And you can think about the bundles for the ABCDF.
00:36:46
Speaker
You can think about how you manage and wean patients from mechanical ventilation that have prolonged mechanical ventilation.
00:36:55
Speaker
All of those, I think, that need to be protocolized.
00:36:59
Speaker
And that protocol needs to be adjusted to the practice where you are.
00:37:02
Speaker
This is
00:37:04
Speaker
It's not the same my hospital that your hospital or even within our hospital, the regional practices between us.
00:37:11
Speaker
And there's differences in how even the units are designed.
00:37:16
Speaker
And I think that's a very important point, Eduardo, in terms of understanding that you have to be very flexible in understanding that evidence changes and there's things that if they don't work, you can change.
00:37:30
Speaker
But on the other hand, you have to be regimented.
00:37:32
Speaker
because if everybody's doing something different, there's no way to figure out what works and what doesn't work.
00:37:36
Speaker
And what the data has showed or the evidence supports is that for certain tasks where we have inherent biases, protocolized care makes a difference.
00:37:45
Speaker
Now, it probably makes a difference for the vast majority of patients, 80%, and maybe there's a small percent, 20%, like that 80-20 rule, where maybe you have to be a little bit more creative or you have to have a little bit more input from the clinician.
00:37:58
Speaker
But I think that ultimately what you're trying to do is really move the needle
00:38:01
Speaker
for the vast majority of patients.
00:38:02
Speaker
And like you said, the large majority of patients who are mechanical ventilation will fall into that simple weaning.
00:38:09
Speaker
So getting to that SPT as soon as possible is probably the best way to move those patients forward.
00:38:15
Speaker
And then even with those who are difficult weaning or prolonged weaning, the protocol clearly will also help get off the ventilator quicker and recognizing what the problems are.
00:38:27
Speaker
Absolutely.
00:38:29
Speaker
I would like to move on to some additional considerations related to this process.
Non-Invasive Ventilation Post-Extubation
00:38:34
Speaker
And I wanted to ask you specifically about non-invasive ventilation after extubation.
00:38:41
Speaker
And I think, or I understand, and I want to hear your thoughts, that there's a big differentiation to make here between preventive use of non-invasive positive pressure ventilation after extubation and the use of this non-invasive positive pressure ventilation
00:38:59
Speaker
as a rescue therapy trying to avoid a failed extubation.
00:39:02
Speaker
Could you comment on that, Eduardo, on how you use it and what the evidence says?
00:39:07
Speaker
Yeah.
00:39:09
Speaker
In general terms, I think that we all agree that in patients that are at high risk of failure after they pass a spontaneous screening trial, the evidence points that using noninvasive on that group of patients decreases the rate of failure.
00:39:28
Speaker
or to extubation, so getting re-intubated, which is a positive thing.
00:39:33
Speaker
And it's moving them from that transition of mechanical ventilation with a tube in their mouth and sedation to now no tube and also positive pressure but through a mask.
00:39:44
Speaker
And so I think under those circumstances, you can choose which patients fall there, the hypercapniic patients, the patients that have underlying COPD, the patients with heart failure,
00:39:58
Speaker
the patient with neuromuscular disease.
00:39:59
Speaker
And I'll put them right there.
00:40:01
Speaker
That's a classic group that have high risk of just not passing the spontaneous brain trial.
00:40:07
Speaker
And you really need to get them out of these to non-invasive to improve their quality of life and whatever and whatnot.
00:40:14
Speaker
So I'll put that group of patients there.
00:40:17
Speaker
There's a second group that you mentioned, which is the patient that
00:40:21
Speaker
get extubated, and then hours later they start failing and you put them on non-invasive mechanical ventilation.
00:40:30
Speaker
And then under those circumstances, the odds are actually against the patient.
00:40:36
Speaker
There may be some that will do fine, but in general, the practice increases the morbidity and mortality of these patients.
00:40:45
Speaker
And the big thought is because you delay the time to
00:40:49
Speaker
intubate this group of patients.
00:40:51
Speaker
So in our practice, we use the post-extubation non-invasive as a preemptive approach for patients at high risk, not for everybody, but not for rescue, which is the one that failed.
00:41:09
Speaker
Now, there may be a group of patients in which there are circumstances that make them
00:41:16
Speaker
appropriate to have non-invasive as a rescue option because of their preferences and the overall picture of their care or the situation that is putting them under that circumstances.
00:41:30
Speaker
But in general, the movement is towards not using it.
00:41:35
Speaker
And that's a very important distinction in terms of the literature and practice today supports the use of
00:41:42
Speaker
non-invasive positive pressure ventilation as part of your plan, as part of your extubation and weaning plan.
00:41:51
Speaker
But the literature also, like you said, has shown that in those patients who we extubate and then two hours, three hours, a day later, they look like they're failing, to try to use non-invasive at that point as a rescue likely will delay the intubation that they need and can be associated with increased morbidity and mortality.
00:42:10
Speaker
I think it's an important distinction that our audience should keep in mind.
00:42:15
Speaker
And there's a good practice that we actually do is at the moment that we're going to extubate a patient, we do a huddle in which one of our physicians, the nurse, and the respiratory therapist just converge at the bedside and then discuss the process for extubation.
00:42:36
Speaker
It's very simple.
00:42:36
Speaker
It takes
00:42:37
Speaker
a couple of minutes, but it's essentially, does he have a difficult airway when we try to intubate him?
00:42:44
Speaker
And what is going to be the strategy to extubate him?
00:42:48
Speaker
Is he going to high flow?
00:42:49
Speaker
Is he going to non-invasive?
00:42:51
Speaker
Is he going to go to nasal cannula and whatnot?
00:42:54
Speaker
And that has decreased the amount of events that are due to lack of communication between the team when you're extubating somebody.
00:43:04
Speaker
That's a great practice, an extubation huddle.
00:43:07
Speaker
And like you said, it probably takes just a little bit of time, but saves a lot of potential miscommunication and stress in the patients as we try to provide the safest care possible.
Managing Post-Extubation Airway Edema
00:43:19
Speaker
You talked about the difficult airway, Eduardo, and I think this would be a good transition into talking about post-extubation airway edema and stridor and the role for a cuff leak test and also steroids and who?
00:43:35
Speaker
Yes.
00:43:37
Speaker
So our practice, I would say the cuff leak test as a test has such a variable performance.
00:43:48
Speaker
But that doesn't make it wrong.
00:43:50
Speaker
So there's two ways to do a cuff leak test.
00:43:53
Speaker
One is probably the easiest for our clinicians is to just put a stethoscope and deflate the cuff and then listen.
00:44:03
Speaker
And if there is a leak,
00:44:05
Speaker
then everybody's happy.
00:44:07
Speaker
That means that there's space around the endotracheal tube.
00:44:11
Speaker
And that means that when I take it out, the patient should be able to breathe.
00:44:16
Speaker
If there's none, then that's a negative test or a test that doesn't show any escape of air.
00:44:24
Speaker
And that raises alarms and bells in our practice, which may be that there is edema around.
00:44:31
Speaker
There's other causes that...
00:44:33
Speaker
we take into account.
00:44:35
Speaker
One of them is the size of the tube in relation to the patient.
00:44:42
Speaker
The other one that we now take much more care on is the presence of a bite block.
00:44:48
Speaker
And bite blocks can, patients that are short, they have the takeoff of the pilot balloon can get crimped by the bite block.
00:45:00
Speaker
And then you have a negative cough leak test, which may delay stubation or administration of steroids on that group of patients.
00:45:07
Speaker
There's other ways of doing the cough leak test in which you can do quantification of the amount of the exhale volume in relation to the inhale volume.
00:45:21
Speaker
And the values, if it's more than 12% or 20%, depending on what...
00:45:27
Speaker
what you read is a test that is positive.
00:45:30
Speaker
Now, that takes more protocolization and more steps, and so that's a little bit harder to implement.
00:45:41
Speaker
So what we do is just the auscultation at the bedside.
00:45:44
Speaker
And if that is negative, so there's no air leak, then under those situations, those patients receive steroids.
00:45:55
Speaker
And this is based on
00:45:57
Speaker
there's been a good amount of trials administering steroids, different types of steroids on patients with a decrease on the post-extubation stridor when you do that.
00:46:10
Speaker
So the question of which type of steroid and how many doses is still up in the air.
00:46:17
Speaker
I think the latest guidelines do recommend doing a leak test.
00:46:23
Speaker
What we usually do
00:46:25
Speaker
is those of we get ENT involved and they usually those that we do is Decadron and we give it every six hours until the next day before they get extubated.
00:46:41
Speaker
And then on those patients, obviously they are on our radar as a patient that may require a re-intubation.
00:46:50
Speaker
So we are the extubation huddle on those patients
00:46:53
Speaker
includes bringing the difficult airway card and whatnot when we're doing it.
00:46:58
Speaker
And do you perform the cuff leak test on everybody, or is it on only patients who've been on the ventilator for a certain amount of time or people you think are high risk?
00:47:07
Speaker
Everybody.
00:47:08
Speaker
This is an easier step to protocolize.
00:47:11
Speaker
It's just to say everybody.
00:47:13
Speaker
It's a relative, it's simple to do, and so we do it on everybody.
00:47:17
Speaker
Perfect.
Tracheostomy Timing and Weaning
00:47:19
Speaker
I want to talk a little bit about tracheostomy, recognizing that we could spend a whole hour on this, so I don't want to go too deep, Eduardo, but I just wanted to ask you about two aspects of tracheostomy.
00:47:31
Speaker
Just in general, timing of tracheostomy, this is something obviously that can be debated for a long time, but my feeling is earlier than we used to when I was in training, and just want to hear your thoughts, and it seems that it's reasonable in people who are
00:47:46
Speaker
moving from the difficulty weaning to the prolonged weaning that we start talking about that with families.
00:47:50
Speaker
And the second question is just some comments on once somebody has a trach, what's the best way to wean them?
00:47:59
Speaker
Yeah.
00:48:00
Speaker
So in terms of timing, I think we are around the 14-day mark.
00:48:07
Speaker
We have not moved towards early trach except in some situations in which the
00:48:15
Speaker
It's clinically indicated because of airway issues that will definitely require a tracheostomy.
00:48:22
Speaker
But I agree.
00:48:24
Speaker
As you go through the literature, we could argue this for probably all night, in which are the benefits and not the benefits and how the study was done.
00:48:35
Speaker
I do think that in patients that have a tracheostomy,
00:48:41
Speaker
especially in those that have been having trouble with sedation, in which you are using sedation because they are uncomfortable and trashing with the biting the tube and doing, and they have already a difficult wean or a prolonged wean, in those patients, it may make sense to do a tracheostomy earlier.
00:49:03
Speaker
But otherwise, our number, our magic number in our practice is around 14 days.
00:49:10
Speaker
which correlates in a sense with those patients that have prolonged wean and that we have done what we need to as much as we can to get them off the device.
00:49:23
Speaker
I do think that as I read the literature about early trachs, one of my concerns is doing trachs in patients that don't need a tracheostomy.
00:49:35
Speaker
and that they, because they would have been extubated in days after, right?
00:49:40
Speaker
And so that would be the main reason why early tracheostomy, unless a study or the evidence guides me otherwise, is not something that we are implementing right now.
00:49:57
Speaker
In terms of weaning on tracheostomy,
00:50:00
Speaker
I think that the best, I enjoyed this study so much by Dubran and in which they grabbed the patients that arrived to a long-term acute care facility coming from an ICU.
00:50:14
Speaker
And the first screening that they did before enrolling them in the trial was putting them on a tray collar and letting them breathe.
00:50:23
Speaker
And they had some criteria for failure and
00:50:27
Speaker
they extubated a large amount of patients before the trial was, before enrolling them on the trial, which just tells you about this practice that you may have in which you underestimate how much these patients could breathe on their own.
00:50:47
Speaker
And so my practice in general is that we should be
00:50:54
Speaker
performing a tracheostomy as soon as the tracheostomy is in place and allowing these patients to breathe spontaneously.
00:51:03
Speaker
And if they go through, that's the way to go.
00:51:07
Speaker
Now, after that, the question is how much you should support them if they didn't do well on that and how much support you should give to shift the load from the respiratory muscles to the patient.
00:51:22
Speaker
And
00:51:24
Speaker
So, if you follow what Gibran did in that paper, then these spontaneous breathing trials intermittently seem to have a better outcome for this group of patients rather than doing gradual reductions on pressure support.
00:51:43
Speaker
And I think it speaks to the fact that once they get a trach, they still probably are going to be better off with the protocol, and a daily trach collar SBT is probably the way to go there.
00:51:53
Speaker
and really try to push them to get off the ventilator at that point.
00:51:58
Speaker
Absolutely.
00:51:59
Speaker
I think that this is an issue of giving them the chance to prove that they can breathe spontaneously and improve everything that goes around.
00:52:10
Speaker
And actually, I think that a lot of these patients that go into this failure to wean or prolong mechanical ventilation,
00:52:19
Speaker
has to do with other items that we need to address on how to improve their respiratory resistance and compliance.
00:52:29
Speaker
What is going on that is making them fail?
00:52:34
Speaker
What's going on with their heart?
00:52:35
Speaker
What's their volume status?
00:52:37
Speaker
What's their mental status?
00:52:39
Speaker
Their nutritional status?
00:52:41
Speaker
How much rehab are they getting?
00:52:44
Speaker
All of these things together
00:52:46
Speaker
I think that have much more impact than just the fact of putting them on a spontaneous brain trial.
00:52:51
Speaker
Actually, I think that it's when it becomes much more essential, the holistic approach to the difficult to wean patient is to say, okay, let's go in order over the common causes.
00:53:04
Speaker
And some of the research that is coming out may help us understand where to hit these patients better.
Comprehensive Weaning Failure Approaches
00:53:13
Speaker
Can you comment a little bit more, Eduardo, on those causes and just a general approach to that failure to wean?
00:53:20
Speaker
So we talked a little bit about weaning-induced pulmonary edema, which is also used to be called cardiac causes of failed weaning.
00:53:28
Speaker
But just in general, what are other important causes that we should be considering in those patients who are falling in that prolonged weaning phase and are not really getting off the ventilator?
00:53:39
Speaker
Yeah, one of the other nice studies that come from the Chikarro group with Lagi is how these patients actually fail.
00:53:50
Speaker
So, and doing very elegant studies about the physiology of the respiratory system in patients that fail.
00:53:59
Speaker
And as you started seeing, these patients have an increase on elastance or decreasing compliance and an increase on the resistive load.
00:54:09
Speaker
And the question is, why is that happening in this group of patients?
00:54:15
Speaker
Because that's the load that the patient cannot, has to deal with using their accessory muscles and their diaphragm.
00:54:22
Speaker
And so bronchodilation, if the patient has underlying causes, the more I think about this group of patients, one of the common features that we see is volume overload.
00:54:35
Speaker
The amount of fluid that they have
00:54:39
Speaker
Just from being in the ICU, it's really hard to not find a patient coming out of the ICU that does not have edema.
00:54:48
Speaker
And if they have edema in the tissue, they have more water in the lung.
00:54:52
Speaker
I think that this trial in which they use BNP to guide the process and giving diuretics and restricting fluids for this group of patients,
00:55:05
Speaker
demonstrated a decrease in less of mechanical ventilation.
00:55:09
Speaker
And I think that's the item where you're going is how to decrease the load on the respiratory system.
00:55:15
Speaker
The other one is delirium and anxiety and the amount of sedation that we give to these patients.
00:55:22
Speaker
And it's clear to all of us now that the times have changed and we're moving towards a more
00:55:31
Speaker
an environment of light sedation and interaction and keeping these patients as functional as possible because that interaction and that mental activity allows them to participate in many things and decreases exposure to others like sedatives and other medications that otherwise they would not need to have.
00:55:55
Speaker
And
00:55:57
Speaker
Along this, actually in the patients, they studied from the subgroup of patients that Gibran studied and how their strength moved.
00:56:08
Speaker
And a key part for me of that study was that if you see the muscle pressure on the patients, the inspiratory muscle pressure did not change that much while they were in the LTAC.
00:56:26
Speaker
they stayed about the same, but the muscles of these patients, the peripheral muscles, the hand grip strength, increased a lot.
00:56:35
Speaker
And when they left, it increased even more when they left at LTAC, which tells me the importance of rehabilitation and maintaining muscle strength and conditioning on them.
00:56:50
Speaker
And I'll put a related to that, and it goes with respiratory elastance and resistance and a telectasis and whatnot, is the ability of the patient to cough.
00:57:00
Speaker
So now you have a patient that has a tracheostomy, so he has lost the glottic closure that is weak on his peripheral muscles, so the muscles of expiration are weaker, and he has the inability to take larger breath.
00:57:17
Speaker
So
00:57:18
Speaker
the ability to bring out secretions is impaired.
00:57:22
Speaker
So the concept here is the better you maintain the muscle strength throughout in the overall situation, even in the throat, in the larynx, and the management of secretions, it has to have impact just by thought in the outcome of these patients that are chronically ill and on a ventilator.
00:57:46
Speaker
So that would be the package where I would put it.
00:57:48
Speaker
And obviously, I cannot leave out nutrition and the electrolytes and under and overfeeding patients, as these are also associated with outcomes.
00:57:58
Speaker
So, yeah.
00:58:01
Speaker
Yeah, I think a systematic approach to those few patients that remain in that difficult-to-wean category, like you mentioned, is really a holistic approach to these patients.
00:58:11
Speaker
And a lot of also what a
00:58:14
Speaker
impede them to wean is probably created by us upstream early on in their critical illness.
00:58:19
Speaker
So paying attention to that is also going to be very important in terms of long-term outcomes.
00:58:26
Speaker
The last portion of our discussion regarding to the liberation slash weaning for mechanical ventilation topic that I wanted to touch was related to weaning and COVID-19.
00:58:40
Speaker
Obviously, it's impossible not to talk about COVID-19 in the current situation, even though a lot of our colleagues might be seeing a significant downtrend in those patients.
00:58:52
Speaker
But one of the observations that a lot of clinicians have made is that these patients that end up in the ICU, for many reasons that we can discuss and many that we probably don't understand, have remained on the ventilator for periods that seem to be longer than our other patients'
00:59:09
Speaker
without COVID-19 and similar ARDS or respiratory failure.
00:59:13
Speaker
Could you just maybe comment on what you think is different about COVID-19?
00:59:18
Speaker
Is it the disease?
00:59:18
Speaker
Is it how we behaved because we were afraid and the things that we did?
00:59:23
Speaker
And what is the current evidence available to guide best practice in the whole area that we're discussing of liberation and weaning?
COVID-19's Impact on Weaning Practices
00:59:34
Speaker
Yes, I think that this is a
00:59:38
Speaker
a manifestation of the challenges that we as clinicians with infection control.
00:59:44
Speaker
And there may be something basic with the disease.
00:59:49
Speaker
I cannot necessarily comment if it's different to others in the terms of the mechanism of winning for them.
01:00:00
Speaker
But what I can say is that
01:00:04
Speaker
Based on my observations, there's a couple of things that are occurring.
01:00:08
Speaker
You know, the first one was that at the beginning, we were sedating these patients a fair amount.
01:00:16
Speaker
And actually, the patient-ventilator interaction has been a real challenge to manage.
01:00:24
Speaker
And in big part is because we try to wake them up.
01:00:27
Speaker
But when they wake up, the level of the synchrony and discordance with the ventilator is very high.
01:00:33
Speaker
And so larger doses of sedation are used to try to control that, and it's not paralytics, which starts prolonging the amount of time on the ventilator.
01:00:45
Speaker
That's one of the parts.
01:00:48
Speaker
The second is, and I would say at least in our practice, one of the main causes for us not to do a spontaneous awakening trial, and this is protocolized, is a
01:01:00
Speaker
a physician or a practitioner saying, no, let's keep it on this patient.
01:01:09
Speaker
And the main cause that we have seen has been with ventilator patient discordance.
01:01:15
Speaker
So either very high respiratory effort or reverse trigger or simply just very or delirium.
01:01:25
Speaker
Oh my.
01:01:26
Speaker
And so the amount of
01:01:28
Speaker
Illyrium seems to be higher and it may be related to our practices to under these Circumstances we have been moving across the spectrum now to to this has become more of a routine case It's not the same that it was occurring at the beginning of the of the pandemic pandemic and and the efforts have been when you asked me about what's the best available evidence I don't have a new
01:01:56
Speaker
guide in particular for these patients.
01:01:59
Speaker
I do know, and I was reviewing the literature on tracheostomy for these patients, that the time for them to get trachis is around 12 to 17, 23 days in even some series.
01:02:13
Speaker
But many of them get weaned off, and that has been our case recently.
01:02:18
Speaker
In our โ both in our practice and in the long-term acute care facility that we interact with, around 75% of the patients get actually liberated from mechanical ventilation.
01:02:32
Speaker
And of those that had prolonged mechanical ventilation that ended up in a long-term acute care facility.
01:02:38
Speaker
And so what our practice has been to try to apply what we have discussed all today to the T.
01:02:48
Speaker
to try to be on top of the protocols, to try to do the SAT, the SBT, to do light sedation on the patients as much as we can and try to contain with that, to use the FACT light to ensure that we are diuresing these patients as much as possible so that they have the best chances to get off the ventilator.
01:03:10
Speaker
And I will tell you is that many times when we
01:03:14
Speaker
get referrals or patients that have been out in the community.
01:03:21
Speaker
The main difference of care that we do is the application of these protocols on the care and do the best basic ARDS, mechanical ventilation care for them.
01:03:33
Speaker
And that is an important lesson that we learned, that these patients
01:03:38
Speaker
may or may not have some very unique characteristics due to the disease, but that the reality is that they fall within the category of other ARDS patients, they fall within the category of other mechanically ventilated patients, and we should do as much as we can to apply the protocols that we know have worked in large populations that are very heterogeneous for both of those categories.
01:04:00
Speaker
So I think that's a very important message for our audience.
01:04:05
Speaker
The other thing that you mentioned, which I think is worth
01:04:08
Speaker
commenting on Eduardo with the COVID-19 patients is the amount of delirium.
01:04:13
Speaker
And it's interesting because one of the things that has been a win maybe in terms of evidence base has been finally, it seems, some stronger evidence towards the use of steroids.
01:04:26
Speaker
And I think we have been using more steroids in these COVID-19 ARDS patients, but we always think of steroids and complications as neuromuscular weakness and infections.
01:04:37
Speaker
but we don't think of delirium, which is a huge probably side effect of using the steroids we're using.
01:04:43
Speaker
Any comments on that?
01:04:46
Speaker
Yes, I think you're right on.
01:04:50
Speaker
When we talk about steroids, I think that the studies should focus on what actually the adverse and the consequences of those adverse events.
01:05:00
Speaker
And I would say that, yes, we're using more steroids now.
01:05:04
Speaker
we see delirium, we see hyperglycemia, we see leukocytosis, and a weakness we will see.
01:05:13
Speaker
I mean, it's hard to go after that, but what I would think is that every single one of those adverse reactions leads to more healthcare expenditures and more interventions, either more finger sticks, more insulin,
01:05:31
Speaker
more blood cultures, more tests to check for infection, and more medications and more time on mechanical ventilation because of the delirium.
01:05:40
Speaker
So time will tell, but I think that a focus should be on what are the consequences now that we know that it works to improve the survival on these patients.
01:05:55
Speaker
Now, I think that the evidence has shifted us that this is a clear,
01:06:01
Speaker
pathway for the management of patients in the ICU that require mechanical ventilation or oxygen with COVID ARDS.
01:06:10
Speaker
But the adverse events, we're going to have to become more attuned and how to deal with them to improve the outcomes of these patients.
01:06:22
Speaker
Eduardo, I really enjoyed the conversation.
01:06:24
Speaker
I really appreciate all your expertise.
Medical Literature Recommendation
01:06:28
Speaker
As we wrap up, I would like to
01:06:30
Speaker
do something that is customary with our podcast and ask you a couple of questions unrelated to the topic.
01:06:37
Speaker
Would that be okay?
01:06:39
Speaker
Absolutely.
01:06:41
Speaker
The first question relates to books, and I would like to know if there's a book or books that have influenced you the most or a book that you have gifted most often to others.
01:06:54
Speaker
I have read a fair, I ship from topic novels and whatnot, but probably the best answer would be what book have I gifted the most?
01:07:04
Speaker
And it has been William Osler's biography by Michael Bliss.
01:07:09
Speaker
I love biographies and this one is one of those in which it brings the whole romantic and backstories of medicine
01:07:21
Speaker
that Osler influenced.
01:07:23
Speaker
He was an amazing physician and had a lot of personality and it brings a lot of stories.
01:07:30
Speaker
So that's something that I give often to our fellows or residents just because of what it brings to the flavor of medicine.
01:07:44
Speaker
And if I am correct, I might be wrong.
01:07:47
Speaker
We can fact check this, but my understanding is that
01:07:51
Speaker
Dr. William Mosler actually died of the 1918 flu.
01:07:56
Speaker
Is that something that I read somewhere and I think that he actually had got sick and got, so he was also part of a big pandemic and had that complication.
01:08:09
Speaker
Oh, that's, I know that he died from pneumonia and with an effusion and they were placing a chest tube, I believe, but the
01:08:17
Speaker
I didn't know it was the flu, so that makes it even more consequential to this time.
01:08:21
Speaker
Absolutely.
01:08:23
Speaker
The second question relates to what do you believe to be true in medicine or in life that most other people don't believe or at least behave like they
Future of Medicine and Technology
01:08:30
Speaker
don't believe?
01:08:30
Speaker
Yeah.
01:08:33
Speaker
So I think the future doctor is going to be very different than us.
01:08:41
Speaker
And that technology will be an essential part of their work.
01:08:47
Speaker
and that the biggest threat will be too much information too easily available embedded opinionated information and which was a threat and continues to be a threat i mean covid just unmasked it as i had never seen it and so the the future doctor is going to have to uh deal with this and uh and create an environment to be able to
01:09:16
Speaker
to find the truth amongst all the information.
01:09:22
Speaker
What a challenge.
01:09:23
Speaker
Absolutely.
01:09:24
Speaker
I think this infodemic that we've seen with the pandemic has had not only tremendous consequences on the public, but I think even furthermore has had very harmful effects on clinicians and on their behavior.
01:09:41
Speaker
And I think we've moved to an era where we are overloaded with information
01:09:46
Speaker
And in the past, access to information was power.
01:09:50
Speaker
Now it's probably the ability to understand which information we should be paying attention to that will be power.
01:09:55
Speaker
And like you said, it'd be a different skill set that people will need to have in the next decades ahead of us.
01:10:07
Speaker
The last question, Eduardo, as a departing thought is, what would you want every intensivist who's listening to this podcast to know could be a quote, a fact, or just a thought?
Understanding Mechanical Ventilation Language
01:10:22
Speaker
I think that the, what I would like everybody to know is that we can do better with mechanical ventilation.
01:10:31
Speaker
Mechanical ventilation is growing, developing, and to be able to do what we want, we need to ensure that we understand what the machine does.
01:10:46
Speaker
And I think that that has evolved and we need to learn to learn new stuff on mechanical ventilation.
01:10:55
Speaker
In that statement, I will also put that words matter.
01:11:00
Speaker
And when I say words matter, it has to do with how we refer a lot to patients.
01:11:09
Speaker
And so when you use the words like, that's his baseline,
01:11:15
Speaker
or that's where he lived, or I don't know, that's a soft blood pressure, that's a new one.
01:11:24
Speaker
All of those alter the behavior of the team around the patient and create views.
01:11:31
Speaker
And so as we think towards the future, I think that we need to use the same words that mean something
01:11:42
Speaker
so that we don't bias the rest of the team when we're taking care of patients.
01:11:48
Speaker
So those are my two departing thoughts.
01:11:52
Speaker
And I think this would be a perfect place to stop.
01:11:55
Speaker
I really appreciate your time, your expertise, and look forward to seeing you in person soon again, but also to having you back on the podcast as a guest.
01:12:04
Speaker
Thank you very much.
01:12:04
Speaker
Sergio, this was a pleasure to talk to you and to hear that you're doing great.
01:12:11
Speaker
Well, and indeed, I look forward to seeing you again.
01:12:14
Speaker
Best to you.
01:12:16
Speaker
Thank you.
01:12:18
Speaker
Thank you for listening to Critical Matters, a Sound Critical Care podcast.
01:12:23
Speaker
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01:12:29
Speaker
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01:12:34
Speaker
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