Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care 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 frequently utilized in the intensive care unit.
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.
Speaker: Duration of mechanical ventilation is a commonly followed quality metric in many intensive care units.
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.
Speaker: Our guest is Dr. Eduardo Mireles Cabo de Vila.
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.
Speaker: His areas of clinical interest include critical care medicine,
Speaker: application of mechanical ventilation, acute and chronic respiratory failure, and extracorporeal life support.
Speaker: He has a special interest in education and critical care, and is specific on the use of stimulation to enhance and accelerate learning.
Speaker: Dr. Mireles Cabo de Villa is also the medical director of the Simulation and Advanced Skills Center.
Speaker: He has developed, along with his critical care simulation team, several courses and devices to enhance the training of healthcare providers
Speaker: at the clinic and elsewhere.
Speaker: He's an accomplished clinician, researcher, and educator.
Speaker: We are truly honored and fortunate to have him on the podcast.
Speaker: Eduardo, welcome to Critical Matters.
Speaker: Thank you, Sergio.
Speaker: Nice to be here.
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
Speaker: So much has happened since, and I hope things are good in Cleveland.
Speaker: So how are things down there?
Speaker: They are much better.
Speaker: It has been a long year, no doubt, Sergio, but now we are preparing for a presidential debate tomorrow for October.
Speaker: We're vaccinating everybody, and we are ready to work.
Speaker: Excellent.
Speaker: So let's dive into the topic that we have at hand today.
Speaker: I would like to start with just some concepts and definitions to introduce the audience to what we're talking about today.
Speaker: And what I wanted to ask you first, the difference between liberation versus weaning from mechanical ventilation, are they different?
Speaker: Can they be used interchangeably?
Speaker: Does it really matter at the end?
Speaker: Well, I think that words do matter.
Speaker: And so I prefer the term liberation because it talks about removal of support, the whole process that occurs.
Speaker: I think weaning, as the word states, focuses on a gradual decrease of support, which is a historical wording.
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.
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.
Speaker: But more and more, the word being used is now liberation.
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.
Speaker: And a lot of what we're going to talk about today is going to focus on those patients as well.
Speaker: That's correct.
Speaker: Majority of the patients will be extubated on the first attempt of the ventilator without any gradual decrease in support.
Speaker: And majority of them, as we'll talk about this, just need a test, the spontaneous breathing trial.
Speaker: And from there, they go on to be liberated without any weaning, as the word means.
Speaker: Excellent.
Speaker: The second thing I wanted to ask you was about the concept of simple liberation versus difficult weaning versus prolonged weaning or liberation.
Speaker: Are these terms that are commonly agreed upon, or do they mean different things to different clinicians?
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.
Speaker: And in 2007, in the sixth international conference, a group of experts got together and came up with this classification, which I think,
Speaker: although at that time it was created by consensus, now after several publications, it does correlate with practice.
Speaker: So the terms matter in this situation, and they correlate well with outcomes.
Speaker: So, for example, simple weaning is the extubation at the first try.
Speaker: So you do as continuous brain trial, the patient gets extubated after he passes it.
Speaker: The term difficult weaning refers to those patients that require up to three
Speaker: spontaneous breathing trials or less than seven days of mechanical ventilation.
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.
Speaker: So I think that it helps to know
Speaker: what is happening in your unit or in the literature that is being presented with certain interventions that we will talk about.
Speaker: So I think that overall, we should be using those terms at this time in our publications and to refer about our patients.
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.
Speaker: But
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.
Speaker: Absolutely.
Speaker: This has been now repeated in a couple of trials in which you can see the
Speaker: mortality, the length of mechanical ventilation and length of ICU stay increasing as you move from one category to the other.
Speaker: And you can also see the incidence of prolonged or difficult weaning according to the population.
Speaker: And so I think that absolutely this is now has been replicated in a couple of studies
Speaker: and it does correlate absolutely with outcomes.
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
Speaker: yet they represent an enormous amount of the total time on mechanical ventilation in a given unit.
Speaker: So they're really super users and consume an enormous amount of resources.
Speaker: That's correct.
Speaker: The amount of time that they spend on mechanical ventilation, length of stay in the ICU, if you compare on the Peñuela study in 2011, they were, if you're a simple wean in six days,
Speaker: difficult weaning nine, but if your prolonged weaning is 18 days and longer.
Speaker: And so these are patients that occupy one of the resources in the ICU that needs to be addressed.
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.
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.
Speaker: So I think it's meaningful to try to shorten that
Speaker: amount of time by intervention.
Speaker: I wanted to ask you the next kind of category of terms relate to failure and failure to wean, failed extubation.
Speaker: What do those terms mean to you and what do they mean in the literature?
Speaker: Yeah, the extubation failure had variable
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.
Speaker: And I think that that's pretty operationally efficient for us to recognize those patients, both in studies and in practice.
Speaker: The second one, which is prolonged mechanical ventilation, has a long story,
Speaker: of how we came to those more than 21 days of mechanical ventilation to be the definition.
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.
Speaker: But actually, it pans out very well with the patients that have prolonged mechanical ventilation that the literature describes.
Speaker: In general, all the series of patients that have had prolonged weaning
Speaker: and that go on to have prolonged mechanical ventilation have more than 21 days on mechanical ventilation.
Speaker: So I think that those two are now pretty well established and accepted.
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.
Speaker: But I do believe that
Speaker: there's a misconception among many clinicians that a reintubation rate of 0% is phenomenal.
Speaker: And I think that there's probably a sweet spot because if you have no reintubations, perhaps you're not being as aggressive.
Speaker: Could you comment on that, Eduardo?
Speaker: Absolutely.
Speaker: That's another metric that we follow, which is how many patients should be
Speaker: failing extubation so that you know that you're being active enough to get them off the ventilator.
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.
Speaker: So the number ranges, and as the literature goes forward, it's around 5% to 10%.
Speaker: I've seen as high as 14%.
Speaker: But it's another metric that we keep an eye on to be sure that we're not using the gestalt.
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.
Speaker: So
Speaker: we may not extubate patients just by looking at them just from their clinical characteristics, not test them.
Speaker: And many of them, up to 85% on some literature, were ready to be extubated.
Speaker: And it always comes to us, Sergio, is the events in which patients get self-extubated,
Speaker: and then half of them do not get reintubated, right?
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.
Speaker: And I think that those are very important points that are worth reemphasizing.
Speaker: And point number one, like you said, is that
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 on their own.
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.
Speaker: And the other thing that you mentioned, Eduardo, which I think is worth repeating is that you follow metrics of quality.
Speaker: You need obviously more than one metric to make sure that you
Speaker: are doing the right thing.
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.
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.
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.
Speaker: Absolutely.
Speaker: Is there any increased morbidity documented with patients who fail in extubation and need to be re-intubated?
Speaker: Yeah, and that's the challenge.
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,
Speaker: I mean, all the things that imply with doing that.
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.
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.
Speaker: because obviously it does have consequences when you fail and the patients get re-intubated.
Speaker: Absolutely.
Speaker: I would like to move on and talk more about evidence-based liberation in adult critical care patients from mechanical ventilation.
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.
Speaker: Absolutely.
Speaker: I think that the, as I think about the practice that we have,
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.
Speaker: That's what we do.
Speaker: And the whole rationale for this, we're going to talk more about it, but essentially they are at the bedside.
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.
Speaker: And so what do we do?
Speaker: We have a WIMP.
Speaker: screening screening screening
Speaker: essential for us and the ones that were being used the most.
Speaker: And then we did a sensitivity analysis and saw that the others were not changing the patients that we should be choosing.
Speaker: So that made us use less steps.
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
Speaker: professional support over five OPEP.
Speaker: And then if they pass that after half an hour, they have an extubation screen.
Speaker: And during that extubation screen, essentially the amount of secretions, do they have a cough leak and their level of interaction.
Speaker: And if they pass the extubation screen, then they get extubated.
Speaker: And so that's the series of steps.
Speaker: We used to have an intermediate step in which we were
Speaker: measuring certain values like the RSVI and minute ventilation and whatnot.
Speaker: And we just took that off from the protocol.
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.
Speaker: That's phenomenal.
Speaker: So let's dissect that a little bit more.
Speaker: And the first thing you mentioned
Speaker: was the weaning screening or weaning readiness assessment.
Speaker: So that is done by protocol by the respiratory therapy colleague.
Speaker: And like you said, what you've learned over the years is that less is better, right?
Speaker: Less is more.
Speaker: So you really focus on just, I presume, a couple of key components.
Speaker: Could you share some of those key components with us, Eduardo?
Speaker: Absolutely.
Speaker: And this is some key word that I heard from my
Speaker: one of my peers, which is the more steps in a process, the higher the chance of error or failure you will have.
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.
Speaker: So what we have right now, the patient has to be able to breathe spontaneously, so to trigger the breath.
Speaker: His FiO2 has to be less or equal to 40%.
Speaker: The pH has to be above 7.3.
Speaker: And the PEEP has to be less than 8 and a respiratory rate less than 35.
Speaker: And if they are on pressers, it has to be less than 5 micrograms per minute of leave of it.
Speaker: That's what we have said.
Speaker: If it's higher than that, then they have to interact with the clinicians.
Speaker: and we decide if it's good or not to put the patient on a spontaneous breathing trial.
Speaker: But it's a team decision at that moment.
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.
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.
Speaker: Yes, we just – there were several reasons for that.
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.
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.
Speaker: the sensitivity and specificity were different.
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.
Speaker: Were they able to breathe spontaneously?
Speaker: And if they were, unless there wasn't any contraindication to it, we would extubate these patients.
Speaker: Excellent.
Speaker: So let's dive into the spontaneous breathing trial, the SPT itself.
Speaker: And I think that, again, it's a very simple concept, but the devil's in the details.
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.
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
Speaker: or a T-piece without any pressure augmentation.
Speaker: Yes, absolutely.
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.
Speaker: And so the fact that they have a
Speaker: endotracheal tube increases the resistive load that the patient's respiratory muscles has to be exposed to.
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.
Speaker: And
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.
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.
Speaker: And I will comment a little bit more here because the issue is, and you may have seen this here in which
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
Speaker: I think that that was our issue.
Speaker: It's easier to do, without a doubt, a pressure support trial because you don't have to disconnect the patient.
Speaker: It's easier for the RTs just to, and you have the monitoring from the ventilator.
Speaker: The patient stops breathing, it kicks in.
Speaker: So there's operational things that makes it easier.
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
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.
Speaker: And perhaps there's nuances in that study, but it just talked about that fear that we had for that group of patients.
Speaker: And we'll talk about some other subgroup of patients in which I think that TPs may be a better option for them.
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.
Speaker: But you did mention that in some instances, you might want to move to a TPS.
Speaker: Could you tell us a little bit more about that?
Speaker: Yes, I think that there's a couple of
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.
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
Speaker: some support in the area with positive pressure may hide and then when they get extubated then they are exposed to this situation.
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.
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.
Speaker: And that may be another way rather than using a TPS for these patients and to protocolize the care for them.
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?
Speaker: Could you share that with that a little bit more?
Speaker: Yes.
Speaker: And this is the group from Javier Monette and Tabul and Dres, which essentially have done in patients pretty invasive patients.
Speaker: monitoring on patients that failed their spontaneous breathing trial.
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.
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.
Speaker: And if the patients have a negative
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
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
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.
Speaker: And they also have done ultrasounds before and after counting the B lines also with relatively good performance.
Speaker: So I think that this is an area that needs further exploration, but it has caught my attention because you can
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.
Speaker: Those patients may be patients that we should be focusing on seeing if this is volume, cardiac dysfunction, and whatnot.
Speaker: Absolutely.
Speaker: And I think I was going to ask you, Eduardo, related to another population that I have observed a
Speaker: empirically or anecdotally, but I really have never seen any literature that I think a TP sometimes might benefit.
Speaker: It's a very similar rationale.
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.
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.
Speaker: Is that something that has been reported or that you have observed as well?
Speaker: I have observed that.
Speaker: Actually, this week, well, last week, we had a similar patient with an intrathoracic mass, and the exact same thing occurred.
Speaker: The clinician at the bedside said he passed the spontaneous breathing trial.
Speaker: He was extubated, failed.
Speaker: re-intubated, and so we did a TP trial just to reassess that.
Speaker: And so I have not seen particularly that reported, but I can relate very clearly with your point.
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?
Speaker: So really good point.
Speaker: Absolutely.
Speaker: The other question I had regarding the SPT is the timing of the day and the frequency.
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?
Speaker: Is that something that you guys have wired down at your practice?
Speaker: Yes, and I think that there's a lot of room for improvement.
Speaker: And I'll put it this way.
Speaker: We are once a day, spontaneous breathing trial, unless the team comes to the conclusion that this patient needs another one.
Speaker: And sometimes it's because you come in the morning, they are doing the SAT, and they're completely snowed.
Speaker: You say, you know, that doesn't even count weights.
Speaker: Let's do it later on.
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.
Speaker: Now, there's some literature saying that if you extubate them at night, the mortality may be higher on those groups of patients.
Speaker: However, I think that this is all related to
Speaker: the site where you work and how you make the operations occur.
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.
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.
Speaker: for that patient when you extubate him.
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.
Speaker: Excellent.
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.
Speaker: Obviously, we have protocols for sedation or daily assessment of sedation.
Speaker: awakening.
Speaker: We have protocols for weaning and liberation from mechanical ventilation for who's ready for SPT.
Speaker: And also now people are including protocols for early mobility and other interventions within the A to F bundles.
Speaker: Could you comment on where that stands and what should be the current practice based on the evidence?
Speaker: Well, yeah, I think that the, there is no doubt in my mind that the way that we need to
Speaker: manage is by protocols.
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.
Speaker: And it has to do with the environment and how we as humans practice
Speaker: I think that we are in an era of information overload.
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.
Speaker: It should be dependent on the performance of the protocol by a team member continuously at the bedside.
Speaker: I think that the other reason for ensuring that we're doing protocols in our practice
Speaker: is that it's very hard for us to detect associations with when the output is rare.
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.
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.
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.
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.
Speaker: And you have to ensure that you create a protocol that speaks to the environment where you are.
Speaker: There's also, and we talked a little bit about that, the desire of inertia on beliefs on our providers.
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.
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.
Speaker: So
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.
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.
Speaker: that's where I would say that we stand right now.
Speaker: And from there you can build up what should be on that protocol, right?
Speaker: And you can think about the bundles for the ABCDF.
Speaker: You can think about how you manage and wean patients from mechanical ventilation that have prolonged mechanical ventilation.
Speaker: All of those, I think, that need to be protocolized.
Speaker: And that protocol needs to be adjusted to the practice where you are.
Speaker: This is
Speaker: It's not the same my hospital that your hospital or even within our hospital, the regional practices between us.
Speaker: And there's differences in how even the units are designed.
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.
Speaker: But on the other hand, you have to be regimented.
Speaker: because if everybody's doing something different, there's no way to figure out what works and what doesn't work.
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.
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.
Speaker: But I think that ultimately what you're trying to do is really move the needle
Speaker: for the vast majority of patients.
Speaker: And like you said, the large majority of patients who are mechanical ventilation will fall into that simple weaning.
Speaker: So getting to that SPT as soon as possible is probably the best way to move those patients forward.
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.
Speaker: Absolutely.
Speaker: I would like to move on to some additional considerations related to this process.
Speaker: And I wanted to ask you specifically about non-invasive ventilation after extubation.
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
Speaker: as a rescue therapy trying to avoid a failed extubation.
Speaker: Could you comment on that, Eduardo, on how you use it and what the evidence says?
Speaker: Yeah.
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.
Speaker: or to extubation, so getting re-intubated, which is a positive thing.
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.
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,
Speaker: the patient with neuromuscular disease.
Speaker: And I'll put them right there.
Speaker: That's a classic group that have high risk of just not passing the spontaneous brain trial.
Speaker: And you really need to get them out of these to non-invasive to improve their quality of life and whatever and whatnot.
Speaker: So I'll put that group of patients there.
Speaker: There's a second group that you mentioned, which is the patient that
Speaker: get extubated, and then hours later they start failing and you put them on non-invasive mechanical ventilation.
Speaker: And then under those circumstances, the odds are actually against the patient.
Speaker: There may be some that will do fine, but in general, the practice increases the morbidity and mortality of these patients.
Speaker: And the big thought is because you delay the time to
Speaker: intubate this group of patients.
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.
Speaker: Now, there may be a group of patients in which there are circumstances that make them
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.
Speaker: But in general, the movement is towards not using it.
Speaker: And that's a very important distinction in terms of the literature and practice today supports the use of
Speaker: non-invasive positive pressure ventilation as part of your plan, as part of your extubation and weaning plan.
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.
Speaker: I think it's an important distinction that our audience should keep in mind.
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.
Speaker: It's very simple.
Speaker: It takes
Speaker: a couple of minutes, but it's essentially, does he have a difficult airway when we try to intubate him?
Speaker: And what is going to be the strategy to extubate him?
Speaker: Is he going to high flow?
Speaker: Is he going to non-invasive?
Speaker: Is he going to go to nasal cannula and whatnot?
Speaker: And that has decreased the amount of events that are due to lack of communication between the team when you're extubating somebody.
Speaker: That's a great practice, an extubation huddle.
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.
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?
Speaker: Yes.
Speaker: So our practice, I would say the cuff leak test as a test has such a variable performance.
Speaker: But that doesn't make it wrong.
Speaker: So there's two ways to do a cuff leak test.
Speaker: One is probably the easiest for our clinicians is to just put a stethoscope and deflate the cuff and then listen.
Speaker: And if there is a leak,
Speaker: then everybody's happy.
Speaker: That means that there's space around the endotracheal tube.
Speaker: And that means that when I take it out, the patient should be able to breathe.
Speaker: If there's none, then that's a negative test or a test that doesn't show any escape of air.
Speaker: And that raises alarms and bells in our practice, which may be that there is edema around.
Speaker: There's other causes that...
Speaker: we take into account.
Speaker: One of them is the size of the tube in relation to the patient.
Speaker: The other one that we now take much more care on is the presence of a bite block.
Speaker: And bite blocks can, patients that are short, they have the takeoff of the pilot balloon can get crimped by the bite block.
Speaker: And then you have a negative cough leak test, which may delay stubation or administration of steroids on that group of patients.
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.
Speaker: And the values, if it's more than 12% or 20%, depending on what...
Speaker: what you read is a test that is positive.
Speaker: Now, that takes more protocolization and more steps, and so that's a little bit harder to implement.
Speaker: So what we do is just the auscultation at the bedside.
Speaker: And if that is negative, so there's no air leak, then under those situations, those patients receive steroids.
Speaker: And this is based on
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.
Speaker: So the question of which type of steroid and how many doses is still up in the air.
Speaker: I think the latest guidelines do recommend doing a leak test.
Speaker: What we usually do
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.
Speaker: And then on those patients, obviously they are on our radar as a patient that may require a re-intubation.
Speaker: So we are the extubation huddle on those patients
Speaker: includes bringing the difficult airway card and whatnot when we're doing it.
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?
Speaker: Everybody.
Speaker: This is an easier step to protocolize.
Speaker: It's just to say everybody.
Speaker: It's a relative, it's simple to do, and so we do it on everybody.
Speaker: Perfect.
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.
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
Speaker: moving from the difficulty weaning to the prolonged weaning that we start talking about that with families.
Speaker: And the second question is just some comments on once somebody has a trach, what's the best way to wean them?
Speaker: Yeah.
Speaker: So in terms of timing, I think we are around the 14-day mark.
Speaker: We have not moved towards early trach except in some situations in which the
Speaker: It's clinically indicated because of airway issues that will definitely require a tracheostomy.
Speaker: But I agree.
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.
Speaker: I do think that in patients that have a tracheostomy,
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.
Speaker: But otherwise, our number, our magic number in our practice is around 14 days.
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.
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.
Speaker: and that they, because they would have been extubated in days after, right?
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.
Speaker: In terms of weaning on tracheostomy,
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.
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.
Speaker: And they had some criteria for failure and
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.
Speaker: And so my practice in general is that we should be
Speaker: performing a tracheostomy as soon as the tracheostomy is in place and allowing these patients to breathe spontaneously.
Speaker: And if they go through, that's the way to go.
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.
Speaker: And
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.
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.
Speaker: and really try to push them to get off the ventilator at that point.
Speaker: Absolutely.
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.
Speaker: And actually, I think that a lot of these patients that go into this failure to wean or prolong mechanical ventilation,
Speaker: has to do with other items that we need to address on how to improve their respiratory resistance and compliance.
Speaker: What is going on that is making them fail?
Speaker: What's going on with their heart?
Speaker: What's their volume status?
Speaker: What's their mental status?
Speaker: Their nutritional status?
Speaker: How much rehab are they getting?
Speaker: All of these things together
Speaker: I think that have much more impact than just the fact of putting them on a spontaneous brain trial.
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.
Speaker: And some of the research that is coming out may help us understand where to hit these patients better.
Speaker: Can you comment a little bit more, Eduardo, on those causes and just a general approach to that failure to wean?
Speaker: So we talked a little bit about weaning-induced pulmonary edema, which is also used to be called cardiac causes of failed weaning.
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?
Speaker: Yeah, one of the other nice studies that come from the Chikarro group with Lagi is how these patients actually fail.
Speaker: So, and doing very elegant studies about the physiology of the respiratory system in patients that fail.
Speaker: And as you started seeing, these patients have an increase on elastance or decreasing compliance and an increase on the resistive load.
Speaker: And the question is, why is that happening in this group of patients?
Speaker: Because that's the load that the patient cannot, has to deal with using their accessory muscles and their diaphragm.
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.
Speaker: The amount of fluid that they have
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.
Speaker: And if they have edema in the tissue, they have more water in the lung.
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,
Speaker: demonstrated a decrease in less of mechanical ventilation.
Speaker: And I think that's the item where you're going is how to decrease the load on the respiratory system.
Speaker: The other one is delirium and anxiety and the amount of sedation that we give to these patients.
Speaker: And it's clear to all of us now that the times have changed and we're moving towards a more
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.
Speaker: And
Speaker: Along this, actually in the patients, they studied from the subgroup of patients that Gibran studied and how their strength moved.
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.
Speaker: they stayed about the same, but the muscles of these patients, the peripheral muscles, the hand grip strength, increased a lot.
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.
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.
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.
Speaker: So
Speaker: the ability to bring out secretions is impaired.
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.
Speaker: So that would be the package where I would put it.
Speaker: And obviously, I cannot leave out nutrition and the electrolytes and under and overfeeding patients, as these are also associated with outcomes.
Speaker: So, yeah.
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.
Speaker: And a lot of also wh at a
Speaker: impede them to wean is probably created by us upstream early on in their critical illness.
Speaker: So paying attention to that is also going to be very important in terms of long-term outcomes.
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.
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.
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'
Speaker: without COVID-19 and similar ARDS or respiratory failure.
Speaker: Could you just maybe comment on what you think is different about COVID-19?
Speaker: Is it the disease?
Speaker: Is it how we behaved because we were afraid and the things that we did?
Speaker: And what is the current evidence available to guide best practice in the whole area that we're discussing of liberation and weaning?
Speaker: Yes, I think that this is a
Speaker: a manifestation of the challenges that we as clinicians with infection control.
Speaker: And there may be something basic with the disease.
Speaker: I cannot necessarily comment if it's different to others in the terms of the mechanism of winning for them.
Speaker: But what I can say is that
Speaker: Based on my observations, there's a couple of things that are occurring.
Speaker: You know, the first one was that at the beginning, we were sedating these patients a fair amount.
Speaker: And actually, the patient-ventilator interaction has been a real challenge to manage.
Speaker: And in big part is because we try to wake them up.
Speaker: But when they wake up, the level of the synchrony and discordance with the ventilator is very high.
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.
Speaker: That's one of the parts.
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
Speaker: a physician or a practitioner saying, no, let's keep it on this patient.
Speaker: And the main cause that we have seen has been with ventilator patient discordance.
Speaker: So either very high respiratory effort or reverse trigger or simply just very or delirium.
Speaker: Oh my.
Speaker: And so the amount of
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
Speaker: guide in particular for these patients.
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.
Speaker: But many of them get weaned off, and that has been our case recently.
Speaker: In our – 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.
Speaker: And of those that had prolonged mechanical ventilation that ended up in a long-term acute care facility.
Speaker: And so what our practice has been to try to apply what we have discussed all today to the T.
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.
Speaker: And I will tell you is that many times when we
Speaker: get referrals or patients that have been out in the community.
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.
Speaker: And that is an important lesson that we learned, that these patients
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.
Speaker: So I think that's a very important message for our audience.
Speaker: The other thing that you mentioned, which I think is worth
Speaker: commenting on Eduardo with the COVID-19 patients is the amount of delirium.
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.
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.
Speaker: but we don't think of delirium, which is a huge probably side effect of using the steroids we're using.
Speaker: Any comments on that?
Speaker: Yes, I think you're right on.
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.
Speaker: And I would say that, yes, we're using more steroids now.
Speaker: we see delirium, we see hyperglycemia, we see leukocytosis, and a weakness we will see.
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,
Speaker: more blood cultures, more tests to check for infection, and more medications and more time on mechanical ventilation because of the delirium.
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.
Speaker: Now, I think that the evidence has shifted us that this is a clear,
Speaker: pathway for the management of patients in the ICU that require mechanical ventilation or oxygen with COVID ARDS.
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.
Speaker: Eduardo, I really enjoyed the conversation.
Speaker: I really appreciate all your expertise.
Speaker: As we wrap up, I would like to
Speaker: do something that is customary with our podcast and ask you a couple of questions unrelated to the topic.
Speaker: Would that be okay?
Speaker: Absolutely.
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.
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?
Speaker: And it has been William Osler's biography by Michael Bliss.
Speaker: I love biographies and this one is one of those in which it brings the whole romantic and backstories of medicine
Speaker: that Osler influenced.
Speaker: He was an amazing physician and had a lot of personality and it brings a lot of stories.
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.
Speaker: And if I am correct, I might be wrong.
Speaker: We can fact check this, but my understanding is that
Speaker: Dr. William Mosler actually died of the 1918 flu.
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.
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
Speaker: I didn't know it was the flu, so that makes it even more consequential to this time.
Speaker: Absolutely.
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 don't believe?
Speaker: Yeah.
Speaker: So I think the future doctor is going to be very different than us.
Speaker: And that technology will be an essential part of their work.
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
Speaker: to find the truth amongst all the information.
Speaker: What a challenge.
Speaker: Absolutely.
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.
Speaker: And I think we've moved to an era where we are overloaded with information
Speaker: And in the past, access to information was power.
Speaker: Now it's probably the ability to understand which information we should be paying attention to that will be power.
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.
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?
Speaker: I think that the, what I would like everybody to know is that we can do better with mechanical ventilation.
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.
Speaker: And I think that that has evolved and we need to learn to learn new stuff on mechanical ventilation.
Speaker: In that statement, I will also put that words matter.
Speaker: And when I say words matter, it has to do with how we refer a lot to patients.
Speaker: And so when you use the words like, that's his baseline,
Speaker: or that's where he lived, or I don't know, that's a soft blood pressure, that's a new one.
Speaker: All of those alter the behavior of the team around the patient and create views.
Speaker: And so as we think towards the future, I think that we need to use the same words that mean something
Speaker: so that we don't bias the rest of the team when we're taking care of patients.
Speaker: So those are my two departing thoughts.
Speaker: And I think this would be a perfect place to stop.
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.
Speaker: Thank you very much.
Speaker: Sergio, this was a pleasure to talk to you and to hear that you're doing great.
Speaker: Well, and indeed, I look forward to seeing you again.
Speaker: Best to you.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
