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Mechanical Power
18 Plays3 years ago
In this episode, we will discuss Mechanical Power and ventilator induced lung injury (VILI). Our guest is Dr. Jason Bartock, a practicing intensivist at Cooper Medical System in Camden, New Jersey. Dr. Bartock is faculty and Program Director of the Critical Care Medicine Fellowship at Cooper Medical School of Rowan University, Camden, New Jersey.
Additional Resources:
Mechanical power: meaning, uses and limitations. L Gattinoni, et al: https://pubmed.ncbi.nlm.nih.gov/36884050/
Mechanical Power: A New Concept in Mechanical Ventilation Poudel, et al: https://pubmed.ncbi.nlm.nih.gov/34597688/
Mechanical power at a glance: a simple surrogate for volume-controlled ventilation. L Giosa, et al: https://pubmed.ncbi.nlm.nih.gov/31773328/
The future of driving pressure: a primary goal for mechanical ventilation? H. Aoyama, et al. https://pubmed.ncbi.nlm.nih.gov/30305906/
Seminal clinical trial comparing low tidal volumes to traditional tidal volumes in ARDS. ARDS Network: https://www.nejm.org/doi/full/10.1056/nejm200005043421801
Educational website with mechanical ventilation content: https://www.criticalcareatcooper.com/masterin-mechanical-ventilation
Books Mentioned in this Episode:
Crucial Conversations: Tools for Talking When Stakes are High. By Joseph Grenny, et al: https://bit.ly/3FL4Xr9
Critical Maters Podcast – Interrupting the VILI Vortex. Guest J. Marini, MD: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=819824731
Critical Matters Podcast- Initial Management of ARDS. Guest R.P. Dellinger, MD: https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=635607780
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
What is 'Primum non nocere' and its relevance to ICU?
00:00:33
Speaker
Primum non nocere, first do no harm, is an old dictum, a first-order principle in medicine.
00:00:39
Speaker
It probably originated millennia ago in the Hippocratic era and remains relevant to the practice of medicine.
00:00:45
Speaker
In today's episode of the podcast, we will discuss mechanical power and ventr-induced lung injury.
00:00:51
Speaker
Mechanical ventilation is a common therapy in the ICU and a perfect place for us to apply Primum non nocere.
Guest Introduction: Dr. Jason Bartok
00:00:58
Speaker
Our guest is Dr. Jason Bartok.
00:01:00
Speaker
Dr. Bartok is an intensivist at Cooper Medical System, and he's a critical care fellowship director at Cooper Medical School of Rowan University, both in Camden, New Jersey.
00:01:09
Speaker
Dr. Bartok is an outstanding clinician, an educator, a ventilator nerd, and a dear friend.
00:01:14
Speaker
Jason, welcome to Critical Matters.
00:01:17
Speaker
Thanks for having me.
00:01:18
Speaker
I really appreciate it.
00:01:19
Speaker
Well, today we're going to tackle a really nerdy topic that, as we were discussing before we started recording, we believe is super important for all our practicing intensivists and APPs at the bedside to hear about.
Understanding Ventilator-Induced Lung Injury
00:01:35
Speaker
And we're going to talk of physics, formulas, but ultimately what we're really trying to do is
00:01:41
Speaker
apply this physiology to our clinical practice and to what we're doing to patients day in and day out who are on mechanical ventilation.
00:01:53
Speaker
So first, thanks for being here, but also thanks for tackling this problem with me and being brave to talk about an area where only the brave dare to venture.
00:02:09
Speaker
Well, I appreciate the opportunity, and obviously I wouldn't be here if it wasn't for you.
00:02:17
Speaker
And I love this podcast, and any opportunity to talk a little bit about mechanical ventilation, I'll take it.
00:02:22
Speaker
This would probably not be my first choice in terms of topic, but I think it's a really important one.
00:02:29
Speaker
And we will nerd out, but we'll try not to be too nerdy because I think it's important for us to kind of build a practical understanding about this topic of energy and the transfer of power.
00:02:43
Speaker
Absolutely.
Evolution of Ventilator-Induced Lung Injury
00:02:44
Speaker
And I think that we'll start with ventilator-induced lung injury and just kind of establishing some basic definitions.
00:02:52
Speaker
But I think it's important to remind people that
00:02:55
Speaker
despite all the advances and all the bells and whistles and all the new and progressive modes that we discussed at the bedside, the real insight or the epiphany that critical care had was that we could probably have the greatest impact on improving outcomes in critical care ARDS patients by decreasing the amount of damage that we were doing on them as we were treating them.
00:03:25
Speaker
And this really led to the understanding of ventilator-induced lung injury that has been described hundreds of years ago, but really wasn't something that was first in mind and really studied to some decades ago.
00:03:42
Speaker
So why don't we start by just basic definitions of what is ventilator-induced lung injury and
00:03:48
Speaker
And like the classical evolution from barotrauma to volutrauma to a telectotrauma and biotrauma.
Defining Types of Trauma in Mechanical Ventilation
00:03:56
Speaker
Absolutely.
00:03:57
Speaker
There's nothing natural about the application of the positive pressure breath, right?
00:04:04
Speaker
You know, on the human respiratory system.
00:04:07
Speaker
And without ventilators, many patients would die, absolutely.
00:04:12
Speaker
And, you know, I think this talk and many other concepts related to the application of the positive pressure breath are so important because, like you said,
00:04:22
Speaker
You know, the machines are getting smarter, the ventilators become more autonomous, the respiratory therapists handle more of the workload.
00:04:30
Speaker
But, you know, what is almost uniformly, if one of the only concepts for mechanical ventilation is there is no right mode of mechanical ventilation,
00:04:42
Speaker
there's only, you know, what matters is the person applying the breath and that's our responsibility and that's why we have to understand this.
00:04:50
Speaker
So, you know, when it comes to ventilator induced lung injury application, the positive pressure breath on a, on a system that is built to breathe negative pressure results in, you know, the, the potential of injury, you know, to the alveolus.
00:05:03
Speaker
And we think about a very simplified respiratory model, you know, kind of a rigid pipe, which is our, our airway.
00:05:09
Speaker
and an elastic balloon, which is, you know, which is our alveolus.
00:05:15
Speaker
And then the application of the positive pressure breath across that, when you reach a certain threshold, will cause injury to the lung.
Positive Pressure Mechanics and Lung Injury
00:05:22
Speaker
So barotrauma, you know, you know, described as, you know, tissue rupture, I think,
00:05:33
Speaker
we're all classically trained to think about it as high end alveolar pressure causing tissue rupture.
00:05:40
Speaker
That's not incorrect.
00:05:41
Speaker
I just don't think it's the whole story.
00:05:43
Speaker
And that's what we're going to talk about today.
00:05:45
Speaker
Similarly, volume trauma, we think about high end alveolar volumes causing tissue distortion.
00:05:52
Speaker
And that also is correct, but might not be the whole story.
00:05:56
Speaker
Adelacta trauma, you know, the shear forces that we think about with the under-distended or inappropriately distended, you know, alveolus leading to opening and closing, you know, shear distortion.
00:06:11
Speaker
That's true, you know, and most of us think about it as inappropriate PEEP application.
00:06:16
Speaker
Not untrue, but probably not the whole story.
00:06:19
Speaker
And then biotrauma, which is the biologic response to injury, um,
00:06:25
Speaker
you know, through the application of the positive pressure breath, kind of irrespective of, you know, whatever your primary driver is, be it, you know, viral or bacterial mediated endotoxin or whatnot.
00:06:39
Speaker
The biological response to injury as it relates to all the things that we just talked about, the application of high end alveolar pressure and then shear forces and distortion across the alveolar interface.
00:06:54
Speaker
So I think all of these things are what cause worsening injury and this cycle of progressively worsening, you know, baby lung physiology.
00:07:06
Speaker
If we're talking specifically about acute lung injury and ARDS, you know, you have hypoxia.
00:07:12
Speaker
This is one of the things that John Marini sort of –
00:07:16
Speaker
coin which is like the billy board we'll talk more about that you know you have hypoxia you have high application um high respiratory rate then you have you know all of these things that we talked about high distending pressures high shear forces then causing worsening capillary leak and then worsening hypoxia and then you start to lose more and more um lung tissue um and then
00:07:42
Speaker
you find yourself in a place where you can rescue a patient.
00:07:45
Speaker
So ventilator-induced lung injury has been talked about for a very long time.
00:07:49
Speaker
You know, I think we all have a good practical approach to trying to minimize this lung injury by thinking about static pressures and the static pressures that we use for best outcomes in our patient.
00:08:03
Speaker
But I don't know that it's the whole story.
00:08:05
Speaker
And I hope that we can sort of tease out some of the important concepts today.
00:08:11
Speaker
Perfect.
Significance of the 2000 ARDSnet Study
00:08:12
Speaker
And I think that you talked about some static pressures, and I want to go there next, but also worthwhile to just remind our listeners that the landmark study that really demonstrated that if we intervened in a way that would minimize what we understood as ventricular lung-induced injury could actually improve outcomes in patients with ARDS was published in 2000.
00:08:40
Speaker
And that's the famous low tidal volume ARDS net study, which we'll include in the show notes.
00:08:47
Speaker
And if you haven't read it, I would recommend that you read it as one of the key studies in ARDS, but also obviously in critical care.
00:08:57
Speaker
We then adopted this idea of lung protective ventilation, which the way I understand it, Jason, is really being very deliberate, intentional, and conscious of settings in the ventilator to the point that we're trying to prevent further damage from the positive pressure ventilation that we're delivering.
00:09:21
Speaker
And you had mentioned that there's some static targets or static measurements that we have utilized or incorporated into our clinical workflow that really move in that direction.
00:09:36
Speaker
Do you mind...
00:09:37
Speaker
sharing with us kind of like the progression and we can start with low title volume and move from there.
00:09:43
Speaker
Like what have we found?
00:09:44
Speaker
What does that mean?
00:09:46
Speaker
And we can move through them and move forward.
Driving Pressure and Lung Stress
00:09:52
Speaker
Sure.
00:09:53
Speaker
I mean, I think all of us who've lived through the pandemic have talked a lot about it, but going back, you know, like you mentioned, the ARDSnet trial in 2000, you know, looking at low tidal volume ventilation, you know, versus, you know, high tidal volume ventilation for patients based off of their predicted body weight.
00:10:15
Speaker
So I think everyone has sort of ingrained into their practice six cc's per kilo ideal body weight.
00:10:21
Speaker
And I think that's important when you understand acute lung injury, you know, and the baby lung physiology that comes with that, that, you know, applying high tidal volumes, you know, lead to the potential for high injury.
00:10:37
Speaker
So, and the things that we talked about causing tissue rupture or tissue distortions.
00:10:43
Speaker
So low tidal volume ventilation, 60 cc per kilo is pretty much ingrained in all of our practical approach and maintaining a low plateau pressure, you know, less than 30 centimeters of water.
00:10:54
Speaker
Another static measure, you know, and that static measure of less than 30 centimeters of water is the surrogate for 20.
00:11:04
Speaker
you know for transpulmonary pressure what we think that the alveolus is seeing provided that we have sort of a negative or negligible pleural pressure and that's what we believe that the end alveolus is seeing again it's a static pressure and we're making the assumption that every alveolus within the system is seeing that and the same thing with low tidal volume ventilation
00:11:25
Speaker
You know, when you apply six cc per kilo, we're making the assumption that every single alveolus in the respiratory system is seeing six cc per kilo predicted body weight.
00:11:36
Speaker
And that's probably not true.
00:11:39
Speaker
Similarly, you know, the PEEP application, which is, you know,
00:11:46
Speaker
know has been studied not showing you know for the high peep trials the mortality benefit that certainly low tidal volume ventilation and low pressure targeting showed but maintaining adequate peep to prevent collapse and and optimize total long compliance is still one of our practical approaches
00:12:10
Speaker
But really that evolution was most impactful when using P for optimal compliance, which brings in the concept of driving pressure.
00:12:19
Speaker
So driving pressure is obviously a measurement that has evolved more recently.
00:12:27
Speaker
It hasn't been studied to the same degree or associated with clinical trials such as the low tidal volume and the plateau pressures with the AridusNet trial.
00:12:36
Speaker
But I do think that, especially like you said, during the pandemic and a little bit before that, it's really picked up steam in terms of interest.
00:12:45
Speaker
So what is the driving pressure, Jason?
00:12:48
Speaker
That's a great question.
00:12:49
Speaker
What is the driving pressure?
Understanding 'Baby Lung' in ARDS
00:12:51
Speaker
I think, and this is a question that I, you know, that I ask our fellows and our residents all the time.
00:12:56
Speaker
Every single one of them can rattle off on rounds, six cc's per kilo, ideal body weight plateau pressure less than 30 and driving pressure less than 15.
00:13:04
Speaker
But what is the driving pressure?
00:13:06
Speaker
And to your point, you know, did show an impact in mortality, but what was a retrospective analysis?
00:13:14
Speaker
But, you know, really what is driving pressure?
00:13:18
Speaker
Well, the calculations, the plateau minus the people, really what does it mean?
00:13:22
Speaker
You know, it's title volume as it relates to compliance.
00:13:25
Speaker
So it's really the title volume over the total compliance in the system.
00:13:30
Speaker
And what we feel it represents is kind of the normalized title volume that that baby lung sees.
00:13:38
Speaker
And I hope I'm not using the term baby lung and everybody's like, what are we talking about?
00:13:42
Speaker
This is what we're talking about, ideal, you know, adult critical care.
00:13:45
Speaker
But no, the baby lung physiology where you have,
00:13:48
Speaker
you know, ARDS, heterogeneous, you know, injury pattern, and then you have this smaller portion of the lung that's adequately aerated, and the rest of the lung is diseased.
00:13:58
Speaker
So what the baby lung is seeing is what really what driving pressure signifies.
00:14:06
Speaker
So it's the normalized tidal volume for the baby lung and, you know, the optimum compliance for the delivered breath.
00:14:13
Speaker
And if there's anything that, you know, that mortality impacts, you know, studies have shown is that everything is about lung compliance.
00:14:25
Speaker
Any way that you can salvage lung compliance or any way that you can prevent worsening lung compliance is what impacts patient outcome.
00:14:33
Speaker
So the driving pressure is,
00:14:36
Speaker
I think makes a lot of sense because it's just another marker of compliance.
00:14:40
Speaker
So if you're doing all the other things that we talked about in terms of sort of static application, you know, 60 cc per kilo, adequate, what we believe is end alveolar pressure, optimum compliance for what the baby lung is seeing, then you're probably doing your best at delivering a safe breath.
00:15:04
Speaker
Perfect.
00:15:05
Speaker
So these are all static measures to some extent, and especially anything involving the plateau pressure involves inspiratory holds, and there's always a question of how accurate those could be if not under the right conditions.
00:15:23
Speaker
But what are other limitations of using a static measure for such a dynamic and heterogeneous process?
00:15:31
Speaker
Well,
00:15:32
Speaker
You know, I think when you look at some of the work, you know, published on this idea of mechanical power and the transfer of energy, you know, they make it very clear that in all biological systems or all systems in general from a physics standpoint, pressure does not cause damage without pressure.
00:15:56
Speaker
motion, right?
00:15:58
Speaker
So although we're looking at static pressures, we're looking at the plateau pressure, you're looking at the tidal volume, you're looking at the PEEP,
00:16:07
Speaker
we don't take into account how we got there, right?
00:16:10
Speaker
And that's how the breath is applied and how the alveolus is inflated and how one alveolus talks to the alveolus sitting next to it.
00:16:21
Speaker
So when you think about cyclical airway trauma, right?
00:16:24
Speaker
So you have someone who has acute lung injury and they're breathing, you have alveoli that are extended,
00:16:33
Speaker
you have alveoli within that same injury region that are collapsed, and you have alveoli that have restricted distension or expansion.
00:16:44
Speaker
And to the idea that every single one of these pressures is applied the same in those three types of alveoli is incorrect.
00:16:54
Speaker
So using a static measure, assuming that you're protecting all of the lung, I think is an incorrect assumption.
00:17:00
Speaker
there is certainly like regional gradients and regional distribution of the way you apply the breath, right?
00:17:06
Speaker
When you think about the way the breath is applied, apex, the base, dorsal, the ventral surface, you know, each one of those regions will see a different amount of distending pressure.
00:17:18
Speaker
So although the entire system may be adequate six cc's per kilo and 30 centimeters of water, one alveolus might be seeing much more of that than the other alveolus,
00:17:30
Speaker
and that's where injury occurs.
00:17:34
Speaker
Absolutely.
00:17:36
Speaker
And I think that this is a perfect time to transition to the first law of thermodynamics, which states that energy can't be created or destroyed.
Stress, Strain, and Energy Transfer in Ventilation
00:17:46
Speaker
It can only be transformed.
00:17:48
Speaker
And I believe that
00:17:51
Speaker
Energy transformation is what produces motion.
00:17:54
Speaker
And this is, I think, where we need to go to understand a little bit more about how injury really occurs in a ventilated lung-induced injury.
00:18:03
Speaker
Could you expand on that, Jason?
00:18:06
Speaker
Sure.
00:18:06
Speaker
You know, this machine that we hook people up to, you set parameters that you want out of, you know, from the mechanical system to translate into the biologic system.
00:18:17
Speaker
And it does that through a transfer of energy, right?
00:18:20
Speaker
It transfers energy to the patient and then you get whatever your targets are.
00:18:26
Speaker
And the machine only knows to do that.
00:18:28
Speaker
And it might be okay, or it might cause injury depending on where that injury threshold exists.
00:18:34
Speaker
So, you know, the idea here is, you know, you have stress, you have strain, you have energy and you have power.
00:18:44
Speaker
And I think
00:18:45
Speaker
that everything that we do, all of these concepts already exist in the approach that we talked about.
00:18:53
Speaker
I just think that it's important to think about them in a kind of a dynamic process with each inflation and not just the static pressures that we measure, right?
00:19:03
Speaker
So stress is just the force on a subject, right?
00:19:07
Speaker
So the force applied.
00:19:08
Speaker
And I think that the stress you can think about, I guess the surrogate for that would be,
00:19:14
Speaker
be the driving pressure would be the best correlate that I can think of.
00:19:19
Speaker
And strain is the response to that applied stress, right?
00:19:23
Speaker
So, you know, you apply, you know, a particular stress at, you know, at the junction of an inflated and an uninflated alveolus,
00:19:31
Speaker
And then depending on how, you know, how that that stress is applied, you'll have deformation or strain across each alveolus, one possibly more than the other.
00:19:43
Speaker
You know, when you think about it, like we talked about the damage in any given lung unit, you think about like a non-compliant alveolus.
00:19:51
Speaker
right, you know, you can give a high amount of stress to that and because it's non-compliant, it won't move very much, there's not a lot of strain.
00:20:00
Speaker
But in a very compliant alveolus, if you give the same amount, right, of stress,
00:20:06
Speaker
you'll get, it's able to, it will over-distend and over-stress, and then there's a lot of strain applied on that.
00:20:12
Speaker
So when you think about the lung, I think we all think about these alveoli like they exist by themselves.
00:20:18
Speaker
But the lung, a better representation is sort of like a honeycomb pattern, like you see in a beehive, and all of them are touching each other.
00:20:27
Speaker
So when there's areas that are damaged and there's areas that are soft and compliant, you'll have regional strain applied both at the level of the alveolus, but also with the lack of movement of the alveolus that's connected to it.
00:20:42
Speaker
I think that that's an important concept, stress and strain, and then how that translates to energy.
00:20:49
Speaker
So, you know, strain is very important when it comes to ventilator-induced lung injury, and that's a dynamic concept, not a static concept.
00:20:58
Speaker
So like we just talked about, you apply a certain amount of stress, and there'll be strain across that alveolus.
00:21:03
Speaker
That will cause injury.
00:21:04
Speaker
And then energy on top of that will also cause energy, will also cause injury, right?
00:21:11
Speaker
So, you know, we have with each breath, you know, a certain amount of potential energy and that potential energy is then transferred into kinetic energy, which will be heat and distortion, right?
00:21:23
Speaker
As it's transferred across that alveolar, that end alveolar wall.
00:21:30
Speaker
So,
00:21:32
Speaker
you know, when you think about the energy transferred from the machine, it's what it takes to distend the lung, what it takes to push the gas, and then what it takes to keep the lung open at the end.
00:21:41
Speaker
And that's the total energy transfer, right?
00:21:44
Speaker
So you...
00:21:45
Speaker
just to try to simplify everything, right?
00:21:48
Speaker
You have, you know, regional gradients that all of that, all of these breaths are being applied to.
00:21:55
Speaker
You have a certain amount of stress that will, that will vary depending on which region it's being applied to.
00:22:03
Speaker
And then a certain amount of strain in response to that stress.
00:22:06
Speaker
And it can be exacerbated by high energy, right?
00:22:10
Speaker
So what it's going to take to open and to extend that alveolus, what it's going to take to push the gas in, and what it's going to take to keep it open.
00:22:18
Speaker
So that's the idea of stress, strain, and energy.
00:22:22
Speaker
And I think that it's, you know, that's a dynamic process.
00:22:27
Speaker
And it's not just about static end alveolar pressures.
00:22:30
Speaker
You know, in order to cause damage, you have to have motion.
00:22:33
Speaker
And with each one of these breaths, we cause motion.
00:22:39
Speaker
And it matters where it's being applied.
00:22:43
Speaker
It matters how it's being applied and with how much energy it's requiring.
00:22:50
Speaker
And I find it interesting that there's obviously an analogy to when we talk about hemodynamic monitoring and static measurements and dynamic measures.
00:23:01
Speaker
And I think it just speaks to the reality that...
00:23:04
Speaker
biological systems, and everything that we're interested in is a dynamic and complex process, right?
00:23:11
Speaker
So as we move from a chalkboard static analysis and a reductionist kind of view to something that's more integrated and dynamic, we probably are closer to what's happening and hope to be closer in predicting what we need to do, which I think is very interesting.
00:23:30
Speaker
And we just have
00:23:31
Speaker
What's intensity, Jason?
00:23:47
Speaker
So intensity is an interesting concept, right?
00:23:51
Speaker
So, you know, you have energy, right?
00:23:55
Speaker
And I guess we can just kind of jump into the concept of power, which is just energy transfer per unit time, right?
00:24:01
Speaker
So here with each one of these breaths, right, we're trying to open, apply a volume, and then maintain an end alveolar pressure.
00:24:11
Speaker
And with that, we transfer energy across that alveolus and
00:24:16
Speaker
potentially, you know, in a high energy state will cause worsening damage.
00:24:21
Speaker
Energy, right, you know, when we said, you know, what it takes to descend the lung, to push the gas into the alveolus, and then to keep it open at the end of exhalation, that's volume, total pressure applied, flow and peep, and then power is energy transferred per unit
Intensity and Lung Injury in ARDS
00:24:39
Speaker
time.
00:24:39
Speaker
There are various mechanisms of power amplification.
00:24:44
Speaker
So, you know, when you think about the total amount of power applied to the alveolus, there are certain things that will amplify that power and then amplify the potential for energy, for injury, I should say.
00:24:59
Speaker
So intensity is one of those things, right?
00:25:02
Speaker
So it's really the amount of energy applied, you know, or power per amount of surface area.
00:25:10
Speaker
So when you think about, you know, baby lung physiology,
00:25:15
Speaker
if we're applying a high energy breath, right?
00:25:20
Speaker
Because you have a lot of heterogeneity and a lot of disease as the surface area that you apply that, that breath or that energy over starts to decrease the intensity goes up and the potential for injury goes up.
00:25:39
Speaker
So yeah,
00:25:41
Speaker
So what does that mean in terms of static pressures, right?
00:25:45
Speaker
So you can have,
00:25:47
Speaker
two ARDS lungs, right?
00:25:51
Speaker
Both of them could have, you know, the same plateau pressure of 30.
00:25:59
Speaker
Both of them could have the appropriate PEEP for compliance, meaning the right, the same driving pressure of 15, but one could have significantly less surface area than the other.
00:26:15
Speaker
and you're applying a six cc per kilo breath to that one with the one with the less amount of surface area will have a much higher amount of power delivered per breath if that makes sense your static pressures are all still the same right plateau pressure is the same driving pressure is the same total surface area and one is less so there's more power there's more energy transfer per breath so there's more injury per breath
00:26:42
Speaker
So I think that that's why it's also important that the static measurements don't speak to everything because we're not thinking about it in terms of dynamic transfer of energy.
00:26:59
Speaker
And I think that's a great point.
00:27:01
Speaker
And it's just the evolution.
00:27:03
Speaker
And obviously, we'll talk about this a little bit later.
00:27:05
Speaker
And full disclosure, we still don't have all the studies to really tell us how to use mechanical power at the bedside.
00:27:16
Speaker
But...
00:27:17
Speaker
Understanding these concepts and limitations is important because what the static measurements, such as low tidal volume and plateau pressures of 30, have demonstrated is that on average, in larger populations, they make a difference.
00:27:31
Speaker
But as we evolve in our understanding of critical illness, our goal eventually is to, for each individual patient, optimize our treatment and minimize the lung injury that we might be producing in
00:27:44
Speaker
And that's where we hope some of these concepts eventually will be very, very helpful.
00:27:52
Speaker
So let's talk a bit more about mechanical power.
Mechanical Power and Lung Injury
00:27:55
Speaker
So mechanical power, like you said, is a measurement of energy over time.
00:28:01
Speaker
And it's expressed in joules over minute by convention.
00:28:06
Speaker
There are different ways that mechanical power can be measured.
00:28:10
Speaker
Some of them obviously require sophisticated interventions that are more efficient.
00:28:18
Speaker
likely to occur in a research setting than in a bedside clinical setting.
00:28:22
Speaker
But a lot of investigators are also trying to develop formulas and validate formulas that perhaps are a little bit simpler and eventually could be integrated to what we're already measuring at the bedside with mechanical ventilation.
00:28:37
Speaker
But why don't you tell us a little bit about the components that influence mechanical power and
00:28:42
Speaker
And specifically, what does it bring to the table that's new from the static pressures that we were talking about earlier?
00:28:51
Speaker
Right.
00:28:54
Speaker
When you think about the equation of motion and we think about the total pressure within a system, we think about the elastic compartment and we think about the resistive compartment and, you know, the things that impact that, right?
00:29:07
Speaker
The total of the things, the variables that impact compliance and the variables that impact resistance, particularly, you know, tidal volume and alveolar pressure, PEEP,
00:29:18
Speaker
You know, and flow and total diameter.
00:29:22
Speaker
I don't think a lot of us were ever taught that the resistive compartment makes a lot of has a lot of impact on.
00:29:33
Speaker
on alveolar injury, right?
00:29:35
Speaker
I mean, it's supposed to be the large airways.
00:29:37
Speaker
But there, even at the level of the small airways, there is flow application, and across the alveolus, there's flow application.
00:29:46
Speaker
And with that, you know, brings things like resistance and transfer of heat.
00:29:51
Speaker
So, you know, the...
00:29:54
Speaker
When we think about the equation of motion, like I said, start with the idea of energy and that's taking into account volume, total pressure, the flow applied, like I said, not something that we think a lot about, and then certainly end alveolar pressure.
00:30:07
Speaker
And, you know, sort of PEEP is a double-edged sword, you know, with good PEEP application, you can optimize lung recruitment and compliance and the system will benefit from it.
00:30:24
Speaker
with high PEEP application or PEEP above optimal compliance, it will certainly add to additional strain across the alveolus.
00:30:37
Speaker
So PEEP will increase the energy in the system if it's above optimal PEEP and above threshold is what I wanna say with that.
00:30:47
Speaker
So I don't want you to think that PEEP's a bad thing just because it's on the energy side of the equation.
00:30:52
Speaker
But certainly the volume, the total pressure applied, the flow and the PEEP make the energy.
00:30:57
Speaker
And then, you know, that energy transferred per unit of time, which is the rate, gives you the mechanical power.
00:31:03
Speaker
So all the things that matter in terms of tidal volume and total pressure, you know, delivered at a particular rate is mechanical power.
00:31:12
Speaker
Okay.
00:31:16
Speaker
What else was your question?
00:31:16
Speaker
Boy, I just got lost in my own head there for a second.
00:31:18
Speaker
No, no, no, that's perfect.
00:31:19
Speaker
So I think one of the things that also you were talking about, the different components of mechanical power, the resistive component and the elastic
Impact of Respiratory Rate on Lung Injury
00:31:28
Speaker
component, and how we have really not paid a lot of attention to the resistive components, right?
00:31:34
Speaker
But I think that studies have shown, more recent studies, and these are animal studies, that you can have, like you said, the same tidal volume, right?
00:31:43
Speaker
the same pressure and PEEP applied, yet a difference in respiratory rate will have a different impact on the amount of lung injury.
00:31:53
Speaker
A difference in flow or how that breath is delivered and inhalation and exhalation can also have a different impact.
00:32:00
Speaker
So could you reemphasize that or the relationship or the impact that respiratory rate and flow have in this mechanical power component?
00:32:11
Speaker
Absolutely.
00:32:12
Speaker
So, you know, with flow application, when you think about, you know, increasing, you know, the insertory flow rate, you know, some of us may do that because we may want to deliver the breath faster.
00:32:27
Speaker
Or if you change, you know, flow patterns, you know,
00:32:31
Speaker
whether you're sort of using a more traditional or widely used mode of mechanical ventilation like volume control that has continuous flow or if you're using something that's pressure control or PRVC where you have a decelerating flow ramp or if you have a smart ventilator, you may have a ventilator that can give you a volume control ventilation with a computer-generated decelerating flow ramp.
00:32:55
Speaker
Okay.
00:32:56
Speaker
I didn't hope I didn't lose anybody on that, but just the way that you deliver the flow, the rate at which you deliver, you know, flow,
00:33:03
Speaker
you know, for a fixed say diameter will increase resistance.
00:33:08
Speaker
And with that, there's transfer of energy, right?
00:33:11
Speaker
You know, usually thermal energy or heat, which will cause distortion and potentially injure the alveolus.
00:33:18
Speaker
You can see this in some animal models, you know, where they look at variable flow patterns, right?
00:33:25
Speaker
And variable modes of mechanical ventilation.
00:33:27
Speaker
John Marini published a paper
00:33:30
Speaker
looking at different flow applications, promoter mechanical ventilation and seeing different injury patterns.
00:33:39
Speaker
There's another paper looking at histopathology of pig lung with different flow patterns.
00:33:45
Speaker
So something that, you know, that may have, you know, a higher peak flow or generate your tidal volume quicker.
00:33:52
Speaker
Certainly, you know, you have to, you can imagine if you're going to generate that volume quicker,
00:34:00
Speaker
you know, like, like something you would see in a decelerating flow ramp.
00:34:03
Speaker
All right.
00:34:03
Speaker
Where the, where the, where the application of flow is highest at the beginning of the breath lowest at the end.
00:34:08
Speaker
So, and to get the pressure or to get the volume faster, there's more energy delivered across that,
00:34:18
Speaker
you know, that unit, whatever unit you're applying that to in the diseased lung.
00:34:24
Speaker
So there is the potential flow causing ventilator-induced lung injury, which is a component, you know, of the equation of motion that we never really used to think was deleterious to our patient, you know, when we would augment flow rates or breath timing.
00:34:46
Speaker
I guess would be one thing to take into consideration.
00:34:49
Speaker
And certainly, respiratory rate is very powerful.
00:34:52
Speaker
You know, we can appreciate how powerful the respiratory rate is when it comes to impacting something like auto PEEP, right?
00:34:59
Speaker
I think that we're all sort of classically trained, you know, to think about the power of the respiratory rate versus all other components of breath delivery when it comes to reducing auto PEEP or intrinsic PEEP in our patients.
00:35:11
Speaker
The same thing
00:35:12
Speaker
and probably be said for ventilator induced lung injury.
00:35:16
Speaker
And, you know, it's, it's probably the most obvious, you know, if you're, if you're walking on a broken, broken ankle, you shouldn't hop on it all day.
00:35:28
Speaker
You know what I mean?
00:35:28
Speaker
Anything you can do to reduce the number of,
00:35:33
Speaker
you know, of cyclical airway traumas that you cause, right, to a particular, you know, a particular situation
00:35:45
Speaker
area of injury in the lung would be beneficial.
00:35:48
Speaker
So the respiratory is very powerful.
00:35:50
Speaker
You know, we looked at some simplified models, you know, one just looking at driving pressure times respiratory rate, not taking into account, you know, other parts of the energy equation.
00:36:02
Speaker
I think that that's probably a good start, you know, because you're thinking about, you know, the stress that the lung is seeing and you're taking into account finally, you know, the rate at which it's applied.
00:36:13
Speaker
But I do think that there's more to it.
00:36:15
Speaker
you know, when it comes to flow and certainly PEEP application, that if you really want to be a good steward of providing a low energy transfer that we need to take into consideration.
00:36:28
Speaker
So, you know, there's, well, we can talk about ways, you know, soon that this can be applied, you know, clinically or at least could be considered clinically, but certainly something as simple as respiratory rate probably has a huge impact, you know, on the amount of ventilator-induced lung injury because it's the total quantity of, you know, cyclical airway trauma that you see in the course of a day.
00:36:52
Speaker
Absolutely.
00:36:54
Speaker
And I think that what I like about this concept of mechanical power, and that's why I wanted to bring it to a discussion at the podcast, is that I believe that the plateau pressure and the low tidal volume are extremely valuable because they're linked to randomized studies that have shown improved outcomes.
Beyond Tidal Volume: Other Ventilator Settings
00:37:13
Speaker
And they probably represent one way that we're producing lung injury that we can minimize.
00:37:18
Speaker
But if we only focus on that, I think we have a very narrow view of what we're doing with the ventilator.
00:37:24
Speaker
And as we broaden that view, we realize that other settings that we do manipulate, such as the PEEP, such as the respiratory rate, such as the flow, also add to the potential of stress and strain, energy transfer, and ventilator-induced lung injury.
00:37:43
Speaker
And finding the optimal settings, I believe, is ultimately what we're aiming for.
00:37:50
Speaker
And it sounds like, from what I understand, Jason, mechanical power is a more comprehensive representation of some of the factors that cause lung injury through these mechanisms.
00:38:02
Speaker
And what I understand in animal studies is that if you look at the same tidal volume, other factors, right, will determine the degree or can determine the degree of lung injury.
00:38:19
Speaker
However, if you equalize mechanical power, even if the factors that got you there are different, those mechanical powers are equivalent in the amount of injury that
00:38:31
Speaker
that they produce in these animals.
00:38:33
Speaker
So that is, I think, what has got a lot of experts in this field excited as a potential application at the bedside.
00:38:42
Speaker
Yes, I agree with that.
00:38:44
Speaker
And I want to move to the next step, which is, what do we know about mechanical power and patient outcomes?
00:38:53
Speaker
You know, I think much of the data, or I should say all the data that I know of is retrospective.
00:39:00
Speaker
You know, I think when you're able to, you know, and some of it will be interesting, you know, coming out of the COVID-19 pandemic, where I think our practical approach is,
00:39:15
Speaker
to ARDS care really became nice and systematic.
00:39:19
Speaker
I can certainly say the same in our own practice.
00:39:22
Speaker
When you're able to control a lot of these variables and all patients, you know, are the same in terms of static, you know,
00:39:35
Speaker
measures, right, and have similar PF ratios, the ones with lower mechanical power had better survival.
00:39:42
Speaker
And I think that that plays into going all the way back to the very beginning, that there's a lot of heterogeneity going on within this respiratory system, that the static, the static measures give you a global idea of what's being applied, but doesn't give you
00:40:01
Speaker
you know, the appropriate insight into
00:40:05
Speaker
um, you know, sort of the regional application of, of those, you know, of the breath and how their, how injury might still be occurring.
00:40:15
Speaker
Right.
00:40:15
Speaker
So, you know, if you are able to control for, for all of the static variables, but the ones with lower mechanical power, it did better.
00:40:24
Speaker
I think it makes sense because either you're able to get to a lower mechanical power because you're better able, um, to, uh, apply that stress, um,
00:40:34
Speaker
you know, over the entire system, or you're able to reduce the total number of cycles that that system sees.
00:40:44
Speaker
And I think that that is what we should be trying to think about in terms of clinical application of mechanical power concepts.
00:40:55
Speaker
Excellent.
00:40:56
Speaker
So let's move into the clinical application, like you said.
00:41:00
Speaker
And it seems that there are a couple of things that are still missing from mechanical power.
00:41:08
Speaker
One of them is measurements of mechanical power that are readily accessible at the bedside.
Integrating Mechanical Power into Practice
00:41:15
Speaker
So a lot of these real measurements require techniques or require setups that are more likely to occur in research settings, like we said, than the bedside.
00:41:28
Speaker
But there are groups, and under Dr. Gattinoni and other groups, that have actually proposed
00:41:33
Speaker
for specific types of mechanical ventilation simplified formulas that could easily be incorporated into measurements on software in the ventilator.
00:41:44
Speaker
And I would imagine that's going to come soon, and we'll see more of that.
00:41:48
Speaker
The other thing that seems that, from what I understand, Jason, that is missing is we still don't have prospective studies that have shown that a strategy targeted at a mechanical power of X versus Y
00:42:03
Speaker
Makes a difference, right?
00:42:04
Speaker
So hopefully those will come in the near future as well.
00:42:09
Speaker
But could you tell us what we can do today?
00:42:12
Speaker
And really it's how would you encourage our listeners to be better stewards of the ventilator and minimizing ventilation?
00:42:19
Speaker
Venture induced lung injury.
00:42:21
Speaker
But before you go there, actually, what I think we didn't really cover is, could you just throw out some numbers out there in terms of mechanical power?
00:42:29
Speaker
I know that there's still a lot of debate, but just to give people an idea of some of the numbers that people have looked at as being a discriminator.
00:42:38
Speaker
Yeah, absolutely.
00:42:39
Speaker
You know, I think there is no consensus as to what, you know, like you would with driving pressure or plateau pressure.
00:42:50
Speaker
I don't know that there's a consensus as to what a safe mechanical power is.
00:42:55
Speaker
I think if you look at studies as a whole, retrospective studies as a whole, you know, we measure mechanics.
00:43:03
Speaker
mechanical power in terms of joules per minute, you know, really joules per minute per kilo predicted body weight.
00:43:09
Speaker
If you really want to, uh, if you really want to drill down, uh, the mechanical power.
00:43:14
Speaker
Um, and you know, I think, you know, from, you know, all of the studies that I've read somewhere between 15 and 17 is your threshold.
00:43:25
Speaker
I don't know how helpful that is per se, but I sort of think about it right along the same lines as, um,
00:43:31
Speaker
you know as uh you know as driving pressure if i can remember 15 that's probably the place um where i want to be um and then i think you know like you mentioned uh when there's easier applications than than us sitting sitting down you know doing calculus at the bedside um i you know or or ones that correlate um you know better um inter irrespective of mode of mechanical ventilation which um which can be a little bit tricky depending on
00:44:01
Speaker
the mode you use.
00:44:03
Speaker
It may impact the formula that you need to use.
00:44:05
Speaker
So I am excited to see if there's that there'll be, you know, software, you know, added to the mechanical ventilators that, you know, might be able to give you, you know, sort of a, you know, a visual readout as to where you stand with your mechanical power.
00:44:23
Speaker
And then you can augment, you know, some of these variables for the breath being delivered.
00:44:29
Speaker
And then you can also think about some of the things that you can do for the patient that may reduce the overall mechanical power while all of the other best practices in ARDS remain constant, right?
Strategies for Reducing Mechanical Power
00:44:43
Speaker
Tidal volume, driving pressure, plateau pressure.
00:44:48
Speaker
And now you'll have a continuous readout for mechanical power.
00:44:56
Speaker
What are some examples, Jason, of other things that you would be paying attention to at the bedside?
00:45:01
Speaker
So obviously, I do believe it's important to reemphasize that let's start with what we know, right?
00:45:07
Speaker
So lower tidal volumes, keep the plateau pressure below 30, look at your driving pressure, keep it below 15.
00:45:16
Speaker
But what are other therapies that perhaps, I mean, we should be at least think, or not therapies, but interventions that should be in the back of our mind and should at least...
00:45:25
Speaker
pose some pause to us and question if I really go ramp up the PEEP, if I really ramp up this respiratory right, could I be having more damage?
00:45:37
Speaker
Absolutely.
00:45:37
Speaker
You know, and these are the, and I'll just, you know, full disclosure, this is sort of my practical approach.
00:45:45
Speaker
But, you know, when you have all of the, you know, all of those best practices applied, you know, and you're, and I think about Dr. Marini's concept of the Vili Vortex, right, which is, you know, similar to the way we think about, you know, the cycle of heart failure or anything else, you know, you have, you know,
00:46:05
Speaker
you know you have hypoxia you have injury you have you know increased minute ventilation then you have more um you know biotrauma then you have worsening um you know baby lung and then you can you know the surface area that you're applying that breath you know even though you can't really um objectively appreciate it continues to dry
00:46:27
Speaker
and then you have more power amplification, you know, with the same, you know, applied best practices.
00:46:34
Speaker
And those are the things that concern me as I have someone sort of sit on the ventilator and I'm waiting for them to get better with all of my static measurements optimized.
00:46:43
Speaker
You know, I worry that there's, you know, ongoing strain, which is then leading to progression,
00:46:51
Speaker
you know, less, you know, reduced ventilator capacity of that baby lung and then more power.
00:46:57
Speaker
So what can I do?
00:47:00
Speaker
you know, to try to limit the power, you know, and to limit the total number of cyclical airway traumas that I deliver with my ventilator, I'm doing it, you know, every single day.
Minimizing Injury through Respiratory Rate Adjustments
00:47:12
Speaker
So I think the first thing that I think is most powerful is thinking about the respiratory rate.
00:47:19
Speaker
And, you know, where you, you know, and where you are with relation to,
00:47:27
Speaker
to permissive hypercapnia.
00:47:29
Speaker
I think that if your patient is otherwise optimized, stabilized, you can certainly think about dropping that respiratory rate to live in an area of permissive hypercapnia that we thought about
00:47:46
Speaker
all the way back in 2000 with the ARDSNet trial.
00:47:51
Speaker
You know, I think we all like to see a normal pH when we come in the morning, but we don't need to.
00:47:56
Speaker
And I think that if you can make the argument that everything else has been optimized, you can lower the overall mechanical power just by limiting the number of injurious cycles that that patient sees in a 24-hour period.
00:48:11
Speaker
So I do think respiratory rate might be one of the most powerful variables that we have that also is the easiest to augment and probably the safest to augment because you'll have a real-time idea of if it impacts them in a negative way, right?
00:48:30
Speaker
So I think you can safely augment your respiratory rate without making a whole lot of changes elsewhere.
00:48:40
Speaker
um you know i think for the other parts of power amplification you know that we were that we didn't really touch on you know position you know which we did sort of talk about the the regional position of each alveolus um you know and their position to each other you know where one is pulling on the wall of the other and there's focusing of some of that power
00:49:03
Speaker
you know, that alveolus wheel, you know, when we look at it, you know, diagrammed out for us as this perfectly, you know, round sphere, but that's just not what's happening when you have diseased, you know, when you have disease around it, when you have some, some, some alveoli that are collapsed and some that are under distended and some that are over distended, um, the geometry, um, uh,
00:49:26
Speaker
on each one of those units, you know, will cause push and pull and you'll have focusing of that power.
00:49:31
Speaker
Well, how can I change like the vector which I'm applying that power and now my head hurts and I don't want to think about it.
00:49:38
Speaker
These are things that we do every single day.
00:49:40
Speaker
You know, prone positioning, I think, is a very, we know is a very powerful intervention.
00:49:48
Speaker
And probably has the biggest impact on mortality when you think about, you know, the relative risk reduction from the PERCEVA trial, you know, for interventions in, you know, in ARDS.
00:50:01
Speaker
So, and I think that that has a large impact on mechanical
Prone Positioning to Reduce Mechanical Power
00:50:06
Speaker
power.
00:50:06
Speaker
Yeah.
00:50:09
Speaker
So yes, you place someone in the prone position, you will better redistribute their ventilatory capacity, apex, abase, dorsum, deventrum.
00:50:19
Speaker
Yes, it does all the great things with VQ matching and everything.
00:50:23
Speaker
But I think more uniformly now those alveoli will see that static pressure
00:50:32
Speaker
or surrogate that you're looking at, right?
00:50:34
Speaker
So there's going to be, you know, less power delivered, you know, against individual units and more delivered against the total system.
00:50:48
Speaker
which I think is probably impactful.
00:50:52
Speaker
And also certainly anytime you have the opportunity to improve compliance, you can improve the ventilating capacity of that baby lung and then the total power in the system per unit breath will go down.
00:51:05
Speaker
So I think that something that we already do, the question is, well, what are your targets when you do it?
00:51:13
Speaker
There is a time where I think we prone patients and
00:51:17
Speaker
we don't see much of a change in their vq matching we might not see a big impact um in the total compliance um is it worth continuing prone positioning and i would say in my own practice as long as it's safe and i have
00:51:32
Speaker
a well-trained staff, I would continue proning that patient, you know, because especially in the early stages of their lung injury, I think it would be beneficial to maintain a low power system.
00:51:47
Speaker
So I think respiratory rate, and again, you know, prone positioning, like we talked about, decreasing total intensity across that system is important.
00:51:59
Speaker
for alcohol.
00:52:00
Speaker
So that's, those are two of the clinical applications I can, I can take to the bedside.
00:52:06
Speaker
Cause I, I, I think they all sort of live under one umbrella, but I can also, I can appreciate them being, uh, you know, uh,
00:52:15
Speaker
a reduced power application on top of ARDS best practices.
00:52:22
Speaker
And I can live within that arena and feel confident while I wait to see what comes out of the world and the literature.
00:52:31
Speaker
Perfect.
Evolution of Critical Care and Personalized Treatments
00:52:32
Speaker
And I think that those are great examples of how we can apply physiology and a better understanding of mechanical power to our daily practice.
00:52:43
Speaker
As you said, Jason, while we wait for clinical trials and more of this fascinating topic to be delucidated, but
00:52:52
Speaker
It is obviously, it's not a revolution, it's an evolution.
00:52:57
Speaker
And as we understand more and more the dynamics of lung injury, I do believe that we will get to a point where we can apply better therapies to individual patients and not only to large populations like we do in clinical trials.
00:53:12
Speaker
I think, finally, what I would say as a take-home message is that
00:53:18
Speaker
Thinking of lung injury, thinking of how everything we do in the ventilator or in the ICU for that matter can have an unintended consequence that could harm our patients is probably the most important for us.
00:53:33
Speaker
Just to be thoughtful of how we treat patients and how everything we do can have a consequence.
00:53:41
Speaker
And as we learn more, I think we will improve, but also just I think it reinforces the importance of sticking to what has been proven, but also expanding the way we think of our patients.
00:53:54
Speaker
This has been a fascinating discussion.
00:53:57
Speaker
More to come, like you said, Jason.
00:53:59
Speaker
It is some of these topics are a little bit, let's say, abstract and very nerdy, but I do believe they're important for our critical care clinicians.
00:54:09
Speaker
So again, thank you for discussing this.
00:54:11
Speaker
I would like to end the podcast with a couple of questions that are unrelated to mechanical power.
00:54:16
Speaker
Would that be okay?
00:54:18
Speaker
Sure, please.
00:54:19
Speaker
I'm ready for something else.
00:54:23
Speaker
So the first question relates to books.
Impact of Communication in Critical Care
00:54:25
Speaker
Are there any books that have influenced you deeply or that you have gifted often to others?
00:54:31
Speaker
Yeah, you know, there was this guy.
00:54:33
Speaker
He was pretty talented.
00:54:35
Speaker
He was my program director.
00:54:37
Speaker
And when a week before graduation gave me a book, Crucial Conversations.
00:54:44
Speaker
And still to this day, I have it on my desk right now.
00:54:49
Speaker
Probably one of the more impactful books I've read, especially for my life as an intensivist.
00:54:57
Speaker
It's become part of our dedicated curriculum here at Cooper for our Going Into Practice series.
00:55:03
Speaker
And
00:55:04
Speaker
You know, we live in a world that is high intensity and a lot is asked of us.
00:55:10
Speaker
And I think, you know, it's not always about necessarily what we can do, but how we deliver care and, you know, and how...
00:55:20
Speaker
how we're able to support those around us to deliver that care.
00:55:25
Speaker
And that starts with your ability to communicate.
00:55:28
Speaker
And certainly the stories you tell yourself, which I think is just one of the more powerful chapters.
00:55:34
Speaker
So that is one of the books that I go back to every year.
00:55:40
Speaker
And like I said, one of the mandatory readings and work groups for our Critical Care Fellows.
00:55:49
Speaker
Awesome.
00:55:50
Speaker
And I think crucial conversations really, for those of who are unaware, really relates to any conversation where the stakes are high and the point of view might be different from different parties.
00:56:08
Speaker
And emotions are high, right?
00:56:09
Speaker
So these are conversations that occur with patients, with colleagues, with family members.
00:56:16
Speaker
And I think, like you mentioned, Jason, it's a super skill to be able to carry these conversations, but it's one that you can learn.
00:56:25
Speaker
So this is a great place to start.
00:56:27
Speaker
And we will definitely include links to everything that we discussed, the studies, more information on mechanical power.
00:56:38
Speaker
There's a wonderful website that Jason and his faculty have created for mechanical ventilation that is open access that he will share with us.
00:56:48
Speaker
And also there's previous podcasts that you mentioned
00:56:52
Speaker
Dr. Marini, he's been on the podcast.
00:56:54
Speaker
We did talk about the Vili Vortex, so I'll definitely link that as well, and I think it would be of interest for our listeners.
00:57:00
Speaker
The second question, Jason, relates to beliefs.
00:57:04
Speaker
What do you believe to be true in life or medicine that most other people don't believe or don't act as if they believe?
00:57:13
Speaker
That's a great question.
00:57:15
Speaker
You know, in medicine, I think we are taught to chase pedigree when I think we should be chasing competency.
00:57:26
Speaker
And what does that mean necessarily?
00:57:29
Speaker
You know, it doesn't really matter where you came from.
00:57:35
Speaker
or who taught you.
00:57:36
Speaker
What matters is when you're called to rescue someone, can you perform?
00:57:42
Speaker
Can you transfer knowledge?
00:57:45
Speaker
Can you execute?
00:57:46
Speaker
And I think that for medical education, it's really
00:57:50
Speaker
really important for us to have clear competencies and milestones.
00:57:59
Speaker
And when we're postgraduate, to continue those and chase competency and make that be, you know, the most important part of what we do, because that's what makes us great clinicians is being able to do
00:58:18
Speaker
something that other people can't.
00:58:21
Speaker
So I think that, you know, I have nothing against, you know, great pedigree.
00:58:26
Speaker
And with that, I'm sure it comes with great competency.
00:58:28
Speaker
But for all the people out there that think they can't do what they want to do or can't be what they want to be, I challenge you to chase competency and you will find yourself in a place that you never thought you would be.
00:58:43
Speaker
I think that's a great observation and believe in it 100%.
00:58:48
Speaker
I think of competency in a different framework.
00:58:51
Speaker
I've talked about skills, super skills and ultra skills.
00:58:54
Speaker
But again, the same idea that it's what we develop and what we tackle that ultimately defines the impact we have on others, which is really what we're looking for in our career.
00:59:05
Speaker
So that's a great thought.
00:59:07
Speaker
And the last question is, what would you want every intensivist listening to us today to know?
00:59:12
Speaker
Could be a quote, a fact or just a comment.
00:59:16
Speaker
Yeah, I have a lot of quotable people in my life.
00:59:19
Speaker
But, you know, I'll go back to, you know, to the quote from Mahatma Gandhi.
00:59:25
Speaker
It is unwise to be too sure of one's own wisdom.
00:59:30
Speaker
I think that that's really important in critical care.
00:59:32
Speaker
It goes with what we talked about today.
00:59:36
Speaker
You know, we need to continue to question what we do and why we do it.
00:59:40
Speaker
Nothing in critical care, I think, should be completely dogmatic.
00:59:45
Speaker
um you know having kind of a baby career um but still being able to be around you know giants like yourself steve treziak and um and phil delinger you can see how cyclical um critical care can be you love one thing one day you hate one thing the next day and you come back around a few years later and you start to love it again um i think we uh
01:00:07
Speaker
We need to continue to question what we do and why we do it as this specialty continues to boom and grow.
01:00:16
Speaker
And I challenge everyone, you know, to with this, you know, continue to grow your competencies and own your space as an intensivist in an ICU, no matter whether it's medical, surgical or surgical subspecialty.
01:00:32
Speaker
And I think this is the perfect place to stop.
01:00:35
Speaker
Jason, thank you so much for sharing your expertise and your time with us.
01:00:39
Speaker
Definitely look forward to having you back and talk about this and maybe other topics.
01:00:45
Speaker
Sure, love to come back anytime.
01:00:50
Speaker
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01:00:54
Speaker
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01:01:00
Speaker
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01:01:04
Speaker
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