I have been
a Registered Respiratory Therapist for greater than twelve years and have never
considered the titration of oxygen a big deal. Furthermore, practicing at >
10 different facilities in eight different States I have never needed to be prompted
by a physician or surveillance system to titrate the FiO2 during mechanical.
Fortunately, I have only worked at facilities with respiratory care practitioner
driven protocols. So when two recent articles were published on the subject
within the last month I took notice [1, 2].
The first
article "Titration of Inspired Oxygen Levels during Mechanical Ventilation
through a Respiratory Therapist Driven Approach Based on an Electronic
Surveillance System (tools). Researchers at the Mayo clinic (Minnesota)
compared the weaning of oxygen during mechanical ventilation via a Respiratory
Therapist encouraged by a surveillance system versus physician assessment.
The results
of the study were not unexpected however; a few intricacies regarding the
institution disturbed me. So what is troubling with this institution and the
study itself?
Physician assessment is the standard
of care
The article
stated that the standard for setting the FiO2 was based on physician
assessment. I can see this standard for initial settings and the very acute
phase of mechanical ventilation but weaning FiO2? This is why the results are
not surprising if one has to wait for physician assessment before FiO2 is
weaned then at most the FiO2 would only be decreased twice per a twenty for
hour period [3]. In contrast if a
respiratory care driven protocol was in place the weaning of FiO2 could be
performed numerous times throughout a 24 hour period, since RCPs’ are in-house
24 hours.
The investment of creating an
electronic surveillance system
This
facility actually invested time, money, and resources into developing an
electronic surveillance system.
This poses various
questions;
Why does your
Respiratory Care Practitioners (RCP’s) need to be prompted to wean FiO2?
-Do the RCP’s lack critical thinking skills? Is this an
educational issue?
-Are the RCP’s under-staffed? Are they out of the ICU,
administering non-indicated
breathing treatments?
-Do the physicians not trust the RCP’s is this why they need
to be prompted and physician assessment is standard of care?
Computer
programmers are not cheap and usually make more than a RCP (unless you
outsource them from India) so I believe these allocations could have been used
more effectively.
That the study was actually performed
The
institution actually devoted time and finances for this study when a fifth
grader familiar with probability could accurately predict the results [4].
The second
article [2] introduced automated closed loop titration of Fio2, provided a
synopsis of operational algorithms for these systems, presented patient
studies, and provided key considerations and possible disadvantages of
utilizing these systems.
The key
driver for the development of these systems is to prevent complications related
to hyperoxia and hypoxemia in infants. The article states that sampled patients
spent ~half the time under the intended SpO2 range and greater than a third of
the time above the intended SpO2 range.
A key
consideration presented is that “hypoxemia spells in preterm infants are
largely triggered by changes in ventilation and lung volume” [2]. Increasing
the FiO2 may briefly resolve the hypoxic episode, however does not address the
root cause, supporting the need for an engage practitioner.
Both of
these articles present using artificial intelligence systems for the titration
of FiO2. These systems may augment the titration of FiO2 however these do not
replace the expertise of the device operator.
Reference
[1]. Pannu
S, et al. Titration of inspired oxygen levels during mechanical ventilationthrough a respiratory therapist driven approach based on an electronicsurveillance system (tools). Crit Care Med 2012; 40 (12)
[2]. Claure
N, Bancalari E. Automated closed loop control of inspired oxygen concentration.
Respir Care 2013; 58 (1): 151-161.
Notes
[3]. A
physician usually rounds on patients in the ICU one-to-two times in a twenty
four hour period and most likely not at during the night.
[4]. The
probability of a RCP weaning FiO2 versus physician is much greater. A RCP is
staffed every 24 hours in the ICU and ventilator patient assessments are
performed at least every four hours. So a RCP team will assess the patient six (6)
times within a 24 hour period versus two (2) times for a physician assessment.
