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| From Global Nerdy @ www.globalnerdy.com |
In a recent
letter to the editor “Ventilatory modes. What’s in a name?”[1] Authors provide
a strong argument for the need to standardize terminology in regards to
mechanical ventilation and propose an oversimplified classification system
specifically for non-invasive ventilatory devices. I applaud the authors for
their call to action; conversely their viewpoint is neither novel nor
applicable to ventilator taxonomy.
For greater
than two decades, +Robert Chatburn has invested tremendously in the creation, refinement,
education, promotion, and defense of a standardized taxonomy for mechanical
ventilation [2-9]. Chatburn’s current
classification system [1, 10] addresses the concerns that Dr. Rabec and
colleagues present, which can be easily applied to non-invasive ventilation
(NIV). Establishing a new oversimplified classification system specifically for
NIV, I believe would further exacerbate the confusion.
As an
alternative to creating a whole new classification system for mechanical
ventilation, I propose three actions that can be executed at the local level
(eg, ICU, facility, organization) that would make management of mechanical
ventilation easier.
First, standardize equipment.
A report identifying
the primary causes of ventilator related deaths from 1995-to-2003, revealed
that greater than 90% of the fatalities were related to human error primarily
lack of orientation/training [11]. Too many devices can cause confusion and
turns a low use device into a high risk machine. Practitioners do not like to
be and should not be “baptized by fire”; operating a device they are not
familiar with. As a respiratory care manager or educator one should observe how
their staff practices. If staff members continually switch out ventilators some
examples;
-Replacing
the transport ventilator in the ER with the ICU ventilator.
-Transporting
on the ICU ventilator instead of the transport ventilator.
-Switching
out a newly purchased ventilator with the older model.
These are
all ciphers that staff members are uncomfortable with the different
ventilators.
Administrators
and mangers of teaching facilities may argue that standardizing equipment does
not provide a sufficient learning environment for physicians in training. I
would argue that these institutions provide the basic concepts and taxonomy of
mechanical ventilation; with a comprehensive understanding of these principles
one can apply this knowledge across many ventilator platforms. Additionally, it
is still foremost the respiratory care practitioner who operates the mechanical
ventilator, implementing the physician orders.
Second, start with one mode of ventilation and
become an expert.
Bruce Lee
once stated “I fear not the man who
has practiced 10,000 kicks once, but I fear the man who has practiced one kick
10,000 times” [1]. As for me I fear the operator of a ventilator who has used
many modes however, is not an expert at any.
Modern day
mechanical ventilators have over-abundance in regards to modes of ventilation, conversely
few are ever used and some are associated with poor patient outcomes. An
example of this is the mode Intermittent Mandatory Ventilation (IMV) aka. SIMV.
IMV has been associated with increased duration of mechanical ventilation and results
in the most patient-ventilator related asynchronies. So why does this mode come
standard in all newer devices?
I would
recommend becoming an expert first with Pressure Control Continuous Mandatory Ventilation
(PC-CMV). This is a versatile mode which can be applied in all patient
categories, and during all stages of patient care. Additionally, once one is proficient utilizing
this mode the operator can apply this knowledge to more advance pressure based
modes of ventilation (eg, adaptive pressure control, Adaptive Support
Ventilation) and predict ventilator interactions to changes in pulmonary
mechanics and/or changes in patient inspiratory demand.
Third, establish and standardize protocols for
mechanical ventilation.
There are
many published examples of how standardizing mechanical ventilation practice
improves patient outcomes. Two examples are weaning protocols and the ARDS Net
recommendations of ventilating patients with lower tidal volumes during acute
lung injury or acute respiratory distress syndrome. Protocols keep
practitioners accountable, and allow for easier monitoring of patient outcomes.
Yes,
mechanical ventilation can be simplified however changing or adding new
taxonomy is not the solution. I would recommend starting at the local level by
standardizing equipment, becoming an expert with basic modes, and standardizing
mechanical ventilation practices.
References
1.
Rabec
C, Langevin B, Rodenstein D, Perrin C, Leger P, Pepin JL, Janssens JP,
Gonzalez-Bermejo J. Ventilatory modes. What’s in a name? Respir Care 2012; 57
(12): 2138-2150.
2.
Chatburn
RL. A new system for understanding mechanical ventilators. Respir Care 1991; 36
(10): 1123-1155.
3.
Chatburn
RL. Classification of mechanical ventilators. Respir Care 1992; 37 (9):
1009-1025.
4.
Branson
RD, Chatburn RL. Technical description and classification of modes of
ventilator operation. Respir Care 1992; 37 (9): 1026-1044.
5.
Chatburn
RL, Primiano FP Jr. A new system for understanding modes of mechanical
ventilation. Respir Care 2001; 46 (6): 604-621.
6.
Chatburn
RL. Computer control of mechanical ventilation. Respir Care 2004; 49 (5):
507-517.
7.
Chatburn
RL. Classification of ventilator modes: Update and Proposal for Implementation.
Respir Care 2007; 52 (3): 301-323.
8.
Chatburn
RL, Mireles-Cabodevila E. Closed-loop control of mechanical Ventilation:description and classification of targeting schemes. Respir Care 2011; 56 (1):
85-102.
9.
Chatburn
RL, Volsko TA, Hazy J, Harris LN, Sanders S. Determining the basis for ataxonomy of mechanical ventilation. Respir Care 2012; 57 (4): 514-524.
10. Chatburn RL. Classification of
mechanical ventilators and modes of ventilation. In: Tobin MJ, ed. Principlesand practice of mechanical ventilation, 3rd edition. New York: McGraw-Hill, 2012.
11. Nilsestuen JO, Hargett KD. Using Ventilator Graphics to Identify Patient-Ventilator Asynchrony. Respir Care
2005; 50 (2): 202.
12. Bruce Lee, Martial Arts Renaissance
Man.
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