Transcript MODE MYTHS - American Lung Association

M, M & M
Modes/Monitoring/Myths
Kevin Fischer, RRT
Disclaimer
• This presentation is my own!!
• This presentation does NOT have the support
of any ventilator or manufacturer
• This presentation is totally made up and not
to be reused or copied in any way; such as for
toilet paper, for armed services/special forces
training, for training wild animals, etc.
• This presentation is mine – all mine!!!!!
Modes
Why so many??
• Every ventilator manufacturer has it’s
“signature” mode. I call it the MODE of the
MONTH!! (just like my wine club – two new
modes every quarter and for you…… special
price!!!)
• And many modes are similar in action as well
as name/acronym so gets confusing
Old versus new…….
2000 BC - Here, eat this root.
1000 AD - That root is heathen. Here, say this prayer.
1850 AD - That prayer is superstition. Here, drink this potion.
1940 AD - That potion is snake oil. Here, swallow this pill.
1985 AD - That pill is ineffective. Here, take this antibiotic.
2000 AD - That antibiotic is artificial. Here, eat this root.
Primary modes….
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Control ventilation
Pressure ventilation
Volume ventilation
Assist control
SIMV
Pressure support
NIV
Old modes
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CMV
AC
SIMV
PS
These modes worked fine for many years –
but didn’t have much flexibility
• Did we need newer modes – and if you say
yes, why??
Designer modes
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PRVC
APRV
PAV
PPV
HFV
ASV
ATC
NAVA
Bilevel (BiPAP)
CPAP
TLV
PLV
– TTFN, TGIF, KMA, SOB, TY, UPS, ASAP, NOC,
Designer (cont)
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Who came up with new modes?
Why?
Do they work?
Who decides which mode to use?
Do you wean from these modes?
Pressure vs Volume
• My perspective
– Pressure ventilation in neo’s/ped’s primary
– High frequency in neo’s/ped’s
– Otherwise I see geographical/facility preferences.
• In the Southeast I saw volume more than pressure in
adults
• In the Central US I saw a mish-mash of pressure and
volume
• In the Northwest I saw more pressure used
New mode preference
• Facility specific
– New mode used seemed to be tied directly to
training of RT’s
• The better the RT staff was trained, when using new
ventilators, the more success with designer modes
– New mode success seemed to be tied directly to
the training of primary intensivist/pulmonologist
– New mode success tied to clinical experience
New mode preference
• There are numerous studies that do show the
value of most new modes
• The problem is non of the studies show
effectiveness in the real world, outside of a
controlled environment
• Evidence exists that support any mode that is
FDA approved – but I am a huge skeptic as i
am a believer in what I see, what I know, what
I practice
New mode issues
• Training is inconsistent
• Staff turnover is a huge issue – lack of
consistency
• Physician knowledge and support can be
lacking
• Some facilities have more than one vent
manufacturer – vents from different platforms
• The ventilator is only as good as the person
running it
Internet access??
Issues with ANY mode
• Lack of RT understanding and comfort with
newer modes leads to inconsistent mode
management
• KNOW IT ALL RTs/physicians/nurses or even
worse, know it all manufacturer reps
• Lack of management support
• Not having SUPER USERS!!!!!
More issues
• One RT knows/uses a specific mode but is
replaced at shift change with someone who
has a different perspective
• Smaller facilities end up purchasing a
ventilator from a great sales person – but ends
up with a ventilator they do NOT need!!
• The modes change faster than my ability to
understand them!!
And sometimes, you didn’t think it
through before you bought……
How do I choose??
• First and foremost, use the mode you understand
and manage the best. The mode is only as good
as you are!!!!! Make sure you understand disease
state management as it applies to ventilation
• Take training serious!! Make it mandatory!!
• With new modes, practice – practice – practice
• Please don’t try to manage a mode you don’t
understand!! Please don’t be afraid to speak up
if you don’t understand a specific mode and ask
for more training
Still choosing…….
• Make sure you set the PATIENT up for
success!!
• If pressure works…. Use pressure!!!
• If volume works….. Use volume!!
• Make sure you understand why a co-worker
chooses a specific mode when setting up a
vent, or changing modes. Make them
explain!!!
KISS
• If a patient has a ventilation issue….
VENTILATE!!!!!!
• If a patient has an oxygenations issue…..
OXYGENATE!!!!!
• If a patient doesn’t need intubated…… DON”T
INTUBATE
Please keep ventilation choices simple……
Monitoring
• Traditional monitoring
– Cardiac
– B/P
– RR
– ETC02
– ETC…….
Monitoring
• New monitoring (maybe not so new but
seldom used)
• VCO2
• Ventilator specific – manufacturers specific
tools
VCO2
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# versus concentration (ETCO2)
Better trending tool
Ability to get actual volumes – dead space
Ability to get VD/VT
Breath to Breath!!!!
Monitoring
• Regardless of parameter, pay attention to
trends
• Understand how to trust your info
• Garbage in, Garbage out……
• Use more than one monitoring parameter to
create a “triangle” of understanding
• Educate your staff – be consistent!!
In closing…
• We are NOT rocket scientists so don’t try to make
a rocket!!!
– Make decisions based on personal knowledge,
comfort, patient condition, patient safety, available
resources, etc.
DON’T PUT YOURSELF IN A POSITION OF TRYING TO
MANAGE A MODE YOU DON’T UNDERSTAND!!
AND DON’T PUT YOUR PATIENTS IN THAT
POSITION!! DON’T PUT YOURSELF IN A POSITION
OF MONITORING EQUIPMENT, INSTEAD OF PTS!