High Efficiency Practices / Vent Management (February 2018)
Articles:
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
Does reading this article change your practice? If so, how?
8 comments
VENT MANAGEMENT – Weingart
1. Compared to prior MICU teachings involving many different modes/variables, this article presented straightforward approaches to initial vent management sufficient for the ED. Being able to place all patients essentially into two different categories, and having a step-wise approach to adjusting vent settings based on the pathology was very helpful. Particularly the ARDSnet stepwise FiO2/PEEP uptitration is very helpful as I have previously seen FiO2 aggressively titrated while PEEP is less frequently changed. After reading this article and particularly given my limited experience with vents, I plan to become familiar with VC first and foremost and know how to properly changes settings based on pathology for my ED patients.
2. Pressure control, APRV, and several other modes are frequently used in the MICU. I was under the impression these modes have RCT proven benefits, however in this article it was very clearly stated that at least in INITIAL management post-intubation, there is insufficient data to suggest more advanced modes than VC having benefit. Further, the potential for harm if not familiar with these modes is made clear by the article. PEEP is almost entirely unnecessary in obstructive disease, and can literally be set at 0 for many patients. FiO2 can be used alone, rather than with PEEP, in obstructive pathology because oxygenation is not the primary problem and should be easily overcome.
3. Most patients, including those with obstructive pathology, should not require paralysis with proper sedation. EtCO2 establishes a minimum possible pCO2, however, the pCO2 may be much higher as EtCO2 is diluted by dead-space air/shunting. PIP in an obstructive pathology does not indicate the pressure on alveoli given that the pressure cannot be transmitted to the alveoli due to the obstructive pattern in the lungs. Therefore, high PIPs in COPD should not be concerning for possible barotrauma, but rather the pressure is necessary to overcome the instruction and inflate the alveoli, so turn the alarm parameters for PIP very high in COPD. If you are truly concerned about barotrauma, plateau pressures should be obtained to determine the alveolar pressure, and if high, RR should be decreased to allow full exhalation (rather than decreasing volume as in the treatment of ARDS).
4. Use of pressure control or other modes for initial management could be compared head to head with volume control in the ED to see if the more long term strategies of the MICU make any difference if applied to initial ED management. Comparison of minimum PEEPs in asthma/COPD to see if the Peep of 5 to “overcome vent resistance” is actually helpful.
HIGH EFFICIENCY PRACTICES – Bobb
1. This study had many, many objective variables that they kept track of while observing the physicians (ex. % time eating/using restroom, running vs checking the board). All of these are things physicians think about on shift (how many patients can I carry? will taking time to eat help me be more efficient later?) that as far as I know, many parameters have not been well studied in terms of their effect on efficiency in an objective manner. This study aimed to answer a difficult question of how can what we spend our time on on-shift effect our efficiency, and are these patterns that we can change.
2. While the data gathered is “objective”, I imagine it would actually be quite difficult to categorize what a physician is doing minute by minute in the ED and have each minute fall into a discreet category. For example, physician’s are often running the board, being interrupted, placing orders, and documenting all at the same time in a minute’s time. Further, RVUs/hour or patients/hour is a rough outcome measure that does not capture patient’s clinical course/outcomes. I fear that some behaviors may increase RVUs or patients/hour while simultaneously worsening patient’s outcomes, such as carrying many more patients at once. Also, physicians being watched likely changes their practice patterns, yet the RVUs and patients/hr was established based on long term, not observed, data. Finally, observational studies determine association but not causality, so further studies would be needed to establish that for example, having physicians change a behavior would cause a change in efficiency.
3. Certain outcomes seem to be undeniably a good idea, such as having systems that allow physician’s to quickly know who is on a patient’s care team so that they can communicate with them respectfully and effectively (can we get a ED nursing staff database with pictures, please???). I love that “Using team member’s name” had a statistically significant impact on efficiency, as this is something I have seen great clinicians do in residency, and is a behavior I hope to emulate. The study also highlights the importance of routine tasks such as “running the board” and visiting patient rooms as ways of increasing efficiency. In contrast, documentation stuck out as the only clear variable that adversely effects efficiency, which is something I personally struggle with every shift.
Interesting study on efficiency practices in the ED. Overall, there’s very little studies on this issue. Most are just expert advice. So it’s good to see a mixed methods study.
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I’ve always advocated “running the board in your head”, in addition to with your team if needed. The other behaviors surrounding team communication makes sense. But more “average patient load” makes you more “efficient” duh! It’s more of a result of efficiency than a behavior that leads one to be more efficient.
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Read on!
Definitely check out the Weingart article. He breaks the complex topic of mech ventilation into much simpler terms. A good read before your ICU rotations!
So I really like the way that the Weingart article outlines ventalotory management initially. We are super lazy here at BMC and just assume that the respiratory therapist will set the vent at an appropriate setting for the patient. We really need to be confirming what settings the patient’s are on before we move on to other tasks. It is incredibly important to calculate at least approximately the tidal volume according to ideal body weight. Additionally, I agree that venting patient’s with airway obstruction can be a real challenge. Starting with a conservative volume and titrating according to patient response (I:E ratio, RR, O2 concentration) can be difficult. In several patient’s I find it is sometimes easier to change to pressure control.
Bobb, Ahmed et al:
Interesting study. My main comment: What are nonwork-related tasks? I’d be interested to know if things like uploading outside images and interrupting seeing patients to put in USIVs would count (probably not but for sure decreases my efficiency, and I don’t see any category to put these tasks in their study).
The other findings are pretty evident: basically know what’s going on with your patients at any given time (run the board as often as possible), and know who your nurses are (which can only help you, glad to know it helps with efficiency).
For the Weingart article:
1) This article was a good reminder to use lung protective ventilation on all patients without obstructive lung disease. I will be better about caculating ideal body weight on patients and then calculating an appropriate tidal volume.
2) I had thought that the lowest tidal volume to be used was 6 mL/kg, but didn’t realize that TVs as low as 4 mL/kg could be safely used if needed.
3) I learned that it’s okay to titrate RRs up to 30-40 if needed in patients without other lung issues/contraindications.
4) It’s interesting that PEEP in obstructive lung disease hasn’t been shown to have any benefit in initial mechanical ventilation. I have had several vent management lectures where PEEP (especially higher levels of PEEP) is strongly encouraged. Perhaps more research is needed or better dissemination of existing researching may be helpful.
For the Bobb et al. article:
1) I think a strength was that they attempted to study high-volume times (1100-0030) in each ED and that they quantified efficiency with RVUs, which are not a perfect or all-encompassing measure of efficiency but do provide a fairly consistent metric for comparison.
2) The biggest limitation seems to me that the sample size was small (especially when considering that not all participants were EM-trained physicians). Data was collected at 4 community hospitals with patient volume of 30-60K patients per year, so perhaps the results of this study are not generalizable to hospitals with much greater or much lower volumes, or to those in other parts of the country outside the mid-west. Obviously, excluding academic centers and resident physicians also decreases the generlizability of the results. As the limitations section points out, this observational study can only comment on association and not causality for each of the behaviors, and behaviors were almost certainly altered by the presence of an observer recording minute-to-minute actions.
3) The main outcome of the study was identifying 5 behaviors associated with efficiency and 2 behaviors associated with decreased efficiency in the ED.
Bobb Study
Mixed methods study, seems like it was a challenging study to conduct which probably explains why not many studies on this topic. High efficiency behaviors included good communication with nursing and running the board often which we get beaten into us our PGY3 year. EDs were lowish volumes 30k-50k. Good to note that documenting on pts out of the ED is considered inefficient.
Weingart: Awesome review. Good reminder about lung protective strategy. 8cc/kg IBW. If hypercapneic, adjust PEEP. If no severe metabolic acidosis then permit hypercapnea. Obstructive pattern: good reminder to set RR low. I have done RR 12-14 but good to know RR 10 is acceptable. Low PEEP. We usually do the default 5 PEEP but will consider lower 0-3 PEEP in the future. Check plateau pressures frequently. If plateau pressure >30, then decrease TV. Good logical, stepwise approach to vent management.