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How can we manage ventilators to decrease alarms, avoid misdiagnosing/mistreating asynchrony, and improve patient comfort and outcomes? Dr. Matt Siuba, MD, the “Zenintensivist”, shares with us his tools to decrease sedation and neuromuscular blockade use.
Episode Transcription
Kali Dayton 0:00
Hello, and welcome back. Before we start as the episode you have all been waiting for, I have to thank you for your resilience and support. I have been receiving many messages, much like the following:
Nurse 0:41
That discussion with the newer nurse to the ICU is exactly how I’ve been feeling. And I can’t thank you know, for the information that you’re providing on your podcast, and the references on Facebook. I’m delving deep into that, as hard as it is, because and still not able to backup my gut feeling and conversation during rounds. And it’s really hard and I’ve been reconsidering even staying in the ICU. But your your podcast has given me the golden thread the strength to keep going. I mean, honestly, I don’t I, I believe in God. And I have a lot of faith and well wavering at times, but I know that he has a plan. And I I’m not out to make a name for myself. And I don’t want to prove anything. I just want to take care of my patients. And I feel like right now. All I’m doing is killing them with the sedation, paralytic protocol that we’re doing in our ICU for COVID.
Kali Dayton 2:06
You know, someday, we’re going to have a conference for ICU revolutionists, and be hanging out in Las Vegas or somewhere and share our journeys, frustrations, tactics, and successes. If you believe in humanizing the ICU, and evidence-based sedation and mobility practices for your patience, I promise you are not alone. There are pioneers around the country and world fighting for the same things. There are experts that are eager to guide and support you. One of which is Dr. Matt shuba, who is known as the Zen intensivist. This episode, he walks us through tools we can use to better manage the ventilators and avoid sedation. Dr. Siuba, thank you so much for coming on. Do you mind introducing yourself?
Dr. Matt Siuba 2:54
Sure. My name is Matt shuba. Eminent medical intensivist. at the Cleveland Clinic in Cleveland, Ohio. My interests are well, my interests are many but pertinent to this podcast, I’m really interested in mechanical ventilation and optimizing mechanical ventilation for patients based on their physiology and their comfort. And obviously the most important thing trying to get them the heck back off the ventilator. Again, my disease related interests are ARDS and septic shock and just sort of have a personalized care and those conditions to the patient’s underlying physiology.
Kali Dayton 3:26
And you do such great work and you have your own podcast called “The Zentensivist”, correct?
Dr. Matt Siuba 3:32
Yeah, so I have this paper that I wrote, I guess just over a year ago now called his intensivist manifesto, we built a blog out of it, too. So it’s intensivist.com, where I discuss a lot of issues about providing minimally invasive maximally attentive medical care. And then so part of that I built it into a podcast at this point. It’s mainly just me going over some of the key points from the written posts. But I plan on developing into something that’s a little more conversational, kind of like what you have.
Kali Dayton 3:59
Great, and I really appreciate your focus of this. This new movement that’s coming in, we’re calling it the Zetensivism, correct?
Dr. Matt Siuba 4:07
Yes. Zentensivism. Yeah.
Kali Dayton 4:11
Tell us. How would you capture that in a couple of sentences?
Dr. Matt Siuba 4:15
Sure. So this is the best way to think about zentensivism is… it’s a holistic approach to the care of the critically ill patient. So we’re we’re focused on three main factors in order to sort of get out of the way the patient as much as possible while still making sure we’re pointing in the right direction. So as an intensivist, somebody who practices intensive ism, it doesn’t have to be a physician. It could be nurses, respiratory therapists, advanced practice providers, pharmacists, the whole focus is being absolutely a clinical master of the domain that you work in.
So you know, when it’s okay to sort of pull back and do less for people. It’s it has to do with tolerating risk, so I’m not going to investigate every little minor abnormality and draw these lab tests and send patients for all these studies and things unless I think it’s really going to have an impact on the big outcome. And the purpose of combining those two things, clinical mastery and risk tolerance is really just to elevate the humanism of the patient whenever possible. So try to restore their humanity, try to bring keep them as engaged in their care as possible while while we’re going through all these difficult moments, and also making sure that we’re not doing things that are inappropriate to them, either based on their goals of care, or based on what’s sort of medically appropriate based on their functional status and underlying comorbidities, and things like that.
Kali Dayton 5:29
I love it. And you’re just making people ask questions, question our culture, our habits, our routines, I really appreciate that, especially bringing your expertise in mechanical ventilation, you’re really making us question, how we’re managing patients on ventilators. I feel like for decades, when we deeply sedate people, then we can mostly put them on the same settings. And it’s probably, quote unquote, easier. Correct? So in your expertise, how, how to ventilator settings, impact paralytic and sedation practices?
Dr. Matt Siuba 6:04
That’s a really good question. One thing that a piece of information I there’s an article I need to forward you I forgot to forward you, I think we have this. First of all, we have this conception, that deep sedation automatically means vent synchrony and an actually, those paper that just came out that suggests that depth of sedation and respiratory effort are not necessarily well correlated. So in the first place, we have to sort of step back and think about is what we’re doing in the first place making any sense.
And in fact, there are certain dyssynchrony is, which may be worse with deep sedation, there’s this condition known as reverse triggering, where the event will fire a breath, and then sort of on a delay, maybe like a half second delay, the patient will then start to initiate the breath. But that means that their breath is persisting through the end of the machine breath. So then it looks like they’re sort of doubled triggering, so people assume they need more sedation, and when in fact, the sedation could possibly be the thing that caused the problem in the first place. So I think that’s the first thing we have to do is think what is what is my goal was sedation.
A lot of the times it’s not going to mitigate the respiratory effort in the way that you think it might, sometimes it does. But I think you have to individualize that to the patients, some people will respond, and some people won’t. A couple of things. I think they’re worth talking about that in some more detail. Number one, when does the patient need to be deeply sedated? That’s still a really, really hard question to answer. There are certain circumstances within which I think it’s possible that a patient making a lot of effort on the ventilator is doing them harm, it could be making their shock worse, it could be making their their ventilator or pardon me their lung injury worse. And that’s a really hard decision about when to make that decision when to make that change and say this person needs deep sedation and maybe needs neuromuscular blockade. That being said, deep sedation in particular, I think is probably overused.
And I think a lot of us don’t necessarily understand to the depth that we should, what impact the different sedatives we use will have on those on that respiratory drive. There’s a lot of dexmedetomidine use, which I think is a beautiful drug. Again, it serves a lot of great purposes, but you shouldn’t expect it to have any impact on the respiratory drive. So if your goal in life is to bring somebody’s respiratory drive down, that doesn’t really help at all, that would be something that helped them maybe be a little bit more calm, and maybe focus on ASIO license, which I think is definitely a good goal. But if you think it’s going to accomplish the goal that of decreasing the respiratory drive, you’re gonna be sorely disappointed.
The same is true for ketamine. So another drug that’s handy for a lot of reasons, but it’s short, you should not expect it to have a significant impact on the respiratory drive. Because one of the nice things about ketamine is it doesn’t really impact the respiratory drive. So then, so then what did I accomplish? If I put somebody on a high dose sedative that doesn’t decrease the respiratory drive, all I did was kind of zonked them. Now they can’t participate in their care or they can mobilize they can’t communicate their needs. They’re probably becoming delirious, and I’m not aware of it. And in the meanwhile, I didn’t even accomplish the goal that I set up to do in the first place. So I think those are kind of the the issues a common issues that we that we encounter with with setting with choosing sedation.
Now in terms of the ventilator, this is also kind of a difficult decision to decide how much control do I need to have as the provider? Do I need them to be perfectly synchronous with what’s going on? Do I need them to have a six ml per kg title line? Or is it somebody that’s in a place where they can have their settings liberalize a little bit? And that question is like the Holy Holy Grail question, particularly in ARDS is like when’s it okay for this person to have eight or even higher CC’s per kg tidal volume. And at this point, it’s it’s a judgment call. And it’s been and that’s what makes it really difficult. But in general, I think we probably over favor I know I’m preaching to the choir in this we probably over favored deep sedation when it’s not necessarily accomplishing the goal. We think it is not to mention all the issues that will come along with that.
Kali Dayton 9:45
Right and efforts to spare the lungs we sacrifice the body, the brain, the soul.
Dr. Matt Siuba 9:51
And at that rate, I don’t even know that we’re helping the lung some of the time. So like if if you didn’t accomplish the goal, then what was it what was it all for?
Kali Dayton 9:58
Right and Doctor Fazili in two episodes ago, talked about his speculations on the concerns that we have about increasing minute volume when we mobilize patients on higher event settings, that, you know, we’ve been accused of not following on protective strategies, but kind of put it in the perspective of the patient walks three times a day, for two minutes at a time. But let’s give it the benefit or exaggerate into that that mobility session, the time during mobilization is total of one hour out of 23 hours. Are we really risking that much harm, by mobilizing them and allowing them to exceed that maximum volume for that brief period of time? Or is it more harmful to risk this Aquila of deep sedation and mobility? So he put it in a really good perspective. But you’re right, there are no studies. Setting hard parameters are really showing what’s going on. Other than we have drastically different outcomes between mobility and mobility.
Dr. Matt Siuba 11:03
Right. And I think that’s, that is that’s part of the challenge. And as you mentioned, for that short period of time, if you’re going to work somebody out for up to an hour a day, how much how injurious is that really going to be? Really hard to say. So a patient, or the best information we probably have about that is like animal studies. So if you give a mouse, let’s say ARDS, and you would ventilate them at high tidal volumes, they can develop histologic changes of lung injury within like 90 minutes.
But again, that’s so that’s longer still, then you’d exercise somebody and that’s in a mouse. So I don’t know how that pertains to a human being. That said, though, there’s there’s two things to consider what are normal physiologic responses to exercise? And then what is acceptable when somebody has lung injury? Right. So I think those those are the things that you have to I think it’s a clinical judgment to try to balance those things out. On the one hand, you know, any of us, if we exercise, our tidal volumes are going to be higher respiratory rate is going to be higher, or oxygen demand is going to go up.
So we should not expect that those things would be different for a ventilated patient. In fact, it’s probably worse because they have less pulmonary reserves to work with. So they actually may need a little bit more in order in order to do that. So I think something that’s important to think about when it comes to mobility, when it’s in bed or out of the bed is just thinking about the right level of support for somebody, and then what happens to them during that time. Now, if you exercise somebody and they, you know, desaturate and D recruit and you know, things, okay? Don’t do it again, like not not that day.
And I’m like, Yeah, but But you don’t, you know, you won’t know if you don’t try and and there’s this balance now. And that’s growing within the mechanical ventilation community is to say, Okay, well, we have to protect the lungs, we also have to, if we’re still thinking just about the respiratory system, we have to protect a diaphragm to, and the diaphragm requires exercise, but it has to be sort of the right level. So over supporting is actually, you know, think about somebody that’s deeply sedated paralyzed, that’s going to be an over supported diaphragm that’s doing no work that’s going to atrophy.
But on the other hand, if you have somebody that’s, you know, basically exercising, even if they’re just sitting still, but you know, overworking on the ventilator that can cause hypertrophy of muscle fibers in a way that’s actually injurious in itself. So it’s kind of about finding that right level. And you would think probably with a skilled team that’s paying attention to how the patient’s doing during the exercise period, you should be able to see if this is too much or not, as long as you’re properly monitoring them.
Kali Dayton 13:28
And patients can really give us feedback. They can tell slowly, they can sense when the work of breathing changes, even before we may notice it on the ventilator monitor. So they can they’re sensitive to the changes that they’re experiencing. And so we have to invite them to give us feedback and help us know what they’re doing and to continue to monitor them. Absolutely. And, you know, it’s anecdotal, but they were from like an ICU. It seems like the rates of paralysis for COVID patients are far lower.
Dr. Matt Siuba 13:58
Yeah, which I think is really fascinating. And I’d love to, to learn more about that, because that’s definitely not the common experience.
Kali Dayton 14:05
Right. And this ICU is one of many in that area. And their outcomes are drastically different. From the COVID patients. They’ve had one, maybe another one traped, they’ve been had in high acuity COVID unit this is this is sure if they’re not sending some sicker patients to other hospitals and avoiding this ICU and they’re one of the top COVID units of the area. So they really don’t paralyze until patients have difficulty with oxygen consumption.
And they are walking to that point, even on high ventilator settings, even though there’s no clear research on that other than they have the experience and they’ve seen time and time again, that harm has not come to patients and rather, they have clearly benefited from it and walked out even after being under people’s 18 and 100% for a few days. So when I hear Are these ICUs? Prone and paralyzing everyone?
You know, in discussion, it sounds like the parameters are different, that maybe some teams are deciding to do it much quicker than others. And some of it I’m hearing now some of their indications for sedation is ventilator dyssynchrony. And yet, suppose someone to do medical reviews, I don’t see any sedation vacation. So how do you know how to synchronous the patient is if you’ve automatically deeply sedated them and or paralyzed them? So what what’s your sense of what’s going on out there? And how would you guide us through that?
Dr. Matt Siuba 15:34
Yeah, that’s a really good question. There’s a lot of cultural practices, as you know, from having talked to many other people, there’s a lot of cultural practices at play that impact how they how the, how the care is managed. So as an example, in during the pandemic, I worked in a number of our hospitals across the system, and each hospital, even though it’s under the same umbrella has different sort of cultural practices.
So at the main campus, we have a very regimented sedation vacation SBT protocol that happens every single day, if somebody’s if somebody is sedated. And that is followed to a really exemplary level, I mean, it’s like to the point where if you, you actually have to place an order into the computer to say this person, for some reason is unsafe to have a sh t, that’s the only way you can get out of it. Now, if you go to places, you know, especially in the surge, portion of the pandemic, there’s a lot of pain, a lot of units that were taking care of these really sick patients that were not used to doing it.
So I think there was unfortunately, a lot of sort of a damage control mindset. And I just need to, you know, whatever I need to do to, you know, perceive that I’m keeping this person alive as what was done. And, I mean, we saw that, you know, I think pretty consistently that the level of surge related to your hospital capacity has a large impact on your mortality. And that’s just, I mean, there’s only so much you can do in that situation. But what I did also see you as places that were not used to having a large number of ventilated patients didn’t understand the value of SHGs VT protocols.
And were afraid to come down on sedation to the point where like, if the ventilator alarmed once they would stop. So that was something that was an opportunity for us to do a little bit better education. In fact, one of the units I was working in, I asked, I got all the nurses together at night when I was working. And I said, Okay, here’s like four things that have an impact on mortality, you know, for years for things that we do to patients every day. And you tell me which one has an impact on mortality. And the only one that I listed ahead, impact on mortality was SATs, SBTs. And that was the one that nobody chose.
So I think it’s just a matter of, you know, that’s not something we’re educated or about, we’re educated about blood pressure goals, and antibiotic timing, and things that are also important. But also, you know, there are some units and I also have done some telehealth ICU coverage. And there are some units, if the patient’s thumb moves, their sedation gets turned up. So it’s, it’s all a matter of redefining the culture and the culture for so long, has been, you know, patients are, you know, deeply sedated until they’re ready to be excavated, basically. And you know, you’ll you’d hear about these anecdotes from when units didn’t have 24 hour, or even, or even daily, reliable coverage for pulmonary critical care or some other sort of intensivists.
And the patients would stay sedated for days at a time until they said, oh, let’s try him today and wake them up and see. So I think there’s still a little bit of that residual behavior that’s left within critical care or as a profession that we have to work through. So I think that’s kind of the biggest issue was just having to deal with, you know, basically having to teach people about a new way to view the care of the ventilated patient in the midst of a surge, which was a really bad combination for for trying to get those messages across. Because you felt like you’re tied up in one room and PPE you can’t have your other person potentially self excavating. You know, so the fear is logical, the practice doesn’t necessarily line up as well. But
Kali Dayton 18:57
absolutely, and I really appreciate the ABCDEF Bundle. I do recognize some difficulties and implementation. Part of that is that education right can overcome our culture without educating the team about the research the why the big picture, but I feel like the choice of analgesia should come with his parentheses, saying when necessary, yes, because I think that caveat is missed. And that becomes a barrier because when we automatically start sedation, and we give patients delirium it from a nurses side, right nurse practitioner, but from a nurses side, it is so laborious, dangerous, stressful, emotionally draining, to deal with a patient with that has delirium on the ventilator, for sure, stressful.
So if a patient nurse has three, four patients on their own, and then we’re saying, Oh, and do that sedation vacation, that’s a really big dangerous ask. I’m coming from a folk perspective in which we don’t automatically state patients upon intubation. It is very rare. So then you have patients coming right out of induction meds If that are able to be reoriented safe, reliable, then we don’t have to do the certifications and such. And I really feel, anecdotally that it is far easier to implement that way, when you immediately have a reliable patient.
Of course, there are exceptions. But with that ventilator dyssynchrony is really rare in this medical surgical ICU that I referred to, so I even had to ask colleagues, you know, keep hearing from people around the country in the world that they’re having to sedate and paralyzed people because they’re the synchronous, are using the synchrony because I feel like I hardly ever see it, maybe I’m just oblivious. And they all agreed that there’s very little synchrony. And the only times that they see it, when a respiratory therapist commented, was primarily and Delirious patients, especially when they come from out to facilities, when they were they’ve been deeply sedated then sent to them, then they’re waking them up.
And that’s when we get all the alarms. Explain that? why? It’s because we’re afraid of alarms, right? Especially when there’s nurses, we’re not trained on the ventilators. So we hear alarms, and we panic, because we’re, we’re responsible for that patient, but we don’t know what’s going on. We don’t know why they’re alarmed me to make it stop, stop, the only thing we can do is turn up the sedation. So why patient alarming? And what do we do?
Dr. Matt Siuba 21:14
Yeah, that is that is the problem, you describe it perfectly? There’s a couple of things to think about in the situation. Number one is there is I have, you know, I definitely don’t doubt that your unit encounters less of this than others. I will also say though, there’s a lot of dyssynchrony that occurs without alarms. So and then the question is how some of that some of that’s harmful, and some of it’s not. So it just kind of it depends on having the right people around the the people that have the right training, to recognize when something is off between the ventilator in the patient. And the the general approach is to address the patient rather than the ventilator. And that’s the problem, because the first thing we should do is say, is there something?
Is there something that I’m doing that is out of sync with what the patient is asking for? And if it is something they’re asking for it? Can I safely provide it to them. Now, if the patient wants to 1200 cc tidal volume, I’m probably not going to be comfortable with that. However, if we’re going like if we’re stretching the boundaries a little bit, or maybe they just wanted a longer breath, or a shorter breath, or wanted to, you know, have a higher respiratory rate, you know, these are all things that are easy to modify, that don’t require turning propofol up or turning it on. But it takes you have to have the right people around that recognize those things.
And that, I think, to your to your unit speaks to a highly trained group of people that understand what to do in those situations, because there’s a lot of dyssynchrony that are easily modifiable by just making minor adjustments. Can I change the amount of inspiratory pressure I’m giving the patient? Can I change your inspiratory time? Can I change your respiratory rate that mitigates a large number of issues in and of itself? And then when you’re at the boundaries, you have to say, Can I tolerate this person taking a slightly higher tidal volume than what I’d be comfortable with. But if you’ve put take everybody in the ICU, and you put them on a six cc per kg title line, no matter what their underlying physiology is, particularly if they’re anxious, that’s probably not going to be a suitable setting.
Because you and I are probably breathing around 60 seats per kg right now with some variation, so we’re not breathing a perfect six every time. As far as I know, neither of us has a RDS and and any other sort of, you know, gas exchange issue. So sometimes it’s a little bit much to ask somebody to to be that tightly controlled, especially when there’s not like a great reason for it. So sometimes I’ll see somebody that gets intubated, like for endoscopy, let’s say they have they have a, you know, massive upper GI bleed, and then they get put in volume control with 60 seats per kg tidal volume, and I’m not really you know, their lungs are fine.
They’re intubated for airway protection. So that’s when we have to sort of think about what are my goals for mechanical ventilation. And, and that’s, that’s where you can start to freestyle a little bit and make decisions about what makes sense for the patient. So the paradigm that we use, it’s there’s three aspects of the goals of ventilation. The first is safety, you want to make sure the patient’s not causing you having ventilator associated lung injury, you want to make sure they have safe gas exchange. The next part is comfort, which is really important. And in my opinion, the area that gets paid the least attention.
So comfort means or do they have a balance worker breathing, so they can do some of the work on their own, they shouldn’t be working really hard, but you know, somewhere in that range where you know, you could be sitting up in bed, communicating with people, you know, doing a sudoku puzzle or something or exercising. And then the third part is liberation. So what what what am I doing with the ventilator to move this person towards a place of liberation? Aside from the ventilator, obviously, that’s where early mobility and physical therapy and other mobilization paradigms come into play.
But this whole thing is a continuum. So all those things, all those three things safety, comfort and liberation or or prior our priorities at all times. But the primary priority depends on the situation of the patient. You have somebody that was on 100% high flow that ended up needing to be intubated. Maybe Thinking about safety, especially in that first 12 to 24 hours more than anything else, because you’re like, I can’t help, I can’t let the situation get any worse. But it doesn’t mean you have to do safety for a week, keep everything tightly controlled for a week, and then say, Alright, I’m gonna, you know, maybe back off at that time, I think you have to take those opportunities to back off and get out of the way, as much as possible.
And usually, you can find out fairly quickly if you made the wrong choice. If there’s any backslide you say, Okay, I have to take a step back. The problem is, a lot of us won’t take that first step to saying, let me try to loosen up what I’m doing a little bit. And I think that’s something that allows, you know, a little more liberal settings and allows less sedation and more mobility.
Kali Dayton 25:39
And I think in those moments, when we’re recognizing the the poor status of the lungs, the high ventilator settings, so we’re considering the safety we don’t include psychological safety, physical safety, I mean, in the preserving their mobility as part of the safety, their long term outcomes, right. So when we make those that reflexive, that instinctive decision to sedate them, we’re discrediting all sorts of other safety measures that need to be in place and part of that discussion as well.
Dr. Matt Siuba 26:09
Yeah, and I think that that’s where our training comes into play as well. And in this way, it comes in a negative way, because we, as care providers of all specialties, learn the mechanics of how to take care of a patient, but we don’t necessarily learn like, if I just go in there and talk to them for a minute, I can mitigate a lot of this issue, if I can explain what’s going on explain what they’re feeling help relieve any symptoms they have, how far away that can go.
I similarly to you receive a lot of patients who are at another facility for a while maybe deeply sedated the entire time, I have no idea if they had sedation vacations or not. And the assumption is, they’re basically coming for a tracheostomy because they’d been there for 10 or 14 days or something like that. And meanwhile, forget all the medical things, fluid balance and respiratory mechanics and all that, but the person has not been awake in a week, they have no idea what’s going on, what do you think they’re going to look like when they wake up?
I mean, how would you feel if you were in, you know, completely out for a week, and then all of a sudden you woke up, especially if you’re in a new hospital, not even the same hospital that you were in before your own new people, your family’s not there? How are you possibly going to react to that. And so that’s where the humanistic side really comes into play. But we don’t necessarily get that. And that’s not like part of any training set of how to take care of a critically ill patient.
Kali Dayton 27:27
Right, we and we don’t think about safety, how to keep them free of delirium. It’s not part of the discussion, that moment, we just see, we look at those numbers, we see Oh, my goodness, their PEEP is 12. And therefore, we have to forget, we have to ignore delirium, we have to ignore their diaphragm ignore mobility, because we’re trained that way.
And you make a good point with communication. That can be a very effective tool to get someone’s respiratory rate down. And that was one of the concerns that’s brought up to me during the webinar was, well, what do you say to them? We How do you talk to them, when I propose letting them wake up after after intubation, so I wasn’t sure what to say I just kind of said, you can talk to them, like you did 20 minutes before that point where their voices anymore, but they’re there. And so it was just revealing I’m not no judgement to that team. I appreciated that good question. But it was just revealing part of our discomfort is the skill of talking to people.
Dr. Matt Siuba 28:26
And I think we’re afraid that we’re going to fail so quickly that if we don’t calm them in 15 seconds, they’re going to reach for the tube and written and yank it out.
Kali Dayton 28:33
Yeah. Which, when you’re waking up at patient and the scenario that you’re describing, that is a risk. That is scary, that is extremely stressful, yet, we don’t understand the studies that show that the risk of that decreases as we decrease our sedation administration, are strongly hand in hand, and all of it and so safety, we have to think what’s going to decrease your risk of self-extubation, while the ventilator settings are high… and it’s not sedation. That’s not going to decrease the risk.
Dr. Matt Siuba 29:04
No, for sure. Yeah, and that’s something that I try to tell bedside nurses, particularly when I’m working with them is that you know, delirium is not just somebody being goofy, it’s an organ failure. And if you don’t treat it as such, then you’re, you know, you’re like, “well, they’re on 100%”. I’m like, “Yeah, but their brains, you know, on whatever that the equivalent of their brain being on 100%”.
They’re in the same situation, you know, their brains Not, not at risk, it’s being injured, or whatever, you know, and adding sedatives to that is not does not improve that. So I think that’s, that’s another piece of education that I don’t think we communicate very well, you know, most a lot of units are moving towards Yeah, people should, you know, at least get sedation vacations, if not be awake most of the time, you know, focus on you know, pain relief first and then you know, if they need an exit letter or something, you go to that next, but I think we still don’t necessarily communicate how much delirium is an issue. You know, we don’t have a we don’t have a delirium machine. You know, there’s not like a CRRT machine for delirium, there’s not a ventilator for delirium. So people don’t necessarily view it as an organ failure in the same way.
Kali Dayton 30:07
I completely agree. And there’s not a number, there’s a cancer score. But it’s not like a cranny clearance number that we can defy that we like to look at. It’s it’s much more subtle. And when we eat listed ate them, we don’t get, we don’t have to see it that doesn’t pop up in our lab values in the morning. That is dependent on our own exam and our own interventions. So yeah, absolutely. And that should be a huge part of the safety discussion in that moment. And you make a good point that someone’s ventilator settings are high mean, their acuity is increasing, their brains are likely to be more compromised, and more important to protect.
I’ve used example, giving the sedation for delirium is like giving bacteria with for bacteremia. I mean, it just doesn’t make sense. But we don’t educate it that way. And so this is never a judgement to this teams that do respond that way. It’s just a reflection on the misinformation within our own field and how we respond to things.
Dr. Matt Siuba 31:03
And I think to your point, too, there’s not not only as adding something, and like adding sedation, probably harmful, but the other thing is, there’s no medication for it, right? So if the medication is maybe taking medication and taking things away, or trying to normalize the environment. But that’s not like you don’t write an order for like, make this a more humanistic setting. Like there’s not an order for that. So I think we just don’t view it in the same way. Because everything that improves delirium is generally subtractive rather than additive. Like everything else we do.
Kali Dayton 31:34
That’s why I like your zenintensivist movement.
Dr. Matt Siuba 31:38
I think it fits nicely. Yeah, absolutely. Absolutely.
Kali Dayton 31:41
So, you’re going safety. What was the next one? Comfort, comfort, and liberation. And I feel like a lot of that is easily addressed by that one decision, at the very beginning, right after intubation. It completely changes the course of someone’s ICU journey and life, and likely decreases the ventilator dyssynchrony The discomfort on the ventilator when we avoid delirium, one of my questions for you, and I don’t think there are any studies, but what are your thoughts? Can delirium cause hypoxia?
Dr. Matt Siuba 32:16
That’s a really good question. I would say, I bet it can in an indirect way. So if you’re doing if you’re, if you’re really if they delirium is causing you to have really injurious interaction with a ventilator, then I think, absolutely, I mean, indirectly, you’d say, Okay, I’m gonna cause some adult trauma and my cousin Barrow trauma, there’s going to be long units that are opening and closing, every time you’re just synchronous. If you take too, you know, if you if you have two breaths back to back, which people often refer to as double triggering, and you’re in volume control, you’re gonna give them double the volume that you intended to give them.
So I’m sure that’s injurious. And on the other hand, if they cough or gag on the tube and don’t take a breath, they probably do recruit. And then when they re recruit, that opening and closing of airways is actually can actually cause inflammatory lung injury in and of itself. So I would say probably, yes, but it would be by an indirect pathway, I think that would be the likely way that that would happen.
Kali Dayton 33:09
No, that completely makes sense. I pose it that way. Because I hope that that would change our perspective. You know, we’re worried about the lungs, and we should also be worried about delirium. For sure. I was reached out to by a nurse in Australia, who was really excited because they had a patient awake on the ventilator for the first time in their whole career. I call them icy revolutionists people are out there doing cool things. She mentioned, they weren’t really comfortable.
They weren’t APRV, which was different, because in that team, they primarily used si MV. And that was a paradigm shift for me, I did not realize that some teams still use SIMV, APRV, even is an extremely rare occasion. I think I’ve maybe seen two patients on APRV in the wake and walk in ICU. And so I was hoping to dress also ventilator modes, how does that impact that quote, unquote, illness? For sedation, and what modes are much more comfortable for patients? Yeah, so
Dr. Matt Siuba 34:04
I think there’s this part of the cause, the this part of the conversation could be a podcast in of itself, I will try, I will try to be concise. So in an in the ideal world, if you could pick your own ventilator setting, you would want to choose when every breath is initiated, when every breath ceases. And you would want to choose your flow. So you want to decide I’m going to take the breath as fast or as slow at whatever pattern I want to take it that would be the ideal circumstance to add to that.
So first of all, we’ll we’ll start there, so I can I just say when every breath starts and stops within reason, and I decide how you know, how I take the breath in terms of the flow, that’s pressure support, basically, pressure support, ventilation meets those criteria, and then it’s just a matter of dialing the amount of inspiratory pressure to the level that is comfortable for the patient. That is okay, if the patient’s awake and can talk to you great ask them get their opinion on where they you know, what’s too much what’s too little. What’s the sweet gets by.
If they can’t, for one reason or another, then you really have to get, you really have to develop expertise in waveform interpretation of the ventilator, because you have to understand where to look for effort. So if the patient’s in a pressure mode, you look at the flow waveform and the way the flow waveform differs from normal will tell you how much effort the patient’s giving. Because this is a podcast and I can’t draw it, what I’ll say is a normal passive waveform flow waveform in a in a patient under pressure mode, whether it’s pressure support, or pressure control, is basically just a concave shape, just like exponential decay just kind of flattens out, the more someone gives effort on the ventilator, that waveform will change from that shape to sort of have a belly to it.
So it’ll kind of swing open. So we can say, like kind of starts to look pregnant. And the more pregnant, the waveform the more patient the more effort the patient is doing. So if that patient if you want the patient to be doing some of the effort, you probably want to you don’t want to see it completely flat, but you’d like to not see it like completely bowled over in the opposite curvature. That’s kind of the way I would think about it. So that’s kind of how you assess that. Now, if you want to take it another step further and say what’s the best way to make this not only comfortable, but also titrated to sort of what the patient wants and needs, then you’re talking about a specialized, most specialized modes of ventilation called proportional modes.
So most modes, so if I put you in pressure control or pressure support, every time you take a breath, you’re getting a set amount of inspiratory pressure, it’s wherever the ventilator whatever we set on the ventilator, the patient can obviously do more work or less work, but that amount of support will be unchanged. If a patient is in volume control, or in PRVC, the more they work, the less help they get. So that’s like the opposite of what you’d want, right. So like, especially if you’re exercising, if I’m exercising, I don’t want less help when I’m working harder, that doesn’t make any sense. So the ideal circumstance would be the the harder I work, the more help I get. There’s only two modes that really meet that criteria.
And most people probably haven’t used them before, because there’s only available on a certain number of ventilators and only certain people are familiar with them. But they’re called proportional modes. So the more more I do it, the more help I get one type, one version of that is called proportional assist ventilation, or path pAB. That’s kind of like power steering. So the harder I work, the more help I get. The other version of that is called Nava, or neurally, adjusted mental or ventilatory assist. This is kind of neat, you actually place a ng or an OG catheter, just like it looks like a normal end, or ng or OG tube, it has electrodes on it.
So you place it down until it gets to right above the diaphragm. So it can sense of diaphragms electrical activity. So then you were really truly synced with the patient. When the patient starts a breath, it senses that at that level. And depending on the intensity of that effort, the event decides how much help to give. So those are those are probably the two most comfortable modes, if you have them in if you have the expertise to use them, but most people don’t necessarily. But that’s sort of like I’m trying to set the ideal circumstance.
Kali Dayton 37:49
Yeah, do you think that will become more common in the future?
Dr. Matt Siuba 37:52
I hope so I think we need a little bit more outcome data on it, there’s some decent data to support it from from a synchrony standpoint. I was thinking about it before this podcast, if somebody was like consistently working like exercising, I think Pav would be an awesome mode because that again, they’re working harder, they get more help. And then they start to settle down and the ventilator settles down with them.
So it kind of keeps their worker breathing balanced. Now that would be really cool. I’m just not sure if that catheter would move would migrate up or down when you’re like walking around the unit. So that one I’m I’ve never done that before. So I’m not sure if that would that would be safe. For me, I think these are things that once we get out of that hyper acute phase, I need to like really be in control of things, I think that that should be that would be a really nice natural next step is to move into those kind of moves.
And I should say, since I mentioned, those are only available on a couple of ventilators, no ventilator companies give me any money, I don’t get anything from anybody. So just want to say like, I just think those are cool nodes in general. In fact, I’m gonna talk about path that just this year, because I’m just a big doozy estimate. Now for the other modes that you talked about. So I am V modes, intermittent mandatory ventilation modes are really interesting and weird. And like you say, it’s not something that we usually do in the United States, it’s still except in some surgical units. They still use them for weaning purposes.
But most of the data suggests that it actually prolongs the weaning process rather than AIDS in it. But the idea here is some of the breaths are fully controlled breaths, meaning that you get the full tidal volume or the full pressure for a set inspiratory time on some breaths. And anything you breathe above that, that you are getting pressure support breaths, that’s an oversimplification, there’s a lot more to it, because there’s like four different kinds of SI MV, but that’s not that’s beyond the scope of what we’re talking about. The interesting thing is that APRV, which you mentioned, is basically a specialized form of IMV.
So the difference is you’re you have a really high set inspiratory pressure, and it’s the ratio of inspiration and exploration is reversed. So usually it’s like six to one. So inspiration for six and expiration for one, that’s an example there’s modifications to it. But in between those large breaths and then a short expiration, you can breathe above that anytime you want. So you can still breathe through that. So in You read that is probably more comfortable. The data on APRV is really mixed. And there’s people that think it’s the greatest thing that’s ever been invented. And there’s other people that think it shouldn’t ever, ever be used.
And I, I don’t use it, but I’m not like a purist about it. So I think those are that kind of covers the the odd modes and terms of things that you might see. Now for things that you’ll see more every day, like volume control is going to be the vast majority of what you see every single day when you go into most ICUs APR VC is another mode that you’ll see very commonly because it allows you to set a tight deadline, but the problem is, it’s actually not find control mode, it’s a pressure control mode, and then adjust up and down how much help it gives you based on how hard you’re working. But in this, this is the opposite of path.
So the harder you work, the less help you get. So if you have somebody that’s anxious or has metabolic acidosis, or is really working hard, it’s not a good mode, it’s you’re basically going to be giving them zero pressure support over whatever people around. Yeah, so that that that’s just something to be aware of. So I think if you felt like you had to have some control, but now total control the tidal volume, and we’re trying to prioritize comfort, pressure controls a reasonable sort of middle ground, but it does require understanding of how to set the inspiratory pressure to make sure the amount of work the patient’s doing is right and make sure they’re getting an appropriate tidal volume and things like that.
Kali Dayton 41:18
Yeah, I worry. And I am embarrassed to say that I hardly address this because I sit, I assume that most people were honest as to control and their ICUs. And so I worried that maybe I’d influence nurses to take off sedation during si MV. And that sounds like that would be very traumatizing for patients. You know,
Dr. Matt Siuba 41:37
I think I think there’s no, I think none of these modes necessarily necessitate sedation. And I think, si MV, there’s nothing wrong with SIMV, it just, it’s kind of a mode that doesn’t have an indication more or less. So it’s like, at what, you know, the times that I use a CMV, as if I have a patient who I really want to do everything themselves, but they’re just not quite like awakened up, like, let’s say they just coming out of anesthesia or something. So their respiratory rates, like for a minute, and I can’t leave them at for a minute. So I’ll set a backup rate at like eight or 10. And then anything above that, they get pressure support breaths. So it’s actually it’s probably not an uncomfortable mode, it’s just not, there’s not a ton of indications for it.
Kali Dayton 42:17
Okay, because I worried that it was something really uncomfortable, just the way, the timing seems really unnatural. That is a consideration for if we expect patients to be comfortable on the ventilator, we need to find settings and modes that are going to be adaptable for them and not with sedation, we expect patients to work for the ventilator, instead of making the computer work for the patient. Right. So as we’re taking off sedation, we have to also adjust how we’re managing the ventilator, for sure.
And I have been very spoiled and have the safety net of extremely experienced respiratory therapists pulmonologists that know how to make those little adjustments how to whisper ventilator to make it comfortable for patients. And I think that’s part of the success and using sedation. So rarely is because patients truly are comfortable when they’re free of delirium. And to even with their high ventilator settings. There, it’s everything is personalized, which we can’t do if we sedate everyone, right? We can’t personalize, we can’t optimize care. If we treat them all the same with all the same medications,
Dr. Matt Siuba 43:22
for sure. And I think that’s where that surge mentality comes into play. So if you’re like overwhelmed, and all you all you can think, you know, you don’t have time to personalize, then you can see why this would happen. The problem is it often happens outside of a certain circumstance. So you know, people like patients to be quiet and out more or less. And I kind of have that we just kind of have to divorce them from that idea. That that’s that’s the ideal circumstance. I love it when I get to see somebody like sitting out like watching TV or talking to their, you know, communicating with their family or reading or something like, and that should be the normal experience. It’s still not quite the normal experience where I am, I don’t have it as it’s not as quite as clean for me as it is for you. But it’s something that we’re definitely actively working towards.
Kali Dayton 44:06
Which I’m so glad it’s definitely a it’s a process of evolution. For sure. I worry about new clinicians, new nurses coming in. During the search. This is all I’ve ever known. And so I just was reached out to by a nurse, I think I’ll have her on the podcast, she listened to the webinar, and she messaged me with dis gratitude for the hope that it brought. She came in to nursing during the search. And she she just after a year of nursing during COVID. She’s also been excavated for the very first time this last week. Oh my gosh, that’s all she’s ever seen as sedated, paralyzed dead. And she’s really rethinking her career choice. Right. And so I would hope that this approach and would be part of our cure to the burnout when we actually see patients be awake, comfortable moving, get to know them for who they are and get to see them get better and excavated. and literally walk out the doors. But there is a lot that goes behind it. And I think I’ve disregarded or underestimated the ventilator side of it. Yeah, it’s
Dr. Matt Siuba 45:09
it’s very important. But the points that you just made are so key, your experience is completely different. If you think of I’m taking care of a body in a bad versus taking care of a person. And that sounds like we’re all dehumanizing everybody. And I don’t mean to imply that at all. But it’s easy to lose sight of the person, if you’re just like, you see just a passive body there with lines, tubes, monitors, and you can integrate that in with who they are. And you know, it, that is the hard part. And that’s why it’s so great to be able to walk in the room with a vented patient and talk to them and see how they’re doing.
And you know, that that shouldn’t be the minority experience. Now, don’t get me wrong, I still think there’s patients who need sedation, I just think it’s way less than what we’re what we’re, you know, what the current, you know, status quo is. So, yeah, it’s something that I think it would make all of our jobs more enjoyable. If you I mean, you could still get to, you know, a lot of the times in ICU, our patients maybe are not in a way they can communicate with us, as well as somebody that’s on like a medical floor, because you know, because of their severity of illness and all the devices. But to have those moments to be able to interact a little bit more meaningfully makes a huge difference. And even just taking that, you know, having those two or three minute conversations helps somebody be calm and say, “Hey, we’re working on getting this to bout, you know, I don’t want it to be there any longer than it needs to be. Let me help you be comfortable in the meanwhile, let’s make this work for you.”
And in the interim. And I think that that those, those experiences are so rewarding. There’s so many people that I meet, and probably you meet that I never had to talk to them before they were on a ventilator, so I know nothing about them. So it’s nice when you start to get that perspective, you know, you can get what you can from the families by talking to them and tank kind of trying to understand but you don’t, you don’t really know somebody unless until you get to really interact with them. And those experiences are so rewarding, especially when you never knew them from anything before. And just to kind of get to see their personalities come back, it’s great.
Kali Dayton 46:56
And they can guide their treatments, they know their bodies better than we do. And they can tell us what they need. If we crank up sedation, because we have spontaneous breaths, or because the respiratory rate has increased without assessing why it has increased, then we’ve missed the key assessments, we’ve basically treated tachycardia with a beta blocker, where survivors had told me I kept motioning, or trying to ask them to write and they would just sedate me again. So that kind of anxiety has to bring up your respiratory rate. Yeah, the response was to deal with to date them. And so and that, you know, we set alarms, and then the respiratory rate goes above that that’s not always the synchrony. But I think we interpret it as such, and we treat it with things that caused it.
Dr. Matt Siuba 47:42
That’s the problem with the way that a lot of our alarms are set is they’re set so tight in a way that we don’t necessarily on their identity, there’s so many false positives, right? So if somebody’s respiratory rate was 22, and then they woke up and all of a sudden, it’s 32. And you set their alarm at 30 events go no alarm, it doesn’t mean that that was actually necessarily harmful. That alarm is just a signal for somebody to look at this patient and see what they need. Is this a safe thing or an unsafe thing they’re doing? If it’s safe, then I’m going to liberalize that alarm. I’m not going to, again, like you said, I’m not going to treat the machines problem by doing something to the patient. It doesn’t make any sense.
Kali Dayton 48:18
But it’s also integrated into protocols. I was a template me there protocols, and indication force. Sedation was spontaneous breaths.
Dr. Matt Siuba 48:28
Oh, that’s, I will say that as at minimum counter to standard of care. So that’s, that’s really striking and a bad way.
Kali Dayton 48:38
But I think there’s value in sharing protocols discussing these things, getting other opinions from other people. And so I hope, through my webinars, services and consulting services that we can have more collaboration and share experiences, because I think these are all good people well intended. Everyone wants to see people survive and have quality of life. We just have to adjust our paradigms and understand what’s really going on when the later alarms. Absolutely. Anything else you chaired the IC community.
Dr. Matt Siuba 49:06
Yeah, I think just as a I mean, I spent our like a lot of ventilator terminology and I just kind of want to bring it back home to kind of the inspiration for this talk was how do you make the ventilator work for the patient especially when you’re trying to mobilize. So the take home messages that I think are important is to realize that when possible pressure support or proportional modes are the most comfortable ventilator settings you can have, you still have to watch for all the safety parameters you would watch in any other mode you have to watch that means you have to actually pay attention to the title line because it’s not set and you have to understand what how to look for work or breathing changes on the on the flow waveform and you have to my inner pressure.
If I’m on the ventilator, please don’t sedate me unless I really really need it and when you go to exercise me I you know put me in pressure support or a proportional mode and have had the skilled person there just watching and make sure things things look okay. I think proportional assist ventilation is a really interesting idea for this setting. Because again, the more I work, the more that ventilator is going to do for me.
The caveat with with pav, though is that if your respiratory effort is very inconsistent, it has a hard time keeping up with you. So if that’s the case, then pressure support is probably the best way to go. People get uncomfortable using pressure support over more than like five of inspiratory pressure because everyone’s like, well, that’s how we we put people in five over five, if somebody needs 15, or 20, under pressure support to have comfortable bounce work or breathing while they’re awake, and their tidal volumes are safe, and work and breathing and safe, that’s fine. Because if they were in mind control, or you know, AC volume control, however you want to call it, and their title line was set at 400.
Their plateau pressure might be 30, which means if there are people’s aid, that you’re giving them 22 events per day pressure to achieve. So it’s already more than what you are doing with the pressure support. So it’s just a way it’s just a matter of how you think about these things. And that’s why it’s really, really important to have experts in mechanical ventilation, take care of these super sick patients, because they will make the ventilator work for the patient rather than the other way around. And experts can be respiratory therapists, advanced practice providers, and physicians. I hope there’s not another group I’m neglecting.
I really would love to get to a day where we’re nurses really deeply understood the ventilator. I think that’s something to aspire to. And I think we can get there but just that minimum, the rest of us need to be able to know how to respond to those changes, or respond to alarms respond to dyssynchrony and make it make the ventilator work for the patient rather than the other way around.
Kali Dayton 51:21
Thank you so much. I have learned so much. I think this is exactly what our podcasts needed. Thank you Dr. shuba.
Dr. Matt Siuba 51:26
Thanks so much.
Transcribed by https://otter.ai
References
Dzierba, Amy L. PharmD1,2; Khalil, Anas M. MD3; Derry, Katrina L. PharmD4; Madahar, Purnema MD, MS1,5; Beitler, Jeremy R. MD, MPH1,5 Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation*, Critical Care Medicine: December 2021 – Volume 49 – Issue 12 – p 2090-2101 doi: 10.1097/CCM.0000000000005113
The Zentensivist Manifesto. Defining the Art of Critical Care
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