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Does sedation always improve ventilator dyssynchrony, or can it cause it? How does a lack of unity between disciplines impact patient care and outcomes? How can we better support and utilize the expertise of respiratory therapists to optimize care for patients on ventilators? Brady Scott, PhD, RRT shares his 20 years of experience and insights.

Episode Transcription

Kali Dayton 0:00
Okay, so these segments on ventilator management would not be adequate without bringing the expertise of the very discipline that has dedicated their whole careers, to mastering the art of orchestrating the ventilator. Let’s dive into how to best collaborate and utilize the expertise of respiratory therapists with Brady Scott, PhD professor and seasoned respiratory therapist. Brady, thank you so much for coming on the podcast. Can you introduce yourself?

Brady Scott, PhD, RRT 0:58
Yeah, my name is Brady Scott. I’m a respiratory therapist. I am an associate professor. And I serve as director of clinical education for RT program in Chicago.

Kali Dayton 1:07
And you and I were in a interdisciplinary meeting, I guess, trying to formulate guidelines for ventilator management, and you had so many good and valuable insights that I just knew that you were who this podcast needed. Thanks. So the last two episodes, we’ve talked about neuromuscular blockade and critical illness, polyneuropathy. And then the zenintensivist, talked about sedation and immobility and ventilator management, we still have been pretty general terms, and it would be completely incomplete to discuss these things without respiratory therapy. And so since you are so experienced, and you’re also training respiratory therapists, I really am excited to pick your brain. So in the big picture of things, especially from the artis perspective, how do sedation and immobility impact the RT role? Does it make it easier doesn’t make it harder when patients are deeply sedated? What’s the big picture?

Brady Scott, PhD, RRT 2:06
Well, I think that, first of all, let me say, Thank you for having me. And I appreciate you know, you, you’re reaching across to me and invited me to be here as part of really this interprofessional interdisciplinary approach to medicine, because in reality, that is the complete picture. That’s the reality. Right? So I’m happy to be here. And, you know, I look forward to our conversation. So you asked me about how does sedation immobility affect RT?

Well, sedation has a tremendous impact on a respiratory therapist. Right? So if you think that, you know, part of my job is if we just for a moment can talk about the intubated patient, or the mechanically ventilated patient, you know, my job is to, to help reduce their work of breathing to help influence you know, or improve gas exchange. And and have them synchronize with a ventilator. And, you know, sedation can either make this more difficult or, or it can help me out, as you’re alluded to, sometimes it makes it harder, and sometimes it makes it easier. So, you know, when I was in respiratory school, this was 20 years ago. So I’ve been a respiratory therapist for 20 years. I admit, I did not like pharmacology. I did not like that course. I think I got it. Okay, great in it. But it was tough. I just, for some reason, I just didn’t care for it.

But when I got out of school, pharmacology became one of my favorite parts of critical care, because it did impact me so much. So I worked with the nurse, bedside nurses and the nurse practitioners and physicians, to better understand propofol, the onset, you know, half lives and you know, the onset of the drug. How long does it last I got I had to better understand analgesia. When you when a nurse was giving fentanyl or your nurse was giving versus anything like that I had to start to understand how this impacted the respiratory drive and my patients comfort because it wasn’t long after I got out of school and really got out into the real world, I realized that not only did this have an impact on my day, it was a tremendous impact on my day, because I had to literally change my event settings based on how those things were being handled.

And you go to immobility well, as I’m, as you know, you know, the lungs are the you know, they need to be you know, you need patients breathing, you need patients coughing, you need patients taking deep breaths, and we don’t have that. We run into all kinds of, of complications, you know, including things like atelectasis and mucus plugging and all those things that really make the mechanical ventilation course more difficult. So in terms of sedation, immobility, it is a daily, hourly concern of the average respiratory therapist.

Kali Dayton 4:53
Oh, that is so profound. And like anything, I think that perspective varies. or clinicians to corner training the culture where Marston? For example, in one online discussion, a respiratory therapist said, You can’t not sedate patients, because then you can’t pull them do pulmonary toileting. And I thought I was personally confused as to where they were coming from, because in my mind, everything you listed, coughing, moving, breathing independently, that’s all part of actual, actually effective pulmonary tilt toileting.

I don’t know if they were just referring to CPT or what they were referring to. But there is a lot of miscommunication between the RNs and the RTS and the MDS. And as far as what we’re really working towards with these patients on mechanical ventilation, and that seems to impact how we use sedation. So you say that sometimes sedation makes it easier to synchronize with a ventilator? And sometimes it makes it harder?

Brady Scott, PhD, RRT 5:51
Correct.

Kali Dayton 5:52
Dr. Siuba, last episode, also mentioned that, so in what ways can sedation cause more to dysynchrony?

Brady Scott, PhD, RRT 6:01
So, yeah, because it almost seems intuitive that when you sedate somebody, there should be synchrony, right. But that’s not always the case. And it really kind of depends on the level of sedation and kind of what’s going on at the same time. So they’re in I can’t quote, a lot of data right now, I don’t have it in front of me. But there’s some, there’s some evidence out there that demonstrate says that, you know, at some point in time, when when some folks are sedated, it can actually kind of lessen their, their drive to breathe, which which can actually cause more issues.

And so rather than if they’re waking up more, they can kind of trigger the ventilator a little bit better, you know, so, you know, when somebody is heavily sedated, or if there’s neuromuscular blockade on board, you know, using that extreme side of that matter, and I realized that’s not sedation, but if you have sedation and neuromuscular blockade, quite frankly, that’s very easy. synchrony is extremely easy. Now, there are some, you know, some, obviously, some issues related there.

But, you know, for the most part, the ventilator does that turn, it’s, you know, the breath is turned on by the ventilator, it’s turned off by the ventilator, and there’s not a lot of issues, but, you know, when a patient is, is is sedated, then you know, you can create a situation where they are kind of having a hard time again, no enough, you know, triggering turning the breath on, they’re kind of they’re a little bit too weak, perhaps are hard to hard to get there. So, you know, sedating people just doesn’t always make things better.

And we know that by sedating folks, that it keeps them on the ventilator longer, which puts them at risk for more complications. So, you know, at the end of the day as a respiratory therapist, and the way that I teach my students is the moment that moment that a patient goes on the ventilator or respirator therapists should be talking about should be thinking about how to get them off, you know, how can I get you off this ventilator?

How can I, I don’t even use the I don’t like to use the word weighing the ventilator, I like to use the word optimize a mechanical ventilator, because I’m constantly adjusting based on what the patient needs. And as the patient’s condition is reversed or reversing, I should be adjusting my ventilator to that point all the time, I just don’t have some turn on where I begin, like some moment where I begin to wane, I constantly adjust and readjust and just give the patient the safest possible mechanical ventilation and give them what they need. I don’t want to give them too much mechanical ventilation, I don’t want to give them not enough ventilation, I want to always give them what they need.

So I like to, say optimize mechanical ventilation. And so, you know, keeping that in mind, you know, when I like to, I like to kind of run along beside the team, the team’s approach is to wake the patient up and see if they can be excavated. You know, that’s, that’s what I want to do, too, because I don’t want the patient on the ventilator for one second longer than they have to be because of the potential complications associated with being on a ventilator for too long. Does that make sense?

Kali Dayton 8:58
Oh absolutely. And I think my proof, of course, I’m just, I’m just thinking of lots of scenarios that I’ve seen and just what I’m hearing from ICU community as far as how these discussions are going. So you’re reaffirming how much work it can be to really adjust the ventilator for every step of the way.

Brady Scott, PhD, RRT 9:18
And I actually well, while I’m at it, I’m sorry to interrupt you just for the listener. So I’m sitting here with a few papers around me because I, I kind of wanted to be able to point to this, but I was actually just looking at a patient that was a paper that was in critical care medicine out of 2013 that actually shows that deep sedation itself is a is an independent risk factor for ineffective inspiratory efforts.

So so deep sedation can can create, like I was saying before, it can actually create problems with inspiratory efforts, which can result in this quote, and I’m using quote fingers here, fighting the vent or just ineffectively triggering the ventilator. So it’s just not it’s just not always the right thing to do. And You know, and I’ve been doing this for a long time. And I certainly think there are times when patients need to be sedated and pain control has to be there. But I think there’s, there’s we should be putting the efforts where we can to adjust ventilators and make patients comfortable without the use of so much sedation.

Kali Dayton 10:15
And you’re bringing so much clarity to me, because I’m coming from a perspective of an awakened walking ICU where patients are allowed to wake up right after intubation. And be very involved present, we adjusted ventilator for them, but it seems like there aren’t going to be as many adjustments because their sedation level, the RAS level, their delirium is not fluctuating every day. And they’re able to control their own breaths, and we can work with those.

Another thought is, right now paralytics are some teams go to for every COVID patient. And there’s everyone’s going to need it, because that’s what we’ve been seeing. I’m wondering, if we start them out with deep sedation, we’re causing this failure to ventilate this dyssynchrony. And it’s getting too hard for too many patients. So we just paralyze them automatically. And that seems to do the trick. That makes it feel better in the moment, and it’s easier for everyone. Are we creating that, quote, necessity with sedation? What are your thoughts?

Brady Scott, PhD, RRT 11:20
You know, I’m not sure I’m really qualified to answer that question. I hate hate to say that. I don’t really know yet. Because I you know, again, I’ll say this, I think for the third time now, I’ve been doing this for 20 years. And it seems like it seems like the in my career we’ve went from don’t use paralytics gene those in like severe ARDS patients up to using paralytics. And back to not using and then there’s concerns about patient induced lung injury and patient self induced lung injury and all these things that come around. And and sometimes, you know, I, it’s hard for me to answer the question when but whether or not we should actually let patients breathe a certain way or not in the setting of like severe or moderate severe ARDS.

So I see what you’re saying, I think that there’s there could be a situation where if we just lift lifted sedation, perhaps we could get them to synchronize and be more comfortable, we wouldn’t have to heavily sedate or paralyzed. But I will also leave room for, you know, the fact that we’re still learning, unfortunately, this COVID-19 group, I think we’re still figuring things out, the best way to treat this, this population, I can tell you that there have been times where I felt better about a patient with COVID-19 being paralyzed, because I could finally get them, you know, to to optimize their mechanical ventilator settings where I could get, you know, prevent alveolar recruitment, I could deal with her hypoxemia better, and so on and so forth, and perhaps even put them into the prime position.

So, you know, again, I’m not trying to I’m not trying to, I guess, evade the question. I think it’s a reasonable concern, I guess I want to leave room a little bit to for right now to say, maybe there’s a certain group in our population that needs to be paralyzed? Well, there’s a group that probably would do just perfectly fine. If we just would just lighten it up and just let them awake up and breathe on the ventilator.

Kali Dayton 13:10
I think that’s a really fair answer. None of this, as I said, really hard parameters and projecting this to project on all patients. Sure. That’s actually what I’m trying to combat. Because we have projected this mechanical ventilation require sedation paradigm in our culture, and that deconstructors patient care. Right, right. sedation is necessary. paralysis can be necessary, in certain cases, sure. But until we really know what’s causing that necessity, or what these interventions really do, we can’t really triage their use, right?

Brady Scott, PhD, RRT 13:46
Sorry to interrupt you. I was just thinking that I think it’s one of the most surprising things when I’m teaching students. So part of my job is to, you know, I get to I get the privilege of teaching masters entry level Respiratory Therapy students, and I get to influence them in early on in their career. And I talked about, you know, I’m like, you know, not all patients are asleep doesn’t matter of fact, I’ve met many patients that are intubated, that are writing notes to me, or they’re, I changed the channel and I watching the same thing on television, whether they’re watching, or I’ve walked down the hallway with them, or I’ve marched at the bedside with them.

And it’s funny that in the in the logical thinking of a Respiratory Therapy students, sometimes it’s like, they always think that people are asleep. And I’m like, that is often not the case. And I said that we’ve actually switched more to try to help you know, waking people up and getting them involved in their care. And speaking of this COVID group, I remember early on when I was taking care of a COVID patient, I remember being at the bedside and marching with one of our COVID patients before he was able to come off the ventilator and he did really good. We were just wanted to make sure he was strong and we were standing it up and we were kind of marching and walking a little bit at the bedside. Okay, so it was cool to see that and know and get those lungs moving and it feel good before we actually extubated him.

Kali Dayton 15:07
I’m sure it’s a respiratory therapist, you especially understood the value of that for the lungs. Sure. I think for other disciplines, sometimes we don’t have that focus that education, that understanding. So I think from the nursing side, sometimes we’re afraid to let people wake up, because we’re afraid it’s going to hurt the lungs, which is probably contrary to your logic and understanding that education.

But that is a genuine concern for many members of the team is that mobility will hurt the lungs. So I wish that we had more bridges, more communication between the disciplines to have respiratory therapists teach us tell us actually moving them will help secretion mobilization, it will improve lung aeration to happen sitting up standing, doing all these things. I some nurses have said the respiratory therapist just demanded that I paralyze them, but I didn’t feel good about it. And the next respiratory therapist came on and change the ventilator settings and the alarms stop.

Brady Scott, PhD, RRT 16:02
Yeah.

Kali Dayton 16:03
And you’re laughing about that, how, let’s just talk about ventilator alarms, because there’s so stressful to the nurse because we’re not trained on the ventilators like you guys are. And then yet, nurses are in charge of making sure the patients Okay, and it makes us feel better when alarms are off. So we crank up sedation. But what could we do about our interdisciplinary interactions, to actually address the alarms without this Aquila of more sedation.

Brady Scott, PhD, RRT 16:30
So alarms are complicated. As you know, we wrote a paper a year or so ago on just alarm fatigue. You know, it’s not only stressful, it’s just uh, we, we basically stopped hearing them after a while and it’s a it’s a real serious concern. It clearly alarms the intent of the alarms hard to keep the patient safe. But it doesn’t help if we respond by one, like you said, perhaps doing something perhaps prolongs mechanical ventilation time to make them go away. So that doesn’t help and then or if we just stop hearing that because of like this issue with, you know, that which is respray therapists deal with nurses, everybody deals with which is alarm fatigue, and mechanical ventilation alarms make up a lot of alarms in an ICU.

So, you know, let me let me go, let me go with the first point about communication. So you know, I am I’m on Team interprofessional and interprofessional approach to ICU care, I’m on Team, nurse, physician, RT, pharmacy, occupational therapy, physical therapy, everybody talks, everybody communicates. And I think Gone should be the days of silos, if they still exist, they need to go. It’s antiquated, it’s it’s tired, it doesn’t work, it needs to go, we got to stop being respiratory and nurses. And that’s what they do. And this is what we do. And we’re like, on these different teams. Because at the end of the day, we’re on the same team with the same exact goal with the same exact game. Right? We’re all in patient care.

And we can’t do this without each other. So I just think that just mentality of nurses versus RTS or RTS versus nursing or whatever needs to stop. Yesterday, it needed to have already stopped if it still exists. So I think what can happen is, you know, let me approach is to first of all, if the RTS nurses are communicating about what ways to maybe reduce the alarms, perhaps that might help, right? Because what we have to admit is ventilator asynchrony. And the type of asynchronous that could be happening with the ventilator causes the alarm goes off. Maybe it’s not the same for RTA, who said pair lights and RTB who fixed, right? You can’t say that what was happening at 8am was is what’s happening at 8pm. So we have different kinds of asynchrony is as you have different metabolic changes, and the lungs are different. And all these things that can occur during the day, maybe there’s more pain, there was more pain at ADM, and we couldn’t get in control of that we had now have control of at 8pm.

So we don’t really know who who was right or wrong in that situation. RTA might have been perfectly correct to record recommend paralysis, or whatever it was you said because they were concerned for whatever it was, I don’t know what the situation was. But there can always be I think, in that case, in either case, if the respiratory therapist wants to recommend something as a serious I believe in my my opinion s as paralysis or neuromuscular blockade, then there should be a here’s why I believe that to be true. Right? Here’s why I am going. I think that the best maneuver here is to do this. And that if you and I were at the bedside, that’s 100% what I would do with you, if you come and said, “Brady, I’m pulling my hair out because the ventilator won’t stop alarming.”

I would say, “okay, let me Take a look at it.” And I would probably stand there for entirely too long. And I would I would then get it figured out. And then I would come directly to you and say, “here’s what I think is true. This is what I think would have to fix this situation. Here’s why I think that I can’t fix it, per se, with a change on my ventilator versus paralysis”, or this is why I would say,” I don’t think paralysis is necessary here. Let me just switch this over. And let me show you why I think that works.”

And I think when we communicate like that, then there’s a lot of clarity about what the thought processes were. Because again, I can’t say that those are teas, either one of them are right or raw, were incorrect. It’s easy to say that saying, please to date or paralyze was wrong. But was it in that situation? We don’t know that to be true, right? Because you can have different kinds, again, to repeat, you can have different kinds of asynchrony at different times in the day. So I may recommend this, the same exact thing. And I’ve got a pretty good understanding of how to correct ventilator asynchronous with a ventilator alone. Does that make sense?

But at the end of the day, you know, my my take home point here is and I teach this in my classroom, there has to be better communication, you have to explain what it is. And you have to understand that saying the words, I think we need to paralyze it, that is not exactly a benign recommendation, right, that comes with that comes with a potential serious consequence. Now, it may be what needs to be done at the time. I mean, you know, whatever situation we’re talking about. But, you know, I, I’d like to instill at least as much as I can, in the people that I mentor and the students that I teach, that if you’re going to recommend something as as, as serious as deeper sedation or paralytics, I should have enough ability if I’m going to recommend it, to describe why I believe that’s true, and why the alternatives to that aren’t helpful.

Kali Dayton 21:57
Oh, so many things that I love. I mean, the the fact that there’s an appreciation for how serious those interventions are sure, just such a higher level of thinking. And I think, just because these interventions have become so common, they’ve become our easy go to. So it culturally, either we never knew how dangerous these interventions can be. Because they’re so new to us. And they came in a time when we didn’t have time to do proper training and discussion on them.

Or, or now we just, we don’t explain it, we don’t really triage whether or not it’s actually necessary, or we don’t communicate those things. And we miss opportunity to educate, collaborate, find other ways, and then really feel good about what we’re doing and come to a consensus. So I think that’s I love that you’re recognizing how harmful it can be, but yet it can’t be necessary and that we have to work together to know and feel good about actually being necessary and being all aware of the risks versus benefits. Right. Sure. And then,

Brady Scott, PhD, RRT 23:00
and I think that takes time, I think like to go back to what I was saying, you know, again, when I was in when I was training as a respiratory therapist, I’m not sure I really at that time, I understood the importance of or the consequences per se of sedation, or, or neuromuscular blockade or, or anything. I just had to develop it and learn over time. And I’m one of those RTS. I’m a clinician that’s lucky that I worked in in facilities where there was nothing but collaboration, right nurses and respiratory therapists they were never at at I mean, there was always times where people individually were odd.

But in terms of like, departmental There was never this. There nursing, we are our tea. And we’re going to you know, it was I’ve just been really lucky to work in places where there’s constant collaboration and discussion and through that, and through experiences and just being at the bedside, and just take an interest in interest on my own. That’s where I learned it, right. I mean, I learned so much about sedation, and analgesia and neuromuscular blockade, I probably have learned more, frankly, from nursing than I did any of my own training. So for sure, I know that to be true. So you know, I think that there’s times where, you know, I can, I can, you know, I would ask a nurse, “can you help me understand?”

And then the nurse would ask me, “Well, what did you do on the ventilator?” And I just didn’t say I made a few changes, right? I would literally say, “Well, the problem was, was the was flow asynchrony”, in order to, you know, the reason that I did this was because I found that and sometimes they’re like, “I don’t know what you’re talking about.” But it was still a conversation. And I think that we all educate each other.

And I think that needs to be a culture that we all seek, is we all discontinuously talk, and we educate and we respect each other’s expertise. And sometimes we just admit we don’t know certain things. And I think if we all do that things one, I think your jobs improved, I think you dislike your job better. Like I like when I go to work and I actually get along with everybody I work with and I go learn something Every day versus you know, being in an environment that would be, you know, like us versus them. And I just think that’s ridiculous and it needs to stop. I’m not afraid to say this on a podcast, that it’s ridiculous to have, you know, this interprofessional disagreements and not be properly communicating, it’s time it’s these, these silos need to stop.

Kali Dayton 25:23
Absolutely. Everything this podcast has discussed, is not possible if we don’t change the interpersonal culture amongst ourselves. Sure. A nurse should never hesitate to call the RT and ask questions. Hey, there’s an alarm, what can we do? And RT should never be hesitate to say, do you think we can lighten sedation and try a breathing trial and be proposing those things I’ve just reached out to buy some dieticians, registered dieticians that I’m going to be having on the podcast. And they’re pulling their whole team together to implement the eight F model as registered dietitians. And that is the future of critical care, where everyone has a seat at the table, and they all have something to contribute. Sure, but we have this hostility or we feel like the nurses handle sedation, physical therapist handle mobility, restaurant therapists handle the ventilators, we will never do what’s right for patients. And won’t, we will continue the cycle of today trach peg for the rest of

Brady Scott, PhD, RRT 26:19
You know, in your right 100%. And I think it takes all of us to sort of recalibrate our brains a little bit to say, it’s really, you know, while while the nurse may be the one who is, you know, adjusting some of this, I think it’s reasonable to say, Hey, I just have a question for you. Why did you stop this and start that I’m not really sure what that comes from. And then that, you know, again, that creates, you know, from an artist perspective, now I understand why you stopped one kind of drip and went to a bolus dose of things only, or whatever.

And, and that just makes me a better clinician. And now I know from then on out why it’s happening. You know, at the same time, though, when when a ventilator is going crazy, it won’t stop alarming. I think it’s my job as the RT to come to the bedside, first come to the bedside in and talk to the nurse and say, Okay, I understand what the issues are. But here are here are the possible solutions. And none of them are good. Or, you know, right now, this, you know, the only way to get this to be quiet is to do this and, or whatever, or I’ve got to loosen the alarms, and I’m not comfortable with doing that, you know, and so, you know, again, there just has to be a discussion about why decisions are being made all the time. And I think when we do that, I think we’re just a better team. And the pay in patient, you know, outcomes for the patient are just improved.

Kali Dayton 27:37
Yeah. And coming from the “Awake and Walking ICU”. I didn’t as a nurse practitioner, I really didn’t have to mess with your alarms very much. Because one, there was hardly ever any dyssynchrony. I asked the artis after I’ve been getting so many questions from doing the podcast, they really said we don’t, we just don’t see it very much. I mean, they would deal with a lot of ARDS, a lot of high acuity patients, I suspect a lot of it had to do it has to do with their sedation mobility practices. But they said, primarily when we see it’s when we get patients from other facilities that have been sedated and they come to us and now it’s, you know, we have this delirium mesh that we’re trying to clean out….

Brady Scott, PhD, RRT 28:14
You know, they’re struggling with sleep, you know, their sleep, but you know, if they’re sleeping seven or eight hours a day, it’s, you know, half of its during the day, so they have all kinds of their, their sleeps all over the place. And, and you know, that it’s kind of almost like if they’re in between if they’re sedated, and it’s tough, right? So it’s, it’s hard. So yeah, and you know, even if a patient’s awake, you know, we may be on the perhaps, maybe like if your institution, they figured out the best kind of modes to breathe with patients that are, are awake, like something like pressure support, which is a spontaneous breathing mode that that has, that has that has a flow, you know, a flow cycle that’s, you know, relatively comfortable for your patients. So good for you, good for your team for your Artis figuring out how to how to keep those patients, you know, comfortable and on the ventilator and not necessarily creating this environment where the alarms are just going off,

Kali Dayton 29:09
and never had to come to me and say, “Hey, we need to sedate this person, because I can’t get them comfortable can’t manage them.” I feel a lot of it has to do with delirium, right? The patients are not uncomfortable because they’re, they know where they’re at. They can they have their coping mechanisms, right. I deal a lot with that in the rest of the podcast. But these are our teas that are ready to grab the oxygen canisters, plug it into the ventilator and walk and they walk the patients three times a day and twice during the day shift once in the evening shift. If restless, agitated during the night, sometimes it’s our tea that will say let’s just think of them. Let’s get up. Let’s stand up. Look through the chair. I mean, there’s so much collaboration, they don’t even bat an eye. When we’re pulling our teams together. What kind of concerns are how can we support respiratory therapy, to be involved in the mobility and to make it easier for them to transition to that change? The process of care.

Brady Scott, PhD, RRT 30:01
Well, let me say something real fast about your your Artis in the fact that they never come to you, or haven’t in a while or whatever come to you for sedation. And I and I want to say this, I don’t know who they are i Good for them. That That suggests to me that perhaps that team, or they’re talented, you know, what we’ve figured out what we’ve learned and what the literature when you read papers on ventilator asynchrony, there’s some really good ones out there. And you learn that ventilator synchrony is complicated, right?

It is a it is not simple. To detect ventilator asynchrony, it is not simple to exactly sometimes know what to do with it. You’re right. I mean, even when I teach mechanical ventilation to physicians and involved in their training, we spend a lot of times recognizing a synchrony. And a lot of times, creating ways to fix asynchrony without pushing, sedation are going for more sedation. So it makes me think, in reality, that you’re working with a talented group that have learned how to adjust ventilator settings, in order to make it to have your patients be comfortable. So kudos to them.

Kali Dayton 31:09
I wonder how much because it’s so normal there. I’ll ask them for cool stories like, hey, what would you share in the podcast, they don’t even recognize what’s and they’re like, I don’t know how to think about it. My patients calling me they want to get off the bed, that the toilet, they’re on the ventilator on the toilet. And they don’t even like that, that is special. You don’t even have normal. I don’t think they appreciate how much they as respiratory therapists and their expertise, impact patient outcomes.

Brady Scott, PhD, RRT 31:36
Sure. And you know what I mean, it’s easy to know why, right? Because, because you can because you don’t you can’t see it immediately, right? It’s not something you touch, like you touch an oxygen knob, right? Turn into 100% the SATs go up, or you turn, you turn, you do something and this happens, right? Mechanical ventilation is interesting, because you can’t exactly see the outcomes. And you almost have to track things over time and look at trends and things to see how that’s happening.

But yeah, you’re probably right, you’re I would, I would be willing to bet that you have a very talented group of respiratory therapists that and you guys have you figured out your recipe to to make to keep your patients awake and moving around. And, and you’re doing it sounds like you’ve done some pretty cool work. And so kudos to them, because, like I said, I am a respiratory therapist. And so I can speak first person to this, it is not easy to learn how to manage asynchronous or detect them, you know, you know, you can use your vent graphics, you can look at patients to see if they’re struggling, there’s a soft geometry, there are certain kinds of software’s and stuff that are out there that are that are even being created.

And certain kind of unique, like devices that we can use that are unique to ventilators. But, you know, a synchrony is is not exactly simple. And if you want to complicate it, go read about it. And you can see how, how complicated it can be back to what you said about I think your question, if I’m, if I recall was, you know, how can we support the respiratory therapist? So? Well, you know, I think one of the, you know, when you and I were talking a minute ago, using that example of an RT, that might have said, I think you just need to stay or paralyzed the patient or whatever. And then I thought about myself going into the room and spending too much time at the bedside, you know, the reality is, we don’t always have that time, you would like to have that time you would like to every time you walk into a patient’s room, you could sit there and stare at the machine, until you get figured out.

And I know that sounds silly, but sometimes what I do was when I’m watching graphics, and I’m trying to understand where exactly the patient is, is asynchronous, I will breathe with the like, I’ll kind of breathe alongside with the patient, I’ll look at them. And I’ll look at the graphics and I’ll make a change and see if it worked. But that takes a lot of my time. That’s not a choice. What I’m trying to do is is given nod to the party, that that that’s listening to this that says Brady that’s fine and everything, but we’re so short staffed. And you know, we have so many patients that I can’t, I just can’t stay in the room that long.

And I am fortunately think in certain situations that might be the truth or at least certain times during the day, you know, you know, oftentimes a respiratory therapist is covered in the ICU has to take, you know, transport patients to MRI or take trans take patients down to CT or wherever. And you know, so that really changes your ability to sit there and truly analyze the graphics and analyze, you know, the patient ventilator interaction and it does make it difficult. You know, so one of the you know, the reality is is sometimes we need you know, I hate to sound like a broken record here but you know, sometimes we need better staffing, you know, better staffing strategies, we need to make sure that respiratory therapists care that’s provided that the the care that’s being allocated to patients is the proper evidence based care you Oh in I am just going to say like in in Respiratory Care, we give a lot of unnecessary albuterol.

A lot of unnecessary treatments. And when you in when a respiratory therapist has an order to go give something that’s clinically on an indicated, that’s taking them away from the ventilator graphics, that’s taking them away from the walking patient that’s taking them away from helping the patient get off the toilet, he’s on the ventilator, because they’re giving a treatment that they’re giving a bronchodilator for a patient who doesn’t need a bronchodilator they you know, somebody wants the patient’s breathing to improve and the strategy is to provide a albuterol nebulizer. And it may not be that albuterol nebulizer is what the patient needs. Right.

So, we have to acknowledge that, you know, the unfortunate reality in that sometimes it’s the misallocation of therapy, is taking the patient away from the actual therapy they need to be providing given and not an A not allowing them to be in front of the ventilator graphic screen and by the patient to actually do that, and help improve this situation. And so and now the rest of the therapists that were listening to this podcast thing, and this guy is an academic, and he’s forgot what it’s like at the bedside, I have not, I still have a clinical role and responsibility. And I have to have a, you know, a called a pre ordering provider and said, You know, I understand what you want in here, but this person, there’s no clinical indication whatsoever for that.

And, you know, we and we’ve got to get better, I think that we, we mean, and collectively all of us, we need to get better at finding ways to allocate respiratory therapies properly based on evidence based guidelines. And then with that, then the allocated therapy needs to be done at the proper length of time, meaning that when the patient is actually improving, it can be discontinued. If the patient is now from the bed, and they are ambulating. And they don’t need it anymore, it needs to be discontinued. You know, of course, you have to go person to person and everybody’s different, but it needs to be a constant reassessment of respiratory therapies that are being done. And if you really want the artis to be more at the bedside to be more in front of the ventilators, to improve patient ventilator synchronized and to help ambulating do all those things, we’ve got to untie them from the other things they’re doing that have no clinical indication whatsoever.

Kali Dayton 37:19
You know, as a nurse practitioner and managing 13 Plus patients, I might order something like albuterol at admission, and it’s not necessary later. And I love a culture where the party can say, hey, I don’t think this is helping out this is necessary. And I’m gonna say what do you recommend? I’m all ears. You are the expert. I’m just here to tie everyone together and have a bit of oversight. And I, I you make such strong points. I mean, isn’t that the case for so many of our disciplines, but I think quietly bears it but you don’t have to and what would a good staffing ratio be? So if I’m talking to administrators and saying, if you make staffing ratios, this this this, then artists will be more available to mobilize patients and ventilator acquired pneumonia will be reduced, and it will save you money? So how what do we advocate for as far as proper staffing ratios for RT’s?

Brady Scott, PhD, RRT 38:08
Well, I think that’s going to be different based on the location where you’re in, in the acuity is so if I’m talking about rest, if I’m talking about staffing, respiratory therapist at an L tech, that may be different essays are in a proper ratio may be different than the one of those in an urban academic medical center, that’s dealing with severely sick patients that are even transferred in from other hospitals. Right.

So if you know so I think in, in some of those numbers are evolving in and it’s really hard for me to say, well, it has to be one to four has to be one to six or something like that, but I think it needs to be, you know, the facility really needs to look at the kind of staffing ratios where the respiratory therapists actually has, frankly, the time to to, to assess patients to you know, work on care plans to properly deliver the care plan, they have to have the time to be able to call the nurse practitioner. And and and then not and not get the phone call and then make the page the nurse practitioner and then wait for the nurse practitioner to call back because under practitioner is placing a line and then we have to wait on that to happen.

And the person has to be able to, you know, close the loop on that communication. So, you know, again, I I don’t want to put a hard number on this. I think that you know that we now have some guidelines that are evolving from our own national organizations that will help us make better arguments for these things. But at the end of the day, the organization needs to look at some important realities, right. So for example, some some organizations really look at productivity of a respiratory therapist by based on how many patients are right. Well, I hate to tell you that the reality is I take care of a lot of non intubated patients.

As a matter of fact, a lot of my job is to Pete keep people keep folks from being intubated in the fireplace, and those patients may work me as much or more than an intubated patient. You know, if I actually have an extremely ill patient who who might be held At least sedated and require neuromuscular blockade, if they’re kind of just kind of going through their disease, you know, there’s, it may be less time of mine throughout the days, then if somebody is requiring, again, ambulation, they’re requiring multiple nebulizers for different things, and, and all those. So, you know, we have to, we have to make sure that, that organizations are really looking at the time that respiratory therapists are spending with individual patients, and really just sort of rethinking how they would staff.

And you know, and as a as a profession, you know, we are, we’re trying to, we’re trying to handle this on our side, some too. So, one is we are increasing the educational standards for restaurant care across the board. Soon, well, now, we’re trying to we’re shifting all respiratory therapy degree programs to like a bachelor’s entry level. And we’re in this phase of moving that to where the bachelors to entry level, we are, we’re getting really more sophisticated with our research and publication in terms of, of those things are outcome based research. And we’re trying to promote it through even graduate programs, like the one I teach in myself, about finding our own solutions to these issues, you know, what is it and how can we actually allocate therapy better? What kind of protocols can we utilize to do that? And what are the outcomes that we’re seeking. But, you know, staffing is a big issue.

And it’s like that in nursing, too. We’re not alone. I understand. I hear you, but it’s so it’s not just staffing, but it’s also utilizing the respiratory therapists to their, to do what they’re actually trained to do. Right? Respiratory Therapists are not just trained to pour albuterol, or any aerosolized medication to a cup and deliver it to somebody who has lung cancer. Right, they are actually responsible for giving a beautiful, they are trained to pour albuterol into a cup and assess the asthmatic patient who needs it, and then they assess how many more times they need it.

And that in that the other so they, and I’m not saying patients with lung cancer don’t need albuterol sometimes, but we have to recognize that things like giving, giving inappropriate actualized medications just simply takes up the time of the rest of the therapists doing things for some patients they may not need. Maybe that lung cancer patient I’m referring to doesn’t need a nebulizer they need something different to help them with their, you know, the shortness of breath or whatever. And we can’t pretend that these medications are fixing everything. It’s just increasing cost and taking your restaurant therapist away from the locations where they need to be.

Kali Dayton 42:47
Yeah, so many important insights, because I think harm prevention should be a greater role in our resource allocation. And it would ultimately cut costs. And I appreciate the role that Artie can play in preventing intubations shortening intubations

Brady Scott, PhD, RRT 43:06
let me say, let me comment on, you said something earlier that I’m glad I’m bringing this up. And I’m pretty sure our podcasts lasting longer than normal, because this is something I’m very passionate about is, is getting our teas to doing the job they’re trained to do. Let me let me let me emphasize the importance of the culture that you allow as a nurse practitioner, for when I call you and I’m like, hey, you know, I’m not sure that room 10 needs these nebulizers and you either say, “Okay, fine, either, like the condition is reversed, perhaps or what do you recommend instead?” which I think is a great conversation.

If that you understand that, that culture really is the difference? Right? If I can call you as a therapist, you know, if I feel comfortable calling you as a therapist, to to help perhaps drive a better direction that’s evidence based or, or just in response to the change in the patient’s condition, then everybody wins. But if you as an ordering provider, just don’t want to have it you don’t just give it because I just want it to be that this creates a culture where I no longer communicate with you the way that I probably should. Or we’re just not communicating together. And I think that unfortunately, when that happens, I think that they’re the person that suffers the most patient.

Kali Dayton 44:23
Absolutely. And word gets around. You’re going to tell other RT’s, like, “Don’t call Kali, she’s not going to change her orders…”

Brady Scott, PhD, RRT 44:28
Oh, yeah, just indiscriminately ordering albuterol for everybody in the air. I keep saying that word up utero but keep ordering nebulizers for everybody in the unit and and then when Kaylee leaves on Monday we get a new nurse practitioner and we get them we and we just we DC 95% of these breathing treatments we have just wait to see leaves. And that is that should happen.

You know egos need to stop it. The respiratory therapist who thinks they know everything about a ventilator should not have the ego should not be there when they’re questioned about the how they’re running it or why they’re doing it, they should just answer, right? Like if I’m an AR T and you come and say, Kaylee, Kaylee, you come in and say, “Brady, why? Why do you think this patient needs blank?” Then I’m gonna say, “Oh, here’s why,” you know, it shouldn’t be an ego thing. And if you say, “Well, I, you know, I was thinking that this would be better.”

You know what, maybe you’re right. You know, I mean, what’s wrong with that? You know, that’s a good point, you know, I’m not, I’m not gonna lie, because maybe what’s happened is at nine o’clock that morning, the patient actually was sedated at noon, you’ve lifted sedation, that patient’s condition is not the same as it was three hours ago. And I just haven’t responded in the appropriate amount of time. It’s just these egos need to stop. It just needs to stop. I don’t know how to stop it. But it needs to stop.

You know, but I really understand however. But I, whoever’s listening to this, you know, if you’re a physician, if you’re a an advanced practice provider, a nurse practitioner or physician’s assistant, you know, that culture of allowing the nurse or the RT, the respect, if you will, of Hear me out, let maybe this is a better direction. That is, that is the kind of culture I think this really creates just simply the better team, you know, or better patient outcome, better outcomes is what I should say, you know, and it’s not always like that. It’s not always like that. But you know, I’ve remember once I remember what I had, I didn’t know how to respond to this, I had a colleague of mine ordering a lot of things. And I and I’m like, so I called and I said, “Why are you ordering all, you know, this person has no history of lung disease whatsoever.”

And that providers literally said, “cuz I just want you to go in there every four to six hours. Let me know if something’s going wrong.” I was like, “Well, okay, I think there are other ways to do this, but I appreciate that. ” But anyway, you know, I, you know, I appreciate Kali, your, your culture, you know, your willingness to listen. And sometimes you have to say, you know, I disagree, I’m going to keep them for now. You know, as a therapist, we’re like, “Okay, fine. But you heard me, you heard my, you heard what we’re saying, and we’re still professionals, we’re still communicating”. And we go about it. And I know, you know, as a respiratory therapist, because I have to respect your decision to you ordered it, that’s what you want, you feel that they still need it for XYZ purposes. It is what it is. But it still takes that communication. That’s what we should strive for in every institution.

Kali Dayton 47:32
When I was a travel nurse, I asked questions initially, I wish looking back, I had more confidence in what I was advocating for. But I’d ask why are they why are they stated? And these physicians will look at me like I was crazy, because they’re intubated. And I said, Well, why are they sedated? Because I was coming from a very awakened walking culture, right? But what if they had listened to me? What did they said? What’s it like, where you come from? What would you like to do? What what do you recommend? And we’d actually had a discussion how many patients could have been treated better, and how many outcomes could have been changed? If there had been that culture? And but that’s not where I was, which is probably why they had to have travel nurses, right. This is, you know, eight years ago, but

Brady Scott, PhD, RRT 48:16
yeah, you know, when

Kali Dayton 48:17
the time someone calls me, and like, what if? What if it was past me recommending something that was evidence based? What did they do have something behind it? And I didn’t listen, and harm happened because I was obstinate.

Brady Scott, PhD, RRT 48:30
Sure, so, you know, I mean, I think that, you know, when when we look at, we look at satisfaction, like employee satisfaction, those things, you know, what is the culture between the ordering providers and the nurses and the parties and all that? Or are they even the culture between the ordering providers and those types of things, and how that and how that really actually plays into our all of our bigger picture. employee satisfaction.

You know, I’ve always, I’ve been really lucky in the two organizations that I’ve spent my 20 years at, I felt respected. I felt like I was being heard. I felt that my opinions were important, even when we even when the team disagreed with my recommendation, I felt respected, to be listened to. Now part of that is the culture of the institution. And part of that was on me, right? It’s on me to recommend the correct thing. It’s wrong on me to know the evidence. It’s on me to go to national conferences and listen to speakers. It’s on me to listen to your podcast and have new ideas. It’s on me to listen to read the to read peer reviewed journals.

And to be able to follow the data. I can’t just recommend willy nilly I have to recommend based on physiology or the evidence. So I think there’s a double side to this. So I think that satisfaction in our jobs come from the respect that we give each other that I think Respect is earned. And I think that once it’s earned but but at least in the beginning, I’m sure Kaley just known you for as little as I have, if you and I had never met, but I called you the first time in the institution and said, Hey, my name is Brady, I’m the new RT here. I feel like you will. And I think that that initial respect is important to open up, you know, subsequent, but I do think that a lot falls on the individual RT, or the nurse or whoever it is, to make sure that their recommendations are, are supported by the best available evidence.

And, again, that think that’s that’s come, you know, that’s, that also is part of the culture of our profession, our professions, we need to realize the importance of these conferences, they need to realize the importance of reading journals, we need to realize the importance of keeping up with our craft, it’s really hard to keep up with the evolving data. So, you know, again, I think that the culture, respect each other is is one that we have for just hey, I want to hear you, but also want to hear you say the right thing.

Kali Dayton 51:06
Yeah, and bringing in the evidence into our discussions. So people are messaging me saying, Well, I mean, those that have not seen the blog yet, they’re asking, Where are the articles that you’re referring to in the studies, and you provide me studies, Brady, which I’m excited to put on the blog, but we have a culture in which we can say, let’s look at the evidence, let’s discuss it together. And that should be what we go off of not just our egos, our habits, our experiences, but we should look at the actual evidence and stay current on it so that we can have productive and effective conversations, and everyone has a right to bring in the evidence

Brady Scott, PhD, RRT 51:39
and have the willingness to change when new evidence when when new evidence is given to you have the open mindedness to actually evolve towards and change your practice. And listen, we know that stuff, you know, right? And

Kali Dayton 51:51
like how much the evidence impacts everything, right? We’re trying to tell the public, this is evidence based vaccines are evidence based, blah, blah, blah, blah, blah, right. But here I am talking to ICU team saying, well, the evidence shows outcomes are completely different. When you avoid sedation and mobilize people are like, I didn’t know about that. Yeah,

Brady Scott, PhD, RRT 52:08
right. Right. We’re saying no, the evidence is there. Right. And you know, it’s slow, we’re slow to adopt things, you know, even even, like, you know, lung protective strategies and ARDS, that was it. Some cases still a tough sale. It’s been 20 years, you know, and it’s, it’s really something I one of my one of my favorite things to do when I give a talk on prom positioning and, and the benefits are prone. And I was actually given that talk before COVID. And so I’d go all over the country and I did some international things.

And it was talking about prom positioning. And I’m like, you know, this is not new. You know, we’ve been propositioning for many years. And I said, I remember in my career actively arguing against Prime positioning, and now and I and I used to say we shouldn’t do it in I’m like, now I go all over the country. And I tell people they should and I help them understand how. And I said, but at the time, though, the literature supported the recommendation not to Pro. But then the literature changed. And we all had to stand back and say, look, it’s not that proning was working, it’s just we didn’t know the right wasn’t didn’t work or couldn’t work.

We didn’t know the right recipe. So we learned how to use that facility. And I use that phrase, the recipe now then we learned how to prune and when to prune, or how to prune better. And we’re still evolving to learn. But I said, you know, eventually, sometimes in your career, you have to say, okay, the evidence is there I was we got, we gotta we got to change our tune. Right. And that’s the key between all of us.

Kali Dayton 53:34
And I see with sedation and mobility, sometimes it’s the skeptics that become the most passionate conference. Sure, because they really have to dive in to support themselves in their arguments. That’s when they see the evidence, and then they and they understand the opposing view. So yeah, that’s it’s part example. proning was like this big deal. And now it’s normal. And I think the same will be of sedation and mobility, or avoiding sedation and mobilizing almost all patients on ventilators. I think that is the future critical care.

Brady Scott, PhD, RRT 54:02
And we we have to break our biases and read the in Read, read the literature, and we have to sort of open our minds up to this right, we have to look at this. You know, I think maybe the first time I ever looked at a patient who was walking on a ventilator, I didn’t know what I was seeing, you know, I just, I mean, I did the same, I’m not any different than everybody else who were skeptics. And now it’s like, Let’s get them up, let’s move them out.

Let’s you know, let’s get, you know, thinking about, you know, mobilizing secretions and doing all those things that help people just be better on ventilators or we can get them off of the ventilator. And we all have to sort of check our biases and be willing to listen to the literature and, and then, you know, again, talk to, you know, and talk to our colleagues and teams of how to implement these programs. Because as you know, you know, you can’t do have a mobility program with just nursing it takes everybody on board and getting everybody on the team And it looks like Kayla, you guys have done a wonderful job at your organization of getting that to happen. And I hope other people’s can, or other people were willing to look at the literature and see how it applies to their practices as well.

Kali Dayton 55:10
Absolutely not the objective of this podcast is to get everyone sitting at the same table, looking over the same research, and then formulating their own plans and how to implement that this team that I referred to, at Salt Lake City, Utah, they’ve done this for 25, almost 30 years. So it’s been an evolution that’s been coming in phases, but it’s not new, but it’s still new to some people. And that’s okay, as long as we’re open and willing to review the evidence, as you say, you make such a strong point for so many things. And I’m excited for further collaboration between all the disciplines and thanks for leading the way in your your discipline.

Brady Scott, PhD, RRT 55:43
So thanks for having me. Again, I think you’re doing great work. And, you know, my message to you know, is same, you know, we have to communicate, we have to read the evidence and be willing to change with the evidence and and actually be willing to help create new evidence. I think that’s a key to right where questions remain. We need we need folks chasing answers to in at the end of the day, the answers are going to come up with better patient outcomes. And that’s what it’s all about.

Kali Dayton 56:08
I have a whole list of things I want to research. So I love hearing that. Polio with you, Brady, thank you so much. I’ll probably have more questions for you down the line and I’m glad you’re such a good resource. Thank you. If you want to join in on the conversation, leave a voicemail at 801-784-0472 or reach out to me on Twitter.

Transcribed by https://otter.ai

 

References

AARC Safe and Effective Staffing Guide: https://www.aarc.org/resources/tools-software/safe-effective-staffing-guide/

Monitoring Asynchrony During Invasive Ventilation: http://rc.rcjournal.com/content/65/6/847

Kleinpell, R., Grabenkort, W. R., Boyle, W. A., 3rd, Vines, D. L., & Olsen, K. M. (2021). The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead. Critical care medicine, 49(12), 2017–2032. https://doi.org/10.1097/CCM.0000000000005276

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