A Pulmonary Pathway for ACLS: An Idea Whose Time Has Come. Is it time for a change to the ACLS certification process? One expert says yes.
As a committed lifelong learner, I was surprised at the sense of resentment I experienced recently while preparing for certification in advanced cardiac life support (ACLS). Like thousands of respiratory therapists across the country, I had dutifully constructed flash cards for reviewing no less than 20 different cardiac rhythms, a dozen or more pharmaceuticalsincluding their bolus and infusion ratesand a collection of abbreviated algorithms for treating a variety of cardiac arrhythmias and arrest scenarios.
The American Heart Associations Web site states: The ACLS Provider Course provides the knowledge and skills needed to evaluate and manage the first 10 minutes of an adult ventricular fibrillation/ventricular tachycardia (VF/VT) arrest. Providers are expected to learn to manage 10 core ACLS cases: a respiratory emergency, four types of cardiac arrest (simple VF/VT, complex VF/VT, PEA and asystole), four types of pre-arrest emergencies (bradycardia, stable tachycardia, unstable tachycardia and acute coronary syndromes), and stroke.
Why should I have a problem with that? Indeed, a substantial portion of the ACLS course work provides important essential knowledge and skills that every respiratory therapist should demonstrate proficiency in performing. The resentment set in when I considered the number of brain cells that were being squandered on identification and treatment of relatively esoteric cardiac arrhythmias, against the relatively superfluous attention to essential respiratory skills. While respiratory therapists busy themselves memorizing (and soon forgetting) the subtleties of P-wave anomalies and S-T interval measurements, I might ask who is being trained and tested on the knowledge and skills respiratory therapists actually need and use? The answer is no one.
The 500-page ACLS manual is divided into 18 chapters, with only one covering the entire field of airways, oxygenation, and ventilation. Many RTs skip that chapter entirely, because the actual test questions and clinical skills they are required to demonstrate are so basic. But that does not mean we have nothing to learn in those areas. While laryngeal mask airways (LMAs), esophageal-tracheal ventilation tubes, intubation, emergency cricothyroidotomy, cephalic mouth-to-mask, and other ventilation techniques are discussed, they are inadequately tested. Algorithms include calling for an arterial blood gas, but the knowledge and skills needed to actually draw the blood and interpret ABGs are no longer tested. ABG and arterial blood gas do not even appear as entries in the index. Meanwhile, an entire chapter is devoted to vascular access and establishing and maintaining central and peripheral lines.
Respiratory therapists preparing for ACLS often feel like square pegs trying to squeeze into round holes as they memorize information they simply never use. This can easily be verified by conducting a roundtable discussion with any group of competent ACLS-certified respiratory therapists a few months after they have completed the course. Ask them about torsades de pointes, and most will quickly and correctly declare that it is not a city in Italy. One bright individual might define it as a unique subtype of polymorphic ventricular tachycardia, but many will be hard pressed to define it and suggest a plan of treatment, much less recite the 44 drugs known to prolong Q-T interval or induce torsades. The PJs, PATs, PSVTs, and so many other arrhythmias quickly become lost in what the ACLS manual admits is a nomenclature potpourri. The old adage use it or lose it takes its toll over time as RTs continually hone and nurture the skills and techniques they employ daily, while losing the skills they are not called upon to use. There are critically important skill sets RTs use every day and others they employ occasionally, which are de-emphasized in the current ACLS program. RTs need to demonstrate competency in the skills they need every day, while being challenged to review the skills they use less frequently. This critical need was recently substantiated by an observational study of in-hospital cardiac arrests that found CPR quality was inconsistent and that ventilation rates were high, even when performed by well-trained hospital staff.1
I am not proposing that we throw out the proverbial baby with the bathwater. ACLS certification is a valuable tool, and like physicians and nurses, respiratory therapists need to have regular reviews of their knowledge and skills.
Could there be a better way for respiratory therapists to get the most out of ACLS? It would not be hard to envision an ACLS program that at some point offered participants a choice. They could choose a cardiac pathway, a pulmonary pathway, or both. The cardiac pathway would present ACLS unchanged from its present format. The pulmonary pathway would include much of the ACLS core material and recognition of life-threatening arrhythmias, but would then focus much more intensely on advanced-level respiratory skills in place of the cardiac algorithms. These would include:
A much more rigorous ventilation scenario. Currently, ACLS offers participants a quick demonstration of the bag and mask technique. Participants then apply the technique, often in an awkward, haphazard manner. Effective bag/mask ventilation looks a lot easier than it is. The ACLS manual describes it as easy to learn, a lifetime to master. Too true. Anyone who has observed an anesthesiologist perform the technique can quickly tell the difference between the experienced practitioner and a neophyte. Instructors are usually effective at observing errors and identifying ineffective efforts, then sending the individual on to the next station. A pulmonary pathway would require participants to demonstrate absolute competence in this and other essential skills, while challenging them to troubleshoot a variety of scenarios and correct unexpected problems. Patients vomit, they lose their dentures, and oxygen lines become disconnected. Intubations can be performed both orally and via a nasal passagewhat are the pros and cons of each? Although the ACLS course consistently acknowledges that establishing and maintaining an airway is essential, the skills required to make that happen are sometimes glossed over as participants scurry to the next station to focus on IV therapy and cardiac arrhythmias. While some team members scrutinize the cardiac rhythm and plot a plan of action, someone else needs to be completely competent (beyond what ACLS currently requires) in establishing, maintaining, and methodically reassessing the airway, breathing, and ventilation components.
Arterial blood gas draws, handling, and interpretation. ACLS algorithms currently require the candidate to call for a blood gas at an appropriate time, but the skills required to obtain and interpret the ABG have been curtailed over the years. A pulmonary pathway would require participants to demonstrate proper ABG technique, including an understanding of the pros and cons of alternate sites including brachial, femoral, and pedal areas. Candidates would be required to demonstrate competent technique, identify an array of possible complications, and be tested on correct ABG handling and transport requirements.
Interpretation of ABG results is another critically important skill that should be tested. Is that an arterial or a mixed venous sample? Is the patient being substantially hyperventilated? What might the repercussions of that be? The ability to correctly evaluate an ABG and suggest changes in the plan of treatment based on those results is at least as important as identifying a second-degree type I heart block and treating it accordingly.
Respiratory emergency scenarios and algorithms. ACLS testing scenarios and algorithms favor cardiac crisis, often at the expense of respiratory complications that challenge clinicians every day. Assessment of impending respiratory failure and subsequent cardiac arrest, including status asthmaticus, pulmonary embolus, COPD exacerbations, carbon monoxide poisoning, patient transport via portable ventilators, noninvasive ventilation, and the many possible ensuing challenges and complications, are all ripe for exploration. What are the mechanisms and implications of hyperventilation-induced hypotension during CPR?2 Inquiring minds should want to know. In an apparent effort to make ACLS a kinder, gentler experience, many of the essential skills that respiratory therapists bring to the bedside have been given short shrift in favor of nursing skills.
ACLS offers a systematic, evidence-based approach that provides physicians, nurses, and respiratory therapists with an exceptional tool for training and certification in the management of patients in VF/VT arrest. The trainers are required to meet a high level of competency and the materials are constantly revised and updated. It is time for a revision that addresses the real-life needs of respiratory therapists.
I am not proposing a dumbing down of our profession, but rather the development of a system that better matches our needs. While one team member scrutinizes the important distinction between a ventricular tachycardia and supraventricular tachycardia with aberrancy, another team member needs to be focusing on other critically important rescue needs. An optional pulmonary pathway for ACLS would be a benefit to both our patients and our profession.
John A. Wolfe, RRT, CPFT, is a clinical specialist, Northern Colorado Medical Center, Greeley, Colo, and a member of RTs editorial board.
1. Abella BS, Alvarado JP, Myklebust H, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA. 2005;293(3):30510.
2. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109(16):19605.