Technology Is Helping RTs Breathe Easier
By Renee Diiulio
While discussing the clinical features of ventilators with Andreas Tzanetakis, marketing manager, Respiratory Care, for GE Healthcare, Waukesha, Wis, a head nurse in Hong Kong likened acquiring a mechanical ventilation device to purchasing a car. One doesn’t need to discuss how the engine makes the wheels turns—the fact that this mechanization occurs is assumed. The same with general design and construction: auto components typically include an engine, body, wheels, doors, windows, seats, dashboard, and trunk. Whether they exist is not to be questioned. It’s how they look and function that matters.
Ventilation equipment, this nurse felt, should be the same way. The fact that machines can help patients breathe should now be taken for granted. Today’s devices are a long way from the iron lung of 1929, and, from a clinician’s point of view, how the mechanics work is not as important as how their function impacts patient care. When it comes to ventilation devices today, respiratory therapists are no longer asking what can this ventilator do, but what can this ventilator do for me?
The foreign head nurse described her wants succinctly: “safety, simplicity, reliability.” And these requests are echoed throughout the market. Clinicians want features that help to reduce the time spent on a ventilator, simplify the use of the device, and integrate clinically useful information into the health care system, both directly and digitally. Improved patient care is the main goal, but an indirect benefit often can—and frequently must—include cost savings.
“The overarching themes have been related to continuing to provide clinically relevant solutions—that improve care on the whole—as well as economic solutions that enhance the ability to save money,” said Jim Willett, vice president/general manager of Respiratory Solutions for Covidien, Irvine, Calif. Fortunately, the dots have been easy to connect—less time spent on a ventilator often translates to less cost for care.
“In mechanical ventilation, [a return on investment] has historically been challenging from a health care provider perspective because there is not a terrific amount of reimbursement in terms of mechanical ventilation,” Willett said.
As a result, respiratory dollars often require proven value for expenditures, which translates to a demand for evidence-based medicine that justifies the investment in new features or equipment. “The economy doesn’t allow the largess it once did, where we could purchase a machine and see if it worked. Today, I’ve got to see the science,” said Garry W. Kauffman, MPA, FACHE, RRT, FAARC, director of Respiratory Care Services at Wake Forest Baptist Medical Center in Winston-Salem, NC.
This means manufacturers can make a technological breakthrough, but adoption occurs incrementally. Scientifically sound evidence (eg, studies with a multi-institutional structure, valid controls, etc) requires significant resources and long periods of time so there can be a delay in acceptance following commercial availability while the science catches up.
In some instances, however, the benefit has been obvious and little proof demanded. “Some new features make a ventilator truly easier to use, and the easier something is to use, the safer it is for the patient,” said John Gallagher, MPH, RRT-NPS, critical care coordinator, Pediatric Respiratory Care Department, University Hospitals—Rainbow Babies and Children’s Hospital, Cleveland.
Make It Better
The patient is always the first concern, and this translates to protocols that minimize the amount of time spent on a ventilator. The longer a patient breathes with the aid of a ventilator, the greater the risk for a ventilator-associated incident (illness or injury). Indeed, as payors have come to notice, ventilation itself is never an ideal choice for a patient.
The Centers for Disease Control and Prevention cites that mortality in patients with acute lung injury on mechanical ventilation has been estimated to range from 24% in persons 15 to 19 years of age up to 60% for those 85 years and older. A 2010 study by Wunsch et al found that among the nearly 800,000 cases involving mechanical ventilation from a study population of 6,650,000 hospitalizations (which ranged across six states), in-hospital mortality was 34.5%, and only 30.8% of patients were discharged home from the hospital.1
Additionally, the use of ventilation was expensive. Extrapolating 2.7 episodes of mechanical ventilation per 1,000 population, Wunsch et al estimated a cost of $27 billion, representing 12% of all national hospital costs.1
At the same time, however, the use of ventilation can serve a significant role in saving patient lives—if you reconsider the Wunsch data from a “glass-half-full” perspective, 65.5% of the mechanical ventilation patients did not die and 30.8% were released home. Denied breath, all of the patients would have died and none of them would have returned home.
Even so, the statistics could improve, and features that help outcomes trend in this direction are always in demand. Anything that can reduce time on a ventilator, help predict the ability of a patient to wean and stay weaned, reduce infection opportunities while ventilated, or preserve physiological function is welcome, said Kauffman.
These factors have, therefore, become the key guideposts for manufacturer development, and a major area of focus has been synchrony.
“For the last 25 years, our focus has been on closing the loop in mechanical ventilation,” said Bob Hamilton, president of Hamilton Medical. The company’s INTELLiVENT-ASV software is a closed-loop ventilation solution that optimizes synchrony between patient and ventilator in order to reduce the work of breathing and reduce intubation time. “Synchrony is about patient comfort,” Hamilton said. “The ventilator evaluates physiological feedback from the patient and adjusts to a safe ventilation zone.” The process is automated and relies on readings from integrated pulse oximetry and capnography sensors to adjust and synchronize the respiratory rate of the device with the patient’s, from the moment of intubation all the way through extubation, forming a fully closed loop.
Covidien, meanwhile, recently debuted Proportional Assist Ventilation Plus, or PAV+, a software option designed to reduce patient-ventilator asynchrony by automatically adjusting ventilator pressure in proportion to patient effort and providing clinically useful feedback for clinicians. “We have placed significant emphasis on developing solutions that promote synchrony…because, generally, if you reduce asynchrony between the ventilator and the patient, you see a reduction in the need for sedation, and in turn, you can stop what can be a very vicious cycle between sedation asynchrony and, ultimately, muscle weakness,” said Willett.
APRV AutoRelease by Dräger Medical Inc, Telford, Pa, functions similarly, with the program automatically optimizing T(low) to terminate expiration at an adjustable percentage of peak expiratory flow and maintaining optimal balance between end-expiratory lung volume and CO2 removal (even as respiratory mechanics and expiratory flow patterns change).
A newer concept introduced by the company, pressure support, extends the effort to mirror the natural but subtle variability in human breathing even further. By generating random changes in inspiratory pressure, regardless of the patient’s spontaneous breathing, Dräger’s pressure support increases and decreases the tidal volume variation within the thresholds that have been indicated by the clinician. Initial studies have demonstrated that a variable pressure support regime can lead to improved oxygenation and V/Q matching.2
Another way to improve performance is to reduce the amount of leakage experienced by the patient. “Every patient on a ventilator generally experiences some type of leak, which can impact the overall effectiveness of ventilation,” Willett said. Covidien has introduced software designed to compensate for leaks through auto-triggering; Dräger has added NIV plus for mask ventilation; and GE Healthcare’s Easy Exhale addresses leaks in patients undergoing transport.
Similarly, manufacturers also have developed solutions to help with the process of weaning; many of them (like Dräger’s SmartCare/PS) incorporate an automated aspect. In fact, a large proportion of new solutions are software-based and allow automatic responses by the ventilator, typically within parameters that can be set and adjusted as determined by the clinician. The easier this is to accomplish, the happier the clinician.
“In Europe, clinicians are asking for automation so they can push a button and the ventilator performs on its own,” Tzanetakis said. Overwhelmed by large caseloads, they no longer fear giving up this aspect of their jobs. Clinicians in the United States, similarly overwhelmed and used to automation in other areas, are already adapting to the new automatic protocols, although complete automation is not yet topping their list of demands.
What they do want is simpler user interfaces and management requirements. Manufacturers have responded with features designed to reduce the clinician’s cognitive workload. For instance, GE Healthcare introduced a FlexPoint interface on the Engström Carestation that bundles clinically relevant context, such as hyperlinks related to the acute respiratory phase or weaning, allowing physicians to create shortcuts, easily switch between interfaces, and speed care delivery.
Automation is integral to Hamilton Medical’s INTELLiVENT-ASV solution, but also to the company’s IntelliCuff technology, an endotracheal tube cuff pressure controller built into its G5 ventilators. The INTELLICUFF system automatically adjusts the cuff pressure for a continuous seal, which helps reduce incidences of ventilator associated pneumonia (VAP). VAP not only threatens patients’ lives but it also can cost hospitals upwards of $40,000 per case, Hamilton said. “It’s important for VAP management. It’s a way to automatically keep the cuff sealed and prevent infections. The ventilator monitors and adjusts automatically, and is more effective than manual pumps.”
Together, these automated features are designed with RTs in mind. “Clinicians can’t be at the bedside 24-7,” Hamilton said. “Our ventilators make it possible to go from intubation to extubation without direct management from clinicians. It’s designed to make their lives easier.”
Enter the Information Age
“The fact is that people are stressed and working hard,” Tzanetakis said. Clinicians can use help not only with ventilation adjustments but also with management of the data produced by the machine. It is no longer enough to be given numbers—clinicians want information.
Graphics are a given; waveforms are the equivalent to the automobile’s speedometer, but new pictures can add another 1,000 words. Philips Healthcare, Andover, Mass, offers graphics options on ventilators, like the Esprit, that enable real-time feedback to help optimize device settings, or incorporate color to enhance display identification.
Hamilton Medical, meanwhile, focuses on continuity when it comes to device interfaces. All five of its ventilators are equipped with the same customizable user display, which means a facility can configure every ventilator with the same graphics and layout, ensuring that clinicians know how to operate every device. “Hospitals want to know their staff are up to speed on these devices,” Hamilton said, which is why his company recently launched Hamilton Medical College, a free E-learning platform designed to train RTs and other clinicians on ventilator functions, from basic to advanced. “We spend a lot of time training end users. The program allows hospitals to set up group learning for staff to learn the base level functions, then one of our staff can come in and teach the more advanced features,” said Hamilton, noting that RTs who complete certain modules can earn CRCEs accredited by the AARC. “It’s been a huge success.”
Manufacturers also have introduced a number of innovations to reduce alarm fatigue, a serious concern for many facilities. Some are designed to create fewer alarms, such as features that reduce leakage; others help to manage the alarms themselves. Smart alarms enable priority settings; graphical alarms provide visual information to indicate urgency; others send alerts remotely to better divide work among personnel.
Information management also applies to connectivity, another near-given in today’s networked, EMR health care world. But today, connectivity extends everywhere, not just within the facility. Covidien’s Vital Sync platform sends integrated ventilator data (as well as pulse oximeter and capnography data) to a central station or any web-enabled mobile device, including laptops, tablets, and smartphones.
The ability to access real time, alongside historical data, through connectivity can help clinicians to make immediate health care decisions, as well as long-term care decisions, such those impacting a patient’s settings or an organizational protocol as a whole through trending analyses, according to Kauffman. And if the ventilator or software system can provide this information automatically, without requiring clinician analysis, the better—because again, it is not about what the ventilator can do, but what it can do for you. RT
Renee Diiulio is a contributing writer for RT. For further information, contact [email protected].
- Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38(10):1947-53.
- Spieth PM, Guldner A, Beda A, et al. Effects of different levels of pressure support variability in experimental lung injury. Anesthesiology. 2009; 110:342–50.