Vent question/concerns

[JPINFV]

So, um, serious question. What happens if a patient doesn't tolerate the transport vent using the same settings as the hospital vent? To be honest, I was shocked when I first heard that some companys run vent transports with an RN. Vent transports without an RT is completely foreign to me.

[tniuqs]

I wouldn't get too stressed out about it there JPINFV, sounds like you may need a Murse or 2, te he.. some RNs are very well versed in this area with backgrounds in CC or ICU, and are quite capable of IVP rx if needed. but just a regular nurse off wards or floors would raise a few eye lids here too.

cheers

[chbare]

Funny, Murse. I suppose JPINFV presents us with a valid question. Perhaps we could be more specific and ask how much interchangeability can we allow between providers? I admit I do not have the specific pulmonary education of a respiratory therapist; however, with my education, is it possible for me to take over some of the roles that the RT would traditionally fill in special situations? I am not sure of your background JPINFV; however, many flight and critical care transport companies in fact utilize RN/Paramedic teams to provide critical care transport. Can we adequately educate these providers to transport patients on ventilators safely and effectively?

The second question is a bit more complicated. Much will depend on the patients condition and clinical presentation. Many hospitals in my area utilize very high Vt's and I usually end up titrating the Vt's down. The real advantage I have is continuous waveform capnography, so it allows me to titrate settings and I actually have some instant feedback regarding the ventilatory status.

Take care,

chbare.

[tniuqs]

Funny, Murse.

The second question is a bit more complicated. Much will depend on the patients condition and clinical presentation. Many hospitals in my area utilize very high Vt's and I usually end up titrating the Vt's down. The real advantage I have is continuous waveform capnography, so it allows me to titrate settings and I actually have some instant feedback regarding the ventilatory status.

Take care,

chbare.

Ok...this is a bit scary, should I ask how high tidal volume settings?

Let us not forget that the "cook book recipie" for estimation of Tidals Volumes is based on ones ideal body weight as well (this is often lost in translation) It is a start point not the rule as one needs to take into account the underlying patho AND what is succsessful...its ALL gray/grey in respiratory care!

I sure hope for the pts sake that Peak Inspiratory Pressures are lower than 40 cmh2O and plateaus are less than .032 or perhaps flip them to Pressure Control ?... that said if a patient is transported on PC then you do need an RRT as things can get a touch more complex Resitance and Compliance changes affect minuite volumes..big time.

We er some RRTs have quite a bit of latitude when it comes to ventilation in hospital settings here in Kanukistan, (some facilities) but a matter in most instances of approval and acceptance from years of working with the attending MDs.

The true irony is EMS initates O2 threapy..we do our best to get Fio2 down as low as we can.... 02 tox and all that.

By all rights the golden standard is ABGs following any Vent setting changes, ETCO2 and Pulse Ox are helpful in trending but in the transport enviroment this may not be readily available.....and dont rush to get a "fresh" gas.... patients need time to equilibrate.

I have posted the paper on "ventilation with lower tidal volumes as compared with traditional volumes for acute lung injury" in other threads from :

NEJM Sept 14, 2000 Volume 343, no. 11.

cheers

ps Ventmedic will you marry me? lol.

[tniuqs]

Funny, Murse. I suppose JPINFV presents us with a valid question. Perhaps we could be more specific and ask how much interchangeability can we allow between providers?

Take care,

chbare.

Yes this does bring up a interesting thread, I stongly suspect that many cross-trained individuals are in the US? but likely more RN/Paramedic than RT/Paramedic individuals. I think there is just a handful in Canada (like 6 of us)

The advantage here to an employer (as Fly boys and gals or interfacility acute care transfers) speaks volumes as only one chair is needed...ie the Lear Jet (the flying cigar tube) far more cost and phyisical space effective.

One that has 2 tickets as will always be in high demand. and when you get old and your back hurts you can always go into home care (coffee with the little old ladies is a hoot)

There is "more than a few" that believe that they understand ventilation....but NOT always the case...I have run across a few RN/ Paramedics that get way too cocky in that regard.

So I guess I am saying that one needs that extra piece of paper to climb the ladder and provide optimal care.

Happy readings.

[VentMedic]

however, many flight and critical care transport companies in fact utilize RN/Paramedic teams to provide critical care transport. Can we adequately educate these providers to transport patients on ventilators safely and effectively?

Of course we can train non-RTs to transport short term on non complex ventilators. That is part of my job descriiption now. Of course, it is much easier to train people if the have a solid education in the sciences. RNs usually understand the usually physiological reasons while the paramedic grasps the technological quicker on the learning curve. If a paramedic has all the prerequisites of A&P, Physics, math, patho and micro, grasping some basic concepts and skills will be relatively easy for them. If they don't have the education, then I have to resort to teaching "basic knobology" since time does not allow to also teach a lot of science. I've seen some of the ventilator "competencies" given by some Flight and CCT organizations. Luckily most transport times are short.

There are a couple of popular flight forums on the web that make me cringe when they try to explain ventilators amongst themselves. Without the BASICS of ventilator theory, it's pretty much guessing. Sometimes it's guessing in the hospital, but RTs have more data to help them make an educated guess. On transport and in the ICU, RTs will have the experience of managing 6 ventilator patients every working day for a few years to rely on if no other equipment is available.

When ventilators are utilized in 911 EMS, they are usually ventilating the dead as in a code situation. Of course, incorrect ventilation and oxygenation can make them deader.

The second question is a bit more complicated. Much will depend on the patients condition and clinical presentation. Many hospitals in my area utilize very high Vt's and I usually end up titrating the Vt's down. The real advantage I have is continuous waveform capnography, so it allows me to titrate settings and I actually have some instant feedback regarding the ventilatory status.

When preparing a patient for inter-facility transport, RTs will sometimes take their ICU vents out of their specialized modes and attempt to mimic a transport vent. Many will know how a patient will react to conventional ventilation by having used transport vents on the patient for inhospital transports such as CT, MRI or IR (interventional radiology). This may be one reason the settings on the ICU patient may appear out of the norm.

There are probably about 10 different lung recruitment strategies used routinely by RT and Pulmonologists. It all depends on the patient, their technology and whatever adjunct therapies being utilized with mechanical ventilation such as proning, Flolan, Nitric Oxide or heliox. For transport, adjustments may have been made such as a higher tidal volume to compensate for the discontinuation of a therapy until they reach the next facility. RTs and Pulmonologists argue/discuss lung recruitment strategy constantly at educational seminars, in the ICUs, and on forums constantly. Big volume vs small volume, high PEEP or no PEEP, high flows or min. flows or auto flow. However, once committed to a plan of action, caution will have to be exercised to change aggressive ventilation strategies. The days of "knob turning" are expected to be in the past. Of course, I also have done my share of "knob turning" as an RT. But, in the hospital setting, I usually have plans A, B or C as backup.

Lung decruitment effects will happen several hours post ventilator change. It many then take hours to recruit again and trauma to the lung tissue may occur due to reopening pressures. Capnography is just one tool utililized in fine tuning a ventilator. The vents in ICU now have sophisticated graphics packages that allow us to graphically visualize when we are meeting the patients flow demands, monitor opening pressure when using PEEP and avoid (or allow) over or under inflation. In RT school, there is now a class 1 semester long on just reading ventilator waveforms. The same with other Pulmonary Function analysis.

For QA studies, we've downloaded some of the data from transport ventilators on one local Flight program RN/EMT-P. During one transport, the crew made 22 ventilator changes. Just like the hospital machines, transport machines store the data. If anythng happens, the ventilator will take the stand as a witness. One's charting will have to reflect these changes with some rationale for them.

Several RTs have been EMT-Ps in their early life and that may be how they worked their way through RT school. The two professions are very complimentary to each other skill wise.

However, I know what I can make as a FT flight Paramedic and what I can make as a FT flight RT that is hospital based. Big difference. Economics is one reason why Paramedics are utilized instead of RN/RN and RN/RT configurations. For HEMS, Florida still requires a paramedic on board, but no problem there since RNs and PAs can challenge the EMT-P(FL State test) and there are still many PDQ medic factories in FL. Of course, challenging a test doesn't substitute for some of the onscene specialized knowledge that a paramedic has. The skills can be fairly easily taught.

RTs also would have a difficult time doing just transport and maintaining their specialized competencies. Even many CCT RNs still work actively in a Critical Care setting to stay current. RTs are also afforded extensive protocols and skills when they do function as transport RTs. North Carolina outlines this best in their State statutes.

http://www.ncrcb.org/Declaratory%20Ruling%...d%2010-6-05.pdf

And, in RT, we also have different abilities and different practices (like nursing) that vary from one geographic area to another and from hospital to hospital. However, RT has stepped up its national licensing minimum standards and there are plans for another step up in 5 years. Hopefully within 5 - 10 years, the RTs that don't want to keep up their education and raise the profession to the next level will be gone. Not everybody does critical care as an RT either. However, RT will still require the same minimumal educational standards for the floor therapists. An RN now would need 2 more years of college to cross train to be an RT. For RT to RN, about 1 year if sciences are current. Much of RTs' education is specialized in the ICU. RT, like nursing and other professions, you can make the most of the profession or you can coast for a paycheck.

Which tranport team configuration works best? Sometimes it's not about the credentials but about the extra steps each individual on the team takes to excel at their profession.

Specialty teams such as Neonatal and Pediatric are a whole different skill and knowledge area. That is where the Respiratory Therapist is most utilized in transport. Keeping the RT in the ICUs to run the various technology with different modalities that are not easily transportable (though not impossible) is the probably the most cost efficient and effective for the care of the adult patient.

In summary, yes, professionals can be interchangeable in SKILLS and some knowledge in the transport setting. The knowledge makes the professionals unique.

When establishing an ARDSnet ventilation protocol, PEEP may also have to be increased as per protocol to maintain oxygenation and adequate lung recruitment. In transport, this may not be hemodynamically feasible.

For more reading on controversies in ventilation, specifically ARDSnet protocols as "One size does not fit all":

http://www.ahrp.org/infomail/05/05/20.php

http://www.thoracic.org/sections/career-de...-list/ards.html

http://scalpel.stanford.edu/articles/protective%20vent.pdf

[chbare]

That about sums the situation up.

Where I work, most of my vented patients are out of an ER. Most of the patients are on some type of ATV such as the Autovent 2000 or they are being bagged. In many cases, the Vt's and rates are very large and their CO2's are very low. I have seen many patients with CO2's in the 10-17 range upon initial presentation, so it does take me a little time and some titration of the settings to obtain pressures, vital signs, and ETCO2's I feel comfortable working with.

In the few cases of ICU vented patients, I find that I really do not need to make significant changes from the sending facilities settings. Most of my care is based on liberal dosing of pain medication and sedation. It never ceases to amaze me when I have an unresponsive patient on a Diprivan gtt suddenly wake up as soon as the rotor begins to turn. I really believe that the extra stimuli outside of the hospital has a profound effect on out patient.

Take care,

chbare.

[VentMedic]

I really believe that the extra stimuli outside of the hospital has a profound effect on out patient.

Very true.

You won't find many experienced Neonatal transport teams running lights and sirens either. Irritating noises and movement can have an adverse effect on a baby's hemodynamic stability. There are specially designed headsets for neonates to mute noises such as helicopters. These were first used in the hospitals with HJV due the the baby's head being close to the flow interupter. However, once in flight, the vibrations can be somewhat soothing.

ERs do have a tendency to over compensate. That is one reason the AHA wants people to understand the new ventilation rates in CPR. Unfortunately some misunderstand how this applies to minute ventilation also. Less frequency doesn't always mean you have to compensate with more volume. Some ER doctors get obsessed with the "6 - 8L" minute volume equation and forget the practical applications. As far as the RTs are concerned, sometimes they pull out their protocols with the doctor and sometimes they say "the heck with it, the patient will be another ICU or hospital's worry soon enough". Not always the correct way of thinking, but sometimes keeps you sane when you have to work with a hundred different doctors and a hundred different thought processes. If the RTs are smiling and very anxious to help you out the door, there's probably a reason behind it.

[JPINFV]

I am not sure of your background JPINFV; however, many flight and critical care transport companies in fact utilize RN/Paramedic teams to provide critical care transport. Can we adequately educate these providers to transport patients on ventilators safely and effectively?

My experience with CCTs is only as a basic. My company has RNs and RTs (no medics) on staff and will always staff a vent transport with an RT. Depending on the status of the patient, there may or may not be an RN attached to the unit for vent transports.

[chbare]

Do your RT's push medications and titrate gtts in addition to vent management and pulmonary interventions? Not to say a have a problem with this practice. Does your company strictly provide CCT, or do you also provide 911 coverage in addition to CCT?

Take care

chbare.