NO. 14 News Critical care · 4 | Critical Care News The ICU at the Edmundston Regional Hospital, Health Authority Four in New Brunswick, Canada, has experienced a decrease in APACHE

NewsCritical careNO. 14

Implementation of a ventilation strategy to prevent respiratory complications

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44 || CCrriittiiccaall CCaarree NNeewwss

The ICU at the Edmundston Regional Hospital, Health Authority Four in New Brunswick, Canada, has experienced a decrease in APACHE scores during the last three years from scores of over 24 to the 15-19 range. In recent years, they also experienced a dramatic decrease in Acute Respiratory Distress Syndrome (ARDS), and a 30% decrease in patient-ventilator days.

These results coincide with the introduction of refined pulmonary recruitment strategies, andimplementation of an analgesia/sedation strategy for ventilated patients in the ICU.

Paul Ouellet, PhD(c), RRT, FCCM is a pioneer who contributed to the development of waveforms and loopsgraphics in mechanical ventilation. He has also been actively involved in lung recruitment and numerousmultidisciplinary education activities for nurses, physicians and respiratory therapists. Critical Care Newsmet with Paul Ouellet to hear more about the evolution of lung protective strategies and the currentpulmonary recruitment protocol that he has implemented at his hospital.

Implementation of a ventilation strategy to prevent respiratory complications

Surgeon Ludger Blier, MD and Paul Ouellet, PhD(c), RRT, with a post-op patient after initial pulmonary recruitment maneuver.

CCrriittiiccaall CCaarree NNeewwss || 55

When and how did the Open Lungmethodology first become used at the center?

We were first exposed to the Open Lung methodology back in 1987 through Dr James Snyder and Dr Alison Froese (The Open Lung Approach: concept andapplication). At that time, the procedure was mainly oriented towards optimization of PEEP. In the early 90’s pressurecontrolled ventilation became verypopular and prepared the grounds for theOpen Lung concept. Professor BurkhardLachman came along with his article“Open up the Lung and Keep It Open”,which became a strong reference for lung recruitment. Technology at this time allowed for adapting a methodology.This is when we first implemented thisprotective strategy, by means ofwaveform and loop analysis. In ourexperience at that time, recruitment wasevident when significant improvement in oxygenation occurred, but was lessevident in more subtle conditions ofrecruitment, and de-recruitment did not appear very obvious from a bedside perspective.

We have done recruitment based onidentification of the inflection points a fewtimes, but this technique was abandonedbecause it appeared less than optimal for us and added more confusion thananything. In order to use the inflectionpoint to determine the opening pressure,a quasi static Volume – Pressure loop ismandatory. Ventilators display dynamicVolume-Pressure loop, and an inflectionpoint is present in almost any condition,especially when resistance is increasedunder constant flow ventilation (volume ventilation). In time cycledventilation (pressure ventilation), pressurebeing constant, the Volume – Pressureloop has an inflection point whatever the condition. The procedure itselfappeared problematic.

To perform a quasi static Volume – Pressureloop, PEEP is set to zero and inspiratoryflow quite low, prolonging the inspiratorytime. In various clinical conditions, wherePEEP values > 15 cmH2O and FiO2 > 0,60– 0,70 are necessary to maintainadequate oxygenation, this proceduredoes not appear safe enough for us.

We developed our first recruitmentprocedures according to the availabletechnology of the 1990’s. We reliedmainly on loops to establish recruitmentand de-recruitment. Volumetric CO2 anddynamic characteristics were available atthat time but not readily displayed in away to optimally facilitate the procedure.

How long have you been using physiological parameters such as VTCO2 and dynamiccompliance in your pulmonaryrecruitment strategies?

Even though VTCO2 and dynamiccharacteristics were available with theServo ventilator technology since theSERVO 900 series, it is only with theOpen Lung Tool of the SERVO-i platformback in 2000 that we introduced thesetwo parameters to our recruitmentprocedure. We feel that tidal eliminationof CO2 is a key parameter with thisrecruitment methodology, and thedynamic characteristics become a naturalcomplement. The introduction of thesetwo parameters coincided with thecontribution of Professor Luciano

Paul Ouellet became an early practitioner of lung recruitment procedures, with an interest that started in the late 1980s.


Gattinoni on what is now known as the‘recruitment potential’ of clinicalconditions.

This terminology brought insight toclinical conditions to the point where itbecame logical to describe lungconditions in terms of recruitmentpotential. One important element inestablishing recruitment potential is toconfirm the clinical tolerance of arecruitment procedure from the patient.Once this is established, we proceed tothe recruitment procedure. A recruitmentpotential procedure should reflect theviews of opinion leaders.

Our procedure mandates setting thePEEP at 20 cmH2O and a PressureControl level above PEEP at 30 cmH2O for two minutes. After this twominute period, we consider this conditionas having recruited the lung units that arepotentially recruitable. We acknowledgethat various conditions can mandatehigher PEEP values to keep the recruited lungs open, but for ourpopulation, a PEEP of 20 cmH2O accounts for almost all the conditions.

We feel that limits of a recruitment pressureshould be adapted to the clinical context ofeach institution. We adopted a recruitmentlimit of 50 cmH2O and should this pressurelimit not appear to establish recruitment,more experienced clinicians are solicitedby less experienced personnel.

Determining the recruitment potential is certainly the initial intervention thatevery clinical condition mandates, andevery initiation of mechanical ventilationraises the issue as to what is the potential of recruitment.

When mechanical ventilation is necessaryfor refractory hypoxemia, the FunctionalResidual Capacity (FRC) is somewhataffected to a certain degree. In order torestore FRC to a functional level,recruitment is certainly a valid procedure.We realized that the sooner recruitment isperformed after institution of ventilation,the sooner we can anticipate weaning. Byestablishing the recruitment potential, wedetermine the opening pressure early inthe course of treatment and it is usuallybelow 50 cm H2O.

If you look at the mix of patients, howmany are surgical versus medical, andhow has the recruitment strategyimpacted on these groups?

For more than ten years our ICUadmissions consists of 60% medical / 40%surgical, with 10 or 12% of admissionsrequiring ventilatory support. Theprevailing conditions are congestive heartfailure, sepsis, and multi-organ dysfunction.Eight years ago, most of our ventilatedpatients had an APACHE score above 24,with elevated predicted mortality rate. Forthe last three to two years, the majority ofour ventilated patients are now in the 15to 19 range of APACHE score. Thistranslates in decreased severity index andpredicted mortality index, a shortenedlength of ventilator time. This conditioncoincides with a decrease in ARDS cases.

Whether these observations are relatedto the protective ventilator strategy weadopted or a combination of other factorsis difficult to determine, but we tend tobelieve there is a relationship.

Have you defined any specificinclusion/exclusion criteria for pulmonary recruitment in different patient categories?

Of course, common obstructivepulmonary diseases (COPD) need to beaddressed on a one-to-one basis.Atelectasis is certainly one of the majorindications for lung recruitment. The morefamiliar we become with this protectivestrategy, the more we anticipate havingexclusion criteria rather than inclusioncriteria. Lung recruitment potential iscarried out early after institution ofmechanical ventilation.

How do you view post-operativepatients as potential candidates for lung recruitment?

It is well documented that anesthesiapredisposes to atelectasis. We believethat recruitment should not only belimited to ARDS, but every timeatelectasis is present or suspected.Atelectasis is really a decrease in FRC,and as far as we are concerned, we havenot seen anything in the literature thatsupports permissive atelectasis as aprotective strategy in mechanical ventilation.

How do you experience therelationship between the recruitmentstrategy and outcomes?

In our population, we believe there is a definite relationship; fewer patientsneed ventilation, and ventilated patientsare not as sick as they were seven, eightyears ago. One should not forget that theAPACHE score is based on the worstclinical signs over 24 hours afteradmission. Within the first 24 hours, non protective ventilation strategies can inflict lung injury, thereby increasingthe APACHE score. For the last threeconsecutive years, most of our patientson mechanical ventilation are in the 15 to 19 range of APACHE score.

Higher APACHE scores were noted priorto the initiation of lung protectivestrategies in place. We also modified ouranalgesia/sedation protocol to incorporatethe Bispectral technology, and that mightalso have contributed as well to decreaseAPACHE scores. For that purpose, wetend to believe that our ventilationstrategy brought a positive contribution to the global picture.

Implementing recruitment and protectivestrategies of ventilation is one thing; stafftraining and maintaining abilities isanother concern. Institutions should beproactive in keeping proficiencies inclinical skills. We believe that it is onlywith planned continued education andseminars that patients will benefit morefrom the technology. The clinical skills of a bedside provider directly impacts on patient care. For that purpose, lung recruitment should be part of an institutional culture.

With such an embedded culture,recruitment is timely carried out as de-recruitment occurs and is recognized.De-recruitment can occur rapidly, ordiscretely as a slow process. Therapeuticbeds with automated rotation can be asource for de-recruitment on a completelyparalyzed patient. With proper training,bedside clinicians can easily detectpatient-ventilator asynchrony and evaluatethe impacts on “Open Lung Status”.

For that purpose, the Open Lung Tool is amajor contribution to patient monitoring.By trending and displaying VTCO2 and


dynamic characteristics, the SERVO-ireadily brings valuable parameters to theskilled clinician. Our recruitment protocolincorporates these important parameterstowards a recruitment maneuver as soonas de-recruitment occurs. By recruiting in such a timely manner, we observedthat recruitment resumes over 10 to 15breaths thereby preventing completealveolar collapse.

We feel that skilled clinicians couldcontribute to a technology that couldinteract with a patient by automaticallycarrying out recruitment maneuversunder preset conditions thereby closingthe loop in opening the lungs and gentlykeeping them open.

Can you give us a specific patient caseas an example?

We recently had a patient who underwenta left lower lobectomy. Fourteen dayspost operative, he developed massivecollapse of his left lung that would havebeen traditionally treated with abronchoscopy. Intubation and mechanicalventilation was instituted. Over an eighthour period, recruitments at 50 cm H2Ocarried out every hour re-expanded thecollapsed lung without the need for abronchoscopy. Proper PEEP to preventde-recruitment was set, and titrated downas the lung mechanics improved over thenext 24 hours. A recruitment protocolshould have set endpoints over a set

period of time. Proper analgesia/sedationis also part of the equation and must beadapted to the ventilation strategy, asimproper analgesia/sedation can lead toasynchrony, de-recruitment and ventilatorinduced lung injury (VILI).

Can you tell us more about yourstrategy for sedation and analgesia?

We provide analgesia/sedation forventilated patients through a protocol:fentanyl or morphine as the opioids andmidazolam (Versed) as the benzodiazepine.Analgesia and sedation are carried out toassure patient comfort. In conditions whereFRC is decreased to a point whereinvasive ventilation becomes necessary,

Paul Ouellet is known for his lectures and presentations about pulmonary recruitment strategy combined with strategy for sedation and

analgesia. He frequently conducts lung recruitment seminars in the course of his work.


we believe that, as clinicians, the least wecan do is to provide comfort to a patientwho has to comply with a technology thatcan cause more harm than good. Oftenneglected and carried out withoutendpoints, analgesia/sedation must be addressed as seriously as theventilation strategy. We believe thatpatient – ventilator interaction andanalgesia/sedation cannot be dissociated.

Generally speaking, during the first 24 hoursof ventilation with oxygenation problems,patients are sedated to the point wherethey will become apneic. Opioids havedirect impacts on the respiratory centresand benzodiazepines add to the sedation.One major drawback to this condition is

over sedation on one end of the spectrumand under sedation on the other end.

We adopted the bispectral technology toguide our analgesia/sedation protocol.This has brought a technology at thebedside that provides valuable data nototherwise obtainable by any other means.Bispectral technology, and for that matter,any other EEG processed technology ismore valuable than subjective scales like theRamsay scale to describe deep sedationconditions. The BIS guided protocolprevents under and over sedation. Oversedation is quite a common situation forventilated patients. Our preliminary datashow those patients with BIS guidedprotocols have shorter time to extubation

than a Ramsay scale guided protocol, alsowith less patient – ventilator asynchronies.We feel that BIS technology has its nichein intensive care as much as in anesthesia.

When did you start using bispectraltechnology?

We started using BIS in intensive care aboutfour years ago. One aspect of my researchwas to establish correlation between theRamsey scale, the Sedation and agitationscale and BIS technology. We establishedthe correlation among these three tools, in the perspective of patient – ventilatoryasynchrony. In the first groupanalgesia/sedation was guided with the

Internist Chantal Violette, MD and Paul Ouellet work closely as interdisciplinary team members.


Ramsey scale measured every four hours.The second group was guided with BIS.Preliminary data show that with a Ramseyscore of 6 (deep sedation), asynchrony canoccur whereas in the BIS guided group, aBIS value in the 40 – 60 range demonstratesless patient – ventilator asynchronies.

BIS is a composite number whereby aninterpretation algorithm of EEG activitiesgenerates a value between 0 – 100.

A value of 0 is associated with corticalsuppression and 100 with maximalactivities. BIS values between 40 and 60are generally associated with an adequaterange of cortical activities. Values below40 are considered over-sedation in mostclinical conditions. An interesting featureof BIS technology is that it monitors EMGactivity of the frontalis muscle of theforehead. Initially considered as aconfounder, EMG might be a pre clinical

pain expression indicator. For noncommunicative patients, this might provea useful parameter not obtainable withconventional pain assessment scales.Behavioral scales to evaluate pain on non-communicative patients are centred onthree axis: facial expression, upper limbmovement, and patient – ventilatorinteraction. This concept is welldocumented mainly by Dr Jean-FrançoisPayen of the Université de Grenoble inFrance. We tend to believe that BIS mightbe the instrument clinicians have beenwaiting for to monitor brain activities incritical care during deep sedation states inorder to adapt a treatment that will perhapsfacilitate patient – ventilator interaction.

In order to add more flexibility to provideadequate analgesia/sedation in a contextof patient – ventilator synchrony, Propofol(Diprivan) is included in our protocol as arescue medication for conditions wheremaximum doses allowed by theanalgesia/sedation protocol are reachedwithout synchrony, and where neurologicconditions mandate rapid emergencefrom the sedative state.

Green supports that the psychologicalprofile prior to ventilation support has animpact on the recovery, and the importanceof delirium in intensive care is often tooeasily neglected. An interesting article by Richman demonstrated that theincidence of patient – ventilatorasynchrony is decreased by using aperfusion of fentanyl and midazolam.

Impacts of patient – ventilator asynchronyare real; de-recruitment, ventilatorinduced lung injury and ventilatorassociated pneumonias (VAP). Our VAPrate is presently 5/1 000 patient ventilatordays, and this represents the lowincidence of complications for ventilatedpatients and reflects a global approach forventilation strategies implemented. Forthat purpose, I feel ventilation strategiesmust develop hand in hand with betterstrategies of analgesia and sedation.Neurally Adjusted Ventilatory Assist (NAVA)is a promising technology that might havean impact on analgesia/sedation needs inventilated patients. Preliminary datasuggests that this technologydemonstrates a marked decrease ofpatient – ventilator asynchronies forspontaneously breathing conditions.

Louisette Plourde, RRT, with respiratory therapy colleagues. The hospital is a teaching

center for other institutions.


Biography

Paul Ouellet, PhD(c), RRT, FCCM, is aregistered respiratory therapist and aFellow of the American College of CriticalCare Medicine. He is team leader of theICU multidisciplinary team and clinicalspecialist at Edmundston RegionalHospital, Health Authority Four in NewBrunswick, Canada. He is also AssociateProfessor, Department of Surgery atSherbrooke University, Quebec Canada,and PhD candidate at the Faculty ofMedicine at Sherbrooke University. PaulOuellet has authored and co-authoredseveral peer-reviewed articles andtextbooks, and has lectured on the OpenLung concept throughout Canada. He is also actively involved in numerousmultidisciplinary education activities for nurses, physicians and respiratorytherapists. Paul Ouellet has authored and co-authored many peer-reviewed articles and textbooks.

Achieving patient – ventilator synchrony in non spontaneously breathing patientsoften mandates deeper sedation states.These conditions are more effectivelymonitored with BIS technology. Adaptingventilation strategy to control ETCO2below the threshold of apnea can be anoption that is worth exploring. Properventilation backup is neverthelessessential in these conditions.

Can you share any patient cases in this respect?

Recently, in the middle of the night, a patient experienced an asynchronyepisode that took us by surprise. A neuromuscular blocker was judgedappropriate to achieve synchrony. The next morning, readjustment of theventilation strategy to allow recruitmentand adequate analgesia/sedation guidedwith BIS resumed ventilation without the

need for neuromuscular blockers. By lowering ETCO2 by 2 mmHg frombaseline suppressed spontaneousbreathing and synchrony was established.We have not done comprehensivecomparative studies to support thisstrategy but we definitely feel thatanalgesia/sedation and protectivestrategies of ventilation go hand in hand.By concentrating only on the ventilationstrategy one side of the equation is missing;i.e. analgesia/sedation for synchrony.

What do you see as future challengesor opportunities in regard topulmonary recruitment?

Our current recruitment procedure wasdeveloped through consultation withopinion leaders in the field. We exploredvarious recruitment strategies anddeveloped our own, based on the kind ofpatients we treat and SERVO-i

technology. We have been influencedmostly by physicians such as FernandoSuarez-Sipmann, Luciano Gattinoni, JohnMarini and Marcelo Amato. We feel thatthere are different ways to restore FRC. Asuccessful protocol implementationmandates a well planned educationprogram coupled with clinical support.Over the years, our recruitmentprocedure has been continuously updatedand transformed as literature has broughtnew evidence and as technology evolved. In my opinion, NAVA, is the nextgeneration of technology and certainlyhas tremendous potentials. In thisrespect, I also believe that a futurechallenge for technology will be to providea clinician directed automated recruitmentstrategy that could re-establish FRCimmediately as de-recruitment occurs. As an illustration, we think that thepresent status in ventilation can besummarized as follows:

- A poor ventilation strategy creates ventilator induced lung injury

- A fair ventilation strategy treats complications

- A good ventilation strategy prevents respiratory complications


References

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maneuver. In this institution, lungrecruitment here is part of our culture.Usually for post-op patients, they areextubated the following day, if not withinthe first twelve hours, with very fewdeveloping atelectasis. Dr David hasbeen a very good precursor in numerousaspects of anesthesia and in critical care. Iremember when I started my career; oneof the first strategies in ventilation DrDavid taught me was be aware ofatelectasis and prevention throughsustained deep inspirations. Adaptingthis basic physiology principle with a newtechnology confirms years of experiencegathered through experienced clinicianslike Dr David. The concept of lungrecruitment is not a new invention, buttechnology helps us refine ways ofadapting this concept in clinicalapplications.

So there is a cross-disciplinaryacknowledgement of the value of recruitment?

Dr David:Yes. We normally havecardiovascular surgeries, thoracicsurgeries, with the majority of ourprocedures being orthopaedic surgeries.We have five anesthesiologists on staff,and on a daily basis, we anesthetize anaverage of 5-6 patients for surgery, lasting

anytime between 30 minutes to severalhours. Nevertheless, 30 – 45 minutes isenough to inflict atelectasis in otherwisehealthy lungs. The endpoint is that we feelthat recruitment helps to maintain thelungs open and thus avoids the start of aninflammatory process that couldeventually spread to healthy lung regionsand other systems and organs.

Dr Chantal Violette, Internist of the multidisciplinary team, Nurses Manon Dionne and Anne Caron andRespiratory Therapy Manager Louisette Plourde related their experiences and perspectives in regard to the implementation of the pulmonary recruitment and sedation strategies.

An interdisciplinary approach to pulmonary recruitment: Critical Care/ICU

Biography

Dr Daniel David received his initialeducation as an anesthesiologist at theUniversity of Madras in 1963. Afterspecialist training at McGill Universityin Montreal, he joined the staff atEdmundston Regional Hospital as ananesthesiologist in 1970. He has beenactively working as an anesthesiologiston staff there ever since.

What is your experience of theinterdisciplinary approach, and how do you think it is working?

Dr Chantal Violette: Our ventilatedpatients recuperate well. The Open Lungstrategy does work for us, no questionabout that, and we adapt patient-ventilation synchrony with theanalgesia/sedation strategy through

protocols. In this institution, all of theseissues are interrelated and must beregarded as such. That is why we haveinterdisciplinary teams.

Manon Dionne and Anne Caron: Wenurses are concentrating more on thesedation and analgesia protocol andmonitor the patient – ventilator interactionby working closely with the respiratory

therapists. We feel we are keen at lookingat the ventilator and when we noticepatient – ventilator asynchrony, we titrateanalgesia accordingly. We start withopioids and titrate within 20 minutes ifnecessary. It has become part of ourculture now to determine if the patient isin asynchrony, and if so, we explore thepossibility of de-recruitment. Now that weimplemented BIS technology to guide

Dr Daniel David has been on staff at Edmundston for over 35 years.


less agitation, easier and shorter weaningtime and affected length of stay in ICU aswell. We are in the process of preciselyquantifying the results and submittingthem for publication.

Have you noticed the decrease inAPACHE scores?

Louisette Plourde: Previously, most ofour ventilated patients had averageAPACHE scores of 24; whereas now, theaverage score is more in the 15 – 19brackets. This translates into less acuteconditions. This coincides with theintroduction of the Open Lung protocoland the BIS technology.

Since the introduction of theseprocedures, on an annual basis, weroughly have the same number ofventilated patients, but we notice a 30%decrease per year for ventilator hours;that seems striking evidence on positiveimpacts. This trend seems to continuethis year as well and we are tempted tointerpret this observation as a logicalendpoint towards optimal and adaptedpatient care.

What has been the experience oftraining your RTs when implementingthe new pulmonary recruitmentstrategy?

Louisette Plourde: We have anorientation program which every RT mustcomply with prior to work in ICU. EveryRT must be certified for each protocol,and an annual recertification is mandatory.For newcomers, it generally takes a fullyear before a therapist is fully operationalwith full delegation, in airway management,ventilator management, sedation andanalgesia, and hemodynamics.

As therapists, we have established a clearrole from a clinical point of view, and wework closely with the multidisciplinaryteam so that means that the educationalbar is quite high. All new RTs from othercenters must to some extent re-learn, sothat they understand the multidisciplinaryapproach. Most of the students here onclinical rotations in their final yearexperience that we are establishing quitehigh requirements and standards. Weincorporate them in the ICU.

enables us to have the endpoints forrecruitment. With the VTCO2 and dynamiccompliance, we now have two validparameters to establish the level ofrecruitment or de-recruitment. As thistechnology evolves the physiologicalconcept remains the same. But we havebetter tools to interpret and delivertherapy.

How many respiratory therapy staffmembers do you have?

Louisette Plourde: We have a total ofeighteen respiratory therapists to coverthe ICU and an outpatient pulmonaryclinic. I have been working here for 22years, and have seen numerous changes,from old piston ventilators to thetechnology we are using now.

Regarding the pulmonary recruitmentprotocol and strategy for sedation andanalgesia to prevent ventilatorasynchrony, can you tell us about whatyou have observed since this has beenimplemented?

Louisette Plourde: Preliminary datademonstrate the positive impact of theseimplemented strategies. The number ofventilator-days decreases and we observe

analgesia/sedation, we can hardly thinkhow we did before to adapt ventilationstrategies without quantitative monitoringof both sedation and ventilation.

Paul Ouellet: When you introduce a newtechnology in the ICU, you have to askyourself, what impact will this have onpatient outcome? If you don’t know howto use it well, do not implement it. If youdo know how to use it and utilize itaccordingly, and if it translates into betterpatient care and outcome, why shouldyou restrain its use? We feel that whenwe introduced SERVO-i with Open LungTool, we have bought technology that hasan impact on patient outcome. When weintroduced the BIS technology, we alsofelt that it had an impact on patientoutcome. I can remember with olderplatforms and learning of the Open Lungconcept that it was a revelation to us,which made so much sense. Whenimplementing waveforms I rememberspeculating at one point, would theexpiratory limb of the volume-pressureloop be more interesting than theinspiratory limb? Of course, now it isobvious that the expiratory limb revealsits secrets. So we have seen theevolution of this concept, and now we areat the stage where the technology

Louisette Plourde, RRT, has observed a 30% decrease in ventilator hours per year.


Ventilatory Assist (NAVA) is certainly themost obvious example to support thisstatement. We anticipate NAVA as alogical forward movement in mechanicalventilation, and as a teaching institution, ourchallenges to incorporate neurophysiologyin mechanical ventilation are quitestimulating. We feel NAVA will bring anew dimension and will serve as a logicalcomplement to conventional ventilation.

feel it becomes a significant advantage tohave only one platform that everybody isfamiliar with when it comes to adults,children and infants. Versatility from allcategories of patients was one of our firstcriteria when we changed the fleet. Froma clinical rotation perspective, studentsfrom Université de Moncton, Universityof New Brunswick in St John, DalhousieUniversity in Halifax, Sherbrooke andChicoutimi Colleges in Quebec, are awareof the only platform we are using and thisallows for very precise objectives in theircurriculum. The clinical rotations havevery precise objectives directed towardsthe Servo platform. Instead of havingseveral platforms, we opted for severalacademic institutions. This has served uswell in recruiting RTs that fit in our team.This is important, particularly in smallerinstitutions like us, where we work veryclosely together, with synchronizedobjectives.

As responsible for the respiratorytherapists here, what do you see asstrategically important in regard tofuture therapies?

Louisette Plourde: We have goodreasons to believe we have made theright decision when we opted for theServo platform. Neurally Adjusted

In regard to the multidisciplinaryapproach to the protocols you areusing, do you have team meetings on aregular basis?

Dr Chantal Violette:The prerequisite to amultidisciplinary approach is to work as ateam, which means close and regularcontact with each other. We have dailyrounds with each function represented,on every patient, with a nurse, respiratorytherapist and physician attending. In allaspects of care, we have a continualdialogue in close proximity to each other.

When you switched the ventilator fleetover to the new fleet, was this achallenge from a training perspective?

Louisette Plourde: Not necessarily,mainly because it was a gradual process.As a new platform was introduced, inservice was carried out over a period oftime that would allow every member ofthe staff to become totally familiar beforemoving to the bedside. We were notrushed to the bedside, and that attitudecreated a sense of security for allmembers of the multidisciplinary team.

For some of our younger therapists, theServo ventilators are the only platformthey have mastered in such depth. We

As interdisciplinary team members, nurses Manon Dionne and Anne Caron are active in monitoring patients on the protocols.

Chantal Violette, MD.


Dr Daniel David has been working as ananaesthesiologist since the early 1960sand joined the staff at EdmundstonRegional Hospital in 1970. Early in hiscareer, Dr David was exposed tosustained inspiratory maneuver beforeemergence from anesthesia and ithas been part of his routine practicethroughout his professional practice.

The pulmonary recruitment strategieshere have led to some impressiveresults. How do you regard the needfor recruitment in anesthesia?

Dr David: I firmly believe in lungrecruitment. When I started out many,many years ago in 1959, I providedventilation and recruitment in anesthesiaby means of my hands by bagging thepatient. I continued to providerecruitment, which was made even easierwhen we came to our current system,which provides pressure controlledventilation in anesthesia. I think it isparticularly important, for patients whoare lying supine on the OR table for three,four or five hours, to consider thatatelectasis is likely to occur, thusdecreasing their functional residualcapacity. What I usually do uponemergence, is to provide pressurecontrolled ventilation at approximately 40 cm H2O for 10 to 15 breaths. I firmlybelieve the anesthetized patient needs to have his alveoli recruited.

So you firmly believe in the relationshipbetween anesthesia and atelectasis?

Dr David: Yes – I can use an analogy – youcan sit in the cockpit and only work thecontrols, but I feel it is more appropriateto understand how the engine worksbefore looking at the controls. With athorough knowledge of the workings ofthe engine, you can appropriately guideyour aircraft, or in our case, adapt theappropriate therapy to the patient. Bychoosing only to sit at the control deck,you are only sitting at the controls andperhaps not optimizing the whole flight.

I have appreciated the benefits for lung

recruitment in anesthesia for many years.In olden days manual ventilation wascarried out by the ‘Educated hand’. Lungrecruitment can be carried out quitesimply, without ceremony; technology isinstrumental to proper patient care.

And how do you perceive the patientsreceiving recruitment in the OR whenthey come to the ICU?

Paul Ouellet:The wonderful thing is thatpatients from the OR are generally easyto ventilate, if atelectasis is reversed inanesthesia; and when we instituteventilation in ICU, we do recruitment,unless patient condition prevents such

The intensive care unit of Edmundston Regional Hospital, Health Authority Four of New Brunswick has anannual average of 900 admissions and 2,500 patient days, with 11% of admitted patients receivingmechanical ventilation.

The pulmonary recruitment strategy is utilized over a multidisciplinary range of staff, including 16 respiratorytherapists, 30 full time nurses in the ICU, and critical care physicians. Lung recruitment is also a priority inthe OR during anesthesia.

Critical Care News had the opportunity to meet with various staff members and discuss the pulmonaryrecruitment and sedation strategies.

An interdisciplinary approach to pulmonary recruitment: OR/anesthesia

Anesthesiologist Daniel David, MD and Paul Ouellet have shared a close collaboration

for many years.

Documents

NO. 14 News Critical care · 4 | Critical Care News The ICU at the Edmundston Regional Hospital, Health Authority Four in New Brunswick, Canada, has experienced a decrease in APACHE