Respiratory Care at 65

Transcription

1 Respiratory Care at 65 Dean Hess Assistant Director of Respiratory Care Massachusetts General Hospital Associate Professor of Anesthesia Harvard Medical School Editor in Chief, RESPIRATORY CARE

2 Disclosures Philips Respironics Bayer Jones and Bartlett McGraw Hill UpToDate American Board of Internal Medicine

3 Respiratory Care at 65

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5 Conestoga, PA

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7 Harrisburg, PA

8 We ve Come a Long Way Since the Days of the OJT Therapist The respiratory therapist of the 21 st century must be a technologist, physiologist, and clinician. The goal of every RT should be RRT. The goal of every RRT should be BS RRT. Every respiratory therapist should be a clinical leader; this requires commensurate education to be respected.

9 In 1972, RT = IPPB

10 Medicare Fee for Service July 30, 1965

11 Respiratory Care in 1972: IPPB with Isuprel and Dornovac IPPB = $$$

12 Lancaster, PA

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15 1977 The Carter Administration s Department of Health, Education and Welfare Secretary, Joseph A. Califano, testifies before congressional hearings on health care costs, citing limited professional evidence for inhalation therapy services. This was an attack on IPPB, which was synonymous with inhalation therapy, and which was a major revenue generator for hospitals at the time.

16 1983: Diagnosis Related Groups Respiratory Therapy became a cost center rather than a revenue center. Questions were asked about unnecessary therapy and overutilization of therapy.

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19 Chest, May 1980

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21 Respiratory Therapies That Have Proven Not Effective Intermittent positive pressure breathing Post op incentive spirometry Weaning parameters SIMV for weaning High tidal volume for mechanical ventilation Albuterol in patients with ARDS HFOV for ARDS (at least in adults) Inhaled NO for ARDS (at least in adults)

22 Don t Just Do Something, Stand There! At the first rehearsal of Irwin Shaw s play, The Assassin, Producer Martin Gabel noticed a young actress gesticulating wildly instead of remaining motionless. Gabel shouted: Don t just do something; stand there. Sometimes our patients get better despite what we do to them.

23 From experience based (what has always worked in the past) to evidence based practice. What have you found works best? What is the evidence for?

24 In my clinical experience is a phrase that usually introduces a statement of rank, prejudice, or bias. The information that follows it cannot be checked, nor has it been subjected to any analysis other than some vague tally of the speaker s memory... the biases of imminent men are still biases. Crichton, N Engl J Med 1971;285:1491

25 Evidence based respiratory care is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. It applies the best available evidence to the unique physiology of the patient. We should all embrace evidence based practice.

26 Less is More Ventilator circuit changes Noninvasive respiratory support CPAP NIV HFNC Lung protective ventilation

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28 Crit Care Med 2015;43:880

29 JAMA 2016;315:1345

30 Chest, January 1977

31 High Flow Nasal Cannula Nishimura, J Intensive Care 2015;3:15

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34 Papazian, Intensive Care Med 2016

35 High Flow Nasal Cannula Flush upper airway dead space Minimize room air dilution Provides small CPAP Reduces inspiratory resistance

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37 Crit Care Med 2016;44:282 Targeting a V T 6 8 ml/kg PBW during NIV for is not achievable in many patients.

38 JAMA 2016;315:1354

39 Puritan Bennett MA 1 Branson, Hess, Chatburn Respiratory Care Equipment 1995

40 ARDS Network Study 861 patients with ALI/ARDS Control: 12 ml/kg ideal body weight 6 ml/kg ideal body weight Pplat 30 cm H 2 O Tidal volume decreased to 4 ml/kg for Pplat 30 cm H 2 O Tidal volume increased to 8 ml/kg for asynchrony or acidosis provided 30 cm H 2 O Volume controlled continuous mandatory ventilation 25% mortality reduction for smaller tidal volume Number needed to treat: 12 patients N Engl J Med 2000;342:1301

41 18% relative increase in mortality for each 1 ml/kg IBW increase in tidal volume.

42 Beware of the Follies of Physiologic Endpoints

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45 Inhaled Nitric Oxide: PaO 2 /FiO 2 Adhikari, BMJ 2007;334;779

46 Inhaled Nitric Oxide: Mortality Adhikari, BMJ 2007;334;779

47 Inhaled NO: Adverse Effects Adhikari, BMJ 2007;334;779

48 New Is Not Necessarily Better

49 1970s 1980s 1990s 2000 IMV PSV PCV Closed Loop 1950s: negative pressure 1960s 1970s: pressure cycled

50 Chest 1973

51 J Trauma Acute Care Surg 2012;73:507

52 High Frequency Oscillation OSCAR OSCILLATE N Engl J Med, January 22, 2013

53 Modern Ventilators are Engineering Marvels Triggering Gas delivery (PC, PS) Leak compensation (NIV) User interface (touch screen) Monitoring (waveforms) Transport (battery) New modes?

54 The Respiratory Therapist As Clinician (Not Technician)

55 BMJ 2011;342:c7237

56 Summary The education level of RTs is increasing RT is a cost center, not a revenue center Evidence trumps anecdote Sometimes less is more Beware of the folly of surrogate endpoints New is not necessarily better Technician to clinician

57 Those Who Can Not Remember The Past Are Condemned To Repeat It. George Santayana,