Why did we start them?
Many of the opportunities for teaching and learning about mechanical ventilation occur during the bedside rounds in the Intensive Care Unit. Unfortunately, time and the number of patients that need to be seen, often limit the ability to have in-depth discussions. Clinicians caring for ventilated patients should understand the basics of assessment respiratory system mechanics, and ways to adjust the ventilator to individualize the settings to their unique condition. To help with this we recently began our weekly mechanical ventilation rounds. Each week we choose a patient in the intensive care unit to discuss at the bedside. These education sessions often last a minimum of one hour, and even the family members of patients have listened to the discussions.
What is the format?
The bedside discussions start by first having the most responsible Critical Care Fellow describe the patient condition. Then, with a structured approach the Fellow is asked to assess respiratory mechanics of the patient and guided when unsure of how to perform measurements on the ventilator (inspiratory and expiratory pauses), or where to find settings or measurement information on the ventilator being used with the patient.
The medical learners have also had exposure to interesting uses of technology such as esophageal pressure measurements both for assessment lung mechanics, as well as monitoring asynchrony, the use electrical impedance tomography to assess the response to setting PEEP, as well as the response to prone positioning, and transitioning from ventilation to trach-mask trial.
The bedside mechanical ventilation rounds have gained popularity and are always well attended (sometimes due to space not everyone can participate). One example of the utility of these rounds was the assessment of an obese patient labelled as “COPD” that had normal compliance and normal resistance. This then led to a discussion about other causes of his hypercapnic respiratory failure, such as obesity hypoventilation which he was then referred to the appropriate service to follow him after ICU discharge.
How can you do the same?
First step is to confirm the ICU leadership team is supportive of the initiative. Next, it is important to select a small group of individuals willing to lead the discussion as facilitators. Individuals with knowledge of mechanical ventilation, respiratory mechanics, that also have an ability to guide others to arrive at solutions are ideal. Once a group is selected, set up a calendar and have each group member select a day they are available to lead the discussion. Create an email list for the group of individuals (in our case the critical care fellows) to let them know which bedside the rounds will occur that day. Finally, have a structured approach. Here is the one used at St. Michael’s Hospital:
- Select one or two patients during the morning or day before
- Tell ICU attending, RT and nurse in charge of the patient´s care that there is a plan to do vent rounds in the afternoon. If
familyis around, let them know.
- During the session: fellow taking care of the patient can give a one-line summary of patient´s clinical condition
- During the session discuss (ABCDE):
- A mode of ventilation and settings, discuss how it works
- Basics of waveforms (waveforms, scales, time, screenshot/freeze)
- Collect information about the patient from the ventilator (mechanics, respiratory drive, gas exchange, waveforms….)
- Discuss specific monitoring if present (esophageal pressure, EIT, diaphragm ultrasound, CO2…). Discuss additional monitoring tools
- Enable adjustments of ventilation and manipulation of the ventilator (ideally the fellows touch the ventilator to do the changes). Before the change, anticipate what will happen, and after, discuss the results.
- Foresight of a ‘prognosis and plan‘ from a mechanical ventilation standpoint