Welcome to the 51st Critical Care Congress. My name is Eduardo Mireles Cabo de Vila. I'm the Director of the Medical Intensive Care Unit and Director of the Simulation and Advanced Skills Center at the Cleveland Clinic, Ohio. Today I will be presenting as part of a session on education in mechanical ventilation, training or future. My lecture is presenting a structured approach to mechanical ventilation training. The learning objectives are to review the basic building blocks needed for structured learning in modern times, balancing in-person and online learning to achieve the educational goals and to collaborate to improve a training platform on mechanical ventilation. We'll start with the current state on training on mechanical ventilation. If you are like me, your training on mechanical ventilation is most likely based on bedside experiences. As a resident, I did not have a structured approach. I was taught by the respiratory therapist and by the attending physicians that care for patients and I would round with them. In fellowship, I was lucky enough to be in a place that had a person that was really deep into mechanical ventilation that served as a mentor for me. However, the majority of the education in mechanical ventilation was done from fellow to fellow and from fellow to resident and from respiratory therapy to fellow. How do we learn today? Currently there's a lot of self-study, just like in the past. We use books, chapters to read, to review, to gather information. There's a plethora of articles, more and more, and easy to obtain online. You could use the manuals on the mechanical ventilator and a lot of the education is done also by the sales rep from the ventilator company. There's a fair amount of information that is now available for education online via social media. You also obtain education at school, the respiratory therapy school or residency or fellowship. There's also a series of offered standalone courses on mechanical ventilation. As you know, as today, you are receiving education from the societies like the Society of Critical Care or the American Association of Respiratory Care, ATS, or whichever society you belong to. But most common and a big part of what we learn is at work, either by competencies that are required by the institution because of you being part of a graduate medical education or simply being at bedside and being taught. Let's talk a little bit more in detail about this. A big part of the education that occurs, especially ones that you have graduated, is through ventilator sales specialists. These are usually sporadic. These occur also at meetings when you attend the location where the ventilators are. It's highly variable. It depends on the level of training, the intentions of the ventilator sales specialist, and the situation in which you are. What you are actually asking is majorly unstructured. In terms of the respiratory therapy school, residency, fellowship, nurse training, this usually occurs once, meaning you cross through your training, and it's variable in the type of curriculum that you may receive. Some centers have very well-structured training programs on mechanical ventilation. Others don't. Most of the time, you're in a time in which it's very easy to be saturated by the amount of information that you're getting, not only from mechanical ventilation, but also for all the other training that you have to do. Most of the time, you're green. You have very little experience, and it's hard to put these things into context. The other area is the self-learning, is using textbooks, articles, blogs, YouTube, social media, or attending courses, as we mentioned. These are usually self-driven. They're not dependent on requirements at the place where you work. This is an opportunity that the caregiver takes to achieve and learn. Many times, this is unstructured, and it may occur as an opportunity, meaning you are going through Twitter, a tweet comes by with information, you acquire it, and that's a way in which you learn more about mechanical ventilation. Finally, as we talked, there's the bedside. There's also the back room where they put the ventilators, and some learners will go there, set up a test lung, and play with the ventilator and learn the nuances of each mode of mechanical ventilation. In some occasions, we may be lucky to have either a simulator or a simulation lab or a structured course to do this, but the majority of the time, this type of education is opportunistic unstructured and experiential. What are the current challenges that we face? The first one, and as Rob mentioned in the earlier lecture today, there's no standardized nomenclature, and this doesn't only apply for mechanical ventilation. The variability in all these areas that provide information on how they use terms, sometimes physiological terms are used with different wording. There's also a lot of legacy terms which are not necessarily appropriate for what we're trying to teach or what they mean. A classic example that we talk often about is in mechanical ventilation is modes that have different names but actually do exactly the same, like PRBC, BC+, adaptive pressure ventilation, all of them doing the same algorithms or similar algorithms, but with very different names. We actually lead to confusion in our learners. You also heard that there's more than 500 modes of ventilation, at least in the US alone on the ventilators that are available, with multiple ventilators available. When you read the manuals, these have different ways of presenting the information with different words and different definitions. The software on the ventilators changes, and it all depends what type of ventilator and what year and when was it last updated, how the mode will perform. And then there's evidently differences in performance between ventilator and ventilator. The other challenge is that there's different levels of education, and that's obvious. Each one of the team members may need a different level of knowledge to deal with mechanical ventilation. However, the way that we're trained as advanced practice providers, nursing, respiratory therapies, physicians have different curriculums, and the way that information is conveyed is not homogenous. The way that care is delivered is different across nations. There's nations that do not have respiratory therapists, in which nurses manage mainly the mechanical ventilator, others in which it's mainly the physicians that manage the mechanical ventilator. Finally, there is the issue with local resources and guidelines. In terms of local resources, what we know is that the availability of mechanical ventilators, certain types of mechanical ventilators, is going to be different across nations and across cities. There's no actual guidelines on what to teach on mechanical ventilation, not the standard curriculum that exists to deliver. You may be faced with scarcity in the area where you are, with the amount of time that you have to learn, and the pressures that come from operations. Nothing can be more evident than the problems that we have with COVID and having to teach providers that did not know mechanical ventilation how to care for patients with it. The question is fair. I mean, you're presenting an issue with education on mechanical ventilation, but why do we need to act on training on mechanical ventilation? I'll put a couple of points for you to recognize. The first one is this nice study by Colway in Applied Ergonomics, in which essentially they went and did an analysis of causes of error in mechanical ventilation. In this fishbone analysis, you can see two areas that are very important for us. One is the representation of medical functions, and then the user characteristics. As they analyzed the process that lead to error, which can create harmful situations that eventually can lead to harm, you can see that the heterogeneous terminology, when there is ambiguous labeling or parameters that do not match or are not understood correctly, when there are acronyms that are used across platforms that don't mean exactly the same thing. You can also have issues with user characteristics, such as low level of experience with certain platforms for ventilators. In many cases, the ventilator is bought, you get training, but you don't use that function or you don't discover how to use that function until later on, once the time has passed from the time that you had that training. Finally, there is this issue with the mental model and how we understand what was the training that we had, the experiences that we have, and how we apply that mode of mechanical ventilation. Finally, there is stress. Whenever there is stress, depending on your level of training and how you understand and what your mental model, how things are going to evolve. The limitations in how to use the device, the premises and physiology of how to use it, are a known cause of error. This is a major issue. There is not much, but there are some hints on the literature about how big the problem is. In a classic paper now by Cox in 2003, they surveyed senior residents, medical residents, and one of the key numbers that came from that study is that only 46 of the trainees were satisfied with the training that they got on mechanical ventilation. You can see, at least in 2003 when the survey was published, that a large number of the senior medical residents could not apply or answer correctly the correct tidal volume or how to set PEEP in hypoxemia. As we drive even further into the literature, you realize that the presence of curriculum is really erratic through the training programs. Right now I'm focusing mainly on the medical realm, but we'll go into other areas. In this article published by Wilcox in 2015, 77% of the trainees in emergency medicine had less than three hours of curriculum per year on mechanical ventilation. They deal with this very often. This is the first area of contact. In terms of our RTs, nurses, and advanced practice providers, the situation is also challenging. A real good, nice work that the ARC performed in 2015 was to survey several respiratory therapy training programs, and they created also competencies for entry to RT practice. One of the competencies that they recommended was that the RT that is going to enter practice before entering practice should be able to apply to practice all ventilation modes currently available on invasive and non-invasive mechanical ventilators and as adjuncts to the operation of modes. This is a tall task to ask respiratory therapy in school. It essentially would take a number of hours of days, probably months, to be able to put in practice all ventilation modes currently available. So there has to be a better answer than that. There has to be a practice pattern to be able to train them to be able to understand and have the basis to be able to apply all the available modes. In terms of nursing training, this is not particular to the United States, but actually comes from work done around the world, but in a survey also done by ROSE in critical care, which actually most ICUs in all countries provided some level of education to nurses where they manage the mechanical ventilator. This varied from almost all giving education to only up to 65% of the units, meaning that there's a fair amount of variability on the requirements of training for those nurses and how in their ICUs. And finally, the advanced practice providers are also in a challenging situation. I mean, they enter the critical care workforce essentially directly from their graduate training, in which they have to go through a series of trainings in which evidently the focus is not necessarily mechanical ventilation. There's few residents in some fellowships in critical care in the country for APPs. So majority or many of the programs that hire advanced practice providers just such as ours at the clinic, we have to create a transition to practice programming, which we train them into those areas of critical care. So if we think about mechanical ventilation, how it has evolved through time, in this graph you see, I mean, just as an example from 1980s when there were essentially three modes present on the ventilators, all the way to now when there's 500 modes and the complexity has gone up to the point that we have now a series of intelligent features and programming on the computers that manage mechanical ventilation. So technology has moved ahead and the education is practically flat. There has been no evolution and now some of the programs and people listening to this come from programs that have really good education programs. So this is not a generalization. There's some local environments and I'll show you some examples that have very good practices, but that is not the generality. And it usually depends on a few people in that institution that drive the education and training of the group there. So the question, is there hope? I will put a couple of examples for you of how this is the case. You can see here in this study in ATS Color just a couple of years ago by SEAMS, you see they created this five-day course for fellows. And the nice thing here is that they compared the course that they created with two parts. The first part was at the beginning of the training and then six months later. And then they compared that with fellows from other specialties also involved in critical care. And they gave them the same exams, 12, 24, and 36 months. The interesting thing is that you can see the hike in learning that these fellows had when they completed a specific curriculum. And within six months of being or seven months of being in training, they had surpassed even the senior fellows at other years. Why is that? Why is it important? I mean, we could take the arm of saying, okay, let them go. The machine is going to manage itself. We don't need to know. However, as critical care providers, and especially in this heterogeneous environment with different resources and with different platforms, we need to understand how these ventilators work and how they react and how they serve the goals of mechanical ventilation for each patient. That will still be dependent on the clinician. And troubleshooting them and adjusting them will still be there. The technology has not gotten to the point in which it can self-drive itself. And even if it gets to that point, the amount of variability that we have in the patient population will require us to be prepared for that. So, there is no alternative here. We need to be prepared as caregivers for critically ill patients receiving mechanical. Now, what is out there? I like this article by Golliger in which they essentially built a consensus curriculum where they tried to get providers not only from academic, but also private practice educators throughout North America. From there, they actually were able to generate around 91 educational objectives, and there was consensus in 56 of them. I have put here the 12 categories in which there were several educational objectives within each one of them. This was very interesting for me because this is, in a sense, a type of needs assessment that needs to occur to know what type of curriculum we need to build to train our caregivers. Now, this was focused on physicians. The same thing needs to happen for our respiratory therapies, for our nursing, for our APPs. What level of knowledge? What are the issues? And then combine them into creating a curriculum that covers the essentials that need to be known for mechanical ventilation. What we need is also standardized nomenclature. This is a key issue and item as we go through the literature, especially for those self-learners or when you're going through on your own to try to elevate the level of knowledge. In physiology, the terminology varies throughout, even though the scientific notations for physiology are very well established. In terms of technology, a lot of work has been done by Rob Chadburn on terms of how to classify and have a standard terminology for modes, but the same for settings. Even between and across platforms for ventilators, the terminology is not standard. The same happens in the clinical realm. How do we identify and interact and convey our knowledge across platforms for the same clinical events that we're seeing? On the other side, we also need to standardize requirements. So our societies that train our caregivers or that set the standards for what needs to be trained on, the ACGME for the residency that involve critical care and management of mechanical ventilation need to define better what it is, not just mechanical ventilation, just such as the ARC did and put out the competencies that need to be done. There need to be consistent guidelines across platforms so that we can apply mechanical ventilation in a more homogeneous way. And finally, there needs to be certification in my mind. This is very similar in a way to the success that the American Heart Association had standardizing the way that ACLS and BLS is performed. There is a body of evidence, there's consensus, guidelines are formed, new areas of research are highlighted, and we have to have routine training to achieve a certificate of competency and maintenance of competency. So the structure that needs to be done in this lifesaving measure, which is mechanical ventilation, is we need to have a curriculum that has a needs assessment that evolves appropriately with the knowledge that is coming from evidence and that is standardized across the learners. There has to be several platforms available and a combination of them as there is different ways to learn and to enhance learning from our caregivers. And this has to be available and able to be transferred across different platforms to allow different learners in different settings to learn and to be able to complete. Finally, there has to be assessments that are fair, that are standardized, and they are valid. And there has to be a maintenance of certification, meaning that we can maintain training and assurance that as we're moving through with more knowledge and learning more about with more evolving technology and learning more about the physiology of how patients and ventilators interact, that we can maintain that, maintain the capacity to care for these patients. So why do we need to refocus this? This is one of those studies that just to highlight, this comes from the ACLS protocols and assessing in a group of patients in which they either survived or did not survive and how many divergence they had from the ACLS protocols. And I mean, just to highlight that when there was wrong actions or wrong timings or they simply forgot or did not do it, it correlated with in patients that did not survive, return of spontaneous circulation. Evidently, there's many other confounders within these studies or types of studies to highlight this. But I do think that whenever we're taking care of a patient, if we have set a protocol and we do not following it, then knowing where we did not follow it and what was the outcome of the patient will be better than applying anything that we think that we're applying without any order. So helping structure learnings and how to apply them seems to me as a natural progression for caring mechanical ventilation. So with this, the summary is mechanical ventilation, as we know, is lifesaving. However, the technology has surpassed our education platforms. And although in your center, you may have outstanding learning, this is not across all hospitals or all caregivers. We do need to catch up. The risk is harm to the patient. Local efforts may succeed, but these are limited in effect throughout the healthcare platform. So we need to work as a society and as caregivers towards a standardized, adaptive, and evolving education platform for mechanical ventilation.

Medical Intensive Care Unit

Simulation and Advanced Skills Center

mechanical ventilation training

bedside experiences

standardized nomenclature

education and training programs