Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research

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Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research Writing 9 pages of summarising articles. Each article should be summarised to two pages double spaced. Also, it should be in APA format. One of the pages will be a reference page so it’s 8 pages long. THE TUTOR SHOULD BE WELL KNOWLEDGED ABOUT MECHANICAL VENTILATOR AND MODES OF VENTILATION. Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research journal_2.asp.pdf journal_3.pdf journal_4.pdf journal_5.pdf journal_6.pdf Special Article Documentation Issues for Mechanical Ventilation in Pressure-Control Modes Robert L Chatburn MHHS RRT-NPS FAARC and Teresa A Volsko MHHS RRT FAARC As hospitals begin to implement electronic medical records, the inadequacies of legacy paper charting systems will become more evident. One area of particular concern for respiratory therapists is the charting of mechanical ventilator settings. Our profession’s lack of a standardized and generally accepted taxonomy for mechanical ventilation leaves us with a confusing array of terms related to ventilator settings. Such confusion makes database design impossible for information technology professionals and is a risk-management concern for clinicians. Of particular note is the complexity related to set airway pressures when using modes whose primary control variable is pressure (versus volume). We review the clinically relevant issues surrounding documentation of the patient-ventilator interactions related to airway pressure and provide suggestions for a standardized vocabulary. Key words: mechanical ventilation; terminology; medical record; charting; simulation; ventilator design; information technology; medical informatics; taxonomy. [Respir Care 2010; 55(12):1705–1716. © 2010 Daedalus Enterprises] Introduction Correspondence: Robert L Chatburn MHHS RRT-NPS FAARC, Respiratory Therapy, M-56, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland OH 44195. E-mail: chatbur@ccf.org. stripped our system of nomenclature for mechanical ventilation. Confused terminology can create problems, especially when very similar or identical names are applied to different ventilation modes, or different names are applied to the same mode. Inconsistencies of this nature can be found in the literature and contribute to misinterpretation of findings and inaccurate reporting. In a comparison of the use of volumecontrol and pressure-control ventilation to treat respiratory failure in patients with chronic obstructive pulmonary disease, Karakurt et al used the acronym “IMV” to mean both invasive mechanical ventilation and intermittent mandatory ventilation.2 Carvalho et al vaguely describe bi-level and pressure-support ventilation (PSV) modes as “frequently used modes of spontaneous breathing” in a report that compared the effect of bi-level ventilation and PSV on oxygenation and pulmonary blood flow.3 They confounded the concept of a “mode” with the concept of “spontaneous breathing,” and the definitions of both were left to the reader’s imagination. Inaccurate descriptions of ventilator modes occur frequently. For example, in a systematic review of 50 published reports, Rose and Hawkins highlighted the inconsistencies that occurred when authors described biphasic positive airway pressure (BIPAP) ventilation and airway pressure-release ventilation (APRV).4 Such inconsistencies are more than just a nuisance; from an educator’s RESPIRATORY CARE • DECEMBER 2010 VOL 55 NO 12 1705 Technological advances in ventilator design provide clinicians with a variety of options to support the work of the respiratory system and improve gas exchange. To safely and effectively initiate and manage mechanical ventilation, the clinician must have a good understanding of the ventilator design and mode capability to appropriately match the ventilator’s output with the patient’s physiologic demand. Ventilators have substantially evolved over the last 3 decades.1 What was once a simple machine has been transformed into a complex computer with sophisticated software. Unfortunately, the advances in ventilator technology and innovative marketing strategies have out- Robert L Chatburn MHHS RRT-NPS FAARC is affiliated with the Respiratory Institute, The Cleveland Clinic, and with Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio. Teresa A Volsko MHHS RRT FAARC is affiliated with the Respiratory Therapy Program, Department of Health Professions, Youngstown State University, Youngstown, Ohio. Mr Chatburn has disclosed relationships with IngMar, Hamilton, Covidien, and Dra?ger. Ms Volsko has disclosed no conflicts of interest. DOCUMENTATION ISSUES FOR MECHANICAL VENTILATION perspective, they create barriers to the learning process, which may prevent the clinician from completely understanding how to properly operate the ventilator.Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research The lack of a generally accepted and standardized vocabulary for mechanical ventilation complicates the assessment process. Educational and competency assessment tools focus on specific knowledge components or technical skills. If terms are not accurately or consistently defined, educators have difficulty developing the content matrices and test items needed to assess work-based training,5 as well as initial and ongoing competency assessment instruments.6 Lack of consistency with terminology may compromise the reliability and validity of the testing instrument. These implications also affect the accuracy from which quality monitoring tools are developed and data are gathered. Lack of a well developed quality-assessment tool may create a barrier to the discovery of procedural and documentation errors. Documentation errors in the medical record increase the risk of medical decision errors and adverse patient outcomes.7,8 A study by Vawdrey and colleagues concluded that even at institutions where manual charting of ventilator settings is performed well, automatic data collection should be used to eliminate delays, improve charting efficiency, and reduce errors caused by incorrect data transcription.9 Yet an incomplete or conflicted lexicon prevents the design of even a simple data-acquisition system to allow efficient data mining; you cannot measure what you cannot describe. Inconsistent terminology makes database normalization impossible. Normalization is the process of creating database tables according to specific rules in order to eliminate redundant or duplicate data and to avoid problems with inserting, updating, or deleting data.10 For example, a database for an electronic medical record that contains a single field called “pressure support” could result in a violation of what is called the “first normal form” for a relational database, because (as we will show below) “pressure support” has multiple meanings, which creates the need to store multiple different values for the same record, which would lead to ambiguous search results if only one data field is available. Specific Problems With Documenting Pressure-Control Modes The general issues of documentation have been at the forefront of discussions during the work-flow design for electronic charting in the intensive care units (ICUs) at the Cleveland Clinic. This task, recently engaged by the respiratory therapy department, was a component of a larger project to expand the use of electronic charting throughout the hospital. The conversion to an electronic medical record has cast a spotlight on some issues related to documentation of ventilator settings, particularly with 1706 IN PRESSURE-CONTROL MODES pressure-control modes, which have previously been “hiding in the shadows” with paper charting. Note that in this paper we use the term “pressure-control” in a generic sense, referring to any mode in which the pressure waveform is preset, in contrast to a mode in which the volume waveform is preset (ie, volume control). The basic problems we are experiencing stem from the evolution of ventilator technology and the lack of progress towards a standardized vocabulary and associated documentation procedures. The problems are in 2 main categories: documenting the inspiratory pressure of mandatory breaths and documenting the pressure support of spontaneous breaths. Mandatory Breaths Mandatory breaths are defined as those for which inspiration is machine-triggered (initiated) and/or machinecycled (terminated). Historically, pressure control of mandatory breaths was initially available only on infant ventilators. On these devices the convention is to indicate the peak inspiratory pressure (PIP) as gauge pressure (ie, relative to atmospheric pressure). When pressure control became available on adult ventilators, the convention switched to indicating PIP as relative to the set end-expiratory pressure (PEEP). Later, when “bi-level” modes such as BIPAP and APRV became features on adult ventilators, the convention for these modes switched back again to indicating PIP as gauge pressure in those modes. Indeed, both conventions are sometimes used on the same ventilator, depending on whether the pressure-control mode is “conventional” or “bi-level.” Bi-level modes are distinguished by the use of an “active exhalation valve” that allows unrestricted spontaneous breathing (either assisted or unassisted) at any time, including during a mandatory breath with an extended inspiratory time (so called “PEEP high” at “T high”). Table 1 gives a sample of the actual definitions found in the operator’s manuals of some common ventilators used in the United States. Figure 1 illustrates the conventions shown in Table 1. Aside from the inconsistency in the abbreviations and the definitions themselves, there is a much more important and fundamental problem: we believe that “inspiratory pressure” is universally understood to mean a change in airway pressure during a breath assisted by a ventilator. However, the baseline reference pressure may be either the atmospheric pressure (Patm) or the PEEP, depending on the ventilator. And some ventilators, such as the Covidien Puritan Bennett 840 and the Maquet Servo-i, use Patm or PEEP, depending on the mode. Spontaneous Breaths Spontaneous breaths are defined as those for which inspiration is both patient-triggered (initiated) and patient- RESPIRATORY CARE • DECEMBER 2010 VOL 55 NO 12 DOCUMENTATION ISSUES Table 1. FOR MECHANICAL VENTILATION IN PRESSURE-CONTROL MODES Definitions From Ventilator Manuals Ventilating Pressures Term Manufacturer Dräger Ventilator EvitaLX Phigh Pinsp Hamilton G5 Plow Pmax Pmean Pmin Ppeak Pplat Psupp ?Psupp Pcontrol P high Pinsp PIP P low Ppeak Pplateau Pmean Psupport Maquet Servo-i PC Paw Ppeak Phigh Pmean Pplat PS PS above Phigh PS above PEEP Covidien Manufacturer’s Definition Puritan Bennett 840 PEEPH PEEPL PMEAN PI PI END Set value of the upper pressure level in airway pressurerelease ventilation (APRV) Set value of the upper pressure level in the EvitaLX’s PCV? mode Set value of the lower pressure level in APRV Set value for pressure-limited ventilation Mean airway pressure Minimum airway pressure Peak pressure End-inspiratory airway pressure Set value of pressure support Setting for Psupp relative to PEEP Pressure control: a control setting in the G5’s PC-CMV and P-SIMV modes: pressure (additional to PEEP/ CPAP) applied during the inspiratory phase High positive airway pressure: a control setting Inspiratory pressure: the target pressure (additional to PEEP/CPAP) Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research applied during the inspiratory phase in the G5’s adaptive support ventilation (ASV) mode Positive inspiratory pressure from glossary Low positive airway pressure level: a control setting Peak airway pressure: a monitored parameter Plateau airway pressure: a monitored parameter Mean airway pressure: a monitored parameter Inspiratory pressure support: a control setting valid during SPONT (spontaneous) breaths. Psupport is pressure (additional to PEEP/CPAP) applied during the inspiratory phase Pressure control Airway pressure Max inspiratory pressure High pressure level Mean airway pressure Pressure during end-inspiratory pause Pressure support Inspiratory pressure support level for breaths triggered during the Thigh period in the Servo-i’s BiVent mode Inspiratory pressure support level for breaths triggered during the TPEEP period in the Servo-i’s BiVent mode High level of positive airway pressure in Puritan Bennett 840’s BiLevel mode Low level of positive airway pressure in Puritan Bennett 840’s BiLevel mode Mean circuit pressure: a calculation of the measured average patient circuit pressure over an entire respiratory cycle Inspiratory pressure: the operator-set inspiratory pressure at the patient Y-piece (above PEEP) during a pressure-control mandatory breath End inspiratory pressure: the pressure at the end of the inspiration phase of the current breath. If plateau is active, the displayed value reflects the level of endplateau pressure. Baseline Reference Pressure PEEP PEEP Patm Patm Patm Patm Patm Patm PEEP PEEP PEEP Patm PEEP Unknown Patm Patm Patm Patm PEEP PEEP Patm Patm Patm Patm Patm PEEP Phigh PEEP Patm Patm Patm PEEP Patm (continued) RESPIRATORY CARE • DECEMBER 2010 VOL 55 NO 12 1707 DOCUMENTATION ISSUES Table 1. FOR MECHANICAL VENTILATION IN PRESSURE-CONTROL MODES Definitions From Ventilator Manuals (continued) Ventilating Pressures Manufacturer Ventilator Term PPEAK PSUPP Pulmonetics LTV 950 MAP PIP Pressure Control Pressure Support CareFusion Avea Insp Pres Pressure Support CareFusion VIP Bird High Pressure Limit Dräger Babylog 8000 Pressure support Pinsp Peak Manufacturer’s Definition Maximum circuit pressure: the maximum pressure during the inspiratory phase of a breath Pressure support: a setting of the level of inspiratory assist pressure (above PEEP) at the patient Y-piece during a spontaneous breath Mean airway pressure Peak inspiratory pressure: the maximum circuit pressure during the inspiration and first 300 ms of the exhalation phase. PIP is measured at the patient Y-piece. The target pressure above 0 cm H2O for pressurecontrol breaths The target pressure above 0 cm H2O for pressuresupport patient breaths During a mandatory pressure breath the ventilator controls the inspiratory pressure in the circuit. For pressure and time cycled pressure limited breaths, the pressure achieved is a combination of the preset inspiratory pressure plus PEEP. The pressure level during inspiration is a preset pressure support ventilation level plus PEEP. A control parameter in the VIP Bird’s Time Cycle mode (ie, IMV/CPAP) that establishes the peak inspiratory pressure for mandatory breaths. This is an alarm parameter in the VIP Bird’s Volume Cycled modes (ie, Assist/Control and SIMV/CPAP). Sets the inspiratory pressure above PEEP/CPAP Inspiratory pressure: a control parameter that sets the maximum airway pressure The measured maximum value of airway pressure during a breath Baseline Reference Pressure Patm PEEP Patm Patm Patm Patm PEEP PEEP Patm PEEP Patm Patm cycled (terminated). The introduction of pressure support (PS) to assist spontaneous breaths added complexity. Historically, we have documented a single setting for PS, defined as an assisted breath that is patient-triggered, pressure targeted to a preset value, and patient-cycled. There has always been some ambiguity with this practice because the target inspiratory pressure (ie, “pressure support level”) is set relative to atmospheric pressure in some ventilators (eg, LTV 950 home-care/transport ventilator, see Table 1) but is set relative to PEEP in others (eg, most ICU ventilators, see Table 1)Assignment: Mechanical Ventilator Technological Advancement in Healthcare Research . Interestingly, when infant ventilators evolved to the point of offering pressure support, a dichotomy was introduced, in that the breath type determined the baseline pressure to which inspiratory pressure was referenced. Inspiratory pressure for spontaneous breaths was referenced to PEEP, as in adult ventilators, whereas inspiratory pressure for mandatory breaths continued to be referenced to Patm (see Bird VIP in Table 1). This ambiguity has simply been ignored, with the idea that operators with sufficient training will recognize the difference. Nevertheless, errors have occurred when operators have charted and set the same value on different ventilators. With the development of the “active exhalation valve,” unrestricted spontaneous breathing became possible during mandatory pressure-control breaths. This feature is particularly prominent in modes such as APRV11 and BIPAP.12,13 Some ventilator manufacturers now allow spontaneous breaths during mandatory breaths to be assisted with pressure support. Unfortunately, there is no standardization among manufacturers, and 2 conventions have emerged from 2 of the major vendors: 1. Covidien (Puritan Bennett 840 ventilator): PS is set as a single value and is always relative to PEEP (and is labeled PS above PEEP on the display). As a consequence, the level of assistance is always lower for spontaneous breaths occurring during the mandatory breaths (ie, during “PEEPH”), because the level of assistance (proportional to 1708 RESPIRATORY CARE • DECEMBER 2010 VOL 55 NO 12 DOCUMENTATION ISSUES FOR MECHANICAL VENTILATION IN PRESSURE-CONTROL MODES Fig. 1. Idealized airway pressure waveform, showing various conventions used for pressure parameters (see Table 1). Note that there are 2 ways to define the inspiratory pressure (blue) of a mandatory breath, and 4 ways to define the pressure support of a spontaneous breath (red). PEEP ? positive end-expiratory pressure. CPAP ? continuous positive airway pressure. P-low ? low pressure. ?P) at “PEEPH” is PS ? PEEPH, whereas the level of assistance at “PEEPL” is PS ? PEEPL. 2. Maquet (Servo-i ventilator): PS is set as 2 values, labeled “PS above P-high” and “PS above PEEP.” As a consequence, the level of assistance for spontaneous breaths occurring during the mandatory breaths may be lower than, the same as, or higher than the assistance for spontaneous breaths occurring between mandatory breaths, depending on the relative values of “PS above P-high” and “PS above PEEP.” Mathematical models have been described that allow generalizations based on hypothetical ventilation scenarios.14-16 These models indicate that during pressure-control ventilation, the delivered tidal volume is a function of the pressure change relative to the start of the breath (ie, ?P). Therefore, defining the operator-set inspiratory pressure as having a baseline reference of PEEP makes physiologic and mathematical sense. On the other hand, defining set inspiratory pressure as having a baseline reference of Patm has the appeal of being equivalent to measured peak airway pressure and thus indicating something about the potential risk of over-distention of the lungs. The problem is that when a patient is changed from one ventilator (or mode) using one convention to another ventilator (or mode) with the other convention, the risk of inadvertently setting the wrong inspiratory pressure increases and could lead to adverse events. For example, imagine a ventilated patient with respiratory system resistance of 10 cm H2O/L/s and compliance of 0.035 L/cm H2O. This patient is transported on a ventilator with set inspiratory pressure of 25 cm H2O (relative to Patm), PEEP of 10 cm H2O, and inspiratory time of 1.0 s. Under the assumption of no intrinsic PEEP, the measured peak airway pressured with this particular ventilator is 25 cm H2O, the ?P is 25 –10 ? 15 cm H2O, and the tidal volume would be 495 mL (note that this value is derived from a model of exponential volume increase in response to a step change in inspiratory pressure14). On arrival to the ICU, pressurecontrol ventilation is initiated with a ventilator in which inspiratory pressure is set relative to PEEP. If the same settings were used (inspiratory pressure 25 cm H2O and PEEP 10 cm H2O), the new peak airway pressure would be 25 ? 10 ? 35 cm H2O, ?P would be 25 cm H2O, and the tidal volume would be 825 mL! In this example the patient is put at risk of ventilatorinduced lung injury and cardiac compromise because of the inadvertent increase in ?P and mean airway pressure. If the transport had been in the opposite direction, the patient would have been at risk of hypoventilation due to a … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10