2009 NCSRC Newsletter, Issue 1

THREE MAGNETIC RESONANCE (MR) ENVIRONMENTS AND THE MR CONDITIONAL SERVO-I VENTILATO

Joe Hylton, RRT-NPS1, Kenny Winn, BS, RRT2 MedCenter Air Critical Care Transport1, Department Of Respiratory Care2
Introduction Carolinas Medical Center, Charlotte, NC
Magnetic resonance imaging (MRI) has become an essential tool for metabolic, anatomical and pathological imaging of the central nervous system that can not be provided by conventional imaging techniques. The MR Suite has a unique environment which demands differing medical equipment. The magnetic resonance image signals being studied are of a very low intensity; high frequency electromagnetic radiation and interference arising from electrical equipment or monitoring devices can interfere with the signals, potentially altering the desired image and/or affecting proper performance of medical equipment.1,2 Thus, special equipment must be utilized to minimize image distortion and safe, effective equipment operation. Ferromagnetic objects will interact with the magnet, possibly moving towards the magnet at a dangerous speed, possibly causing potential harm or death to the patient.1 These issues must be addressed to optimize patent safety and allow for quality imaging. A growing number of patients likely to benefit from MRI technology are critically ill, requiring mechanical ventilation.3 Furthermore, patients requiring advanced modes of ventilation, such as high levels of PEEP, Bi-Level or Airway Pressure release ventilation (APRV) can not be transitioned to a non-ICU ventilator due to their lung pathology and mechanical ventilation requirements. There is substantial risk in switching critically ill patients between different ventilators that may not support the same modes. Many critically ill patients require specialized ventilator settings and can deteriorate when ventilated with different equipment or in different modes. For patients in whom transport to and from the MRI scanner represents increased risk, using the same ventilator in the ICU and the MRI suite avoids possible errors in transferring complex ventilator settings. 2
Methods There is a need for a mechanical ventilator that can provide adequate control mechanisms to provide advanced ventilation in the MRI suite. The MR Conditional Servo-i gives prospect to the clinician for consistent ventilation.
A Pre-use check was performed on the MR Conditional Servo-i ventilator before initiating testing. Outside of each MRI suite, the ventilator settings were entered in the adult and infant modes: Pressure Control of 25 cmH2O, Respiratory Rate of 25 breaths/min, PEEP of 5 cmH2O, Inspiratory Time of 1 second, FiO2 of 0.4. Peak pressure, PEEP, RR, Inspired and Exhaled Tidal Volume and FiO2
Conclusion were recorded in each mode. Inside the MR suite, a calibrated gauss meter was utilized to identify the 200 gauss distance from each magnet. The ventilator was placed at the 200 gauss line; the wheels were then locked for safety. A scan was performed with a phantom dummy. During the phantom scan, the clinical specialists recorded the measured values in adult and infant modes. The scan was then read by a radiologist and the MR engineer to determine the quality of the image. Measurements made during phantom scans demonstrate that ventilation is not compromised when using the MR Conditional Servo-i. Artifact was not noted when the MR Conditional Servo-i is behind the 200 gauss line. Thus, the MR Conditional Servo- i ventilator provides consistent measurements without the compromise of patient safety or loss of image quality.
Critically ill patients receiving mechanical ventilation often require MR imaging. Anxiety among the medical staff, patient safety issues and delays in care exist when a non-ICU ventilator is required for the MR environment. With the MR Conditional Servo-i there are now several options for patients on advanced modes of ventilation who require transport to the MR suite. The MR Conditional Servo-i ventilator enables the medical staff to utilize a familiar ICU tool for transport. Patient safety is maintained and care is not delayed when there is a need to transport a critically ill patient to the MR suite.

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Video-assisted laryngoscopy may decreases esophageal intubation in an emergency medicine residency program

Joseph B. Shepheard RRT, Jhaymie L. Cappiello RRT, Michael A. Gentile RRT, Neil R. MacIntyre MD
Duke University Medical Center, Durham NC
BACKGROUND: Video laryngoscopy is shown to improve laryngeal view over direct laryngoscopy, add benefit to teaching intubation, and may decrease procedure learning curve.(1,2,3) These advantages led our emergency medicine residency program to obtain the Storz DCI® Video Intubation System. Respiratory Care Practitioners (RCP’s) obtained IRB approval to develop and review a database to evaluate the effectiveness of this device.
METHODS: Attending physicians, residents and RCP’s were trained on the device. Residents would use direct visualization technique when using the videoscope (VS) and the monitor would facilitate the trainers’ evaluation and instruction. Residents were allowed 2-3 intubation attempts before more experienced personnel would take over and perform the intubation (an unsuccessful RAP). The database recorded resident airway procedures (RAP) with and without VS, number of laryngoscopies per RAP, and tracheal/esophageal intubations over a six month period. Population included adult medical and trauma patients. Equipment use was determined by availability.
RESULTS:

CONCLUSION: Residents’ successful tracheal intubation and laryngoscopy insertion rate were clinically similar. The VS esophageal intubations appear to be the result of operator error. One VS esophageal intubation occurred due to operator not heeding the advice of monitor observers and the other with observers not actively viewing the monitor. Based on this data, the VS showed no effect on resident intubation success rate but did appear to lower the incidence of esophageal intubation. This could decrease adverse events for patients’ during resident intubation training.
1. Kaplan, Comparison of direct and video-assisted views of the larynx during routine intubation. Journal of Clinical Anesthesia (18) 2006,357-362
2. Low, The use of the BERCI DCI Video Laryngoscope for teaching novices’ direct laryngoscopy and tracheal intubation. Anesthesia (63) 2008, 195-201
3. Kaplan, A new video laryngoscope – an aid to intubation and teaching. Journal of Clinical Anesthesia (14) 2002, 620-626

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Critical Care Practitioners Attitudes Toward Withdrawal of Life Support in a Tertiary Care Center

N. Tate Bennett RRT, Anthony J. Asciutto RRT, Nicole Garrison RRT,
Michael A. Gentile RRT FAARC, Jan J. Thalman RRT FAARC,
C. William Hargett MD, Neil MacIntyre MD FAARC
Duke University Medical Center
Durham, NC
Background: Withdrawal of life support from patients who require intubation and mechanical ventilation is an issue faced by Critical Care Practitioners of all disciplines. There are different methods of carrying out the process of life support withdrawal and caregivers have variable views of how it should be done. The main issues involve comfort of the patient, family, and health care personnel involved. The purpose of this study was to evaluate Critical Care Practitioners views on the life support withdrawal process.
Method: A five (5) question survey was distributed to 104 Critical Care Practitioners in our institution. These questions focused on the management of the endotracheal tube, the need for physician attendance and the sedation strategy. Data were also collected for respondents profession and years of experience.
Results: Responses were received from 31 respiratory therapists, 52 nurses, and 22 physicians (total = 104). Ninety five percent responded that endotracheal tubes should be removed as part of the process of withdrawal of life support; 25% felt supplemental O2 should be given (75% felt room air breathing was more appropriate); 67% felt family should be asked to step outside the room during the process; 23% felt that the physician should be in the room; and 68% favored changing the pre-extubation analgesia regimen to include morphine (32% felt the pre-extubation regimen should be maintained).
Conclusion: Opinions vary among Critical Care Practitioners as to the consistent method of withdrawal of mechanical ventilatory support. However, maximizing patient and family comfort during the process seemed to drive most responses.

IMPACT OF A UNIFORM VENTILATOR PROTOCOL UTILIZING A MODIFIED OPEN LUNG CONCEPT AND OTHER LUNG PROTECTIVE STRATEGIES ON LUNG RECOVERY

Sharon L McRee RRT, RCP, C. Michael Buechler MD, FACS, FCCM, Abenámar Arrillaga, MD, FACS, FCCP

Background: At Mission Health System the number of lungs physiologically suitable for organ donation has been far below that of other perfused organs. This mirrors the rest of the nation. In 2007 an aggressive approach to ventilating potential lung donors was trialed in Neuro-Trauma ICU. It was hypothesized that ventilating donors with a modified open lung technique utilized in the Trauma Ventilator Management Protocol and consistent critical care management may result in an increased number of lungs available for transplantation. In 2007 Trauma Surgery assumed critical care management of all organ donors. After declaration of brain death all potential lung donors were placed on a pressure mode, Bi-Level or PCV, PEEP 10-18cm/H2O, I:E 1:1, and Vt 6-8 cc/kg IBW.
METHOD: A retrospective, observational, cohort study of all consented organ donors in 2006 and 2007 was conducted. Data was collected from the time brain death was declared to the last recorded parameter. The MAP, Mode, I:E Ratio and PEEP were collected and means were calculated. A P/F ratio was calculated from data collected from ABGs. All statistical analysis was completed with Minitab 14 statistical software. Analysis of Variance (ANOVA), along with main effects and interaction plots were used to identify significant factors. Baseline data was compared to post process change data to identify a statistically significant change. A comparison of proportions was used in that analysis. All data analysis was completed assuming a 95% Confidence Interval (CI). A p-value < 0.05 was considered statistically significant in proportional comparisons.
RESULT: In 2007 the mean I:E (p-value of 0.000), MAP (p-value 0.002), PEEP (p-value of 0.001) and P/F ratio (p-value 0.009) all increased. This resulted in a significant increase in lungs placed in 2007 (p-value 0.000). In 2006 from 13 potential lung donors 2 were taken to OR for recovery, a 15% success rate. In 2007 from 16 potential lung donors 12 were taken to OR for recovery, a 75% success rate. An incidental finding was in 2006 the total number of organ per donor was 2.81 and that increased to 3.78 in 2007.
CONCLUSION: By adopting an open lung technique of ventilating potential lung donors using lung protective strategies that keep the alveoli open and prevents volutrauma along with consistent critical care management, it appears possible to significantly impact the number of physiologically acceptable lungs available for transplantation.

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Tim King & Lawson Millner of the NC PACT went to represent the NC RCP’s in Washington, DC to advocate changes in Medicare Part B

Tim King & Lawson Millner of the NC PACT went to represent the NC RCP’s in Washington, DC to advocate changes in Medicare Part B.  This bill would permit qualified respiratory therapists to provide certain services under the general supervision of a physician, but without the doctor present.  We had a great response from the represenatives that we met.  All seemed to be aware of the changes that we discussed and were receptive to the information that we provided.
Taken from www.AARC.org.  On March 9 and 10, 2009,105 members of the AARC’s Political Advocacy Contact Team (PACT) from 46 states and the District of Columbia traveled to Capitol Hill to educate lawmakers on the Medicare Respiratory Therapy Initiative and other legislation important to your patients and your career.  Three patient advocates accompanied the group.
Over 10,000 letters from respiratory therapists and friends streamed in to Washington lawmakers in the weeks and days before the visit, but we still need you to send your letter by going here, http://www.aarc.org/headlines/09/01/30/rtbill.cfm

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