Ventilation patient management in an aeromedical setting
Sean Bryan, Director of Medical Operations - Western Hemisphere at REVA, Inc talks about equipment, training, and preparedness when it comes to transporting patients with mechanical ventilation needs
It certainly has been a long two years, but we would like to think we are through the roughest parts and there is light at the end of the tunnel. Over this time, we saw a significant decrease in flight volume for international patient transports. This was mainly a result of the obvious lock downs, difficulty crossing and entering certain borders, as well as a decrease in travel and leisure for the general population.
Over the past six months though, we have begun seeing an increase in leisure travel, and with an increase in travel across the globe comes an increased need for medevac and patient transports. For months we were moving many more stable patients than we were used to, as well as Covid-positive patients that really were not that symptomatic. A lot of these mildly symptomatic and asymptomatic Covid transports needed to be air ambulance because of commercial travel restrictions. Obviously when someone was positive for Covid they were placed into isolation, not allowed to fly commercial, and really the quickest way out was via an air ambulance. These transports tended to be a little less stressful than some of the typical critical care transports being completed on a routine basis prior to the pandemic.
As nice as it is to have a decrease in patient acuity levels, it also takes our critical care transport professionals away from what they typically do on a regular basis. Like with everything in life you do not want to become complacent. As a medical management team, we vowed that we would not allow that to happen to anyone on our team. We made a conscious effort to ramp up our critical care training because we wanted to keep our staff engaged and prepared for when the acuity level would return to pre-pandemic times.
Keeping current with best medical practice
One of the biggest focuses over these past six months has been mechanical ventilation and advanced airway education. This is a topic that I believe as an industry we can never educate enough on. This is also an area we can never practice enough on. As critical care transport professionals, it’s crucial that all crew members have a thorough understanding of advanced airway management. Although we are seeing a decrease in the overall amount of Covid positive patients we are transporting, we are still seeing and moving some very sick patients that had been previously Covid positive.
Many times, these patients that have Covid and acute respiratory failure require higher oxygen that needs to be managed appropriately. Some of the options available are (NIV) noninvasive ventilation, (MV) mechanical ventilation after being intubated, (HFNC) high-flow nasal canula, and in extreme cases extracorporeal (ECMO) membrane oxygenation. It is also not uncommon for some of these Covid patients to deteriorate very quickly and need rapid respiratory interventions. Now, mix this patient population moving forward in with our other respiratory failure and common pulmonary complications population, and that justifies the need for further training and education on airway management and mechanical ventilation.
Those in the transport world know that not all ventilators have that ability to be utilised safely with the neonate population
Before we dive into the importance of the training aspect of mechanical ventilation and airway management training, its equally important that your flight program has selected the correct transport ventilator. To make sure the appropriate transport ventilator is chosen, it is crucial that those who are making that decision choose a ventilator that will accommodate the demographics that will be transported it is crucial that those who are making that decision choose a ventilator that will accommodate the demographics that will be transported
For instance, our flight program transports all populations, including neonates with our newborn intensive care unit (NICU) team. Those in the transport world know that not all ventilators have that ability to be utilised safely with the neonate population, so it’s important to have a ventilator that will accommodate that population safely. As a company, we chose a ventilator that safely accommodates the needs for all demographics and is essentially an ICU ventilator in a more compact design. Next, make sure that whatever ventilator you are choosing meets airworthiness criteria as well as meeting transport standards.
Which ventilator is right for you?
These are some of the big questions I would say are important when it comes to deciding on what ventilator should be purchased for your program:
- Is the ventilator durable, and meant to be utilized in high stress environments?
- Are you able to dim and make contrast adjustments? How is the alarming on the ventilator, is it both audible and visual?
- How is the battery life? What if you are transporting in a foreign place and you are unable to plug into the electrical outlets in the back of the ambulance?
- Does the ventilator have all the ventilation modes you need?
- Are you able to easily mount and safely stow this equipment?
Education, training, and hands-on experience are the keys to success for mechanical ventilation and advanced airway management. To become proficient with ventilators and airway management it’s important to have a thorough initial training, followed by continuous ongoing training.
Education, training, and hands-on experience are the keys to success for mechanical ventilation and advance airway management
Just because a crew member is signed off to run and manage a ventilator does not mean their training is done, and quite frankly it should be alarming if that crew member would feel they need no further training. An extensive training program for mechanical ventilation is much more than just reviewing the different buttons, knobs, and how to transfer the patient over to your transport ventilator. Anyone running a ventilator needs to have a thorough understanding of the pathophysiology of the pulmonary system.
The critical care transport professional needs to understand what exactly that means when you are adjusting some of the knobs and settings, and how that is affecting the patient’s pulmonary system. It is for this exact reason why a ventilator class absolutely needs pulmonary pathophysiology involved in it. Pulmonary pathophysiology, ABG review and interpretation, and complex review of all ventilator modes and management, should be reviewed not just in ground school but also all recurrent, and ongoing mechanical ventilation training.
The acuity level is already returning to pre-pandemic times, and we need to make sure our teams are prepared for any situation that may arise
In addition to extensive training on pulmonary pathophysiology and the ventilator itself, it’s also critical to understand alarms. It’s important to get away from just simply silencing an alarm without investigating the cause.
The ventilator screen should be always within eyesight, with additional continuous monitoring such as EtCO2 and Oxygen saturations. Having the ability to visualize the ventilator waveforms can assist the critical care transport professional in diagnosing what is going on with the ventilated patient.
An equally important training piece for mechanical ventilation is ensuring that that medicals crews understand ventilator-induced lung injury (VILI) and the importance of avoiding it. VILI is typically a direct result of mechanical ventilation and it is critical to understand it because we transport a large population of patients that are prone to this. Some of the populations prone to VILI are those patients with chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), and asthma. An understanding of barotrauma, volutrauma, and atelectrauma and how to prevent them are crucial to all professionals operating a ventilator.
In addition to mechanical ventilation, it’s important that we are not just training and practicing intubations in mandated quarterly training. This is a skill that needs to be practiced frequently and in different settings. Along with practicing airway placement, it is equally important that we are continuously reviewing best practice and techniques and bringing this to our medical crews.
Making sure we have the best tools in place to use, policies and procedures in place, and we are continuously training with the tools we use in the field, is pivotal to success. Policies and procedures when it comes to advanced airway management need to be reviewed on a routine basis and evaluated for best practice.
Lastly, as important as training and education is, every program needs to have a strong QA/QI process in place. Any advanced airway management case should always have a thorough QA and review. It is important to provide feedback to these crews in a timely manner whether it be positive or need for reassessment. QA and QI will allow us to quickly identify areas that need some extra attention of improvement. QA and training go hand in hand with anything, but when it comes to managing a patient’s airway in a critical situation, we all need to act fast and make sure that our crews are providing the highest level of care, and safest level of care.
The acuity level is already returning to pre-pandemic times, and we need to make sure our teams are prepared for any situation that may arise.
With many people travelling again, it is critical that we all as an industry to continue full steam ahead with our training and education programs and identify where we can continue to grow. The acuity level is already returning to pre-pandemic times, and we need to make sure our teams are prepared for any situation that may rise.