Dr. Fred Helmholz Education Lecture Series

1. Dr. Fred Helmholz Education Lecture Series Presented by the Commission on Accreditation for Respiratory Care

2. Teaching Students How to Stay Up-to-date on Mechanical Ventilation Issues Susan P Pilbeam, MS, RRT, FAARC St. Augustine, FL

3. Disclaimer • Within the past 12 months I have worked as a consultant for Maquet, Inc.

4. Objectives • Describe faculty and student perspective on what is important to teach/learn about mechanical ventilation. • Identify essential concepts that students need to understand in relation to the application of mechanical ventilation. • Review relevant behaviors related to medical care. • Discuss how educators and students might maintain competency.

5. Remembering H. Fred Helmholz, Jr., M.D. • www.alumniblog.mayo.edu/people/alumni-profiles • Dr. Helmholz was born in Indiana in December, 1911. • Rochester, age 10 • His father, Henry F. Helmholz, M.D., was asked by Dr. William Mayo to develop pediatrics at Mayo Clinic. • At Mayo, Dr. Helmholz’s interest in human physiology began, and he pursued his medical education.

6. Medicine • After medical school, Fred returned to Rochester • Fellow in Physiology and Pathology for the Mayo Foundation, in the Physiology Institute. • Dr. Helmholz studied decompression chambers

7. How Dedicated Was He? • Dr. Helmholz put himself into an oxygen chamber with the equivalent of 40,000 feet in altitude. • “I promptly passed out and there was much venting and letting air into the chamber to resuscitate me. • “I learned that, at 40,000 feet, unless I purposely hyperventilate or over breathe, I can’t stay conscious even breathing pure oxygen. • “So I learned something about myself that I could apply to aviators.”

8. Impact of WW II • Then Second World War began • WW II worked at Consolidated Aircraft Corporation in San Diego. and developed a way for B24 bomber pilots to safely fly at 35,000 feet

9. Working with Respiratory Therapists • Dr. Helmholz’s most lasting impact -- his work with respiratory therapists, locally and nationally. • “I had some friends …who were kind of interested in getting an organization, the American Association of Inhalation Therapy, the AAIT… • “so I worked with them and that’s how my interest in respiratory care [grew].”

10. Dr. Fred Helmholz Dr. Helmholz early chairman and participant in the Joint Review Commission for Inhalation Therapy (JRCRTE) Now the Commission on Accreditation for Respiratory Care Appointed to the NBRC and served as one of its presidents. NBRC

11. NBRC and the Helmholz-Davenport Nomogram

12. Thank You, Fred…. • He retired in 1978, but continued to remain active with the CoARC and the NBRC and also the Sputum Bowl. • He died in 2012. • He was 100 years old.

13. SURVEY OF FACULTY AND STUDENTS

14. FACULTY MEMBER • Responses from schools and hospitals in Maine, Florida, Louisiana, Texas, Georgia • “As a faculty member who teachings mechanical ventilation: • “What do you think is most important in teaching or learning mechanical ventilation? • “And second, what techniques are the best way to teach mechanical ventilation?

15. FROM FACULTY MEMBERS • Consensus Items: • Modes of Ventilation (4 of 8) • Graphics (2 of 8) • Lung protective strategies • Troubleshooting • Weaning process and parameters • Learning basic physiology of the lungs such as compliance and resistance and effects of PPV on organ systems.  • Initial settings for normal and COPD • How to control sensitivity and adjust to patient

16. FROM A NATIONALLY-KNOWN RT CLINICIAN • Learning how to assess the patients needs in terms of the goals of mechanical ventilation, - safety, comfort, and liberation. • Teaching how to identify the technological capabilities available to meet those needs • Teaching how to match the available technology to the needs.

17. FROM AN R.N. • Be sure graduate know how to recognize respiratory distress. • This is key to their function as RTs • Identify the problem before the patient codes.

18. Besides The Content…. • Patient Safety • Team work • Compassion • Effective communication • Posting signs

19. Mechanical Ventilation Competencies of the Respiratory Therapist in 2015 and Beyond • Robert M Kacmarek, Respir. Care, 2013; 58(6) pg 1087-1092 • The RT has to be knowledgeable of the limits of ventilatory support and competent in identifying, via waveform analysis, patient-ventilator asynchrony, since asynchrony has been associated with patient outcome.

20. Ventilator Waveform IdentificationGeorgopoulos (2006) • “Flow, volume, and airway pressure waveforms are valuable real-time tools in identifying various aspects of patient-ventilator interaction.” • However, “If you aren’t looking for something, you surely will not to find it.”

21. Experts Versus Non-Experts Columbo, et al, CCM 2011, 39:11

22. Experts Versus Non-Experts Columbo, et al, CCM 2011, 39:11

23. Experts Versus Non-Experts Columbo, et al, CCM 2011, 39:11

24. Experts Versus Non-Experts Columbo, et al, CCM 2011, 39:11

25. Experts Versus Non-Experts Columbo, et al, CCM 2011, 39:11

26. Patient-Ventilator Asynchrony

27. Electrical Activity of the Diaphragm

28. Edi Catheter Position

29. Meanwhile More From The Faculty Survey Results As a faculty member who teachings mechanical ventilation, the second question: What techniques are the best way to teach MV?

30. The Best Teaching Methods • Lectures with case studies (3 responses) • Simulations (mannequins) (2 responses) • Regular lab with vents and case studies (3 responses) • Labs with repetition of graphics (1 response) • Inservice from ventilator representative (1response) • Clinical rotations (1 response)

31. Also Mentioned By Faculty • “I would have to say, however, that I think the most effective strategy occurs when they have to breath on the ventilator connected to a mouth piece with an HME so they experience the ventilator settings.” • Two faculty mentioned this.

32. STUDENT QUESTIONS • "As you were taking your mechanical ventilation classes, labs and clinicals, • “…what did you find to be the top 3 most important things that helped you understand the application of mechanical ventilation in the clinical setting?" • (please list in order of importance).

33. STUDENT RESPONSES • Total of 13 responses • Very limited agreement on what they perceive as important. • INDIVIDUAL RESPONSES 1. Understanding the concepts of each ventilator settings 2. Comprehension and explanation of wave forms 3. Troubleshooting and ventilator changes Lecture, Lab, Inservice from vent reps Boxes, Tables and Cases

34. Continuing Student Responses (1) Paying attention and TAKING NOTES during lecture. Including drawing my own scalars and graphs. (2) Patients being mechanically ventilated. It is important to see the application of different modes and how they correlate with different pathologies as well as seeing the results in real time. (3) Handling several different ventilators in lab and learning each of their basic modes and functions.

35. Additional Student Responses (1) Visualizing the ventilator graphics in class- seeing examples of the scalars on the different modes was by far and away the best way for me to truly grasp the principles of the modes and how they apply to disease processes.  (2) Use of ventilators on actual patients in the hospitals. (3) The textbook and supplemental reading- reading, on my own, and having time to interpret and compare the modes

36. Some Insightful Student Ideas (1) The way the information linked what was happening physiologically with the patient and making appropriate vent changes to compensate. (2) The hands on exposure (labs) with vents, mannequins and other equipment was invaluable. Also being able to physically do certain procedures on real patients in clinicals was a great confidence builder.  (3) Trending of pulse oximetry, labs, ABGs, x-rays, ascultation etc were also helpful in understanding and following the various stages of a patient's condition and vent manipulation.

37. "What Single Thing Was of Least Value to You in Learning Mechanical Ventilation? • The concepts of transducers and electrical physics as applied to how a mechanical ventilator works. • Modes that are not presently used in a clinical setting. (3 responses) • The time spent on learning all the outdated ventilators which we no longer use, or even see in the hospital and more time devoted to current applications. (2 responses) • Working in groups with the ventilators. • The lab activities are confusing and hard to follow. • Every resource provided to me during the course has been valuable. • Oscillators

38. "How ready are you to care for a patient being mechanically ventilation in the ICU?" • Most responded that they felt they were prepared • I feel comfortable being in the ICU with another therapist but I am not comfortable being alone because I tend to panic in certain situations when the patient appears to be under distress (like when waking up from sedation and starting to fight the vent).

39. Essential Concepts in Mechanical Ventilation

40. Mechanical Ventilation Competencies of the Respiratory Therapist in 2015 and Beyond, by Robert M Kacmarek, Respir. Care, 2013; 58(6) pg 1087-1092

41. COMPETENCIES FOR RTs • AARC “2015 and Beyond” task force. • Individual RTs must be highly competent in a number of areas. • They must be experts in mechanical ventilation

42. Essential Areas Where Competencies Are Required (2015 and Beyond) • All technical aspects of the mechanical ventilator • Indications for and pathophysiology requiring mechanical ventilation • Independent application of mechanical ventilation • Pharmacology of critical care • Adjuncts to mechanical ventilation (aerosolized pulmonary vasodilators, prone positioning, non-conventional forms of ventilatory support

43. Competency Areas in Mechanical Ventilation • Modes of mechanical ventilation • Disease specific management approaches • Effects of application on the cardiopulmonary system • Waveform analysis • Identification and correction of asynchrony • Provision of lung-protective ventilation • The independent management of ventilatory support by protocols, guidelines, or standard order sets.

44. The RT of 2015 and Beyond • A Technical expert in every aspect of mechanical ventilation. • Capable of comparing the capabilities of one ventilator to another. • Discuss mechanism of action of all modes and adjuncts that exist on the mechanical ventilator • Monitoring and data trending • “They should be the individual whom all other professions seek out when questions in this area arise.” (Kacmarek, 2013 RC)

45. Are They Paying Attention? • Limited brain attention span • The human brain can only focus on one thing at a time

46. Maintaining Competencies and Keeping with New Technoligies Faculty and Graduates

47. How to Maintain CompetencyFaculty and Graduates • Educational conferences • Literature • Clinical skills: how up-to-date do you need to be? • Ventilator manufacturers and their representatives • How do graduates and practicing therapists manage?

48. RT Graduates –Affective Skills Needed • Recognition that a Respiratory Therapist is a professional. • Knowing when to get help • Learning to work as a team • Keeping everybody safe • Critically evaluating medical literature • Sharing what they learn • Being compassionate • Communicating effectively • Staying motivated

49. The Great Cholesterol Myth:Why Lowering Your Cholesterol Won’t Prevent Heart Disease By Dr. Stephen Sinatra, M.D. Cardiologist Dr. Jonny Bowden, Ph.D. Nutritionist

50. Cholesterol and Statins • True or false – lowering cholesterol reduces the incidence of heart attack. • True or false – people with cholesterol values more than 260 mg/dL are more likely to die. • True or false – statins reduce cholesterol levels.