Category: E-Learning

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Which ventilator should I buy ?

We get that important question frequently, but If you want me to tell you a specific brand and model, sorry I mislead you.

When it comes to a decision to buy a ventilator or multiple ventilators, it is a really tough decision with so many brands, models with different capabilities, modes and of course prices.

But one thing for sure, they are not all the same.

I encourage you to read this article: “Decision analysis for large capital purchases: how to buy a ventilator”

I welcome your feedback and comments on any other important factors that I might have skipped.

So what factors are involved ?

Price/Budget

Let’s start with the easy/difficult one. Price and budget are very important, but as my mother used to tell me “You get what you paid for”

Of course price/budget could restraint you but trust me it should not be the only decisive point.

Cost Efficiency

Initial Cost: Balance between features, brand reputation, and cost.

Operating Costs: Include consumables (filters, tubing), maintenance, software updates, and licensing fees.

Longevity: Consider the lifespan of the device and the potential need for future upgrades.

Capabilities

I always say: a fancy expensive car and a working 2nd hand old car will take you from one point to the other, but others will tell me it wouldn’t be the same journey.

Depending on your needs, you should consider a ventilator with neonatal, pediatric, adult capabilities (3 in 1). Having high flow oxygen therapy, non-invasive capabilities are a great plus (another 3 in 1)

Integrated humidification and options for delivering aerosolized medication is beneficial too.

Technological Features

Finally the exciting stuff

Modes: When it comes to modes, most of ventilators have the base set point modes like volume-control, pressure-control, pressure support, SIMV, APRV, etc. Few others have their own automated or smart modes. Evaluate your needs and consider their benefits. Just please don’t get confused by names of different modes names that sound fancy but they are basic modes that might be available in all other ventilators.

Monitoring: don’t disregard monitoring, in my opinion it is the most important feature of a ventilator. Now most of ventilators have airway pressure, flow, volume – time and loops to monitor. Advanced monitoring like esophageal pressure, transpulmonary pressure vs time and volume curves, volumetric capnometry, and maybe one day Electrical Impedance Tomography (EIT) integrated in the ventilator.

Accuracy of delivered flow, volume and pressures are very important especially in neonates or pediatrics. FDA and ISO have standards of usually +/- 5 – 10% deviation which could be significant in those patients’ population.

Connectivity: Ability to interface with central monitoring systems and other hospital technology for remote monitoring and data collection.

Durability and Reliability

Build Quality: The robustness and durability for long-term use in different environments (ICU, transport, MRI).

Maintenance Needs: Evaluate how frequently maintenance is required and the ease of servicing.

Battery Life and Backup: adequate battery life for power outages or patient transport.

Ease of Use and Usability

User Interface: A clear and non confusing intuitive touch-screen interface for quick adjustments and monitoring

Workflow Integration: Easy integration into existing workflows, including charting and electronic health record (EHR) systems.

Mobility and Portability: If it needs to be moved frequently, consider its weight, mobility (e.g., battery life for transport), and size.

Training and Support: Availability of comprehensive training for staff and 24/7 support services from the manufacturer.

Brand Reputation and Reviews

Manufacturer Reputation: Consider the track record and reputation of the manufacturer for quality, reliability, and service.

User Reviews: Feedback from healthcare facilities and clinicians using the same or similar models can provide valuable insights.

At the end, good luck and remember so far for the most part, clinicians control the machine not the machine control the clinician

At least for the time being

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Which one are you ?

We all seen it, some clinicians are very enthusiastic about mechanical ventilation spending time to watch and analyze what is going on, while others who come do their routine round, check some nobs and go chart. Why is that ? and does it make a difference?

This is all speculative and not studied to my knowledge

A clinician who works with ventilators and genuinely loves the field might display several differences compared to those who don’t have the same passion for it:

Deep Engagement and Curiosity

Passionate Clinician: They are likely to be more deeply engaged in their work, continually seeking to understand the nuances of mechanical ventilation. They might stay updated on the latest advancements, research, and best practices in the field. This curiosity drives them to explore new technologies and methodologies with enthusiasm.

Less Passionate Clinician: They may still be competent but might approach the work as a routine task rather than an area of deep interest. They might not actively seek out new knowledge or innovations unless required.

Problem-Solving and Innovation

Passionate Clinician: They are more likely to take initiative in solving complex cases, perhaps coming up with innovative solutions or custom settings for patients with unique needs. Their love for the field might push them to think creatively and go the extra mile.

Less Passionate Clinician: While they may still solve problems effectively, they might rely more on established protocols and may be less inclined to explore unconventional approaches.

Patience and Persistence

Passionate Clinician: They might exhibit greater patience and persistence when dealing with challenging cases or troubleshooting ventilator issues. Their love for the work sustains them through difficult times, making them more resilient in the face of setbacks.

Less Passionate Clinician: They might prefer to stick to what they know works, potentially becoming frustrated more quickly if a situation doesn’t resolve easily.

Education and Mentorship

Passionate Clinician: They may be more inclined to educate others, sharing their enthusiasm and knowledge with colleagues, students, or trainees. They might take on a mentorship role, helping to cultivate the next generation of ventilator specialists.

Less Passionate Clinician: They might still teach but might not do so with the same level of enthusiasm or depth, possibly focusing more on the basics rather than inspiring others with the broader possibilities within the field.

Emotional Connection

Passionate Clinician: Their love for ventilators might translate into a strong emotional connection with their work, leading to a greater sense of fulfillment and satisfaction. This could also make them more attuned to the emotional aspects of patient care, as they see their work as a vital, life-sustaining effort.

Less Passionate Clinician: They might approach the work more clinically and objectively, focusing on the technical aspects without as much emotional investment. This can still be effective but might lack the same depth of personal satisfaction.

Overall, the key difference lies in the level of enthusiasm and commitment to the specific field of ventilators. A clinician who loves working with ventilators is likely to be more proactive, innovative, and emotionally invested in their work, which can positively impact both patient outcomes and their personal job satisfaction.

So, lets get the enthusiasm and energy again, but how ?

There is no pill for that unfortunately

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The High vs. Low PEEP Debate in Mechanical Ventilation: Are We Just Blowing Hot Air?

In the world of mechanical ventilation, few topics spark as much debate—and as many eye rolls—as the discussion around PEEP settings. Yes, that’s right, we’re talking about Positive End-Expiratory Pressure, the setting that keeps our patients’ lungs open, their oxygen levels up, and our Journal and conferences locked in never-ending debates. But while some clinicians treat this debate like it’s a life-and-death matter (because, well, it kind of is), let’s take a moment to breathe deeply and look at the High vs. Low PEEP controversy with a bit of humor. After all, who says we can’t laugh at ourselves since we really don’t know

The High PEEP Advocates: More is More, Right?

If you’ve ever met a High PEEP enthusiast, you know they’re a passionate bunch. For them, cranking up the PEEP is akin to turning up the volume on your favorite song—louder is always better. They argue that higher PEEP levels keep the alveoli open, improve oxygenation, and prevent the dreaded atelectasis from rearing its ugly head. And, in many cases, they’re right. For patients with severe ARDS, a higher PEEP can indeed make the difference between life and death.

But let’s be honest—High PEEP proponents can sometimes take it a bit too far. It’s as if they believe that more pressure will magically solve every problem, much like the guy at the gym who thinks adding more weight to the bar will instantly turn him into the Hulk. But here’s the thing: while High PEEP can be a powerful tool, it’s not a one-size-fits-all solution. There are risks, like barotrauma and hypotension, that can make this approach a double-edged sword. So, while we applaud their enthusiasm, maybe it’s time to dial it back just a notch. Not every patient needs to feel like they’re in a wind tunnel.

The Low PEEP Loyalists: Less is More (And Also Safer)

On the other side of the battlefield, we have the Low PEEP loyalists—those who believe that when it comes to PEEP, less is definitely more. For them, the idea of pumping high pressures into delicate lung tissue is as appealing as putting pineapple on pizza (a practice that sparks its own set of heated debates: The Hawaiians ruined the Pizza according to Anger from Inside Out)).

Low PEEP advocates argue that keeping PEEP low reduces the risk of barotrauma, minimizes the potential for hemodynamic instability, and generally makes life easier for the lungs. And they’ve got sorta a little point.

Low PEEP settings are often preferred for patients with conditions like COPD or when there’s a concern about blood pressure dropping faster than a Wi-Fi signal during a Zoom meeting. The Low PEEP approach is all about caution, careful monitoring, and avoiding the pitfalls of too much pressure. It’s the respiratory equivalent of the “minimalist” movement—why add more when less will do just fine?

The Gray Area: Why the Debate is Far From Over

Of course, as with most things in life, the truth lies somewhere in the middle. The High vs. Low PEEP debate isn’t black and white—it’s more like fifty shades of gray, each with its own clinical nuances. Patient variability, underlying conditions, and real-time monitoring mean that what works for one patient might not work for another. It’s like trying to find the perfect temperature for your shower—everyone’s got their own sweet spot.

But wait, how about the science, the prospective studies, the meta analysis, the Biblical societies guidelines, the PEEP-FiO2 tables. Those solved the problem and ended the debate right ? I’ll leave you to laugh at that for a little bit…..

The reality is that the High vs. Low PEEP debate is as much about philosophy as it is about physiology. Some clinicians are risk-takers, willing to push boundaries for the sake of better oxygenation. Others prefer a more conservative approach, focusing on steady, reliable outcomes. And both sides have valid points. So, while we may never fully resolve the debate, it’s important to keep the conversation going. Because in the end, what really matters is doing what’s best for the patient in front of us—even if it means admitting that maybe, just maybe, we’re all just blowing a little hot air.

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Indociated (Induced-Associated)

Don’t bother for a definition, it’s a made up hybrid word, may be a neologisms in the making

The mechanical ventilation literature is jammed with those 2 acronyms VALI (Ventilator Associated Lung Injury) & VILI (Ventilator Induced Lung Injury)

Is there a difference between them ? Are they synonyms ?

If they are the same then why use different terms for the same meaning ? and if they are different, how to differentiate between them ?

is it “You Say Tomato, I say Tomato”

To add to the confusion, some authorities decided to create the term VAE (Ventilator Associated Events), a garbage term that indicates that the condition is worse denoted by the increase in FiO2 or PEEP just to penalize hospitals for it. What they don’t know is sometimes you need to increase PEEP even if FiO2 is 30-40% just to prevent lung injury (whole different lond discussion). Anyway lets go back to VILI-VALI

If you look at the definitions:

VALI: implies lung injury that can happen while the patient is on mechanical ventilation, it could be directly caused by the ventilator (actually our settings, let’s be honest) or just a progression of the disease process that lead the patient to be on the ventilator in the first place.

VILI: is a subset of VALI which implies and incriminates the ventilator (again our settings for the most part) to the progressive worsening of the lung mechanics.

Can we differentiate between both conditions clinically:

maybe but mostly not, the easy one is barotrauma like pneumothorax, pneumomediastinum, but how about all the other terms. volutrauma, atelectrauma, ergotrauma, rheotrauma, biotrauma, ergotrauma ? maybe CT scans, EIT, US can be suggestive but not diagnostic

So far there has been no clinical golden marker or bio-marker that can differentiate or incriminate the ventilator (there are many biomarkers used in research labs and the literature) in the worsening of the patient condition or for gosh sake even VAP (Ventilator Associated Pneumonia) remains a pathological diagnosis as a gold standard despite all the studies, definitions, labs, cultures, etc.

So, lets not fool ourselves and pretend to know what we are talking about when we use one term over the other, or argue which one is correct and which one is incorrect and maybe use the made up term “Indociated” till we really know.

Hopefully, one day we will know

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AI in Mechanical Ventilation: Friend or Foe ?

Clinicians may understandably have concerns about the impact of AI in medicine. While AI has the potential to revolutionize healthcare by improving diagnostics, treatment plans, and patient outcomes, it is unlikely to completely replace clinicians “in the near future”. Instead, AI is more likely to augment their skills and support their decision-making processes.

Artificial Intelligence (AI) can be applied during mechanical ventilation to improve patient outcomes and reduce healthcare costs. AI algorithms can be used to analyze patient data to dynamically adjust ventilator settings and predict patient needs. This allows for more precise control of ventilation, reducing the risk of patient harm and improving treatment efficiency. Additionally, AI can assist in detecting and diagnosing respiratory problems, such as VAP, VILI earlier and more accurately. AI in mechanical ventilation is a rapidly growing field with the potential to significantly impact patient care.

The future of AI in mechanical ventilation looks promising, with increasing potential for further advancements and wider adoption in clinical practice. Here are a few areas where AI is expected to make a significant impact in the future:

– Predictive analytics: AI algorithms will become more sophisticated and able to provide real-time predictions of patient needs, allowing for more proactive and personalized treatment.

– Automated decision making: AI-powered systems will increasingly be able to make automated decisions, such as adjusting ventilator settings, without human intervention, thus reducing the risk of human error.

– Improved patient outcomes: As AI becomes more widely used in mechanical ventilation, it is expected to lead to improved patient outcomes through more precise and efficient treatment.

– Cost savings: The use of AI in mechanical ventilation is expected to lead to cost savings for healthcare organizations by reducing the need for manual intervention and reducing the risk of patient harm.

– Overall, the future of AI in mechanical ventilation is exciting, and it is likely that we will see significant advancements and improvements in patient care in the coming years.

We need to be vigilant assessing, monitoring and learning the impact and the hypothetical benefits or harms of AI during mechanical ventilation in the ICU and in health care in general.

(This blog is written with some assistance from ChatGPT/Bard)

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