Ventilation in 2050: Exploring the Future of Respiratory Support

Podcast Transcript

Dr. Raed Dweik, MD :

Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease in the areas of lung health, critical illness, sleep, infectious disease and related disciplines. We will share with you information that will help you take better care of your patients. I hope you enjoy today's episode.

Dr. Dan Culver, DO :

Welcome, everybody. Thank you for joining this edition of Respiratory Exchange. My name is Dan Culver. I'm the Chair of Pulmonary Medicine here at Cleveland Clinic. Today, we're going to talk about the future of mechanical ventilation, or what will mechanical ventilation will look like in 2050. I have two excellent expert guests with me here today. I'm joined by, uh, Dr. Eduardo Mireles. Eduardo is the director of the Medical Intensive Care Unit here at Cleveland Clinic Main Campus, as well as the director of the Simulation and Advanced Skills Center here at Cleveland Clinic. Welcome, Eduardo.

Dr. Eduardo Mireles-Cabodevila, MD :

Thank you.

Dr. Dan Culver, DO :

And I also have Professor Rob Chatburn, who's the director of Respiratory Research Care here at the Cleveland Clinic and an expert in long-standing mechanical ventilation. Welcome, Rob.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Thank you.

Dr. Dan Culver, DO :

So intensive care medicine really started with the advent of mechanical ventilation over 50 years ago, and it seems apt to think about where the future might lead us. You two have been intimately involved in the delivery, application, and education of mechanical ventilation. And as I think back to my days in training and the few number of modes we had and how relatively simple mechanical ventilation was, I think one of my teachers said the goal of the ventilator is just to push air in, and that's all you really have to think about. And the rest of it is just engine wiping. <laugh> I think we've come a few miles since then. With mechanical ventilation, of course, I think one of the things that's readily apparent is that it's become much more complex with many modes, a large number of manufacturers, a proliferation of acronyms.

And so, one of the things to think about is just very simply, what are we really trying to do with mechanical ventilation? And I, I think you've spelled out three core goals really well here, Rob. Safety, comfort and liberation. So even though we're changing a lot over the next several decades, just talk to me about the goals and how they are and how you see those going.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Well, I think that's a, a useful framework because it simplifies your approach to very complex technology. So, safety, by safety, we mean that we want to obviously keep the patient alive by having adequate gas exchange. And comfort then would mean that the ventilator's designed to take the place of the patient's brain or in controlling the respiratory system and breathing gas in and out. And so, when you take a machine and try to make it substitute for the brain, there's always going to be synchrony issues. So, comfort means making sure that the patient is, the ventilator delivers the gas as the patient demands it. And then liberation simply means that we want to get the patient off the ventilator as soon as possible without causing any lung damage.

Dr. Dan Culver, DO :

So those are goals that I think that we are hopeful technology can help us achieve. Of course, mechanical ventilation started off with continuous mandatory ventilation and evolved over time. Where do you think we've made the most progress in those three goals since CMV up until today?

Dr. Eduardo Mireles-Cabodevila, MD :

Yeah. Actually, I think that the cool part is that, as you see, the technology has expanded and there's all this plethora of modes and acronyms and whatnot. And in reality, they're trying to serve the patient better. So, all of this is not ill-conceived in the goal of - I'm trying to do better for the patient. What is happening is that it's poorly directed. There are, uh, there's some modes that do safety very well. There's a plethora now of modes that are trying to achieve better comfort, and there's very few modes that focus on liberation, which is, tells you how the clinicians are thinking. They're really focusing on the part in which they try to keep the patient comfortable. There is a few patients that need technology for liberation, but we are put very little into that development. And then for safety, we are still in some ways in a dogma of, it's only volume control and 60 C, so that has tightened the developments on, on some of that, although some automation has come, come there.

So, I think this organization just needs to be organized into where we need to develop in the future. So, it's good to see development. It's just, we need to organize it.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah. I think it's fairly easy to keep someone alive on a ventilator. You can do that with virtually any ventilator, any mode, but to do that in a way that is most comfortable for the patient, there's many, many different approaches, and that's why there are so many engineering answers to that question.

Dr. Dan Culver, DO :

I think that I want to get into the liberation piece later, and the whole issue around muscle dysfunction and other aspects that come into the longer-term outcome of patients. It's definitely got to be a place where, where this field moves towards more. But to go back a little bit to the time when I was in training, our goal was simply to maintain oxygenation and ventilation with however much Lorazepam and Versed we needed to use. And so, we didn't think that much about comfort. Now I think there's a notion that perhaps we're thinking too much about comfort and not enough about patient doing work. And so how do you think this notion of patient being comfortable and what the patient per- should perceive and tolerate in terms of ventilation has evolved? Where, where are we right now with that and where do you see that going?

Have we gotten to a place where we're adequately comfortable for the patient?

Dr. Eduardo Mireles-Cabodevila, MD :

Uh, that's a great question. I mean, I think focusing on comfort, there have been a lot of advances in the last decade in terms of recognizing the patient-ventilator interactions. We have done a lot of work trying to organize them and at least aligning what we all are seeing but naming it the same thing. However, there's also technological features that have come out to serve some of the, one, the goal of, of synchrony per se, but the other one that was highly unrecognized and that it has to do with both safety, comfort and liberation is the amount of work of breathing. So if you notice how this has evolved lately then is that now we have some measures that are less cumbersome than it was in the past, in which you may remember, uh, oh, work of breathing, a concept that sounds easy, but very com- complex to measure at the bedside.

So now we have simplified it to something that we call the POC, um, a surrogate measure of muscle pressure, that it's easily implementable at the bedside, for example. So, I think that we are gathering more understanding so that we can tailor care based on bedside measures and technology so that we can serve the patient better.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

And what we're missing is the research, the clinical research to tell us what thresholds for these different indices we have. And you mentioned that when you were in training, the ventilators are much simpler. Well, I was actually around 50 years ago <laugh> and all the ventilators that we had only had one or two modes on them, and nobody cared what you called them because everybody knew what you were doing. Just for perspective, now in the United States, we have nearly 80 ventilators that are available. We have almost 700 unique names, brand names for modes, which is a problem, right? 700 brand names. And if we classify them and create generic names for them, that's still about 100. But it's the reason we've had a proliferation is engineers keep coming up with different ways to address these issues, you know? What's the best way to wean?

Auto, can we do it automatically? What's the best way to provide comfort for the patient? And so, it's interesting. <laugh>

Dr. Dan Culver, DO :

It reminds me of the tower of battle.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Mm-hmm.

Dr. Dan Culver, DO :

Exactly. Do you think there is a bigger issue right now, Rob, with the application of so many choices and a giant smorgasbord where it's difficult to choose the meal, or is the problem more that the choices still are not quite good enough?

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

It's a little of both, but frankly, as clinicians, most of us are at the bedside are like driving a Ferrari and we can't get out of second gear. There's this gap in education because the technology has advanced exponentially where the resources for training and education are just barely chugging along linearly. And so daily, the gap, the knowledge gap grows. And so even without adequate clinical data to say one mode is better than another, we simply don't know how to make the best use of what we have at the bedside just to make the patient more comfortable and, you know, intuitively.

Dr. Dan Culver, DO :

That reminds me of your metaphor about self-driving cars. <laugh> And maybe that's really where you're talking about going.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Exactly. Right?

Dr. Dan Culver, DO :

I wouldn't want to get behind a Ferrari in first gear or in second gear, but I might get into a self-driving Ferrari. So, is that really what's going to happen here?

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Uh, it is already happening. There is at least one ventilator that has not been approved by the FDA that's used outside the United States that has almost a full, uh, set of tools that are under the control of AI. So, you can put a patient on a ventilator, you put in basically their height and their sex and walk away. And the ventilator manages their oxygenation, the ventilation, and even at the appropriate point, it'll start weaning the patient as well. That's the direction we're going. I think the barriers to that in the United States have been the FDA's reluctance to approve automated things and, uh, then there's a certain amount of clinician reluctance to trust this because it's, it's never going to be the case that we have definitive research that tells us that one mode is superior to another. It's just not; we don't have the time and the resources to do that.

So, it's a cultural thing, you know? It happens slowly.

Dr. Dan Culver, DO :

So, Dr. Mireles, will you trust hooking your patient up to a black box and telling the computer, "Here are a couple of goals I have for the patient, now have at it."

Dr. Eduardo Mireles-Cabodevila, MD :

I think the answer will be yes at a given point. We do it actually already. The way that ventilators work has a certain degree of automation in them that the regular clinician does not understand completely. Part of the work that we have been doing over the last decade and a half, uh, has been trying to educate the clinicians to understand what the black box is doing. So however, you're asking if we push it all the way to a black box in which essentially the machine, you can imagine a ventilator that has the capabilities of doing all the available modes out there and then based on the patient interaction, measurements, apply the mode that we think that it's better or that the black box has been educated to apply. And I think that, certainly at the speed that we're going, it is possible to happen both technologically and, and second, at the bedside.

And would that be better? I would say that it's likely because if you educate them appropriately, if you have the appropriate measures and we get to select the appropriate patients to do this, it would, it would be likely that the robot would perform better than myself because I'm not there all the time. The robot would be completely there. And notice that I'm calling it a robot because it's implementing a series of tools to achieve a series of goals that either it's detecting or we have fed onto the device to achieve. So, I think that it's going to come there. What I would just say then I say is that that doesn't mean to be just a blind observer and a, a passive observer of the world pass through. I think that the responsibility that we have to our patients is to have understanding of what we're applying and when we're applying it.

Just like a surgeon right now is using robotic surgery. It's not like, "All right, do it, do it on your own. I'm just going to go have a coffee."

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, and the promise of machine learning is that ventilators could be networked together, and they can learn from each other's experience, and they can learn from the medical record and the whole internet of medical things. And that's a massive amount of data that no single human being could ever absorb and learn from.

Dr. Dan Culver, DO :

Yeah, that's one of the things I wanted to ask you both about, because this idea of smart ventilators or AI-driven ventilators really has to take the role that we currently have as clinicians. The ventilator right now doesn't know what's happening with the hemodynamics. It doesn't know what the nurses put in the bedside charting. It can't see the diaphoretic patient or the dyssynchronous patient. [Mm-hmm.] It probably can see the dyssynchronous patient, but not the same way I do.

Dr. Eduardo Mireles-Cabodevila, MD :

It doesn't detect it yet.

Dr. Dan Culver, DO :

Yes. And so, we're really talking about not a ventilator. We're talking about, uh, a life support system that integrates all the technologies that are measuring- [Exactly.] ... patient-related output. Is that something you see coming, and when do you see that coming?

Dr. Eduardo Mireles-Cabodevila, MD :

Uh, I mean, I certainly see that coming. I see that the challenge is that right now we're still at the crayon phase, you know, even though they look very fancy and, and sometimes it's scary, but it's still crayons that machines are not communicating about, amongst themselves. They are not agnostic in the way that the output comes. There's all this proprietary stuff and having them all speak together is a barrier to achievement. And obviously there's the economics throughout the system, right? Uh, not only in healthcare here, each one of our hospitals doesn’t use the same healthcare record or the same devices or the same. So, there's all these items that we have as a healthcare environment to change to make it happen. But I think eventually-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

The technology is there; it's the cultures is in a way.

Dr. Dan Culver, DO :

It is a regulatory issue or a business model issue-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

That too.

Dr. Dan Culver, DO :

Or a cultural issue.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

All that. Yeah.

Dr. Dan Culver, DO :

All of those things are combining- [All of that.] ... to prevent us from really harnessing what we have in front of us.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Indeed.

Dr. Eduardo Mireles-Cabodevila, MD :

Yeah. So, uh, we, we are ... I mean, if you think about it, there's all this stream of data that is being generated just flying by and that we cannot capture because of the, all those barriers that you have, you have mentioned. It's just, I mean, just in our ICU, connecting a pump to our EMR is a challenge, right? Fraught with a number of little details. And once that you get to solve it, it's time for the new pump to come out. So, you have to go and, and maybe there's a cheaper vendor. So, if we think about these companies implementing smart algorithms or AI into each one of their devices, which one is going to be the best one? Or are they all going to talk amongst themselves? So, um, is there going to be one brand that, uh, dominates all mechanical ventilation or are they going to share and grow and deliver in better practice across the environment?

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Well, we have the technology right now to connect the ventilator hardwired right into the electronic medical record. Mm-hmm. So just collect all this data and sit there in a black hole. We have no way of using it at this point.

Dr. Dan Culver, DO :

No way of using it, no way to even understand the volume of data. <laugh> [Exactly.] Second by second, many thousands of data points every second.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah.

Dr. Dan Culver, DO :

When you think of flows and pressures and all the other data coming from the patient.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah.

Dr. Eduardo Mireles-Cabodevila, MD :

Uh, actually, I would put it ... This, this is, this is why the work that we're doing right now is relevant towards the future, is ... And I'll give you a simple example. I was reviewing a, a paper in which they had grabbed a database for AI machine learning, and they had put the definitions and all the measurements that they had done, and something as simple as the peak inspiratory pressure, it turns out that in this manuscript, they had peak inspiratory pressure as defined for by X ventilator, by this ventilator on this mode of mechanical ventilation, because it depends. <laugh> And the meaning is so context dependent on what you're doing and not everybody, uh, refers to peak inspiratory pressure in the same, same way, which is not ... Some of them are in reference to atmospheric pressure. Others are in reference to peep.

Yep. So how do you grab all of this right now? It's a plethora of information, all disorganized. So creating a standard way of speaking a taxonomy and a nomenclature becomes essential for the future, for a future in which the devices can talk and be in a platform that it really doesn't matter that you are, this ventilator company or this ventilator company, the data that is coming can speak and can be compared between them.

Dr. Dan Culver, DO :

It makes you feel like health systems, maybe in countries that are, are less fragmented and a bit more centralized, may have a leg up [Mm-hmm.] ... on the US. It's a bit of a cacophony here-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Mm-hmm.

Dr. Dan Culver, DO :

... with the number of vendors, the number of different payers.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yes.

Dr. Dan Culver, DO :

The health care delivery system is, it's a beautiful experiment of various different scenarios, but it's very difficult to get enough experience with any one given technology to really-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, it's largely garbage in, garbage out at this point. It's unorganized data going in, and no good way to translate it coming back out. And that's where the challenge is right now.

Dr. Dan Culver, DO :

I want to pick up on something you said a minute ago, Eduardo, and that is the idea of context. [Mm-hmm.] We think of these mechanical ventilators or healthcare support systems as being able to learn, being able to talk to each other, being able to develop what looks like experience. As clinicians, we always think about the context, understanding the disease pathophysiology, understanding the expected natural course of the disease, even what the patient experienced a decade earlier in their healthcare journey are important to decisions that we make in the ICU. So, as you think about the future of mechanical ventilation and you think about the individual patient, that's a context. And how do you see that context playing into the issue of about how the ventilator delivers support? And also, I think another piece that we don't talk about that often is, uh, individualization around the interface.

What we see as mechanical ventilation is not just the machine pushing air in, but also the interface with the patient; is that evolving at the same time?

Dr. Eduardo Mireles-Cabodevila, MD :

Those are very, very good items because ... So, I would say that right now we are in the part of time that we're generating a lot of information that we have to be more open and move into trying what technology can apply better for that context for that patient in particular. There's a lot of information that you can generate from this rather than just using the five modes that everybody uses, is how do we apply it and improve this pathway? Because otherwise, you're going to get into lanes that are always going to be ... You have to have the ability to do curiosity and get out and explore for that given patient. What is the right thing?

There are patients that we do outside of the box interventions like we wean them when they are on 19 or peep. <laugh> We wake them up, and we let them breathe, which in any algorithm, the rule-based system or the machine learning would say that's not the way to move because the majority of environments, they would not do this.

But there's these places where this does occur. And so this is going to influence in a way I would be sad to see moments in which patients in which the creativity that we have right now at the bedside and that we, you had when we didn't have all these machines and all these, the cell phones and all this stuff that you had to think and use your mind to say, "Well, how do I do this? " And these new items came out to do it, then change the course of medicine and the course of how we treat many of the patients. I mean, and I would say, in sarcoidosis, and we would say it in ILD and any other disease, there's all these moments that come from error, from not doing the conventional stuff. So I think as long as there is the ability to explore and that we have openings, there is going to be a, a place for some of this automation and there's going to be a place for getting out of the automation, out of the protocol. That's in general what, how I'm trying to-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

And I think there'll be a phase that we'll go through where we have open loop decision support- [Mm-hmm.] ... by AI. So, the AI doesn't control a ventilator, but you ask it a question, you'll say, "Well, what evidence is there that doing this and this will help?" And it'll just tell you, boom, immediately. And I show you all the evidence, all the research, and then you make the decision as a human, and you put your hand on the vent, and you change the controls.

But ultimately, I think all of this will be incorporated and there won't be different ventilators. There'll be a little box that delivers gas, and all the knowledge will be up in the cloud somewhere, right? And so <laugh> there'll be a little switch that says on and off, a little switch that says connect the patient, a little display says, connect the patient, disconnect the patient, that's all you need to know. <laugh>

But that's, that's your 50 years in the future.

Dr. Dan Culver, DO :

That sounds also somehow a bit full circle from the original ventilator. <laugh> At least from where I stand.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, yeah.

Dr. Eduardo Mireles-Cabodevila, MD :

Exactly. It would be a single mode, right? On and off.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Whatever the patient needs, it'll give it to them. Independent of separate little silos of modes and ways of thinking.

Dr. Eduardo Mireles-Cabodevila, MD :

It would be a little Rob Chatburn. <laugh>

Dr. Dan Culver, DO :

Rob Chatburn there driving the ventilator.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

My voice, right? <laugh>

Dr. Dan Culver, DO :

What, uh, what do you see ... This seems to me as an opportunity for thinking more broadly about the application of mechanical ventilation, or should I call it respiratory support. And it makes me think about places that are more resource-impoverished or places where there's not as much ability to provide hands-on care, things that happen in the home, things that happen in other countries, war zones. How do you see the evolution of respiratory support impacting care for respiratory failure in those settings?

Dr. Eduardo Mireles-Cabodevila, MD :

Well, once they make it, it has a price point and availability to cross with, without a doubt. I mean, you, you ... Just think five years ago in the middle of the pandemic, I mean, there, there were ventilators. I mean, I know that at times there were no ventilators, but then there were ventilators and there were no people that could manage the ventilator appropriately. <laugh>

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Like COVID, you mean?

Dr. Eduardo Mireles-Cabodevila, MD :

Yes. <laugh> It's exactly what we're talking about. It's the, it ... During that period of time, I would have said that if you had automation, even here in a world con- dominating country, you know, that you have excessive resources, that you didn't have enough respiratory therapists to help out, that having a ventilator that had that level of automation would have been better than having the patient on a ventilator- [Yeah.] ... itself with a, with an ophthalmologist managing. And nothing against an ophthalmologist…

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Or a veterinarian, right?

Dr. Eduardo Mireles-Cabodevila, MD :

But we were in a very challenging situation. So, when you think about a resource limited place, if this is allocated and we have the ability to have those resources placed in these areas, I think that that makes complete sense. It may not serve 100% of the patients, but if it serves 80%, 70%, I would say that that's a positive thing.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah. I know for a fact that the military is interested in, in finding automated systems to help transport soldiers, wounded soldiers from the battlefield to medical facilities and in the transport planes, for example, you know, it's, they need the automation because they don't have the personnel and they don't have the ability to interact with the patient like you would in an ICU. So, there's a huge push in that direction, unfortunately, because <laugh> the world's situation. But yeah, that's just a specific example.

Dr. Eduardo Mireles-Cabodevila, MD :

And that's a great example of areas where our patients are vulnerable- Yeah. ... in which AI would be very useful and-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

And they're very sick.

Dr. Eduardo Mireles-Cabodevila, MD :

Every time that you're transporting a patient, I mean, sometimes you have respiratory therapy available, but you're more focused on certain items of the transport, not bouncing the wall- <laugh> ... Thermodynamics. And the lung protection itself, I mean, it would be putting on 60 C, there could be the worst interaction, and they may not have the appropriate people- [Right.] ... so, a certain level of automation in that phase or on patients that are in a long-term acute care facility, you can see-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

That too, yeah.

Dr. Eduardo Mireles-Cabodevila, MD :

... how the amount of RTs that you may allocate to that environment, especially when your, their shortage may go down, even though they are essential for that period of time. So having a level of automation there would be better than not.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, it's like what you said, Dan, and that's a situation where a patient's on a ventilator for a long time, and the ventilator could theoretically learn what that patient's needs are over time. [Mm-hmm.] They would learn what would work and what didn't work, and if you reduce support, the patient didn't like it, put it back on. So yeah, there's a lot of opportunity along those lines.

Dr. Dan Culver, DO :

Well, this has been very interesting, and it's hard to imagine really where things will go. As you mentioned, the speed of technological advancement and knowledge is exponential. I think just at the end here, I'd like to give each of you the chance to describe a scenario to me. <laugh> And this is walking into whatever an ICU looks like in 25 years from now, and a patient is there with respiratory failure from whatever causes that 25 years from now, and tell me what you see in front of you for support of the patient. What does that look like, the interface, the delivery, the actual physical part of it, how, how does that go 25 years from now, if you just had to imagine just in one or two minutes each, give me your idea about that imagination game.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Well, I'm going to push it way out there. So, I'm going to be taken to the hospital in a car that has no steering wheel, right? I'll be dropped off at the front door, and I'll walk into the ICU and there will be very few people there, one or two people, there will be some robots, there'll be very few displays like you see on the ICUs. There wouldn't be a bunch of alarms going off and flashing lights because it's all going to be communicated to the robotic arms that are helping the patient and the robots that are at the bedside.

Dr. Dan Culver, DO :

A quiet ICU.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Quiet, it'd be silent and no flashing lights. [Lovely.] It will be just, just the things touching the patient that absolutely must be touching the patient and no disturbances. And there will be human oversight, of course, but I think much of the automation would be, you know, I could see robotic arms coming out of the wall or actual robots moving in the hallways when, when necessary, but I think literally that would be necessary. I suppose in a situation with a code, that would be a little more challenging, but I don't know, I mean, you're watching the science fiction movies, you can see how you can do that as well, but that's, that's way out there, and that's the way I see it.

Dr. Eduardo Mireles-Cabodevila, MD :

Yeah. I hope that it's a lonely place ... In that there's no patients. I mean, if we have achieved the pathway of enlightenment and having understanding disease and that would mean that we can prevent and get through it. But recognizing that right now we have mechanical ventilation as a part of our life-sustaining therapy, I would say, I love your vision because it's probably the end pathway. I would like the transition in which I'm still practicing [Mm-hmm. <affirmative>.] and I could come to the bedside, and the devices are interacting amongst themselves. So, there's less, less friction between that. I would love to have some marker that guides the interactions with the patient regarding lung suffering. Because right now we do it a lot based on very cru- crude measurements. [Mm-hmm. <affirmative>.] That we do what, there has to be a marker just like we have a pain score or temperature or heart rate variability or whatever you want of the lung that would tell you, you know, forward-

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, this transition period would be very interesting, won't it?

Dr. Eduardo Mireles-Cabodevila, MD :

Yeah. I, I, so I think that having that marriage of technology availability with knowledge and then using that marriage and clinical education may be a really nice, nice period for us. I do think that when we get to that level, perhaps my presence in the ICU will just be to be a part of a family reunion and be with them.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah, all human beings.

Dr. Eduardo Mireles-Cabodevila, MD :

... family members and interacting or trying to explain the pathway of where we're going, but at the level that you're talking about right now, Rob.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Yeah. There, there probably won't be very many sick people, but there's always going to be trauma, right?

Dr. Eduardo Mireles-Cabodevila, MD :

Well, the, the- Unfortunately, the computer fell on your foot. <laugh> <laugh>

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

My self-driving cars smashed into another self-driving car.

Dr. Dan Culver, DO :

Yeah. Self-driving car went haywire for the day. <laugh>

Dr. Eduardo Mireles-Cabodevila, MD :

The line went out. Then, the lights went out.

Dr. Dan Culver, DO :

Yeah, the lights went out.

Dr. Eduardo Mireles-Cabodevila, MD :

That's when we would have to come in.

Dr. Dan Culver, DO :

This has been very fun for me. Uh, mechanical ventilation is certainly one of the things that was the most exciting as a medical student and really piqued my interest as well as many other people's interest to get us into this specialty and the complexity of it and the challenges of understanding taxonomy and proliferation of modes and more and more nuances of how to optimize outcomes for our patients around safety and support and liberation are going to keep us all busy.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Oh, yes.

Dr. Dan Culver, DO :

And so, I want to thank both of you for joining me today. Thank you very much, Rob.

Robert L. Chatburn, MHHS, RRT-NPS, FAARC :

Thank you, Dan. It's been a pleasure.

Dr. Dan Culver, DO :

And thank you, Eduardo.

Dr. Eduardo Mireles-Cabodevila, MD :

Thank you. Thank you, Dan. Thank you, Rob. [Mm-hmm.] Uh, this has been a ride. <laugh>

Dr. Dan Culver, DO :

<laugh> Thank you all for joining another episode of Respiratory Exchange. I hope you enjoy today's episode. We'll look forward to seeing you next time.

Dr. Raed Dweik, MD :

Thank you for listening to this episode of the Respiratory Exchange Podcast. You can find additional podcast episodes on our website, clevelandclinic.org/podcasts or wherever you get your podcasts.