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Eduardo Mireles, MD, director of the Medical Intensive Care Unit and vice-chair of the Department of Critical Care Medicine at Cleveland Clinic, joins this episode of Respiratory Inspirations to cover all things mechanical ventilation. Dr. Mireles starts with the basics of what mechanical ventilation is and the different ventilators used, then explains why someone may need one. He also describes how ICU teams work together to ensure the comfort and safety of patients on ventilators.

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Mechanical Ventilation: How Ventilators Work, Who Needs One and What to Expect

Podcast Transcript

Raed Dweik:

Hello, and welcome to the Respiratory Inspirations podcast. I'm Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families, and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Dr. Hassan Khouli:

Hello everyone, and welcome to the Respiratory Inspirations podcast. I'm your guest host Dr. Hassan Khouli, Chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. My guest today is Dr. Eduardo Mireles, our director of the Medical Intensive Care Unit, and the Medical Director of the Simulation Center at the Cleveland Clinic. He's also the Vice-Chair of the Department of Critical Care Medicine. We will be talking today about mechanical ventilation. Eduardo, welcome to the program.

Dr. Eduardo Mireles:

Thank you very much Hassan, happy to be here.

Dr. Hassan Khouli:

Thank you. So maybe we can start setting the stage for our audience here, Eduardo, about, you know, what is mechanical ventilation? How you can describe it to people who are listening to us today?

Dr. Eduardo Mireles:

Mechanical ventilation is a way to support the way that we breathe, Hassan. In order for us to breathe, you need your respiratory muscles. Your respiratory muscles make your chest wall expand and your diaphragm move down. And that lets air go into your lungs. In situations in which we cannot breathe on our own, because of either you're going to go, for example, for a surgery, and they have to sedate you so that you can undergo the surgery. Or your lungs get sick, and they get, for example, a pneumonia. And that pneumonia, or COVID like we lived these last two years, it makes the lungs stiffer, harder to expand, and so your muscles, which before used very little energy, now have to use a lot of energy. And if you can imagine, for example, you'll, going out for a run, after a while you get tired. And so that may happen to patients that are using these muscles continuously at a higher amount of intensity. Then they need some help.

And the help that we provide is with a mechanical ventilator that essentially provides positive pressure, so it blows air inside the lungs, which makes the respiratory muscles rest. So, the respiratory muscles are not doing as much work as they were doing before. And there are different ways that we can do this. We can do this with a tight-fitting mask that goes over your face, and pushing the air in to help you breathe. Or we can do it placing a tube through your mouth, into your throat, into your lungs. And then that puts the air in and out of your lungs.

Dr. Hassan Khouli:

Well, thank you, Eduardo for describing it really as simply as it is. It is a bit complicated, you know, the air, and you already actually, you know, described some of the different breathing support devices that we may use there. Some of them, you know, may deliver oxygen, some of them may deliver the pressure support that you talked about there too. How is that different do you know, in terms of what the mechanical ventilation will do above and beyond delivering the oxygen that can help the patients?

Dr. Eduardo Mireles:

Yeah, so the machine, the ventilator, the mechanical ventilator will help push air inside your lungs. So, the first thing that it will do is it will, at the minimum level, will give you the same amount of air that you can generate with your muscles. We can also make it give you larger breaths, or faster breaths. We can also use something next to increase the amount of air within your lungs, so that your lungs are bigger, and so that you have a little bit more gas exchange within them, so that the more air fits into them. And that helps us increase the amount of gas exchange, oxygen, to go into your bloodstream, and CO2, which is what we try to eliminate from your body to come out.

So, by adjusting the, the machine, we can support both the oxygen function, and the gas exchange that the release of CO2, or, carbon dioxide from your body, and keep you within what we would call normal levels so that you can go through either a procedure or a disease.

Dr. Hassan Khouli:

Thank you. So, maybe if you can describe to our audience, you know, like, what type of conditions sometime will require, or will need that type of mechanical ventilator support?

Dr. Eduardo Mireles:

So, there's a fair amount of use of, and, and many of the listeners will recognize this one. When we talk about non-invasive mechanical ventilation, when we use the face mask, or a nose mask, or actually sometimes a mouthpiece to help our patients. This is used in conditions like obstructive sleep apnea. So, you have heard about CPAP, which essentially is just giving pressure to keep the airway open. But some patients that are at home are using technical BiPAP, in which actually the machine gives you extra pressure to augment, to make your breathing volumes larger. And that is used also by some groups of patients with the conditions at home like diaphragm weakness. They use this to augment the size of their breaths.

So that happens out there in the community. Within the, the hospital we use a fair amount of non-invasives, and again, non-invasive is with the mask, for patients that may come in with afflictions from COPD, emphysema, affecting the lungs. And those patients, as the disease evolves, or when they get infections do not have enough lung to work with, or muscle strength to augment and eliminate the gasses that they have, they build up in their bloodstream. So, we may use the non-invasive to help them eliminate those gases.

The next level if we cannot use the non-invasive then, or the non-invasive is not achieving the goals that we want, we may move into the realm of invasive, with that tube that I talked about. The tube within your throat is called an endotracheal tube, meaning that it goes into the trachea. And when we put it in, we usually make the patients very comfortable. We give them medications for pain, and to keep them, and to remove the anxiety. And sometimes, like, fully asleep. And we try to avoid getting into, into those types of, just because we, it's better to have a patient that is awake and interactive. Right? But sometimes you cannot achieve it.

So, conditions that makes us move into that are, for example, pneumonias or injury to the lung. And there's multiple things that can injure the lungs. Or sometimes other organs are failing, and they manifest in the lung, and they put water inside the lung, and it's harder for the patients to breathe. So, in those patients we use the invasive mechanical ventilation.

Most of you heard through the last three years a lot about COVID, and COVID caused injury to the lungs. And so that was the main reason why we were using either non-invasive or invasive mechanical ventilation in patients with COVID while they were in the hospital.

Dr. Hassan Khouli:

I'm glad you touched on COVID, and how that really, large, you know, significant use really of mechanical ventilation support during that period of time there. So maybe we can talk a little bit about that a bit too. You know, during COVID there was that concept of it's a death sentence when you need to go on a, on a ventilator, there too. Can you share with us how the ventilators were used during COVID here at the Cleveland Clinic? And what are some of the outcomes that we had for patients who are on mechanical ventilation?

Dr. Eduardo Mireles:

Yeah. That feels actually like if it was a decade ago, even though it was a couple of years ago. Right? But what I will say is that the fear at the beginning that came from reports from the countries and centers that were receiving large amounts of patients with COVID in the first wave really alarmed a lot of people. Not only lay people, but also physicians. And there were reports that when they were coming out seemed, I mean, that were terrifying, to say the least. What we have learned after now living through this is that that was not the case. That, indeed by using what we call standard of care, so good, well-designed, evidence-based practices, using the best, that we can from the science, and the technology, and medicine that we have available, the outcomes of these patients were similar to the patients that had a similar disease. I mean a non-COVID related acute respiratory failure.

So, it turned out to be life-saving for large number of patients. And so, we did have to battle with fear from providers, and from patients regarding the initiation of mechanical ventilation, because there was the fear that this was death sentence, that they will never come out of that. For some, unfortunately that was the case. And it was not related to the mechanical ventilation, it was related to the disease itself. On those that we were able to get through it, they continued to have their life thanks, in big part to the application of mechanical ventilation. We applied it in both types, the non-invasive and also the invasive mechanical ventilation. And it all depended on the level of disease that the patient had, and other series of factors that we take into account when making those decisions.

In general, as I said, we tried to keep the, our patients awake and interactive, as long it's safe, that they can breathe appropriately. But the other, the other thing for the audience to hear is rarely do you have an event where you have so many patients with the same disease, and for such a long period of time. For a good amount of time, we were having the greatest number of patients with respiratory failure that I had ever encountered. I mean, now we have taken care of a lot of patients with respiratory failure, but this was one after the other with the same disease. And these really helped us in many ways. One, to prove that what we were doing in general was the appropriate thing, and actually to adjust some of our protocols to get better.

To learn a lot about the disease, and the number of publications that came out, research and knowledge that was generated over the last three years is overwhelming. It will take a lifetime or more to, to really dig through all the stuff that was generated through, through this time. So, at the end of these three years, I think that we, I mean, for anybody in the future is better thanks to those three years of communication, preparation, protocolization. And the technological development for our patients that are critically ill.

Dr. Hassan Khouli:

Yeah, very much so. You know what you mentioned really is very important. Mechanical ventilators when they're being used wisely, when they're being used by the experts who know what they're doing and in a share type of decision, sometime maybe a trial or so, they can be very, quite helpful, and they can actually save lives too. And we have seen that quite a bit, before COVID, during COVID, and now with COVID being not as dominant with us too. Maybe if you could actually share with our audience, what should families and patient expect when they are placed on a mechanical ventilator?

Dr. Eduardo Mireles:

From the patient side, I will start by saying that our number one priority when we place somebody on mechanical ventilation is that they are as comfortable as we can possibly make them. Because we understand that being in a bed with a tube in your mouth is not part of your life plan. Right? This is an event that put you there, and that we are trying to get you out of that situation as fast as we can. And so, you will have the tube in your mouth. You will not be able to communicate, but we make actually as much efforts as we can to help you communicate. Not only by sometimes trying to read your lips, sometimes by augmenting your ability to write, or with boards to help you there. But we will also bring, obviously your family members to be around you that know you better and understand you better, so that you are more comfortable within it.

In terms of the family members, this can be really distressing for, I mean, for any age, from kids to adults. Seeing a loved one in life support, which is the mechanical ventilator, can be really distressing. Most of the time the team around will be guiding you. Sometimes you will be there on your own, but there is the time, most of the time our team will walk you through what you're seeing. And that will help understand a little bit better what's happening. There are times that the patients are gonna be sleeping, and they will not interact with you. Or they will wake up and they are in a state in which they not really interact well with you. They can open their eyes, but they're not aware, or not responding to your commands. And that's because of some of the medications that we use for some of these patients when they need to be more comfortable, or that we need them to relax so that the ventilator can do it.

There are other times that we're gonna wake them up. And sometimes those awakenings are stressful for the family because they see the patient with the tube in, and sometimes working hard to breathe. That we do, because we know that that will help them be less time on the ventilator. And sometimes we're testing them to get off of the tube. And so, at the end, we try to minimize those episodes as much as we can. We try to keep the patient as comfortable in that goal as we can.

And the nurses at the bedside are, in the ICU, are especially trained to how to do that. Right? So, they know how to recognize pain. We have scales and measurements. They know to help to recognize anxiety. And a condition that happens in these patients, which I alluded briefly before, which is called delirium. So, it's often that these patients because of the medications, the critical illness, and the tube in their mouth they get more confused. And so, the nurses and our team are ready to deal with that, and trying to wake the patient more up, orient them, get them back to level.

Finally, I will also mention a thing that causes distress in family, and actually patients too. Sometimes they may find their loved one wearing what we call restraints. So, these devices around their wrists that hold the hand away from the face, or of away from devices that they can pull. And that is done as little as possible as we can, and for the least amount of time possible. To try to prevent the patients that are confused from removing devices, the tube, or others that can put them at risk of other things. And so that can be distressing, but rest assured that, number one, that's a big deal for us to put somebody on, on restraints. And number two, we try to do it for the least amount of time possible, recognizing that that's not something that we would like to be doing, but sometimes we have to do to keep them safe.

Dr. Hassan Khouli:

Thank you, Eduardo. You described a really vivid picture of what families and patients can, can live through being on a mechanical ventilator in the intensive care unit, usually. And how important it is for our team of nurses, respiratory therapists, the physicians, the pharmacists all worked very well together to ensure that comfort to prevent the harm that can happen sometime, you know, from being on any device such as a mechanical ventilator too. And how often really, it's a good outcome. It's the outcome that families and patients desire as well too.

You know, some of these patients end up needing to be on mechanical ventilation for some time. And that breathing tube, we may need to do something about it. People hear about tracheostomy, if you can really share with us, what is a tracheostomy? Why do we need it sometimes? How do we use it? Where do patients really go if they are to have a tracheostomy done in the intensive care unit?

Dr. Eduardo Mireles:

That's a great topic to educate our families about. This is a common misconception, I would say. Tracheostomies are full of stigmas and history behind them. In the past the thought was that a tracheostomy was, in a patient on mechanical ventilation, meant that you were gonna be on the ventilator forever. And it's actually quite the contrary, I would say. The majority of the patients that get a tracheostomy have it for the least amount of time. And then they are removed. So, the first message is a tracheostomy, which is this tube that we place in the throat to, instead of having the tube in the mouth of the patient, we put it on the neck. And the majority of those tubes can be placed and discontinued. They can be pulled out when the patient doesn't need them, and the wound closes. And done deal. It doesn't, majority of the time, it doesn't need another procedure.

Why do we do it? We do it because two items. The first one is after several days of having that tube in your mouth there is a concern, and actually a documented concern that the vocal cords of the patient may get injured by the presence of a tube where it shouldn't be. And those injuries can be just swelling for an amount of time, but they can become bigger issue in the future. And so, recognizing that, in general we try to remove the ET tube and place that tracheostomy into place to prevent those vocal cord injuries.

The second one is that in patients that have gone for an amount of time, and in others that may not have even gone for that amount of time, but in some group of patients, the presence of a tracheostomy may make it easier for us to discontinue the mechanical ventilation. Because of two reasons, one, the tube is shorter so the amount of work that they have to do to breathe through is it is less. But it also allows us to remove them and place them without having to go through the whole process that entails placing a tube through the mouth, which requires sedation, and sometimes paralysis. And it's an event that has its risks and its benefits. So, this actually just bypasses that need of doing that procedure. So, and it may be better for the patient to have that at that period of time, that having the risk of having to go through the reintubation process.

In majority of the patients when we place it, the goal, and when we place it is to, is that we're focusing actually on how to get them off the ventilator. So rapidly after we place it, we start working on decreasing the amount of support from the ventilator. Not that we were not working before on that, but it's actually, it allows us in some cases to take them completely off, and let them breathe on their own. And then when they tired, place them back up on the ventilator.

And so, the, the first one is, this is not forever, it can be removed. The second one, if we place it is because we want to prevent injury and to make it easier to care for your loved one. And the third one is, where do these patients go? These patients can be cared classically with, after the acute process, we will move them to a long-term acute care or weaning facility where the team there is focused on actually decreasing the amount of support, on nutrition, on rehab, on getting them back to gain their skills, or get them to recovery. And so that's one of the pathways.

In some patients, actually, they don't go to the long-term acute care facility, or a weaning facility. Some of them can actually go home, or actually some of them we may remove the trach while they're in the hospital. For those patients going home, there is a series of things that we have to focus, and that, to make sure that the family and the support that the patient will have, and that it's safe for that patient to go home with the, with the respiratory support. But it's certainly doable. And we do it and care for them at this time. So, the third one is that there are different places that you're gonna go.

And the fourth message is that for those patients that actually end up going to a weaning facility, a large amount of them will be able to come off the device. The physicians, and actually the whole care team, inter-professional team, will let you know where the process is going. Sometimes we can't, but in a big proportion of them we will. And sometimes you may require some degree of extra support, for example, the non-invasive at night, or BiPAP, or extra help. You may require oxygen still. But it's not an outcome that you would say, oh, there is, there is nothing out there. And, actually I will just voice this that in some of the research that has been done, Hassan, regarding what patients say after they have left one of these weaning facilities, after having gone through what many of us would have said is that's a rough ride, the research says that many of them, the majority of them would say, yes, I would have gone, done the same again.

And so, they're really challenging the way that we used to see tracheostomies from the social standpoint, and also from the healthcare viewpoint, in that this is not a terminal event, but it's actually a transition event. It's a part of the continuum of care, and obviously it has to balance what you also as a patient want, and what the care team wants for you. And then obviously come together to deliver a good care plan. But that's a tracheostomy in a nutshell.

Dr. Hassan Khouli:

Thank you. Thank you, you know, for explaining tracheostomy. And, it is really, it's like how you describe it, it's a transition. It really for patients who are, the way you and I talk about it often is, if somebody has an acute illness and they have a hope of, of recovering from it, it's not a terminal illness that got them to the intensive care unit, and got them on a mechanical ventilator support too. They just need more time. And that time may take days, make take a little bit more than days, weeks, and sometimes longer than that. Then the tracheostomy, and being weaned from the mechanical ventilator is something that is reasonable, if that's the goals of care that the patients or the families are really choosing in consultation with the care team in the intensive care unit there. And there is hope. It's not always the outcome as we have heard about, in a way, to there.

Well, thank you very much, Eduardo, for spending the time with us. Dr. Mireles joined us today. And I want to thank you, everyone, for listening to our podcast today. I'm your guest host, Dr. Hassan Khouli, chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. And my guest today was Dr. Eduardo Mireles. Dr. Mireles is the Director of the Medical Intensive Care Unit, and the Medical Director of the Simulation Center at the Cleveland Clinic, and the Vice-Chair for the Department of Critical Care Medicine. Today we talked about mechanical ventilation as our topic. Thank you.

Dr. Eduardo Mireles:

Thank you. Have a great day.

Raed Dweik:

Thank you for listening to this episode of the Respiratory Inspirations podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.

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