Respiratory Support and Therapy in the ICU

Podcast Transcript

Raed Dweik, MD:

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.

Umur Hatipoglu, MD:

Hello everyone and welcome to the respiratory inspirations podcast. I'm your guest host, Umur Hatipoglu. I serve as the enterprise medical director of respiratory therapy and the section head of respiratory therapy in the Department of Critical Care Medicine. And my guest today is my very good friend, Dr. Eduardo Mireles-Cabodevila, who is the director of the medical intensive care unit at the Cleveland Clinic Main Campus, and also the vice chair of the Department of Critical Care Medicine. Welcome Eduardo.

Eduardo Mireles-Cabodevila, MD:

Thank you. Thank you, Umur.

Umur Hatipoglu, MD:

So, Eduardo, I thought we would talk about the general aspects of respiratory support for our listeners in the ICU. Can you start the conversation for me? I'm going to be egotistical. Let me put it that way. I'm going to ask you about the role of a respiratory therapist in the ICU, because that's all I can think about, respiratory therapy.

Eduardo Mireles-Cabodevila, MD:

Well, within the ICU we have several roles and these roles that help us care for the patient. In general, if we count every role in the ICU, there's around 26 to 28 roles of caregivers that come and help us care for patients. The fundamental ones that the ICU cannot be run without, it's around 15, and one of those is the respiratory therapist.

The respiratory therapist is the expert in the application of respiratory support, which has different facets. It has the facet of helping the patients breathe in and out, so they have enough gas exchange, have enough oxygen, as well as clearance of secretions. How to get whatever we're producing, mucus, sometimes you cannot be able to bring it out and make it happen.

And so, they are experts in the interface of technology and devices that provide this type of support to our patients. More importantly, it's not just providing the support, but providing advice to the teams on how to apply and which type of therapy is the best. And lastly, and more importantly, perhaps, is interaction with the patient. They are at the bedside during some of the most critical times for patients in the ICU.

And it is very common that we get feedback from patients regarding those interactions with our respiratory therapists that either calm them down, relieve their anxiety, their pain, and make that critical time more dignified and calmer for all of them. So yes, that's the role, an essential one. We cannot be without respiratory therapists in the ICU.

Umur Hatipoglu, MD:

Absolutely. And you know why I ask you this question? I want people to choose respiratory therapy as a profession. So, if I can summarize how to be a respiratory therapist. So, you have several venues to do that.

Most people choose the two-year associate degree by enrolling in a CoARC accredited program in the United States, a respiratory therapy school. So, after school, you take a multiple-choice examination. And if you pass that examination, you become a certified respiratory therapist. After that, you can take a clinical simulation examination, and if you pass that, then you become an RRT.

Now, there are opportunities for further education. RRT stands for Registered Respiratory Therapist. There are other venues, further education, I should say, that you can get. So, you can get a bachelor's degree, that's two more years of schooling. You can get a master's degree in respiratory therapy, and you can also get sub specialization. You can become neonatal.

Pediatric specialist, for example, or adult critical care specialist. These are all additional designations that you can take. So, although from an employment standpoint, it doesn't matter whether you have an associate or bachelor's degree, we are very quick to boast that half of our staff is actually bachelor's degree RRTs because these are people who are really committed to the profession. But in general, it is rigorous schooling, but it's relatively short period, and it's certainly a very fulfilling profession.

Eduardo Mireles-Cabodevila, MD:

Yeah, we cannot do without them. And there continues to be education during their stay as respiratory therapies, right Umur? Can you tell me a little bit about how you approach that?

Umur Hatipoglu, MD:

Yeah, so they are actually mandated to have continuing education credits which we provide at the Cleveland Clinic. So, we have programs through which they can get what's called CRCE credits. But beyond that, we think that it's really important for respiratory therapists to improve and we have original programs like the standardized education, ventilatory assistance program. We offer competences to our respiratory therapists that help them refresh their skills every year.

We have an enterprise educator whose sole job is to create such programs. So, this is really not much different than any other healthcare profession. There are opportunities to educate yourself and in fact it's mandated for the safety and welfare of patients.

Eduardo Mireles-Cabodevila, MD:

So, really, they, they not only come out of school trained, but we continue to work on them, and they continue to grow through their career?

Umur Hatipoglu, MD:

Yes.

Eduardo Mireles-Cabodevila, MD:

That’s why they're so good at giving support in the ICU. That's awesome.

Umur Hatipoglu, MD:

Yeah, absolutely. So, Eduardo, let me ask you something that is near and dear to your heart so our listeners can have a better idea because ICU sometimes is a scary environment, right? Not sometimes, always. I've been in the ICU for 25 years. I'm still kind of scared going into the ICU.

Probably the most important aspect of providing critical care is providing assistance to those who have respiratory failure. Can you walk our listeners toward the spectrum of treatments that we have available for respiratory failure patients?

Eduardo Mireles-Cabodevila, MD:

Absolutely. So as the patients come into the ICU, it is common that they will require some level of support in terms of their respiratory system. And this is usually escalated from the most basic to the most invasive. And I'll start with the most basic, which in general, is just oxygen and they give you oxygen through some nasal, what we call cannulas.

It's a little tube with two prongs that goes into your nose or a face mask, giving you oxygen therapy. So pure oxygen that you're inhaling, and it combines with the air around you, and it increases the amount of oxygen that you put in. Sometimes that is just enough, but sometimes there's patients that have conditions that require higher levels of oxygen.

And for those patients, we have a technology that actually allows us to administer larger amounts of oxygen while maintaining some of the moisture that you get, because oxygen is very dry. So, when you are going very high on certain levels, you have to humidify it. And so, this is called the high flow systems, or you have high flow nasal cannula or also we can do it with a mask that heats up the oxygen and delivers to the face of the patient and to the nose, and that helps the patient maintain the oxygen levels.

And actually, in some cases, it may decrease the difficulty that they have to breathe in. So that's a welcome addition to our arsenal that actually has around 10 years that we implemented clinically at the bedside.

Umur Hatipoglu, MD:

Which is more comfortable for patients.

Eduardo Mireles-Cabodevila, MD:

Much more comfortable. And that came back actually to change a lot, it put an intermediate step to the next level of support because what used to happen is we didn't have a very reliable intermediate level of support, and this came to do with the high flow nasal cannula.

The next level is sometimes we cannot maintain the levels of oxygen with the high flow nasal cannula, and we need to administer a little bit of pressure to open up the lungs. That's the general term. And so, we may use a mask. We call that noninvasive mechanical ventilation. And that mask, essentially, it's a soft mask that seals around your nose or your mouth or your nose and mouth or your full face or a helmet.

We actually now have devices that look like helmets that help deliver this pressure and these high oxygen concentrations and may help you just with the oxygen or it may help you actually breathe better. That works pretty well most of the time, but there's sometimes that so for other reasons, either you're not awake enough or you're really struggling to breathe, then we have to move on to the next level.

And the next level is the invasive mechanical ventilation and the invasive part, even though it sounds like a pretty aggressive thing I have never realized it but it's a little tube that we place through your mouth into your throat, or we can also do it through a tube through the neck called a tracheostomy to help patients breathe. And that device is used every day in the, all around the world, millions of times to help support breathing for patients that go into for surgery, for example, or for patients that are sick, like in the ICU that require support to breathe.

And then if that cannot do it, and it's very rare that it cannot support it at the level that it should, or sometimes the machine is being harmful to the patient, and we had decided that we need something to let the lungs rest.

Umur Hatipoglu, MD:

So, can you explain that? How can the device be harmful to the patient?

Eduardo Mireles-Cabodevila, MD:

Mm-hmm. So that's a great, great question, Umur. So, in general, these devices work very well providing support for the patient and they will not cause harm if appropriately set. But in certain circumstances, the lung is so injured that little stretches that it can have can make it suffer more.

And we call that ventilator. So, induced lung injury so that the ventilator helps or causes injury. A way that I like to explain to people is that, for example, if you ever have fallen down and have rock burn or road burn, which your skin is bleeding if you stretch it, it will bleed more.

And so sometimes that happens with the lung in which the lung is injured and every time you give a breath with the machine, it can stretch it a little bit more and that stretch can cause more injury.

We know to a certain extent some of the parameters that are injurious. And so, whenever we are setting up the machine, the respiratory therapist and the medical team in general will come and try to put it in settings that we know that can protect the lung. But there's sometimes that even in spite of all our attempts, we know that it's hurting, or it cannot support the lung without causing injury.

And in those cases, we move to the last stage, which is a stage that we call extracorporeal support, in which essentially, we grab blood through some hoses that come out of the body. We put it in the groin or in the neck and it pulls out blood, and it passes it through a machine that essentially acts like an artificial lung, and it helps you put oxygen and remove carbon dioxide out of the blood and put what we would call clean or oxygenated blood back into the patient.

Umur Hatipoglu, MD:

It sounds like an out of body experience.

Eduardo Mireles-Cabodevila, MD:

It looks like it because it's a pretty highly detailed and intense process to do. But it saves lives and we do it only when needed because it's much more convoluted and obviously putting big hoses into vessels is a problem for anybody. And it's another day in the ICU and another thing that we're doing, but we will do it for those patients that we can help get through this.

Umur Hatipoglu, MD:

So, Eduardo, I mean, this is very complicated and obviously it requires a lot of training and expertise to do. Also, I'm thinking that patients don't want to really be experiencing any of this. So how do we keep patients comfortable throughout all of this?

Eduardo Mireles-Cabodevila, MD:

That's a fantastic question because it's a source of distress for family members and patients at the same time. So, I'm going to talk from two viewpoints. The first one is the viewpoint of the patient. The patient is now requiring support. And as you're requiring support, the aim is to keep you awake and interactive the most time as we can.

Why? Because we want to know if you're uncomfortable, know if you're hungry or if you're thirsty, know if you are anything that you need to convey to the family. So having the brain active and interactive is very important for us. At the same time, we recognize that having a tube in your mouth is not a comfortable item. And so there are medications that we use to help make this more approachable.

At the beginning, when you put somebody in mechanical ventilation, most of the time we're going to send them, send them completely to sleep so, first of all, that you don't remember the process of having the tube placed in, but second, at those times, we are trying to figure out where the lungs are, where is the level of injury.

And during that period of time, we may deeply sedate you, so they don't remember anything. And we sometimes actually make them not being able to move so that we can protect really well the lungs. But very soon thereafter it is our constant desire to keep the patients awake. So, we'll wake the patient up. And the goal there is to have somebody that is awake, interactive, but comfortable. And if we can achieve it with minimal number of drugs or with the appropriate dose of drugs, we will do it.

If the patient is not comfortable and we cannot achieve it, then we will obviously raise the levels of sedations until we find a level that they're comfortable. But this can cause a lot of discomfort also for the family.

Umur Hatipoglu, MD:

Of course. Yes. That's what I was going to ask you. You know, those people are fully awake, how do we make them comfortable? What are some of the things that we're doing in the ICU to achieve that?

Eduardo Mireles-Cabodevila, MD:

For the family?

Umur Hatipoglu, MD:

Yes.

Eduardo Mireles-Cabodevila, MD:

Yes. So, there are several things that you as a provider can do that we do here in the hospital. The first one is we need to explain what's happening to the family.

You come in and you're in a completely foreign environment. You could have seen millions of movies about the ER and patients there. Nothing looks like our ICUs until you're in there. And so, our nursing team, our clinician team explains a lot about what's happening, what are the devices that are around the room. And number two is we have to explain the purpose and what we are trying to achieve because there's a lot that the family can do for this.

A family that is engaged in the care of the patient is a family that will be able to tolerate and to have fewer poor memories about the stay in the ICU.

And so, when you have a family member besides me, as a patient, I would want to have one of my family members on the side. So, we free up the time for our families to be at the bedside 24 hours a day, if they want to be there. If not, we will take care and let you rest. That's why we're there.

But during the time, if you want to be there as much time, you should be there because when the patient wakes up, many times they don't remember stuff. And the first thing that they're going to see is my face and they don't know me.

So, it's better that they see somebody that knows the patient, that they recognize. And number two, that they speak to them and calm them down so that they can explain in their language or in their environment what's going on. And if you have a calm family member that also happens to calm the patient.

So that's one of the things, a lot of communication, a lot of education to the patient and empowering them to be part of the care team.

Umur Hatipoglu, MD:

Yeah, that's great. And you said empowering, which is a very important word there. So, let me ask you, what should patient relatives or loved one's demand of us? What, what should be the behaviors that they should expect in terms of communication, for example?

Eduardo Mireles-Cabodevila, MD:

I think that the first one is that you are approached in a respectful way, that we listen to your questions, that we answer your questions. There is no dumb question. There is no bad question. We want to hear what is going through your mind.

There are a lot of times that our patients hear something that we say, they don't understand it and they interpret it as they wish. So, good practice and something to the man is that all your questions are answered. And number two, and I think that in general it is a good practice is to say, "What did you understand from what I just said?"

Umur Hatipoglu, MD:

Yeah.

Eduardo Mireles-Cabodevila, MD:

What do you think we're doing for your loved one? What is the plan for today? This holistic view of having the family member, not just the patient, the family member and the patient involved in the decisions of care and on understanding why we're doing this helps us understand the direction where you're going.

Because if you don't know, and you just see yourself hooked to all these machines days on end, it can bring a lot of challenges to, "Well, am I going to recover about this?" Right? So, all those questions, you should interact with your care team and have them answered to your satisfaction. That's a key item that you should demand.

Umur Hatipoglu, MD:

Yeah, absolutely. And I think, you know, obviously we don't expect family members to be at the bedside all the time, right?

Eduardo Mireles-Cabodevila, MD:

Yeah.

Umur Hatipoglu, MD:

We're early birds. We round early. They may not be at the bedside, but whenever they are, we call them out and be part of the rounds, right? To be part of rounds. And that typically generates questions and improves communication between us and, you know, patient caregivers.

Eduardo Mireles-Cabodevila, MD:

Yeah. Especially in the ICU, as I said, there's 15 roles that are going to be going into the room. And so sometimes this person comes in, tells you one thing. The other one comes out and you're going to have several people going in and out of the room. And that can really leave you with a confusion of so many things. So the same way that we ask to have a spokesperson for the family so that the communication is consistent because if you start informing every single family member, then there's all these items that will happen the same way you should recognize within the care team, who is the spokesperson that is going to filter and correct the amount of information.

So, in the medical ICU of the Cleveland Clinic, it's a closed unit for that reason, because the staff and the the fellow are the ones that drive that conversation that is sure that there is a consistent message because there's going to be a whole army of people going through your bedside conveying messages. And sometimes because that confusing. And it's expected because you're going to have people that come and see it from the heart standpoint or from the surgical standpoint and the goal of the critical care intensivist and respiratory support provider is to see you from a holistic point and put everything under context.

Umur Hatipoglu, MD:

Yeah. So, one thing then the patient relative should demand is, who's the boss here? Who should I talk to? Who's the quarterback? Identify yourself.

There's nothing wrong with that. You should really demand that. That's great. Eduardo, you know, I've, I've heard it said from patients and patient relatives, that particularly for patients who have underlying cardiopulmonary disease, once they're on mechanical ventilation, they're on mechanical ventilation and they go to a nursing home. So, I've even heard it said that mechanical ventilation is addictive. Should we involve the DEA?

Eduardo Mireles-Cabodevila, MD:

No, that's actually one of those items that we have been working a lot into changing the perception into the layman community, which is not the minority actually of the patients end up requiring what we call prolonged mechanical ventilation. In the rest, they are relatively short-lived episodes. So, the majority of the surgical patients that go on mechanical ventilation get liberated after the surgery.

In the medical ICU for patients that are coming with respiratory failure, on average, usually the length of stay on mechanical ventilation is around, depending on the cause, around 7 to 14 days depending on how severe the process is. But there's a group that may require what we call prolonged mechanical ventilation. And this is not due to the fact that the patient got placed on mechanical ventilation.

It's certainly the patients that get placed on mechanical ventilation that require support to support their oxygenation or their gas exchange in general. And some of them may have other conditions that make it harder for them to breathe unassisted, meaning without the ventilator. Things like malnutrition, things like muscle weakness, things like having a lot of fluid in your body. Or, lastly, that the problem that caused it has not been solved, that continues to complicate through there.

And none of those, as you can imagine, solve themselves from one day to the other. I cannot make you nourished in one day. I cannot get you strong, sorry, Umur, in one day.

Umur Hatipoglu, MD:

Well, lose weight in my case. You cannot do that in one day.

Eduardo Mireles-Cabodevila, MD:

You cannot do that. And so, it takes time, and we have teams that specialize in that. And some of them are in those environments that you call the long-term acute care hospitals that really focus on getting patients stronger, getting patients nourished, getting rid of all that fluid, continue to treat the cause. And so, we do those types of care for patients that are going to require that prolonged weaning or prolonged liberation from the ventilator. The other fact that I also hear a lot is, "Oh, if they put you on mechanical ventilation, you're dead."

And the mortality rate is very high. That happened during COVID as you recall. And the message in general is that that's not true. I mean, it's a complete lie. We put you because you're at risk.

Umur Hatipoglu, MD:

You need it.

Eduardo Mireles-Cabodevila, MD:

Yes. Without it, you would die. And so many of those patients do go on to die, but they die from the disease, not from the mechanical ventilator itself. That's good that you brought those out. So, in plain terms, number one, the mechanical ventilator is not addictive. And number two, the mechanical ventilation does not cause death by itself. So, it's not, you're on it and you die.

Umur Hatipoglu, MD:

Yeah, that's perfect. I remember that discussion about COVID. And in the end, when numbers shook out, right? COVID causes a condition called acute respiratory distress syndrome. And the mortality of COVID ARDS was not that different from regular ARDS. So, it's really interesting. Another, you know, area that our listeners may be interested in is the issue of tracheostomy, this hole in the windpipe that we use to facilitate prolonged mechanical ventilation. And there are some misconceptions about that too, that, you know, once you have a tracheostomy, you're nursing home bound and you're never going to come off the ventilator. What are the facts about that, Eduardo?

Eduardo Mireles-Cabodevila, MD:

So, a tracheostomy is essentially replacing the tube that is going through your mouth. Sometimes we place it actually even in patients that do not have a tube in their mouth. It's a way to maintain the passage of air safely into your lungs.

And as such, it has many different causes for it to go in. Sometimes it's because of a patient that we could not free from the vent mechanical ventilation fast enough. Right? But for others it's because they have an obstruction of the airway, and they need that temporarily.

The same way that trash goes in, trash goes out. A large number of our patients get what we call decannulated, meaning that we remove the cannula, the tracheostomy gets pulled out. And once that you pull it out, it within a day, actually within hours, and you've seen this, that we pull out the trach and the hole start closing very rapidly. And so, the fear of, you know, this is gonna be there forever. It's not a terminal event.

Umur Hatipoglu, MD:

It's not.

Eduardo Mireles-Cabodevila, MD:

Exactly. It's not a terminal event. I think that the key question here that the family should ask is, "I mean, you're placing this, what caused this and is the cause solvable?" And so, when, the problem is solvable and it's a matter of time, for example, getting rid of the fluid, getting nourished, getting strong, letting those lungs heal, then you know that there's a path at the end of the tunnel in which that trach is going to come out. Even if you go to a long-term acute care facility, patients get decannulated daily in this environment. And although it does leave a scar because it's a surgical procedure or a procedure itself, it is not a thing that you need to go back into the OR to close it.

Umur Hatipoglu, MD:

Yeah.

Eduardo Mireles-Cabodevila, MD:

In some rare cases you have to, but it's the majority of the time we pull it out and it closes. And so be it. So, a very useful tool. It allows us to care for patients better in certain instances, but obviously we just do it when we know that we cannot remove the tube in the near term because we rather not do it. You have nothing rather than that.

Umur Hatipoglu, MD:

Yeah. So, it sounds like this is really a procedure that facilitates comfort and safety of the patient who requires prolonged mechanical ventilation and it's completely reversible, right?

Eduardo Mireles-Cabodevila, MD:

Completely reversible. And I would ask you, I mean, in your practice, how do you approach this with the families? What do you tell family and the patient when you're going to put them on a tracheostomy?

Umur Hatipoglu, MD:

Yeah, so I basically say exactly what I told you, which is, "This is a procedure, a relatively easy procedure now that we perform at the bedside that will facilitate coming off the ventilator, liberation from the ventilator." And I am outright with possible complications. There could be bleeding during the surgery. There could be sometimes narrowing of the windpipe after the surgery. There could be infections associated with prolonged mechanical ventilation, not necessarily with tracheostomy.

But this is something that is really for the good of the patients. And most patients eventually become liberated from the mechanical ventilator. And the other thing they ask is, you know, "Can he eat? Can she eat? Can she talk? Can he talk?" And the answers to those questions are yes, as you know.

As patients improve, they are able to take oral food with a tracheostomy in place and they are able to talk with very simple devices that facilitate phonation. Well, this has been a great conversation, Eduardo. We're at the end of our podcast. I'd like to thank all of our listeners for tuning in.

My guest today was Eduardo Mireles-Cabodevila, who is the director of the medical intensive care unit at the Cleveland Clinic Main Campus, also the vice chair of the Department of Critical Care Medicine. And I'm Umur Hatipoglu, your host, and I bid you farewell. Until next time.

Raed Dweik, MD:

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.