An interview with Jessica Dietz, MS, RRT and Kimber Catullo, BSRC, RRT – Clinical Educators with IngMar Medical.
Q: IngMar recently released new Patient-Ventilator Synchrony Modules for its RespiSim System. Just why is dysynchrony such a prevalent problem in patient respiratory care?
A: Because every patient and disease state is different. This creates a huge amount of variability, making it incredibly difficult to maintain the proper ventilator settings. This common situation is exactly what these new modules address.
Q: What is so unique about the IngMar training modules — doesn’t similar training already exist?
A: We don’t know of any comparable training available elsewhere. The key unique factor about our training is the presence of the ASL 5000 and its ability to accurately reproduce spontaneous breathing. Without this spontaneous breathing, it is very difficult, if not impossible, to accurately reproduce dysynchrony in the clinical training and simulation environments. Also, we break the training down to a very granular level, so that the repetition and practice of each step and scenario can be highlighted. Accomplishing this without the ASL 5000 would be very difficult.
Q: Don’t clinical staff receive training on managing dysynchrony as part of their medical education?
A: Yes, they do. However, because of the different types of dysynchrony and all of the many variables present in patient-ventilator interaction, clinical staff need hands-on practice and experience. Patient states change constantly. Time, practice, and continual training, such as with our modules, really lock in the knowledge necessary to recognize and manage dysynchrony proficiently.
Q: What are the main goals of the modules?
A: The main goals are improved patient care and comfort. Also critical is the prevention of lung damage, resulting from improper ventilator management, which is more common than you might think. In fact, there is an acronym for this phenomenon – VILI – ventilator-induced lung injury.
Q: Who is the learning audience for these new modules?
A: The intended audience for these new modules is primarily respiratory therapists, doctors, and nurses. The modules are not just for beginners, but are also appropriate for seasoned professionals who need continuing education to maintain their skills in this critical area of respiratory care.
Q: Do you believe that going through interactive, hands-on training such as this ultimately results in better patient care?
A: Yes. The interactive and hands-on aspects of our modules are critical to successful learning outcomes because they ultimately help develop critical psycho-motor skills.
Learn more about the types of dysynchrony presented in the modules.
An interview with Jessica Dietz and Kimber Catullo, Clinical Educators with IngMar Medical
Q: IngMar has recently released new Clinical Exam Prep Curriculum Modules for its RespiSim System. What is unique about these Curriculum Modules and why is this an important development for the profession?
A: These modules are geared toward the National Board for Respiratory Care (NBRC) Clinical Simulation Examination taken by all respiratory therapists in order to join the registry. The modules are a good preparation because they focus on the clinical assessment and critical thinking skills tested in the exam. Using hands-on simulation with a real ventilator is a unique approach to exam prep. As far as we know, this has never been done before. The goal of simulation training is to produce better clinicians – by cementing knowledge firmly into place with hands-on experience. This helps develop the “muscle memory” that is so important to successful patient care. These modules take the student to a level that goes well beyond just passing the test.
Q: How realistic is this curriculum in terms of simulating clinical reality and real-life patient scenarios?
A: It is a very realistic approach because it’s immersive and even includes a functioning manikin. Using equipment that improves realism allows students to learn how to think on their feet – to adapt to rapidly-changing scenarios involving patient/ventilator interaction, especially when the patient is spontaneously breathing.
Q: Why do the module cases consist of COPD, cardio-pulmonary, and trauma? Are these the most common patient states found in hospitals?
A: Not necessarily. It really has more to do with the fact that these cases are what is tested on the exam. Going forward, we will add more cases to the modules if customers need and request them.
Q: Can the modules be used for purposes other than preparing for the exam?
A: Yes, they can. The advanced modules help prepare you for actual patient care. They can definitely be used in the classroom, prior to the exam prep. They are unique in that they are educating students on the content behind the exam, helping to develop critical thinking skills.
Q: Do you believe that going through immersive, hands-on training such as this, ultimately results in better patient care?
A: Yes, because it tests you and prepares you for how to approach a patient scenario, using your critical thinking and bedside assessment skills. Students can be “book-smart,” but yet not competent at the bedside. This more realistic, immersive, hands-on format absolutely helps to produce better Respiratory Therapists in the end.
The world’s most advanced system for ventilator management training just got even better. Software 3.6 for the RespiSim® System is more intuitive and user friendly than ever before. Below is an interview with IngMar Medical President Dr.-Ing. Stefan Frembgen.
Q: What makes Software 3.6 so exciting?
Stefan: Software 3.6 offers a whole new level of simplicity for educators. It takes the idea of our RespiSim System, that is, to deploy plug-and-play ready simulation modules for ventilator management training, to a level where the beginning learner can start with just basic patient models. We call it the QuickChoice Menu – an instructor can pick from a library of patients and start right away.
We also added a very visual teaching aid for respiratory mechanic basics – the Equation of Motion screen. Students need to understand this concept. Seeing how breathing parameters shift during a breath is a great way to foster this kind of understanding.
Q: How will Software 3.6 change the way educators teach mechanical ventilation concepts?
Stefan: Educators will find that it is much easier to pull together some quick simulation scenarios when they are talking about basic challenges in managing a patient on a ventilator. Using the QuickChoice menu as a starting point for more complex scenarios will also result in more educators designing their own scenarios instead of relying on what they buy as full-featured RespiSim modules from IngMar Medical.
Q: What is your personal favorite feature of Software 3.6?
Stefan: It definitively is the Advanced Waveform View with the Equation of Motion bar graph. It’s just so nice to be able to slowly move through a single breath in a time warp while explaining what is actually happening in the patient’s lungs.
Q: What is the benefit of upgrading your current IngMar Medical product to Software 3.6?
Stefan: There are a host of small improvements that stem from what our clinical educators brought back from visits in the field. They see first-hand how customers use the software and what the wish list looks like. So it’s a no-brainer to get the upgrade if you are an educational customer and use RespiSim or the ASL 5000 Breathing Simulator to teach ventilator management, in my view.
Interview with Amanda Dexter, module co-author (with Eric Kriner)
Q: IngMar Medical will be releasing its new Initiation of Mechanical Ventilation Modules for the RespiSim® System shortly. Why is this topic important?
A: This is a high-stakes emergency situation where the Respiratory Therapist (RT) plays a central role. Everyone is relying on the RT to be the expert and take charge. Unfortunately, there are no nationally accepted guidelines for initiating mechanical ventilation or for setting alarms. Guidelines vary from school to school and from hospital to hospital, therefore students need to have a deep understanding of lung mechanics.
Q: What are some common problems that occur when initiating mechanical ventilation?
A: People tend to use the modes they feel most comfortable with – this is understandable in a high-risk situation. However, sometimes the modes used are not appropriate for the particular patient. RT’s can also be timid about using spontaneous modes at initiation. Setting the correct alarms can be a challenge. Students can forget that a patient may require mechanical ventilation for reasons other than a problem with the lungs. For example, patients with a drug overdose often cannot breathe on their own as a result of a neurological issue, not a lung issue.
Q: What can be the impact of those errors?
A: Using an inappropriate mode can result in a longer time on the ventilator. If alarms are not set correctly, alarm fatigue can occur. This is a serious patient safety concern.
Q: How can simulation training help?
A: Simulation training allows students and clinicians to become comfortable with a wide range of ventilator modes. Learners can experiment, take risks, and practice individual skills and teamwork without harming patients. You can also fast-forward to a point when the patient’s condition or their effort has changed.
Q: Can you walk me though how the new “Initiation of Mechanical Ventilation” modules work?
A: Learners get to experience the whole process, starting with intubating the RespiPatient manikin. The learners then must set up the initial ventilation and alarms according to the flowchart. Then we fast-forward four hours and the ventilator is alarming because the patient’s condition has changed. The student must adjust the ventilator and alarm settings, making sure to record ventilator and alarm settings on their flow sheets. See example.
There are ten different modules so learners can become familiar with a wide range of cases.
Q: Will these modules help students pass the NBRC Simulation exam?
A: Initiating mechanical ventilation is big topic in the NBRC SIM exam. Practicing the analytic and hands-on skills should help to deepen and anchor knowledge. We are also working on a set of modules specifically designed to help prepare for the NBRC SIM exam.
An interview with Dr.-Ing. Stefan Frembgen, President of IngMar Medical
How did IngMar Medical get involved in ventilator management training?
Before establishing IngMar Medical in 1993, I worked in the ventilator industry. IngMar Medical’s flagship product, the ASL 5000™ Breathing Simulator was originally designed for the respiratory device research and engineering community. It has indeed established itself as an essential tool in R&D departments of all major ventilator manufacturers.
However, the ASL 5000’s unique ability to simulate spontaneous breathing in the whole range of patients encountered in the ICU and NICU made it an excellent tool for teaching about managing patients on the more advanced modes available with modern ICU ventilators. Recognizing this, we set out to create a unique system to leverage the power of the ASL 5000 for teaching ventilator management.
Why is there a need for ventilator management training?
At the recent AAMI/FDA Summit on Ventilator Technology, the call for more extensive and consistent training was repeated over and again. A quarter century after the advent of graphics on ICU ventilators, it cannot be said that the potential of this tool is fully understood nor routinely applied. While new modes enable better treatment, they do not necessarily make ventilator management easier. The plethora of names for modes and the lack of user interface standardization create confusion.
This points to the need for a significantly increased depth of education in the art of ventilator graphics interpretation, and the diagnostic and caregiver skills to match. Let us make no mistake: In order to significantly improve outcomes for patients critically impaired in their ability to breathe, more resources, both time and financial, need to be dedicated to teaching the art of ventilator management. Simulation, if done in an efficient way, has the potential to give maximum results with manageable allocation of resources.
What do you mean by efficiency?
Efficiency, from the perspective of an educator, has many aspects:
- Minimum time to prepare high-impact learning materials and cases
- Well thought-out integration of simulation sessions into an overall curriculum covering relevant topics of ventilator management
- Flexibility to adapt materials and scenarios to the level of the students being taught
The RespiSim® System has been designed with all these requirements in mind. It enables the creation of different types of patients and disease states within curriculum designed by leading educators around ventilator management.
Can the RespiSim System be used for competency testing?
The System can be used to simulate nearly any respiratory patient on any ventilator in any mode and to even record data from a multitude of ICU ventilators directly. It is a tool for education as well as for competency testing.
What is IngMar Medical’s vision for RespiSim?
We would like to give educators a “clinical flight simulator” to enable efficient, immersive learning and competency testing to improve patient outcomes. Another part of our vision for the RespiSim System includes facilitating collaboration within the respiratory care community resulting in time savings for instructors, more consistent training, higher skill levels, and ultimately better patient care.
A recent study conducted at Mass General Hospital in Boston found that the leak-compensation performance of ventilators used for pediatric NIV varied widely. Using the ASL 5000 Breathing Simulator, the study examined the ability of acute care ventilators to prevent triggering and cycling asynchrony in the presence of leaks during pediatric NIV.
The study by Oto, Chenelle, Marchese, and Kacmarek found that smaller patient size, obstructive lung mechanics, and higher system leak decreased the ventilator’s ability to synchronize during NIV. The study also found wide differences between the ventilators tested in their ability to synchronize.
The study “A Comparison of Leak Compensation During Pediatric Noninvasive Ventilation: A Lung Model Study” was published in the February 2014 issue of Respiratory Care.
It is evident in both clinical practice and research that patient-ventilator dysynchrony is far too common. This “tug of war” between the patient and ventilator is associated with adverse effects such as increased WOB, discomfort, increased need for sedation, prolonged ICU stay, and possibly higher mortality rates.
To give clinicians hands-on experience recognizing and correcting dysynchrony, we have created a new RespiSim®-PVI Curriculum Module with four clinical simulations.