Simulation: From Bench to Clinical Practice
Teresa Volsko, MHHS, RRT, FAARC; Director, Respiratory Care, Transport and the Communication Center, Akron Children’s Hospital
The Department of Respiratory Care at Akron Children’s Hospital (ACH) used the ASL 5000™ Breathing Simulator to improve the transitioning of patients from ICU to home care ventilators. In our project highlighted below, registered respiratory therapists (RRTs) used information gained through simulation to change the way we provide bedside care.
Patient Model Validation
In conjunction with a Rush University graduate respiratory student, we used the ASL 5000 to construct and validate models based upon the pulmonary mechanics of healthy infants and children and those with pulmonary pathophysiology. We created models for patients who most likely required home ventilatory support – an infant with severe BPD, and a pediatric patient with neuromuscular disease; as well as two control models – a neonate with RDS and a pediatric patient without lung disease.
Portable Ventilator Performance Testing
Once validated, the models were used to test the performance characteristics of four portable ventilators frequently used for home ventilatory support for our patients. Figure 1 provides representative waveforms captured by the ASL 5000 after breath stabilization and during data collection for each ventilator tested.
This experiment demonstrated how each ventilator reacted differently when lung disease was present. The figure shows that some ventilators auto-trigger when connected to a healthy control and/or chronic lung disease model. Auto-PEEP was detected with every model type and each ventilator tested. This was an important finding and helpful in understanding why our patients had difficulty transitioning from an ICU to a home care ventilator. We used this information to construct ventilator information tables (Table 1).
Several devices fell outside of the +10% ASTM international standards for tidal volume and inspiratory time. We shared these results with our pediatric pulmonary and ICU physicians. Since no device was clearly superior in all aspects of the evaluation, the Akron team decided to manage the transition of patients from ICU to home care ventilator on a case by case basis.
Reducing Guesswork with Real-Patient Simulation
Our team of physicians and RRTs implemented a plan to model the pulmonary characteristics of each individual child ordered to transition from an ICU ventilator to a portable home ventilator.
Prior to transitioning a patient from an ICU to a home care ventilator, the patient’s pulmonary characteristics are obtained from the ICU ventilator (inspiratory VT, RR, spontaneous TI, airways resistance and pulmonary compliance) and then modeled with the ASL 5000 Breathing Simulator. The RRT then attaches the ventilator to the ASL 5000 and adjusts the ventilator parameters to optimize synchrony with the specific patient model. This sometimes means selecting a different mode of ventilation or a different ventilator.
“Our research also reinforced the value of using the ASL 5000 to better understand the operational characteristics of the equipment our RRTs use. Most importantly, we demonstrated that RRTs can use the ASL 5000 to drive clinical changes at the bedside.”Teresa Volsko, MHHS, RRT, FAARC; Director, Respiratory Care, Akron Children’s Hospital
The RRT discusses the setting selection with the attending physician and then transitions the patient to the portable ventilator. A process that took a few days conducting trials of different ventilator settings with the child now takes less than 30 minutes with the patient. Nhi Haines, RRT is the principle investigator of an IRB approved study using the ASL 5000 modeling to improve transition from ICU to home care ventilators.
Our work transformed a graduate research bench study into a process for improving the care we provide to children with chronic ventilatory needs. Our research also reinforced the value of using the ASL 5000 to better understand the operational characteristics of the equipment our RRTs use. Most importantly, we demonstrated that RRTs can use the ASL 5000 to drive clinical changes at the bedside.