Increasing safety in mechanical ventilation

Contents

• The dark ages

• Aviation and medicine – what we can learn

• The Ventilation Cockpit …

• … and beyond

The dark ages

L‘AVENIR DE LA VENTILATION MÉCANIQUE

• Simple, efficace et sure…

See also: Five system barriers to achieving ultrasafe health care. Amalberti et.al. Ann Intern Med. 2005; 142:756-764

The sad truth

• The dominant contributing factor to patient death on ventilators was inadequate orientation/training (1)

• Errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge or judgment(2)

1. "Root Cause Analysis of 23 deaths or injuries related to long term ventilation" by the Joint Commission on Accreditation of Healthcare Organizations, Sentinel Event Alert 26.2.2002 byJCAHO

2. Causes and prevention of laparoscopic bile duct injuries. Lawrence et.al. 2003, Ann. of Surgery237:460-469

Recent insights into medical errors

What we see…

… is often what we believe we see

The reality: To err is human

…it is becoming clear that progress (in improving patient safety, ed.) requires substantial, long-term effort directed at supporting human performance rather than trying to prevent its failure (1)

1. Woods et.al. Perspectives on human error: Hingsight biases and local rationality. In Durso FT et. Al. Handbook of applied cognition, New York, Eiley&Sons 1999:141-171

Aviation and medicine:what we can learn

A key issue: situation awareness (SA)

DecisionPerformance

ofActions

State of the

Environment

Epidemiology of disasters (US air accidents)

Jones, D.G. and Endsley, M.R. (1995). Investigation of situation awareness errors. In Proceedings of the Eighth International Symposium on Aviation Psychology, Columbus, OH: Ohio State University Press.

over50%

What makes commercial aviation safe?

• Improved situation awareness

• Appropriate automation (e.g. autopilot)

• Reliable equipment platforms

• Advanced crew training methods

The past

machinemachine act

IntegrateInterpreteEvaluateDecide

data

The present

act

evaluatedecide

integrateinterprete

visualization

What makes ICU ventilation safer?

• Improved situation awareness

• Appropriate automation (e.g. autopilot)

• Reliable equipment platforms

• Advanced ICU-team training methods

Patient

Improving situation awareness (SA)

The dominant contributing factor to patient death…

... inadequate orientation/training: are you surprised?

Drews et.al. The right picture is worth a thousand numbers: data display in anesthesia. HUMAN FACTORS 2006, Vol 48

Drews et.al.: Current numerical and waveform displays do not supportanaesthesiologists optimally.

The Ventilation Cockpit: Augmented Situation Awareness + Autopilot

Ventilation Cockpit improves Situation Awareness

• Inform on the present status (How much ventilatory supportdoes the patient have? What is the status of the patient? Is theventilator operating normally?)

• Bring the present status in relation to the target(What direction, weaning or WOB unload? How fast? What level of support?)

• Alert if something unexpected happens (malfunction, acute exarcebation, etc.)

The HAMILTON-G5 provides improved SA

Highly visiblealarm lamp

Simplifiedmonitoring

Improve SA: Inform on present status

symmetric lung, nicelymovingno airway obstructionpatient activity

oxygenation OKCO2 elimination OKsponaneous activiy OK

Improve SA: Bring present status in relation to target

symmetric lung, nicelymovingno airway obstructionpatient activity

oxygenation target achievedCO2 elimination target achievedsponaneous activiy target achieved

=> Weaning target achieved

Improve SA: Alert if something unexpected happens

=> No alarm – patient and ventilator states are consistent

Example ARDS

asymmetric stiff lungslight airwayobstructionno patient activity

oxygenation not OKCO2 elimination not OKsponaneous activiy not OK

=> No alarm – patient and ventilator states are consistent

Attention: you are still in charge!

• The Dynamic Lung tells you how the patient’s lung are doing. It does not tell you how to treat the patient

• The Vent Status tells you how much the ventilator supports the patient. It does not tell you how to set the ventilator!

A ventilation „autopilot“

• Prevention of ventilator induced lung injury• Strain-stress related (breath pattern)• Gross overdistention (pneumothorax)• Limiting plateau pressure

• Lung protective ventilation• Appropriate tidal volume• (Appropriate PEEP level)• (Appropriate FiO2)

• Strict adherence to protocol

The HAMILTON-G5 combines SA with autopilot

Integratedmonitoring

Autopilot:

Adaptive Support Ventilation ASV

The proof is in the pudding

Wachter et.al. The evaluation of a pulmonary display to detect adverse respiratory events using high resolution human simulator. J Am Med Inform Assoc. 2006:635-642

Drews et.al. The right picture is worth a thousand numbers: data display inanesthesia. HUMAN FACTORS 2006, Vol 48

Intelligent Ventilation

Try me!