NO News Critical Care · Medical Center, Coimbatore, India Evaluation of a ventilator solution in a mobile ICU The Mobile ICU Project Members, Kristianstad Regional Hospital and KAMBER-Skåne,

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Global intensive caring – by means of lung protectiveventilation strategies

ICU implementation and clinical application of non-invasive ventilation protocolsGuilherme Schettino, MD, PhD, Director of the ICU at Sirio-Libanes, São Paulo, Brazil

NAVA – past, present and future perceptionsThe Intensive Care Unit of theDepartment of Anesthesia andIntensive Care, Ospedale Maggioredella Carità, Novara, Italy

Open Lung methodology in ARDS patientsDr Gopalakrishnan Raman, ChiefConsultant of the medical ICU and Dr VR Pattabhi Raman, Pulmonologist, KovaiMedical Center, Coimbatore, India

Evaluation of a ventilatorsolution in a mobile ICUThe Mobile ICU Project Members,Kristianstad Regional Hospital andKAMBER-Skåne, RegionalAmbulance Transport Service.

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Clinical evaluation of NAVA in a series of pediatric ICU patients

Dr Brendan O'Hare, Director of Intensive Care Our Lady’s Children's Hospital Crumlin, Dublin

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Critical Care

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This document is intended to provide information to an international audience outside of the US.

22 || CCrriittiiccaall CCaarree NNeewwss

Global intensive caring – by means of lung protective ventilation strategies

This issue of Critical Care News features articles from ICU departments from a wide range ofgeographical locations: Sao Paulo, Brazil; Coimbatore, India; Novara, Italy; Dublin, Ireland and a regionalhospital serving patients from southern Sweden. What do these institutions in such contrasting areas of the world have in common, in addition to the worldwide ICU nursing shortage?

One common denominator for all of these intensive care units is a continuing focus on lung protective,patient friendly ventilation therapies. Their mutual belief seems to be to strive for such gentle, synchronizedand lung protective therapies as possible for the mechanically ventilated patient, and to get the patientoff the ventilator at the earliest opportunity.

This issue of Critical Care News highlightsa wide range of ventilation strategiesused at various ICU departments aroundthe world, in their continuing efforts toachieve lung protection and patient comfort.

NNeeuurraallllyy AAddjjuusstteedd VVeennttiillaattoorryy AAssssiisstt –– NNAAVVAAiinn aa sseerriieess ooff nneeoonnaattaall aanndd ppeeddiiaattrriicc ppaattiieennttssiinn DDuubblliinn

The continuing global interest of theintensive care community in NAVA

as a means to provide improved patientventilator synchrony has led to a clinicalevaluation of NAVA at Our Lady’s Children’sHospital Crumlin in Dublin, Ireland.

The clinical evaluation has engaged andinvolved many ICU staff members, includingphysicians, nurses and clinical engineers,and parents as well. The staff membersshare their experiences, observations andexcitement in connection with the clinicalevaluation, as well as some of their thoughts

on the possible future cultural shift frompneumatically driven ventilation therapiesto ventilation that is neurally based.

CClliinniiccaall iimmpplleemmeennttaattiioonn ooff nnoonn--iinnvvaassiivveevveennttiillaattiioonn pprroottooccoollss

The first Intensive Care Unit in Brazil at Hospital Sirio-Libanes in Sao Paulo,Brazil, has implemented strategies and protocols for weaning patientsmechanically ventilated for over 48 hours,

Dr Brendan O'Hare, with NAVA patient, parents and staff in Dublin.

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to extubation or to non-invasive ventilationwith a protocol developed according tocurrent guidelines in research andliterature. Dr Guilherme Schettino, who is internationally known for his research in mechanical ventilation and non-invasive ventilation therapy, shares hisexperiences in regard to the utilizationand implementation of these protocols.

NNAAVVAA ffrroomm aa hhiissttoorriiccaall ppeerrssppeeccttiivvee aannddccuurrrreenntt cclliinniiccaall oobbsseerrvvaattiioonnss

Neurally Adjusted Ventilatory Assist,as a new approach to improve patient-ventilator interaction, was first reportedby Christer Sinderby and published inNature Medicine in 1999. Dr Paolo

Navalesi participated in this initialresearch, and is currently involved in an ongoing clinical evaluation of NAVA in adult patients together with his ICUcolleagues at the Ospedale Maggioredella Carità in Novara, Italy.

EExxppeerriieenncceess wwiitthh lluunngg rreeccrruuiittmmeenntt iinn AARRDDSS ppaattiieennttss

The medical ICU of the Kovai MedicalCenter and Hospital in Coimbatore, Indiahas been investigating and utilizing lungprotective strategies in ARDS patients formany years. For the past two years, thestaff have been gaining experience with a lung recruitment tool with a protocol for titration of physiological endpoints.

Hospital Sirio-Libanes, Sao Paulo

Dr Gopalakrishnan Raman,

Coimbatore, India.Dr Paolo Navalesi, Novara, Italy

Mobile ICU patient and nurses at Kristianstad Regional Hospital, Sweden.

LLuunngg pprrootteeccttiivvee vveennttiillaattiioonn aanndd ppaattiieennttccoommffoorrtt iinn aa mmoobbiillee IICCUU

Regional transport of critical care patientsbetween hospitals is becoming a commonsituation in densely populated metropolitanregions, where availability of ICU specialtycare and procedures is being optimizedamong hospital institutions. The KristianstadRegional Hospital in the south of Swedenhas been creating solutions within thisarea for the past 30 years. The ICU staffand project team members share theirexperiences and data in the creation of a customized mobile ICU solution tomaintain ventilatory care and comfortduring ICU patient transports.


Clinical evaluation of NAVA in a series of pediatric ICU patients

Our Lady’s Children's Hospital Crumlin in Dublin is the largest pediatric hospital in Ireland, and isresponsible for providing the majority of tertiary care services for children. The hospital is also a leadingresearch and educational institution in Ireland, and provides training to undergraduate students fromUniversity College and Trinity College in Dublin as well as The Royal College of Surgeons in Ireland. The Children’s Research Center, based in the hospital, generates many scientific publications and has an international reputation in pediatric medicine.

The most recent research at the pediatric ICU at Our Lady’s Children’s Hospital Crumlin has been anevaluation study of Neurally Adjusted Ventilatory Assist – NAVA. Critical Care News met with the keyinvestigative physicians and other staff members involved in the study.

Dr Brendan O´Hare with 2 week old NAVA patient and parents.


Critical Care News spoke with Dr BrendanO’Hare, who is a Consultant PaediatricAnaesthetist and Director of IntensiveCare at Our Lady’s Children’s HospitalCrumlin. He reported his experiences and perceptions of NAVA in the series ofpatients in the evaluation study, as wellas his thoughts for potential opportunitieswith NAVA in the future.

CCaann yyoouu ggiivvee uuss ssoommee bbaacckkggrroouunnddaabboouutt yyoouurr iinnssttiittuuttiioonn aanndd hhooww yyoouurroorrggaanniissaattiioonn bbeeccaammee iinnvvoollvveedd iinn tthheeNNAAVVAA eevvaalluuaattiioonn ssttuuddyy??

To give a sense of our department andwhat we do, we are a multidisciplinary

unit encompassing 26 beds, 850-900patients per annum, including pediatricICU, high dependency care andtransitional care unit, with intensive carefacilities located on three levels in thehospital. We have a high infant patientpopulation, of which 25% are neonates, andup to 70% need some sort of ventilatoryassistance. About 40% of our workload iscardiac, as we are the National Center forthe Congenital Heart Disease Program inIreland, with approximately 350 surgicalcases per annum.

We have a dynamic relationship with our MAQUET representative, and wehave standardized our ventilation platform

with SERVO-i ventilators in recent years,as we have wanted a platform that wasrobust and reliable for the broad spectrumof patients we treat here. We first learnedabout NAVA from the same representative,and the concept of neurally adjustedventilatory assist as a new, excitingdimension in ventilatory management.After that, we attended an internationalNAVA workshop in The Netherlandsearlier this year, and that was ourbackground before agreeing to collaboratein the clinical evaluation study.

We are delighted to be part of what is quite an exciting time in ventilationresearch and development.

Dr Brendan O'Hare is Director of Intensive Care at Our Lady´s Children´s Hospital Crumlin in Dublin.


HHooww iiss tthhee NNAAVVAA eevvaalluuaattiioonn ssttuuddyypprrooggrreessssiinngg,, aanndd ccaann yyoouu tteellll uuss aabboouuttyyoouurr ccuurrrreenntt eexxppeerriieenncceess??

We have enrolled nine patients thus far, all ofwhom completed the trial protocol withoutany specific problems and all tolerated themode extremely well. Indeed one brittleinfant with pulmonary hypertension becamevery agitated and difficult to settle uponcompletion of the trial protocol whenattempting to re-establish the ventilatorystrategy that was in place pre NAVA.

WWhhiicchh ttyyppeess ooff ppaattiieenntt ccaatteeggoorriieess aarreeyyoouu ttrreeaattiinngg aatt tthhiiss ppooiinntt??

The predominant patient category wherewe have used NAVA so far are cardiacpost-op patients who have progressedthrough their initial post op course and areon the weaning phase.

We have also evaluated a two week old neonate with an arrhythmia-inducedcardiomyopathy with severelycompromised pulmonary compliance. My consistent observation is that togenerate effective minute ventilationbased on the parameters that we have,we are consistently achieving this usingNAVA with lower peak inspiratorypressures than would be required onPressure Support.

Upon observing the patients in our studya potential very attractive feature of NAVAis hinted at, namely that the Edi signalprovides us with the opportunity of anobjective, parametric measurement ofthe patient’s effort of breathing, whichcould be trended.

In the neonatal pediatric population, inconsidering the work of breathing and the

oxygen consumption and metabolic costof that in terms of asynchrony, I think weperceive the very valuable potential ofNAVA, where we might better marry theeffort to the machine. Better synchronymust potentially provide many benefits in this respect.

WWhhaatt ddoo yyoouu tthhiinnkk wwiillll bbee ooff iinntteerreessttrreeggaarrddiinngg NNAAVVAA iinn ffuuttuurree rreesseeaarrcchh??

In terms of future research, there areother aspects of NAVA that potentially areof interest as well. The ready availability of atrial electrocardiograms will open new horizons for arrhythmia diagnosisand management. Allowing for improvedsynchrony, the lower mean intrathoracicpressures that you are generating as aconsequence of the effect of tidalventilation at consistently lower meanairway pressure, NAVA presents us with

After 30 minutes of Pressure Support as per the clinical evaluation protocol, a marked decease in pressures was

noted after switching over to NAVA in this infant patient.


a scenario that may guarantee aneffective tidal ventilation with anotherfurther drop in our intrathoracic pressurefrom ventilation, which I think would be amajor area for research in future, in termsof hemodynamic performance in patients.These subtle differences may even bemore important in the sicker categories of patients. I think this is a ripe area forfurther research and investigation, lookingbeyond the respiratory mechanics.

AArree tthheerree aannyy ootthheerr ppaattiieenntt ccaatteeggoorriieesstthhaatt yyoouu fifinndd ttoo bbee ppootteennttiiaallllyyiinntteerreessttiinngg iinn ffuuttuurree??

Most of the patients in our validationstudy have been extubated twelve hourspost NAVA. Sometimes these patientscould benefit from an extra period of “noninvasive” ventilatory assistance followingtheir initial extubation and it would be very

attractive to be able to withdraw theendotracheal tube to above the vocalcords and still provide some ventilatorysupport via this supraglottic airway.

It would be attractive to see NAVA in this regard, since triggering in NAVA is independent of leaks and the wholeproblem of leakage, since triggeringdepends upon the electrical activity of the diaphragm in these children. Otherspecific populations that I would considerthat may benefit include infants withcongenital diaphragmatic hernia and the preemie group with IRDS.

HHaavvee yyoouu hhaadd aannyy ppaarrttiiccuullaarr ppaattiieennttccaasseess wwhheerree yyoouu hhaavvee mmaaddeeiinntteerreessttiinngg oobbsseerrvvaattiioonnss??

We have had an interesting scenario,where we had one patient generating

an impressive Edi potential which wasgreater than expected, who seemed to be doing reasonably well otherwise. This Edi profile was similar to earlier casereports of a partially paralyzed diaphragm,where the phrenic nerve was an issue.We pursued and screened to determinethat the phrenic nerve was fine, butinterestingly there was a substantialsubpulmonary effusion; the base of thelung was remote from the diaphragm andthere was a sequestered subpulmoniceffusion. The Edi signal gave us a clue as to the presence of this abnormality.

Phrenic nerve injury is a subtle clinicaldiagnosis, diagnosed radiologically, butsimpler means of detecting this earliercould be useful. NAVA may contribute to this more prompt appreciation of a significant abnormality.

In another neonate, even more contrast in decrease in pressures was noted when switching from Pressure Support

to NAVA, without significant changes in frequency.


Dr Martina Healy, Consultant Anaesthetistat Our Lady’s Hospital for Sick Children,has also been involved in the NAVAevaluation and shared her thoughts inregard to her experiences.

IInn tthhee eevvaalluuaattiioonn ssttuuddyy,, tthheerree hhaavveebbeeeenn aabboouutt 99 ppaattiieennttss iinn ttoottaall ssoo ffaarr,,hhooww mmaannyy ooff tthheessee hhaavvee yyoouu hhaaddeexxppeerriieennccee wwiitthh??

I have had experience with about 4 so far.Selecting the patients is not a problem;

we pick out the cardiac patients, and run 3 hours of NAVA as a weaning program.

WWhhaatt aarree yyoouurr ppeerrcceeppttiioonnss ssoo ffaarr??

The first patient was a 16 year old, a quitelarge patient who had a restrictive lungproblem. The positive impressions werenot as obvious in this patient as comparedto the neonates we later treated. Theneonates have a high respiratory rate andoften require a great deal of sedation justto keep their tube in, so my impression of

NAVA in these patients is that it seemsto be quite useful in this group.

HHaavvee yyoouu nnoottiicceedd aa ccoonnttrraasstt sswwiittcchhiinnggoovveerr ffrroomm PPrreessssuurree SSuuppppoorrtt ttoo NNAAVVAA??

Yes, I think that in the patients I have seen that they seem to be incrediblycomfortable when switching them over.As a point of interest, we tend to usePRVC with Automode as a verycomfortable mode of weaning, in thispatient category for straightforward

Dr Martina Healy is Consultant in Paediatric Anaesthesia and Intensive Care at Our Lady´s Children´s Hospital Crumlin in Dublin.


post-op situations, so it was interesting to observe that NAVA seems to provideeven more comfort and require lesssedation in these patients. It also seemsas though the smaller they are, the easierit is for the patients to do well on NAVA.

TThheessee ssppeecciifificc ppaattiieenntt eexxppeerriieenncceesshhaavvee bbeeeenn pprriimmaarriillyy ssmmaalllleerr cchhiillddrreenn..AArree tthhee EEddii ssiiggnnaallss ooff vvaalluuee iinn tthhiissppaattiieenntt ggrroouupp??

In the group of patients we have seen so far, Edi seems to have been of valuefor diagnostic purposes. Based on the Edi signals of one particular patient, we were wondering whether the patienthad a paralyzed diaphragm or not. It is early days yet, but I can certainly seewhere it could be useful in the future.

FFrroomm yyoouurr eexxppeerriieennccee aatt tthhiiss ppooiinntt,,wwhhaatt iiss tthhee mmoosstt iimmppoorrttaanntt tthhiinngg ttoo kknnooww aabboouutt NNAAVVAA??

Based on the current experience inweaning, it is important to have a group of patients who are ready to be weaned,where you want to require less sedation,less invasive weaning, you would use it.That is where I see the usefulness atpresent, based on my experience this far. Cardiothoracic post-op patients, to be weaned after surgery, seem to do very well on NAVA.

WWhhiicchh ttyyppeess ooff ppaattiieennttss aarree yyoouu mmoossttiinntteerreesstteedd iinn ggaaiinniinngg mmoorree eexxppeerriieenncceewwiitthh NNAAVVAA??

The group of neonates I see for potentialfor NAVA are the chronic lung diseasegroup. If they are on morphine, they willbe on it for longer periods of time, andsometimes the weaning period takesweeks rather than days in this group. If NAVA can provide better patientcomfort and less sedation in this group, I think it would be great.

We have not yet had any bronchialpulmonary dysplasia patients, usually we seem to get them in groups of threeor four, but of course we are curious howNAVA will work in these BPD patients.They also have a fast respiratory rate, and are on morphine and can becomeagitated when you try to wean them, so I think we are curious to see how NAVA

will work in these patients as well.

In general, I think we all find a group ofpatients who are difficult to wean, andeverybody is looking for a way to treatthose patients. These can includeasthmatics, pneumonia patients andthose with diaphragmatic hernias. Thereare general questions as to how to measurepeak pressures, and other values that wehave seen, such as PEEP, in pneumaticventilatory modes. NAVA is a totallydifferent concept, what you set on theventilator traditionally is not necessarilywhat the patient will set himself in NAVA.

You can see the difference in compliance– what NAVA has done is not only to helpus to look at what we set for the patients,

and how the patient requirement might differ, but it also makes us thinkabout how we are using the other modesand settings on the ventilator, in terms of lung compliance.

HHaavvee tthheerree bbeeeenn aannyy pprraaccttiiccaallccoonnssiiddeerraattiioonnss oorr ccoonncceerrnnss aatt tthhiiss ppooiinntt iinn tthhee eevvaalluuaattiioonn??

There really have been no issues in connection with the Edi catheterplacement, or from parents of patients in regard to the nasalgastric tubes. Themain concern from the parents has beenif their child will be disturbed in any way,and there is no disturbance, as once thenasogastric tubes are in, they can be leftthere for a few days anyway.

Dr Healy shared her thoughts in regard to her experiences with NAVA in the evaluation study.


Linda O’Donnell, RN, has been workingas a nurse for 20 years and is a ClinicalNurse Facilitator at Our Lady’s Hospitalfor Sick Children. She shared her firstimpressions and thoughts about NAVA.

WWhhaatt wweerree yyoouurr fifirrsstt iimmpprreessssiioonnss ooff NNAAVVAA??

I heard about the concept of NAVA fromthe clinical engineers, and then I learnedmore about it by means of the internet.

I have seen it on two or three patients.My initial impression was a somewhatdisappointed reaction, since I perceived itas an answer to be used to ventilate in allpatient groups, in different physiologicaland anatomical needs. At present, the

evaluation study might pose somelimitations. It appears that it might belimited in some groups such as phrenicnerve damage or muscular dystrophy,which are patient categories that needlong term ventilation, and that I hope tosee a solution for. But I think that theselimitations that I perceive at the presenttime might be due to our limitedexperience and knowledge of NAVA inthese patient categories, due in turn tothe limitations of the evaluation studyprotocol.

DDoo yyoouu sseeee aannyy ppootteennttiiaall wwiitthh NNAAVVAA iinn ffuuttuurree??

Absolutely, but we are in very early days. Until it gets into regular clinical

practice, we won’t know the full potential.At present, it appears that it works verywell as a means for weaning specificpatient categories, and I think that this is a safe and effective process ofdevelopment, to use it on these specific groups to begin with.

WWhhiicchh ppaattiieenntt ggrroouuppss ddoo yyoouu tthhiinnkk aarree tthhee mmoosstt iinntteerreessttiinngg iinn tthhee ffuuttuurree??

In terms of patients needing lungprotection, such as very small neonates or lung diseased patients whoare physiologically compromised already,such as BPD, this is the group we mostneed to help find solutions for, where it will be interesting to see how NAVA will help.

Clinical Nurse Facilitator Linda O´Donnell.


Members of the Clinical EngineeringDepartment at Our Lady’s Hospital forSick Children have been intensivelyinvolved in the NAVA clinical evaluationstudy from the onset. The staff hasextensive experience of differentventilation treatment modes andmodalities that have been introduced over the span of many years. Critical CareNews spoke with Jim Davenport, ChiefClinical Engineer, and Tony Fitzgerald,Principal Clinical Engineer about theirlatest experiences.

WWhhaatt aarree yyoouurr oobbsseerrvvaattiioonnss ffrroomm tthheeNNAAVVAA eevvaalluuaattiioonn ssttuuddyy aatt tthhiiss ppooiinntt??

JJiimm DDaavveennppoorrtt:: In general, it seems tobe working excellently, and the synchronywith the patient is quite remarkable. Thechildren are so comfortable on it. NAVAseems to coincide well with the naturalprogression as we have associated withthe SERVO ventilators for many years. It is

very interesting to see the diaphragmsignals activating the ventilator.

Basically we were surprised with NAVA to see all the additional informationcoming from the nasal gastric tube, whichyou have been putting down in many ofthese patients anyway.

HHaass iitt bbeeeenn ddiifffificcuulltt ttoo lleeaarrnn NNAAVVAA??

TToonnyy FFiittzzggeerraalldd:: No, not at all, but it canbe more user friendly in time. At this pointin time, you need to have a great deal ofunderstanding of what you are doing inNAVA in order to be able to use it effectively.From a patient perspective and a triggeringperspective, it looks fantastic so far, butfrom a user-perspective we simply have alot more to learn about the neural methodin terms of interpreting Edi signals andunderstanding the background ofswitches from NAVA to Pressure Support,and/or Pressure Control, and back to

NAVA again. It is a new way of thinking,and a lot of new terminology, whichpeople do not as yet have reference to.We have all been living in thePressure/Volume world for such a longtime, so that this is a clinical culturalchange for many of us.

JJiimm DDaavveennppoorrtt:: I agree, we have been educated and experienced in thepneumatic ventilatory mode environment,and now it seems that we are moving into the patient-neurally controlled future.At the moment we do not have manydefinitive answers on NAVA, since we are participating in the evaluation study.

But we observe that it has worked very well, and the children are comfortableon it, and even the parents have noticedthe difference. The parents are a little bitanxious about their children participating inthe study, but they seem to quickly noticethat their children are more comfortable.

Tony Fitzgerald, Principal Clinical Engineer, and Jim Davenport, Chief Clinical Engineer have been involved in the NAVA evaluation from

the beginning.


In fact, we had one father who couldn’tmake up his mind if his child shouldparticipate in the study, and he came over tosee NAVA in use on another child, and hesimply said, “Oh, yes, we will go for that!”

In future, I think it will make a hugedifference, especially with small babies,to make use of their diaphragmaticmuscle electrical activity.

BBiiooggrraapphhyy

Brendan O´Hare completed hismedical training and graduated withhonours from The Medical Faculty,University College Dublin, Ireland in1984. His surgical and medicalinternships took place at MaterHospital in 1984-1985, followed by atwo-year medical rotation at MaterHospital, Wexford General Hospitaland Louth County Hospital. Hisanaesthesia general professionaltraining took place at a number ofDublin hospitals during the years1987-1990, followed byanaesthesia/ICU higher professionaltraining during 1991-1992.

Brendan O`Hare was Clinical Fellowat the Department of Anesthesia and

the Department of Critical Care of theHospital for Sick Children in Toronto,Canada during the years of 1993-1994, and Research/Clinicalfellowship in the same hospital inToronto in 1995. He was SeniorClinical Fellow during 1995-1996 atthe Cardiac Intensive Care Unit of TheChildren’s Hospital and HarvardMedical School in Boston.

He is currently Consultant inAnaesthesia and Intensive Care, OurLady’s Hospital for Sick Children,Crumlin, Dublin, and ConsultantAnaesthetist, Royal Victoria Eye andEar Hospital, Dublin. He has wonnumerous distinctions, including theHynek Rothbart Award, Shields

Research Day, University of Torontoin 1995.

Brendan O´Hare has conducted andpublished research for a number ofyears, and is a frequent speaker atnational conferences. He is amember of many associations,including the Royal College ofPhysicians of Ireland, EuropeanSociety of Paediatric and NeonatalIntensive Care, Irish PaediatricAnaesthesia and Critical Care Society(convenor) and the Association ofPaediatric Anaesthetists of GreatBritain and Ireland.

TToonnyy FFiittzzggeerraalldd:: We have seen a lot ofexcitement among the other physicianshere, pediatricians and neonatologists,who are looking forward to seeing andusing it. In our experience this far, therehave been no real difficulties with it,compared to other new modalities we havelearned. These patients are intubated, and already have the nasogastric tube in place, so it is very simple.

Most of the children we see areextubated within the first 24 hours; it would be interesting to see how NAVAwill be useful in the long term patients.The most fascinating experience so farwas to learn that one of our patients had a partial paralysis and phrenic nervedamage, just from doing the NAVAevaluation study.

Tony Fitzgerald and Jim Davenport

have over 30 years experience with

different ventilation modes.


RReeffeerreenncceess

1) Beck J, Weinberg J, Hamnegard C-H, Spahija J, Olofson Grimby G,Sinderby C. Diaphragm function in advanced Duchenne MuscularDystrophy. Neuromuscul Disord2006; 16(3):161-167.

2) Emeriaud G, Beck J, Tucci M,Lacroix J, Sinderby C. Diaphragmelectrical activity during expiration in mechanically ventilated infants.Pediatr Res 2006; 59(5): 705-710.

3) Beck J, Campoccia F, Allo JC,Brander L, Brunet F, Slutsky AS,Sinderby C. Improved synchrony and respiratory unloading by neurallyadjusted ventilatory assist (NAVA) in lung-injured rabbits. Pediatr Res2007; 61: 289-294.

4) Beck J, Sinderby C. Monitoringrespiratory drive and respiratorymuscle unloading during mechanicalventilation. Yearbook of Intensive Careand Emergency Medicine, SpringerVerlag, Ed. J.L. Vincent, pp. 468-476,Berlin, Germany 2006.

5) Allo JC, Beck J, Brander L, Brunet F,Slutsky AS, Sinderby C. Influence ofneurally adjusted ventilatory assistand positive end-expiratory pressureon breathing pattern in rabbits withacute lung injury. Crit Care Med2006; 34: 2997-3004.

6) Sinderby C, Beck J, Spahija J,DeMarchie M, Lacroix J, Navalesi P,Slutsky AS. Inspiratory muscleunloading by neurally adjustedventilatory assist during maximalinspiratory efforts in healthy subjects.Chest, 2007; 131(3): 646-648.

7) Beck J, Tucci M, Emeriaud G,Lacroix J, Sinderby C. Prolongedneural expiratory time induced bymechanical ventilation in infants.Pedatr Res 2004; 55(5): 747-754.

8) Sinderby C. Ventilatory assist drivenby patient demand. Am J Respir CritCare Med 2003; 168(7): 729-730.

9) Beck J, Gottfried SB, Navalesi P,Skrobik Y, Comtois N, Rossini M,Sinderby C. Electrical activity of thediaphragm during pressure supportventilation in acute respiratory failure.Am J Respir Crit Care Med 2001;164(3): 419-424.

10) Sinderby C, Navalesi P, Beck J,Skrobik Y, Comtois N, Friberg S,Gottfried SB, Lindstrom L. Neuralcontrol of mechanical ventilation inrespiratory failure. Nat Med 1999;5(12): 1433-1436.

11) Eustace N, O´Hare B. Use ofnonsteroidal anti-inflammatory drugsin infants. A survey of members of

the Association of PaediatricAnaesthetists of Great Britain andIreland. Paediatr Anaest 2007; 17(5):464-469.

12) Crowe S, Mannion D, Healy M,O´Hare B, Lyons B. Paediatric near-drowning: morality and outcome in a temperate climate. Ir Med J 2003;96(9):274-276.

13) Charles R, Marsh B, Carton E,Power M, Motherway C, Claffey L,Crowley K, Donnelly M, O’Hare B,O´Leary E, Ryan T. Accessibility ofintensive care facilities in Ireland tocritically ill patients. Ir Med J 2002:95(3): 72-74.

14) McGinley J, Corcoran T, Canny G, O´Hare B. A case ofpneumomediastinum in paediatricARDS: to oscillate or not? PaediatrAnaesth 2001; 11(3): 366-369.

15) Sinderby C, Beck J, Spahija J,Weinberg J, Grassino A. Voluntaryactivation of the human diaphragm inhealth and disease. J Appl Physiol1998; 85(6): 2146-2158.

16) Beck J, Sinderby C, Lindstrom L,Grassino A. Effects of lung volume ondiaphragm EMG signal strengthduring voluntary contractions. J ApplPhysiol 1998; 85(3): 1123-1134.

BBiiooggrraapphhyy

Dr Martina Healy received her initialdegrees as MB, BCh, and BAO at theNational University of Ireland in 1984,followed by Fellowship of the Facultyof Anaesthetists of the Royal Collegeof Surgeons in Ireland (FFARCSI) in1991. She obtained her Certificate ofCompletion of Higher ProfessionalTraining in 1995. Her continuedprofessional training in anaesthesiabegan at the Liverpool CentralRotational training scheme in

Anaesthesia in Liverpool, U.K. during1986-1992, followed by ResearchRegistrar in Anaesthesia, MaterMisericordiae Hospital in Dublin1992-1993. Her Higher Professionaltraining scheme in Anaesthesia inIreland occurred from 1993 to 1996.

Her paediatric intensive care trainingwas initiated as Registrar in IntensiveCare, Royal Children’s Hospital,Parkville in Melbourne, Australia from

1998 to 1999, followed by a positionas Trust Fellow in Paediatric IntensiveCare at Great Ormond Street Hospitalfor Sick Children from 1999 to 2001.

Dr Martina Healy is currentlyConsultant in Anaesthesia andPaediatric Intensive Care at OurLady’s Children’s Hospital, Crumlin,Dublin, Ireland where she has beenappointed since 2001.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16488607&ordinalpos=16&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

















ICU implementation and clinical application of non-invasive ventilation protocolsThe very first intensive care unit in Brazil was opened at Hospital Sirio-Libanes in 1971. The principles of humanism, pioneering and excellence are still prevalent in the current ICU environment of 22 beds,scheduled to expand to forty beds in the next year. For many years, the ICU at Sirio-Libanes has focusedon less invasive and more patient friendly therapies, and this unit is internationally recognized as a center of excellence.

Critical Care News spoke with Guilherme Schettino, MD, PhD, Director of the ICU at Sirio-Libanes, São Paulo, Brazil, regarding their utilization of non-invasive ventilation and weaning protocols on a routine basis.

Guilherme Schettino, MD, PhD, is internationally known for his research and lectures. He has conducted research for many years in the areas

of mechanical ventilation and non-invasive ventilation.


AAss aann iinntteerrnnaattiioonnaallllyy--kknnoowwnn pprroofifillee iinn rreesseeaarrcchh aanndd oonn tthhee lleeccttuurree cciirrccuuiitt,,ccoouulldd yyoouu tteellll uuss bbrriieeflflyy aabboouutt yyoouurrbbaacckkggrroouunndd??

I have been working in critical caremedicine for the last 15 years as apneumologist and intensivist, and I havepublished some studies on mechanicalventilation. I also work together with CarlosCarvalho and Marcelo Amato at Hospitaldas Clinicas at Sao Paulo University whereI did my PhD thesis on mechanicalventilation. I did my research fellowship fortwo years with Bob Kacmarek in Boston atMassachusetts General Hospital, where I also conducted some research on non-invasive ventilation. When I returned toBrazil, I assumed the position of ICUDirector here at Hospital Sirio-Libanes.

CCaann yyoouu ddeessccrriibbee yyoouurr ccuurrrreenntt IICCUUooppeerraattiioonnss aanndd ccaappaacciittyy??

Yes, we are operating with two adultmedical-surgical ICUs, one on the firstfloor with 12 beds, and the other one onthe eighth floor with an additional 10 beds.We also have an intermediate care unitwith 24 beds for adult patients, where wedo a lot of non-invasive ventilation andinvasive ventilation for chronicallyventilated patients with tracheostomies.

We are now completing a project for anew ICU with forty beds to consolidatethe ICU operations. It will be quite large,but we are expanding the hospital andneed more beds for critically ill patients. I think it will be up and operating in thebeginning of 2008.

WWhheenn ddiidd yyoouu ssttaarrtt uuttiilliizziinngg nnoonn--iinnvvaassiivvee vveennttiillaattiioonn tthheerraappyy??

I used non-invasive ventilation for the firsttime more than 14 years ago at Hospitaldas Clínicas, after reading the Meduri´spaper on non-invasive ventilation forCOPD patients. We started by using anICU ventilator with a mask. I think wewere the first group to start using non-invasive ventilation here in Brazil.

WWaass tthheerree aa ppaarrttiiccuullaarr ppaattiieenntt ccaatteeggoorryyaatt tthhaatt ttiimmee??

At that time it was patients with COPD exacerbations. We were using ICU ventilators with Pressure Control anda mask to deliver non-invasive ventilation.Since that time, non-invasive as aventilation therapy has changed a lot, with different interfaces and differentventilators that are more tailored for non-invasive treatment, with leakagecompensation, and so on.

Currently, when we use non-invasiveventilation, we use either BIPAPmachines or ICU ventilators that havesoftware to compensate leakage, such as SERVO-i.

YYoouu mmeennttiioonneedd tthhaatt yyoouu aarree uussiinnggmmaasskkss,, hhaavvee yyoouu hhaadd eexxppeerriieennccee oofftthhee hheellmmeett iinn nnoonn--iinnvvaassiivvee vveennttiillaattiioonn??

I received a few helmets from PaoloPelosi in Italy, so I have used the helmet a few times, and it worked well. I thinkhowever, that the helmet works better on patients who need non-invasiveventilation for a short period of time, for instance patients with cardiogenicpulmonary edema. The cost of thehelmets is a factor here in Brazil.

YYoouu ssttaarrtteedd oouutt bbyy ggaaiinniinngg eexxppeerriieenncceeooff nnoonn--iinnvvaassiivvee vveennttiillaattiioonn wwiitthh CCOOPPDDppaattiieennttss,, wwhhiicchh ppaattiieenntt ccaatteeggoorriieess ddooyyoouu uussee nnoonn--iinnvvaassiivvee vveennttiillaattiioonn mmoossttffrreeqquueennttllyy oonn ttooddaayy??

Now I think we are using non-invasive in almost all COPD patients in the ICU. I really think the best way to take care of patients with COPD exacerbation is to use non-invasive very early in thetreatment. We also use non-invasiveventilation in most patients with

Dr Schettino in conference with other ICU staff members at Sirio-Libanes.


cardiogenic pulmonary edema and inpatients weaning from invasiveventilation, and also in patients withhypoxemic respiratory failure. In patientswith COPD exacerbation or patients withcardiopulmonary edema, we use non-invasive in the emergency room or in thestep down unit, but for patients withhypoxemic respiratory failure, we onlyuse non-invasive here in the ICU, sincewe have all the facilities for monitoringand intubating the patient, if necessary.All of the ICU staff members are trained in non-invasive ventilation, and we have agood team of nurses and physiotherapists.Our situation here differs a bit from theUnited States, where they haverespiratory therapists; here in Brazil it is similar to Europe in that we have no respiratory therapists but a teamconsisting of physical therapists, andnurses specialized on respiratory supportand mechanical ventilation, workingclosely together with physicians.

We are using a lot of partial facial masks,and total face masks. But I am waiting forthe helmet to become commerciallyavailable in Brazil, which I think will beuseful for patients with cardiogenicpulmonary edema and some patientswith post-operative respiratory failure,

because most of these patients are usingnasogastric tubes, and it may be easier to provide non-invasive ventilation with a helmet than a mask in these patients.

WWhhaatt iiss yyoouurr rraattiioo ooff ppaattiieennttss,, rroouugghhllyy,,iinn tteerrmmss ooff iinnvvaassiivvee aanndd nnoonn--iinnvvaassiivvee??

I think that for patients with respiratoryfailure in the step down unit, most ofthem use non-invasive ventilation. Here in the ICU I have at least three to fourpatients using non-invasive ventilationeach day, which means roughly 25-30%of patients in the ICU receive non-invasive, or at least we try to administer it before intubation. This has grown inrecent years. We have now 12 BIPAPventilators at Sirio-Libanes, andsometimes all twelve are in use.

WWee ttaallkkeedd aabboouutt CCPPAAPP ffoorr ppaattiieennttsswwiitthh lluunngg eeddeemmaa aanndd nnoonn--iinnvvaassiivveevveennttiillaattiioonn mmaayy bbee ccoonnttrroovveerrssiiaall iinn tthhiiss sseettttiinngg.. CCoouulldd yyoouu tteellll uuss mmoorreeaabboouutt yyoouurr uussee ooff nnoonn--iinnvvaassiivveevveennttiillaattiioonn iinn ppaattiieennttss wwiitthh ccaarrddiiooggeenniicc ppuullmmoonnaarryy eeddeemmaa??

We use non-invasive ventilation inpatients with cardiogenic pulmonaryedema, and one question posed in the

medical research is which mode is best to treat these patients; CPAP, BIPAP,Pressure Support and PEEP? I think thatfor most patients if you use CPAP, it isokay to treat cardiogenic pulmonaryedema. But for some patients, especiallythose with hypercapnia, I think it is betterto use BIPAP or Pressure Support withPEEP to increase the alveolar ventilation.In a paper that was published some yearsago, there was a report of a few patientswith myocardial infarction treated withBIPAP, which was subsequently followedby a lot of papers published to show thatBIPAP or Pressure Support with PEEP issafe in this patient category. There was ameta-analysis in JAMA 2006 showing thatyou can use both modes; both are safeand work similarly. One very nice studythat has been published about using non-invasive ventilation for patients withcardiogenic pulmonary edema; comparingBIPAP with CPAP, was done by a Braziliancolleague named Marcel Parker atHospital Clinicas a few years ago andpublished in Critical Care Medicine.

WWhheenn yyoouu eennccoouunntteerr aa ppaattiieenntt iinn aannyyccaatteeggoorryy wwiitthh lleeaakkaaggee pprroobblleemmss,, hhoowwddoo yyoouu aaddddrreessss tthhiiss ssiittuuaattiioonn??

I think that the first action is to try to adjustthe mask and avoid leakage. But this maybe difficult at times, and if you have to usehigh pressures, you can change the facemask to a total face mask that will workbetter with high pressures. If you use anon-invasive ventilator, like the BIPAP, itworks very well even in the presence ofhigh leakage. Non-invasive ventilation withSERVO-i with leakage compensationworks also very well in these situations.You can also adjust the cycling off criteriafor Pressure Support that is good in non-invasive ventilation. If you are using an ICUventilator where you cannot adjust thecycling off criteria for Pressure Support,then one option is to change the mode toPressure Control – which works well and isan alternative – but in this case it is not socomfortable for the patient.

SSiinnccee ffaacciiaall mmoorrpphhoollooggyy ccaann ddiiffffeerr ffrroomm oonnee ppaattiieenntt ttoo aannootthheerr,, tthhiiss mmuussttbbee aa cchhaalllleennggee??

Yes – it is always a challenge for thepatient interfaces – sometimes we needto try a number of different masks and

Dr Guilherme Schettino.


adjust them in a variety of different wayson different patients. It is an individualprocess in each patient.

CCaann yyoouu tteellll uuss mmoorree aabboouutt uussiinngg nnoonn--iinnvvaassiivvee vveennttiillaattiioonn aass aa sstteepp iinn tthhee wweeaanniinngg pprroocceessss??

Yes, we use it in the step down unit, butalso in the ICU, as a method for weaning.We developed a very nice weaningprotocol for patients who we believe are at high risk to develop post-extubationrespiratory failure. For that group ofpatients, immediately after extubation,even if the patient is ok, I use non-invasiveventilation for 4-6 hours. Patients receivingnon-invasive ventilation after extubationinclude patients with COPD, all patientswith cardiological problems, and patientsthat have been invasively ventilated morethan 4 days, as well as patients who failed

spontaneous breathing trials the daybefore. Our team utilizes the protocolsevery day: the physical therapists check forcriteria for weaning against the protocol,and the therapists and nurses follow theprotocol. We use non-invasive ventilationto avoid reintubation, whenever possible.

TThheerree sseeeemmss ttoo bbee aa ttrreenndd iinn ssoommeeccoouunnttrriieess,, wwhheerree nnoonn--iinnvvaassiivveevveennttiillaattiioonn iiss nnoott rreeccoommmmeennddeedd iinnppaattiieennttss wwiitthh ggaassttrriicc pprroobblleemmss??

In my opinion, non-invasive ventilation is contra-indicated in patients withesophageal surgery. For patients withgastric surgery, we do use non-invasiveventilation in some cases. I discuss thecase with the surgeon, and we decidetogether if the patient is a good candidatefor non-invasive. Some obesity patientshaving gastric surgery receive non-

invasive ventilation before the surgery,because of issues like sleep apnea. There are some papers published in the literature saying it is safe to use non-invasive ventilation in this category, andI think that this patient category benefitsfrom the use of non-invasive ventilation,to avoid post-op atelectasis. But again,with patients with esophageal surgery,non-invasive ventilation is contra-indicatedin my opinion. Non-invasive ventilation isobviously also contra-indicated in patientswith gastric distention, or vomiting.

IInn rreeggaarrddss ttoo IICCUU ccoolllleeaagguueess aarroouunndd tthhee wwoorrlldd wwhhoo aarree ccoonnssiiddeerriinnggiimmpplleemmeennttiinngg nnoonn--iinnvvaassiivvee vveennttiillaattiioonn,,wwhhaatt aarree yyoouurr mmoosstt iimmppoorrttaannttrreeccoommmmeennddaattiioonnss iinn ssttaarrttiinngg uupp??

I think that first you have to train yourteam in non-invasive ventilation. Just like

MV weaning protocol used at Sirio-Libanes Hospital, Sao Paulo.


other interventions in the ICU, you needto train the physicians, nurses, physicaltherapists or respiratory therapists. I thinkthat one good recommendation is todevelop your own protocol for using non-invasive ventilation. It makes it easier toutilize in terms of patient categories andsituations, based on literature and localexperience. Define clearly what kind ofcontra-indications should be made fornon-invasive ventilation. You can use non-invasive in a lot of patients with

respiratory failure, but define theconditions that are not safe for thepatients, like patients with shock, inpatients with esophageal surgery orgastric distention.Together with theteam, define the criteria for failure of non-invasive ventilation: when you wouldneed to intubate the patient, to avoidusing non-invasive ventilation for too longand needing to intubate in a worseningclinical situation. In my opinion, if thepatient condition does not improve in the

first two hours of non-invasive ventilation,I think it is better to intubate.

AArree tthheerree aannyy rreesseeaarrcchh ddeevveellooppmmeennttsstthhaatt yyoouu sseeee tthhaatt mmiigghhtt hhaavvee aann iimmppaaccttoonn nnoonn--iinnvvaassiivvee tthheerraappyy iinn ffuuttuurree??

I believe that NAVA (Neurally AdjustedVentilatory Assist) will play a significantrole in non-invasive ventilation, where you can solve the problems of synchrony,leakage and patient comfort.

Non-invasive protocol developed and used by Dr Schettino and staff at Sirio-Libanes Hospital.


5) Amato MBP, Barbas CSV, MedeirosD, Magaldi RB, Schettino GPP, LorenziG, Kairalla RA, Deheinzelin D, MunozC, Oliveira R, Takagaki T, CarvalhoCRR. Effect of a protective-ventilationstrategy on mortality in the acuterespiratory distress syndrome. N Engl J Med 1998; 338: 37-354.

6) Park M, Sangean MC, Volpe Mde S,Feltrim MI, Nozawa E, Leite PF,Passos Amato MB, Lorenzi-Filho G.Randomized, prospective trial ofoxygen, continuous positive airwaypressure, and bilevel positive airwaypressure by face mask in acutecardiogenic pulmonary edema. CritCare Med. 2004;32:2407-15.

7) Meyer EC, Lorenzi G, Schettino GPP,Carvalho CRR. Ventilacão não invasivano cardiopata grave. Rev Soc CardiolEstado de São Paulo 1998; 8: 420.

8) Carvalho CRR, Schettino GPP,Maranhão B, Bethlen EP. Hyperoxiaand lung disease. Curr Opin in PulmMed 1998; 4: 300-304.

9) Carvalho CRR, Andrade MG,Schettino GPP. Lung Disease induced

BBiiooggrraapphhyy

Guilherme Schettino, MD, PhD isDirector of Intensive Care at HospitalSirio-Libanes, Sao Paulo, Brazil, aswell as a staff member of theRespiratory ICU at Hospital dasClinicas in Sao Paulo.

He obtained his medical degree atthe Universidade Federal do Rio deJaneiro in 1988, and was resident atthe Faculdade de Medicina daUniversidade de Sao Paulo where hereceived his degrees in Pneumologyand Intensive Care in 1992. Heattained the degree of PhD at the Faculdade de Medicina da


1) Schettino G, Altobelli N, KacmarekR. Noninvasive positive pressureventilation reverses acute respiratoryfailure in select "do-not-intubate"patients. Crit Care Med 2005;33:1976-82.

2) Schettino GPP, ChatmongkolchartS, Hess D, Kacmarek RM. Position of exhalation port and mask designaffect CO2 rebreathing duringnoninvasive positive pressureventilation. Crit Care Medicine2003;31:2178-82.

3) Chatmongkolchart S, SchettinoGPP, Dillman C, Kacmarek RM, Hess D. In vitro evaluation of aerosolbronchodilator delivery duringnoninvasive positive pressureventilation: effect of ventilatorsettings and nebulizer position. Crit Care Med 2002; 30: 2515-1519.

4) Schettino GPP, Tucci MR, Sousa R,Valente Barbas CS, Passos AmatoMB; Carvalho CR. Mask mechanicsand leak dynamics during noninvasivepressure support ventilation: a benchstudy. Intensive Care Med 2001;27: 1887-1891.

Sirio-Libanes Hospital.

by parasites. Clin Pulm Med 1998; 5: 93-103.

10) Meyer EC, Lorenzi G, Schettino GPP,Carvalho CRR. Ventilacão não invasivano cardiopata grave. Rev Soc CardiolEstado de São Paulo 1998; 8: 420.

11) Meduri GU. Noninvasiveventilation in physiological basis ofventilatory support: A series on lungbiology in health and disease. Editedby Marini J, Slutsky A. New York:Marcel Deccer Inc, 1998: 921-998.

12) Meduri GU. Noninvasive positive-pressure ventilation in patients withacute respiratory failure. Clin ChestMed 1996; 17: 513-553.

13) Ho KM, Wong K. A comparison of continuous and bi-level positiveairway pressure non-invasiveventilation in patients with acutecardiogenic pulmonary oedema: a meta-analysis. Crit Care 2006; 10(2): R49.

Universidade de Sao Paulo in 1998, and completed his ResearchFellowship at MassachusettsGeneral Hospital, Harvard Medical School in Boston 2002.

Guilherme Schettino, MD, PhD is an internationally-known profilewho has lectured at manyinternational meetings andcongresses, and has conductedresearch for many years within theareas of mechanical ventilation andnon-invasive ventilation.











NAVA – past, present and future perceptions

The centuries-old “Ospedale Maggiore della Carità” associated with the Università del PiemonteOrientale in Novara, Italy, has a long history of clinical activity and a shorter institutional research andeducation life, stemming as an independent branch of the University of Turin since 1998. The GeneralIntensive Care Unit within the Department of Anesthesia, Critical Care and Critical Emergency Medicine is presently evaluating the clinical application of NAVA – Neurally Adjusted Ventilatory Assist, for futureresearch. NAVA, in contrast to conventional mechanical ventilation, triggers the ventilator by means of electrical diaphragm activation from signals originating in the patient’s brain.

Critical Care News spoke with Department Director Professor Francesco Della Corte, MD about thehospital history and department background, and with Dr Paolo Navalesi, who presently works at theDepartment directed by Professor Della Corte as Head of the Intensive Care Unit and has contributed to some of the early research on NAVA and is involved with the current NAVA evaluation.

Department Director Professor Francesco Della Corte, MD and staff members within the Department of Anesthesia, Critical Care and Critical

Emergency Medicine.


Department Director, Professor FrancescoDella Corte is an internationally knownprofile within the Critical Care, Emergencyand Disaster lecture circuit and hasconducted extensive research within the areas of anesthesia, critical care andemergency care. We talked with him aboutthe hospital and the general operations of the Department of Anesthesia, CriticalCare and Critical Emergency Medicine.

CCaann yyoouu ddeessccrriibbee tthhee ssiizzee ooff yyoouurr ddeeppaarrttmmeenntt,,aavveerraaggee nnuummbbeerr ooff ppaattiieennttss aanndd ssttaaffff??

We are a level 1 hospital for the Piemonteregion in Italy, which means that we havea patient uptake area of over 860,000inhabitants. Our department embodiesthree units – anesthesia, ICU andemergency care.

CCaann yyoouu tteellll uuss aabboouutt tthhiiss hhoossppiittaall??

Historically, it is a very old hospital, and has been located here for centuries,with the oldest part of the institutiondated from the 17th century. We are a university research hospital, and ourspecial research areas include mechanicalventilation, sepsis and trauma as well aseducation and training, emergency anddisaster management. We are currentlyin the process of rebuilding and extendingthe hospital, which should be completedin a few years time.

We are the regional referral hospital for all emergencies and level 1 trauma, andtransplantation. We provide 750 beds andoffer day surgery as well as ambulatorycare. All hospital specialities are

represented here, with the exception of a burn unit.

WWhhiicchh ttyyppeess ooff IICCUU ppaattiieenntt ssiittuuaattiioonnss ddooyyoouu mmoosstt ffrreeqquueennttllyy eennccoouunntteerr??

We provide a general ICU with 14 beds,and treat an average of 800 patients peryear. Our patient ratios are roughly a mixof 40-50% medical ICU patients, 25% -30 % major trauma patients, while therest is comprised of complex post-oppatients including cardiothoracic andneurological surgical patients.

Our daytime staff usually comprises 5 physicians, 3 residents and 2 staffmembers, and our nurse to patient ratio is generally 1 nurse to every 2 patients.

In addition to his responsibilities at the Ospedale Maggiore della Carità, Professor Francesco Della Corte, MD is also Course Director and

co-founder of the European Master in Disaster Medicine.


Dr Paolo Navalesi has conductedextensive research within mechanicalventilation, and was an early contributorto the original research about NAVA. He is currently involved in the ongoingclinical evaluation, and he shared his pastexperiences, his current perceptions, andsome of his ideas in regard to the futureof NAVA.

YYoouu wweerree aa ccoo--aauutthhoorr wwiitthh CChhrriisstteerrSSiinnddeerrbbyy oonn tthhee iinniittiiaall rreesseeaarrcchh ffoorr tthheellaannddmmaarrkk ssttuuddyy ““NNeeuurraall ccoonnttrrooll ooffmmeecchhaanniiccaall vveennttiillaattiioonn iinn rreessppiirraattoorryyffaaiilluurree”” ppuubblliisshheedd iinn NNaattuurree MMeeddiicciinnee iinn 11999999..CCaann yyoouu tteellll uuss ssoommee ooff tthhee bbaacckkggrroouunndd ooffhhooww yyoouu ccaammee ttoo bbee iinnvvoollvveedd iinn rreesseeaarrcchhiinnggtthhee mmeetthhoodd ffoorr aaccqquuiissiittiioonn aanndd pprroocceessssiinnggooff ddiiaapphhrraaggmmaattiicc eelleeccttrriiccaall ssiiggnnaallss??

It began very simply, with humble origins.I was doing research in Montreal, at theMeakins Christie Laboratories, with aprototype for a new mode of mechanical

ventilation called proportional assistventilation when I met Christer Sinderby,who was working with diaphragmaticEMG research. We developed a closefriendship, and in the course of ourrelationship, I urged him to research theopportunity of the EMG signal to drivethe ventilator. Naturally, as ChristerSinderby is a physiologist, he was not all that interested in this subject, in thebeginning. About two years later, whenhe was my guest in Italy, late one eveningover a bottle of Grappa and a Cuban cigar,we theorized more about this opportunity,and decided to do some tests and tomake a simulation.

Later that summer we met at an ERSmeeting in Stockholm, and he presentedthe simulation that was exciting andextremely promising. He started to dowork on the algorithm, and the firstversion of NAVA was very rough – on ahomemade ventilator. But in time, a

SERVO 900C ventilator was used totrigger on a neural signal. Finally, ChristerSinderby decided that we had enoughresearch to provide a paper, and hecontacted the editor of Nature Medicine,who thought the research was interestingand asked for a submission. The originalarticle is simple yet very communicative,but it took us some time to complete it.Ultimately, the paper was published andreceived very good reviews. It isimportant to point out that I have neverhad any commercial interest in thesubject, in the past or otherwise.

WWhhaatt wweerree yyoouurr ppeerrcceeppttiioonnss aatt tthhaatt ttiimmee,,iinn rreeggaarrdd ttoo tthhee ccoonncceepptt ooff NNAAVVAA aanndd wwhhaatt yyoouu ppoossssiibbllyy ssaaww aass tthhee ffuuttuurree ooff tthhee mmeetthhoodd ooff NNeeuurraallllyy AAddjjuusstteedd VVeennttiillaattoorryy AAssssiisstt??

In Montreal, the reason why I urgedChrister to develop the EMG triggeropportunity was my interest at that time

Dr Navalesi was a co-author in the

original study by Christer Sinderby

"Neural control of mechanical

ventilation in respiratory failure"

published in Nature Medicine 1999.


that stemmed from my work with COPDpatients with acute exacerbation requiringmechanical ventilation, and the methodwe used of applying external PEEP tocounterbalance intrinsic PEEP, which wasnot an easy task. Because of thedifficulties in setting up the right ventilatorsettings in the COPD patient, it becameapparent to me that the best approach inthese patients would be to use the effortof a major respiratory muscle in order toavoid any other products in between thepatient and the ventilator. So the idea withNAVA was born to treat COPD patientswith acute exacerbations in the ICU - I stillbelieve this is one of the most potentially

important areas for the application,although in recent years the COPDpatients who require endotrachealintubation is largely reduced secondary tothe use of non-invasive ventilation, whichhas been shown to be very effective inthis patient population. That was thebeginning, in this disease category.

DDoo yyoouu tthhiinnkk tthheerree wwiillll bbee ddiifffificcuullttiieess iinnttrryyiinngg ttoo aaddaapptt ttrreeaattmmeenntt ccuullttuurree ffrroommccoonnvveennttiioonnaall ppnneeuummaattiicc mmeecchhaanniiccaallvveennttiillaattiioonn ttoo nneeuurraallllyy ddrriivveenn vveennttiillaattiioonn??

Yes. I believe these difficulties come witha sort of medical inertia within the field.

Changing our attitudes in regard toprocedures, methods and devices thathave been used in a certain manner formany, many years can be a long process.We have to consider that this may takesome time. However, I think that theremight be a general level of curiosity tothis new approach that may help verymuch in this respect.

HHooww mmaannyy ppaattiieennttss hhaavvee yyoouu ttrreeaatteedd wwiitthhtthhee cclliinniiccaall aapppplliiccaattiioonn ooff NNAAVVAA aatt tthhiiss ttiimmee??WWhhiicchh ttyyppeess ooff ppaattiieenntt ccaatteeggoorriieess aarree tthheeyy??

We have been using the current clinicalapplication in the last month in a series of

Dr Paolo Navalesi is involved in evaluation of the current clinical application of NAVA.


10 adult patients so far, in a broadspectrum of very different types ofunderlying diseases with no specificpathologies. Our underlying statisticalanalysis will start, and we will have morediscussions with the manufacturer beforewe proceed further.

WWhhiicchh vveennttiillaattiioonn tthheerraappiieess wwoouulldd nnoorrmmaallllyyhhaavvee bbeeeenn uusseedd iinn tthheessee ppaattiieennttss??

Pressure Support is primarily used. That iswhy we want a head-to-head comparisonof Pressure Support and NAVA in thisseries of patients. We are dealing with

forms of partial ventilatory support, so weshould compare it to other forms of partialventilatory support, to assess whether ornot we can have advantages. Anotherinteresting future use of NAVA might bein patients with acute lung injury andARDS. Some believe it might be possibleto maintain these patients in assistedspontaneous breathing and thehypothesis is that NAVA might provideprotective ventilation while avoiding thelevel of sedation compared to controlledmechanical ventilation in this patientgroup. Again, however, at this point, it is still only a hypothesis.

AArree tthheerree ssoommee ssppeecciifificc ppaattiieenntt eexxppeerriieenncceesstthhaatt aarree ooff ssppeecciiaall iinntteerreesstt??

I think that any patients with alteredneuro-mechanical coupling are goodcandidates for NAVA. Newborns areprobably one of the most potentiallyinteresting categories. In some patientswith very severe disease, NAVA may helpmaintain non-invasive ventilation moreextensively than other more conventionaltechniques. I think perhaps three generalcategories may be of interest in thefuture: patients with acute or chronicairway disease, children, and patients

Dr Davide Colombo and Dr Gianmaria Cammarota have also been involved in the current clinical evaluation of NAVA in adult patients.


using non-invasive ventilation.

WWhhaatt iiss yyoouurr ppeerrcceeppttiioonn ooff ppaattiieenntt––vveennttiillaattoorr ssyynncchhrroonnyy iinn rreeggaarrdd ttoo NNAAVVAA??

In patients with wasted inspiratoryefforts, the use of NAVA is absolutelybeneficial in my opinion, in helping thesepatients to avoid wasted inspiratoryefforts. In COPD patients, we definitelyobserved a clear improved synchronywith NAVA, as opposed to other forms ofpartial support, both at the onset and theend of the inspiration. End inspirationsynchrony is improved in most of thecases, in our observation. It is not

possible, however, at this time tosubstantiate a preference for neuraltriggering over the conventionalinspiratory triggers for the large majorityof patients.

IInn tteerrmmss ooff ppaattiieenntt--vveennttiillaattoorr aassyynncchhrroonnyy,,wwhhaatt aarree tthhee mmoosstt ssiiggnniifificcaanntt rriisskkss??

At present, there is an interesting paperpublished by Professor LaurentBrochard’s group in regard to outcome ofpatients with poor ventilatory synchrony,with much longer duration of mechanicalventilation and longer ICU stay. Thisresearch documents that compromisedsynchrony affects patient outcome.

WWhhaatt iiss yyoouurr ooppiinniioonn rreeggaarrddiinngg tthheeaaddvvaannttaaggee ooff EEddii ssiiggnnaallss aass aa ccoommpplleetteellyynneeww ppaarraammeetteerr iinn vveennttiillaattiioonn??

I think that the Edi signal, besides NAVA,provides a very interesting new parameterto the ICU physician to help deal with and improve knowledge of the patientundergoing mechanical ventilation.

This is the closest signal to the brainstemrespiratory center that we can collecttoday. In patients with altered neuro-mechanical coupling, the Edi might bereally useful, as you might have a poormechanical output (i.e. a very limitedamount of pressure generated by the

Dr Navalesi and Dr Colombo are in the process of studying the clinical data from the first series of patients in the evaluation.


diaphragm) but very strong Edi signal, dueto the altered respiratory muscle function.Indeed, Edi signal may provide a new areafor research in the field of control ofbreathing during mechanical ventilation.

HHaass iitt bbeeeenn ddiifffificcuulltt ttoo tteeaacchh yyoouurr ootthheerr ssttaaffffmmeemmbbeerrss iinn rreeggaarrdd ttoo tthhee ccoonncceepptt aannddaapppplliiccaattiioonn ooff NNAAVVAA??

There are two aspects to this issue: the first being education in the knowledgeof what this signal means. As we in theICU are used to the aspect of pressure indiscussions, it is easy to misunderstandEdi and confuse it with what pressure the signals results in. This is the primaryaspect for learning and teaching. Thesecondary aspect is the practical one ofpositioning the catheter, which has beenindeed much easier than expected in theclinical application.

WWhhaatt aaccccoorrddiinngg ttoo yyoouurr eexxppeerriieennccee ssoo ffaarr,,aarree tthhee mmoosstt iimmppoorrttaanntt aassppeeccttss ffoorr IICCUU ssttaaffff ttoo lleeaarrnn,, pprriioorr ttoo iinniittiiaattiinngg NNAAVVAAvveennttiillaattiioonn tthheerraappyy??

As mentioned previously, I think the mostimportant issue is the understanding ofthe physiological aspect of the Edi signaland learning the significance of it.

WWhhiicchh ttyyppeess ooff ppaattiieenntt ccaatteeggoorriieess wwoouullddyyoouu rreeccoommmmeenndd ootthheerrss ttoo ssttaarrtt wwiitthh,, iinnoorrddeerr ttoo ggaaiinn eexxppeerriieennccee??

I have seen NAVA used in many patientcategories: brain damage, quadriplegic,acute lung injury and COPD, to namesome. In my experience, COPD patientsare those to get the most immediatesatisfaction from a user experience. But I really do not see many limitations ingeneral, although it is too early to discusswhich groups would benefit the most.I think it might be good for new users tostart with tracheotomised patients, asthis group generally needs less sedation,and as sedation may alter neural drive,it may be easier here to start to evaluateand experience NAVA. The impact ofdifferent types and amounts of sedativeson diaphragm activation and, consequently,on NAVA, is one of the problems thatdeserves more attention; at the timebeing we are setting up a study to define this aspect.

DDoo yyoouu bbeelliieevvee tthhaatt aa ssiiggnniifificcaanntt nnuummbbeerr ooffIICCUUss aarroouunndd tthhee wwoorrlldd wwiillll bbee ggaaiinniinngg cclliinniiccaalleexxppeerriieennccee wwiitthh NNAAVVAA iinn tthhee nneexxtt ffeeww yyeeaarrss??

This is a difficult question to address, but should be considered in a generalmanner. Certainly NAVA will never be the only mode of ventilation used in the ICU and it will never replace entirelyconventional mechanical ventilation,however in the coming years it may more generally be seen to be beneficial in improving patient synchrony in thecategories we have discussed earlier.

BBiiooggrraapphhiieess

PPrrooffeessssoorr FFrraanncceessccoo DDeellllaa CCoorrttee,, MMDDreceived his medical degree at theCatholic University in Rome in 1979,where he also completed his trainingin Anesthesia and Intensive Care.Professor Della Corte was also namedAssociate Professor in Emergencyand Disaster Medicine at CatholicUniversity in Rome, and AssociateProfessor in Intensive Care at theUniversity of Eastern Piedmont, Italy.

Professor Francesco Della Corte iscurrently Director of the Departmentof Anesthesiology, Critical Care andCritical Emergency Medicine at

Ospedale Maggiore della Carità inNovara, Italy. He is also Full Professorof Anesthesiology and Intensive Careat the University of Piedmont.

Professor Della Corte has a long-standing affiliation with severalinternational associations, includingSociety of Critical Care Medicine, the European Society of IntensiveCare Medicine, the Italian Society forAnesthesia, Analgesia and IntensiveCare, as well as the EuropeanSociety for Emergency Medicine,where he has been Secretary of the Society from 1999 to 2006.

He is Course Director and co-founderof the European Master in DisasterMedicine, a well known international,inter-university academic program.He is reviewer to numerousinternational journals, includingEuropean Journal of EmergencyMedicine, Critical Care Medicine,Intensive Care Medicine, MinervaAnesthesiologica, International Journalof Disaster Medicine and the AmericanJournal of Disaster Medicine.

Professor Francesco Della Corte, MDhas contributed to 14 chapters inbooks, and has over 64 papers

It will start out in a niche position in some patient categories, and I am notsure at this time how large that niche will become. But we can say that mostmodes of mechanical ventilation startedout in niche positions at one time oranother. If we look at the historicalperspective, currently in our ICU, about80% to 85% of our patients are usingPressure Support, and twenty years agoprobably this same ratio of patients werereceiving controlled mechanical ventilation.So we have seen a historical shift on along-term perspective. Incidentally, I thinkthat Pressure Support is still an excellentmode of ventilatory assistance.

WWhhiicchh rreesseeaarrcchh ooppppoorrttuunniittiieess ddoo yyoouu sseeeewwiitthh tthhee cclliinniiccaall aapppplliiccaattiioonn ooff NNAAVVAA iinn tthheeccoommiinngg yyeeaarrss??

I think that, as we have discussed, in thearea of patient-ventilator synchrony, NAVAis a perfect tool for this type of research,and in general I think that we will re-writesome pages in regard to control ofbreathing in mechanical ventilation, as wewill probably find things that were neverconsidered before. And as we have alsodiscussed, I think that as NAVA entersinto the area of pediatrics and newborns,it might represent a positive revolution forthese types of patients.


5) Sinderby C, Navalesi P, Beck J,Skrobik Y, Comtois M, Friberg S,Gottfried SB, Lindström L. Neuralcontrol of mechanical ventilation inrespiratory failure. Nat Med 1999;(12): 1433-1436.

6) Navalesi P, Costa R, Ceriana P,Carlucci A, Prinianakis G, Antonelli M,Conti G, Nava S. Non-invasiveventilation in chronic obstructivepulmonary disease patients: helmetversus facial mask. Intensive CareMed 2007; 33(1): 74-81.

7) Nava S, Navalesi P, Conti G. Time of non-invasive ventilation. IntensiveCare Med 2006; 32(3): 361-370.

8) Gregoretti C, Squadrone V, FogliatiC, Olivieri C, Navalesi P. Transtrachealopen ventilation in acute respiratoryfailure secondary to severe chronicobstructive pulmonary diseaseexacerbation. Am J Respir Crit CareMed 2006; 172(8): 877-881.


1) Sinderby C, Beck J, Spahija J, de Marchie M, Lacroix J, Navalesi P,Slutsky AS. Inspiratory muscleunloading by neurally adjustedventilatory assist during maximalinspiratory efforts in healthy subjects.Chest 2007; 131(3): 646-648.

2) Thille AW, Rodriquez P, Cabello B,Lellouche F, Brochard L. Patient-ventilator asynchrony during assistedmechanical ventilation. Intensive CareMed 2006; 32(10); 1515-1522.

3) Navalesi P, Costa R. New modes of mechanical ventilation:proportional assist ventilation,neurally adjusted ventilatory assist,and fractal ventilation. Curr Opin CritCare 2003; 9(1): 51-58.

4) Beck J, Gottfried SB, Navalesi P,Skrobik Y, Comtois N, Rossini M,Sinderby C. Electrical activity of thediaphragm during pressure supportventilation in acute respiratory failure.Am J Respir Crit Care Med 2001; 164(3): 419-424.

9) Squadrone E, Frigerio P, Fogliati C,Gregoretti C, Conti G, Antonelli M,Costa R, Baiardi P, Navalesi P.Noninvasive vs invasive ventilation inCOPD patients with severe acuterespiratory failure deemed to requireventilatory assistance. Intensive CareMed 2004; 30(7): 1303-1310.

10) Antonelli M, Pennisi MA, Pelosi P,Gregoretti C, Squadrone V, Rocco M,Cecchini L, Chiumello D, Severgnini P,Proietti R, Navalesi P, Conti G.Noninvasive positive pressureventilation using a helmet in patientswith acute exacerbation of chronicobstructive pulmonary disease: afeasibility study. Anesthesiology 2004; 100 (1): 16-24.

published on indexed reviews. Hewas also Editor for the Manuale diEmergenze Medico-Chirurgiche(McGraw Hill 2002). He has madeextensive presentations as invitedspeaker in over 200 national andinternational congresses.

DDrr PPaaoolloo NNaavvaalleessii received his medical degree in Italy from theUniversity of Genoa with the highestscore and completed his training inPulmonary Medicine and in CriticalCare Medicine at the University ofMilan. Dr Navalesi also completed apost-graduate research fellowship inPulmonary Medicine at the McGillUniversity, Montreal, Canada.

Dr Paolo Navalesi works at theOspedale Maggiore della Carità in

Novara Italy, where he is Head of the Intensive Care Unit of theDepartment of Anesthesia andIntensive Care. He teaches at theSchool of Anesthesiology andIntensive Care of the University of the Oriental Piedmont.

Dr Paolo Navalesi is the Secretary of the scientific group “Non invasiveventilatory support” of the EuropeanRespiratory Society. He collaborateswith the Italian Health Minister forContinuous Medical Education inPulmonary Medicine. He is anindependent referee for severalinternational scientific journalsincluding the American Journal of Respiratory and Critical CareMedicine, Critical Care Medicine,Intensive Care Medicine, European

Respiratory Journal, Thorax, andRespiratory Medicine. He is authoror co-author of several publicationsmainly focused on mechanicalventilation, and has published innumerous international journals such as Nature Medicine, AmericanJournal of Respiratory and CriticalCare Medicine, Journal of AppliedPhysiology, Critical Care Medicine,Intensive Care Medicine, Chest,Anesthesiology, and RespiratoryMedicine. He has been invited as an expert to the InternationalConsensus Conference on Weaning,held in Budapest in April 2005. He has contributed to numerousreview articles and book chapters.












The Kovai Medical Center and Hospital of Coimbatore, India, established in 1990, is a private, super-speciality hospital offering multi-disciplinary care in over 40 medical disciplines. In addition to 10 surgical theaters, the center is also a site for research and education, through the Kovai Medical Research Center and Educational Trust.

The medical ICU of Kovai Medical Center has been utilizing lung recruitment procedures in the interest of lung protection for many years. For the past two years, the ICU has been gaining experiencein the use of a tool with a protocol for titration of physiological endpoints and breath-to-breath graphicsfor lung recruitment in specific patient categories.

Critical Care News spoke with Dr Gopalakrishnan Raman, Chief Consultant of the medical ICU at Kovai Medical Center, and Dr V R Pattabhi Raman, Pulmonologist, about their experiences with the lung recruitment tool.

Open Lung methodology in ARDS patients

Chief Consultant Dr Gopalakrishnan Raman assessing an ICU patient after lung recruitment maneuver.


HHooww aanndd wwhheenn ddiidd yyoouu ccoommee ttoo uusseeOOppeenn LLuunngg mmeetthhooddoollooggyy iinn ccoonnnneeccttiioonnwwiitthh AARRDDSS ppaattiieennttss iinn tthhee hhoossppiittaall??

DDrr GGooppaallaakkrriisshhnnaann RRaammaann:: We heardabout the methodology and tool from themanufacturer, and decided to try it outabout two years ago. We had very goodresults on the first series of 4 patientcases, and continued to use the OpenLung Tool, primarily in ARDS patients.

WWhhiicchh ttyyppeess ooff pprroocceedduurreess wweerree yyoouuuussiinngg ffoorr AARRDDSS pprriioorr ttoo tthhee OOppeenn LLuunnggTTooooll??

DDrr PPaattttaabbhhii RRaammaann:: Prior to that we hadread about a procedure with 180 secondsof inspiratory pressure with PressureControl but we were not brave enough totry that. We then heard about theprocedure of recruitment of 40 cm at 40seconds, and we tried this and saw somedramatic results in some patients. Basedon this recruitment experience, we heard

about the Open Lung Tool and wereinterested in trying it out. So our lungrecruitment measures have beenconcentrated primarily in this group.

HHaavvee yyoouu ddeefifinneedd aannyy ssppeecciifificciinncclluussiioonn//eexxcclluussiioonn ccrriitteerriiaa ffoorr lluunnggrreeccrruuiittmmeenntt iinn AARRDDSS??

DDrr GGooppaallaakkrriisshhnnaann RRaammaann:: In terms ofexclusion criteria, basically we would notrecruit any patient with embolisms, asthere is too much risk in this patientcategory. Another exclusion group ishemodynamically compromised patients,which is a category where we would notrisk recruitment.

IInn yyoouurr eexxppeerriieennccee aarree ppaarraammeetteerrss ssuucchhaass ddyynnaammiicc ccoommpplliiaannccee aanndd VVTTCCOO22

uusseeffuull iinn eevvaalluuaattiioonn ooff tthhee rreeccrruuiittmmeennttmmaanneeuuvveerr??

DDrr PPaattttaabbhhii RRaammaann::Yes, it is very helpful in setting the PEEP to always

use dynamic compliance as a tool. In the past we were looking at tidal volumesand pressures, so dynamic compliance isgiving us more specific information inorder to set PEEP, or adjust PEEP inselected patients. We have found thatpatients with extrapulmonary ARDS have a much better outcome with therecruitment maneuver using dynamiccompliance and the Open Lung Tool,probably since we can follow the patients’progress more closely and monitor therespiratory situation in more detail.

WWhhaatt aarree yyoouurr ooppiinniioonnss ooff tthhee AARRDDSSnneettgguuiiddeelliinneess aanndd rreeccoommmmeennddaattiioonnss??

DDrr GGooppaallaakkrriisshhnnaann RRaammaann:: We havefollowed the 6 ml/kg tidal volumerecommendation, but perhaps deviatesomewhat in regard to recommendationsfor PEEP. We have tried to follow thePEEP recommendations in the ARDSnetprotocol, but we felt we had the need toincrease it sometimes. Sometimes wewill adjust the PEEP according to theblood gas oxygenation, if it would be toolow. So we increase the PEEP individually,as each patient needs it.

DDrr PPaattttaabbhhii RRaammaann:: We have found that there are some groups that don’trespond. Basically extrapulmonary ARDSand septic patients respond well in ourexperience, but with more complexpulmonary patients we do not increasethe PEEP to high levels, but moremoderate levels. At present, you couldsay that we generally follow ARDSnet,butwith variations, we don’t usually go to arespiratory rate of 35, so there are certaindeviations we have from ARDSnet.

DDrr GGooppaallaakkrriisshhnnaann RRaammaann::To summarize, you could say that wefollow ARDSnet recommendations, withsome deviations at the present. At leastuntil we get something better, in terms of guidelines.

DDrr PPaattttaabbhhii RRaammaann::Yes – part of theproblem today is that we are lumping the whole thing together; in looking at the population of patients, the distinctionbetween pulmonary and extrapulmonaryreally cannot be made. In general, theintensive care community probably needsmore data about etiology, and aboutcertain factors, for example the use of

Dr V R Pattabhi Raman is Consultant in Pulmonology at the Kovai Medical Center

and Hospital.


surfactant therapy in ARDS patients. I think that once we have data in a morehomogenous population, instead oflumping data together, and a moreprecise global consensus of the definitionof ARDS, we will have the possibility toadjust and adapt the guidelines moreprecisely.

WWhhaatt iiss yyoouurr eexxppeerriieennccee aanndd ooppiinniioonn iinnrreeggaarrdd ttoo PPEEEEPP lleevveellss iinn ccoonnnneeccttiioonn ttoolluunngg rreeccrruuiittmmeenntt??

DDrr PPaattttaabbhhii RRaammaann:: Once we haverecruited, we generally maintain PEEPlevels between 15 and 19; we rarely goover these levels.

WWhhaatt ssoorrtt ooff oouuttccoommeess aarree yyoouueexxppeerriieenncciinngg wwiitthh uussee ooff OOppeenn LLuunnggTTooooll iinn AARRDDSS ppaattiieennttss?? HHooww iiss tthheessiittuuaattiioonn ccoommppaarreedd ttoo tthhee pprreevviioouusspprroocceedduurreess yyoouu wweerree uussiinngg iinn tthhiissppaattiieenntt ggrroouupp??

DDrr GGooppaallaakkrriisshhnnaann RRaammaann:: We initiallystarted using the Open Lung Tool twoyears ago in lung recruitment in a seriesof 4 or 5 patients, with very positiveresults. These first positive experienceswere the reason why we have continuedto use the recruitment tool.

DDrr PPaattttaabbhhii RRaammaann:: We do not have anydata or studies at this point, but on anobservational level we have definitelyexperienced a distinct difference, and weknow more about what is happening inthis recruitment process as you get moreinformation by means of using this tool.Our perception is that outcome isdefinitely better in terms of inflectionpoint and getting down to the levels ofPEEP where we want to be, with moreconfidence than we had before.

DDrr GGooppaallaakkrriisshhnnaann RRaammaann:: It is a moreobjective way of applying the procedure,in a more scientific manner than in the

past, in terms of recruiting the patient andadjusting the PEEP level, by means ofadjusting PEEP according to lungmechanics rather than gas exchange. Andit also allows us to track the changes thathave been made or occurred during thecourse of recruitment, which provides uswith more information in order to furthertailor the treatment.

AArree yyoouu uussiinngg aannyy pprroottooccooll ffoorr wweeaanniinnggwwhheenn ppaattiieennttss aarree iimmpprroovviinngg aafftteerr lluunnggrreeccrruuiittmmeenntt pprroocceedduurreess?? WWhhaatt iiss tthhee aavveerraaggee wweeaanniinngg ttiimmee ffoorr AARRDDSSppaattiieennttss wwhhoo hhaavvee bbeeeenn uunnddeerrggooiinnggOOppeenn LLuunngg rreeccrruuiittmmeenntt mmaanneeuuvveerrss??

DDrr PPaattttaabbhhii RRaammaann:: We follow astandard weaning procedure, where weuse CPAP or Pressure Support on aspontaneous breathing trial, and checkingthem, prior to extubation. The averageweaning time for ARDS patients from

Dr Pattabhi Raman performing a lung recruitment maneuver in an ARDS patient.


start of Pressure Support to extubationusually ranges between 2 to 5 days.

WWhhiicchh ttyyppeess ooff ssttaaffff mmeemmbbeerrss aarreeiinnvvoollvveedd iinn aappppllyyiinngg oorr mmoonniittoorriinngg tthhee rreeccrruuiittmmeenntt mmaanneeuuvveerrss wwiitthh tthheeOOppeenn LLuunngg TTooooll??

DDrr GGooppaallaakkrriisshhnnaann RRaammaann::The physicians are in charge, but therespiratory therapists are conducting therecruitment maneuvers. There is no hardand fast training, but we teach them bydoing the procedure, and monitoring theirrecruitment maneuvers as they learn andbecome more experienced. We havededicated respiratory therapists who lookafter the ventilators, under direction of thephysicians.

IIss tthheerree ddeelleeggaattiioonn ffoorr rree--rreeccrruuiittiinnggaafftteerr ssuuccttiioonniinngg//ddiissccoonnnneeccttiioonn??

DDrr PPaattttaabbhhii RRaammaann:: As a rule for ARDSpatients, suctioning is not a routineprocess. We try to avoid suctioning andonly conduct it when it is absolutelyrequired. Following suctioning, we repeatthe recruitment maneuver to re-establishthe values accordingly. If the requirementof PEEP is heavy, we use closedsuctioning systems, which are more expensive here.

WWiillll yyoouu bbee eexxppaannddiinngg oorr mmooddiiffyyiinnggtthhee pprroocceedduurree iinn ffuuttuurree,, oorr mmooddiiffyyiinngg iittffoorr ootthheerr ppaattiieenntt ccaatteeggoorriieess oorroouuttccoommee eennddppooiinnttss?? IIff ssoo,, wwhhiicchheennddppooiinnttss aarree ooff iinntteerreesstt aanndd wwhhiicchhcchhaannggeess wwiillll bbee mmaaddee??

DDrr PPaattttaabbhhii RRaammaann:: Based on the two-year experience we have, we have seensome patients do well, and some doextremely well. Since we cannot be reallydogmatic about anything, we would liketo continue concentrating on thesubgroups, and identifying which of thesubgroups that are responding mostpositively, and examining how therecruitment procedure is benefittingthese patients. We have a lot of findingsand observations at this point, but itwould be nice to conduct a controlledclinical trial to postulate on why some ofthe subgroups, such as extrapulmonaryARDS and sepsis, do so well with theprocedure.

RReeffeerreenncceess::

1) ARDSNetwork. Ventilation withlower tidal volumes as compared withtraditional tidal volumes for acute lunginjury and the acute respiratorydistress syndrome. N Engl J Med2000; 342 (18): 1301-1308.

2) Amato MBP, Barbas CSV, MedeirosDM, Magaldi RB, Schettino GP, Lorenzi-Filho G, Kariralla RA, Deheinzelin D,Munoz C, Oliveira R, Takagaki TY,Carlvahlo CRR. Effect of a protectiveventilation strategy on mortality in theacute respiratory distress syndrome. NEngl J Med 1998; 338 (6): 437-354.

3) Suarez-Sipmann F, Bohm S,Lachmann B. Clinical perspectives of“The open lung concept”. MinervaAnestesiol 1999; 65 (5): 310-312.

4) Villar J, Slutsky AS. The incidence ofthe adult respiratory distress

syndrome. Am Rev Respir Dis 1989Sept; 140 (3): 814-816.

5) Villar J, Pérez-Méndez L, KacmarekRM. Current definitions of acute lunginjury and the acute respiratorydistress syndrome do not reflect theirtrue severity and outcome. IntensiveCare Med 1999 Sep; 25(9): 930-935.

6) Marini JJ, Gattinoni L. Ventilatorymanagement of acute respiratorydistress syndrome: A consensus oftwo. Crit Care Med 2004; 32 (1): 250-255.

7) Suarez-Sipmann F, Böhm S, TusmanG, Pesch T, Thamm O, Reissmann H,Reske A, Magnusson A, HedenstiernaG. Use of dynamic compliance for openlung positive end-expiratory pressuretitration in an experimental study. CritCare Med 2007; 35: 1.

BBiiooggrraapphhiieess

Dr Gopalakrishnan Raman attendedCalicut Medical College, receiving hisdegree in 1991. He obtained his MD inAnesthesiology from King Edward VIIMemorial Hospital in Bombay in 1995and passed his National BoardExamination the same year.

He worked as a lecturer at King EdwardVII Memorial Hospital during 1994-1995, and was Senior Resident inCardiac and Anesthesiology at theprestigious Sree Chitra Tirunal Institutefor Medical Sciences and Technology in1996. In 1997 he worked in varioustraining posts in the United Kingdom,becoming Staff Anaesthetist andIntensivist at the University Hospitalsof Hartlepool and North Tees. Afterworking for several years in the U.K, DrGopalakrishnan Raman returned toIndia to assume the position of ChiefConsultant Intensive Care Medicine atthe Kovai Medical Center and Hospitalin Coimbatore.

Dr V R Pattabhi Raman received hisMBBS degree from Tirunelveli MedicalCollege and obtained his MD andDiploma in National Board inRespiratory Medicine from MadrasMedical College. He was awarded 3gold medals in MD for academicexcellence in pulmonology. He haspresented papers in national andinternational congresses, and is amember of the Indian Chest Society,the American College of ChestPhysicians – Indian Chapter, the IndianMedical Association and the IndianSociety of Critical Care Medicine.

After gaining experience in respiratoryand critical care medicine in Chennai,and sleep medicine in Sydney,Australia, Dr Pattabhi Raman returnedto India to assume the position ofConsultant in Pulmonology, critical care and sleep medicine at the KovaiMedical Center and Hospital inCoimbatore.










Kristianstad Regional Hospital has been creating solutions and generating experience in transportingventilated patients in the southern region of Sweden since 1978. In recent years, they have cooperated with partners and authorities to create a customized transport carriage for a mobile ICU to facilitate transport of critical care patients within the region. All inter-hospital patient transports in the mobile ICU were documented on protocol during the year 2006.

Critical Care News met with the project team members representing key functions; project director,anesthesiologist, ICU physicians, ICU nurse and clinical engineering, to discuss their impressive results.

Evaluation of a ventilator solution in a mobile ICU

Ronny Knutsson, RN and Anne Magnusson, RN prepare an ICU patient for mobile transport.


YYoouu hhaavvee aa lloonngg ttrraaddiittiioonn ooffttrraannssppoorrttiinngg vveennttiillaatteedd IICCUU ppaattiieennttss iinntthhiiss rreeggiioonn ooff SSwweeddeenn.. CCaann yyoouu tteellll uuss aa lliittttllee aabboouutt tthhee hhiissttoorriiccaall bbaacckkggrroouunndd??

LLeennnnaarrtt OOhhllssssoonn,, MMDD,, DDeeppaarrttmmeenntt ooff AAnneesstthheessiioollooggyy aanndd IInntteennssiivvee CCaarree::We started back in 1978 or 1979 when we equipped an ambulance with a SERVO900A ventilator with gas cylinders and anelectrical converter that was quiteadvanced for the time, with 220 voltagethat was approved and validated for thefirst time in an ambulance. In 1990 weimplemented a SERVO 900 C ventilatoron an integrated stretcher-trolley, whichworked well as a transport solution for 13years. During these years, we havegained experience and have developedpractical solutions during the course ofthis experience. Our goal has always beento provide continuous ventilation therapyto the patient during transport, whileminimizing interruptions as much aspossible. But one of the difficulties withthe older ventilator models was the needto interrupt ventilation while transferringthe patient from the ICU down to theambulance, and interrupting again whenarriving at the receiving hospital.

When the SERVO-i ventilator waslaunched in 2001, we saw the possibilityof developing a mobile ICU with a bedsideadaptation to provide uninterruptedventilation to the patient for the entiretransport chain, from ICU bedside, duringinter-hospital transport to the ICU bedsideat the receiving hospital. The projectgroup received approval during 2002, andstarted to customize and develop the newsolution, based on our previous years ofexperience.

This new mobile ICU solution has alsobeen used for transport of small neonatalpatients between university hospitals inthe region.

Many people in different groups have beeninvolved in the various stages of the process,but we are the primary project team thathas been involved in the development andimplementation of this latest solution, andmany of us have been actively involved inthe transport experiences of the past. Our project team has had the resources,some luck, but we have also had enoughdetermination to finalize the project, and

implement this latest solution. Thismeans that we have found the evaluationresults to be especially rewarding to uswithin the group.

RRoonnnnyy KKnnuuttssssoonn,, RRNN,, IICCUU nnuurrssee:: Manyof us who accompany the patients in themobile ICU today have had experience ofpatient transports with the older systemsand vehicles. This means that we haveexperienced details from practical andcare giving aspects that were areas forimprovement in the past. We took theseexperiences with us into the developmentprocess for the new solution in this mostrecent project group for the new mobile ICU.

CChhrriisstteerr KKaarrllssssoonn,, KKAAMMBBEERR,, PPrroojjeeccttDDiirreeccttoorr:: The mobile ICU consists of the TRANSMOBIL stretcher-basecombination, which is secured to thetrolley and allows transfer of the patientwithout changing position. The transfertrolley houses the SERVO-i ventilator, upto six jet infusion pumps, patient monitorand suction equipment, with fixedconnections and couplings as well aslocking mechanisms for the equipmentand trolley. This means that the trolley is completely self-sufficient with anoperational capacity of 3-4 hours for air,oxygen and power.

The specially designed vehicle containsboth a 12 V DC and a 230 V AC powersupply. Double air and oxygen tanks areavailable with 5000 liters each of air andoxygen, and switching between them iseasy. Strength, durability and stabilitywere key parameters in designing themobile ICU, which required specialcustomized frames and braces to hold theequipment. These have been developedto twice the strength and durability required,and will function even after a collision.

WWhhaatt pprraaccttiiccaall aanndd cclliinniiccaall aassppeeccttss lleeddttoo tthhee ddeevveellooppmmeenntt ooff yyoouurr ccuurrrreennttmmoobbiillee IICCUU ssoolluuttiioonn?? CCaann yyoouu tteellll uussaabboouutt tthhee pprroojjeecctt ggrroouupp bbeehhiinndd tthheessoolluuttiioonn??

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: It is important topoint out that this has been a cooperativeproject between KAMBER, the RegionalHealth Ambulance provider, and theRegional Hospital here in Kristianstad,where we have team members from keyfunctions within the hospital; physiciansand nurses from the Department ofAnesthesia and Intensive Care, and ourClinical Engineering Department.

MMaattttiiaass SSvveennssssoonn,, CClliinniiccaall EEnnggiinneeeerr::The entire mobile ICU is composed of

Loading ICU patient on transport trolley into the mobile ICU.


region, when ICU patient capacity isoverloaded at the other hospitals. In thisrespect, we also cooperate with theregion of Själland in Denmark, primarilywith neonatal patients. As thecooperation between hospitals in theregion increases, we have seen anincrease in our receiving patients from the hospitals in Malmö, Lund andHelsingborg, while maintaining the sameamount of patients we have transferredout of Kristianstad for care in thosecenters. We understand that thisincreasing trend of transferring ICUpatients between hospitals is at an evenhigher level in other parts of Europe, forexample Germany and Great Britain.

During the course of our one yearevaluation of the mobile ICU in 2006, we collected data showing the transfer of a total of 84 ICU patients from 12 ICUdepartments in the different hospitalswithin the region. A total of 68 of thesepatients were mechanically ventilated, ofwhich 15 of these were transported dueto capacity overload at the transferringintensive care department.

TToommaass ÅÅhhlluunndd,, MMDD,,AAnneesstthheessiioollooggyyaanndd IInntteennssiivvee CCaarree:: The mobile ICU isnot often used in acute cases – accidents,bleeding, trauma – these cases are mostfrequently transported in conventionalambulances.

The mobile ICU is mainly used fortransporting intensive care patients whoneed the clinical performance of an ICUventilator during transport. Historically,we have transported ICU patients back toKristianstad ICU from the UniversityHospital of Lund, where the patients havebeen sent for specialist care, for examplethorax, neurological or plasma phoresistreatment, ICU patients who are returninghome here to Kristianstad for continuingICU care. This inter-hospital transfer of ICUpatients within the region started to growduring the 1990’s, and is continuing toexpand, due to temporary lack of ICU patientbed capacity within hospitals in the region.

Our hospital here in Kristianstad is aboutan hour away from the big metropolitanareas and larger hospitals, so we havebecome a “buffer” hospital within the

many components, but must be regardedas one system. There are a lot ofregulations to follow when developingand customizing components and theentire system. The initial risk analysisprocess is the key basis for initiating aproject of this scale. It is a long thoroughprocess of identifying every possible riskfor the system, components andtransport process, and adjustments andmodifying details to avoid each risk.

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: We planned andanticipated anything that could possiblyhappen with the patient and treatmentduring the transport process: traffic jams,vehicle breakdown, the need to intubateor reintubate during transport; weconsidered every possible risk scenarioand came up with solutions to how wewould handle these.

IInn rreeggaarrdd ttoo yyoouurr ppaasstt eexxppeerriieennccee ooffttrraannssppoorrttss ooff iinntteennssiivvee ccaarree ppaattiieennttss,,wwhhaatt pprrooppoorrttiioonn ooff ppaattiieennttss aarreeaaccuuttee//eemmeerrggeennccyy aass ooppppoosseedd ttoosseeccoonnddaarryy ppllaannnneedd IICCUU ttrraannssppoorrttss??

Nurses Ronny Knutsson and Anne Magnusson accompany ICU transport patient from ward to mobile ICU.


equipment has become much smaller and lighter, with increased battery time.

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: Another bigdifference is that in the past the nursewas alone with the patient duringtransport. Now, depending on the status of the patient, an anesthesia nurse and an intensive care nurse mayaccompany the patient. We also havebetter communication with mobilephones, and can be in contact with theresponsible physician for consultancyduring the transport process, ifnecessary. The quality of care is muchimproved; in fact, it is as if the entire careteam is accompanying the patient, someof us physically and the rest electronically.Nowadays, we also have room for a third

staff member in special situations, andwe can also accommodate an aorticballoon pump if needed.

IInn tthheessee ggeenneerraall IICCUU ppaattiieenntt ccaatteeggoorriieess,,wwhhiicchh ttyyppee ooff cclliinniiccaall ppeerrffoorrmmaannccee iissrreeqquuiirreedd ffrroomm tthhee mmoobbiillee IICCUUvveennttiillaattoorr tthhaatt iiss ddeelliivveerriinngg tthheerraappyy??

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: In general, themobile ICU ventilator should provide thesame clinical performance that the patientrequires of the ventilator bedside in theICU. This is a great benefit to the patient,to be able to use the ICU ventilator withthe same settings bedside, and continuewith the same ventilator and settingsthroughout the entire transport process,bedside to bedside at the receiving ICU.This is without a doubt best for the patient, it is safer and more comfortablethan interrupting therapy, and it is alsobeneficial to the staff since it requiresfewer staff members and less time.

TToommaass ÅÅhhlluunndd,, MMDD:: I agree that it isimportant to maintain the same clinicalperformance in ventilation throughout theentire process. Transporting ICU patientsis a risk factor per se, and the idea thatthe intensive care patient should receive a lower level of care or become more

WWhhiicchh ttyyppeess ooff ppaattiieenntt ccaatteeggoorriieess aarreesseeeenn mmoosstt ffrreeqquueennttllyy iinn tthheessee ppllaannnneeddIICCUU ttrraannssppoorrttss??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: Basically, youcould say that the patients transported in the mobile ICU are the same mix ofpatient categories in the ICU ward:general ICU patients with pneumonia,COPD, sepsis, post-op, you name it. TheICU patients we treat in the departmentare the same categories transported inthe mobile ICU to other hospitals.

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: We can transportpatients in the mobile ICU that otherwisewould have been regarded as not suitablefor transport in the past. Our objective isto give the patients the same level of carein the mobile ICU as they receive in theICU departments. This means the samelevel of patient monitoring, the sametreatment medications, the same qualityof ventilatory care, without interruption. Inorder to monitor and ensure that the levelof care is the same quality, we documenteverything that happens, prior totransport, during transport, and aftertransfer to the new ICU, in order to followthe patients as closely as possible.

CChhrriisstteerr KKaarrllssssoonn,, PPrroojjeecctt DDiirreeccttoorr::We are also in the process of includingblood gas analyzers in the mobile ICU. We have started to include these in theneonatal patient population, and they will be available for all patient categoriesby this summer.

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: Much hashappened in regard to development andexperience during the past decades wehave been involved in patient transports.Today, we have syringe infusion pumps,which facilitate the process and are easierto place. In general, most of the

Reasons for mobile ICU transports152224

Capacity overloadMedical indicationTo hospital of origin

ICU patient transport protocol data, 2006

Mobile ICU Project Director Christer Karlsson is employed by KAMBER-Skåne, the regional

ambulance transport service.


uncomfortable due to a suboptimalventilator during the transport process isvery negative indeed. The other factor isthat we see a continued increasing focuson non-invasive and supported ventilationin recent years. This means that themobile ICU must have a ventilator toaccommodate these modes, just as atbedside, and the other modes as well: forintubated patients with controlled orsupported ventilation modes as well aspatients with non-invasive ventilation.When we purchased the SERVO-i in 2002,it was clear to us that it would suit all ofthese treatment requirements intransport, as well as the battery back-uptime and the other practical features.

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: It can be ofinterest to note how we came to theoptimal arrangement of the equipment.We knew what supplies we wanted onthe trolley, but we were not sure how tofit each item optimally in proportion toeach other, so we were continuallysketching and drawing up drafts. At thesame time, we had construction going onin the Department of Anesthesiology andIntensive Care, and the floor was coveredin sheets of protective paper, so we tooksome of them and cut them to the sizeand dimension of the lower level of thetrolley. We arranged the gas cylinders,ventilator and other equipment on thepaper “trolley”, so that everything wouldbe placed compactly and proportionately.We called this starting at “ground level”.

CChhrriisstteerr KKaarrllssssoonn,, PPrroojjeecctt DDiirreeccttoorr::Another issue we were struggling withwas how to ensure an uninterrupted gas supply to the ventilator. We werelooking at all kinds of elaborate vents, andvalves, and ended up with a very simpleand easy solution in the final version:a valve on every hose that could beopened or closed, to let us run gas fromthe cylinders, or from the vehicle supply.

MMaattttiiaass SSvveennssssoonn,, CClliinniiccaall EEnnggiinneeeerr::Everything had a challenge, especiallyhow to ensure that all procedures werefree from interruption during the entireprocess. It all stemmed from the riskanalysis, right down to extra hoses, tubes and suctioning devices.

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: We strived foroptimal simplicity, with one connection

WWhhaatt iiss tthhee nnoorrmmaall rraannggee ooff ttrriiggggeerrsseettttiinnggss uusseedd dduurriinngg ttrraannssppoorrtt??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: Of the 68 patientswho were mechanically ventilated duringthe evaluation period, 47 patients hadflow triggering and 21 patients hadpressure triggering. The trigger functionworked optimally in 67 of 68 cases. In one instance, in the very beginning, weexperienced auto-triggering, where webelieve that the ventilator sensed somevibrations in the tubes. This was solved byswitching from flow triggering to pressuretriggering instead. Apart from this instance,we had no problems with auto-triggering.

TThhee oobbjjeeccttiivvee ooff tthhee pprroojjeecctt tteeaamm wwaassffoorr tthhee mmoobbiillee IICCUU pprroocceessss ttoo pprroovviiddeeuunniinntteerrrruupptteedd ddeelliivveerryy ooff vveennttiillaattiioonnaanndd ccaarree dduurriinngg tthhee ttrraannssppoorrttaattiioonnpprroocceessss..WWhhaatt rreessuullttss ddiidd yyoouu rreeccoorrdd iinn yyoouurr eevvaalluuaattiioonn aafftteerr oonnee yyeeaarr??

RRoonnnnyy KKnnuuttssssoonn,, RRNN::There was norecorded instance of interruption of gasdelivery during the transport process, and there were no recorded instances ofinterruption of power from the ventilator. Inone case, there was loss of power from thevehicle to the ventilator when a fuse wentout in the mobile ICU, but the ventilatorbattery provided back-up power supply inthis case, with no interruption in ventilation.

for the entire trolley that supplied andconveyed everything; electrical power,oxygen and air. At the same time wewanted to make sure that if anythinghappened when the patient trolley wasenroute in the corridors between the ICU and the mobile ICU, we could simply plug into a wall outlet.

MMaattttiiaass SSvveennssssoonn,, CClliinniiccaall EEnnggiinneeeerr::The more cords, tubes and hoses youhave, the greater the risk of forgettingsomething, or something becomingdamaged.

WWhhaatt aarree tthhee ttyyppeess ooff vveennttiillaattiioonnssttrraatteeggiieess oorr mmooddeess tthhaatt aarree mmoossttccoommmmoonnllyy uusseedd dduurriinngg mmoobbiillee IICCUUttrraannssppoorrttss,, aanndd wwhhyy?? HHooww oofftteenn ddooyyoouu ttrraannssffeerr tthhee iiddeennttiiccaall sseettttiinnggss ffrroommtthhee ppaattiieenntt’’ss vveennttiillaattoorr iinn tthhee IICCUU ttootthhee SSEERRVVOO--ii iinn tthhee mmoobbiillee IICCUU??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: A total of 84patients were transported in the mobileICU during the year of evaluation in 2006.Of these, 68 patients were mechanicallyventilated, with 66 receiving invasiveventilation and 2 patients receiving non-invasive ventilation, with CPAP andmasks, which worked very well. A varietyof ventilation modes have been utilizedduring the evaluation.

Modes of Ventiliation - mobile ICU transport

30

25

20

15

10

5

0Pressure Support

Pressure Control

CPAP Volume Control

PRVC Volume Support

Invasive Non-Invasive

ICU patient transport protocol data, 2006


WWhhaatt iiss tthhee aavveerraaggee vveennttiillaattiioonn ttiimmeeffoorr iinntteennssiivvee ccaarree ttrraannssppoorrtt ppaattiieennttsstthhaatt yyoouu hhaavvee ddooccuummeenntteedd iinn yyoouurreevvaalluuaattiioonn??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: Overall, theevaluation revealed an average mean time of ventilation to be 72 minutes perpatient. The shortest case was ventilatedfor 45 minutes, and the longest case wasa patient who was ventilated for 300minutes.

DDiidd yyoouu ddooccuummeenntt yyoouurr eexxppeerriieennccee iinn rreeggaarrdd ttoo CCOO22 mmoonniittoorriinngg wwiitthhvveennttiillaatteedd ppaattiieennttss iinn tthhee mmoobbiillee IICCUU??

We monitored four patients with end tidalCO2 during the evaluation period, and hadno difficulties at all from a technical orclinical perspective, it worked excellently.

CCaann yyoouu ddeessccrriibbee tthhee pprroocceessss ooffpprreeppaarriinngg aa vveennttiillaatteedd iinntteennssiivvee ccaarree ppaattiieenntt ffoorr ppllaannnneedd ttrraannssppoorrtt::aatt tthhee rreemmiittttiinngg hhoossppiittaall aanndd aatt tthhee rreecceeiivviinngg hhoossppiittaall??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: Preparing thepatient in the ICU prior to departure is the most important part of the process.We fasten the tubes and cords, and makesure that everything is stable and in goodorder, before leaving the ward. If you missa step here, you will most likely encounterdifficulties of some nature later on duringthe transport period. In the mobile ICU,we are seated to the left of the patient, so if all of the tubing is fastened on theopposite side of the patient, this makesaccess extremely difficult, for example ifyou need to administer pharmaceuticalsor adjust infusion tubing. It is alsoimportant that the staff who are preparingthe patient for transport at bedside arethe ones who accompany patients in themobile ICU, which provides experienceand continuity in the process. Preparingthe patient prior to transport is key to thesuccess of the entire procedure.

LLeennnnaarrtt OOhhllssssoonn,, MMDD::There are many challenges with these procedures,but now we are at a point where theequipment is so optimal and advanced,

Ronny Knutsson, RN, Lennart Ohlsson, MD and Tomas Åhlund, MD have collaborated together at Kristianstad regional hospital for many years.

Lennart Ohlsson, MD


that if you do have problems or if thepatient’s condition should become worse,you can be confident that the equipmentyou have can be relied upon. Down theyears, there have been a few instanceswhere a patient has almost lost a tube,which is probably the worst scenario. But we are even prepared for this risk,and can reintubate the patient ifnecessary. We have a case with all kindsof pharmaceuticals and support items, to handle almost any kind of situation.

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: A part of thepreparation process includes having theappropriate pharmaceuticals with us. We have standard drugs in a case for alltransports, and each individual patient,depending on his condition, will requirespecific pharmaceuticals, that we bringwith us from the ICU prior to departure.

TToommaass ÅÅhhlluunndd,, MMDD:: We have to statethat we have almost never had anyserious difficulties. Almost all of thetransports have been very successful andwithout any problems. But the fact thatmost transports are so uneventful is dueto the detailed preparation process priorto departure. The key for each successfulpatient transport is in the preparation. It isa procedure similar to a pilot prior to take-off, with control of equipment and check-lists for every step of the way in the ICU.The staff involved in each individual caseis also part of the preparation, to providethe proper competence to the patient need.

WWhhaatt aarree tthhee ccoonnttrraassttss iinn vveennttiillaattiioonnttrreeaattmmeenntt iinn ttrraannssppoorrtt wwiitthh aann iinntteennssiivveeccaarree vveennttiillaattoorr ccoommppaarreedd ttoo ttrraaddiittiioonnaallttrraannssppoorrtt vveennttiillaattoorrss,, ssuucchh aass OOxxyylloogg??

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: In the beginningin 1978, there were no reliable transportventilators, which is why we used theSERVO 900. Some years later when thetransport ventilators started to show upon the market, we used these in theambulance as well, but we noticed thatthe patients were generally in a muchworse condition upon arrival at thehospital. ICU patients many times alreadyhave lung complications, which is why anICU ventilator is to be preferred in amobile ICU.

HHooww ddoo yyoouu hhaannddllee sseeddaattiioonn?? FFoorr IICCUU ppaattiieennttss wwhhoo aarree nnoott sseeddaatteedd::hhooww ddoo tthheeyy ggeenneerraallllyy eexxppeerriieennccee tthheettrraannssppoorrtt pprroocceessss?? DDoo yyoouu nneeeedd ttoorreegguullaarrllyy cchhaannggee tthhee sseeddaattiioonn lleevveellbbeeffoorree ttrraannssppoorrttiinngg tthhee ppaattiieennttss??

RRoonnnnyy KKnnuuttssssoonn,, RRNN:: The relationshipbetween sedated and non-sedatedpatients in the mobile ICU is generallyidentical to the relationship to sedatedand non-sedated patients in the ICUdepartment. In a few specific cases, wehave increased the level of sedation if the patient has required a higher level of

Tomas Åhlund, MD

Lennart Ohlsson, MD, lecturing on the first generation ventilator-equipped ambulances at the hospital in 1978. He was involved in the process,

and in all subsequent developments ever since in Kristianstad.


comfort during transport. However, ourtradition in the ICU is to avoid sedation if it is not necessary, in order to help thepatients wean and recover more quickly.

WWhhaatt ddoo yyoouu tthhiinnkk aarree tthhee ffuuttuurreettrreennddss iinn rreeggaarrdd ttoo ttrraannssppoorrtt ooffiinntteennssiivvee ccaarree ppaattiieennttss?? WWiillll tthheerree bbeeiinnccrreeaassiinngg nnuummbbeerrss,, rreeqquuiirreemmeennttss oorrssppeecciiaall ddeemmaannddss iinn ffuuttuurree??

CChhrriisstteerr KKaarrllssssoonn,, PPrroojjeecctt DDiirreeccttoorr::In regard to ambulance care, our currentsolution is very unique. We did a greatdeal of research prior to starting theproject in 2002, but we could not identify any optimal solutions from ourperspective, most of what is being usedseems to require equipment that isanchored to the vehicle, which disturbsand complicates the transport processfrom the ICU to the vehicle. Our conceptof securing the customized stretcher-trolley as an integral part of the transportsolution means that we now have abedside-to-bedside solution in transport,from beginning to end.

MMoobbiillee IICCUU pprroojjeecctt mmeemmbbeerrss,,KKrriissttiiaannssttaadd::

Lennart Ohlsson, MD, has worked as an anesthesiologist since 1972. He has been developing and workingwith mobile ICU transport since 1976.

Tomas Åhlund, MD, has worked as an anesthesiologist since 1991 and has a special interest in intensive caremedicine. He has developed medicalroutines for the mobile ICU.

Anne Magnusson, RN, has been ananesthesia nurse since 1987 and is amember of the design group for themobile ICU.

Project director Christer Karlsson, and Mattias Svensson, clinical engineer, have worked closely together in regard to the design and

validations of the transport solutions.

Ronny Knutsson, RN, has been an intensive care nurse since 1984, and is a member of the design group as well as transport coordinator.

Mattias Svensson is a Clinical Engineer at the Department of Clinical Engineering and Physics, and is a member of the design group.

KKAAMMBBEERR--SSkkåånnee,, RReeggiioonnaallAAmmbbuullaannccee TTrraannssppoorrtt SSeerrvviiccee::

Christer Karlsson is project director forthe mobile ICU and has been workingfor KAMBER-Skåne since 2002. Hebecame an anesthesia nurse in 1974,and has devoted 25 years to trainingnurses at the University of Lund, Sweden.

LLeennnnaarrtt OOhhllssssoonn,, MMDD:: Other hospitals inother regions have shown interest in ourmobile ICU solution. We are certain thatthe need to transport ICU patients willcontinue to increase, as the trend to transfer

patients between hospitals grows. Andthe increasing population density in citiesand overcrowded hospitals will influencethe need to transfer ICU patientsbetween hospitals.

CRITICAL CARE NEWS is published by MAQUET Critical Care.Maquet Critical Care AB171 95 Solna, SwedenPhone: +46 (0)8 730 73 00 www.maquet.com©Maquet Critical Care 2007. All rights reserved. Publisher: Leif LohmEditor-in-chief: Kris Rydholm ÖverbyOrder No. MX-0343Printed in [email protected]

The views, opinions and assertions expressed in the interviews are strictly those of the interviewed and do not necessarily reflect or represent the views of Maquet Critical Care AB.

©Maquet Critical Care AB, 2007.All rights reserved. No part of this publication may be reproduced,stored in a retrieval system, or transmitted in any form or by any othermeans, electronic, mechanical, photocopying, recording, or otherwise,without the prior written permission of the copyright owner.

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Documents

NO News Critical Care · Medical Center, Coimbatore, India Evaluation of a ventilator solution in a mobile ICU The Mobile ICU Project Members, Kristianstad Regional Hospital and KAMBER-Skåne,