Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS
Welcome to the Fall-Winter edition of the Bulletin. 2020 has turned out to be quite a year from many perspectives. Faced with a pandemic, the respiratory therapy community rose to the occasion and demonstrated the value we bring with our expertise. The AARC Congress pivoted from an in-person meeting to a virtual event and I hope everyone was able to partake of the excellent critical care lectures that were available. I certainly missed being able to see so many of my friends this year, which is always my favorite part of attending the Congress. I also missed being able to congratulate Felix Khusid, BSRT, RRT, RRT-ACCS, RRT-NPS, RPFT, in person on his selection as our Specialty Practitioner of the Year. He certainly deserves it.
In this Bulletin we have articles from Donna Tanner, MHA, MBA, RRT, RRT-ACCS, FCCP, and Joyce McCullers Lanier, BS, RRT, CCRC, related to our time and experience with COVID-19.
My time as chair has come to an end. I have certainly enjoyed my tenure. The value of the Adult Acute Care Section lies in the membership. Our section members are some of the brightest, sharpest, and most patient-focused critical care practitioners in practice today. We always enjoy robust discussions on our AARConnect discussion list, be it a highly technical discussion about ventilator operations or a conversation on how to approach patient care.
I am pleased to be handing off the chair to Maria Madden, MS, RRT, RRT-ACCS, research coordinator and ECMO specialist per diem at the University of Maryland Medical Center/R. Adams Cowley Shock Trauma Center. I know she will enjoy the member engagement as much as I have, and I am also confident that our members will benefit from her leadership and expertise.
Donna Tanner, MHA, MBA, RRT, RRT-ACCS, FCCP, Cleveland Clinic, Cleveland, OH
Extracorporeal membrane oxygenation (ECMO) has been recommended by the World Health Organization for patients with severe COVID-19 who suffer from refractory hypoxemia.1 ECMO has been effectively used in the management of COVID-19 related ARDS.2
However, this finite resource comes with limitations related to ECMO consoles, disposable equipment, suitably trained staff, and adequate isolation requirements.1,3 Although ECMO has an essential role in supportive care of COVID-19 patients, there is also currently inadequate data to determine efficacy, optimal patient selection, and management on ECMO.1,3 Pre-COVID criteria for patient selection may have been liberated during this pandemic for patients who are now being cannulated based on the selection criteria used in the EOLIA trial for venovenous (VV) and venoarterial (VA) ECMO.1
The Extracorporeal Life Support Organization (ELSO) has provided absolute contraindications for ECMO in COVID-19 patients with their guidelines for cardiopulmonary failure as well. These include advanced age, severe multisystem organ failure, clinical frailty, severe neurological injury, significant comorbidities, mechanical ventilation >10 days, uncontrolled bleeding, and those with contraindications to anticoagulation, leading to the increased use of VV-ECMO in acute respiratory failure as a distinctive feature of COVID-19.4
Due to refractory hypoxemia experienced in this disease process, once patients are cannulated, increased flows are required to manage ECMO. The addition of a second venous drainage cannula may remedy the hypoxemia, but can lead to fulminant myocarditis and heart failure. If this occurs, a transition to VA ECMO may be necessary, making the management course more challenging.1,2,4 In a recent publication by Alom et al, 22% of COVID-19 patients experienced cardiovascular complications, such as heart failure, myocarditis, and hypercoagulability, favoring the use of VA-ECMO for both respiratory and hemodynamic support.5
Traditionally, ECMO is a bridge to a collective endpoint. Pre-COVID, we typically knew prior to cannulation that patients suffering from severe ARDS were bridging to recovery. Patients with non-recoverable lungs were bridging to transplant. Now the question of bridging is a grey area. Clinicians struggle with the risk-benefit factor as the pathophysiology of the virus’ effects are characterized to guide management and optimize outcomes.3
In 2014, Schmidt et al, developed the RESP score as a robust prediction tool comprised of 12 simple variables to predict survival after ECMO initiation.6 This clinically relevant tool suggests an association with decreased mortality when early ECMO intervention has occurred.7 Outcome-related data from ELSO last reported 2076 confirmed COVID-19 ECMO cases, with a 42% in-hospital mortality rate.8 However, the time-to-ECMO remains unreportable on a global dashboard, making it impossible to compare results for early versus late intervention.
Key takeaways from the ECMO-COVID experience in patient management include the recognition of distinctive shared characteristics. Patients are similar in size and age, they universally have an inability to oxygenate, they are difficult to ventilate, and the high ECMO flow required to maintain them usually results in right heart compromise.
Still, supporting patients’ recovery from COVID-19 by utilizing ECMO may be the last chance these patients have for a meaningful recovery or survival. Patients are not cannulated just for the sake of cannulation. We place patients on ECMO to help, to heal the lungs and heart through rest and recovery, and to reduce mortality during a pandemic outbreak that presents us with critically ill patients.
Joyce McCullers Lanier, BS, RRT, CCRC, Office of Clinical Trials, University of North Carolina at Chapel Hill
Do you remember your first terminal extubation? I do . . .
I had just started my shift for the day. I had received a vague communication report from the previous respiratory therapist about the patients that I needed to care for that day. I was assigned to the burn unit, and anticipating a busy shift, headed there immediately after receiving report. Shortly after I arrived on the unit, I was approached by a visibly shaken physician who asked me if I was “respiratory care.” I acknowledged that I was. He proceeded to inform me that the family in a certain room was ready for withdrawal of life support. He emphasized the fact that it needed to be done immediately and then abruptly left.
As I entered the room of an unconscious eight-year old boy in the burn ICU, it was filled with profound grief. Navigating through the currents of sadness almost made my steps, as a recent respiratory therapist graduate, impassable. The sound of the mechanical ventilator was distinct, striking, and deafening. Eye contact with the mother was captivating, almost paralyzing. I was apprehensive about whether to smile or nod. Talking seemed inappropriate at the time due to the pronounced suffocating silence that emphatically demanded its space.
I walked over to the young boy, pre-silenced potential alarms, disconnected him from the ventilator circuit, and turned the machine off. Internally, many questions proceeded to interrogate me. Do I remove the endotracheal tube? Should I stay at the bedside to suction? Do I walk out, or do I engage the family?
This scenario occurred more than 28 years ago. It was my first terminal extubation and I had received no formal education or training on how a respiratory therapist should conduct it. My professional competence felt challenged and inadequate in that moment. It was an extremely stressful and uncomfortable introduction to end-of-life care.
As respiratory therapists, we are trained to place patients on mechanical ventilation, which is a life-sustaining therapy.1 We are likewise the health care professionals that remove the mechanical ventilator when it is no longer needed. This responsibility integrates the respiratory therapist into end-of-life care conditions. The services we provide within end-of-life care are more complicated than the mechanics that are routinely taught to a respiratory therapist about how to remove an endotracheal tube from a patient.2
End-of-life care is especially challenging when death is inevitable if life-sustaining therapies are withdrawn.3 End-of-life care is often associated with ICU discord as well.4 This discord can arise between physicians and family members, or due to conflict within multiple members of a patient’s family.4 Sometimes due to the discord, respiratory therapists may find themselves stuck in the middle while simply adhering to the functionality of their job.2 Even without discord, traversing the grief associated with end-of-life care can be challenging to the respiratory therapist.3
The role of respiratory therapists in end-of-life care has been heightened by the demands of the COVID-19 pandemic.5 COVID-19 has added new components to end-of-life care, not the least of which is the fact that respiratory therapists are encountering patients who are dying alone. This could have pragmatic implications for the respiratory therapists who are performing these terminal extubations.2 Additionally, the sheer volume of end-of-life care encounters due to the number of mechanically ventilated COVID-19 patients has created an unprecedented challenge for respiratory therapists.5
This additional burden on our frontline respiratory care practitioners merits further consideration and investigations to make sure that those who are willing to care for our most vulnerable patients are not only equipped with ventilators and personal protective equipment but are equally prepared and supported for their management within end-of-life care.
Section discussion list: Go to the Adult Acute Care Section on AARConnect to network with your fellow section members.
Next Bulletin: Spring/Summer Issue. Please email Karsten Roberts if you would like to contribute an article. He will be happy to help guide you through the process if you’re a new contributor!