Spring/Summer 2020 Adult Acute Care Specialty Section Bulletin
Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS
Providence Regional Medical Center
Karsten Roberts, MS, RRT, RRT-ACCS, RRT-NPS
Hospital of the University of Pennsylvania
In this issue:
Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS Notes from the Chair: Notes from the Chair: COVID Madness
Christopher Culter, RRT, RRT-ACCS Compassion Fatigue, Burnout, and Secondary Traumatic Stress
Sajjad S. Raza, BS, RRT, RRT-ACCS Driving Pressure
Notes from the Chair: COVID Madness
Carl Hinkson, MSRC, RRT, RRT-ACCS, RRT-NPS
Welcome to the Spring Bulletin. During the last few months I’ve heard people cite a saying — or maybe “curse” is a better word — that goes, may you be blessed to live in interesting times.
The past few months have been interesting to say the very least. We have seen a pandemic in the United States and across the world. We have also seen respiratory therapists everywhere rise up to meet the challenge head on. Numerous news articles and video clips have been made highlighting our important work. Never have I been more proud to call myself a respiratory therapist.
In this Bulletin we have two great articles for your pleasure, dealing with topics that should concern us all: compassion fatigue and driving pressure. Enjoy!
Compassion Fatigue, Burnout, and Secondary Traumatic Stress
Christopher Culter, RRT, RRT-ACCS, Michigan Medicine, University of Michigan, Ann Arbor, MI
At some point in your career you will have at least one story to tell about a particular code or trauma situation that had an effect on you personally. Dr. Charles Figley described this type of secondary trauma as “compassion fatigue” back in 1982. “Most often this phenomenon is associated with the ‘cost of caring’ for others in emotional pain,” he said.
1 Dr. Figley first noticed this phenomenon in soldiers while serving in the Vietnam war.
Compassion fatigue, burnout, and secondary traumatic stress are all terms you may have heard before. But you may not understand what makes them different from each other. Compassion fatigue is most commonly defined as, “a state of exhaustion and dysfunction biologically, physically, psychologically, and socially as a result of prolonged exposure to compassion stress and all it invokes.”
2 Burnout is when an individual has emotional and physical fatigue from prolonged exposure to emotional and stressful situations.3 Secondary traumatic stress occurs from helping or wanting to help someone who has been in trauma, and the subsequent stress involved. 3
Another term that is often used in the literature surrounding compassion fatigue is “compassion satisfaction.” “Compassion satisfaction is about the pleasure you derive from being able to do your work well,” wrote Thomas P. Reith.
In Figure 1 below, the relationship between these terms is illustrated.
Next, you may be asking yourself, do I have any of these? The good news is that there is a tool that can be used to measure your compassion (fatigue and satisfaction) and burnout. The most recent version of this tool is the Professional Quality of Life Scale (ProQOL) Version 5.4 Based on your response to 30 questions, you are given a score for compassion satisfaction, burnout, and secondary traumatic stress.
Each of the three categories has a scale based on your score; low, moderate, and high. Scoring high in any category at one point in time doesn’t necessarily mean you are burnt out or lack compassion satisfaction. Try taking the questionnaire at a later date/time and see if your scores change. If your scores stay at an elevated level, consider some ways to increase your compassion satisfaction and decrease your burnout and secondary traumatic stress.
Let’s say you continue to score high (>41) in the burnout section. What does that mean? Should you care if you have a high burnout score? The short answer is yes, you should care. There is a correlation between burnout and major medical errors, as well as an increased likelihood of being involved in a malpractice suit.
5 Burnout also leads to greater turnover and thoughts of quitting. 5 Burnout can have long-term physical consequences, such as higher body mass index, higher cholesterol, insomnia, depression, and mental disorders, as well. 6
By now you should realize that burnout and secondary traumatic stress are bad. What can we do about them? How can you increase your compassion satisfaction and decrease your burnout/secondary traumatic stress (compassion fatigue)?
Several studies have shown success in reducing burnout with structured meditation and interactive group seminars, including exercises using resiliency educational materials.
7 Decreased secondary traumatic stress and increased compassion satisfaction were seen as well. These studies all had a component that focused on teaching and/or bolstering resilience. 7
Many institutions recognize that compassion fatigue is a growing issue and are creating ways to reduce burnout and secondary traumatic stress. If your institution doesn’t have a program, consider starting one. Johns Hopkins Medicine offers a two-day workshop that trains the trainers who want to implement a peer-to-peer support program at their facility.
Figley CR. What is compassion fatigue: prevention & treatment – PTSD resources. Post Traumatic Stress Disorder Information & Healing (PTSD) – Gift From Within. Last modified July 16, 2014. https://www.giftfromwithin.org/html/What-is-Compassion-Fatigue-Dr-Charles-Figley.html.
Figley C. Compassion fatigue as secondary traumatic stress disorder: An overview in CR Figley. In Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatised; Brunner/Mazel: Bristol, UK, 1995; p.235.
Martin EM, Myers K, Brickman K. Self-preservation in the workplace: the importance of well-being for social work practitioners and field supervisors. Soc Work 2019;65.1:74-81. 4. Professional Quality of Life. 2019. Retrieved from https://proqol.org/Home_Page.php.
Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus 2018;10(12).
Kelly L. Burnout, compassion fatigue, and secondary trauma in nurses: recognizing the occupational phenomenon and personal consequences of caregiving. Crit Care Nurs Q 2020;43(1):73-80.
Cocker F, Joss N. Compassion fatigue among healthcare, emergency and community service workers: A systematic review. Int J Environ Res Public Health 2016;13(6):618.
Caring for the Caregiver | Second Victims | Johns Hopkins Solutions. Retrieved from https://www.johnshopkinssolutions.com/solution/rise-peer-support-for-caregivers-in-distress/.
Sajjad S. Raza, BS, RRT, RRT-ACCS
The current standard for lung protective ventilation in patients with ARDS is the use of low VT based on ideal body weight (IBW) and high PEEP.1,2 However, the implementation of said strategy does not completely mitigate the risk for worsening lung injury. Excessive increases in intra -and transpulmonary pressure via mechanical ventilation can still result in barotrauma, leading to ventilator induced lung injury (VILI).
1 Therefore, a more complete lung protective strategy uses the additional parameter of maintaining the Pplat < 30 cmH20 in an effort to further reduce VILI. 2-4
This ongoing effort to further reduce the risk of lung injury has led to an interest in Driving Pressure (∆P) as a key variable in ventilator management. The assessment of its role in achieving the overall goal of improving patient outcomes has markedly increased since the Amato et al. study. While the data are currently insufficient to provide a complete understanding of how ∆P can best be used, a few questions are beginning to be answered.
Factors to consider
∆P is defined as the difference between static plateau pressure (Pplat) and PEEP. It can also be represented as the ratio between tidal volume (Vt) and respiratory system compliance (Crs).
5 Driving pressure can therefore be derived as the corrected Vt for the patient’s Crs. 3,5
Calculating ∆P is fairly simple and easily performed at the bedside with even the most basic ventilator. First, obtain the Pplat by performing a manual inspiratory hold during a controlled mechanical breath, and then subtract the PEEP. That said, however, an active spontaneous effort of the diaphragm during an assisted mechanical breath can underestimate the Pplat, resulting in a falsely lower ∆P.
2-4 The additional question of which PEEP value to use, set PEEP vs. total PEEP, also remains unclear. 4
There is some consensus as to when ∆P should be used as a metric to determine ventilator management.
2-7 In patients with ARDS, using ∆P as a method to reach a target tidal volume or PEEP appears to be the most agreed upon approach. 2-5 The current data suggest that patients with ARDS benefit the most from a lower ∆P, according to Amato, 13-15. 2-5,7 Additional studies also indicate improved mortality in patients with moderate-to-severe ARDS when a similar ∆P is achieved. although disagreement exists over how to achieve the optimal range for ∆P, either through PEEP titration or adjustment in VT. 2-4,6,7
Recently, Sahetya et al. showed a reduction in ∆P by titrating PEEP levels based off the ARDS Network low PEEP/FiO2 table. Although there were limitations, including population size and duration of the study, the variable adjustments to PEEP are noteworthy as some patients required a decrease in PEEP to achieve optimal driving pressure.
8 More study needed
Using ∆P as a target strategy to replace the current lung protective strategy lacks sufficient evidence, and more prospective studies are required. There are also limited data to support using ∆P as a target variable for spontaneously breathing patients and patients without ARDS.
2-4,6,7 Monitoring ∆P can be used as a possible prognostic indicator of lung health in the presence of ARDS. 2-7 However, caution should still be applied due to the risk of obtaining an inaccurate ∆P based on imprecise values for Pplat or PEEP. 3,4,6,7
Despite the undetermined role ∆P plays in ventilator management, it’s a variable that can’t be ignored in our efforts to reduce VILI and overall mortality in patients with ARDS. Further studies are required to determine its true significance among other parameters used to reduce risk of lung injury, along with its safety and feasibility as an alternate lung protective strategy. The current consensus indicates that ∆P be used as an additional metric in a low Vt targeted strategy in patients with ARDS.
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: The berlin definition. JAMA 2016;315:788-800.
Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? Crit Care 2017;21:199.
Aoyama H, Yamada Y, Fan E. The future of driving pressure: a primary goal for mechanical ventilation? J Intensive Care 2018;6:64.
Sreedharan JK, Akqahtani JS. Driving pressure: Clinical applications and implications in the intensive care unit. Indian J Respir Care 2018;7:62-
Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015;372:747-55.
Pelosi P, Ball L. Should we titrate ventilation based on driving pressure? Maybe not in the way we would expect. Ann Transl Med 2018;6:389.
Vaporidi K, Xirouchaki N, Georgopaulos D. Should we care about mechanical ventilation? J Intensive Crit Care 2017;3:2.
Sahetya SK, Hager DN, Stephens RS, Needham DM, Brower RG. PEEP titration to minimize driving pressure in subjects with ARDS: a prospective physiological study. Respir Care 2020;65(5):583-589.
Section discussion list: to network with your fellow section members. Go to the Adult Acute Care Section on AARConnect
Next Bulletin: Fall/Winter Issue. He will be happy to help guide you through the process if you’re a new contributor! Please email Karsten Roberts if you would like to contribute an article.