Episode 192: Debunking Myths- Sedation and Ventilator Asynchrony
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Before we dive into this exciting episode, I want to share a call to action. Revolutionists, there are thousands of you out there. You are all at different points of leading the movement in your ICU, but every little drop in the bucket helps and does make an impact. One of the big needs this revolution has right now is for you to join your local and national chapters and organizations.

organizations. This includes but is not exclusive to SCCM, APTA, AOTA, ATS, AARC, AACN, CHESS, MEACH, ELSO, etc. Join the committees, submit abstracts to publish and or present,

Take leadership in these organizations, etc. Don't just wait for the organization to lead this movement. It is time for us all to jump in and guide these ships to head in the right and the same direction. This may be a new and even uncomfortable consideration for you. I totally get it. I am the first to empathize with feeling inadequate, unprepared, and often really uncomfortable to speak up and push for what is right. What has driven me to get on the mic and to

and take on these roles and events is that it just needs to be done. For decades, I've had the personal slogan, don't just complain about it, do something about it. Now, this phrase slaps me over the face as I have a lot of concerns and complaints about ISU culture and practices. I know you all do. Don't just complain about it, do something about it. Join your organizations, contribute and lead. Find the opportunities,

and I have seen that the revolutionist spirit will help you rise to the occasion. I deeply believe that we as ordinary people can do extraordinary things. We all need to be playing a part. All right, now to this episode. I think we all love a good myth debunking.

I am really excited to have Sylvia Stephanos take the myth of sedation as a treatment for ventilator synchro by the horns here. Sylvia, welcome to the podcast. I'm so excited to have you on. Can you introduce yourself to us? Yeah, it's so exciting to be here. My name is Sylvia Stephanos. I am currently a medical ICU clinical pharmacist at Houston Methodist Hospital in the Medical Center. And I heard you present at the Texas chapter of SCCM.

Loved your topic. It was really cool to see a pharmacist talking about the impact of deep sedation on ventilator synchrony, which has been such a hot topic for years. And you almost had me jumping out of my seat. I mean, physical reaction because light bulbs were going off like crazy.

Yeah, it was very exciting to be part of that symposium. And even as the person presenting, it was so exciting to see at the back of the room, just looking elated when I was presenting. And that always makes the speaker very comfortable. And so I was excited that somebody else was just as excited as I was. Were you surprised that someone was that excited about this topic of how sedation impacts ventilator asynchrony? Yes, absolutely. And you gave your talk right before mine and I was enthused to go after you just because it tied it together so beautifully.

Totally. And to have also a pharmacist talking about this just thrilled me because we're very siloed in the ICU. We're very territorial. So it was an aha moment to have a pharmacist concerned about ventilator synchrony and sedation management for that asynchrony. And there were so many things that you shared, which we're going to get into, that finally happened.

Made sense to me. Having worked in an awake and walk-in ICU for seven years, it was medical surgical ICU, but informally an ARDS unit. We would get transfers from all over the region with patients with ARDS and severe ARDS. Even during COVID, we had one of the highest acuity COVID units in the state of Utah. And our practices seem so different than everyone else. And I couldn't explain why it worked.

Especially when I started the podcast, I was like, just, you just get them up and you just move. And yeah, but the rest of the country and the world was saying, but ventilator is synchrony, but ventilator is synchrony. You can't get them to synchronize the ventilator. And I was looking around the unit thinking, am I missing ventilator synchrony? I know it can be elusive, but really these patients are usually sitting up, watching the TV, walking around in their rooms. They're okay. And we don't have them sedated unless they kind of auction it with movement. But

Maybe it would give a little fentanyl, maybe a little drip lightly, but that was it. And that was rare even. So hearing your discussion about what sedation actually does to mentally nursing green just made sense.

So tell me, why did you look into this? Why did you do this literature review? What got you as a pharmacist caring about ventilator asynchrony? Yeah, absolutely. You definitely have a very unique experience in having a very awake ICU because my experience has been in ICUs where we are sedating patients, especially who are very sick and have severe ARDS. And your experience is seeing how are they so comfortable being awake?

We have great outcomes in patients with ARDS. And my observation has been we are deeply sedating them because we are trying to optimize the patient-vent interaction and it's not working. Why is it not working? And I'm looking at all of these studies that we have in ARDS, some that have different sedation strategies and potentially different outcomes.

And so that got me doing a deeper dive on, okay, so we're saying sedation impacts respiratory drive, respiratory timing, but does it actually suppress respiratory drive in the way that we think it does to be able to optimize the patient for interaction? And I learned so much more, debunked so many common myths that we have and beliefs around sedation and analgesia, and that it doesn't work in the way that we think it does. I think it potentiates the...

harm associated with the patient-vent interaction in ways that maybe it causes more asynchrony than nothing at all. So this podcast has done a lot of myth debunking. You know, a lot of our perceptions and assumptions are unfortunately very untrue. And so let's debunk this myth that the more asynchronous someone is with a ventilator, the more sedation they need. Because that really, I think it's always existed, but especially during COVID when we had

lots of new clinicians in there. RTs were spread so thin, they didn't have time to come to the bedside and really look at the ventilator. They're getting calls from these nurses oftentimes who don't have very much experience. They don't know what these alarms mean. And they're panicking over both Sarah and saying, the vent's alarming and RTs can't think about it because they're intubating a patient in another room. And they just say, turn up sedation. But then it doesn't work. And then they're calling them back. Then I did, it's not working. And they said, just give him a paralytic, just give him a paralytic. So

Why so often did that not work to turn up sedation? What do we know? Yeah.

So one, it is very important to address pain and sedation needs in the ICU. Correct. We are using our scoring tools. We're making sure that patients are comfortable. But oftentimes when we're talking about patients being asynchronous with the vent, you look at the patient and they're completely out of it. It could be at least for us of negative three. And we're still trying to optimize sedation and analgesia and wondering why it doesn't work any further. And so, yes, definitely optimize analgesia in these patients.

But think about what is causing this asynchrony. Whenever we're talking about asynchrony, there are some common types. So there's ineffective triggering. Oftentimes that's because the patient initiates an ineffective breath. And that just happens naturally with

diaphragmatic weakness with prolonged mechanical ventilation. Oftentimes it may not lead to a phenotype that can cause bent and induced lung injury because it doesn't increase tidal volume, it doesn't cause breast sacking, that sort of thing, but it can eventually lead to one if it's strong enough. And then there is double triggering, which is one that we may be most associated with because you'll see two waveforms back to back without complete exhalation. And then you see a larger tidal volume, of course, in patients with ARDS. We talk about

unprotected mechanical ventilation. We want to minimize tidal volumes in these patients, prevent lung over distension. And so you're seeing these two breast back-to-back large tidal volumes potentially bad. And so we're saying, okay, let's prevent the patient from breathing more. And so maybe get rid of that double triggering when that doesn't always work by increasing sedation. One that has

been brought to light more recently is reverse triggering. And this is a form of asynchrony that has actually been characterized more in patients with deeper sedation. It was first described in 2013, so it's fairly new. But what essentially happens is that there's an external stimulus, in this case, it's the ventilator that induces an involuntary breath that is initiated by the patient. It stimulates the central system, so it

in the brain to then deliver a stimulus to the phrenic nerve that then stimulates this involuntary diaphragmatic contraction. It can happen in different phenotypes. It could happen in the inspiratory phase or it could happen late inspiratory or expiratory phase that can lead to a double triggering event, in this case, the reverse trigger. So it could look like a reverse triggering or it could look like double triggering and that you see those two breasts back to back.

But in this case, it happens in a very classic pattern, which we call an entrainment ratio. So it could happen with every breath delivered by the vent or every other breath. And so for me as a pharmacist, I can actually easily look at the waveform and say, oh, this is happening in a one-to-one entrainment ratio. And it's most likely a reverse triggering that's occurring.

Probably because they're deeply sedated. A lot of the papers that look at optimizing vent asynchrony talk about optimizing vent settings first. That should be our first step. And a lot of times the nurses are the ones at the bedside and their first instinct is to reach for sedatives that abolish your respiratory drive. But when we talk about how sedatives interact with our respiratory drive, those

This has been mostly studied with things like propofol, which we use very commonly in the ICU. And it's actually shown that it doesn't impact respiratory drive like we think it does. It actually may induce a more rapid, shallow breathing pattern with deeper sedation. And several studies have looked at various steps of sedation with rates of asynchrony and showing that you have higher rates of asynchrony with deeper steps of sedation using propofol because of its ability to simulate this rapid, shallow breathing pattern.

And so that is a big myth that we see in the ICUs that increase the propofol, we will just make them stop breathing altogether when that doesn't necessarily happen. And we're going to leave citations in the transcript of this episode. Right. Because people are going to want the citations. They're going to be saying, are you serious, Sylvia? Because this is what I've been doing for years.

And you're telling me that's the opposite effect that I was intending to have. Yeah, that's great. And this has been described very commonly with propofol. It is very clear pattern in several papers that show

various types of sedation, higher rates of asynchrony index, and other sedatives like midazolam has also been described. There has been more literature looking at maybe the impact of ones that don't impact your respiratory tract like dexmedetomidine compared to patients that those agents may actually have less of an impact on vent asynchrony than using true sedatives like Cropofol and midazolam. And so for me as a pharmacist at the vet side, it

okay, let's not deepen sedation. Let's use sedatives that make the patient comfortable that can still maintain the patient's respiratory drive like dexmedetomidine. Opioids have also been compared to sedatives in this case and that opioids may impact more respiratory timing than respiratory drive. And so agents that can prolong the expiratory phase can actually help abolish this asynchrony. And so opioids have been shown to also reduce the rates of asynchrony than through sedatives like propyl.

And so I can make the recommendation, let's lighten sedation. They still need something. We can optimize non-medication.

respiratory depressive agents like Presidex and maybe increase opioids. But even then, it's used as little as possible and you can optimize the dose to what the patient tells you they need based on scoring tools. If you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout.

We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task. How does this transformation start?

It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

It's just making me laugh because when I did this episode in October, I looked it up, episode 86. I interviewed one of my RTs from my awake and walking COVID unit, and he had been floating throughout the entire system. So to multiple ICUs with other COVID patients, same community, same patients, same diagnosis, same acuity. So I asked him, I know it was anecdotal, but I wanted to understand what managing ventilators was like comparatively from the other ICUs to our ICU.

Because I was hearing ventilator synchronicity, ventilator synchronicity. So I thought, Jeff, really tell me, is it really worse out there than in our unit? Why aren't we having to slam them with sedation? He said, it's so much harder to manage these patients when they've been sedated. They are so dyssynchronous. It's such a headache. It's really challenging. But in our ICU, it's not really a thing. It's not really a big deal.

Which sounded insane. I believed it. I've seen it, but I just couldn't explain it. So next episode, we're going to talk with JJ, the RT, about ventilator management, those ventilator settings that you're talking about. Because having worked in this ecosystem, I honestly did not have to mess with those things very often. Because the RTs and the pulmonologists were such pros.

wizard. Now that I'm training other teams, I've come to realize that every discipline has a certain skill set they don't develop when they don't have patients awake. And for RTs, that's one of those skill sets is they don't really have to troubleshoot the ventilator so much when patients are deeply sedated because they're all in the same settings and just not a skill set they develop. So we'll go into what then do we do instead of drinking up sedation, because now we understand that makes it worse. What else do we do? But

Talk to me about the neural reflex that you mentioned in your presentation that really drew me in. Yeah, so with reverse triggering, it's an involuntary breath. And so we really look at it as this reflex that's occurring because of an external stimulus being that that induced breath that the patient was getting. And this happens with deeper sedation because it essentially removes the patient's ability to manage the breath that they're using to...

becomes synchronous in a more awake state. A patient that is more awake is actually better able to interact with the ventilator in that way. And once you suppress that completely, then your reflexes take over and you're becoming entrapped in this entrainment ratio with the ventilator that can lead to reverse triggering.

And so lightening sedation, once you already observed that reverse shirting would be the first step. And then you start looking at your vet settings and a way to optimize preemie once you observe a different form of asynchro. So going back, maybe you're seeing ineffective shirtering, maybe you're seeing double stacking. And a lot of times the patients on like,

assist control ventilation mode. We've seen pressure support mode being more effective, switching to that in terms of abolishing different forms of asynchrony, increasing your inspiratory time because it can prevent that early inspiration or late expiration phase of the patient's own triggered breath that can lead to some of these forms of asynchrony. Sometimes we can

especially in patients with severe ARDS. Sometimes it's not always feasible to switch to a pressure support mode because you risk increasing tidal volumes in those patients. But again, if the patient

case-by-case decision and ones that we have to try to optimize first before deepening sedation and then eventually going to neuromuscular blockers, which we know are reliable in abolishing all forms of synchrony. But those don't come without risks and deep sedation also doesn't come without risks. And so we want to do everything at the bedside possible before

jumping to those strategies, but oftentimes we are jumping into it sooner than trying other forms and playing around with the vet first. It's also really hard once patients have been sedated and they develop delirium, especially if they have ARDS, sick lungs that need a lot of finessing, to then try to take sedation off. Once you have delirium, you've now got this whole other behavioral coughing, gagging, panic going on. You have hyperactive delirium. So it's really hard to backtrack

So you go down this rabbit hole, especially if you do this early on where you land with deep sedation, that's not going to help the synchrony. Now you try to with the deep sedation with the synchrony from that. But now you've got this other complication of delirium, agitation, coughing, gagging. Now it's a whole mess.

Yeah. And we do see it jump to very soon. And once they are deeply sedated, you look like the crazy person suggesting lightning sedation and somebody who looks super sick because of all the reasons that you think it'll help. And it just, it's definitely hard to backtrack that. Especially in an environment where the team doesn't know how to come together and troubleshoot that to say, okay, let's give it some time. Let's put them on pressure support temporarily. Let's put them up at the side of the bed.

Let's get the family in there. Let's calm them down, bring them back to reality. Maybe we can help their brain. Maybe that will help with the synchrony. But that's not the perspective. It's like all sedation or a little bit of sedation, but we're never trying to get them to actually take their own breath.

synchronized with the ventilator, we want full control. We have sacrificed the brain, quote, for the lungs, but the lungs don't even really get the benefit that we're anticipating. Exactly. Yes. So we have all heard the risks that come with deep sedation, mostly the long-term ones, increased ICU length of stay, increased mechanical event duration, that leads to acquired weakness, impairs your ability to have early mobility,

And then, of course, much higher risk of delirium, increased mortality and post ICU syndrome. Right. And so those are all the things that we hear about. But we oftentimes are worried about the acute outcomes for these patients. We want them to have better ventilation, better oxygenation. We want to protect their lungs first.

We may risk increasing the risk of delirium, increase their risk of being on the bed longer because of all of it. But we want to make sure that we get them through this acute illness. When in reality, this deep sedation is actually not helping the primary problem that we are trying to target, which is to improve their ventilation, oxygenation and interaction. And so we're seeing that deeper sedation may not even be effective for the primary problem of delirium.

improving lung ventilation and oxygenation. We don't have outcomes showing that deeper sedation is associated with improved PF outcomes or improved ARDS outcomes. And so that's the reflex and the myth we've been told to believe about deeper sedation being associated with those when we don't have

True evidence of that or even true evidence that it suppresses your respiratory drive in a way that will improve the ventilator interaction. And so we're already starting in a place that is leading us to failure. And once we get to deep sedation, it is really hard to back off of that, especially once they look really sick. And early deep sedation is an independent predictor of mortality. Correct. So especially if they're sick and they already have a life-threatening condition,

doesn't make sense to add on a life-threatening intervention on top of it, which is sobering to think about. Yeah. And this has been a huge light bulb moment because it is very hard to change the culture around that, especially being at the bedside where all of the nurses, most of our providers do have that reflexive deepening sedation, eventually adding on their muscular blockade because of

The safety impacts we're having with the patient with regards to asynchrony and not having one protective mechanical ventilation. And so we're doing everything we can to help Hail Mary because we've already started with deep sedation in those patients in the first place. Who's really pushing this perpetuatedness? Who really controls this?

Yeah, so like most hospitals, sedation and analgesia is a very nurse-driven protocol. We give them a target RAS goal and they have their free will to titrate based on parameters and orders to the target RAS.

Oftentimes, the patient ends up being in rafts that's deeper than the target because of, like we often hear, the patient is asynchronous with the vent. They're triggering the vent. I'm going to keep going up on sedation. And this is very much nurse driven. They're the ones at the bedside today. They're the ones that manage sedation and analgesia in these patients. And I think it's the intervention that will

acutely dissipate the problem. And so once that patient is already in that deep sedation state and the provider comes along and they said, okay, that intervention didn't work, we're going to reach for the neuromuscular blocker next. We're just adding insult to injury at that point. And so for me as the pharmacist, just being involved in education across the whole unit from residents, fellows, I know that I'm heavily involved with communication about sedation strategies with nurses day to day also. And so whenever I

see a really sick ARDS patient, I'm always communicating about why did you infestation this patient? And most of the time the answer is because they were triggering the vent. And then I explain to them how this may not be helping the problem. Let's try lightened sedation again and see what happens. Just looking at the ventilator waveform and the pattern of asynchrony that we're seeing. And how cool to have a pharmacist going in and looking at the ventilator, looking at the waveforms,

and helping guide that because you guys have so much stewardship and expertise and management of so many medications, but it feels like when it comes to sedation, there's, you're intentionally shut out. Staying sane, that's not, you can't order that and you can't tell me how to titrate that and you can't, but you should be looking at, is sedation indicated? Just like an antibiotic, you would never let us give vancomycin just because we feel like it. You would want to look at the cultures. Absolutely.

So it's like looking at the ventilators, looking at the culture saying this is reverse triggering. This is not helping that. This is the wrong antibiotic for the infection. Don't give this. Yeah, I would. I would love to say that as a pharmacist, I don't have to care about anything besides the medication itself. But I have to know the indication that we're using these medications for. And if the indication is asynchronous, I will do my best to learn about the different forms and learn about how this impacts.

the indication that we're treating it with. And so that's something that I've made sure to push myself to be able to learn more about and understand because I can't make these recommendations without understanding why they're using this medication for that medication. And you're at the bedside looking at the rat, which is like looking at the bankotra. Exactly. Because you want to make sure that we're giving the right dose and that might offend some nurses to have a pharmacist looking at the rat, but that makes sense because you would never let us just

titrate up for fun the vancomycin because we want to make our own decision but that's what we're often doing with sedation is we're just titrating up but we're going past that order and that's a liability for everyone but dangerous to the patient so having pharmacists aware of actual indications for sedation the actual adverse events with sedation how to actually understand how much sedation is being given watching the levels on the pump

I see lots of variability. A lot of times pharmacists, sometimes in some facilities, they're over five ICUs at once. They can't check the rates in every pump on every patient overnight. So having the bandwidth for pharmacists and the culture in which they're looking at that saying, did something happen? Okay, so what's their rest now? I see you went up on the probe of fall. So what does that mean? But right now, a lot of ICUs, there isn't that kind of accountability or safety net.

So I would love pharmacists to be doing what you're doing, treating sedation like an antibiotic, having proper stewardship and oversight to make sure that it's being used only when indicated and appropriately when it is indicated.

Absolutely. And I love empowering our pharmacists to be able to do that and having safe patient to pharmacist ratios so that we do have the capacity to focus on that for every patient. And so this is where multidisciplinary rounds really do come into play. We have the nurses, the physicians, the RTs, the pharmacists at the bedside on each patient. And I'm assessing what the patient looks like, what their sedation is at, and do we need to be at that?

For everybody, every day, we go through our A to F bundle. It's analgesia address. And then we go to choice of sedation analgesia. And are we at the appropriate step that we need to be? If at all, does it need to be on at all? Every day, I'm recommending stopping sedation on people. And so less is more definitely in this case. And when they say ventilator synchrony,

You don't take that as an appropriate answer. I love that. It's not just one type of asynchrony and everybody uses it as an umbrella term that's all encompassing, but we really have to start thinking about the different forms and what to be contributing to different ones to be able to manage it in a very patient-specific way. Now we don't get vancomycin for every pneumonia. Absolutely not. Okay. Thank you so much, Sylvia. Appreciate it. Thank you. Thank you.

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