Episode 193: Empowering Respiratory Therapists with JJ the RT
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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.

Okay, so many exciting things are happening. If you are interested in going to the ADS or American Delirium Society Conference, June 29th through July 1st in Nashville, Tennessee, hurry and get your application for a scholarship in by March 31st. Early bird registration is open now. I will be running a pre-conference simulation training day with Heidi Engel and other delirium experts throughout the

Thank you.

This is a good opportunity to share with your nursing leadership as an AACN stamp of approval on awake and walking ICUs. I lay a foundation of knowledge about post-ICU syndrome and the ABCDEF bundle as the vehicle to creating awake and walking ICUs. Hopefully it will help get the conversation going and advancing on your units. Just Google AACN and walk.

Awake and Walk in ICU, and you'll find the link to the presentation and resources. Share with your leadership and colleagues. Okay, this episode is a great addition to last episode's discussion on ventilator synchrony with an expert RT and educator. If you're not an RT, you especially need to hear this. Share this with your RTs. Let's do more to loop in and support these key players and their vital role in the ABCDEF bundle.

JJ the RT. Welcome to the podcast. Can you introduce yourself to us? Yeah, my name is JJ Valdez. Some people know me as JJ the RT, but I am super excited to be here. I've been on a few other podcasts. I did something by myself for a short minute. But as you know how good it is to keep content coming. That was my challenge too. So

Mine ran short, mine ran dry, but super excited to be here. Thank you for having me. And I think this is perfect to have you coming on after Sylvia Stefano's talking about the impact of sedation and ventilator synchrony. And I think we can all appreciate, actually, let's go back.

Yeah. Tell us what you're up to right now. What is your position? What's been your experience in critical care medicine? And how are you influencing our team world right now? Yeah. The life that I've had as a respiratory therapist,

graduated from Midland College with my associates back in 2008. In 2007, I was able to do an internship. And in that internship, I was given an assignment and my own patients. And I had some oversight with a therapist that was always kind of there with me. But I always count that time because I

I learned so much by having my own assignment, even while I was still in school. And once I got done with my assignment, I would go either to the emergency department or the ICU because I knew that that's where I wanted to be. I knew that I didn't have time to look up information if I was going to be in the emergency department or if I was going to be the ICU. If I needed to know something, I had to pull it right then. So I had to know my stuff.

So after I'd finished my assignment, I would be down in the ED or I'd be in the ICU. So I always counted that time as critical care time, even though I wasn't assigned to those areas. But after that, I started working and quickly I progressed as a team lead.

As an educator at the hospital. And then I did some mid-management stuff. And I traveled all over the country being a respiratory therapist. Then COVID hits. And we need respiratory therapists really, really badly. We need respiratory therapists really badly. And so I came back to the bedside to do bedside care.

And that took me traveling again. And during that time, I was working on my master's and I ended up getting my master's in 2021, December of 21. And I knew I wanted to get into teaching. So I am now teaching at an associate program in Victoria, Texas, and I have.

the best students in the entire country. And this is really great to have someone that's so seasoned in bedside practice, in critical care, even helped with an early mobility initiative in your hospital at one point in the 2010s. And now you're really impacting the education of respiratory therapists, which we'll get into. But I thought it was appropriate to have you respond kind of to Sylvia Stefano's episode talking about the impact of sedation and ventilator asynchrony, because this became such a

Hot topic or catchphrase during COVID. That's what everyone was talking about.

And as I explained in the previous episode, I didn't recognize or see a ton of it. And then like walking ICU and talking to my RTEs, they're like, no, it's really not bad here. It's the other COVID units where everyone's sedated. But I just didn't know literature on it. So having Sylvia talk about that, we know that sedation increases ventilator synchrony because of the neural reflexes, because propofol increases the rapid shallow breathing. And so then if we're not going to use sedation to quote, treat,

ventilator synchrony, if it really actually causes it. I want to hear from you quick and dirty. I mean, for the spectrum of disciplines we have listening to this podcast, right? We don't all speak our tea.

So how would you explain what we should be looking at when we have ventilator synchrony and how we're going to prevent and treat it instead of running to sedation? Yeah. So one of the things that we have to look at is what is the type of respiratory failure that the patient's in? Are they in a deoxygenated state or are they in a hypercarbic state? Right. So is their CO2 really high or is their oxygen really low or is it a mix of both?

Right. We even do it for metabolic processes, too. So patients that are in liver failure or kidney failure, sometimes we put them on the ventilator just to protect their airway because they are breathing so hard. So we have to really identify what's the cause of them being on the ventilator to begin with.

And especially with COVID, one of the things that we had to worry about is those lungs, they were getting so damaged. There was so much consolidation and so much congestion that it's almost like trying to get oxygen through a cement brick. It's not going to work very well. So if I look at the oxygen that's being delivered to the cells, tissues and organs.

And it's not enough. Now I'm going to go from a oxygen rich state to an oxygen poor state. So I go from aerobic metabolism to anaerobic metabolism. And my byproduct of that is lactic acid. So I know that's going to be an acid that's increased. So what's my CO2 have to do? It's got to go down to normalize the pH. That's what our body is always trying to do is trying to find the state of homeostasis. And

Depending on what's going on, we either try to assist the patient with their breathing or we allow them to breathe on their own, but in a protected manner. So we have to identify what's going on with the patient so that I'm either helping them or assisting them in a protective manner.

So I've heard it said this way, that when we commit a patient to being on mechanical ventilation, we are saying that we can breathe better than they can on their own. So we dang sure better be able to do it. So that's where we come in as respiratory therapists is we know how to tweak and we know how to make the right adjustments when we see these dyssynchronies. But also with the previous episode, what we're seeing is now

Our sedatives are causing dyssynchrony. So we've got a mindset where, oh, my goodness, my patient, they're bucking the vent, right? Air quotes, bucking the vent. We need to sedate them more. Well, now the studies and the evidence is showing that that's causing even more dyssynchronies. And it's just wild because.

I had a senior therapist tell me this once. They said, JJ, nobody cares about what you think. What does the evidence say? And when the evidence is pointing towards all of these markers and all these triggers that are causing dyssynchrony, why the heck are we continuing to do like it's the definition of insanity?

And how often did we end up having to paralyze patients because no matter how high we gave, well, no matter the high levels of sedation that we gave, we'd add in benzodiazepines, we'd crank it up, up, up, thinking that we were taking away the respiratory drive, which we were. But by doing that, we were also causing a neural reflex, causing double triggering and all these things that would end up paralyzing them so that they could not have any kind of contradiction to the ventilator settings. But was that really beneficial? Did that really help?

And I just think that we just really thought that sedation was going to take away the respiratory drive and therefore fix all the problems. But they still have, their body is still fighting underneath that, all of that. Like that is just a mask. It's like putting lipstick on a pig. It's still a pig underneath. And I say we mask agitation. We don't,

free agitation. We don't treat anxiety. We mask it. I hadn't thought about masking ventilator asynchrony with sedation and it's still happening underneath. And I like that you bring up this pulmonary congestion obstruction because there's such an impact to pulmonary toileting when we have patients awake, able to cough, clear their own secretions, getting upright and mobilizing. That's what we did for most of my patients in this COVID ICU.

So I just hadn't thought about that being part of ventilator synchrony is I knew that they were awake, usually free of delirium, at least not nearly as severely delirious if they did have delirium, not like when you're doing an awakening trial and they're agitating, thrashing and buying the tube and trying to self-extubate. All of that obviously creates terrible dyssynchrony. So I knew that that was better. I didn't realize that sedation increased ventilator synchrony and didn't think about treating and preventing pulmonary congestion.

as part of improving their ventilator synchrony.

Yeah. I mean, when you look at what we can do for like pulmonary congestion, there's limits to what we can do. Right. And a lot of the evidence that we have currently with any of the studies for like chest physiotherapy or anything like that during mechanical ventilation is geared a lot towards cystic fibrosis. So it puts us in this little box and it's,

The evidence is limited when it talks about some of these other patient populations, whether it's a garden variety pneumonia that is just a complete consolidation that's leading to poor oxygenation.

that is leading to them being on the ventilator. There's not a whole lot of evidence for that, but there's other things that we can do that help with those secretions, whether that's using a heated wire circuit, whether that's mobilizing that patient, whether that is verticalizing them if they can't actually get up and walk. There's so many other things that we can do and we can monitor that helps us

move and progress that patient off of being off of the ventilator. And yet sedation would take us down a totally different route. It does. And it's like that consolidation almost settles even lower and deeper and becomes more harsh if we are using heavy amounts of sedation.

I've heard from PTs and OTs and nurses repeatedly that certain patients that they can't seem to wean or they're about to do a tracheostomy or they're having a hard time getting them off the ventilator. When they come in as revolutionists and they're like, hold on, everybody just stop. Let me try. Let me set them up.

They always talk about this massive pulmonary toilet and they have so many secretions. And yes, it's a hot mess initially. When you first set these patients up after they've been down for a long time, I've got some glottic secretions, their endotracheal tube is full. It's distressing for the patient. It's a lot of work for everybody involved. But then after that dust settles, bam, they're so much better. And a lot of times they magically get extubated shortly after. And that's where

and awake and walk nice to you, you're able to stay on top of those secretions and you're providing that benefit early on. So you don't have this kind of break versus extubation moment. It is, you're just off the ventilator as soon as you can. Yeah. I wish we could look at the average VIT days closer, right? I don't know what it is currently. The last handful of years ago was, I think it was 4.2, 4.3 days is what the average national average was.

I don't know. Maybe that's old data, but I think it also depends on the ICU, right? Like a mixed ICU, I always have them pull out our CAPT patients and certain populations. Yeah. And so like, where do we sit? Where does my hospital, where does my area sit in comparison to the national average? Right. That's our measuring stick.

is the national average. And then you start to measure against yourself. In 2020, we were at 7.8 days. In 2021, we were at 6.9 days. Right. And then what is your trend when you start to look at that? The COVID years kind of have their own asterisk to it. Right. But after COVID, you start to create your own measuring stick again to see where you align. And in 2022,

What was my average Vint days? 23 was my average Vint days. And then we can look at compliance to the A to F bundle too. But are we really looking at outcomes or are we looking at documentation? What are we looking at? You know? Yeah, with the national average, I mean, obviously if your ICU is above national average, you dread flag. If you're right at national average, I would say...

It won't stop there. Right. Because national average is amidst poor compliance with the bundle. So we can do so much better than national average if we really adhere strictly to the bundle, having a walking approach. And it's fun to piece all these things together as to why that is. They're able to obviously take their own breath. They're mentally more intact to be able to take over the work of breathing. They're stronger, physically able to take over the work of breathing.

I just hadn't understood they had less ventilator synchrony. And when you respond to ventilator synchrony with more sedation, it causes more synchrony. When do you get off the ventilator, right? And now maybe the pneumonia is cleared up and now patients are so weak or so delirious or they're still sedated. I mean, you can take off that propofol on certain patients. You could have another few days, especially for midazolam in which they're still sedated.

And did we ever actually need that sedation? Did that sedation ever do what we intended it to do? But something I've noticed is that a lot of our

Our new RTs are not prepared. I think even some of our intensivists, when I go to chest or SCM, these classes on ventilator management are completely full. Stand-in room only. You can't even get in there because everyone wants to attend these classes. So I think there's a huge gap in knowledge and education. So if I say, nurses, don't just crank up sedation. Call your RTs to come in and manage the ventilator.

Do they necessarily know what that means or how to do that? Yeah. I mean, so for me and my students, one of the things that I try to prepare them with, especially in the ICU is,

Are we using lung protective strategies? Number one, like, are we doing everything that we possibly can to protect the lungs? Because we are forcing oxygen into the lungs. We don't breathe naturally with positive pressure. We breathe with negative pressure. So one, are we doing it in a safe manner? Well, and with lung protective strategies, I think that is oftentimes used as rationale to increase sedation.

We have to control every single breath. We have to keep this 46 milliliters per kilogram of tidal volume. So we have to crank up sedation so they don't take any of their own breaths. What are your thoughts? No, I would much rather allow the patient to breathe spontaneously. We talked about COVID patients. Towards the end, once we started figuring out that Rubik's Cube of how to treat these stinking patients,

I was throwing them on SIMV with a really, really low rate so that they could breathe their spontaneous breaths with pressure support

So that they were getting their own breaths. And I was giving them that little boost with pressure support to get the tidal volumes that they needed to maintain the minute ventilation to keep up with their metabolic demand. So... Now, some of that kind of pulmonary rehabilitation, you're trying to get them to engage their own muscles again and build up the strength to independently breathe. They probably weren't strong enough to just run with the ventilation. Right. So they were doing their own efforts with a little bit of support. Yeah. Yeah. I mean...

After 18 hours, it's been studied after 18 hours, there is significant diaphragmatic atrophy. That's less than a day. Like, oh, we're just going to rest them for the day and then we'll start with them tomorrow. 18 hours, it's been studied that you get significant diaphragmatic atrophy. So why would I start 24 hours from now? Why would I start tomorrow? And one of the biggest assaults to the lungs is just being on mechanical ventilation.

So then that theory isn't one of the best ways to protect the lungs is to minimize the time in which it's being exposed to mechanical ventilation. And one of the best ways to do that is to keep them awake

breathing on their own, free of delirium, mobilizing, all those things are going to minimize time on the ventilator, therefore decrease their risk. Now you don't want them to just be pulling eight, 10 milliliter per kilogram tidal volumes all the time, but you're saying it's okay that they do some of their own work of breathing, that we set the ventilator to provide that kind of support, but we don't have to control every single breath that they take. No, we don't. You and I have both done it during this call.

We've sighed. We've had a, I can't believe they're doing that. Your body does that naturally five to six times in an hour. Naturally does that. And if I limit that patient to only having four to six or maybe even six to eight mls per kilo, I don't ever give them that time to naturally take a sigh breath.

And old school ventilators, we use the side breath and we would throw a side breath in every once in a while. But we don't necessarily do that nearly as much anymore. But what the side does is it resets your diaphragm. When you get talking and you go in and you get really excited about something, your diaphragm will start to inch up.

So then you take a and it resets that diaphragm back down to the spot that it needs to be so that you can get your tidal breaths. And so if we have these patients zonked, they never have the opportunity to take that side breath to allow the diaphragm to reset to where it needs to be.

The other thing that we can look at is there's actually a value and a parameter that will tell us that patient's neuro drive to breathe. Like I can tell you if a patient's over sedated based off of the ventilator. There is a number that I can look at. It's been around since the 80s. Tell everyone what is it?

This is the P100 or the occlusion pressure. And what this does is it looks at the first 100th of a second and it measures a normal inspiratory pressure. So when we look at liberating patients from the ventilator, we'll look at a maximum inspiratory pressure. Let me coach that patient to see how far their diaphragm will pull down to see how much pressure they can create. Well, in a normal breath, your diaphragm moves 0.5 to 1.5 centimeters.

And when it does that, it generates three to five centimeters of water pressure. So if I look at a normal breath or a normal inspiratory pressure, what I'm looking at is the T100 or the occlusion pressure. And this is directly from the phrenic nerve, which comes from the brainstem that tells me how hard my patient's trying to breathe.

So if I monitor my P100 and I can trend this, and if my P100 is less than normal, then I'm knocking out their respiratory drive to breathe and they're over sedated. Now, we don't know exactly at what RAS score that happened, right? But I've heard some of our experts theorize it's around RAS of negative three. Certainly it's not happening at negative one. Yeah. Probably not at negative two so much.

And I look at even just in our bare bone medical reviews that I do, if they're not taking spontaneous breaths, if their respiratory rate and the right side of the ventilator is exactly the same and they're charged at a RASA negative one, I've got questions. And so that's even more detailed.

That's going to show even a more profound level of suppression and suppressed brain function, right? Sure. Yeah. I mean, you and I both know that the longer that we're on this sedation, the more likely they are to remain on the vent, the more likely they are to get trached.

And ultimately, the more risk that they have for mortality, like the longer you're in the bed, the longer you're on the vent, the higher your mortality rate goes. Not to sound crass, but like I'm in the business of helping patients and we need to do a better job. We need to do a better job of identifying some of these parameters.

We need to look at, are we truly being lung protective? Are we ventilating? Are we oxygenating adequately? And are we satisfying that patient's neuro drive to breathe? The last thing I have my students answer is the patient getting better? Are they staying the same or are they getting worse? And they do a little narrative.

on what's going on with the patient every time that they're in the ICU. So part of their closing assessment looks at all five of those questions and it's, are we using lung protective strategies? Are we ventilating? Are we oxygenating? Are we satisfying their neuro drive to breathe? And are they improving, declining, or staying the same? So if we looked at those things regularly and we answered those for ourselves as practitioners,

we would be able to answer a lot of questions about how my patient's doing and the A to F bundle. 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.

Yeah, those questions alone would radically change so many patient outcomes. I'm just thinking about when I go on site and even by then teams have heard the webinars, they're trying to lighten sedation, they've made progress. And yet I see this huge gap in ability to determine why someone is still intubated. I see patients that should have been extubated days ago,

And I hear these discussions around and rarely is RT there, unfortunately, because they're spread so thin. Maybe they've told the nurse they failed their SPT. If RT is there, a lot of times they'll give great reports on the numbers. But that is probably the extent of the critical thinking. They're talking about their respiratory rate, their tidal volumes, their NIST. And then it stops there. And even the physicians will say, OK, sounds good. We'll try again tomorrow. Instead of saying why were those numbers higher?

outside of the realm of normal why didn't they pass not just what exclusion criteria did they meet and so if they could say are they getting better is the pneumonia better for many of these patients yeah it's better it's been better for five days okay so why were they quote agitated during awakening trials which by the end of training no one's allowed to use the word agitation anymore so why were they arrested plus one or plus two

Then put that then play into why the respiratory rate was so high and why their tidal volumes were so low. And now how are we going to treat it? But that's just not happening. So even have physicians not taking leadership and having that kind of critical thinking themselves, how can our respiratory therapists

take that kind of high level critical thinking assessment and intervention. If that's the culture of just report the numbers and then thinking stops there. I mean, this is a bigger issue than simply the ICU vented patients, right? So the statistics show that by 2030, we're five years away from that. We will be over 100,000 respiratory therapists short.

In the United States. So that is a big gap right there. We're doing more as respiratory therapists. We're asked to raise the bar and to carry a bigger load, but we don't have as many hands to do so. So that creates a bit of a challenge. There's a lot of wasted therapy or what we call charades in respiratory therapy. So how many of our patients truly have reactive airway disease that are getting albuterol and atrivant?

How many of our patients that are post-surgical patients are on IS therapy that has zero efficacy? How many of our patients are getting mucumist that has zero efficacy other than instilled? If you instill mucumist, it has, it works. But if you nebulize it, not a chance. It doesn't do anything.

So we are doing oxygen checks. What are the heck are we like? What are we doing? There's a lot of wasted therapy when it comes to what we are doing. I know that a lot of facilities have respiratory therapists doing EKGs. There is an entire class that a certificate class that you can get at community colleges and you can hire EKG techs.

Right. I get that we have to be in so many different areas. That's one of the best things about being a respiratory therapist is I'm not stuck in one unit.

I wanted to actually be a rad tech. I'm so glad that I did not get into x-ray or CT or MRI because I would have been going crazy in the little rooms that they're in, right? But as a respiratory therapist, I need to be able to be in all these different areas. So one, if we can eliminate the waste, that's going to be huge to help us spend more time focusing on our patients. The other thing is,

Like you have to have a passion for what you're doing. If you want to spend more time hanging out with the buddies or watching a TV show or scrolling, you're not it. You're not it. I'm sorry. I have worked at hospitals where the employee of the month for the department had to carry their personal charger because they were on their phones that much throughout the day. And it's like, if you truly recognized what was going on,

this person would not be getting these accolades, right? So if we can eliminate that waste, find that passion again, then we can build some influence as to what we are expected to do at the bedside. One of the last places that I worked, very similar to what you said, the respiratory therapist may be going to rounds. They may not. If they're there, they're just talking about the current event settings. Well, I can look over and see that.

You're not telling me anything that I don't know. You know, tell me something that I don't know about what's going on with my patient. One of the best residents that I ever worked with would ask me that whenever I was on night shift. Hey, JJ, tell me something about this patient that I can tell in rounds that will make me sound smart. So we would find something like the two of us, we would go into the chart and we would find things that we could then share or he could then share.

in rounds the next morning.

And so that led to so much growth for me and that resident whenever it came to doing what we needed to do for our patients. Once we can do those things, now we can start really focusing on, all right, what are we doing to be lung protective? How are we ventilating? How are we oxygenating? What's the neuro drive to breathe? And is my patient getting better? And I've heard from seasoned RTs that know how to do this saying we don't have time for it.

And so what you're talking about with high value care versus low value care or no value care really reinforces that. I think I've heard throughout the years, lots of frustration when they're like, those that do know how to get patients off the ventilator, they do know how to do these high level things. They're spread so thin throughout so many departments. They're like, I want to, but I just can't. So especially during COVID, I had this sense of helplessness where our T's were like,

We've been thrown into this hellfire and nurses are going to do what they're going to do. We know they're overstating them, but there's nothing we as RTs can do. They're just going to try to go into LTAC. It's just the way it is. We just keep ventilator running until then. Versus when I get to train these teams and we really engage RTs and show them their power and show them that level of excellence that they're supposed to be practicing that and create an environment in which that is enabled.

That is appreciated. And to say you coming in and optimizing the ventilator for the patient leads the nurses to not feel like they have to sedate them. You talking to the patient and helping them situate the endotracheal tube in a place that's comfortable, that can change their lives. Look what that does. Just even the rest of this shift versus, and as well as five days later, you can do that as an RT. And they see that and they engage in that. And they're the ones, for example, Mercy San Juan Hospital,

train them over a year ago their rts can now order pt and ot they're the ones looking at the whole picture and saying this patient needs consultants to help them with high level of mobility and i understand why indeed that's part of my scope as master mechanical ventilation they see that power and they use it and they see those changes and outcomes now they're engaged they're not just like well this all sucks patients do poorly and i have to do stupid stuff that means nothing it's

I'm freaking saving lives. And this is what I signed up for. And this is what I get to do. Why is PT and OT not part of the bundle? Like, what do we have to get to the MNOP for them to be a part of the bundle? Right. So that's where RTs are like shortly after intubation. They're ordering them. One of those things where I've heard it said this way, that RTs can be the key to unlock the care that the patient needs.

So that all of the potential gates can be open for whatever the patient needs. You know, another thing that we have to be aware of is communication. A lot of times as students, I could not verbalize my thoughts. As a new grad, I could not verbalize my thoughts very well.

And sometimes my attending would be patient with me and other times they wouldn't. And they need to understand that there is a growth process for us. Same thing. You were a resident once too.

You know, and sometimes it's a challenge for me to communicate my thoughts. For example, there was a patient that we were taking care of, been intubated for two or three, four days. And I'm a clinical instructor at this point. I was training the students that we had in the ICU where I was. And we had a patient that we did that spontaneous weight trial. We threw them on pressure support of 10, PIPA 5. Patient's doing well.

RSBI is great. RSBI is not a good indicator anymore, by the way. But at the time, that's one of the things that we were looking at. And my student at the time was documenting and getting more patient information off of their patient that they had just flipped over into spontaneous. And.

Like this, it starts, you get that, get your butt up right now, Alar. You know? And she goes and responds appropriately. And then watches her patient. Her patient was apneic. Don't really know what the cause was. They weren't biting. They weren't doing anything overtly to cause an obstruction. They were getting really, really small tidal volumes. And put the patient back in AC. Okay.

They were apneic, right? It's not saying that they completely failed, but it's something that we could, for the moment, we probably have something going on. We can come back to spontaneous. But then when the attending was asking what happened, it was a, I don't know, I just did this because I don't know, I just did. I don't know. And the lack of patience that was with that, right? The student did the right thing.

It was a matter of an inability to communicate what they had seen so that they could take care of the patient. And some of that is a growing process too. You know, some people call it soft skills, but they're not really soft. Those are skills that you have to develop as well. And these are pieces that we all have to grow in, in order for us to be a part of the team. If you want to save an environment, you need everyone to be

competent and confident and playing their part. But that doesn't just happen overnight. It requires mentorship. So when I work with medical directors, I say, how do you feel like your RTs are optimizing their role? Where do you feel like their gaps are? Okay, what are you going to do to support them in that? Are your physicians prepared to go to the bedside with the RTs and walk them through ventilator management to help them assess and treat ventilator asynchrony?

And honestly, I've had multiple medical directors say, I don't think our physicians really know how to do that. Right. So that's really concerning, right? So then who mentors, but certainly have an environment in which someone gets demeaned. They get chewed out because they couldn't have those high level discussions that creates an unsafe environment with psychological wellbeing. And then no one learns in that environment. And I think back to my awake and walking. I see that I always refer back to you, right? But

My RTs were invaluable. I don't think I realized what all goes into the RT role in such an environment because they just did it. They just did things or they'd pop in into my office and be like, hey, I switched over to this and this and this. Can you write those orders? Sure. Like I just trusted them. You know, they just they could troubleshoot. And I'm sure it was much easier now that sedation was not an issue. Right. You didn't have constant asynchrony. But when it happened, they just handled it.

So now I'm here being like, how do I recreate that for the RT role?

Yeah, we can't oversimplify the fact that, you know, minimal sedation will allow the patient to breathe spontaneously and then we can just set pressure support. There are still things that we can do. The patient can miss trigger, right? The patient wants to take a breath, but we do not allow the patient to take a breath. Like how irritating would that be? And that causes agitation and we respond to that with sedation, which is going to cause a whole nother route of intralaterous synchrony. Exactly.

Exactly. So like we can't simply like it's not that one, two, three step process. Right. As respiratory therapists, we still have to be able to recognize when there are asynchronies or dyssynchronies in spontaneous modes or modes that have spontaneous breaths. So is our exhalation trigger set appropriately? Is our ramp appropriate? All of these things are part of.

the assessment and it's part of the seasoning and the tweaking that we can do when it comes to setting these ventilators to be what the patient wants, not what I want. I don't care. Like what you tell me and you will tell me by what your brainstem does to your diaphragm. Yeah. When I suggest to RTs in this post intubation period, when patients are really trying to adjust to mechanical ventilation, which is so abnormal,

When I say you can ask the patient, did that help? I just changed the setting. Increase inspiratory time. Ask them, did that help? So look on the RT's faces.

They're trying to process asking the patient if those settings help, like having a patient that awake and compliant and involved in their care. That blows their minds, right? Until they get used to it. But that's a new concept. It's wild. It's absolutely wild. I hear stories from, you know, our respiratory therapists that have come before us that like they were sitting patients in the recliner.

in the 70s and 80s. What happened in the late 80s, 90s, and 2000s to where we are now, where even patients on BiPAP are getting some sort of just a touch of sedation? Which we know increases their risk of intubation and mortality. It does.

Yes, it's just anyone that has a machine doing work for them. It means that we are going to shut down the entire rest of their body. Again, it goes back to what I was told. JJ, nobody cares what you think. What does the evidence say?

Like your one time that you experienced this or one patient is anecdotal. And that's the lowest level of evidence that we could possibly have. And to be honest, when I had my associates, that was those were words that didn't register with me. Mm hmm.

Those were not landing in JJ's ear. You were just trying to mimic what everyone else around you was doing. We've all been there. Yeah. And so not until I continued to advance in my studies did I really delve into and understand that the evidence is very, very supportive. Or it's not. Yeah.

Right. Or it's not. And so then you take that and you use the evidence to empower your communication. You use the evidence to empower your decisions to help take care of these patients. That's what I love about how you teach your current students, how you're educating the community in general to show them what the evidence actually shows. I noticed when I trained teams, they will say,

This is new. This is experimental. That's why I just started doing didactic before I even show up because logistics don't matter unless everyone understands this is evidence based. Even still, people will say things like,

well, this is against our protocol and I will have their protocol and their policies printed out. And I'm like, I'm so glad you mentioned that. Actually, this is completely compliant with your guidelines. What isn't compliant is sedating to a RAS negative four when it's prescribed as a negative one. What is not compliant is waiting until they're extubated to mobilize them. So we don't even understand what evidence

guidelines, policies, protocols are when we're just mimicking the culture around us. I don't think it, for me, I had experience in the ICU with my associates to start out with. I was not looking at the evidence to compare what was going on in my workplace versus what the evidence shows. I didn't have that capacity. And that's where we're really vulnerable right now is we fell into peer culture during COVID and

And now we're having to dig our way out to get back to the evidence. Absolutely. So during my career, when I graduated, we used tidal volumes from 8 to 12 mLs per kilo. So I, exactly. It's like, what are you doing? ARDSNet, that came out in 1999 and you were entering in 2008. That's how long the stuff takes. Absolutely. And I would use 10 mLs per kilo because that was the easiest math.

Like I didn't do what was specific. If I had somebody that had a raging infection in their left upper lobe was just full of Klebsiella. I wasn't thinking about the compliance in that moment. Like I was thinking, oh, easy math, multiply by 10. Right.

And you grow, right? You stop growing. You're already behind. Right. So it's one of those things where you just have to continue to look at what the evidence is showing that you can continue to grow as a practitioner. They call it a practice for a reason because we never get it perfect.

I was that respiratory therapist as it was transitioning from eight to 12 mls per kilo to six to eight mls per kilo. I was like, there's no way. Like if I was to walk from here to like the next town over, which is 30 minutes driving, right? If I were to walk and take like heel toe steps, I would be more tired than if I were to take normal strides. And

And that was my rationalization. That was me making an argument for what my agenda was. That's what you do constantly with this, right? 100%. I get it. I was there too. Yeah. Right. But hopefully we grow from that and we continue to progress because, you know, it's all about continual improvement. And especially when I started this journey of,

this revolution. I heard a lot about RRTs won't. RRNs won't. They can't. It's impossible.

But I've seen that when you create the right environment and you empower them, you give them the knowledge, the tools, the support, the grace to make these changes and to work collaboratively. They absolutely can. Our clinicians are so smart. They're so compassionate. They're so willing. And when it really gets rolling, everything is easier for the team. And our teams are finally able to get resolution for these things that have bothered them.

Like one RT said that oftentimes they wanted ABGs before every single extubation. How insane. So we put that on the table and said, to make this a wake and walk and make you work, that's got to go. There's no evidence to that. So all those little things, this is the opportunity to say, we're working towards this, but here are our barriers. And a lot of them are things with politics, cultural things, things that are holding us back. And we get to cleanse that. Then we get to practice at a new higher elevation and no one wants to go back.

But that won't happen unless we sift out what's actual fact and what is just myths that we've inherited. Right. And when implementing, you said there's areas that say that this is impossible, right? One of the things that we did at the hospital that initiated this early mobility program is we had somebody that would work for four hours a day. They would work four hours a day and they were our mobility therapist.

So they would go in, I think it was like nine to one or eight to 12, something like that. And they were a part-time employee. It was perfect. You're getting 20 hours a week. You're working. Kids are in school, you know? Yeah. And I would have called it a princess shift because when he was my boss, he would always schedule me for four hour shifts. He would call me princess all the time. Thanks dad. But you can hire, or you can have somebody that's there for four hours, five days a week. And

And we did that temporarily. I think we did that for less than six months. By that point, the rest of the staff has it down. They figured out a new workflow to make mobility happen. And then we got to a place to where we were extubating our patients so quickly that they never even needed to get out of bed. Like they would sit on the side of, they would dangle and they would be liberated immediately.

So fast that we never even had to walk, which was I thought was crazy. That's where we got. And then it impacted the workload throughout the entire unit. All right. So we're always saying we don't have enough staff to do this. But once I lay out how much extra work their current practices are causing, it changes the discussion to we don't have enough staff to sustain what we're doing. We can't afford to keep patients on ventilators for five, 10 days extra throughout this entire unit.

So looking at what is efficient care, what's safe care, what's evidence-based care, what's practicing at the top of our licenses, and how are we going to empower our teams to do this? So debunking myths like sedation increases ventilator compliance. I hear that all the time. We've got to break that down to say, now that we know that's not true, how are we going to liberate our T's and get them ready to go in and actually make the ventilator work for the patient?

Because we know that we're not doing a good job of making the patient work for the ventilator. Yeah. Again, when you commit a patient to being on the ventilator, you're saying that you can breathe better than they can. So you dang sure better be able to do it. And what we've seen is we're not. We're not able to do it because they're on the vent for longer and they're getting traigued and they're having debilitations as a result of being on the vent and being sedated for so stinking long.

I love what was said on RT sidebar when I was doing a podcast episode with them. I think it was Matthew who said that we intubate to extubate. That's right. I don't know why I thought that was so profound. And it's so true. And I love seeing RTs take the lead on that. So RTs, if you're listening, be the ones to say, hey, I think sedation is causing this synchrony.

Let's lighten it up. Let's take it off. I'm here. I'll help you. Let's go, RN. We're doing this. Absolutely. And for the RTs, right? Ask your RNs, hey, how do you calculate that RAS thing? I see that we have a target of one to negative two. Like, ask. But I see this T100 level looking a little bit concerning. I'm worried about them not taking any of their own spontaneous breaths. So how do we work together to keep this patient safe? 100%.

Absolutely. Well, any last thoughts, JJ, for the ISD community? Oh my goodness. I...

I have so much to thank for allowing me to be on here. This is so much fun. I just have such a passion when it comes to early mobility and taking care of these patients because I saw how much it impacted the patients when we started doing this. And the analytical side of me was like, okay, we went from six and a half event days down to 2.8 or whatever the numbers were. And what did that do to the financial benefit? Just from time on event later, what did you guys find?

So we were able to look at the cost of just the ventilator costs, not meds, not the bed, not the room, any of that. Not readmissions, not pressure injuries. Bounce back to the ICU. None of that. We weren't looking at any of that. We were strictly looking at what is the ventilator charge associated with that time.

And by reducing our event days, I think the reduction was 4.6 days was our average reduction. And we ended up saving the hospital a million dollars a year. And that's, we were a small ICU. We had 24 beds. So I can only imagine, I can only imagine these 75 bed hospitals or these hundred bed hospitals that have ICU patients going through them all the time. Our average number of ventilators that we ran were 50. We averaged

50 events a month. And you still saved that much in ventilator costs and 4.6 day reduction. That is wild. That is a lot of work for everybody involved. That is crazy. When you look at it, you can,

Our good friend, Matt, I blotch go with Archie sidebar, shout out, Matt. He did the math for me. He's like, this is 13 FTEs. So if you've got a department that's saying how we can't afford, we can't afford more help because of X, Y, and Z. Well, what can we do to reduce the cost so that we can increase the amount of hospital savings or cost avoidance? These are all just like funny money terms. That's all they are.

They're just terms that allow you to on paper show that you can hire more staff. And I'm going to plug in my new website, ABCDEFbundle.com. It's just on the financial benefits. So if that's the excuse for not doing life-saving care, then lean into that.

Use the evidence to advocate for safe staffing to do this cleanse of no value care. Let's create better work environments by using the financial benefits as bait. Absolutely. If you guys aren't doing this yet, we're not like shaking our fingers at you because I would, I fell short too. Right. But you can grow from this. And hopefully that's your big takeaway is if you are one that is falling short currently, you can grow and you can adopt these models.

Well, I'm excited for this evolution that's happening in the RT role, that they're having names placed to their badges and that they are not just being seen as valuable, but they're seen as leaders. And I invite you to go back a couple of episodes and listen to the RTs from Mercy San Juan Hospital and talk about their leadership. It's awesome to see RTs like you, JJ, really ringing the bells and moving everyone in the right direction.

Thank you so much. Much. Yeah, this has been great. Appreciate you. To schedule a consultation for your ICU, as well as find supportive resources, such as the free ebook, case studies, episode citations and transcripts, please check out the website www.daytonicuconsulting.com.