Jesse Carroll, RRT: Hamilton T1 Lung Protective Ventilation (10/6/23)

Welcome to the new version of the Florida EMS webinar. And this is Friday, 11am and I think this is going to be great. Fridays work out really well for many people. We already have quite a number of people here today and as you know, every Friday we have just really intriguing speakers, whether they're folks who have published papers, whether there is a clinical topic. And today is going to really, I think, come home for everybody because Jesse Carroll is number one. He's a veteran. So Jesse, thank you for your service. He is also an incredible respiratory therapist, but he really understands the pre hospital space.

We personally don't yet use the Hamilton, but when I started to learn more about it, what I was intrigued about was.

How this device can kind of be used to perhaps help our medics out in a complicated situation by making it just a little easier. So I asked Jesse to come on to give us some information on that today and I'll put the references for his talk that he sent me in the chat. And Jesse Carroll, take it away, my friend. Thanks for joining us.

Yeah, thanks Peter. And thanks everybody for being on here today.

So when Peter and I talked about this, what I wanted to bring to the forefront is, and I've talked to Paul about this as well and a couple other medical directors in this space. And what I wanted to bring to the forefront is the challenge that is on us in pre hospital care with actually implementing lung protective ventilation strategies. So and how that's going to impact our patient outcomes. So and it was, it was actually great because this morning one last reference came across my way and I'll share that with you as well, Peter. That was the one I talked with you right before this and they published it in late 2022. And the most important thing I put out there first is.

Mechanical ventilators in the pre hospital space. There's a lot of sparse data. Maybe you see it in air critical care, air medical transport, but we don't have a ton of data out there specific to the EMS and on the ground care. It's just not out there. And so this kind of offers us the opportunity, especially with the T1 to explore that and what lung protective ventilation looks like. And the big takeaway from that specific study and many of the other studies that Peter will share with you guys today is that it is extremely challenging in an austere environment with limited resources to actually provide lung protective ventilation and to balance, well, am I giving 6mls per kilo or am I giving 5 or 7 or 8 or 9 or what am I doing Here. And how do I create that consistency from one rescuer to another, from an EMT performing BLS or acls, to a paramedic or a critical care paramedic, or to a firefighter, and then how do I put that across the continuum of emergency management services to actually lead to better outcomes? And so one of the significant and unique aspects about the T1 that offers us the ability to do that is it utilizes a proximal flow Sensor that's measuring 200 data points per second and is able to augment on a breath by breath basis while it measures for static lung compliance and airway resistance, which we just can't do from one rescuer to another. And more importantly.

When we think about.

How to optimize for outcomes, oftentimes we're thrown with, well, I've got a short transport or, and it's not going to be that big of a deal, but we're spending a good amount of time with these patients. And the ability to get lung protective ventilation on these patients early has actually led to decreased mortality. But more specifically, it's actually led to more appropriate lung protective ventilation for a tidal volume standpoint in hospital care for the patient. So it's led to shorter terms in the icu, shorter times that the patients are spending in the actual facilities themselves. And one of the studies I'll reference is actually from New England Journal of medicine in 2008 that looked at diaphragmatic dysfunction. And when it looked at that, what they showed was from the time that we placed an advanced airway in the patient, within the first 18 hours of receiving any form of manual or mechanical ventilation, we saw an atrophy of the diaphragm, which is our, obviously our primary breathing muscle of up to 54%. Now that's pretty significant, right? Because if we're not using lung protective ventilation and we're not setting more appropriate tidal volumes, the chances that these patients are going to struggle to come off the ventilator, which will lead to potential readmissions within that 30, 45 day range. It adds a significant amount of workload to our rescuers and our EMS professionals that are out there doing this job every single day. So that's kind of the underlying undertone of, of why I think it's so important to get true lung protective ventilation in pre hospital is it's going to impact their workflow, it's going to reduce their workload and it's going to reduce their cognitive load while they're on, while they're on scene and while they're transporting these patients. So while it may be easier to slap a bag on and to start bagging our patients, it's not necessarily. And more importantly, I actually think it's the association's position statement as of, as of 2023 that BVM, if you have access to a mechanical ventilator, you should be using a mechanical ventilator. If that's, you know, that's one of the takeaways I got from the latest NEMSP physician statement on ventilation. So, so Peter, correct me on that if I'm wrong.

I think one of the other aspects about these studies is the ability to identify and minimize risk to creating both volume and barotrauma lung trauma on these patients. Right. And one of the ways we can do that is by minimizing plateau pressures below 30 cm of water pressure. But more importantly, it's being able to identify optimal driving pressures in these patients. And again, from one patient that's bagging or one rescuer that's bagging to another ventilator that doesn't necessarily measure driving pressures, it becomes a challenge from one rescue to another rescue. And the T1 actually will also measure with that proximal flow sensor driving pressures. All of these providing data and feedback in a closed loop for the rescuer to actually improve their clinical decision making, to actually improve that workflow and that throughput for the patient, setting that patient up for success when they arrive at the facility that they're gonna be going to. Here it is. As of 2023, the NAMSP has recommended that the use of mechanical ventilation and specific to the Hamilton T1, we can implement something called ASV. I'm going to take a, I'm not going to go through this whole presentation, Peter, but I, I'm going to go to some of the, the high points and the takeaways. I, I use this for training on, with, with my teams that are using the T1. So, so patient ventilator to synchrony. You know, in, in your conventional ventilation. Oftentimes what we're versed with is whether if the patient's passively being ventilated, it's not as common. But if you have a patient that's engaged or completely spontaneously breathing and we're either bagging and, or conventionally ventilating them, it can become a challenge that creates this dyssynchrony and leads to auto peeping. That's a, that's or air trapping. That's definitely, I'm sure touching on some of Paul's past articles and research. That he's done. And it also risks increasing patients experiencing barotrauma and volume trauma.

So.

I want to point out the significance of what ASV is able to provide your rescuers with visual feedback loops to have them better understand the pulmonary mechanics and dynamics that are going on from breath by breath basis. So we look at four different lung conditions on the T1. We look at, we look at poor lung compliance or resistive, resist restrictive lung diseases, mixed lung conditions that may carry both restrictive and obstructive. More like an ARDS septic picture or an asthmatic picture. We look at normal lung conditions, maybe we just have this patient intubated for airway protection, but we still have to ventilate them.

Right.

So we may see normal lung conditions and then we see straight up obstructive lung conditions like a COPD chronic bronchitic. And I really point out COPD in this space because that's one of the most challenging patient populations to provide lung protective ventilation to. Because COPD has components of two different disease processes, one of which that can present with restrictive lung disease aspect or poor compliance like emphysema, and then one like chronic bronchitis that presents with over lung compliance. Right. And the T1 in ASV, because it's measuring that airway resistance and static lung compliance on every single breath, is actually augmenting and ensuring that we provide those appropriate tidal volumes which are 6-8mls per kilo, depending on where you're at from a protocol standpoint. Paul, you and I have talked about this as well, that, you know, the ardsnet, there's, there's a little bit of confusion with belief there in Ardsnet. So I, I kind of fall right at the 6mls per kilo because it kind of borrows from both sides of that argument. And it also reduces that opportunity for patient to synchrony, which is going to lead to. Or air trapping, which is going to lead to that patient to synchrony. Yes, sir.

I'm going to interrupt you for just a second because I'm just learning about ASV from hearing it from you. There are people on this call who have no idea what ASV means. Can you explain to them what that is?

Yeah, my apologies. I get excited about this stuff, Peter, so I appreciate you.

That's all right.

Letting me back in sometimes that's what I'm here for. Yeah, so. So real, real quickly, ASV is considered, it's called adaptive support ventilation. And essentially what we're doing is, is by measuring the airway resistance and the static lung compliance. On a breath by breath basis, the ventilator is looking at a number of different pulmonary mechanics and is able to match the patient's minute volume based on gender and height, which would lead us to an ideal body weight. Right. So we ventilate based off of ideal body weight. This eliminates the guesswork in the bagging. Right. We go to bag a patient. How do we know what the patient's ideal body weight is? How do I know that when I squeeze the bag right. In a, in a stressful environment where I've got a bunch of other things on my mind as a rescuer, how am I able to create that consistency from one breath to another, provide lung protective ventilation, and make sure that I'm giving 6mls per kilo based on an ideal body weight? When I go to the T1 and I choose my patient gender and height, the ventilator is going to automatically identify the patient's ideal body weight. And when we select asv, it's going to ventilate at by minute volume versus the rescuer having to decide initial settings. That's one of their biggest challenges, which in this environment can create a lot of stress for them. I think you and I have talked about this, Peter, is that when you talk to a rescuer about mechanical ventilation or they think about some of the traditional transport vents that are out there, that in and of itself provides an increased stress rate for them because they're just like, I'll just go ahead and bag the patient. Because they get that tactile feedback and that response of what? Oh, I felt the patient give a little breath there. I'm not going to squeeze as hard or I'm, you know, and that could be good, but it also could be bad because they don't have the full picture of the pulmonary mechanics that are going on with the patient. But the T1 with that proximal flow sensor does. Right, right, right.

So that, that, that's what I think for me, listen, I'm, I'm a simple minded kind of guy. And as far as like rolling stuff out, you know, many of us on this call, we have large agencies, we have, you know, some of us have thousands of paramedics that were, that we're working alongside with. And.

You know, I, I think of this kind of like more of a, of an artificial intelligence. You basically, you pay, it's male, it's, they're this height, you press ASV and it, it does the rest for you is what I'm understanding.

Yeah. And which I get that sometimes actually posed as like an against it does it for you thing, right? Because some people's mindset that are, that are more advanced using this, they would say, oh, that's a set it in, forget it. And I actually don't teach it that way at all. And the reason I don't engage it in that way is you have such a sliding scale of rescuers, right? You've got rescuers out there that really feel good about ventilation and so they're, they can actually take ASV and utilize it in their patients to a whole another level. But to your point, I can take the, the entry level rescuer that maybe has just come out of school and is still learning and, but they're managing the airway now in the back of a rig, which is oftentimes what I find. It's some of the, the youngest rescuers that are, they're put on airway management, right, for oxygenation and they don't really feel comfortable. So ASV can actually come alongside them and as they get more reps underneath them while ASV is doing its job, they're watching how the ventilator is managing a patient with restrictive lung disease. Like take a post ROSC patient. We have talked about this, a post ROSC patient. We've just compressed the chest for however long, right? We probably have some pulmonary contusion going on, we probably have some bruising, maybe we've got some fractures going on. And there's probably astronomically different pulmonary dynamics in a POSTEROS environment. But the T1 with that proximal flow sensor in ASV is actually going to be able to pick this, this, this feedback up and it's going to help that rescuer more optimally support the patient ventilating to get them to the facility safer and set up for success. I go back to that beginning of setting them up for the best case success when they get to the ED and into an ICU environment. So it really does.

It really does allow for. Oh, I see. It says meeting Summer summary with Zoom iq. Did something kick off, Peter?

I don't know. I think, I think there's some new AI thing that's going on in here where it summarizes the meeting.

Okay, all right.

Anyway, but the question I have for you, Jesse, as you mentioned that, so you know, is there data? Because I think the people on this call would want to say, okay, sounds like a good idea. Is there, is there pre hospital data that takes a look at what ASV or. Because obviously we're not here to promote one Specific product, obviously.

But we're all data driven. I know you are as well. Can you point us towards anything as far as the pre hospital literature that you have showing about how ASV could.

Have an impact.

Not specific to asv, but from a pre hospital measurement of implementing successful lung protective ventilation? I do have that data. There's a gap there. The gap currently based off the data. And this will be when you guys get the reference sheet. It's in reference seven and eight. I've got that labeled out for you all. Currently only 13 to 55% of our patients are receiving the recommended tidal volumes in a pre hospital setting. Right. And augmenting training for that is a really heavy lift. So when we have tools, clinical decision making tools and devices that can actually support that implementation, we can really improve that potential outcome. You know, so by, by bridging that you actually mentioned, Peter, this built in AI, right? This built in AI can actually help, help coach our rescuers and improve that ease of use by smoothing out some of the ridges in our workflow for oxygenation and ventilation.

And one of the things we used to say when I was in the service is complacency kills.

Right?

And it was this, this, this thing that we constantly checked each other by when we said that it was more of like, hey, if you accept the status quo, then we're ultimately going to fail at our mission of creating success. Right. And so the gaps have been. We know that, we know and everybody agrees that that BVM ultimately is not the way to go. And so we've got some instances where mechanical ventilation has been instilled in some of our practices, but it still leaves that open loop mindset of it requires the rescuer to put information in, in an area where the rescuers don't get a ton of coverage and support. And more importantly, they're managing the patient much differently in a pre hospital environment than we would in the hospital. So the data, what I would say that could really support this is as the awareness is created around the availability and the accessibility of a device that actually offers this closed loop. Right. We can really look at truly improving outcomes, especially in the blood programs that are around the nation now that are really popping up around the nation because we also implement volumetric capnography where we can measure that expired volume of carbon dioxide and truly give our rescuers data driven information where they're making much more appropriate decisions.

On a second by second basis versus minutes basis, which could really lead to positive outcomes. Right?

Yeah, Jesse, only because we have five minutes left Dr. Marv Wayne says, are there other brands that have the same, same capacity, lung protective?

So unfortunately, yeah. So unfortunately, no. There are no transport critical care ventilators that are out there. There are some ventilators that are in hospital ventilators that are not approved for transport, that are trying to come out with what are called closed loop ventilation strategies. The biggest thing that separates this out is that ASV leverages the power of that proximal flow sensor. So we're. When I say proximal flow sensor, we are placing a flow sensor directly at the patient's airway where we're measuring 200 data points per second. Okay. And that.

Right.

So that. I hope that answers that question.

Yeah, yeah. And so that does. And I think that's important to understand that concept. I'm wondering, are there people on the call who can comment?

I see.

There'S some folks in the call who I think are using the T1. If there are, does anyone mind unmuting? Because I think that most of us would like to know, most of us who run large 911 systems. How is it going out there? Obviously, we'd love to hear from Jesse, but in the last couple of minutes, are there. Is there anyone on the call who currently has comments or can give us their insight?

Feel free to unmute yourself if you do.

Let's see. John Applebaum. Are you guys using the T1 or. I thought Andrew Bauman was on here earlier. I thought.

Hey, it's John Ecklebaum.

We are not. But as we're exploring in the future.

As we are seeing about developing our.

Critical care services, we're seriously considering that. Okay. Yeah. And we are looking at it as well for our EMS captains. And I'm excited about it, not just because of the ease of use, but I'm very focused in on the cardiac arrest, the cpr. So, Jesse, talk to us for a few minutes. I know there's a setting and I know you don't have time to do it in three minutes, but the, the setting of post Ross or. Or during cpr, is it correct?

You.

Okay, tell us about that.

Yeah. So there is a CPR mode setting, which is. Which will allow for you to automate the. The ventilations during CPR cardiac arrest, which, again, it's going to help improve the outcomes more specifically by streamlining that workflow. It's going to reduce the additional cognitive workload for the rescuer so that you can place that advanced airway in, you can initiate cpr and we can set it up specifically in Pressure control to ensure that whether you're on your automated CPR chest compression device or you're still on your hands on however you're doing it within your practice, whether you're on the upstroke or the downstroke, that patient's going to get a guaranteed volume. And so, you know, there's still some.

You know, you've just got to set the ventilator up. The settings you're going to need to do is selecting gender, selecting height and hit CPR ventilation. So again, it's streamlining that ease of use so that they can offload and they can begin to get their line access, they can begin to do their slow drip epinephrine, they can begin to start getting their blood products on. So again, that stuff becomes way more critical in a CPR environment than needing to be worried about. Hey, do I have a correct seal on the, on the face? Did I give lung protective ventilation? Right? Did I do all of these things? The T1 can take over for that in your practice.

And Jesse, that, that just, just to remind myself that's what you want up to the lab, the pig lab, to actually look at. I know we don't have time to talk about it now.

That's right.

That's what you did. Okay.

That's right. Yeah.

I see Todd unmuted. Todd, do you want to give a comment?

Oh, yeah. Hi, Todd Yantek. I'm with the Advent ems. We've got about four or five.

Counties that we cover. We do a lot of inter facility transport. So of course we're a little bit different than the pre hospital. But yeah, we use Hamilton T1s extensively. They've been very successful in our program. They're compact, they work well. I think they're easy to train on. You know, we have like a short course we run medics to who've not used vents before and they seem to pick it up pretty, pretty quickly. We're not, we don't use a lot of that. I think it's the APD or ASV system we talked about.

But for the medics who are a little bit concerned or not so confident, it's nice to have that as a backup. I do see that in some, you know, charting that they, they are using it out there and it seems to work fine. The other thing I would mention too is the state has a grant process that I think a lot of the EMS agencies could use that grant process to get some of these T1s. I think it's, you pay for 25% and the state will pay for like 75%. So I know picked up a couple of those.

Todd, I actually have a quick question for you on that. On the asv. So what mode do you find yourself or modes do you find your rescuers that when they're not using ASV that your primary go to? Because I, I wonder if I can sneak a little something in there that I think is. It'll be a value add for you.

I think a lot of them are going right to a volume support mode to where they're typically used to. So they calculate, you know, what they think the title volume is supposed to be and put a, you know, rate in and then kind of monitor it from there. Yeah, that's really kind of probably the go to mode. I think usually it's kind of the typical, it's easier to teach, you know, pr.

So you're talking about PRVC or pressure regulated volume control.

Exactly. Yeah. The Hamilton's got, there's one, one thing I would say the Hamilton has a different terminology than all the other events that I've used. So it's kind of like I just, you just go to the, you know, the volume set area and you pick the one that you're looking for. But I can never remember the acronyms for all the different names they've got.

Yeah. So what I would share with you is this is the, what most people can learn from ASV is that ASV actually uses PRBC when the patient is passive or engaged and when the patient becomes fully spontaneous, it's using volume support. So it's already using those modes that your rescuers are having to take time to place those settings in that you're referencing. And more importantly, the study that I shared with early on in the call actually talked about when it's open loop like that, where the rescuer has to actually put those settings in, it is less likely, the outcome is less likely that the patient receives lung protective ventilation than if they were to be in a closed loop setting. And so I just, and I'd love to talk with you a little bit more offline if you have more questions questions about it. I'll, you know, I'll definitely share my information and I'm happy to jump on a call if you'd like. But it really, that's actually how it uses and leverages between a passively breathing patient, an engaged patient, and then a fully spontaneous patient utilizes PRBC and volume support. That's how it does it.

Right.

Talk more about it. But I would definitely, as I hop off here, I would definitely say, hey, all these agencies, there is money out there to get these ventilators, and we successfully put through a grant. So if, you know, you can find.

Yeah. So we, we. So, Todd, I'm gonna. I'm gonna ping you offline because I want to learn more about that. And we have to jump off to Dr. Pepe's webinar. I'm gonna give everyone the link here in a minute, but that's kind of what the meat of the matter, what I was trying to figure out here was can this ventilator be used in agencies like ours to, you know, simplify things, but actually to improve patient care, protect the lung, use, use during CPR, because God knows we do 60amonth in Palm beach county, in Brevard, we. We had five just yesterday alone. And so I think that we are, you know, I know my agencies and a lot of your agencies here are seeing lots of these. And, you know, I'm trying to see if there's some value we could provide to our community. So, Jesse, thank you so much. If you wouldn't mind putting your email in the link in the. In the chat. I'm going to put in right now, the link to the Eagles. So what I'm going to ask everyone to do now.