“
Respiratory Care 2015 and Beyond”
Charting a Future for the RT Profession
Bob Kacmarek PhD, RRT Harvard Medical School Massachusetts General Hospital
Boston, Massachusetts 4-27-09-WSRC
Potential Conflicts of Interest
Received research grants from Hamilton,
Covidien, Drager, General Electric,
Newport and Cardinal Medical
Received honorarium for lecturing from
Cardinal Medical and Covidien
Consultant for Newport
Kacmarek RM, Durbin CM, Barnes TA,
Kageler WV, Walton JR, O’Neil EH.
Respiratory Care 2015 and Beyond.
Respiratory Care 2009;54:375
Task Force/Planning Committee Representation Committee Members
Respiratory therapy director Bob Kacmarek (MGH) Respiratory therapy educator Tom Barnes (Prof Emeritus- NE) Administrator (acute care hospital) Karen Stewart (CAMC) Administrator (healthcare system) John Walton (Resurrection Health ) Healthcare workforce expert Ed O’Neal (Center for Health Profess) Patient/consumer John Walsh (Alpha One)
Physician (critical care) Charles Durbin (SCCM Past Pres) Physician (critical care) Woody Kageler (Disease Mgt) 2 year college representative Jolene Miller (NN2) 4 year college representative David Gayle (ASAHP) Federal government representative Judy Blumenthal (HHS)
Military representative COL Michael Morris (Brooke Army)
*
Questions to Be Addressed
How will patients receive healthcare services in the future?
How will respiratory therapy be provided?
What knowledge, skills and attributes (KSAs) will respiratory therapists need to provide care safely, efficiently and cost-effectively?
What educational and credentialing systems are needed to provide these KSAs?
How do we get from the present to the future with minimal impact on the respiratory therapy workforce?
Conferences to Address Questions
Conference 1 March 2008
– focused onidentification of the emerging values of our nation’s evolving health care delivery system and defined the potential roles and responsibilities of the respiratory therapist in 2015
Conference 2 Spring 2009 –
focused on theskills, knowledge and attributes that RT’s in 2015 and beyond will need to possess in order to execute their roles and responsibilities and to identify the competencies required.
Conferences to Address Questions
Conference 3 Fall 2009
–
will focus
on addressing the question “How do we
get from where we are today to where
we’ll need to be in order to adequately
prepare for 2015 and Beyond with
minimal impact on the workforce.
1stConference 3/3-5/08 - 20 Stakeholder
Organizations 37 Participants Alpha 1 Foundation
American Association for Cardiovascular and Pulmonary Rehabilitation (AACPR) American Association for Respiratory Care (AARC)
American College of Chest Physicians (ACCP) American Thoracic Society (ATS) California Board for Respiratory Care Center for Health Professions
Commission on Accreditation of Allied Health Education Programs (CAAHEP) Committee on Accreditation of Respiratory Care (CoARC)
COPD Foundation
National Association for Medical Direction of Respiratory Care (NAMDRC) National Board for Respiratory Care
National Heart Lung and Blood Institute National Home Oxygen Patients Association
National Network of Health Career Programs in Two Year Colleges (NN2) North Carolina Board for Respiratory Care
Society of Critical Care Medicine (SCCM)
The Association of Schools of Allied Health Professions (ASAHP) The Joint Commission
United States Public Health Service
Drivers of Health Care Change
Cost of Care
16% of GNP, 2 trillion dollars/yr, Medicare Part A funding a concern, private insurance more expensive, employers paying less Demographics
Baby Boomers will soon be 65, US pop to grow by 20% between 2000 and 2025 Shift in the disease burden
US Pop lives 35 yrs longer than 100 yrs ago, acute to chronic care, US health care must refocus to chronic care
Drivers of Health Care Change
Technology
Information and communication will change administrative tasks, clinical work and redistribute knowledge from experts to consumers
Innovation will affect all aspect of medicine Consumers of health care
Will demand quality, convenience, price and satisfaction
Disease Management: A system of coordinated
health care intervention and communication for populations with conditions in which patient self-care efforts are significantly expected to expand.
New models of healthcare delivery (such as the
“Hospital at Home” and “Medical Home”) will emerge with increasing emphasis on coordination of care through the healthcare system including the home
Public health issues, military and disaster
responseconcerns will continue and require new
skill sets for respiratory care providers
Current Status of RC within the
Healthcare System
RC is an important and integral part of health
care because of prevalence and seriousness of
pulmonary disease and the freq of pulmonary
complications
Most RC provided in the acute care setting
COPD 12 to 14 million diagnosed, another 12
million undiagnosed, 4
thleading cause of
death, 2004 37 billion cost of care
Current Status of RC within the
Healthcare System
Asthma – 22 million diagnosed, annual cost 19 billion, 4,000 – 5,000 die each year
OSA – still essentially undiagnosed, estimate 18 million affected, 6 million moderate to severe disease, impact of OSA on other systems still immerging
Needed skills – Education, protocol use,
preventative care, risk factor modulation, disease
self management, smoking cessation 2016 145,000
122,000 2006 132,651 2005 111,706 2000 Bureau of Labor Statistics State Licensure Boards
Active Respiratory Therapists
Respiratory Therapists per 100,000 Population
19.97_________________________ 32.10/100,000 population Utah_______________
United States mean
22.54 Minnesota 22.76 New Jersey 22.89 Alaska 23.69 Wyoming Bottom Five 42.35 Nebraska 46.06 Kansas 46.25 Ohio 52.74 Indiana 56.00 District of Columbia Top Five
Graduates From Associate Degree and Baccalaureate Degree
CAAHEP Accredited Programs
24,174 5,812 7,203 6,056 5,079 Total 22,083 5,241 6,612 5,570 4,634 AS Degree 2,091 569 591 486 445 BS Degree Total 2007 2006 2005 2004 Year
Respiratory Care in the Beginning
-1947!
Oxygen Therapy – H-Cylinders and
O
2Tents!
Schwartz Rebreathing Tubes!
Aerosol Therapy!
Negative pressure ventilation!
IPPB!
Puritan Bennett TV-2P and PR-2
The Role of the Respiratory
Therapist in the Beginning - 1947!
Technician (O
2Technician)
Setup and operation of basic
equipment
Delivery of aerosol therapy
Provision of IPPB
Assistance with ventilatory support
Performance of diagnostic tests
Where Are We Today – 2008!
Sophisticated ICU Ventilators
Ventilation In All Care Settings
Non-invasive Ventilation
Extracorporeal Life Support
Aerosol, Oxygen and Bronchial Hygiene Rx
Home Care, Subacute Care
Sleep, Transport
Patient Education
Extracorporeal Life Support
Role of the Respiratory Therapist Today
Provider of Basic Respiratory Care
Ventilator management
Delivery of aerosolized medication
Transport of critically ill patients
Extracorporeal Life Support
Performance of diagnostic studies
Patient Education!
Respiratory Care 2015 and Beyond!
ICU - increased Technical and Clinical
Sophistication, Expanded Monitoring
Explosion of Aerosol Therapy Applications
Genetic Based Aerosol Therapy
Sleep, Transport, Extracorporeal Life
Support
Subacute Care, Physician Offices and Home
Disease Management, Patient and Staff
Education, Team leadership
Clinical Application of
Mechanical Ventilation
Protocolized approaches to
providing mechanical ventilation
Modes of ventilation
Integrated Monitoring Systems
Diagnostic Algorithms
Protocolized Ventilation
ARDSnet Protocol
Recruitment Procedure
Determination of Correct PEEP
Ventilator management protocol
for Asthma, COPD, Post-Op etc!
Closed Loop Ventilation-The Future
Expect to see additional closed loop
approaches!
Approaches that manage both patients
receiving assisted as well as controlled
ventilation and during weaning!
Ideal feedback should include:
Patient effort/ ventilatory pattern Hemodynamic response Gas exchange
The problem finding the correct algorithm!
Lellouche, Brochard AJRCCM 2006;174:894
CDPW system operational rules:
PSV 2 -4 cmH2O steps establish a “comfort zone”
RR 15 to 30 breaths per min, 34 COPD VT> 250 ml or 300 ml based on size PETCO2< 55 or < 65 if COPD
When PSV minimal, SBT at minimal settings:
Trach + HH = 5 cmH2O
Trach + HME = 10 cmH2O ETT + HH = 7 cmH2O ETT + HME = 12 cmH2O
Ventilator indicates if patient passed SBT
Pt extubated if P/F > 200 and PEEP < 5 cmH2O
Adaptive Support Ventilation,
Calculates Optimal Breath Pattern:
Least Work of Breathing
Avoid: a: apnea b: volu/barotrauma c: AutoPEEP d: excessive V’D/tachypnea 0 500 1'000 1'500 2'000 0 10 20 30 40
Frequency in breaths per minute
Vt i n ml a b c d
Proportional Assist Ventilation
PAV based on the equation of motion:
Paw + Pmus = V’ x R + ΔV x E
Increases or decreases ventilatory support in
proportion to patient effort
Similar in concept to
Power Steering
Tracks changes in patient effort and adjusts
ventilator output to reduce work
Introduced by Younes in 1992
(Younes M, ARRD 1992;145:121)
Neurally Adjusted Ventilatory Assist
-NAVA
Sinderby Nature Med 1999;5:1433
Evidence Based Medicine
The practice of evidence based medicine is the
integration of:
– An
individuals clinical experience
with
– The best available clinical evidence from
systematic research and the integration of
– The
patient’s values and expectations
!
“
The best evidence changes over time”!
Individual Clinical Expertise
Based on clinical skills and clinical
judgment
The right patient, the right time, the
right place, the right dose, the right
resources….
Used to determine if the evidence
applies to the individual patient!
Taubes Science 1996;272:22
1,000,000 RCTs have been
carried out over the past 50 years
and most have been forgotten or
disregarded!
The outcomes from many of these
RCTs conflict with each other
!
Role of the Respiratory Therapist 2015
and Beyond!
Sophistication knowledge of multiple
classes of increasing complex ventilators
Expert consultant on the application of
mechanical ventilation
Ability to assess the validity of the evidence
Research methodology
Developing Monitoring Technology
Electrical Impedance Tomography Schible ICM 2006;34:400 Meier ICM 2008;34:543 Acoustic Thoracic Monitoring
Tejman-Yarden Anesth Analg 2006;103:1489
Lechner Eur J Anaesthesiol 2004;21:694 Optoelectronic Plethysmography
Dellaca CCM 2001;29:1801
Electrical Impedance Tomography
EIT uses the variability in electrical
impedance among tissue, air, and fluid to
provide a map of impedance changes.
It is an online dynamic monitor that is:
Radiation free,
Noninvasive,
Portable to the bedside
Relatively inexpensive
Adler JAP 1997;83:1762
Role of the Respiratory Therapist 2015
and Beyond!
Working knowledge of and ability to
utilize complex bedside monitoring
techniques
Increased understanding of complex
physiology
Role of the Respiratory Therapist 2015
and Beyond!
Extracorporeal Gas Exchange
Intravascular Blood Oxygenator
ASAIO J 2006;52:180
Implantable Oxygenator
ASAIO J 2006;52:291
NovaLung Extracorporeal CO2 Removal
Int J Artif Organs 2005;28:985
Pumpless Extracorporeal Lung Assist
Aerosol Therapy Applications
Drug Delivery via the lung!
– Pulmonary hypertension – iloprost, PGI2
Emmel Heart 2004;90:2
– Diabetes – inhaled insulin (Exubra)
NEJM 2007;354:497
– Allergen immunotherapy
Inflamm Allergy Drug Targets 2006;5:43
– Rejection immunosuppression in lung transplant
Burckart Expert Opin Investig Drug 2006;5:43
Genetics Based Respiratory Care
Genetic predisposition of Respiratory
Diseases: Asthma, Alpha-1 Antitrypsin
Deficiency, Cystic Fibrosis, Sepsis and
ARDS
Customization of therapy based on a
patients genetic makeup!
Human Genome Project – The human
genome has 3 billion pairs of bases, their
order determines human diversity
Genomics and Asthma
Polymorphism of the beta-2 adrenergic receptor – May influence airway response to inhaled beta
agonists (Curr Opin Pulm med 2006;12:12) – May explain response to salmeterol (AJRCCM
2006;173:519)
– Gly 16 alelle predisposes to nocturnal asthma (J Allergy Clin Immunol 2005;115:963)
Polymorphisms of a single gene may explain variation in response to inhaled steroids (Proc Am Thorac Soc 2004;1:364)
Genomics and ARDS
Polymorphism in the surfactant Protein-B gene is associated with susceptibility for ARDS in women but not men (Chest 2004;125:203) Association between genetic polymorphism and risk of development of ARDS and increased mortality in ARDS ( CCM 2007;35:48) Identification of candidate genes may provide potential targets for ARDS therapy (Am J Physiol Lung Cel Mol Physiol 2006;29:1113)
Gene Replacement Therapy
Alpha-1 Antitrypsin deficiency (Curr Opin Pulm Med 2006;12:125)
– Weekly intravenous alpha-1 replacement therapy available – Possible role of alpha-1 antitrypsin therapy in reducing progression
of disease
– Role for inhaled therapy (only 2% of infused drugs reach the lung)
Cystic Fibrosis (J Aerosol Med 2003;15:229)
– Two vectors have been used for inhaled gene therapy (CFTR): adenovirus and liposomes
– In vivo gene transfer to the bronchial epithelium by aerosol can be achieved
Role of the Respiratory Therapist 2015
and Beyond
!
Administering pharmacologic agents affecting systems other then the heart and lung!
Administering gene therapy agents via aerosol! Consulting on selection of a broad range of therapies!
