Cardio Respiratory Monitoring —
Training activity: 8

Details

Advise a clinical colleague on the different patterns of gas delivery during ventilation, how different patterns of ventilation deliver the breaths to the patient and the advantage and disadvantages of the various breath delivery types

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Communication with patients, relatives and the clinical team
• Risk management
• Troubleshooting

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to advising a colleague on patterns of gas delivery (e.g., flow patterns), how breaths are delivered (e.g., pressure-controlled, volume-controlled), and the pros/cons of different breath delivery types.
• Consider how the learning outcomes apply, specifically in relation to appraising respiratory techniques, demonstrating effective communication of complex concepts, and practicing safely by ensuring the colleague understands the physiological consequences of different delivery patterns.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific gas delivery patterns and breath types (volume vs. pressure control) most relevant in your practice, and the level of detail needed for advising on their clinical impact.

What is your prior experience of this activity?

• Think about what you already know about different patterns of gas delivery (e.g., decelerating flow, square flow) and how they affect pressure and flow dynamics during a breath cycle.
• Consider possible challenges you might face during the activity, such as explaining the physiological trade-offs between pressure-controlled and volume-controlled breaths or comparing the advantages for different patient pathologies (e.g., ARDS vs. obstructive lung disease).
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if a colleague asks for detailed advice on managing dynamic hyperinflation related to flow patterns that requires an intensivist’s input.
• Acknowledge how you feel about embarking on this training activity, particularly your confidence in explaining the technical and physiological aspects of gas delivery patterns and breath types.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as improving your ability to clearly describe how different flow patterns affect ventilation mechanics or articulating the clinical implications of choosing a specific flow pattern to improve patient-ventilator synchrony, drawing upon previous experiences.
• Identify the specific insights you hope to gain into how subtle changes in gas delivery patterns can impact patient comfort, auto-PEEP generation, or oxygenation/ventilation efficiency.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of mechanical ventilation or advising colleagues on ventilator settings.
• Identify important information you need to consider before embarking on the activity, such as reviewing the academic content on modes and patterns used in mechanical ventilation, and the basic physics of gas flow, pressure-volume relationships, and how these relate to breath delivery types.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst advising a colleague on gas delivery patterns (e.g., decelerating flow) and breath delivery types (Volume vs. Pressure control)?
• Are you encountering situations such as:
  • The colleague challenges the stated advantages/disadvantages of a specific breath delivery type (e.g., the benefit of Volume control over Pressure control in a specific lung pathology)?
  • Unexpected questions arise about the technical setting of the inspiratory pause or rise time, requiring precise knowledge of how these affect the flow pattern?
  • Difficulty arises in using clear, non-ambiguous language to compare the physiological impact of a square flow versus a ramp flow pattern on airway pressure?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to visualising the pressure-volume loop or using respiratory mechanics analogies?
• Consider the steps you are taking in the moment, such as:
  • Immediately referencing the ventilator’s graphics display (if available) to physically illustrate the difference between breath delivery types
  • Focusing the discussion on the basic principles of lung protection rather than engaging in highly complex mathematical discussions of flow dynamics
• How are you feeling in that moment? For instance, are you finding it difficult to articulate the physiological trade-offs between different gas delivery patterns? Is it affecting your confidence in maintaining factual accuracy when comparing complex mechanics?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully providing accurate and balanced information on the mechanics and benefits of different delivery types? Or are you needing support because the colleague requires a recommendation for a highly complex lung pathology (e.g., severe ARDS) that necessitates specialist respiratory therapy consultation?
• What are you learning as a result of the unexpected development? For example, are you mastering the precise terminology for describing ventilation mechanics? Or gaining insight into the critical factors that govern optimal ventilator waveform selection for lung recruitment?

On action

What happened?

• Begin by summarising the key steps you took when advising the clinical colleague on patterns of gas delivery, how they deliver breaths, and their advantages/disadvantages.
• Consider specific events, actions, or interactions which felt important, such as contrasting the physiological impact of volume-controlled versus pressure-controlled breaths or discussing how decelerating flow patterns affect plateau pressure.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately using the ventilator’s graphics display to demonstrate the difference between a square flow and a ramp flow pattern.
• How did you feel during this experience, e.g., did you feel focused on articulating complex physics clearly or challenged by the need to ensure the colleague grasped the clinical relevance?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding advising colleagues on fundamental ventilation mechanics. What strengths did you demonstrate, e.g., systematic approach to comparing the pros and cons of different delivery types?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the specific mechanism of trigger sensitivity settings?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in articulating the clinical implications of flow patterns (e.g., impact on I:E ratio)?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the optimal time cycle setting for a complex pressure-controlled mode in an ARDS patient, and how you reacted to this.
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to reviewing the principles of respiratory mechanics and physics related to gas delivery.
• What will you do differently next time you approach advising on ventilation gas delivery patterns, for instance, by proactively preparing non-technical analogies to explain complex pressure/volume relationships?
• Do you need to practise any aspect of the activity further, such as explaining the advantages and disadvantages of volume versus pressure control or key learning outcomes related to appraising techniques for respiratory function?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of managing ventilator graphics for patients with severe acute respiratory distress syndrome (ARDS) requiring lung protective ventilation since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, a subsequent case requiring differentiation between volume-control and pressure-control breaths for optimal lung protection forced you to re-evaluate the clinical trade-offs you presented between breath delivery types during your first attempt at this training activity.
• Considering what you understand about airway pressure limits and mechanical coupling now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your advisory communication regarding the advantages of different gas delivery patterns based on further learning and experiences? For example, how you proactively integrated simplified visual aids explaining the difference between square flow (volume control) and decelerating flow (pressure control) waveforms based on further learning.
• Has discussing the effect of inspiratory pause settings on auto-PEEP or the impact of inappropriate flow patterns on oxygenation/ventilation efficiency with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior therapist about a case where poor flow selection caused excessive dynamic hyperinflation refined your understanding of the critical relationship between flow pattern mechanics and clinical safety.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent advisory and clinical observation experiences, contributed to your overall confidence and ability in explaining different gas delivery patterns (e.g., flow types) and their physiological impact, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated understanding of volume vs. pressure breath delivery mechanics now enables you to efficiently appraise the options of ventilation patterns with a clinical colleague during an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to advising colleagues on ventilation breath delivery types? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or Intensivist immediately when asked to troubleshoot severe issues related to dynamic hyperinflation or patient-ventilator dyssynchrony linked to flow patterns, recognising this requires advanced clinical intervention.
• Looking holistically at your training journey, how has this initial gas delivery patterns advisory experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to appraising techniques to maintain patient respiratory function and practising safely? For example, how this foundational experience has supported your development in applying fundamental respiratory physics and principles of lung protection to clinical scenarios.

Relevant learning outcomes

#	Outcome
# 3	Outcome Appraise techniques to maintain patient respiratory function, advising on appropriate techniques for the clinical scenario.
# 5	Outcome Communicate effectively with the patient and the multi-disciplinary team.
# 6	Outcome Practice safely, managing risk in all elements of patient care.