Transcription
Okay. So, today's a very special session, and with us is a very, uh, I would say, we are privileged to have the guest on the channel. Professor Giacomo Bellani from Trento, Italy. And he's very passionate about, um, mechanical ventilation and respiratory physiology. So, when we were going through these mechanical ventilation courses and all those things, I was very fortunate that he accepted that he can share his insights, his immense insight and wisdom for so many years which he has, uh, given to the, uh, students and other healthcare professionals.
Not only this, uh, today's session is important and special because after a long wait, his book is going to release next week, coming week, and, uh, we will discuss a little bit about that. And just for the audience who is listening, because of the network glitch, there is a slight frame lapse in the video, uh, from, uh, in the professor's video, but audio is good. I think you all will enjoy and learn a lot from this. So, welcome Dr. Giacomo Bellani, professor. We are very, very delighted to have you on the ICU channel. Thank you so much.
Thank you so much, Ankur. And please, Giacomo is more than fine. Thank you. Thank you. So, um, uh, before I start, um, asking some of the questions which we and our audience have in the mind, um, I know you are very passionate about mechanical ventilation and, um, many of the guests who, or many of the viewers who are watching this, know about you. But if, if, if I can ask you to, uh, tell a little bit about yourself to our viewers, because if I start, it will take a whole day to explain the things about you. So, Giacomo, if you can, uh, say, introduce a little bit about you to our audience.
Sure. Sure. Well, at first, thank you so much, Ankur, for this nice invitation. It's a, it's a great honor and privilege, um, being here. And I know you have a very well-attended audience. So, thank you so much for giving me the opportunity of, for, for being here. Uh, yes, I, uh, am passionate about mechanical ventilation, and that's, uh, something that started back in the, uh, roots of my career. I was born and up in Milan, and, um, that was, uh, almost 50 years ago, I have to say. And then I went into medical school there. I got a great interest into physiology, generally speaking, not so much into respiratory physiology. And then I, I decided I wanted to do anesthesia and critical care because in Italy, it's just one, one specialty, anesthesia and critical care. And so, while I was graduating, I was lucky enough to meet my, um, my mentor, Antonio Pesenti, and I've been working in Monza as a resident and then a PhD student for many years. And then I, I was able to get a position there as what you would call assistant professor and then associate professor. And during this, this period, I had a break in the United States at Massachusetts General Hospital. Uh, that was a great opportunity. And then I, I came back to Italy and, as I said, I, I did my career there in, in, in Monza. And throughout the years, I, I've always been working as, as a, well, for a few years, anesthesiologist and then mainly critical care physician, always carrying on my, um, my, our research projects, uh, in, in respiratory mechanics, respiratory failure. Um, a big project for me was, uh, back in 2013, '14, the, the LUNG SAFE study through the, uh, which we published and, and which we ran thanks to the support of European Society of Intensive Care Medicine. And, and that was really something very important for me. And, uh, as of three years, I became, um, chief here in Trento, which is in the, uh, northeast of, of Italy. Probably, uh, you, someone might know about the Dolomite Mountains, which are beautiful mountains, uh, in, in Italy. And, uh, so, I, I came here and I am head of the Department of Anesthesia Critical Care and a professor at the University of Trento. So, that's a little bit my, my professional journey. I can take a break, breathe now, in between.
So, Professor, um, uh, uh, one thing I would like to ask that much of your work is there in the early days in the Monza, I would say, and also in the Massachusetts General Hospitals. So, if we look at you, if we think about you, the first thing which comes in our mind is the respiratory physiology in critical care, which you, I think you have done a lot of work on that. So, what compelled you or what made you, um, think about, or what made you interested about this, or any case was there which sparked your this lifelong fascination for the lung, I would say?
Yes. Thank you for the, for the question, because I, despite many years passed, I still have, like, some vivid recalls of that early days. It's a little bit when you, if I can, can make a comparison, when you fall in love with a person, you very well remind where you met her and so forth. And so, despite it was now more than 25 years ago, I, I remember that as I mentioned, I was an intern in physiology, neurophysiology, and then I decided I wanted to still have, like, a more clinical internship, so I went to anesthesia. And I remember that that respiratory physiology, I didn't like it much when I studied it at the university. I, I did not quite understand it, and it seemed very complex. And, and then I remember the, the days in Monza that, uh, uh, I, I was assigned to a project on, on CT scan and, and measurement of end-expiratory lung volume. And so, I, I spent a lot of time reading the, the papers. And at the time, it was real papers. You would go in the library, make photocopies, and everything. Internet was starting, but most of it was on papers. And I read the, the papers done by, by Gattinoni and, and Pesenti. What was there? He was my professor. Those seminars paper on, on the, on the, on the baby lung and on, on the concept that lung mechanics depends on its size. And, and really, I saw an approach to, to the diseases that was really based on, on physiology. And that, as you mentioned, for me was, was a spark. That was something I really wanted to, to do in the following years. And, uh, you know, and then, as you mentioned, I, I went to MGH, and that was another type of experience because large part of the group was, was made by engineers. And so, uh, I, um, working with, with them has been really something that has set, given mindset on, on method, because as you can imagine, engineers are very methodical. And so, I, I think these, these two elements together, the, the, the, the fascination for, for research and, and the strong method, really, in a way shaped my, my career to, to follow.
Okay. That's interesting. Um, and now, as we know that, um, after so many years later than, uh, you told that that time there were real papers, going to the library and taking out those papers and reading. And now internet has evolved to a lot of extent, and now not even internet, we are in the age where there are a lot of quick references, apps, and, uh, online protocols are there. So, you authored many lectures on respiratory failure and mechanical ventilation. And your book is also coming. So, in the era where there are a lot of online protocols, quick references, apps are there, why did you feel it necessary that you should sit down and write a comprehensive text on the lectures which you hold recently on respiratory failure and mechanical ventilation?
Yeah, I >> [laughter] >> I also had a, a friend of mine who read a little bit of what I wrote and told me, "Oh, you know, this is very nice, but my friend, books are dead." And so, it was not very encouraging. But of course, as you say, we are in a world which is changing, and I, I see my residents, they always check everything on internet, and, and I do the same. But still, I think especially in the early year of the careers, the ability of sitting down, concentrate, reading something, and then going back to what you did not understand is, is an added value. And, you know, I, I have the, the privilege and, and the honor to give lectures around, and sometimes I feel like that given that all the material is, is prepared, the slides and, and the talk and everything, it was just a little bit of an extra effort, not such a little bit. It was quite some effort, but already the ideas were there. And I, I like to, to put it down on papers. It was also a useful exercise for me to put the ideas in a, in a more, let's say, clear and, and organized structure. And, and still I think that the, as you said, quick references, protocols, apps, everything is very useful, but understanding and also being challenged because, because in the book, as we might touch upon later on, there are some provocative concepts. Um, the idea of, of, of challenging your own mind and your own knowledge with, with these new concepts could be useful. I hope maybe for, especially for the more junior colleagues.
So, Giacomo, if I'm not wrong, the book is titled Respiratory Failure and Mechanical Ventilation. Yes. So, um, let me ask this. Um, there are many good books and many books, I would say, are available on mechanical ventilation per se. Two, three books which we refer frequently. So, why did you feel that this book is a little bit different, or is the approach is a little bit different in this book for mechanical ventilation?
Yeah. No, it's an excellent question because, as you say, there are many, many excellent books out there. And, and honestly, I don't think that the book I'm, I'm preparing by itself could prepare a clinician. So, it's, it's not, let's say, a standalone reference. It's not the Tobin book, just to, to mention a book that it's an absolute reference in its field. In a way, I think it's a little bit different in that I tried to present what is the evidence on a given topic. For example, let's say the definition of ARDS, what is the current status of the definition of ARDS, and then what is my opinion, which is, as it is, my opinion for the good and for the bad, and, and my interpretation. And, and I believe that this is a quite useful exercise for the readers to compare what is their own opinion with what is my own opinion and what is the, the evidence that we have from, from the guidelines. The, the published books, which, as I say, are excellent, do need, however, to be fully comprehensive on a given topic, okay? In, in, in my book, I have decided to speak about some aspects of a given problem, like, for example, PEEP settings. You can write a book on, on PEEP setting with all the papers, all the, I, I don't provide an encyclopedic view of the PEEP setting. I, I provide my own theoretical and practical view on how to do this. And this is the last element, I would say, of, of novelty. I, I always try in my talks to put together the, a little bit the, let's say, the more theoretical part, the more general part, but also bring it to the bedside with real actual clinical examples because, at the end of the day, that's, that's what it's needed to, to, for something to be useful.
So, now, this is a very interesting fact. Let me take it a little step further. So, there are certain protocols, as you said, that there is certain reference books or certain standard protocols which are there in the textbook. And then you are having a patient which has a certain physiology which may be different in that patient. So, as an intensivist or those working in the critical care, how do we have a, how do we strike a balance between those standard protocols in the books and the patient physiology which is in front of us? How do we strike a balance?
Yeah, I think it's, it's an excellent question. So, the point is, at first, uh, you need the books and also you need the, the protocol. Well, maybe you need the books at first to understand how the system works. So, uh, first of all, for example, you need to very well understand the equation of motion, how it works, what does it tell you, what are the meanings of resistance, compliance, and so forth. And then you need the, the, let's say, the, the protocols because they kind, kind of give you a guidance on where you should aim at. For example, lung protective ventilation, we know tidal volume should be 4-8 ml per kilo. All guidelines say that. But between 4 and 8 ml per kilo, there is a 100% range of variability. And so, how do we decide where to hit? And this is, I believe, where physiology comes into place. So, we have to try and stay within a, a protocol, if this is what we use in our institution, but also we need to be able to understand when we should deviate. For example, I give you another example. PEEP FiO2 tables. I, I personally don't use them at the bedside. Some people do, and I think there's nothing wrong with that, but you cannot just rely on PEEP FiO2 tables. For example, if you start to increase PEEP and respiratory mechanics worsens, okay, at, at this point you need to say, "Okay, the protocol brought me to here, but then at some point, I will have to take a little bit of a detour from, from the protocol." So, that's, that's the general idea.
So, very interesting because, uh, applying the guidelines and the protocols to the patient physiology makes sense. And also, I love this line that we should know when to deviate. This is very, very important, which one should understand that when to deviate from the guideline. And in this patient, this deviation is technically helping. So, um, uh, when I was getting a glimpse of your book, I think you often mention, not only in the book and the lectures which I heard, that you always say that ventilation or ventilator is not just a treatment, it's a sort of diagnostic tool also. And often the ventilator waveforms can tell you or give you the information which the good CT scan of the chest doesn't give. So, can you elaborate a little bit of, for, in detail to our listeners?
Again, I would say No, sure. I, I, Yes, I, I like to say these, these about mechanical ventilation because, um, like, uh, well, of course, we, we think of mechanical ventilation as a therapy. And, and that's where it started from, right? In the polio pandemics and so forth, to avoid patients from, from dying. We ventilate them. But on the other hand, we get many information. For example, we can measure airway resistance and understand whether compliance, whether the, the problem is initially restrictive or obstructive. And then we have a measurement of airway resistance, which is increased, and we say, "Okay, let's try and give steroids to this patient." How do we measure the effectiveness of our treatment? And this is exactly by measuring resistance. So, or in a spontaneously breathing patient, which we cannot separate from the ventilator, we could be wondering whether the problem is the fact that the patient is weak or he's overly sedated, the drive is not enough. And by simple maneuvers on the, on the ventilators, which are, uh, by the way, completely free of charge, okay? Completely free of charge, and there is no extra cost. We can learn so many things. And, of course, sometimes we, we definitely need to go to the CT scan because it's providing us so much information, but on the other hand, when you are at the bedside and you put the patient prone, you immediately can understand whether you improved or worsened the respiratory mechanics of, of the patient. And again, this comes for free, and it's continuous. So, that's why I, I think that mechanical ventilation is, is definitely a diagnostic tool.
So, means those who are listening, viewers, those are listening, two, three things from this that ventilator provide diagnostic things which is free of charge. And secondly, most importantly, it's dynamic, it's continuous. It's minute to minute providing you what is happening with the patient. So, anybody who wants to work on the ventilator or come across the ventilator should master, I think, the ventilator graphics, which is very, very important. They can be in real time, can see what is happening with the patient's lung, which we cannot pick in the CT scan. Now, coming to the next question. Almost 20-25 years have passed. You started some 25 years back. You just said that. So, at that time, roughly, it was ARMA trial was there. ARMA paper which came in 2000. So, over the period of 25 years or 26 years, how you have seen or witnessed the evolution of, what I could say, the management of respiratory failure? Um, since 2000. Have you seen any changes? Uh, uh.
Oh, yeah, definitely. So, ARMA trial told us that that lung protective ventilation was important. And then, of course, there were criticisms because the, on the fact that the control group of the ARMA trial was not real control group because tidal volume were too high. But still, I believe that after the ARMA trial, and I was in my very early days, so I barely knew what was happening, but I understood it later on. Anyway, in the, let's say, between 2000 and 2010, um, we could not deny that that lung protective ventilation was important. But lung protective ventilation was basically tidal volume 6 ml per kilo, plateau pressure less than 30. That was the concept of lung protective ventilation. And then, totally after the, the, the setting of tidal volume, the focus of, of both the NIH ARDS network and other investigators moved on on PEEP. And I think on PEEP, the situation was a little bit, well, at the end of the day, the situation turned out to be a little bit more blurred than with, with tidal volumes. Because at some point, and I am still convinced on that, but we were convinced that higher PEEP would be beneficial in, in more severe patients. But then, the ARDS trial somehow put cast some some doubts on the effectiveness of, of using a higher levels of PEEP. But still, I would say that for PEEP, we've learned much. We still, but we are at the point where we collected pieces, and now we have to put them together. Um, and then, in 2015, I think it was, the, the, the concept of driving pressure came. And, and that was really a, a game-changer, okay? That was the greatest change after the, the ARMA trial publication. So, the fact that we somehow finally had a very strong, uh, parameter associated with, with lung injury, uh, that was the, the greatest change that we witnessed in the last 10 years. And that added an important, crucial element to lung protective ventilation. So, that, that was the, let's say, the next step of, um, lung protective ventilation. And finally, I would say, also, through COVID, we now use prone position more and more frequently. And that added a further layer, I should say, of, of lung protection. Um, so that it's my feeling, and I don't have, uh, numbers to sustain this, but it's my feeling that after COVID, the number of patients needing ECMO has dropped. Because most patients are ventilated much more protectively and receive prone position much more often. And so, the, the explosion, let's say, of the, of the use of, of lung, of prone position led, in my opinion, again, uh, on to a decrease of the incidence of refractory hypoxemia and need for ECMO.
So, uh, means, it was in the early days, it was low tidal volume, which was 6 ml per kg body weight. Then, we had plateau pressure. Then, we switched to driving pressure, which you were saying. And then, now, prone position. And it should be applied early, if we say. And that use of prone position early may get a patient out of the ventilator without the needing of ECMO. This is a trend. This is a trend which we are seeing. We don't have a study, but this is something which we are witnessing. Exactly. But one thing for sure that prone position needs to be started early. Now, uh, PEEP came into the picture when this trial came, and there was different tables. This is FIO2 table, this is a PEEP table. But the problem is clinicians or the healthcare professional intensivists always struggle with this PEEP optimization, PEEP titration. It feels that, in spite of many protocols, it, in spite of many guidance, this is a never-ending debate or struggle sort of things. So, what's your say on this?
Hm. Uh, so, I, I think that, uh, the, the, there is one, one paper we, we recently published a reanalysis of the LUNG SAFE that clearly shows that PEEP, at the population level, has a U-shape association with outcome, okay? Too low PEEP associated with, with bad outcome, too high PEEP associated with, with bad outcome. So, and I think this U-shape relationship is not just valid at, at a population level. It's valid probably at a single patient level. So, that's, that's why, um, we, uh, with lung protective ventilation, it's, it's easier. It's not necessarily the lower the better, but generally speaking, uh, the, the lower we keep the driving pressure, the better, okay? With PEEP, it's, it's not exactly the same. We need to find the, the, the best balance between overdistension and collapse. And how to find it has been elusive so far. I personally liked the, the, uh, approach from the ARDS trial. So, recruitment and a PEEP that would, uh, uh, lead to the best compliance. But unfortunately, and this is not a criticism to, to the colleagues, that's what it was. The, the, the, the way it was, um, it was applied was very aggressive. And that's, that probably led to the, to the negative, uh, results we saw. Uh, so, EIT is, is providing a lot of help in this, in that it's able to dissect the heterogeneity of the different lung regions. And I, I am quite optimistic that in the next 10 years, we won't have a protocol to set PEEP because, as we say, it's, it's very, uh, in patient, in patient individual, uh, but we will improve our understanding on the effects of, of, of PEEP, and so being able to optimize it in each patient.
So, correctly said, you said in the next 10 years, maybe we, we, we'll not have a table or something to optimize PEEP sort of things. But in the next 10 years, I would say, uh, there will be AI which is coming as of now. And, and it is coming in the mechanical ventilation over the next 5-10 years. >> [snorts] >> So, will we teach the future lectures or something, we will teach to this AI sort of thing or to machines, or we'll teach to the humans at that time? How, means, ventilator, will they be able to adjust automatically, or still we need to teach the humans or intensivists which are there?
Yeah, you know, that's, that's an excellent question. And, and of course, AI is, is coming. It's coming quickly. Uh, and, and myself, also taking advantage of AI to, let's say, put down into words my, to text the words I had recorded. So, of course, it's changing many aspects of our lives. Um, the way I see it applied to mechanical ventilation is probably an earlier detection of given phenomena. For example, there are already ventilators that have AI algorithms to detect asynchronies or, for example, detect overdistension or detect flow limitation. And probably, the ventilator could suggest clinicians, I would like, I would suggest to do this and to do that. But at the end of the day, at least for the next years, I think that the, the finally the responsibility will still be in, in, in human hands, okay? It's like some self-driving cars. They can drive themselves, but still you need a, a human that is sitting there and be able to intervene. Um, the other point is, in order to train properly the AI, I think we, we need to have large data sets, which is nowadays more relative, more, more relatively easier to find. But we also need benchmarks, okay? So, for example, if I want to train my eye on, on asynchrony, I need to be able to, to have a human that is teaching, uh, okay, what, what these asynchronies are on the waveforms. So, that's the other challenge, I would say, having proper gold standards for what we teach to the machines.
So, means, what you see is that AI will assist in picking up the problems early. And so that we can intervene more methodologically earlier in managing those patients. It will help as a more better tool as a smart ventilator sort of things rather than as an isolated thing. So, right now, so, so, for, but for, as of now, what we could understand from you is keep the driving pressure low and keep a balance, optimal PEEP which is not too high and not too low sort of thing, and prone early. That's, that's something. Now, other than this ARDS and all this thing, uh, there is one, uh, uh, question which I personally wanted to ask that intubation or intubating a patient is something very different if you are doing it in OT and very different when you are doing in a ICU or emergency sort of scenario where the patient is crashing technically. So, in spite that we need to do it fast, we need to do rapid sequence, and we need to do that, which one principle you feel that it should never be compromised, even if for the sake of speed, we should not compromise that thing in a crashing patient while intubating?
Sure. Yeah, I think on this, we've been doing some, some work with my, my friend and colleague Vincenzo Pesotta from Turin, Italy and, and really, he has been able to, we have been able to show how dramatically the moment of intubation can be for, for patients, not because of the difficult anatomical airway, that's pretty much easy in many cases, but because of the difficult patient. And I think that a good level of, a proper monitoring where everything is, is in place to monitor patient respiratory rate, heart rate, blood pressure, and as soon as the patient is intubated, end-tidal CO2 should never be compromised for the, for the speed. We, we saw that so many centers still did not have an ETCO2 verification of the proper endotracheal intubation, and that's something that, that really should, should absolutely be, be avoided. But sometimes for the need of speed or for the lack of equipment, we make trade-offs. And, and to me, the presence of high-quality monitoring should, should never be accepted as, as a trade-off. And the, the human factor, right? Of course, if we are able to have colleagues supporting us, if we are able to have the, the nursing prepared, just a little bit of, a moment of briefing so that everybody knows her or his tasks, that's, that's the other aspect. So, monitor with the machines, but also monitor the human factor would be my, my suggestion.
It's so encouraging. I, I could not say how, how much encouraging is this for ESBICM, which is the B stands for the bedside educational society of bedside intensive care medicine. And your words like that, you cannot rule out the human factor. Small debriefing, briefing about the intubation procedure at that moment with who is going to do what, what we are going to do, good monitoring, and, and obviously an ETCO2 in place. But team working as a team at the bedside is a factor which, which cannot be compromised. So, thank you for this, this beautiful words. And now, once we have taken on the ventilator, and now I see that many of the young, uh, intensivists or trainees or nurses who came to the ICU and always a ventilator, they look at the ventilator skin, ventilator screen, and they feel a little bit shy, a little bit intimidated with this ventilator. So, what would you say, what would you give message of words to them who are seeing the ventilator for the first time? As just as words of encouragement, I would say.
Yeah. Yeah, I know. I, I think it's, it's an excellent question and, and sometimes I, I tell a joke which is partly a joke, and it is the fact that I like mechanical ventilation because I am a little bit, I'm fundamentally lazy. And so, with mechanical ventilation, you just need to know one equation, the equation of motion, and that's it, okay? So, first of all, don't, don't be discouraged because there is one thing you have to learn, the equation of motion. Then you have to understand it and, and put in, in, the various concepts. And, and to me, the suggestion is to take the ventilator off the patient and see how it works and, and take the pieces of the equation of motion one by one. See what happens in the airway pressure when you change the flow. See what happens in the airway when you change the volume. What happens when you change the resistance, when you change the compliance. And so, at first, understand the equation of motion in the, in the passive patient, one piece by piece. And there are also excellent and free of charge simulators online where you can, you can learn this. Then put yourself in a little bit more complex situation, which is pressure control ventilation. Pressure control ventilation, it's, well, physiologically has some advantages, but long story short, it's a little bit more challenging to understand how resistance and compliance impact the flow during pressure control ventilation. And so, you took one step further. And then on top of this, add the activity of the patient. And every time you see a waveform, try to interpret it in terms of equation of motion. So, your, uh, waveform, your airway pressure waveform, always, in any time, should respond to this basic rule. That, that would be my, my personal suggestion.
Thank you, Giacomo. We, I'll tell you a little fact about ESBICM. We, we do a course which is called the MacVent course, and right now we have almost 300 people in that, and it's from people from 24 countries. And I'm very happy to see that equation of motion is getting so much importance by you. It again emphasizes that this is something you need to understand, and everything plays around it. If you understand that and the ventilator graphics, that thing, ventilator becomes very easy, and I would say, as a sort of your friend or colleague in your ICU. Ventilator becomes very easy sort of things. So, I'm sure that if people can get benefited with this short 20-25 minutes of conversation, they will get immense value addition, immense benefit from your book which is Respiratory Failure and Mechanical Ventilation. And as we talk on this day, uh, I think in 5-7 days, it is getting released. Um, I hope. Yeah. So, please share the link so that we can post in the comment in the description of this video so that we can, our viewers can go and whatever they pre-order or get notified about that book there. And to request one, if you, if you can, we can have a copy so that we can have some lectures from it online.
>> Oh, sure. Just send me your, your postal address and I, I will mail you a, a copy definitely. And second, in our mechanical ventilation course, if we can have a guest lecture from you based on your book, that would be very nice for our audience. Yes. And students would love to hear from you. I don't like to invite myself, but I think that I, I came through your, through your ICU channel, and I think it's, it's really beautiful because it's really, as I like teaching, teaching at the bedside. It's always also, you know, in the ICU with the residents, but during the courses, we always try to have some hands-on which is not exactly at the bedside, of course, but still, it's, it's practical because at the end of the day, you can teach people, okay, you have to measure driving pressure. Fine, but I need to know which button on my own ventilator I need to push to be able and measure the driving pressure, right? So, the, the concept of, of ESBICM, so bedside, it's, it's really, it's really a helpful one. And, and so if you, if you feel like having me in one of your, uh, uh, lectures, thank you, thank you very much. And when you have the book, perhaps you can pick the lecture you like the most, and I can do it for you.
Thank you, Professor Giacomo. And it was, means, I can continue this for a very long period of time, but because of the, your busy schedule, we'll, we'll close it here. And those who are listening, they can always post their comments, questions in the comment section of this video. We'll post a link to the book in the, uh, in the, what we'll call, description of the video. And we can share your email also in this if they want. So, we'll share your email on the video so that if somebody wants to connect with you in the regarding to mechanical engineering from across the world, they can just drop an email to you for that matter.
Yes. Be a little bit patient in that, it might take a while to, to reply, but definitely, please. So, it was very nice talking to you and thank you for joining us. Thank you. See you soon. Thank you. See you soon. See you soon. Thank you.