Virtual reality as a simulation tool for field hospital's and COVID-19 hospital's staff training / A virtuális valóság mint szimulációs módszer alkalmazása a telepített sürgosségi egységek, valamint COVID-19-kórházak személyzetének képzésében.

Összefoglaló. Bevezetés: A COVID-19-pandémia okozta nagyfokú betegszám-növekedés ellátásának érdekében az egészségügyi rendszerek gyakran a kórházak teljes átszervezésére kényszerültek. A szakállomány gyors és hatékony felzárkóztatása kulcsfontosságú ilyen körülmények között. A telepített kórházi egységek személyzetének felkészítésére a virtuális valóságban levezetheto csoportos gyakorlatozás ígéretes módszernek mutatkozik. Célkituzés: Célunk egy telepített kórház személyzetének felkészítésére alkalmazott virtuális szimulációs gyakorlatsorozat tapasztalatainak bemutatása, valamint a létrehozott és kipróbált virtuális gyakorlatcsomagok adaptálási lehetoségeinek elméleti bemutatása a COVID-19-kórházak személyzetének gyors felzárkóztatását szolgáló gyakorlatsorozat lehetséges kivitelezése érdekében. Módszer: Három, prototípusként eloállított virtuális gyakorlat került alkalmazásba két próbatanfolyam keretén belül. A virtuális színterek kialakítására az XVR szimulációs szoftvert használtuk. A gyakorlatok alkalmazhatóságának és hasznosságának kiértékelésére anonim kérdoíves felméréseket készítettünk. Az adatok feldolgozásában kereszttábla-elemzést és khi-négyzet-próbát alkalmaztunk. Eredmények: A két próbaképzésen nyolc ország képviseletében összesen 76 gyakornok vett részt. A résztvevok 63,9%-a szerint a módszer alkalmas ilyen jellegu gyakorlatok levezetésére, de további fejlesztéseket igényel. Véleményük, hogy technikai használata "elég könnyen" elsajátítható (59,7%), és interaktív (90,32%), valósághu (45,0%) szimulációs közeget biztosít. Megbeszélés: Eredményeink alapján a virtuális valóság egy alkalmazható módszer a telepített kórházak szakállományának valós bevetésekre való felkészítésére. A létrehozott virtuális gyakorlatcsomagok tartalma és szerkezete könnyen adaptálható egy COVID-19 ideiglenes egészségügyi egység sajátos munkakörülményeihez való gyors személyzeti felzárkóztatást szolgáló muhelygyakorlatok megszervezéséhez. Következtetés: A virtuális valóság ígéretes oktatási eszköz, amely kiegészítheti a nagy költségekkel és bonyolult szervezéssel járó terepgyakorlatokat, megközelítve azok oktatási hatásfokát. A virtuális térben megélt tapasztalatok valós szakmai élményekké alakulnak, és hozzájárulnak egy biztonságos és hatékony munkaközeg gyors kialakításához. Orv Hetil. 2021; 162(40): 1591-1600. INTRODUCTION: COVID-19 pandemic imposed sudden increase in hospital admissions, thus medical systems needed to reorganize entire hospitals quite often. Quick and efficient training is of outmost importance. Virtual reality team training is a promising tool for newly organized hospital units' staff. OBJECTIVE: Our goal was to present the usefulness and applicability of virtual simulation exercises for training of field hospital personnel and to evaluate the adaptability of these created and tested exercise packs for urgent staff training of COVID-19 hospitals. METHOD: Three prototypes of virtual reality exercises were assessed through two test courses. XVR simulation software was used to create virtual environments. Evaluation of exercise applicability and utility was performed by anonymous questionnaires. Statistical data-processing was performed using contingency table and chi-square tests. RESULTS: 76 trainees from eight countries participated in the two pilot courses. 63.9% of the participants stated that the method is suitable for conducting such exercises, but needs further development. Its technical use is "easy enough" to learn (59.7%) and provides an interactive (90.32%) and realistic (45.0%) working environment. DISCUSSION: Virtual reality is applicable to train field hospital staffs for real missions. The created virtual exercise packages are easily adaptable, both in content and structure, to workshops dedicated for quick training of specific COVID-19 temporary medical facility's personnel. CONCLUSION: Virtual reality is a promising educational tool that can complement the expensive and laborious field exercises, with comparable training efficiency. These virtual reality experiences may become real professional memories and create swiftly a secure and efficient professional milieu. Orv Hetil. 2021; 160(40): 1591-1600.

Improving nontechnical skills of an interprofessional emergency medical team through a one day crisis resource management training.

Errors are frequent in healthcare, but Emergency Departments are among the highest risk areas due to frequent changes in team composition, complexity and variety of cases, and difficulties encountered in managing multiple patients simultaneously.Crisis resource management (CRM) training has been associated with decreased error rates in the aviation industry as well as in certain areas of acute medical care, such as anesthesia and emergency medicine. In this study, we assessed whether a single day CRM training, combining didactic and simulation sessions, improves nontechnical skills (NTS) of interprofessional emergency medical teams.Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through 2 in situ simulated exercises. The exercises were videotaped and were evaluated by 2 assessors who were blinded as to whether it was the initial or the final exercise. They used a new tool designed specifically for the assessment of emergency physicians' NTS. The intervention consisted of one-day training, combining didactic and simulation sessions, followed by an instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.A significant improvement (P < 0.05) was shown for all the NTS assessed, in all professional categories involved, regardless of the duration of prior work experience in the Emergency Department.This study shows that even a short intervention, such as a single day CRM training, can have a significant impact in improving NTS, and can potentially improve patient safety.

Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study.

PURPOSE: The use of noninvasive ventilation (NIV) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure (hypoxemic ARF) has never been explored. This pilot study aims to assess the feasibility of early extubation followed by immediate NIV, compared conventional weaning, in patients with resolving hypoxemic ARF. METHODS: Twenty consecutive hypoxemic patients were randomly assigned to receive either conventional weaning or NIV. The changes in arterial blood gases and respiratory rate were compared between the two groups at 1, 12, 24 and 48 h. Differences in the rate of extubation failure, ICU and hospital mortality, number of invasive-ventilation-free-days at day 28, septic complications, number of tracheotomies, days and rates of continuous intravenous sedation, and ICU length of stay were also determined. RESULTS: No patient interrupted the study protocol. Arterial blood gases were similar during invasive mechanical ventilation, 1 h after NIV application following extubation, and after 12, 24 and 48 h. Respiratory rate was higher after 1 h in the NIV group, but no different after 12, 24 and 48 h. The number of invasive-ventilation-free-days at day 28 was 20 ± 8 (min = 0, max = 25) days in the treatment group and 10 ± 9 (min = 0, max = 25) days in the control group (p = 0.014). The rate of extubation failure, ICU and hospital mortality, tracheotomies, septic complications, days and rates of continuous sedation, and ICU length of stay were not significantly different between the two groups. CONCLUSIONS: In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF.

Noninvasive ventilation through a helmet in postextubation hypoxemic patients: physiologic comparison between neurally adjusted ventilatory assist and pressure support ventilation.

PURPOSE: Neurally adjusted ventilatory assist (NAVA) has been shown to improve patient-ventilator interaction and reduce asynchronies in intubated patients, as opposed to pressure support ventilation (PSV). This is a short-term head-to-head physiologic comparison between PSV and NAVA in delivering noninvasive ventilation through a helmet (h-NIV), in patients with postextubation hypoxemic acute respiratory failure. METHODS: Ten patients underwent three 20-min trials of h-NIV in PSV, NAVA, and PSV again. Arterial blood gases (ABGs) were assessed at the end of each trial. Diaphragm electrical activity (EAdi) and airway pressure (P (aw)) were recorded to derive neural and mechanical respiratory rate and timing, inspiratory (delay(TR-insp)) and expiratory trigger delays (delay(TR-exp)), time of synchrony between diaphragm contraction and ventilator assistance (time(synch)), and the asynchrony index (AI). RESULTS: ABGs, peak EAdi, peak P (aw), respiratory rate, either neural or mechanical, neural timing, and delay(TR-exp) were not different between trials. Compared with PSV, with NAVA the mechanical expiratory time was significantly shorter, while the inspiratory time and duty cycle were greater. Time(synch) was 0.79 ± 0.35 s in NAVA versus 0.60 ± 0.30 s and 0.55 ± 0.29 s during the PSV trials (p < 0.01 for both). AI exceeded 10% during both PSV trials, while not in NAVA (p < 0.001). CONCLUSIONS: Compared with PSV, NAVA improves patient-ventilator interaction and synchrony, with no difference in gas exchange, respiratory rate, and neural drive and timing.

Influence of lung collapse distribution on the physiologic response to recruitment maneuvers during noninvasive continuous positive airway pressure.

PURPOSE: Noninvasive continuous positive airway pressure (n-CPAP) has been proposed for the treatment of hypoxemic acute respiratory failure (h-ARF). Recruitment maneuvers were shown to improve oxygenation, i.e., the ratio of arterial oxygen tension to inspiratory oxygen fraction (PaO2/FiO2), during either invasive mechanical ventilation, and n-CPAP, with a response depending on the distribution of lung collapse. We hypothesized that, during n-CPAP, early h-ARF patients with bilateral (B(L)) distribution of lung involvement would benefit from recruitment maneuvers more than those with unilateral (U(L)) involvement. METHODS: To perform a recruitment maneuver, once a minute we increased the pressure applied to the airway from 10 cmH2O to 25 cmH2O for 8 s (SIGH). We enrolled 24 patients with h-ARF (12 B(L) and 12 U(L)) who underwent four consecutive trials: (1) 30 min breathing through a Venturi mask (V(MASK)), (2) 1 h n-CPAP (n-CPAP1), (3) 1 h n-CPAP plus SIGH (n-CPAP(SIGH)), and (4) 1 h n-CPAP (n-CPAP2). RESULTS: Compared to V(MASK), n-CPAP at 10 cmH2O delivered via a helmet, increased PaO2/FiO2 and decreased dyspnea in both B(L) and U(L); furthermore, it reduced the respiratory rate and brought PaCO2 up to normal in B(L) only. Compared to n-CPAP, n-CPAP(SIGH) significantly improved PaO2/FiO2 in B(L) (225 ± 88 vs. 308 ± 105, respectively), whereas it produced no further improvement in PaO2/FiO2 in U(L) (232 ± 72 vs. 231 ± 77, respectively). SIGH did not affect hemodynamics in both groups. CONCLUSIONS: Compared to n-CPAP, n-CPAP(SIGH) further improved arterial oxygenation in B(L) patients, whereas it produced no additional benefit in those with U(L).

Inhalational anesthetics in acute severe asthma.

Acute severe asthma is characterized by a state of airway inflammation and increased bronchiolar smooth-muscle tone that leads to increased resistance to expiration and lung hyperinflation. Despite the better knowledge of its pathophysiology, the incidence and severity of asthma in the last twenty years is increased worldwide, although with significant age and geographic variation. As a result, the number of patients requiring more intensive medical therapy has also increased. In the most severe cases, often referred to as near-fatal asthma, the institution of mechanical ventilation may be required. Volatile anesthetics have bronchodilator effects on the bronchial smooth muscle. The use of inhalational anesthetic agents for treatment of severe status asthmaticus has been documented in case reports, case series and small uncontrolled studies. Their use may be considered in any mechanically ventilated patients whose severe bronchospasm failed to respond to maximal medical treatment. In the present review article, we aim to provide a brief description of the physio-pathological and clinical features of acute severe asthma, and of the principles of treatment, focusing our attention on the use of the inhalational anesthetics in severe patients requiring mechanical ventilation and not responding to conventional therapy.