After the 6 years of preliminary work that ultimately led to the publication of ISO 19223 the ISO TC 121/SC4 project team received significant encouragement when contacted by Dr. Morley following the publication of his and Dr Keszler’s paper, Ventilators do not Breathe (1). He was pleased to learn that an ISO project team was already working towards addressing this concern.  Their paper was written as a result of their own concern regarding the current state of ventilation terminology. 

Drs Morley and Keszler explained that during their investigations of neonatal respiratory support and resuscitation, they had been interested in reporting how a baby’s spontaneous breathing interacts with manual or ventilator inflations while being resuscitated or ventilated. They needed to find words to describe clearly the detailed interaction of a baby with the ventilator or resuscitation. They then realised the serious problems with the terminology used for ventilation and resuscitation. If they wrote about breaths, it was not clear to the reader whether this referred to the baby breathing or inflations by the ventilator or resuscitator.

Also, if they described the inspiratory time, they were concerned that readers might not know if this was the ventilator or baby as the words breath, inspiration and inspiratory were being frequently misused and could easily be misinterpreted.

They wrote that respiratory support is difficult to understand, even for experienced practitioners, and that ambiguous or inaccurate terminology exacerbates this problem and hinders accurate communication. The interaction between the patient and ventilator can be particularly difficult to describe, but in an era of minimal sedation and synchronised ventilation, with patient’s breaths and ventilator inflations closely linked, it was essential to be able to describe accurately what they are both doing and how they are interacting.

They conceded that clinicians may argue that this imprecise use of language does not matter because this terminology has been used for years and everyone knows what it means but that they believed that precise use of language relating to ventilation is essential for the sake of clear and precise communication. Therefore, it is crucial that all those engaged in clinical care, teaching or research use a standardised terminology.

They asked readers to consider the difficulty of a new doctor or nurse trying to understand all these terms, especially when English is not their first language; it is hard enough for anyone to understand all the concepts of ventilation and resuscitation, but it can be very confusing when the words do not mean what they say.

They then clearly stated their primary assertion: ventilators do not breathe, and so they do not deliver breaths, they deliver inflations.  Only living people and animals breathe.

The 19223 project team had been tentatively trialling the use of several questionable existing compound terms to denote this concept but immediately recognised that the use of the term “inflation” in the paper had demonstrated that “inflation” served very well as a self-explanatory designator of the concept and should be adopted as the standardized term.

Drs Morley and Keszler finish their article by reminding readers that it is well known that communication errors and misunderstandings are a major cause of medical error and that the time has come to take a big breath and change from the old, inaccurate, and confusing terminology to words and phrases that are clear and mean what they say. They appreciated that people hate change but stated that it is not a reason to continue the embarrassing misuse of important clinical and scientific terminology.

It was a great encouragement for the ISO project team to read their own concerns and objectives expressed so explicitly from an entirely independent perspective, in this paper.  Inevitably, it was not practical to adopt all the authors’ proposed solutions due to conflicts with the additional requirements that the project team had to cover in the broader scope of their standard.  However, every effort was made to address the authors’ underlying concerns on these exceptions while formulating the much clearer definitions and explanations for previously ambiguous terms, now specified in ISO 19223.

Reference: (1) Arch Dis Child Fetal Neonatal Ed 2012;0:F1–F3.