Nursing perspectives from an Italian ICU.

ABSTRACT: In Europe, the novel coronavirus outbreak started in the northern regions of Italy at the end of February 2020. Initially, resources were insufficient to deal with the abrupt influx of critically ill patients requiring respiratory support. This article recounts the authors' experiences caring for patients with COVID-19 in an Italian ICU during this period in order to help colleagues in the international critical care nursing community successfully manage similar circumstances in the ongoing pandemic.

Differential diagnosis of high peak airway pressures.

BACKGROUND: The sickest patients often require mechanical ventilation. Although mechanical ventilation is often a lifesaving intervention for many, it can also have life-threatening complications. Monitoring a patient on mechanical ventilation requires skill and prompt troubleshooting to ensure its proper function. The high peak airway pressure (HPAP) alarm is one of the most common alarms. It is critically important that clinicians understand the pathophysiology of the lung and the various causes behind the alarm and have a working differential diagnosis for the causes of HPAPs. The differential diagnosis for HPAP is extensive but can be managed quickly and effectively if you follow a systematic approach. OBJECTIVES AND METHODS: In this article, we aim to describe the basics of respiratory mechanics that contribute to HPAP alarms and describe concepts such as airway resistance, lung compliance, peak airway pressures, and plateau pressures. This is followed by a systematic approach to diagnosing the cause of the HPAP alarm. DISCUSSION: The list of probable causes of HPAP is extensive. Many causes may be overlooked when there is not a clear understanding of its meaning and potential danger. Providing this algorithm gives relevance and importance to understanding the HPAP alarm and provides essential information for troubleshooting potentially dangerous situations.

[The critical role of the nurse in successful non-invasive ventilation in acute respiratory failure]. / L'infirmière moteur de la réussite de la ventilation non invasive dans l'insuffisance respiratoire aiguë.

Non-invasive ventilation is a common therapy for acute respiratory failure. Nurses play an important role in the setting up of this treatment, a time-consuming process, as well as its monitoring. It has been shown that the tolerance of non-invasive ventilation significantly influences the success of this treatment.

The utility and futility of non-invasive ventilation in non-designated areas: can critical care outreach nurses influence practice?

OBJECTIVE: To explore the practice of delivering non-invasive ventilation (NIV) in non-designated areas within a large university teaching hospital by critical care outreach nurses. METHODS: Local audit was prospectively conducted over a five-month period of all patients commenced on NIV in non-designated areas. The audit was repeated a year later and again four years later. MAIN OUTCOME MEASURES: Documentation of patient diagnosis and management plan including whether they were suitable for attempted cardiopulmonary resuscitation and endotracheal intubation as per British Thoracic Society guidelines (2002). Patient outcome (to hospital discharge) and arterial blood gas results pre and post commencement of NIV. RESULTS: 115 patients received NIV for the treatment of acute respiratory failure. The mortality rate for the first 2 years data combined (n75) was 57% and attributed to the fact that patients were elderly, acidotic and had diagnoses associated with a poor response to NIV. 86% of patients had a documented resuscitation status and management plan. Resuscitation status (p=0.01) and arterial blood gas improvement within two hours of therapy had a significant effect on patient outcome (p=0.001). Four years later the mortality rate had reduced to 35% possibly due to appropriate patient selection. More patients were deemed suitable for resuscitation, were transferred to designated areas and electively ventilated. CONCLUSION: Inappropriate use of NIV in non-designated areas is associated with a high mortality. Critical care outreach nurses can play a pivotal role in influencing appropriate patient selection for NIV.

Flexible bronchoscopy assisted by noninvasive positive pressure ventilation.

Noninvasive positive pressure ventilation is an alternative to intubation in critically ill patients with respiratory insufficiency or poor gas exchange who may require flexible bronchoscopy for diagnostic or therapeutic purposes. This ventilatory technique might help decrease the risk of bronchoscopy-related complications in patients with refractory hypoxemia, postoperative respiratory distress, severe emphysema, obstructive sleep apnea, and obesity hypoventilation syndrome and allows bronchoscopic assessment of patients with severe dyspnea from expiratory central airway collapse. In this review, the physiological rationale, indications, contraindications, techniques, and monitoring requirements for flexible bronchoscopy assisted by noninvasive positive pressure ventilation are described, with an emphasis on the role of critical care nurses in this procedure.

Acute respiratory distress syndrome--a case study.

This case study explores the management of an unusually complicated case of acute respiratory distress syndrome (ARDS) extending over 52 days of hospitalization. Despite the utilization of conventional medical treatments and optimum respiratory support modalities, the patient's condition worsened and death was imminent without salvage therapy. After cardiovascular surgery consultation and spousal affirmation, extracorporeal membrane oxygenation (ECMO) therapy was initiated for 6 days. The patient recovered and was able to return to regular employment. The collaborative roles of the acute care nurse and intensivist will be discussed in association with clinical evaluation and management.

[Initiation of domiciliary non-invasive ventilation: proposals of the Casavni working party]. / Mise en route d'une ventilation non invasive au domicile: propositions du groupe de travail Casavni.

INTRODUCTION: In France, there are no good practice guidelines or a regulatory framework for the initiation of long term non-invasive ventilation (NIV). METHODS: The ANTADIR federation set up a working party to examine the feasibility of new methods of initiation of NIV and to consider the possibility of initiation in the home. Two problems were considered: (1) logistical and technical requirements, (2) the responsibilities of the professions involved and the regulatory framework. RESULTS: Clinical effectiveness, improvement in quality of life and adherence to treatment are similar whether NIV is initiated in hospital or at home. Domiciliary management is possible only when the patient is clinically stable. It should be undertaken by a competent physician or, on medical prescription, by a physiotherapist. A nurse or trained technician may check the apparatus but should not initiate NIV alone. Installation of domiciliary NIV should be considered under the following conditions: patients with spontaneous ventilation, availability of urgent assistance and appropriate family support. Close surveillance of the quality of ventilation is necessary, whether in hospital or at home. For the initiation of domiciliary NIV each professional involved needs a clear understanding of his/her role. CONCLUSION: Academic societies should propose good practice guidelines for the initiation of NIV. Domiciliary initiation is possible under certain conditions and the results are as good as those obtained in hospital.

Using non-invasive ventilation on acute wards: how to provide an effective service.

Non-invasive ventilation is increasingly used on acute wards to treat patients with acute type 2 hypercapnic respiratory failure. This article highlights the main factors that should be considered in providing an acute NIV service outside of a critical care setting.

Where is end expiration? Measuring PAWP when the patient is on pressure support ventilation.

BACKGROUND: The hemodynamic information obtained from the pulmonary artery catheter provides physiologic rationale for a selected therapy and allows rapid determination of patients' response to the therapy. A wide range of pressure support levels have been used in pressure support ventilation (PSV), and patients' breathing patterns change from a spontaneous breathing pattern with low levels of PSV to a pressure control pattern with high levels of PSV. Different levels of pressure support have different effects on intrathoracic pressure. Changes in intrathoracic pressure may change the respiratory pattern and affect the timing for measuring the pulmonary artery wedge pressure. PURPOSE: The purpose of this study was to identify the pressure support level at which a patient's breathing pattern switches from a pressure control pattern to a spontaneous breathing pattern. SAMPLE: Fourteen patients admitted to the cardiovascular surgery ICU between January 2001 and December 2001 agreed to participate in the study. Four patients' data were not useable. Ten patients' data were analyzed. In this group, nine patients were male and one female. Patients'ages ranged, from 45 to 87-years-old with a mean age of 66.7 years. One patient had a left ventricular aneurysm repair, four patients had aortic valve repair and five patients had aortic coronary bypass performed. METHOD: This study was an exploratory descriptive study. Simultaneous pressure tracings of the pulmonary artery wedge pressure (PAWP) and proximal airway pressure were recorded during the weaning of pressure support at 2 cm H2O intervals from 18 cm H2O to below 10 cm H2O. End expiration was identified by using the proximal airway pressure when measuring the PAWP. Simultaneous pressure tracings of the PAWP and proximal airway pressure were used to analyze changes in respiratory patterns at different pressure levels during weaning of PSV. FINDINGS: One patient's breathing pattern switched into the spontaneous pattern at PSV 16 cm H2O, one at 14 cm H2O, and the rest of the patients at 12 cm H2O. CONCLUSION: Different levels of pressure support have various impacts on the intrathoracic pressure and alter the respiratory pattern. Using the proximal airway pressure, nurses can identify the location of end-expiration and measure the PAWP accurately.

Noninvasive positive pressure ventilation: an ABC approach for advanced nursing in emergency departments and acute care settings.

Noninvasive ventilation has become a widespread tool of treatment and support for patients in acute care settings. The treatment is used for various clinical conditions, particularly chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. The utilization of a simple nursing care checklist allows treatment in a systematic fashion. This article discusses the respiratory features of this topic: criteria for noninvasive ventilation, choice of the interface for acute clinical conditions, ventilators and modes of ventilation in noninvasive ventilation, management of setting parameters, patient/ventilator interactions, and monitoring.

[Impact of sophrology on non-invasive ventilation tolerance in patients with acute respiratory failure]. / Impact de la sophrologie sur la tolérance des séances de ventilation non invasive chez des patients en insuffisance respiratoire aiguë.

OBJECTIVES: Non-invasive ventilation (NIV) in patients with acute respiratory failure (ARF) is subject to a large number of failures due to discomfort of the art, the feeling of difficulty breathing and pain. The purpose of this study was to evaluate the efficiency of sophrology to improve conditions for the realization of NIV in patients with ARF. PATIENTS AND METHODS: In this prospective randomized and controlled study, consecutive patients with ARF were included. From the very first NIV session, they received either sophrology during the first 30 min of NIV (S group), or standard care by the same nurse during 30 min (T group). The hemodynamic and ventilatory data were recorded continuously; pain, respiratory difficulty and discomfort were measured with a numeric scale at the end of the session. RESULTS: Thirty patients were included in the study, 27 have been analysed. Each patient received an average of four sessions NIV during the protocol. There was no significant difference between the two groups in terms of improvement in gas exchange. In contrast, there was a significant difference in terms of reduction of difficulty in breathing (-76%), discomfort (-60%) and decrease the pain (-40%) in the sophrology group (p<0.001). Respiratory rate, heart rate and systolic arterial blood pressure were decrease during NIV. CONCLUSION: Sophrology constitutes aid for the achievement of the meetings of NIV in patients' IRA.

Noninvasive ventilation in emergency care.

The use of noninvasive ventilation (including bilevel positive airway pressure and continuous positive airway pressure modalities) has become increasingly more widespread in emergency care, offering an alternative to traditional ventilation using an endotracheal tube. This article provides an overview of the types and potential uses of noninvasive ventilation, the risks and benefits of its use, and current evidence to support its use in specific patient populations. Guidelines for appropriate selection of patients for noninvasive ventilation therapy are provided. Management considerations, assessment techniques, troubleshooting, and transportation of patients receiving noninvasive ventilation are also discussed. Advanced practice nurses in the emergency department can provide leadership and advocacy for its use in appropriate patients, and this article provides the foundational knowledge to do so.

Lung recruitment--a nurse and/or physician task. A national survey on requirements for education, regulations and guidelines.

International and national guidelines on requirements for performing lung recruitment manoeuvres are lacking. This paper presents a nationwide descriptive survey of the occurrence of and conditions for lung recruitment in adult patients treated with mechanical ventilation in intensive care units (ICUs) in Sweden. All ICUs except neurological, cardiac, paediatric and neonatal ICUs were invited (N=73); of these, 60 ICUs participated in the study (82%). The main outcome measures were prevalence of lung recruitment, whether ICU nurses and/or physicians carried out lung recruitment, requirements for nurses to perform lung recruitment and the existence of local guidelines. Lung recruitment was performed at 92% of the ICUs. Only physicians performed lung recruitment at 27 ICUs (49%), and in 28 units (51%) both physicians and nurses performed this treatment. Lung recruitment was performed more often in units where both physicians and nurses performed lung recruitment than in units where only physicians performed the manoeuvres (46% vs. 12%, p=0.03). Further, local guidelines on lung recruitment manoeuvres were more common in units where both physicians and nurses performed this treatment (71% vs. 41%, p=0.02). The results suggest that recommendations of repeated and prompt lung recruitment manoeuvres are better met if nurses, along with physicians, perform lung recruitment.

Survey of cuff management practices in intensive care units in Australia and New Zealand.

BACKGROUND: Cuff management varies widely in Europe and North America. Little is known about current practice in Australia and New Zealand. OBJECTIVE: To characterize important aspects of cuff management in intensive care units in Australia and New Zealand to compare with international reports. METHODS: A questionnaire was sent to all nurse managers of adult intensive care units in Australia and New Zealand. RESULTS: Survey response was 53% (92/175). After intubation, most units (50/92, 54%) used both minimal occlusive volume technique and cuff pressure measurement; 5 (5.5%) used these methods along with pilot balloon palpation. Twenty units (22%) used cuff pressure measurement exclusively and 16 units (17.5%) used the minimal occlusive volume technique exclusively. Only 1 unit (1%) used the minimal leak technique after intubation. For ongoing management, cuff pressure measurement was the preferred method, used exclusively in 42 units (46%), with the minimal occlusive volume technique used in 40 units (43%; sole method in 6 units [7%]) and palpation in 4 units (4%). In most units (65/92, 71%), cuffs were monitored once per nursing shift. In units using the minimal occlusive volume technique, oropharyngeal suctioning (74%) and semirecumbent positioning (58%) were routinely incorporated; sigh breaths (6%), discontinuation of enteral feeding (10%), and nasogastric tube aspiration (26%) were uncommon. Cuff management protocols (37%) and subglottic suctioning (12%) were used infrequently. CONCLUSIONS: Cuff pressure measurement was the preferred method, used exclusively or in combination with other methods. The minimal occlusive volume technique was used more often after intubation than for ongoing management.

Difficult mask ventilation in 5-year-old due to submental hypertrophic scar: a case report.

Airway evaluation and management are of critical importance to providing safe and effective anesthesia. Burn injuries in and around the airway are of particular concern to anesthesia providers. The following is a case report of a 5-year-old patient who had neck contractures and a large hypertrophic scar on his chin secondary to a burn injury. The patient initially was easy to mask ventilate, but ventilation became difficult when muscle relaxants were given and positive-pressure ventilation was attempted. An alteration of conventional hand placement during mask ventilation enabled the anesthesia provider to maintain a patent airway and the surgical procedure to proceed.