Guideline implementation powered by feedback and education improves manual hyperinflation performance.

AIM: To determine whether a literature-based guideline, powered by educational meetings and individual feedback, improves manual hyperinflation (MH) performance by intensive care unit (ICU) nurses. BACKGROUND: MH is frequently applied in intubated and mechanically ventilated ICU patients. MH is a complex intervention, and large variation in its performance has been found. MATERIALS AND METHODS: First, a literature-based guideline on MH was developed. The intervention consisted of education of this guideline and individual feedback. Before and 3 months after the intervention, ICU nurses performed MH maneuvers in a skills laboratory. Data collected included applied volumes, peak inspiratory flows (PIF) and peak expiratory flows (PEF), and the use of inspiratory holds. RESULTS: Eighty nurses participated. Decrease of PIF was not statistically significant. PEF increased from 52 ± 7 to 83 ± 23 L/min (P < 0·01). PIF to PEF ratio decreased from 1·4 [1·1-1·7] to 0·8 [0·6-1·1] (P < 0·01). Peak inspiratory pressures decreased from 40 ± 14 to 19 ± 6 cm H2 O (P < 0·01). The proportion of nurses applying inspiratory holds increased from 14% to 58%; use of rapid release of the resuscitation bag, considered mandatory, increased from 4% to 61%. CONCLUSION: Implementation of a literature-based guideline on MH, powered by educational meetings and individual feedback, improves MH performance by ICU nurses. RELEVANCE TO CLINICAL PRACTICE: If it is decided to practice MH in the care of the intubated and mechanical ventilated patient, a standardized, uniform performed MH procedure is a prerequisite.

Weaning automation with adaptive support ventilation: a randomized controlled trial in cardiothoracic surgery patients.

BACKGROUND: Adaptive support ventilation (ASV) is a microprocessor-controlled mode of mechanical ventilation that switches automatically from controlled ventilation to assisted ventilation and selects ventilatory settings according to measured lung mechanics. METHODS: In a randomized controlled trial, non-fast-track coronary artery bypass grafting patients' lungs were ventilated with ASV or pressure-controlled/pressure-support ventilation (control) to compare time until tracheal extubation, duration of controlled ventilation versus assisted ventilation, and ventilation characteristics. RESULTS: One hundred twenty-eight consecutive patients were randomized. ASV patients had their tracheas extubated after median 16.4 and interquartile range 12.5-20.8 hr, and control patients after 16.3 (13.7-19.3) hr, respectively (P = 0.97). The percentage of time patients were on assisted ventilation (expressed as the median percentage of total duration of ventilation) was 43% (28%-67%) in the ASV group and 52% (33%-75%) in the control group (P < 0.05). However, the number of switches from controlled to assisted ventilation was higher in the ASV group (43.0 [14.0-74.0]) than in the control group (4.0 [2.0-9.0]) (P < 0.001). In ASV patients, mean tidal volumes were significantly larger during controlled ventilation than in control patients (8.6 +/- 0.8 mL/kg predicted body weight vs 7.1 +/- 1.4 mL/kg predicted body weight; P = 0.05), and no differences in tidal volumes were found during assisted ventilation. CONCLUSION: Weaning automation with ASV is feasible and safe in non-fast-track coronary artery bypass grafting patients. Time until tracheal extubation with ASV equals time until tracheal extubation with standard weaning and allows for frequent (automatic) switches between controlled and assisted ventilation.

Performance of manual hyperinflation: a skills lab study among trained intensive care unit nurses.

BACKGROUND: The aim of manual hyperinflation (MH) is to mobilize airway secretions and prevent sputum plugging in intubated and mechanically ventilated patients. With MH, the nurse applies a larger than normal breath with a slow inspiratory flow and, after an inspiratory pause, a high expiratory flow is created by completely releasing the resuscitation bag. MATERIAL/METHODS: This was a prospective observational study in a skills lab of a university hospital. Intensive care unit nurses performed MH procedures for an imaginary patient in three different compliance settings. Data were collected via direct video recordings and an air-flow analyzer. RESULTS: One hundred nurses participated. Video recordings demonstrated inappropriate performance of MH, reflected by the appearance of inspirations which were too rapid (53% of cases), absence of holds (60%), and absence of complete release of the resuscitation bag (78%). In the majority of cases the applied volumes were too large according to what was advised in the local guideline (80%). Peak inspiratory flow was 70 (range: 55-89) l/min for all compliance settings and peak expiratory flows were low: for over-compliant (46, range: 42-51), normal (51, range: 45-57), and noncompliant lungs (58, range: 52-64 l/min). CONCLUSIONS: Performance of MH by certified ICU nurses is far from appropriate. These results emphasize the necessity for clearer guidelines with explicit directions for this frequently applied procedure, if it is decided to practice it in the daily care of intubated and mechanically ventilated patients.

Medical-grade honey kills antibiotic-resistant bacteria in vitro and eradicates skin colonization.

BACKGROUND: Antibiotic resistance among microbes urgently necessitates the development of novel antimicrobial agents. Since ancient times, honey has been used successfully for treatment of infected wounds, because of its antibacterial activity. However, large variations in the in vitro antibacterial activity of various honeys have been reported and hamper its acceptance in modern medicine. METHODS: We assessed the in vitro bactericidal activity of Revamil (Bfactory), a medical-grade honey produced under controlled conditions, and assessed its efficacy for reduction of forearm skin colonization in healthy volunteers in a within-subject-controlled trial. RESULTS: With Bacillus subtilis as a test strain, we demonstrated that the variation in bactericidal activity of 11 batches of medical-grade honey was <2-fold. Antibiotic-susceptible and -resistant isolates of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecium, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae, and Klebsiella oxytoca were killed within 24 h by 10%-40% (vol/vol) honey. After 2 days of application of honey, the extent of forearm skin colonization in healthy volunteers was reduced 100-fold (P < .001), and the numbers of positive skin cultures were reduced by 76% (P < .001). CONCLUSIONS: Revamil is a promising topical antimicrobial agent for prevention or treatment of infections, including those caused by multidrug-resistant bacteria.

Adaptive support ventilation with percutaneous dilatational tracheotomy: a clinical study.

We determined the need for changes in minute ventilation with adaptive support ventilation after percutaneous dilatational tracheotomy under endoscopic guidance in 34 intensive care unit patients. During the procedure, minute ventilation was not changed; only maximum pressure limits were adjusted, if necessary. After insertion of the tracheotomy, cannula minute ventilation was adjusted only if Paco(2)-values changed >or=0.5 kPa from baseline. In 74% of patients, adaptive support ventilation was unable to maintain minute ventilation during the use of the endoscope, mandating pressure limitation adjustments. In a minority of patients (26%), minute ventilation had to be adjusted to achieve similar Paco(2) values.

Manual hyperinflation of intubated and mechanically ventilated patients in Dutch intensive care units--a survey into current practice and knowledge.

BACKGROUND: In the daily bedside routine of the intensive care, potentially hazardous interventions that lack evidence need critical consideration. Therefore we examined current practice and knowledge of basic principles of manual hyperinflation (MH) in intubated and mechanically ventilated patients among intensive care unit nurses in the Netherlands. METHODS: A written survey method was used, questionnaires were sent to ICU nurses specialised in mechanical ventilation in 115 Dutch hospitals. The questions related to following domains: (1) demographics; (2) use of MH; (3) presumed benefits; (4) essential elements of the MH procedure; (5) equipment and safety. RESULTS: The response rate was 77%. From responding ICUs the majority (96%) stated they performed MH; 27% as a daily routine procedure, 69% performed MH on indication only. MH was mainly performed by ICU nurses. Half of ICUs reported to have a MH guideline available. Improved oxygenation and better removal of sputum were presumed benefits of MH. While slow inspiration and rapid expiration are considered to be essential elements of MH procedures, the majority of respondents stated to use rapid inspiration and slow expiration. CONCLUSIONS: This survey indicates that MH is widely used as an important item of airway management. Importantly, there is no uniformity in the performance of the procedure. Before definitive research can be developed, standards for the MH procedure should be established.