The Effect of a Respiratory Algorithm on Respiratory Transition to Extrauterine Life.

PURPOSE: This evidence-based practice project evaluated the efficacy of a respiratory algorithm administered by specially trained transition nurses on the reduction of preventable NICU admissions for infants experiencing mild respiratory distress during transition. DESIGN: A retrospective chart review compared a cohort of newborn admission rates for seven months before and seven months after initiation of a respiratory algorithm. SAMPLE: Records of infants were included if they were born >35 weeks' gestation, had documented mild respiratory distress after birth, required <48 hours of noninvasive respiratory support, and had a length of stay less than four days. RESULTS: Ninety-six infants (before n = 34, after n = 62) were included. Before implementation of the respiratory algorithm, infants requiring noninvasive respiratory support were admitted to the NICU. Following implementation of the algorithm, NICU admissions for mild respiratory distress significantly decreased (86 percent), despite a concurrent increase in maternal acuity.

Intermediate life support for the adult.

Stuart Barker, Graduate Tutor in Adult Nursing, Northumbria University (stuart.j.barker@northumbria.ac.uk), discusses more advanced skills to complement basic life support, including early recognition of deterioration, different types of airway support for an unconscious patient and automated defibrillation.

Developing an e-learning resource for nurse airway assistants in the emergency department.

The aims of this project were to determine the required competencies for a nurse in the emergency department assisting with a rapid sequence induction of anaesthesia (RSI), and to produce a relevant e-learning resource. A three-round multidisciplinary Delphi process produced the following competencies: ability to describe the steps and sequence of events of an RSI, familiarity with the equipment used during an RSI, ability to recognise and help manage problems occurring during an RSI, ability to prepare for an RSI, ability to apply cricoid pressure, and understanding the modification of an RSI in special circumstances. An interactive e-learning package was produced and made available online. Twelve emergency department nurses took part in an evaluation of the e-learning package. All either agreed or strongly agreed that they had increased their knowledge and found the learning useful, and 11 out of 12 nurses reported being somewhat or very confident in the role of airway assistant following completion of the learning.

Noninvasive Ventilation in Premature Neonates.

BACKGROUND: The use of noninvasive ventilation is a constantly evolving treatment option for respiratory disease in the premature infant. The goals of these noninvasive ventilation techniques are to improve gas exchange in the premature infant's lungs and to minimize the need for intubation and invasive mechanical ventilation. PURPOSE: The goals of this article are to consider various uses of nasal interfaces, discuss skin care and developmental positioning concerns faced by the bedside nurse, and discuss the medical management aimed to reduce morbidity and mortality. This article explores the nursing role, the advances in medical strategies for noninvasive ventilation, and the team approach to noninvasive ventilation use in this population. SEARCH STRATEGY: Search strategy included a literature review on medical databases, such as EBSCOhost, CINAHL, PubMed, and NeoReviews. FINDINGS: Innovative products, nursing research on developmental positioning and skin care, and advanced medical management have led to better and safer outcomes for premature infants requiring noninvasive ventilation. IMPLICATIONS FOR PRACTICE: The medical focus of avoiding long-term mechanical ventilation would not be possible without the technology to provide noninvasive ventilation to these premature infants and the watchful eye of the nurse in terms of careful positioning, preventing skin breakdown and facial scarring, and a proper seal to maximize ventilation accuracy. IMPLICATIONS FOR RESEARCH: This article encourages nursing-based research to quantify some of the knowledge about skin care and positioning as well as research into most appropriate uses for noninvasive ventilation devices.

Airway management in the hospital environment.

In the hospital environment, patients can deteriorate rapidly and for many different reasons. Maintaining a patient's breathing is the main priority in any emergency situation, although achieving airway control can be difficult. All health professionals need to be able to undertake airway management safely. The key is a thorough assessment to ensure first of all whether the airway is patent (open and clear) or not. This article will discuss airway management, both acute and chronic, as well as associated nursing care.

Benefits of standardizing additional airway clearance in the trauma patient population.

The objective of this project was the development of a systematic preventative approach toward the treatment of respiratory complications among the trauma population. The team used and documented existing treatment regimens within specific study groups, to determine an effective structure to combat respiratory complications. The project included retrospective data collected from the Trauma Registry of an American College of Surgeons verified Level 1, adult rural, academic facility. Review data indicated significant inconsistencies in the pulmonary treatment among the trauma population. Pulmonary hygiene orders lacked consistency, and the patient-focused standards of care led to the creation of nonspecific or omitted orders. The results of the analysis revealed that the overall rate of unplanned upgrades to the higher level of care and intubations due to respiratory compromise were significantly impacted by the design of a collaborative pulmonary care regimen defining role delineation, timelines, and education. This project provided support to the credence of the designated pathway.

Airway management in patients with brain injury.

Research has highlighted potential for changes in the technique and implementation of the bag-valve-mask system, a common piece of equipment used during resuscitation attempts to ventilate patients' lungs and deliver oxygen. This article analyses a critical incident involving a patient who experienced traumatic brain injury and required airway management. In reference to a reflective model, the article discusses the technique, implementation, complications and limitations of the bag-valve-mask system, and provides implications for practice.

Prehospital airway management: high tech meets trauma: an air medical perspective.

Trauma is the leading cause of death in the United States for those younger than 35 years and injuries sustained from trauma are a significant source of moderate to severe disability. The inability to establish, secure, or maintain a definitive airway is a major cause of preventable death and secondary injury due to inadequate oxygenation and ventilation. Prehospital airway management is an essential skill of any prehospital care provider. A critical component to providing excellent airway management is the ability of the provider to quickly establish endotracheal intubation without complications such as hypoxia, hyper/hypocapnea, or hypotension. These complications have been shown to cause increased morbidity and mortality, especially in patients suffering from traumatic brain injury. This article presents some of the challenges faced by flight nurses in the air medical environment and how Airlift Northwest has developed a structured, standardized approach to airway management both in training and it the prehospital setting. We will discuss the process improvements that lead to the implementation of video laryngoscopy as our first-line intubation tool. The ultimate goal of any air medical or prehospital emergency medical services program is to manage 100% of airways without complications, which will decrease morbidity and mortality, ultimately improving patient outcomes.

Emergency and intensive care: assessing and managing the airway.

Airway assessment and management skills are vital in an emergency department (ED) as they are the most sensitive indicator of patient deterioration. Problems as common as head injury or alcohol intoxication are associated with an inadequate airway or diminished respiratory function and can cause a patient's condition to decline rapidly. Maintaining a patient's airway and facilitating breathing is the main priority in any emergency situation, although achieving airway control can be difficult. All health professionals need to be able to safely undertake airway management. The key is a thorough assessment to determine whether the airway is patent or not. This paper will discuss the importance and practicalities of airway management and assessment in the emergency and intensive care.

Basic Airway Management for the Professional Nurse.

The registered nurse (RN) on a medical-surgical nursing unit may be the first health care professional to encounter a patient with the signs of impending respiratory failure. Importantly, the RN must recognize the signs of respiratory compromise and possess the competence and confidence to intervene without delay. Signs of respiratory deterioration, physical assessment, and respiratory laboratory studies are reviewed. Modes of oxygen therapy, basic airway management techniques, including bag mask ventilation, and use of oropharyngeal and nasopharyngeal airways are discussed. The assembly of equipment and medications frequently used for intubation are also outlined.

Airway Management for Deep Sedation: Current Practice, Limitations, and Needs as Identified by Clinical Observation and Survey Results.

Using deep sedation, adjunct airway devices such as oral or nasal airways are frequently required to maintain airway patency. Traditional oral airways (TOAs, made of rigid plastic) or nasal airways (made of pliable materials) can be associated with adverse effects, contributing to a trend of anesthesia providers placing nasal airways orally. A clinical observational study and an electronic provider survey were conducted to examine this emerging practice. The observation study objective was to investigate reported postoperative sore throat occurrence associated with use of either a nontraditional airway (nasal airway used orally) or TOA in deep sedation procedures (N = 243). Patients receiving nontraditional airways reported significantly less postoperative sore throat than those receiving TOAs (17% vs 40%, respectively; P < .001). These results prompted a broader exploration into airway practices of anesthesia providers via an electronic survey. Most respondents (n = 293) reported adverse effects, including gagging/coughing on insertion, oral cavity injury, and bleeding with TOAs. More than half (52.8%) reported using nasal airways orally. These results suggest a clinical void in current airway management options for deep sedation. Providers indicated the need for airway devices that provide a patent airway while mitigating adverse effects associated with commonly used airways.

Nursing outcome "airway permeability" in postoperative patients.

OBJECTIVES: to evaluate the evolution of clinical indicators that characterize airway permeability in patients in the postoperative period of thoracoabdominal surgeries and to analyze their relationship with the occurrence of the diagnosis "ineffective airway clearance". METHODS: descriptive, quantitative, longitudinal research with 60 patients who were followed for five consecutive days. Eleven indicators of the nursing outcome "respiratory status: airway permeability" were used. RESULTS: on the first day of evaluation, the most compromised indicators were: respiratory rate, cough, depth of breath and use of accessory muscles. During follow-up, most of the indicators presented a slight deviation from normal variation and, in the last evaluation, there was a predominance of indicators with some degree of impairment. CONCLUSIONS: with the aid of the Nursing Outcomes Classification, it was observed that patients submitted to thoracoabdominal surgeries may present compromised airway permeability even days after surgery.

Anesthesia Implications of Patient Use of Electronic Cigarettes.

Electronic cigarettes are essentially electronic nicotine delivery systems (ENDS). Use of ENDS has increased sharply in the United States in recent years, particularly among youth. We reviewed the literature on ENDS use, based on a PubMed search, with a focus on effects that could influence anesthetic and surgical outcomes. We also included a meta-analysis of articles published between 2016 and 2018 reporting injuries from exploding ENDS. These devices deliver nicotine, which is addictive and a cardiac stimulant. The nicotine in ENDS has been linked to increased risk of heart disease and myocardial infarction. Also, ENDS deliver vapors of solvents, flavorings, and other chemicals that can cause chronic and acute respiratory diseases. Furthermore, ENDS use may pose a cancer risk. However, ENDS are somewhat less dangerous than cigarettes and are used as smoking cessation devices. From the literature review, we identified 15 articles reporting injuries from ENDS fires and explosions to 93 patients. Most of these patients were young (mean age = 31.6 years) and male (91%). The most common injury sites were the thigh (62%) and hand (33%). Because the anesthetist will likely encounter increasing numbers of ENDS users in the future, it is important to identify these patients and to understand the risks of ENDS use.

Managing the airway in acute care patients.

Understanding how to assess, secure, and manage an airway can save a patient's life in an emergent situation. This article briefly describes the basics of airway management in the acute care setting.

Nursing outcome "airway permeability" in postoperative patients / Resultado de enfermería "permeabilidad de las vías aéreas" en pacientes en el posoperatorio / Resultado de enfermagem "permeabilidade das vias aéreas" em pacientes no pós-operatório

ABSTRACT Objectives: to evaluate the evolution of clinical indicators that characterize airway permeability in patients in the postoperative period of thoracoabdominal surgeries and to analyze their relationship with the occurrence of the diagnosis "ineffective airway clearance". Methods: descriptive, quantitative, longitudinal research with 60 patients who were followed for five consecutive days. Eleven indicators of the nursing outcome "respiratory status: airway permeability" were used. Results: on the first day of evaluation, the most compromised indicators were: respiratory rate, cough, depth of breath and use of accessory muscles. During follow-up, most of the indicators presented a slight deviation from normal variation and, in the last evaluation, there was a predominance of indicators with some degree of impairment. Conclusions: with the aid of the Nursing Outcomes Classification, it was observed that patients submitted to thoracoabdominal surgeries may present compromised airway permeability even days after surgery.

RESUMEN Objetivos: valorar la evolución de los indicadores clínicos que caracterizan la permeabilidad de las vías aéreas en pacientes en el posoperatorio de cirugías toracoabdominales y evaluar su relación con la ocurrencia del diagnóstico "desobstrucción ineficaz de las vías aéreas". Métodos: investigación descriptiva, cuantitativa, longitudinal en la cual participaron 60 pacientes que recibieron seguimiento por cinco días. Se utilizaron 11 indicadores del resultado de enfermería "estado respiratorio: permeabilidad de las vías aéreas". Resultados: en el primer día de evaluación, los indicadores más comprometidos fueron: frecuencia respiratoria, tos, profundidad de la respiración y utilización de músculos accesorios. Durante el seguimiento, se verificó que la mayor parte de los indicadores presentó una leve desviación de la variación normal y, en la última evaluación, hubo un predominio de indicadores con algún grado de comprometimiento. Conclusiones: con la ayuda de la Clasificación de los resultados de enfermería, se observó que los pacientes sometidos a cirugías toracoabdominales pueden presentar comprometimiento de la permeabilidad de las vías aéreas incluso después de algunos días de realizar el procedimiento quirúrgico.

RESUMO Objetivos: avaliar a evolução dos indicadores clínicos que caracterizam a permeabilidade das vias aéreas em pacientes no pós-operatório de cirurgias toracoabdominais e analisar sua relação com a ocorrência do diagnóstico "desobstrução ineficaz das vias aéreas". Métodos: pesquisa descritiva, quantitativa, longitudinal realizada com 60 pacientes que foram acompanhados por cinco dias consecutivos. Foram utilizados 11 indicadores do resultado de enfermagem "estado respiratório: permeabilidade das vias aéreas". Resultados: no primeiro dia de avaliação os indicadores mais comprometidos foram: frequência respiratória, tosse, profundidade da respiração e uso de músculos acessórios. Durante o acompanhamento, verificou-se que a maior parte dos indicadores apresentou desvio leve da variação normal e, na última avaliação, houve predomínio de indicadores com algum grau de comprometimento. Conclusões: com auxílio da Classificação dos resultados de enfermagem, observou-se que pacientes submetidos a cirurgias toracoabdominais podem apresentar comprometimento da permeabilidade das vias aéreas mesmo após dias da realização do procedimento cirúrgico.

Comparison of airway management practices between registered nurses and respiratory care practitioners.

BACKGROUND: Airway management, an essential component of care for patients receiving mechanical ventilation, is multifaceted and includes oral hygiene and suctioning, endotracheal suctioning, and care of endotracheal tubes. Registered nurses and respiratory care personnel often share responsibilities for airway management. Knowledge of current practices can help facilitate evidence-based practices to optimize care of patients receiving mechanical ventilation. OBJECTIVES: To describe current practices for airway management of intubated patients and determine if practices differ between registered nurses and respiratory care practitioners. METHODS: A descriptive, comparative design was used. Registered nurses and respiratory care practitioners who provided direct care to intubated patients receiving mechanical ventilation were recruited to complete an online survey of self-reported practices. RESULTS: A total of 85 participants completed the survey. Most were experienced caregivers with a bachelor's degree and certification or registration in their field. Selected practices have improved, including increasing oxygen saturation before endotracheal suctioning, maintaining pressure of endotracheal tube cuffs, and providing oral hygiene and suctioning. The practices of registered nurses and respiratory care practitioners differed in many ways. The nurses assumed responsibility for oral antisepsis, whereas the respiratory care practitioners managed the endotracheal tube. The 2 groups shared responsibility for oral and endotracheal suctioning. Knowledge of current guidelines for endotracheal suctioning was lacking. CONCLUSIONS: Practices in airway management have improved, but opportunities exist to develop shared policies and procedures based on current evidence.