Prone Team: A Large-Scale Prone Position Initiative During COVID-19 Pandemic.

AIM: To identify strategies to improve time to prone in ICUs during the coronavirus disease 2019 (COVID-19) pandemic for patients meeting the criteria for prone position ventilation. BACKGROUND: Healthcare systems worldwide experienced an influx of COVID-19 patients, especially in critical care. COVID-19 patients are at risk of acute respiratory distress syndrome (ARDS). Prone position ventilation is the standard of care for mechanically ventilated patients with moderate to severe ARDS. Prone maneuvers in and of itself are time-consuming and labor-intensive, posing additional risks to patients. APPROACH: Our academic medical center developed a travel proning team to address the rapid increase in COVID-19 patients with ARDS necessitating prone positioning. EVALUATION: Over a period of 30 days, 420 ICU patients were intubated, 131 had moderate to severe ARDS and underwent prone positioning. Patients were placed in prone position or returned to supine position more than 834 times over 38 days. At the highest point, 37 procedures were done in 24 hours. CONCLUSION: This quality initiative demonstrated that utilization of a traveling proning team provides efficiency in time to prone. Developing a travel prone team allowed for efficiency in time to prone, supported the ICU clinical teams, and enhanced interdisciplinary collaboration, which is essential during times of crisis.

Nasal cannula or high-flow oxygen for patients with COPD in acute respiratory distress?

ABSTRACT: There may be some confusion regarding the use of supplemental oxygen in patients with chronic obstructive pulmonary disease (COPD) who are experiencing acute respiratory distress. This article addresses a common nursing misconception regarding the use of high-flow oxygen administration via non-rebreather masks instead of low-flow oxygen administration via nasal cannulas in patients with COPD who are in acute respiratory distress, an issue that was investigated in a simulation education exercise and survey of the nursing staff at the authors' facility.

Acute Respiratory Distress Syndrome Definition, Causes, and Pathophysiology.

First successfully described in 1967, acute respiratory distress syndrome has since garnered much interest and debate. Extensive studies and clinical trials have been carried out in efforts to address the associated high mortality; however, it remains a significant burden on health care. Despite the heterogeneous etiologies that lead to the development of acute respiratory distress syndrome, this rapidly progressing form of respiratory failure, characterized by severe hypoxemia and nonhydrostatic pulmonary edema, has a recognizable pattern of lung injury. In this chapter, we will review the clinical manifestations, definitions, causes, and a brief overview of the pathophysiology of this complex syndrome.

[Prone Position and Nursing Care].

Acute respiratory distress syndrome (ARDS) is a life-threatening disease, as acute inflammation in the lungs typically leads to hypoxia and symptoms of dyspnea. The treatment modalities of ARDS include mechanical ventilation, corticosteroid, extracorporeal membranous oxygenation, inhaled nitrogen oxide, and the prone position. Among these, the prone position is supported by evidence showing significantly reduced mortality in patients that adopt this modality. Lying in the prone position reduces atelectatic lung volumes by recruitment of dependent parts and facilitates normal regulation of alveolar ventilation, giving better-matched ventilation perfusion and, thus, improved oxygenation. Lying in the prone position should be initiated as early as possible and may be implemented when there is limited improvement after 12-24 hours under mechanical ventilation and when the PaO2/FiO2 ratio is less than 150 mmHg. However, the prone position may not be appropriate for patients with increased intracranial pressure, hemodynamic instability, an open abdominal wound, or pregnancy. Prior to setting a patient in the prone position, fixation of tubings should be affirmed, and all tubings should be reexamined after each adjustment in position in order to ensure that they are free of twists and function well. In addition, caution should be given to the skin at pressure points to avoid pressure sores and foam dressings may be applied in advance for protection. This article summarizes the pathophysiology of ARDS, the principle of applying the prone position, and related indications, complications, and nursing care in order to give nurses more confidence in caring for patients using the prone position.

PEEP titration during prone positioning for acute respiratory distress syndrome.

No major trial evaluating prone positioning for acute respiratory distress syndrome (ARDS) has incorporated a high-positive end-expiratory pressure (high-PEEP) strategy despite complementary physiological rationales. We evaluated generalizability of three recent proning trials to patients receiving a high-PEEP strategy. All trials employed a relatively low-PEEP strategy. After protocol ventilator settings were initiated and the patient was positioned per treatment assignment, post-intervention PEEP was not more than 5 cm H2O in 16.7 % and not more than 10 cm H2O in 66.0 % of patients. Post-intervention PEEP would have been nearly twice the set PEEP had a high-PEEP strategy been employed. Use of either proning or high-PEEP likely improves survival in moderate-severe ARDS; the role for both concomitantly remains unknown.

Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score.

RATIONALE: Increasing use of extracorporeal membrane oxygenation (ECMO) for acute respiratory failure may increase resource requirements and hospital costs. Better prediction of survival in these patients may improve resource use, allow risk-adjusted comparison of center-specific outcomes, and help clinicians to target patients most likely to benefit from ECMO. OBJECTIVES: To create a model for predicting hospital survival at initiation of ECMO for respiratory failure. METHODS: Adult patients with severe acute respiratory failure treated by ECMO from 2000 to 2012 were extracted from the Extracorporeal Life Support Organization (ELSO) international registry. Multivariable logistic regression was used to create the Respiratory ECMO Survival Prediction (RESP) score using bootstrapping methodology with internal and external validation. MEASUREMENTS AND MAIN RESULTS: Of the 2,355 patients included in the study, 1,338 patients (57%) were discharged alive from hospital. The RESP score was developed using pre-ECMO variables independently associated with hospital survival on logistic regression, which included age, immunocompromised status, duration of mechanical ventilation before ECMO, diagnosis, central nervous system dysfunction, acute associated nonpulmonary infection, neuromuscular blockade agents or nitric oxide use, bicarbonate infusion, cardiac arrest, PaCO2, and peak inspiratory pressure. The receiver operating characteristics curve analysis of the RESP score was c = 0.74 (95% confidence interval, 0.72-0.76). External validation, performed on 140 patients, exhibited excellent discrimination (c = 0.92; 95% confidence interval, 0.89-0.97). CONCLUSIONS: The RESP score is a relevant and validated tool to predict survival for patients receiving ECMO for respiratory failure.

Vasopressor stewardship: a case report and lesson shared.

A case report, focused on vasopressor use and presented in this article, is likely to resonate with many critical care nurses. In this article the authors describe opportunities to enhance safety with vasopressor therapy. Specifically, the goal of improving communication among physicians, nurses, and pharmacists around desired endpoints for vasopressor therapy, triggers for reassessment of the therapeutic strategy and cause of the patient's shock was identified as an area for improvement. A form piloted within an organization for use during multidisciplinary rounds and key findings is shared. Vasopressors constitute the mainstay of therapy for nearly every hemodynamically unstable patient in critical care. It is hoped that the lessons and information shared help empower critical care nurses to facilitate vasopressor stewardship within their facilities and, ultimately, enhance patient safety.

Acute chest syndrome of sickle cell disease.

As patients with sickle cell anemia (SCA) are living longer, health care practitioners increasingly manage the chronic effects of the disease. Although significant strides in management of children with SCA over the past decade resulted in decreased mortality, less research exists to guide the care of the adult with complications from the disease. This case study reviews the care of a young woman with SCA admitted to the hospital for vaso-occlusive crisis with subsequent acute chest syndrome and acute respiratory distress syndrome. The pathophysiology and management of SCA, vaso-occlusive crisis, and pulmonary and neurologic complications of the disease are discussed.

[If the extracorporeal lung assist comes to its limit: use and management of extracorporeal membrane oxygenation in severe acute respiratory distress syndrome]. / Lungenersatzverfahren - Einsatz und Management extrakorporaler Lungenersatzverfahren.

In patients with the most severe forms of acute respiratory distress syndrome (ARDS) refractory to conventional mechanical ventilation and adjunctive or rescue therapies like kinetic therapy, inhaled vasodilators or extracorporeal CO2-elimination (extracorporeal lung assist), the use of the extracorporeal membrane oxygenation (ECMO) can secure gas exchange. Due to technical improvements and miniaturization, the new ECMO system is safer and simpler. Nowadays the ECMO-systems are heparin-coated, so that there is no need of therapeutic systemic anticoagulation, and thus bleeding complications are less frequent. Recent data suggests, that outcome of patients with severe ARDS treated with ECMO may improve. This review describes the function and the management of ECMO-therapy in ARDS-patients.

Analysis of the Nursing Effect of Respiratory Critical Illness Based on Refined Nursing Management.

In order to improve the nursing effect of respiratory critical illness, this paper combines the refined nursing method to explore the nursing plan of respiratory critical illness. Moreover, this paper uses the variable control method to explore the effects of nursing management, combines the hospital patient samples to conduct a controlled trial analysis, and conducts sample grouping according to the random grouping method. The patients in the control group are managed by traditional nursing management methods, the patients in the test group are managed by refined nursing management methods, and other conditions are basically the same. In addition, the experiment process variable control is carried out according to the mathematical statistics method, and the reasonable statistics and data processing are carried out. Through the comparison method, we can see that the refined management method proposed in this paper has a good effect in the nursing of respiratory critical illness.

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.

Pulmonary complications in pregnancy: considerations for care.

Anatomic and physiologic changes of pregnancy predispose the mother to increased morbidity and mortality whereas increasing risks of a less than optimal outcome for the fetus. The frequency and significance of acute and chronic respiratory conditions in pregnant women have increased in recent years. Clinicians must have an understanding of cardiopulmonary physiology to promptly recognize and treat pregnant women with respiratory conditions ranging from asthma to adult respiratory distress syndrome. Hospitals must establish systems to assure timely assessment, multidisciplinary care, and possibly a plan for transfer to a higher level of care to provide highest quality care to the perinatal patient presenting with a severe respiratory condition to promote optimal outcomes for the woman and the fetus.

A retrospective exploration of patient-ventilator monitoring intensity, therapeutic intervention intensity, and compliance with lung protective guidelines in a cohort of patients with adult respiratory distress syndrome.

BACKGROUND: The current approach to mechanical ventilation for adult respiratory distress syndrome (ARDS) and acute lung injury (ALI) involves maintaining key patient-ventilator parameters within established lung protective targets. Monitoring is part of the processes of nursing care believed to guide therapeutic intervention and facilitate compliance with these targets. Empirical relationships between monitoring, therapeutic intervention, and compliance with these practice guidelines have not been adequately explored. METHODS: A retrospective observational design was used to explore relationships between monitoring intensity, therapeutic intervention intensity, and compliance with a lung protective philosophy of mechanical ventilation in a cohort of patients with ARDS or ALI. Compliance with lung protective targets was measured as the proportion of time oxygen saturation, alveolar distending pressure, and tidal volume were maintained within recommended guidelines as evidenced by medical record documentation. Monitoring intensity and therapeutic intervention intensity were based on the frequency of recorded assessments and interventions in the medical record. RESULTS: Monitoring intensity correlated positively with both severity of illness (r = 0.39) and with therapeutic intervention intensity (r = 0.30), and was inversely related to compliance with lung protective guidelines (CLPG) (r = -0.34). A regression model including monitoring intensity, severity of illness, risk for abdominal hypertension, and CLPG was statistically significant (p = 0.02) but explained little of the variance in compliance with lung protective parameters (R2 = 0.13). DISCUSSION AND CONCLUSIONS: Compliance with recommended lung protective parameters in the absence of standardized monitoring and intervention protocols is suboptimal. Preliminary evidence of positive relationships between monitoring and both severity of illness and therapeutic intervention was established. Control for nursing and physician practice variation is needed to rule out the influence of surveillance and performance bias on collaborative practice outcomes. Explicit standardized protocols that address the frequency of assessments and interventions along with therapeutic targets are recommended for collaborative practice guidelines.

Nursing Management of Prone Positioning in Patients With COVID-19.

BACKGROUND: At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. OBJECTIVE: To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. METHODS: A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. RESULTS: Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. CONCLUSIONS: Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.

Developing clinical competency in crisis event management: an integrated simulation problem-based learning activity.

This study aimed to evaluate the integration of a simulation based learning activity on nursing students' clinical crisis management performance in a problem-based learning (PBL) curriculum. It was hypothesized that the clinical performance of first year nursing students who participated in a simulated learning activity during the PBL session would be superior to those who completed the conventional problem-based session. The students were allocated into either simulation with problem-based discussion (SPBD) or problem-based discussion (PBD) for scenarios on respiratory and cardiac distress. Following completion of each scenario, students from both groups were invited to sit an optional individual test involving a systematic assessment and immediate management of a simulated patient facing a crisis event. A total of thirty students participated in the first post test related to a respiratory scenario and thirty-three participated in the second post test related to a cardiac scenario. Their clinical performances were scored using a checklist. Mean test scores for students completing the SPBD were significantly higher than those who completing the PBD for both the first post test (SPBD 20.08, PBD 18.19) and second post test (SPBD 27.56, PBD 23.07). Incorporation of simulation learning activities into problem-based discussion appeared to be an effective educational strategy for teaching nursing students to assess and manage crisis events.