Helmet CPAP bundle: A narrative review of practical aspects and nursing interventions to improve patient's comfort.

BACKGROUND: The application of Continuous Positive Airway Pressure (CPAP) with a helmet is increasing around the world, both inside and outside of the intensive care unit. Current published literature focus's on indications, contraindications and efficiency of Helmet CPAP in differing clinical scenarios. Few reports, summarising the available knowledge concerning technical characteristics and nursing interventions to improve patient's comfort, are available. AIM: To identify the crucial technical aspects in managing patients undergoing Helmet-CPAP, and what nursing interventions may increase comfort. METHODS: A narrative literature review of primary research published 2002 onwards. The search strategy comprised an electronic search of three bibliographic databases (Pubmed, Embase, CINAHL). RESULTS: Twenty-three studies met the inclusion criteria and were included in the review. Research primarily originated from Italy. Nine key themes emerged from the review: gas flow management, noise reduction, impact of gas flow and HME filters on delivered FiO2, filtration of exhaled gas / environmental protection, PEEP monitoring, airway pressure monitoring, active humidification of gas flow, helmet fixation and tips to implement awake prone position during Helmet-CPAP. CONCLUSIONS: A Helmet-CPAP check-list has been made of nine key interventions based on the available evidence regarding system set up, monitoring and management. Implementation of this check-list may help nurses and physicians to increase the comfort of patients treated with Helmet CPAP and enhance their compliance with long-term treatment.

[Continuous bedside pressure mapping in a general intensive care unit: a prospective observational study]. / Monitoraggio continuo delle pressioni di contattoin una terapia intensiva generale:uno studio prospettico osservazionale.

. Continuous bedside pressure mapping in a general intensive care unit: a prospective observational study. INTRODUCTION: A continuous bedside pressure mapping device (PMD) can provide real-time feedback of ideal body position to allow off-loading of high-pressure areas to prevent pressure ulcers development. OBJECTIVE: To describe the implementation of a PMD to measure tissue interface pressure (PIT) in Intensive Care (ICU) patients. METHODS: Prospective observational study in ICU critically ill mechanically ventilated adults, in an Italian University Hospital. Subjects were enrolled in the first 24 hours after ICU admission. A pressure mapping system (M.A.P. System TM) was used and 3 measurements of PIT with patient in supine position, every 6 hours after admission, were performed. The following anti-decubitus surfaces were used: Duo2® - Hill-Rom, Proficare®, Nimbus 3® or Therakair Visio® - Arjohuntleigh, Getinge Group. RESULTS: 27 patients (8 females) were enrolled; average Body Mass Index 27±6 (range: 16-43); 4 patients (14%) were diabetic. The average pressure of the 1215 areas analyzed was 26.7±19.6 mmHg (range: 3-78); the region with the highest contact pressure was the dorsal region (average: 48.7±12.5 mmHg), followed by the occipital (44.7±19.6 mmHg), and sacrum (44.7±10.7 mmHg). The three anti-decubitus surfaces showed different performances in the distribution of PITs, with statistically significant differences for the following factors: body weight (p = 0.017), patient height (p = 0.034), with increased pressures in taller patients, and higher BMI (p <0.0001). CONCLUSIONS: Mean values of PIT were above critical levels, especially in the dorsal, occipital and sacrum region.

How different helmet fixing options could affect patients' pain experience during helmet-continuous positive airway pressure.

BACKGROUND: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. AIMS AND OBJECTIVES: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: 'armpits strap' versus 'counterweights system'. DESIGN: This was a non-randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. RESULTS: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0-10 scale was: 0·5 ± 1·4 at T0 (baseline), 1·5 ± 2·0 at T1 (after 1 h) and 2·6 ± 2·5 at T2 (end of cycle) (p = 0·023). The same analysis was performed for the counterweights fixing option. The mean score was 0·3 ± 0·6 at T0 , 0·3 ± 0·2 at T1 and 0·5 ± 0·7 at T2 (p = 0·069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3·0 ± 1·0 and 3·9 ± 2·3 h, respectively (p < 0·001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0·23 ± 0·20 cm2 . After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0·27 ± 0·21(p = 0·099) and 0·30 ± 0·25, respectively (p = 0·080). CONCLUSIONS: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. RELEVANCE TO PRACTICE: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience.

[Enteral nutrition during prone positioning in mechanically ventilated patients]. / Nutrizione enterale continua durante la postura prona in pazienti in ventilazione invasiva.

. Enteral nutrition during prone positioning in mechanically ventilated patients. INTRODUCTION: The Enteral Nutrition (EN) tends to be stopped during prone positioning to prevent the risk of acid reflux and vomiting. AIMS: To compare the gastric residual volume during continuous enteral nutrition in patients in prone and supine position. METHODS: Observational restrospective study on Acute Respiratory Distress Syndrome patients, mechanically ventilated, with continuous enteral nutrition implemented according to the same protocol, in prone and supine position. RESULTS: The 25 patients included had a mean age of 51.13±15.93 (range: 16-80) years. Gastic residual volume was checked on 656 occasions (408 in supine and 248 in prone position). Mean infusion rate was 63.3±18.5 ml/h: 62.1±18.9 ml/h in supine and 66.2±16.5 ml/h in prone position. The mean overall gastric residual volume was 24.4±54.2 ml: 20.6±18.9 ml in supime and 23.6±50.0 ml in prone posizion. In 4 occasions (2 in prone and 2 in supine position9, the gastric residual volume was > 300ml; EN was interrupted on 1 occasion with a gastric residual volume >500ml. CONCLUSIONS: No clinically relevant differences of gastric residual volume were observed in prone and supine position. A protocol for the management of gastric residual volume allows a safe and effective administration of EN also in patients positioned for several hours in prone position.

[Level of sedation level and modifications of vital signs during hygienic care in patients admitted to an intensive care unit]. / Livello di sedazione e alterazioni dei parametri vitali durante le cure igieniche nei pazienti ricoverati in una terapia intensiva polivalente.

INTRODUCTION: Hygienic care practices may represent a source of stress for intensive care patients. AIM: To identify the hygienic care practices more involved in changes of vital signs and the association to the level of sedation. METHODS: Prospective observational study of eleven patients admitted to a general intensive care unit, observed for three consecutive hygiene care morning practices. A protocol for standardizing hygiene practices was adopted. Vital signs were recorded on an electronic database at the beginning of each of the following phase: before the start of hygiene, of mouth cleaning, of sponge bath, positioning of bedpan, first and second side rotation, change of position of endotracheal tube and replacement of tapes, and at the end of hygiene. RESULTS: 29 events of hygiene practices were observed in the 11 patients included in the study (the measurements of three events were discarded). Significant vital signs alterations were induced mainly by the rotation and change of position of the orotracheal tube. Significant correlations were observed between changes in Heart Rate and Bispectral Index (BIS) (coefficient of 0.345; P: 0.329), between BIS and systolic arterial blood pressure (0.774, P: 0.009), BIS and Tidal Volume (-0.569, P: 0.086), and BIS and Respiratory Rate (0.707, P: 0.022). CONCLUSIONS: The hygienic care in intensive care patients may negatively impact on vital signs. Some nursing manoeuvres cause variations of the vital signs also related to changes in the state of consciousness caused by possible defects or excesses of sedation. The sedation level, during hygienic care, should be constantly monitored.