Point-of-Care Ultrasonography to Confirm Endotracheal Tube Placement: A Review for the Emergency Nurse Practitioner.

Ensuring correct placement of the endotracheal tube (ETT) during intubation is an important step to avoid complications. Appropriate placement of the ETT can be challenging and, if done incorrectly, can lead to complications such as hypoxemia, atelectasis, hyperinflation, barotrauma, cardiovascular instability, end organ damage, and even death. Although several procedures exist to help assess ETT confirmation, all have limitations, are not always reliable, and vary in their degree of accuracy. Point-of-care ultrasound (POCUS) has emerged as a useful tool in the emergency department for quick diagnosis and treatment of many emergency conditions (Gonzalez et al., 2020). The purpose of this paper is to describe a systematic approach for the emergency nurse practitioner to use POCUS to assess proper endotracheal placement and the positioning within the trachea based on prior studies that compare this modality to traditional ones.

Boas práticas na aspiração endotraqueal em uma unidade de terapia intensiva: estudo observacional / Buenas prácticas en aspiración endotraqueal en una unidad de cuidados intensivos: estudio observacional / Good practices in endotracheal aspiration in an intensive care unit: observational study

Objetivos: descrever as boas práticas realizadas pela equipe multiprofissional durante a aspiração de vias aéreas inferiores em pacientes adultos, internados na Unidade de Terapia Intensiva. Método: estudo quantitativo, observacional, descritivo e prospectivo, norteado pela ferramenta STROBE, realizado em uma Unidade de Terapia Intensiva adulto, entre maio e agosto de 2022. A amostra foi composta por 25 observações e a coleta de dados através de checklist, incluídos os profissionais de enfermagem, fisioterapia e medicina. Os dados foram processados no Statistical Package for the Social Sciences, sendo calculadas as frequências absolutas e relativas. Resultados: a maioria das aspirações foram realizadas pela equipe de enfermagem, 20 (80%) profissionais não regularam a fração inspirada de oxigênio antes e após o procedimento, 06 (60%) profissionais não clampearam a sonda durante a sua inserção. O uso de máscara (100%), capote (92%) e luva (100%) foram as boas práticas com maior aderência entre os participantes. Conclusão: reforça-se a necessidade de incentivar os treinamentos abordando as boas práticas durante a aspiração endotraqueal.

Objetivos: describir las buenas prácticas realizadas por el equipo multiprofesional durante la aspiración de vías aéreas inferiores en pacientes adultos, ingresados en la Unidad de Cuidados Intensivos. Método: estudio cuantitativo, observacional, descriptivo y prospectivo, guiado por la herramienta STROBE, realizado en una unidad de cuidados intensivos adulta, entre mayo y agosto de 2022. La muestra fue compuesta por 25 observaciones y la recogida de datos a través de checklist, incluidos los profesionales de enfermería, fisioterapia y medicina. Los datos fueron procesados en el Statistical Package for the Social Sciences, siendo calculadas las frecuencias absolutas y relativas. Resultados: la mayoría de las aspiraciones fueron realizadas por el equipo de enfermería, 20 (80%) profesionales no regularon la fracción inspirada de oxígeno antes y después del procedimiento, 06 (60%) profesionales no clampearon la sonda durante su inserción. El uso de máscara (100%), capucha (92%) y guante (100%) fueron las mejores prácticas con mayor adherencia entre los participantes. Conclusión: se refuerza la necesidad de incentivar los entrenamientos abordando las buenas prácticas durante la aspiración endotraqueal.

Objective: to describe the good practices performed by the multiprofessional team during lower airway aspiration in adult patients admitted to the Intensive Care Unit. Method: quantitative, observational, descriptive and prospective study, guided by the STROBE tool, conducted in an adult intensive care unit, between May and August 2022. The sample consisted of 25 observations and data collection through checklist, including nursing, physiotherapy and medicine professionals. The data were processed in the Statistical Package for the Social Sciences, and the absolute and relative frequencies were calculated. Results: most aspirations were performed by the nursing team, 20 (80%) professionals did not regulate the inspired fraction of oxygen before and after the procedure, 06 (60%) professionals did not clamp the tube during its insertion. The use of mask (100%), cloak (92%) and glove (100%) were the best practices with greater adherence among participants. Conclusion: there is the need to encourage training addressing good practices during endotracheal aspiration.

Ministério da Saúde anuncia estratégias de reabastecimento de medicamentos de intubação - 25.08.2020

Demonstração de intubação orotraqueal com fio guia

Atenção, profissional de saúde! Você tem aqui a demonstração de intubação orotraqueal com fio guia. Evite contaminação. Acompanhe a técnica com profissionais fisioterapeutas capacitados. Veja as novidades na área da saúde no site oficial sobre coronavírus no Ceará www.coranavirus.ceara.gov.br!

Montagem de sistema fechado para pré-oxigenação e intubação

Atenção, profissional de saúde! Saiba o passo a passo da montagem de sistema fechado para pré-oxigenação e intubação de paciente com Covid-19. Evite contaminação. Acompanhe a técnica com profissionais fisioterapeutas capacitados. Veja as novidades na área da saúde no site oficial sobre coronavírus no Ceará www.coranavirus.ceara.gov.br!

Intubação orotraqueal com fio guia

Atenção, profissional de saúde! Saiba o passo a passo da intubação orotraqueal com fio guia. Evite contaminação. Acompanhe a técnica com profissionais fisioterapeutas capacitados. Veja as novidades na área da saúde no site oficial sobre coronavírus no Ceará www.coranavirus.ceara.gov.br!

Relationship Between Delirium and Ventilatory Outcomes in the Medical Intensive Care Unit.

BACKGROUND: Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored. OBJECTIVE: To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes. METHODS: This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation). RESULTS: We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05). CONCLUSIONS: Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.

Critical Events Leading to Endotracheal Reintubation in the Postanesthesia Care Unit: A Retrospective Inquiry of Contributory Factors.

The tracheal reintubation of a surgical patient in the postanesthesia care unit (PACU) is a critical event that increases patient morbidity and mortality, cost, and staff demands. We performed a descriptive retrospective cohort study to identify the incidence of reintubation after planned extubation (RAP) in the PACU from 2010 to 2017. The incidence of RAP was 0.00083% (89/107,845) for the entire study period, an incidence range from 0.00014% to 0.00172% (1/7,407 to 26/15,139) with a steady decline from 2011 to 2017. A post hoc application of published prediction tools demonstrated that most RAP cases could be predicted preoperatively when the RAP predictive risk index (described in 2013) was applied to patients over the age of 64 years. Preoperative attention to increased risk of RAP decreases the incidence of RAP. Neuromuscular blockade (NMB) must be monitored, and reversal must be ensured. Attempting to reverse moderate to deep NMB with increased dosing of neostigmine should be avoided, and NMB reversal with sugammadex should be used in these cases and when residual weakness is observed. Hypothermia must be avoided, and a multimodal pain management regimen must be adopted.

Effect of minimally invasive endotracheal tube suctioning on physiological indices in adult intubated patients: An open-labelled randomised controlled trial.

BACKGROUND: Endotracheal tube suctioning (ETS) is one of the most frequent procedures performed by nurses in intensive care units. Nevertheless, some suctioning practices are still being performed that do not provide any benefit for patients. OBJECTIVES: To investigate the effects of minimally invasive ETS (MIETS) versus routine ETS (RETS) on physiological indices in adult intubated patients. METHODS: In this single centre parallel randomised controlled, open label trial, 64 adult intubated patients in the four intensive care units of Alzahra University hospital, Isfahan, Iran, were randomly allocated to a MIETS or a RETS group. Physiological indices including systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, and peripheral oxygen saturation were assessed immediately before, immediately after, and 10 min after ETS in both groups. The chi-square test, independent t-test, and repeated measures analysis of variance were used to analyse the data. RESULTS: Sixty-four patients were randomised and analysed. There were no significant differences in mean heart rate between the both groups across the three time points. However, there was a significant drop in peripheral oxygen saturation across the three time points in the RETS group compared to the MIETS group. Furthermore, there was a significant increase in systolic blood pressure, diastolic blood pressure, and mean arterial pressure across the three time points in the RETS group compared to the MIETS group. CONCLUSION: The results of this study indicate that the use of MIETS has less effect on the alterations of physiological indices and consequently fewer adverse effects than RETS.

Endotracheal suction in intensive care: A point prevalence study of current practice in New Zealand and Australia.

BACKGROUND: Despite the evidence and available guidelines about endotracheal suction (ETS), a discrepancy between published guidelines and clinical practice persists. To date, ETS practice in the adult intensive care unit (ICU) population across New Zealand and Australia has not been described. OBJECTIVE: To describe ICU nurses' ETS practice in New Zealand and Australia including the triggers for performing endotracheal suction. METHODS: A single day, prospective observational, binational, multicentre point prevalence study in New Zealand and Australian ICUs. All adult patients admitted at 10:00 on the study day were included. MAIN OUTCOME MEASURES: In addition to patient demographic data, we assessed triggers for ETS, suction canister pressures, use of preoxygenation, measures of oxygenation, and ETS at extubation. RESULTS: There were 682 patients in the ICUs on the study day, and 230 were included in the study. Three of 230 patients were excluded for missing data. A total of 1891 ETS events were performed on 227 patients during the study day, a mean of eight interventions per patient. The main triggers reported were audible (n = 385, 63%) and visible (n = 239, 39%) secretions. Less frequent triggers included following auscultation (n = 142, 23%), reduced oxygen saturations (n = 140, 22%), and ventilator waveforms (n = 53, 9%). Mean suction canister pressure was -337 mmHg (standard deviation = 189), 67% of patients received preoxygenation (n = 413), and ETS at extubation was performed by 84% of nurses. CONCLUSION: Some practices were inconsistent with international guidelines, in particular concerning patient assessment for ETS and suction canister pressure.

"When no-one's looking," the application of lung recruitment and normal saline instillation with paediatric endotracheal suction: An exploratory study of nursing practice.

BACKGROUND: The complex nature of the Paediatric Intensive Care Unit (PICU) patient requires the bedside nurse to make rapid, complex decisions regarding endotracheal suction (ETS) interventions. It is not understood what influences nurses' decision making in the context of ETS, however, the actions of the clinician have a direct impact on the efficacy of the ETS event and patient outcomes. OBJECTIVES: To explore and describe the use of normal saline instillation and lung recruitment with paediatric ETS in a cohort of Australian nurses, and to identify factors that influence normal saline use with ETS. METHODS: A descriptive, exploratory study. An evidence-based practice model formed the conceptual basis for the study. Semi-structured interviews were conducted with 12 nurses from an Australian tertiary referral paediatric intensive care unit. Audiotaped interviews were transcribed. Inductive thematic analysis was used to code and analyse the interview data and identify themes. FINDINGS: Data analysis revealed three themes: patient's clinical presentation, clinician judgement and unit practice norms. CONCLUSIONS: Variability in nurses ETS practice was marked. In the absence of evidence based clinical guidelines, nurses relied on knowledge derived from clinical experience and the local setting to guide NSI and LR intervention decisions. Participants reported uncertainty regarding ETS best practice and perceived the lack of research evidence as a barrier to making informed clinical decisions at the bedside. Rigorous research evaluating the safety and efficacy of NSI and LR with ETS is urgently required for patient care; however PICU nurses rely on multiple sources of evidence to inform ETS practice decision.

A first contribution to the validation of the Italian version of the Behavioral Pain Scale in sedated, intubated, and mechanically ventilated paediatric patients.

BACKGROUND AND AIM OF THE WORK: Numerous negative outcomes of inadequate pain management among children have been cited in the literature. Inadequate pain management may be particularly detrimental to children and adolescents facing life-threatening injury or illness on a Paediatric Intensive Care Unit (PICU). It is therefore absolutely necessary that professionals utilize effective and efficient tools in order to evaluate a person's sensations of pain in the most objective way possible. The COMFORT-B scale is recognised as the gold standard in such patients. However, the use of this instrument in the clinical PICU setting is disputed. It requires long periods of observation to ensure an adequate utilization. Boerlage et al. noted that nurses are often impatient and do not always observe the patient for the recommended 2 minutes period. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. This observational pain scale requires shorter observation time compared to the COMFORT-B. Moreover, BPS three subscales are included in other observational pain scales for paediatric patients. Therefore, the objective of this study was to assess the applicability of the BPS for use with paediatric patients. METHODS: Firstly, a questionnaire was administered to physicians and nursing staff that work in the units where the study was conducted in order to investigate the actual use of observational pain scales in their units. A second questionnaire was administered to a group of experts regarding the BPS, to assess both face validity and content validity, and to gain opinions on the relative appropriateness of each item. A descriptive, comparative design was used. A convenience sample of non-verbal, sedated and mechanically ventilated critical care paediatric patients was included. 39 observations were collected from 9 patients, all in their first year of age. Patient pain was assessed concurrently with the three observational scales, before, during and after routine procedures that are considered painful and non-painful. RESULTS: The data collected through questionnaires for professionals gave a useful insight into pain assessment in the investigated units: only 46% of respondents stated that they assessed patients' pain levels, with an average of 2.8 times per shift; 60% of respondents declared to be unhappy with the observational scales that they utilise. Regarding the observations, internal consistency was α = .865. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the test. T test and ROC curves demonstrated a good discriminant validity as well. CONCLUSIONS: Although the current study is based on a small sample of participants, these first results encourage us to continue working in the validation of the BPS in paediatric patients.

Unplanned extubations in general intensive care unit: A nine-year retrospective analysis.

BACKGROUND AND AIM: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself.  In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. METHODS: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016. RESULTS: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. CONCLUSIONS: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.

Long-Term Effects of Saline Instilled During Endotracheal Suction in Pediatric Intensive Care: A Randomized Trial.

BACKGROUND: Saline instillation is still used to assist in removal of secretions from endotracheal tubes in some pediatric intensive care units. OBJECTIVE: To compare the effect of using either no saline, quarter-normal (0.225%) saline, or normal (0.9%) saline during endotracheal suctioning of children receiving ventilatory support in a pediatric intensive care unit. METHOD: An unblinded, randomized trial with 3 treatment groups was conducted with 427 children who received ventilatory support for at least 12 hours. Children were randomly assigned to receive no saline, 0.225% saline, or 0.9% saline during routine endotracheal suctioning. RESULTS: The primary outcome was the number of hours of invasive mechanical ventilation; oxygen therapy and length of stay in the unit were secondary outcomes. There were 138 children randomly assigned to the no-saline group, 141 to the 0.225% saline group, and 148 to the 0.9% saline group. In Kaplan-Meier intention-to-treat analysis, the median (interquartile range) number of hours of invasive mechanical ventilation was 32 (20-68), 43 (21-86), and 40 (20-87) in the no-saline, 0.225% saline, and 0.9% saline groups, respectively. Although the no-saline group received fewer hours of invasive ventilation, oxygen therapy, and intensive care than the other groups combined, the differences were not statistically significant. CONCLUSION: Using no saline was at least as effective as using either 0.225% or 0.9% saline in endotracheal suctioning. The optimal policy may be to routinely use no saline with endotracheal suctioning in children but allow the occasional use of 0.9% saline when secretions are thick.

Prevention of ventilator-associated pneumonia in newborns.

OBJECTIVE: The aim of the study is to optimize the prevention of the development of ventilator-associated pneumonia in newborns by developing a method for tracheal rehabilitation and assessment of its effectiveness. PATIENTS AND METHODS: Materials and methods: A prospective cohort randomized clinical study was organized, particularly artificial ventilation of the lungs was conducted on 90 newborns. Patients were divided into two groups. In the main group (n = 50) an intubation tube of author's design was used, which design allowed prophylactic tracheal sanation on the outer wall of the intubation tube, which included vacuum aspiration of the tracheal secretion and irrigation with a solution of antiseptic decamethoxin 0.02% every 3 hours. In the comparative group (n = 40) the classical non-cuff structure of the intubation tube was used; preventive tracheal sanation on the outer wall of the intubation tube was not carried out. RESULTS: Results and conclusions: Preventive tracheal sanation on the outer surface of the intubation tube in newborns units that undergo artificial ventilation of the lungs exhibit high efficiency against the main types of microorganisms that are dangerous from the point of view of the development of ventilator-associated pneumonia. The use of prophylactic tracheal sanitization in newborns - patients of neonatal intensive care units, which undergoes artificial ventilation of the lungs, can significantly lower the frequency of the implementation of ventilator-associated pneumonia.

¿Cómo fijamos el tubo endotraqueal en la unidad de cuidados intensivos pediátricos? / How to secure the endotracheal tube in the pediatric intensive care unit?

Introducción: Las extubaciones no planeadas son eventos adversos frecuentes en áreas críticas de pediatría. La técnica y el material para llevar a cabo la fijación condicionan la aparición de estos eventos adversos. La evidencia científica que evalúe factores es escasa. Objetivos: El objetivo principal de este trabajo fue obtener datos concretos al respecto de las prácticas de los enfermeros en la fijación del tubo endotraqueal (TET) e identificar técnicas. Métodos: Estudio de carácter descriptivo y prospectivo. Se encuestaron 125 enfermeros de las diferentes Unidades de Cuidados Intensivos durante el mes de noviembre de 2016. Resultados: El 88% de los enfermeros basan su método en la utilización de cinta adhesiva. La técnica de fijación de 3 tiras prevalece por encima de las demás (64%). No existen grandes preferencias al respecto del tipo de cinta adhesiva, no obstante, el 22% menciona a la cinta de óxido de zinc. La alternativa de fijación en niños quemados muestra a la venda de tela como una opción (42%). El 27% de los enfermeros consultados coincidió en que no existe una técnica ideal ya que esta va a depender de la circunstancia clínica del niño. Las complicaciones asociadas a la fijación inadecuada son en primer lugar el desplazamiento por introducción (54%) y la extubación (31%). Conclusión: Se evidencia una amplia variedad de criterios al momento de llevar a cabo la técnica de fijación de TET. Finalmente podemos concluir en que los métodos de fijación dependerán exclusivamente de las características clínicas del niño, el criterio del operador y los recursos disponibles en cada institución (AU)

Introduction: Unplanned extubations are frequent adverse events in critical care in pediatrics. The technique of endotracheal tube (ETT) fixation and the materials affect the appearance of these adverse events. Studies that evaluate these factors are scarce. Objectives: The main aim of this study was to collect data on the practices of nurses in the fixation of the ETT and to identify techniques. Methods: A prospective, descriptive study was conducted. A survey was administered to 125 nurses from different Intensive Care Units in November 2016. Results: 88% of the nurses use tape to secure the ETT. The method of fixation with three strips was the most widely used (64%). There was no preference on the type of tape used; however, 22% preferred to use zinc oxide tape. In burned patients an alternative method with a cloth bandage was used (42%). Overall, 27% of the nurses surveyed coincided that an ideal method to secure the ETT is lacking, as this depends on the clinical circumstances of the child. Complications associated with inadequate tube fixation are displacement during fixation (54%) and la extubation (31%). Conclusion: A wide variety of criteria is used in the techniques to secure the ETT. Finally, we may conclude that fixation methods depend exclusively on the clinical characteristics of the child, criteria of the operator, and resources available at the institution (AU)

Knowledge and skills of critical care nurses in assisting with intubation.

Assisting with tracheal intubation is an aspect of clinical practice that requires knowledge and skill if the procedure is to be carried out in a timely and safe manner. Maintaining this knowledge and skill requires good quality education and regular opportunities to practise. These two factors appear to be inconsistent in critical care units. This article details an audit performed on a large tertiary referral centre critical care unit. It was undertaken in two phases: the first was a self-assessment of knowledge and the second was a practical assessment of the audit subjects in a simulated setting. Results indicated that formal training was inconsistent, as was the opportunity to assist with tracheal intubation. These factors may have contributed to the varying levels of skill seen in the practical assessment phase. The authors recommend devising a standardised training programme to address these issues, which could be distributed nationally. High standards need to be instilled early in critical care nurses' careers, with regular updates to maintain knowledge and skills.

Cánulas nasales de alto flujo ¿aportan valor? / High-flow nasal cannulas. Do they give value?

No disponible