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      Nurses and ventilators

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      Author(s): 1 , 2 ,
      Publication date (Electronic):
      Journal: Critical Care
      Publisher: BioMed Central

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          Abstract

          In the previous issue of Critical Care, Rose and colleagues report the results of a survey on the frequency with which ICU nurses are involved in decision-making in ventilator management. About 63 to 88% of the decisions were made by nurses in collaboration with physicians, and as much as 68% of ventilator adjustments were performed by nurses independent of physicians. Nurse involvement in decision-making was twice as likely in ICUs that use weaning protocols. The ICU nurse performs many roles, the most important being the continuous observation of a patient. The diversion of a nurse's attention from constant vigilance by performing tasks of no benefit, such as the use of weaning protocols, would be a most unfortunate turn of events.

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          Predictors of successful extubation in neurosurgical patients.

          L. Douglas Case, E Ely, Jeffrey F. Kelly … (2001)
          A respiratory therapist-driven weaning protocol incorporating daily screens, spontaneous breathing trials (SBT), and prompts to caregivers has been associated with superior outcomes in mechanically ventilated medical patients. To determine the effectiveness of this approach in neurosurgical (NSY) patients, we conducted a randomized controlled trial involving 100 patients over a 14-mo period. All had daily screens of weaning parameters. If these were passed, a 2-h SBT was performed in the Intervention group. Study physicians communicated positive SBT results, and the decision to extubate was made by the primary NSY team. Patients in the Intervention (n = 49) and Control (n = 51) groups had similar demographic characteristics, illness severity, and neurologic injuries. Among all patients, 87 (45 in the Control and 42 in the Intervention group) passed at least one daily screen. Forty (82%) patients in the Intervention group passed SBT, but a median of 2 d passed before attempted extubation, primarily because of concerns about the patient's sensorium (84%). Of 167 successful SBT, 126 (75%) did not lead to attempted extubation on the same day. The median time of mechanical ventilation was 6 d in both study groups, and there were no differences in outcomes. Overall complications included death (36%), reintubation (16%), and pneumonia (9%). Tracheostomies were created in 29% of patients. Multivariate analysis showed that Glasgow Coma Scale (GCS) score (p or = 8 at extubation was associated with success in 75% of cases, versus 33% for a GCS score < 8 (p < 0.0001). Implementation of a weaning protocol based on traditional respiratory physiologic parameters had practical limitations in NSY patients, owing to concerns about neurologic impairment. Whether protocols combining respiratory parameters with neurologic measures lead to superior outcomes in this population requires further investigation.
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            Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea.

            Kai P. Leung, M. Tobin, A Jubran (1997)
            In 11 ventilator-dependent patients, we undertook a head-to-head comparison of patient-ventilator interaction during four ventilator modes: assist-control ventilation (ACV), intermittent mandatory ventilation (IMV), pressure support (PS), and a combination of IMV and PS. Progressive increases in IMV rate and PS level each decreased inspiratory pressure-time product (PTP) (p < 0.0001). These reductions in PTP were greater with PS than with IMV at lower but proportional levels of maximal assistance (p < 0.005). When PS 10 cm H2O was added to a given level of IMV, greater reductions in PTP were achieved not only during intervening (PS) breaths (p < 0.001), but also during mandatory (volume-assisted) breaths (p < 0.0005); this additional unloading during mandatory breaths was proportional to the decrease in respiratory drive (dP/dt) during intervening breaths (r = 0.67, p < 0.0001). Maximal unloading occurred with ACV, achieving more than a fivefold decrease in PTP compared with unassisted breathing. Decreases in PTP were confined to the post-trigger phase, and PTP of the post-trigger phase correlated with dP/dt (r = 0.78, p < 0.0001). Effort during the trigger phase remained constant despite marked changes in drive and intrinsic positive end-expiratory pressure (PEEPi). Ineffective triggering occurred with all modes, and wasted PTP increased with increasing levels of assistance as a result of the accompanying decrease in drive and increase in volume. Breaths preceding nontriggering efforts had shorter respiratory cycle times (p < 0.0005) and expiratory times (p < 0.0001) and higher PEEPi (p < 0.0001), indicating that neural-mechanical asynchrony resulted from inspiratory activity commencing prematurely before elastic recoil pressure had fallen to a level that could be overcome by a patient's muscular effort. Thus, increases in the level of ventilator assistance produced progressive decreases in inspiratory muscle effort and dyspnea,which were accompanied by increases in the rate of ineffective triggering.
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              A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation.

              Cynthia Rand, Jerry Krishnan, Henry E Fessler … (2004)
              Weaning protocols can improve outcomes, but their efficacy may vary with patient and staff characteristics. In this prospective, controlled trial, we compared protocol-based weaning to usual, physician-directed weaning in a closed medical intensive care unit (ICU) with high physician staffing levels and structured, system-based rounds. Adult patients requiring mechanical ventilation for more than 24 hours were assigned to usual care (UC) or protocol weaning based on their hospital identification number. Patients assigned to UC (n=145) were managed at their physicians' discretion. Patients assigned to protocol (n=154) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention. There were no significant baseline differences in patient characteristics between groups. The proportion of patients (protocol vs. UC) who successfully discontinued mechanical ventilation (74.7% vs. 75.2%, p=0.92), duration of mechanical ventilation (median [interquartile range]: 60.4 hours [28.6-167.0 hours] vs. 68.0 hours [27.1-169.3 hours], p=0.61), ICU (25.3% vs. 28.3%) and hospital mortality (36.4% vs. 33.1%), ICU length of stay (115 vs. 146 hours), and rates of reinstituting mechanical ventilation (10.3% vs. 9.0%) was similar. We conclude that protocol-directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care
                Journal ID (iso-abbrev): Crit Care
                Title: Critical Care
                Publisher: BioMed Central
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2012
                Publication date (Electronic): 27 February 2012
                Volume: 16
                Issue: 1
                Page: 115
                Affiliations
                [1 ]Division of Pulmonary and Critical Care Medicine, Edward Hines Jr Veterans Affairs Hospital, 111N, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA
                [2 ]Loyola University Medical Center, Division of Pulmonary and Critical Care Medicine, 2160 South 1st Avenue, Maywood, IL 60153, USA
                Article
                Publisher ID: cc11186
                DOI: 10.1186/cc11186
                PMC ID: 3396265
                PubMed ID: 22369739
                SO-VID: cff643a9-6184-4220-afb4-75a045a5d485
                Copyright © Copyright ©2012 BioMed Central Ltd
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                Subject: Commentary

                ScienceOpen disciplines: Emergency medicine & Trauma
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                ScienceOpen disciplines: Emergency medicine & Trauma

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