Student Nurse Resources, Study Tips, Skills and more…
Author: Claire
Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta.
Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.
Pulmonary Oedema refers to an accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli. This accumulation causes severe hypoxia. Thus, in pulmonary oedema nursing care, the patient’s oxygenation needs are prioritised.
Pulmonary Circulation VS Systemic Circulation
Pulmonary Oedema Pathophysiology
excess vascular water fills the interstitium
interstitial lymphatics situated within the pulmonary system are unable to drain excess water
alveolar spaces flood and become unable to perform gas exchange due to ventilation/perfusion (V/Q) mismatch
RIGHT SIDE Heart Failure = Peripheral Oedema
LEFT SIDE Heart Failure = Pulmonary Oedema
Retrieved from https://www.otsuka.co.jp/en/health-and-illness/heart-failure/symptoms/ on 19th December 2022
Cardiogenic Pulmonary Oedema VS Non-Cardiogenic Pulmonary Oedema
Pulmonary oedema can be Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic (pressure-related), Non-Cardiogenic Pulmonary Oedema (increased permeability), or a combination of both.
Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic Oedema happens due to increased left ventricular filling pressure.
Non-Cardiogenic Pulmonary Oedema happens in the absence of elevated left ventricular pressure.
Pulmonary Oedema Signs & Symptoms + Radiographic Features
Pulmonary Oedema signs and symptoms onset is usually sudden, requiring immediate medical attention, usually due to intense dyspnoea resulting from the sudden V/Q Mismatch (happens when part of the lung receives oxygen without blood flow or blood flow without oxygen – respiratory reserve can help continue/preserve perfusion in V/Q mismatch, but only for a limited time), which leads to the patient becoming anxious and scared. Noisy respirations are also present due to secretions within the larynx and trachea. The patient’s skin becomes moist, cold and clammy – signs of shock.
Cyanosis develops rapidly in the late stage of respiratory failure. The patient develops a cough with copious frothy blood-stained sputum. Crepitations are heard throughout the chest on auscultation. A chest x-ray typically features a bat-like picture of the lungs. Note that a chest x-ray featuring pneumonia is very similar to one featuring pulmonary oedema, thus, in critical care it is important to distinguish between the two.
Full list of signs & symptoms of pulmonary oedema includes:
restlessness
anxiety
breathlessness
sense of suffocation
cyanotic nail beds
greyish skin tone
cold and moist hands
weak and rapid pulse
jugular vein distension
coughing
increasing foamy sputum
confusion and stuporous (as pulmonary oedema progresses)
rapid noisy moist-sounding breathing
significant decrease in oxygen saturation level
assessment includes crackles on auscultation
Retrieved from https://twitter.com/onsquares/status/1346344297214447616 on 18th December 2022
Cardiogenic Pulmonary Oedema Causes
Congestive Heart Failure (CHF) – the heart muscle doesn’t pump enough blood as it should, causing blood to back up, leading to fluid build-up in the lungs
Mitral Stenosis – narrowing of the valve between the two left heart chambers which reduces or blocks the blood flow into the heart’s left ventricle, leading to left-sided heart failure
Cor Pulmonale – a condition that causes the right side of the heart to fail
Myocardial Infarction a.k.a. heart attack – when blood flow to the heart muscle is blocked
Non-Cardiogenic Pulmonary Oedema Causes
Acute Respiratory Distress Syndrome – ARDS occurs when fluid builds up in the alveoli, keeping the lungs from filling with enough air; less oxygen reaches the bloodstream, depriving the organs of much needed oxygen to function adequately
Smoke Inhalation Burns
Pulmonary Oedema Nursing Care
record and monitor vital signs
administer high oxygen concentration to relieve cyanosis
position patient in an upright position or with legs and feet down or ideally dangling over the side of bed to promote better circulation – correct positioning increases the vital capacity of the patient’s lungs
reassure patient to reduce anxiety – do not leave patient alone
morphine can be administered to help further with the reduction of anxiety, as well as dilating peripheral circulation leading to a reduction in left ventricular pressure during diastole; IMPORTANT – morphine can depress the respiratory system, so never leave patient unattended
administer diuretics – monitor for medication effects including patient’s fluid and electrolyte levels; diuretics, especially if loop diuretics are administered, waste potassium and sodium; potassium administration may be required
bronchodilators can be used to relieve bronchospasm and facilitate bronchial toilet a.k.a. toilet bronchoscopy – a potentially therapeutic intervention to aspirate retained secretions within the endotracheal tube and airways and revert atelectasis; aspiration of airway secretions is the most common indication to perform a therapeutic bronchoscopy in the intensive care unit (ICU)
patients with pulmonary oedema are at times electively ventilated so that through PEEP,t further water leakage into the alveoli may be prevented
identify and treat primary cause eg. need for mitral valve prosthesis, opening blocked arteries etc.
NOTE: PAWP refers to Pulmonary Artery Wedge Pressure which is the pressure within the pulmonary arterial system that occurs when catheter tip ‘wedges’ in the tapering branch of one of the pulmonary arteries.
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A cross sectional study is observational in nature. It involves collection of information about a population at a particular point in time.
A descriptive cross sectional study would assess distribution and frequency eg. measuring the prevalence of cancer amongst a defined population
An analytical cross sectional study would examine the association between variables to identify determining factors related to health eg. examining the association between living a sedentary lifestyle and having hypertension
Hierarchy of evidence
Retrieved from https://www.sketchbubble.com/en/presentation-hierarchy-of-evidence.html on 18th February 2023
Advantages
affordable – a cross sectional study requires no follow-ups since only one set of data is analysed, making this a low-cost research method
efficient – a cross sectional study is ideal for studying exposures or conditions that are reasonably common, and which require only one-time assessment
no risks – this type of study requires no long-term considerations.
potential completeness – due to easily accessed key data points
Disadvantages
collecting data at one point in time leads to limited causation testing especially where exposure and/or outcome are expected to change over time
needs to be an adequate representation of the population being studied
requires a larger sample size for accuracy basis
bias may affect results if for example incomplete responders are related to a specific group
may result in an association, however such association may not be the reason for the association
unable to measure incidence
Critically Appraising a Cross Sectional Study
When critically appraising a cross sectional study you need to focus on the following:
Sampling
Non-response
Methods used for measuring variables of interest
Controlling for confounders in the analysis
Sampling
note sampling bias – population needs to be clearly identified since final results will be inferred onto the target population
consider choice of sampling frame – how was the sample selected from the actual population? Remember that when it comes to measuring prevalence, the actual population is of utmost importance. Thus, consider sampling procedure used eg. random vs convenience sampling, using inclusion or exclusion criteria etc
consider the procedure used for the selection of participants – was inclusion/exclusion criteria used? And was the sample taken at random or was it convenience sampling?
consider sampling size – ideally, previous studies performed within the same area should be sought so that the occurrence frequency within the sample reflects the occurrence within the target population
consider expected precision of results – rare occurrence and precise results require a bigger sample
Non-Response
respondents may differ from non-respondents – respondents are more likely to be interested in the subject being studied, which may lead to more adherence to suggestions/requirements. Thus, replacing non-respondents to increase the sample size may still not bypass the sampling bias resulting from no response
researchers are required to report the response rate as well as to compare the characteristics of both the respondents and non-respondents
Controlling Confounders
A confounding factor is a third variable in a study which examines a possible cause-and-effect connection. It is related to both the supposed cause and supposed effect of the study. At times it is difficult to separate the true effect of the independent variable from the effect of the confounding variable.
Whilst performing a research study, it is important that potential confounding variables are identified and a plan is drawn so that their impact is reduced.
von Kries, R., Koletzko, B., Sauerwald, T., von Mutius, E., Barnert, D., Grunert, V., & von Voss, H. (1999). Breast feeding and obesity: cross sectional study. BMJ (Clinical research ed.), 319(7203), 147–150. https://doi.org/10.1136/bmj.319.7203.147
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Ventilated patient nursing care requires a lot of observation, preparation and monitoring. This is not just specific to monitor readings…the patient needs to be evaluated as a whole in conjunction to the readings being provided.
Safety Checks
When working in a critical care setting, at the beginning of each shift:
check that the manual ventilation bag is connected to oxygen supply
check that the suctioning equipment is in good working order
check for availability of equipment and drugs required for re-intubation and resuscitation
check that the ventilator settings are the same as documented and mentioned in handover
Retrieved from https://slideplayer.com/slide/2746191/ on 12th December 2022
Airway Management of the Ventilated Patient
Ventilated patient nursing care includes:
care of the endotracheal tube or tracheostomy
humidification
suctioning
cuff pressure management
patient communication
patient swallowing ability
weaning from mechanical ventilation
Ventilated Patient Monitoring
Ventilated patient monitoring is crucial, especially since deterioration can happen fast. Monitoring requirements include monitoring the patient’s:
haemodynamic stability
pulse oxymetry
capnography
level of consciousness
pain and agitation
Sedation and Analgesia
A ventilated patient can benefit from sedation and/or analgesia since these:
provide the patient with comfort and tube tolerance
reduce oxygen consumption by promoting patient-ventilator synchronisation whilst reducing dyspnoea and anxiety
reduce the risk of complications such as self-extubation and laryngeal damage
reduce the need of muscle relaxants
NOTE: Muscle relaxants may still be necessary in patients with head injuries and/or with excessive airway pressure; when administering muscle relaxants ensure that the patient is fully sedated.
sedation disadvantages
vasodilation – patient may need IV fluids and inotropes eg. norepinephrine, epinephrine, and vasopressin
sedative accumulation – sedatives with long half-life are not ideal for patients with hepatic or renal failure
over-sedation – prolongs ventilation period and lengthens the patient’s stay in the critical care setting
NOTE: sedation breaks may lead to shorter duration of mechanical ventilation and shorter stay in the critical care setting.
NOTE: sedation scores such as the Ramsay Sedation Scale, the Richmond Agitation-Sedation Scale (RASS), and the Nursing Instrument for the Communication of Sedation (NICS) can help prevent over-sedation.
Ramsay Sedation Scale – Retrieved from https://www.researchgate.net/figure/Ramsay-Sedation-Scale_tbl1_228361277 on 12th December 2022
Retrieved from https://www.researchgate.net/figure/Richmond-Agitation-Sedation-Scale-RASS_fig1_51078510 on 12th December 2022
Retrieved from https://ebrary.net/40984/health/sedation_assessment_with_subjective_methods on 12th December 2022
Analgosedation
Retrieved from https://healthmanagement.org/c/icu/issuearticle/sedation-and-analgesia on 12th December 2022
Patient Comfort Guidance
E-CASH – early comfort with the use of analgesia, minimum sedation and maximum care.
ABCDEF BUNDLE:
A = ASSESS, prevent, and manage pain
B = BOTH Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
C = CHOICE of analgesia and sedation
D = DELIRIUM – assess, prevent and manage
E = EARLY mobility and exercise
F = FAMILY engagement and empowerment
Ventilated Patient Personal Care
Mouth Care
clean patient’s teeth using a small soft toothbrush and toothpaste twice daily
use antiseptic liquid or gel between brushing for oral cleansing and moisturising; this helps prevent plaque formation whilst reducing oral colonisation of Gram-negative bacteria and resulting respiratory infections
provide frequent oropharyngeal suctioning for the hypersalivating patient due to endotracheal tube use; this reduces the risk of central line contamination and risk of micro-aspiration
Eye Care
provide artificial eye lubricant (methyl cellulose) – a patient on sedation loses the blink reflex, making the eyes exposed to corneal drying, infection, abrasion and dust
apply eye pads and/or tape if required
assess regularly for infection and conjunctival oedema
Nutritional Care
While the patient is Nil-By-Mouth, a nasogastric tube is usually used so that abdominal distension is prevented, since it hinders ventilation.
ensure that the patient is started on enteral nutrition early since this promotes gut integrity whilst reducing GI complications; it also helps provide the patient with caloric and protein required for mechanical ventilation, prevents muscle atrophy, as well as helps during the weaning process
prop the patient up in a semi-raised position to prevent aspiration; aspirate the patient’s stomach regularly to assess absorption
assess for need of a PEG or TPN
stress ulcer prophylaxis may be prescribed
Elimination & Related Care
document patient intake and output on proper charting sheets to ensure patient fluid and electrolyte balance; document any abnormal stools
constipation may result from use of drugs, diet changes and immobility, which may cause abdominal distension; to avoid problems with diaphragmatic and ventilatory capacity consider using glycerin suppositories and enemas
diarrhoea may result from antibiotic resistance and enteral feed intolerance; take stool specimens for culture and sensitivity testing and Cl. difficile, apply barrier cream to prevent moisture lesion formation, and ensure fluid and electrolyte balance are maintained
Psychosocial Care
assist patient to use alternate means of communication since this is a common trigger for patient frustration
provide constant orientation and reassurance
provide health literacy to the patient’s family in simple terms free from medical jargon
involve relatives in patient care – encourage touch and patient reassurance, communication and orientation, and lip care
Patient positioning
ensure that no lines, wires and catheters are left under the patient
provide regular position changes for pressure relief and movement of secretions; this also helps provide a conscious patient with a different perspective of surroundings
splints, passive and active ROM (range of motion) exercises
ensure patient is seen by physiotherapist and that chest physio in the form of percussion, vibration, and postural drainage is provided (unless contraindicated as with neurological patients)
whenever possible help the patient into prone position since this optimises alveolar recruitment by expanding the dorsal aspect of the lungs, and improves oxygenation and survival in ARDS (acute respiratory distress syndrome) patients
NOTE: with prone positioning, caution needs to be exerted: ensure an adequate amount of personnel are available to reposition patient, ensure that the patient’s airway is protected at all times, ensure that the ETT, IV lines and tubes are all secure, ensure adequate pressure area care, and provision of mouth and eye care as well as suctioning as required.
Retrieved from https://turnmedical.com/helpful-links/ on 12th December 2022
Retrieved from https://www.grepmed.com/images/2314/pronepositioning-criticalcare-cornishpasty-instructions-management on 12th December 2022
The HOTSPUD Ventilator Care Bundle
Head of bed elevated 30-45 degrees
Oral care performed frequently
Turn patient from side to back to side every 2 hours
Sedation vacation – adjust sedation so as to wake patient up once every 24 hours
Peptic Ulcer prophylaxis to be administered to high risk patients
Deep vein thrombosis prophylaxis in the form of drugs or leg compression
Other Ventilation Strategies
ECMO – Extra-Corporeal membrane oxygenation
blood oxygenation outside of the body
allows lung rest without exposure to high pressure oxygen levels
Permissive Hypercapnia
tolerate higher carbon dioxide levels to provide protection to the lung from barotrauma
High Frequency Ventilation HFV
very high frequency ventilation of 60-2000breaths/min
very low tidal volume of 1-5ml/kg
Preventing Ventilator-Associated Pneumonia (VAP)
avoid intubation unless absolutely necessary
extubate as soon as possible
perform meticulous hand washing and gloving
ensure correct endotracheal tube cuff pressure is maintained
use HME (heat and moisture exchanger filters)
remove any condensation formation from ventilator circuits
avoid unplanned extubation
perform endotracheal and supraglottic suctioning
High Flow Nasal Cannula
High Flow Nasal Cannula is a light cannula with soft pliable prongs, warmed and humidified, with a Flow of up to 60L/min and FiO2 up to 100%. The HFNC:
improves oxygenation
reduces breathing work
provides a continuous flow of fresh gas at high flow rates, replacing the patient’s pharyngeal dead space
washes out the patient’s re-breathes of carbon dioxide and replaces it with oxygen
Retrieved from https://www.researchgate.net/figure/Basic-components-of-a-high-flow-nasal-cannula-HFNC-system_fig1_333448617 on 12th December 2022
Respiratory Support Progression
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Ventilation is the movement of air into and out of the lungs. Ventilation carries oxygen to provide tissue perfusion and removes carbon dioxide which accumulates from aerobic metabolism. Sometimes, especially within the critical care setting self-ventilating becomes difficult or impossible for the patient. This is where mechanical ventilation is introduced – to provide artificial control or support during each breathing cycle through the use of a machine, namely a ventilator.
A ventilator typically has the following colour-coded pipes:
white pipe – oxygen at 100%
white and black pipe – compressed air at 21%
yellow pipe – suction
These pipes have the following features:
uncrushable – cannot be crushed if stepped over etc
pin indexed – one pipe cannot be inserted by mistake into a different socket by mistake
tug test – may tug oxygen hose after the probe is plugged into wall or cylinder socket to ensure it is firmly attached
internal battery
electricity supply
Mechanical Ventilation Indications
Before mechanical ventilation takes place, clinical judgement has to ascertain that such an intervention would be providing improved quality of life whilst lowering the mortality risk of the patient. Thus, mechanical ventilation should be opted for…
when the patient’s own ventilation mechanism is unable to sustain life
when the critically ill patient needs ventilation control
when there is the risk of impending collapse of physiological functions, in which case mechanical ventilation is opted for as a prophylactic measure
(Byrd et al., 2006)
Mechanical Ventilation helps the critically ill patient by:
improving alveolar ventilation and oxygenation
decreasing the required breathing effort and oxygen consumption
reversing hypoxaemia (low level of partial pressure oxygen in the blood)
reversing acute respiratory acidosis (too much carbon dioxide leading to an acidic base)
enabling sedation and muscle relaxation eg. prior to surgery
Specific indications for mechanical ventilation include:
ARDS (Acute Respiratory Distress Syndrome – a life-threatening condition with which the lungs are unable to provide the body’s vital organs with enough oxygen)
COAD acute exacerbation (Chronic Obstructive Airway Disease – a long term lung disease a.k.a. chronic bronchitis or emphysema, or the latest term COPD)
neuromuscular disorder
acute brain injury – mechanical ventilation almost always required since it controls the level of air that is exchange; the more carbon dioxide, the more vasodilation and the more blood pooling in the brain
coma
Mechanical Ventilation aims to prolong life, not prolong death…
Negative Pressure Ventilation
Air moves from one area to the other due to the difference in pressure a.k.a. pressure gradient. Spontaneous breathing happens through the generation of negative pressure. Negative pressure ventilation increases the normal physiological breathing pattern by producing a negative pressure outside the chest wall, which then causes the air to be automatically inhaled when the patient opens the airway.
Retrieved from https://understanding-vertebrates.weebly.com/respiratory-system.html on 9th December 2022
The Iron Lung vs Today’s Negative Pressure Ventilation Equipment
The Iron Lung, which was used extensively for patients up to the mid 1950’s, was a large airtight metal cylinder which enclosed patients fully, exposing only their head and neck. It worked through an electric pump which generated negative pressure, causing the patient’s chest to rise.
The Iron Lung – Retrieved from https://www.rochester.edu/newscenter/brief-history-of-ventilators-424312/ on 9th December 2022
Modern Negative Pressure Ventilation equipment comprises of airtight jackets or flexible canopies a.k.a. cuirass, which cover the chest area only. They are available in oscillatory mode so as to assist with secretion clearing.
Patients who benefit from such equipment include patients receiving home care who suffer from respiratory muscle group weakness, skeletal problems which restrict thoracic function, and patients with central hypoventilation syndrome.
Modern Negative Pressure Ventilation Equipment – Retrieved from https://link.springer.com/article/10.1007/s42600-021-00149-0 on 9th December 2022
Negative Pressure Ventilation Limitations
Within the critical care setting, it is difficult to achieve accurate pressure, volume and gas flow due to abnormal lung compliance and impaired airway control. Additionally, the seal required around the patient’s chest wall may lead to pressure sores. With regards to nursing care, invasive procedures and chest examinations become difficult to perform. And while a Negative Pressure Ventilator provides ventilation, it does not provide oxygenation.
(Ashurst, 1997)
Positive Pressure Ventilation
Through positive pressure ventilation, the normal pressure gradient is reversed as oxygenated air is forced into the patient’s lung by the ventilator, and as airway pressure drops, recoil of the chest causes passive exhalation by pushing out the tidal volume.
Retrieved from https://journals.rcni.com/nursing-standard/an-overview-of-mechanical-ventilation-in-the-intensive-care-unit-aop-ns.2018.e10710 on 10th December 2022
This is achieved through the use of a NIV – non-invasive ventilator. Whilst this type of ventilation does not require sedation and it reduces the risk of nosocomial pneumonia, a NIV requires that the patient is conscious, breathing spontaneously and is compliant. It also requires the use of a tight-fitting face mask, nasal cannula or helmet.
Retrieved from https://www.sciencedirect.com/science/article/pii/S2452247317302765 on 10th December 2022
NON-INVASIVE VENTILATION with CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP):
PEEP – positive pressure is maintained throughout inspiration and expiration
reduces breathing effort requirement
improves oxygenation
improves compliance
NON-INVASIVE VENTILATION with BI-LEVEL POSITIVE AIRWAY PRESSURE (BiPAP):
2 positive pressure settings include IPAP – inspiratory positive airway pressure, and EPAP – expiratory positive airway pressure
increases tidal volume
reduces PaCO2
improves oxygenation
reduces breathing effort requirement
Retrieved from https://www.cpap.com/blog/difference-bipap-cpap/ on 10th December 2022
Mechanical Ventilation Ventilator Variables
CONTROL: ventilator controls the pressure and the volume
TRIGGER: what starts off inspiration, where the flow, pressure or volume are generated by the patient, whist the time is triggered by the ventilator itself if the inspiration is not initiated by the patient (in other words, either the patient triggers inspiration, or the ventilator)
CYCLING: time, flow and volume trigger expiration
Retrieved from https://rc.rcjournal.com/content/56/1/39 on 10th December 2022
Volume Controlled Ventilation
In Volume Controlled Ventilation, a preset gas volume is forced into the lungs, whilst pressure is dependable on lung compliance.
Volume Controlled Ventilation ensures delivery of a constant tidal and minute volume, and is set based on the patient’s ideal body weight, height and sex.
However…
When a patient’s lung compliance decreases, an increased amount of pressure is required. Volume Controlled Ventilation will deliver the preset tidal volume with no regards to a patient’s airway condition change, which may lead to VILI (Ventilator-Induced Lung Injury)
Pressure Controlled Ventilation
In Pressure Controlled Ventilation, the lungs are inflated up to a preset pressure. The tidal volume is variable, depending on both lung compliance and resistance in breath delivery.
Pressure Controlled Ventilation helps prevent excessive airway pressure whilst reducing the risk of VILI (Ventilator-Induced Lung Injury).
However…
It does not guarantee minute volume, and this may lead to the patient experiencing hypoventilation leading to hypoxia.
To prevent this from happening, Volume Guaranteed Pressure Control Ventilation ensures that with each mandatory breath, a set tidal volume (VT) is applied with minimum pressure. Additionally, pressure adapts gradually to resistance and/or compliance changes so the set tidal volume is administered.
Mechanical Ventilation Ventilator Settings
FiO2 – FRACTION OF INSPIRED OXYGEN
FiO2 is the fraction of oxygen in each delivered breath. FiO2 should be set somewhere between 21% (0.21) and 100% (1.0). FiO2 is used to maintain oxygenation along with PEEP.
Oxygen toxicity risk increases when the patient’s dependency and duration on FiO2 are high. Additionally, oxygen metabolites may lead to tracheobronchitis (inflammation of the trachea and bronchi), absorptive atelectasis (loss of lung volume caused by the resorption of air within the alveoli), hypercarbia (increase in carbon dioxide in the bloodstream), lung fibrosis (lung tissue damage and scarring), and diffuse alveolar pulmonary membrane damage (changes which occur to the structure of the lungs).
PEEP – POSITIVE END-EXPIRATORY PRESSURE
Positive pressure is maintained throughout inspiration and expiration, thus, pressure is not allowed to drop to zero at the end of expiration. This prevents the alveoli from collapsing, improves oxygenation without increasing the FiO2, helps prevent oxygen toxicity, whilst increasing the availability of alveolar surface area for gaseous exchange.
However, PEEP should be used with caution in patients with either a head injury and/or poor cardiac output. This is because PEEP increases the intra-thoracic pressure and hence reduces venous return, therefore cardiac output is reduced, and intracranial pressure is increased.
Similarly, patients with COPD and/or asthmatic patients who are not able to completely exhale tidal volume should also receive PEEP with caution.
Mechanical Ventilation Modes
CMV – COntinuous Mandatory Ventilation
CMV delivers a preset number of breaths with a preset tidal volume or pressure. In CMV the patient’s inspiratory efforts make no difference since all settings are preset. Settings involved include TV, Inspiration Pressure, FiO2, PEEP and RR.
All breaths controlled by ventilator, no triggered breaths – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022
a/c – Assist / control Ventilation
In A/C ventilation, the patient can trigger the ventilator to deliver the breath. This type of setting has the ability to sense the natural negative pressure generated by the patient, delivering a breath with a set volume or pressure. However, if the patient does not trigger any breaths, a set number of breaths is still delivered.
Every patient-triggered breath is fully supported, a backup rate is set; in the absence of patient-triggered breaths, AC acts like CMV – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022
In SIMV, a preset number of ventilator breaths per minute are delivered. Spontaneous breaths may be initiated by the patient at any point between ventilator breaths.
To augment the tidal volume of spontaneous breaths, pressure support is often used. Settings involved include a set rate, tidal volume, FiO2, with optional pressure support and PEEP.
NOTE: monitor total breathing rate, minute volume, and airway pressure.
Preset minimum mandatory breaths are synchronised to the patient’s efforts, with the patient able to breathe spontaneously between supported breaths – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022
PS/ spn-cpap: Pressure support ventilation
SPN refers to spontaneous mode of ventilation in which respirations are started and ended by the patient. SPN requires no preset rate and TV since both are determined by the patient, thus, need to be monitored well.
SPN may be combined with pressure support, where spontaneous breaths are aided by an extra push from the ventilator. Thus, if apnoea is detected, the ventilator starts providing backup mandatory ventilation.
With Pressure Support, all breaths are triggered by the patient, each of which is supported by preset pressure – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022
CPAP promotes spontaneous breathing at an elevated baseline pressure – Retrieved from https://ddxof.com/tag/ards/ on 11th December 2022
BiPAP – Bi-Phasic Positive Airway Pressure
In BiPAP, the ventilator alternates between IPAP (Inspiratory Pressure) and PEEP. BiPAP provides mandatory breaths synchronised with the patient’s breathing attempts for both inspiration and expiration. With this setting in place, the patient can breathe spontaneously at any time, supported by pressure support. This helps reduce the need for patient sedation whilst improving oxygenation.
Complications of Mechanical Ventilation
Carbery, 2008. Retrieved from https://journals.sagepub.com/doi/10.1177/175045890801800303 on 11th December 2022
Weaning Patient from Mechanical Ventilation
A patient on mechanical ventilation can be weaned off of the ventilator if he/she:
is conscious and cooperative
has an FiO2 of <50%
has adequate minute ventilation
is able to cough
has minimal or clear secretions
has no evidence of septic shock
has an adequate fluid status
has no significant acid-base or electrolyte imbalance
has minimal vasopressor requirement
is showing evidence of resolution of the primary reason which required mechanical ventilation
If the patient meets the criteria mentioned above, ventilatory support is decreased (mandatory breaths, FiO2 and Pressure Support), and replaced with spontaneous ventilation. Spontaneous breathing trials can be performed with the use of T-piece humidifier and flow inflated ventilation bags.
Whilst attempting to wean patient off of mechanical ventilation, it is very important to monitor for signs of respiratory distress!
Signs of respiratory distress include:
tachypnoea
tachycardia
hypoventilation
bradycardia
hypertension
hypotension
hypoxaemia – SPO2 <90%
agitation
altered level of consciousness
labored breathing
use of accessory muscles of breathing
References
Ashurst, S. (1997). Nursing care of the mechanically ventilated patients in ITU: Part 1 and 2. British Journal of Nursing 6(8, 9): 447-454, 475-485.
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Statistics are quantities or sets of quantities which one can calculate from observed data. Thus, unless they are ratios, statistics should be reported in units. Medical statistics is a subdiscipline of statistics. Medical statistics can assist researchers in answering healthcare-related challenging questions.
“It is the science of summarizing, collecting, presenting and interpreting data in medical practice, and using them to estimate the magnitude of associations and test hypotheses. It has a central role in medical investigations. It not only provides a way of organizing information on a wider and more formal basis than relying on the exchange of anecdotes and personal experience, but also takes into account the intrinsic variation inherent in most biological processes.”
Kirkwood, 2003.
Population VS Sample
In relation to statistics, the term population refers to a well defined group of subjects that a researcher chooses to investigate about a particular issue. The size of such a population may be known or unknown, but when the study population is too big to be investigated fully, sampling becomes needed.
A sample is a feasible number of subjects chosen to represent a population, thus, the sample involved in the study needs to be as representative as possible to the target population. This can be achieved by:
selecting an adequate sampling population
using randomly selected participants rather than convenience sampling
Simple Random Sampling
Simple random sampling is a sampling method in which all members of a population have an equal chance of being chosen to participate in the study sample.
Retrieved from https://www.shsu.edu/~mgt_ves/mgt481/lesson9/sld014.htm on 20th November 2022
Stratified Random Sampling
In stratified random sampling, the population is stratified into defining blocks eg. gender and age.
Retrieved from https://analyticssteps.com/blogs/stratified-random-sampling-everything-you-need-know on 20th November 2022
Weighted Sampling
In weighted random sampling the subjects are weighted and the probability of each item to be selected is determined by its relative weight. This allows the sample to be more representative of the population.
Retrieved from https://www.geopoll.com/blog/weighting-survey-data-raking-cell-weighting/ on 20th November 2022
Cluster Sampling
In cluster sampling, random groups of individuals are recruited for the study sample.
Retrieved from https://www.simplypsychology.org/cluster-sampling.html on 20th November 2022
Convenience Sampling a.k.a. Opportunity Sampling
In this type of sampling, no consideration is taken with regards to representation. Thus, all members of a population that a researcher can access have the opportunity to be recruited.
Retrieved from https://sites.google.com/site/glossary2019/c/convenience-sampling on 20th November 2022
Snowball Sampling
When recruiting members into a sample population becomes difficult, researchers revert to snowball sampling, where recruits are asked to suggest friends who may be willing to participate in the study.
Retrieved from https://www.simplypsychology.org/snowball-sampling.html on 20th November 2022
Sampling Used in Qualitative Studies
Sampling used in qualitative studies is usually either purposeful sampling or theoretical sampling:
PURPOSEFUL SAMPLING – the researcher seeks individuals who can provide the required data
THEORETICAL SAMPLING – the researcher uses a sampling method which, although similar to purposeful sampling, also includes changing and/or adapting the participants’ selection throughout the study based on results obtained from previous participants
NOTE: sample size does not matter in qualitative studies, since the aim is to acquire in-depth understanding of a phenomena.
Data Collection Variables in Medical Statistics
Variables are characteristics, numbers, or quantities which can be measured or counted. Some examples of variables include age, sex, blood pressure results, oxygen saturation levels etc.
Data collection in qualitative studies typically takes place during in-depth interviews such as one-to-one interviews or focus group interviews, and in some cases, non-structured observation may also be involved.
Categorical variables give qualitative information about the subject being investigated. Thus, possible responses in this variable are not numerical in nature, but instead are different categories related to the subject.
Categorical variables can also be divided into two:
Nominal Variable– a variable with a number of categories eg. occupation
Binary Variable – a variable with only two possible responses eg. yes or no
Continuous variables give quantitative information about the subject in question. Thus, continuous variable responses can be any quantities within a set interval of values. Some examples would be age and BMI.
Data collection in quantitative studies may include:
readily available data such as data related to hospital activity, registers, prevalence and determinants
self-administered questionnaires which may include numerical scales
structured interviews through phone, electronic media, or face to face interviews, all of which allow an element of explanation and feedback between the researcher and the participant
structured observation which typically happen during observation schedules within a particular setting
Ordinal Variables a.k.a. Discrete Variables
Ordinal variables give limited quantitative information because responses achieved are numerically related to each other, yet have to be one within a limited number of values.
Retrieved from https://prinsli.com/categorical-variables/ on 20th November 2022
Data Analysis
Descriptive Statistics
Descriptive statistics feature a summary of data in a clear, concise and easy-to-understand way, usually through a numerical approach.
Inferential Statistics
Inferential statistics are statistics which, after being calculated from a sample, inferences are made on the original population using the same statistics.
Retrieved from https://www.z-table.com/z-score-table-blog/the-differences-between-descriptive-and-inferential-statistics on 20th November 2022
Reference
Kirkwood, Betty R. (2003). essential medical statistics. Blackwell Science, Inc., 350 Main Street, Malden, Massachusetts 02148–5020, USA: Blackwell. ISBN978-0-86542-871-3.
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When searching through literature searching strategies for the purpose of writing your dissertation, you need to seek a good strategy which is both comprehensive and systematic. A systematic collection of observations from research subjects (such as demographic characteristics, physical characteristics, biological markers, behaviours, or feelings, emotions or views) aiming to create information about these subjects is otherwise referred to as research. This can be performed in the following order:
Reflect on potential research areas or questions which are of interest to you
Carry out simple searches, both on Google and in textbooks so as to obtain general knowledge on the subject of your interest
Attempt to develop your research question; you may find the need to refine your question at a later stage or even restart your search from scratch to change your chosen subject
Seek assistance by experts in the field of your interest and discuss related information sources
Carry out advanced electronic research
As part of the selection process, search manually through resulting key studies so as to confirm their relevance to your PICO question
At this stage you should now have a clear idea of which relevant studies you can use for your own review
Seek once again your chosen expert in the same field of study to confirm whether your refined idea is appropriate and relevant to the local scenario and clarify any related questions
Study Approaches and Designs
Every research study aims to answer a research question, which in itself determines the best approach and design to be used.
CHOOSING THE BEST DESIGN:
EXPERIMENTAL DESIGN – Randomised Control Trial (RCT)
OBSERVATIONAL DESIGN – Cross Sectional, Cohort, and Case Control Study
CHOOSING THE BEST APPROACH:
QUANTITATIVE APPROACH – emphasises on objective quantifiable measurements of attributes, aiming to generalise to a wider population; this approach involves theory testing and numerical data collection which can be analysed using statistical techniques
QUALITATIVE APPROACH – emphasises on subjective measures which may be varied or may change over time; this approach, which usually relies heavily on data interpretation, involves theory development, commonly including data in words and narratives such as perceptions and experiences aiming to understand or explain a typical behaviour.
NOTE: in qualitative research, rigor influences the validity of the produced results, which in turn determines how useful the evidence produced is, in terms of evidence based practice.
Literature Searching Strategies
Carrying out an Electronic Search
To carry out an electronic search you should search for articles within electronic databases which provide access to various electronic journals eg. International Journal of Nursing Studies and Journal of Nursing Education. Such journals include a number of publications a.k.a. articles.
The efficacy of an electronic search depends on how well your research question has been designed, how extensive was your search in relation to words and phrases used, the use of search tools such as Truncations and Boolean Operators, the use of good databases, and your review of literature search strategies until you are happy with your end results.
Choosing Search words and/or Phrases
A well designed research question should feature PICO elements…
Retrieved from https://libguides.cdu.edu.au/c.php?g=167917&p=3738712 on 19th November 2022
Search terms used can be in the form of single words or phrases. Phrases should be put in inverted commas. Always keep in mind that search engines provide you ONLY with articles containing the words you use in your searches.
Finding synonyms for each of the PICO components may be facilitated by:
brainstorming
thesaurus
MeSH browser
taking ideas from previously written related articles
using all word options including words containing hyphenations, alternative spelling and abbreviations
Additional Search Tools
Boolean Logic Operators
Use of Boolean Logic Operators AND, Or, and NOT:
AND combines words/phrases together so that both appear within one article found by a search.
Example: a search for ‘needles AND fear’ will find only those articles that contain both the words needles and fear.
OR enables a selection of any one of a number of specified words in a list.
Example: behavioural OR behavioral
NOT excludes specific words so articles containing them will not be identified.
Example: ‘fear of needles NOT fear of hospitals’
Truncation
Truncation helps search all the variations of a word without writing them.
Example: Child* picks up child, children, childhood etc
Wildcard
Wildcard helps you identify alternative spellings of the same word easily.
Example 1: An?emia would pick up anaemia and anemia
Example 2: H?emoglobin would pick up haemoglobin and hemoglobin
Phrase Searching
Phrase searching through the use of inverted commas helps you pick up articles containing your chosen phrase only.
Example: “pressure sores” picks up the phrase as written and not where both words are used separately
Searching within a Database
When conducting an electronic search, you can use databases that facilitate your work. Universities tend to subscribe to a substantial number of databases which include a wide variety of articles across different fields of study. For students following a course at the University of Malta there are a good number of databases that students can use for their literature searching strategies.
After finding a database to search in:
use limiters – eg. ticking peer reviewed articles increases the likelihood of finding articles which are of good quality
choose date/s – ideally limit your search to the last 3 years; if no interesting articles come up, widen your search to the last 5 years or more if need be
do not use ‘Full text’ as a limiter
do not use unnecessary limiters
combine keywords in your searches using Boolean Operators
use other search tools as mentioned further above to help define your searches
stop searching only when you have exhausted all possible literature searching strategies for relevant content
NOTE: Keep a record of ALL searches you apply, including implemented changes, as well as the results obtained with each of your searches!
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In a critical care setting, the main aim is always oxygen perfusion; perfusion = survival = healing. Acid Base Balance a.k.a. pH balance, is the level of acids and bases in the blood at which the human body functions at its best. A pH between 7.35 and 7.45 is considered to be an optimum pH level since it promotes good oxygen perfusion throughout the body.
A cell without oxygen can compensate with the help of anaerobic respiration. This however produces lactate a.k.a. lactic acid. Thus, anaerobic respiration can only provide compensation for a short period of time.
Physiological pH values in the human body: retrieved from https://www.researchgate.net/deref/https%3A%2F%2Fdoi.org%2F10.1080%2F17425255.2021.1951223 on 18th November 2022
In normal circumstances, the body aims to maintain a healthy balance between the acid and alkaline within. This process is mostly active thanks to the lungs and the kidneys, both of which play an important role in maintaining the body’s pH balance. This means however, that for individuals with compromised kidneys or lungs, compensating pH imbalance becomes even more difficult.
An acid is a substance which is chemically able to donate a hydrogen ion to another substance. Acids, which have a pH <7, are formed by free H+ ions and carry a positive electrical charge a.k.a. cations.
A base a.k.a. buffer is any substance which is chemically able to accept a hydrogen ion. Most bases are insoluble, however, ones that dissolve in water are also called alkali. Alkalis are formed by OH– ions a.k.a. Hydroxyl ions. They have a pH of >7 and carry a negative electrical charge a.k.a. anions.
pH is the measure of H+ (hydrogen ion) concentration in water.
pH is controlled by the following active organs:
LUNGS: excrete carbon dioxide in the form of carbonic acid (H2CO3), and dissociates into H2O + CO2 for excretion.
KIDNEYS: control bicarbonate excretion; the kidneys can form ammonia which combines with acid products of protein metabolism for excretion.
PLASMA PROTEINS: able to bind both to free H+ and OH– ions, preventing changes in the pH (fine-tuning pH levels that are still within their normal range i.e. between 7.35-7.45).
Bicarbonate and pH Balance
Normal Blood Gases Values
Arterial
Venous
pH
7.35-7.45
7.33-7.43
PO2 (Partial Pressure of Oxygen)
80-100mmHg / 11-15KPa
35-49mmHg / 4.5-6KPa
PCO2 (Partial Pressure of Carbon Dioxide)
35-45mmHg / 4.5-6.1KPa
41-51mmHg / 5-6.5KPa
SO2 (Oxygen Saturation)
95-100%
65-80%
HCO3 (Bicarbonate)
22-26mmol/l
24-28mmol/l
Base Excess
-2 to 2
0 to 4
NOTE: In the UK, PaCO2 and PaO2 are normally measured in kPa (kilopascal) whereas in Malta they are usually measured in mmHg (millimetres of mercury). 1kPa = 7.5mmHg.
pH – acidity or alkalinity measurement based on the hydrogen ions present
PaO2– partial pressure of oxygen which is dissolved in arterial blood
SO2– arterial oxygen saturation
PCO2– the amount of carbon dioxide dissolved in arterial blood
HCO3– the amount of bicarbonate in the blood
Base Excess – the amount of excess or insufficient level of bicarbonate in the system
Retrieved from http://medcraveonline.com/JACCOA/JACCOA-05-00199.pdf on 26th May 2021
Retrieved from https://www.slideshare.net/kerolus/basic-abg-notes on 26th May 2021
Retrieved from https://cardiopulmnaz.weebly.com/arterial-blood-gases-abgs.html on 26th May 2021
Restoring Acid-Base Balance Through Compensation
The human body naturally attempts to keep the pH within normal range by restoring acid-base balance through the opposite unaffected system. For example, if the respiratory system is affected, the metabolic system attempts to compensate so as to restore normal pH.
Respiratory Compensation happens 2-4 HOURS following an established metabolic process.
Metabolic Compensation happens 2-4 DAYS following an established metabolic process.
ABGs Interpretation Algorithm
Retrieved from https://www.yournursingtutor.com/wp-content/uploads/2018/08/ABG-Decision-Tree-Freebie.pdf on 18th November 2022
Acid Base Balance Disorders
CO2 builds up and reacts with the water in the blood, forming carbonic acid – Retrieved from https://healthjade.net/respiratory-acidosis/ on 26th May 2021
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Tracheostomy is a procedure in which an artificial opening a.k.a. stoma is created at the level of the second or third cartilaginous ring from where the tracheo-bronchial tree is accessed and a tracheostomy tube is inserted. Proper tracheostomy nursing care in the critical care setting ensures patient safety.
Retrieved from https://entokey.com/laryngeal-anatomy/ (left) and https://www.pinterest.com/pin/83387030589729256/ (right) on 1st November 2022
Tracheostomy indications
airway obstruction in relation to problems with tongue, pharynx, larynx, trachea and oesophagus
anaphylaxis
foreign body
facial trauma
facial or respiratory burns
prior to extensive head and neck surgery
vocal cord paralysis
sleep apnoea
instable cervical spine
inflammation
tumor
congenital anomalies (structural or functional anomalies which occur in-utero)
NOTE: Tracheostomy is preferred as a prolonged airway maintenance and ventilation method. It is also used in cases of failed and/or repeated intubation, following intubation complications, and where there is need for deep secretion removal.
Tracheostomy Advantages
less restricting for the patient
enables swallowing
enables better communication
less sedation requirement
allows better mouth hygiene
helps avoid upper airway complications related to ETT use
easier secretion removal
reduces anatomical dead space (shorter, wider and less curved tube = better breathing = quicker weaning from ventilator use)
Tracheostomy Preparation & Surgical Procedure
explain tracheostomy procedure to the patient and accompanying relatives
gain operation consent
ensure availability of needed drugs (sedatives/analgesics/muscle relaxants), blood in reserve, suction equipment, cautery machine (helps in cutting and stopping bleeding immediately and effectively), and procedure trolley
help patient in supine position with blanket roll between shoulder blades to ensure neck is adequately exposed.
an incision is made between the sternal notch and cricoid cartilage
a midline vertical incision is made to divide strap muscles
thyroid isthmus between ligatures is divided
cricoid is elevated along with the cricoid hook
an incision is made through the tracheal wall
a tracheostomy tube is inserted while the endotracheal tube is withdrawn
cuff is inflated
keyhole dressing is applied
tube is secured either with tape around the neck or with stay sutures
tube is connected to the ventilator tubing
Retrieved from https://www.surgeryencyclopedia.com/St-Wr/Tracheotomy.html on 1st November 2022
Percutaneous Dilational Tracheostomy
As seen above, a surgical tracheostomy requires a surgical dissection to be made down to the trachea, the creation of a window in the trachea with the insertion of a tracheostomy tube for ventilation…
Compared to surgical technique, the percutaneous dilational tracheostomy (PDT) uses a modified Seldinger technique where the trachea is accessed with a needle and then a guidewire is inserted. The tracheostomy tube is introduced over the guidewire after dilation.
Rashid & Islam, 2017
Thus, a percutaneous dilational tracheostomy avoids surgical incision, is less traumatic, and carries a lower bleeding risk.
a large bore needle is inserted into the tracheal lumen between the 2nd and 3rd ring
a flexible guidewire is then inserted
serial dilations are made
tube is inserted
NOTE: Ideally, a percutaneous dilational tracheostomy are done under ultrasound or bronchoscopy guidance. The procedure is contraindicated in patients with goitre, obesity, and acute upper airway obstruction.
Tracheostomy Complications
During placement of tracheostomy, arising complications may include:
laryngeal nerve injury (may cause hoarseness, difficulty in swallowing or breathing, or loss of voice)
vagal nerve stimulation (may lead to bradycardia, hypotention, or cardiac arrest)
incorrect placement
Post-op complications following a tracheostomy may include:
haemorrhage
aspiration
wound infection
infection in the trachea
infection in the lungs
tube obstruction caused by blood or secretions
tube displacement
subcutaneous emphysema (usually this is solved without any interventions)
Late complications related to tracheostomy use may include:
tracheal stenosis (abnormal narrowing of the trachea which restricts the patient’s ability to breathe)
tracheo-oesophageal fistula (abnormal connection between the trachea and oesophagus which causes swallowed liquids or food to be aspirated into the lungs)
tracheoinnominate artery erosion by cuff or tip of tube (may require resuscitative and operative measures)
stoma does not close following removal of tube
overgranulation and scarring
Types of Tracheostomy Tubes
Retrieved from https://www.exportersindia.com/product-detail/white-fenestrated-tracheostomy-tube-6433292.htm (left) and https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2019.28.16.1060 (right) on 1st November 2022
Cuffed Tube with Disposable Inner Cannula – Used to obtain a closed circuit for ventilation.
Cuff should be inflated when using with ventilators
Cuff should be inflated just enough to allow minimal airleak
Cuff should be deflated if patient uses a speaking valve
Cuff pressure should be checked twice a day
Inner cannula is disposable
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Cuffed Tube with Reusable Inner Cannula – Used to obtain a closed circuit for ventilation.
Cuff should be inflated when using with ventilators
Cuff should be inflated just enough to allow minimal airleak
Cuff should be deflated if patient uses a speaking valve
Cuff pressure should be checked twice a day
Inner cannula is not disposable; you can reuse it after cleaning it thoroughly
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Cuffless Tube with Disposable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.
Save the decannulation plug if the patient is close to getting decannulated
Patient may be able to eat and may be able to talk without a speaking valve
Inner cannula is disposable
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Cuffed Tube with Reusable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.
Save the decannulation plug if the patient is close to getting decannulated
Patient may be able to eat and may be able to speak without a speaking valve
Inner cannula is not disposable; you can reuse it after cleaning it thoroughly
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Fenestrated Cuffed Tracheostomy Tube – Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak.
There is a high risk for granuloma formation at the site of the fenestration (hole)
There is a higher risk for aspirating secretions
It may be difficult to ventilate the patient adequately
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Fenestrated Cuffless Tracheostomy Tube – Used for patients who have difficulty using a speaking valve.
There is a high risk for granuloma formation at the site of the fenestration (hole)
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Metal Tracheostomy Tube – Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.
Patients cannot get a MRI
One needs to notify the security personnel at the airport prior to metal detection screening
Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
CUFFED VS NON-CUFFED VS FENESTRATED
Retrieved from https://www.mountsinai.org/files/MSHealth/Assets/HS/Care/ENT/General/TracheostomyEducationPatientsCaregivers2019.pdf on 1st November 2022
SINGLE VS DOUBLE TUBE
Double lumen tubes contain an inner cannula which can be removed for cleaning.
Retrieved from https://www.jcvaonline.com/article/S1053-0770(15)00077-4/fulltext on 2nd November 2022
TRACHEOSTOMY VS LARYNGECTOMY
Retrieved from http://sinaiem.org/foam/dont-fear-the-tracheostomy/ on 2nd November 2022
SHILEY TUBE
Upper Airway Bypass Effects
In normal upper airway functions there is humidification, warming and filtration of inspired air, ability to taste, smell and swallow, speech production by the passing of exhaled air through the larynx, and involvement in the cough reflex.
When bypassing the upper airway, lack of humidification leads to impaired mucociliary function, thicker secretions which can easily cause tube obstruction, as well as atelectasis (partial or full lung collapse) and infection. Similarly, air below body temperature may cause bronchoconstriction, reduced air flow, decreased PO2 (partial pressure of oxygen) and decreased SaO2 (oxygen saturation of arterial blood).
Humidification
Requirements for optimal gas exchange, which are in normal circumstances achieved through the upper airway, include:
a temperature of 37 degrees celsius
100% humidity
filtered air
Adequate humidification may reduce the need for suctioning, thus, in situations where the upper airway is bypassed by an ETT or tracheostomy, an external method providing warmth, humidity and filtration is needed.
Through an external humidification system, inspired gas is passed over heated water with a set temperature of about 60 degrees celsius. As the air passes along the tubing, it cools down to around 37 degrees celsius when reaching the patient.
Although this system provides a setting similar to what is required for optimal gas exchange, it poses a couple of problems: it requires equipment care, it restricts patient mobility, and it may also become an infection source for the patient.
The HME Filter – Heat Moisture Exchanger
HME filters a.k.a. heat moisture exchanger filters are devices used in patients who are mechanically ventilated to help prevent mucus plugging and endotracheal tube occlusion due to lack of humidification.
HMEs are made of hydrophylic material which retains heat and moisture in exhaled air, which are then recycled in subsequent inspirations, following filtration of inspired air.
HMEs improve patient mobility and lower risk of infection. However, they can still become easily blocked by secretions, and so, require frequent filter changes (usually changed within a couple of days based on manufacturer’s recommendations) or even cessation of use in case of profuse secretions.
Retrieved from https://www.atosmedical.ca/support/heat-and-moisture-exchanger-hme/ on 2nd November 2022
Suctioning in Airway Management
Secretions are cleared by coughing under normal conditions. Cough involves pressure build-up in the lungs which depends on closure of the glottis. The use of a tube prevents the patient from increasing enough abdominal pressure to produce a cough that clears secretions in the airway. Additionally, the tube may also cause irritation which leads to increased sputum production.
Suctioning is a procedure that needs to be performed as often as required based on the patient’s individual needs, so as to clear secretions and maintain a patent tube.
suctioning should not be performed routinely but as needed
suctioning should be performed using a sterile technique
suctioning can be scary and unpleasant for the patient, thus, it needs to be performed with confidence and speed
Suctioning Indications
coughing
respiratory distress
increased peak airway pressure
decreased SaO2 (oxygen saturation of arterial blood) and PO2 (partial pressure of oxygen)
audible and/or visible secretions
suspected aspiration
signs of discomfort
Open Suctioning Procedure
explain procedure to the patient
provide the patient with hyperoxygenation at 100% oxygen
whilst keeping the catheter in its wrapper, attach it to suction tubing and switch it on
wear mask and sterile suction glove
insert catheter up to 1cm more than the tube length
apply suction on the way out; oropharyngeal cavity may also need suctioning
hyperoxygenate again
monitor patient
NOTES:
do not exceed 15 seconds in performing suctioning so as to prevent hypoxia
catheter width should not exceed half the tube’s diameter
catheters with multiple eyes produce less damage
negative pressure should not exceed 120mmHg
instillation of saline is not recommended any more, however, saline nebulisation may help in loosening secretions
Suctioning Complications
HYPOXAEMIA – arterial blood oxygen level lower than normal: happens due to the patient being disconnected from the oxygen source whilst suctioning is being performed; reduce risk by performing suctioning for not longer than 15 seconds and ideally using a closed suction system instead of the open suction one.
ATELECTASIS – complete or partial collapse of the entire lung or lobe of the lung: happens when excessive pressure is being used while suctioning; reduce risk by ensuring that pressure does not exceed 120mmHg.
BRONCHOSPASM – tightening of the muscles lining the bronchi a.k.a. airway tightening: happens due to catheter use stimulating the airway.
DYSRHYTHMIAS – abnormal or irregular heartbeat (especially bradycardiafollowing suctioning): happens due to hypoxaemia and vagal stimulation.
HAEMODYNAMIC CHANGES – increased blood pressure and intracranial pressure; reduce risk by avoiding suctioning in patients with head injury.
TRACHEAL MUCOSA TRAUMA – reduce risk by avoiding deep suctioning, large catheters and excessive pressure.
INFECTION – reduce risk by using strict aseptic technique and using a closed suction system. NOTE: send specimens for C+S if infection is suspected.
Closed Tracheal Suctioning Procedure
Using a closed tracheal suctioning procedure allows suctioning of the airways without the need for disconnecting the patient from the ventilator. This is done by attaching the suction catheter in plastic sleeve directly to the ventilator tubing.
Advantages:
maintains oxygenation and PEEP (Positive End Expiratory Pressure) during suction
reduces the risk of complications related to hypoxaemia
provides HCPs with protection from secretions
Disadvantages:
possible auto-contamination (reduce risk by cleaning catheter after each use and change every 24 hours)
inadequate removal of secretions
extra weight on ventilator tubings may cause an unintentional extubation
expensive
Cuff Management
The use of a cuff provides a seal in mechanical ventilation of a patient. This seal provides protection from gross aspiration. However, it does not offer complete protection from aspiration, and it may also disguise aspiration signs. Additionally, cuff exerts pressure on the oesophagus, anchoring the larynx, thus reducing laryngeal elevation. Considering all the above…
The patient with an inflated cuff should be kept nil-by-mouth!Provide needed nutrition through a nasogastric tube, a nasojejunal tube, gastrostomy, or jejunostomy.Important: assist the patient as needed to maintain oral hygiene!
Cuff used should be a high volume low pressure cuff. Cuff pressure should be checked at the start of every shift, after turning the patient, after physiotherapy, after dressing change and if a leak can be heard. Pressure should be kept between 15-25mmHg.
A low cuff pressure causes a drop in tidal volume due to leak of exhaled air around the tube, as well as possible aspiration of gastric content.
A high cuff pressure may create a fistula between the trachea and the oesophagus a.k.a. tracheoesophageal fistula, especially if a stiff nasogastric tube is being used on the patient. It may also cause obstruction of capillary blood flow within the tracheal wall, leading to pressure sore necrosis and tracheal stenosis following formation and healing of scar tissue.
Tracheostomy Communication Through Speaking Valves
In normal circumstances, speech is created by the passing of exhaled air through the vocal cords. Since tracheostomy tubes are inserted below the vocal cords, sound cannot be formed. This may cause the patient to become anxious and feeling isolated.
The nurse should provide reassurance to the patient by explaining that loss of sound being experienced is only temporary, and voice returns once the tracheostomy tube is removed. The nurse should also encourage the patient to use different ways of communication whilst with a tracheostomy tube is inserted, such as using electronic devices, paper and pen, or speaking valves.
Speaking Valve Use
When using a speaking valve, ensure that the patient has a good gag reflex and that he is using either a non-cuffed or a fenestrated tube; if patient is using a cuffed tube, ensure that the cuff is totally deflated before attempting use of speaking valve
Upon inspiration, the valve opens, allowing air to be inhaled through the tracheostomy
Upon exhalation, the valve closes; air passes around the tube and through the vocal cords, enabling exhalation from the upper airway and voice production
NOTE: DO NOT USE A SPEAKING VALVE if the patient has poor lung compliance, in the case of excessive secretions, and if laryngeal or pharyngeal problems are present.
Retrieved from https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2021/08/Tracheostomy-tubes-and-safety-1.0.pdf on 4th November 2022
Tracheostomy Nursing Care – Wound Care & Tape Changes
The surgical wound needs to be kept clean and dry at all times. The wound dressing used needs to be changed daily or whenever it becomes soiled. The aseptic non-touch technique should be used whilst cleaning the wound with saline, including careful cleaning of the area underneath the flange. Note that between the patient’s neck and tape there needs to be a space for one to two fingers.
prepared equipment for an arising emergency
1 spare tube in the same size as the one being used
1 spare tube in a smaller size than the one being used
suction and suction catheters
oxygen
tracheostomy mask
securing tape
tracheal dilators
scissors
suture cutter
lubricating gel
syringe (to inflate cuff)
drugs and equipment for resuscitation
sterile keyhole dressing
non-sterile gloves
Tracheostomy Tube Change
A single lumen tracheostomy tube should be changed every 7-10 days so as to prevent obstruction. Other indications for a tracheostomy tube change include:
cuff failure
blockage within the tube
displacement of the tube
needing to change to a larger or smaller tube
Tracheostomy Weaning and Decannulation
A tracheostomy is no longer needed if:
the reason for a tracheostomy has been resolved
the patient is alert, stable, and self ventilating on air
the patient has no significant signs of airway obstruction
the patient is able to swallow and cough up secretions
the patient is able to maintain good oxygen saturation
In case of the above:
cuff is deflated
tube is occluded for 24 hours
if no respiratory distress is experienced by the patient, tube is removed
the stoma is covered with a small occlusive dressing
monitor patient for signs of infection and/or inflammation
monitor patient for evidence of tissue damage
monitor cuff pressure and ensure it is kept within normal limits
monitor amount, colour and consistency of secretions
Reference
Johns Hopkins Medicine (n/d). Tracheostomy Service. Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022
Rashid, A. O., & Islam, S. (2017). Percutaneous tracheostomy: a comprehensive review. Journal of thoracic disease, 9(Suppl 10), S1128–S1138. https://doi.org/10.21037/jtd.2017.09.33
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WASP International Scientific Paper Writing Course is an intensive three-day event with formal lectures & interactive sessions delivered by highly experienced researchers and journal editors. All aspects of paper writing are covered, from proposals, to presenting to dealing with journal editors. Statistical analysis is demonstrated within Excel® and includes hands on sessions on attendees’ own laptops. Excel modules used for analysis are given to attendees along with soft copies of the presentations.
Research and Publication are Career Critical! WASP International Maximises YOUR Chances of Getting Published!
Since 2010, over 20 WASP Courses have already been held, specifically in Malta, London, Bahrain and online. WASP International Scientific Paper Writing Course is suitable for all individuals in the sciences who wish to enhance their paper writing skills by acquiring sound competences in academic writing. WASP International is not only intended for the medical profession: engineers, architects, pharmacists, nurses etc. have all joined, enjoyed and benefited from WASP.
WASP International covers all aspects of paper writing:
literature review
proposal
grant
ethics
data protection
data collection
analysis
writing
abstracts/posters/presentations
paper formatting
referencing software
submission
peer review
dissertation
facilitated statistics using Excel™
At the end of the WASP event, attendees are also presented with a certificate of attendance attesting to the 18 CME points that are allotted to this event via the Medical Association of Malta (MAM).
More details about the WASP Faculty can be found here.
We practice what we preach in WASP – all of the talks (as well as related topics) have been published in the peer-reviewed journal (impact factor 2.2) Early Human Development in a series of medical education sections in consecutive issues of the journal. See PubMed link.
Prof. Victor Grech, creator and director of WASP.
WASP has now been endorsed by the Royal College of Paediatrics and Child Health for the equivalent of 18 category 1 (external) CPD credits. In addition, the course is also endorsed by the following international and local bodies:
Now is your chance to learn scientific paper writing the proper way. An early bird registration and discount are currently available. You may register at http://www.ithams.com/wasp/ (there is an early bird registration and discount…make sure you don’t miss out!!)
Are you organising events or have products or information that can enhance the knowledge of local and international student nurses on their way to registration? I’d love to hear from you! Contact me here…
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use of the most appropriate airway maneuver for the patient
appropriately choosing and introducing airway adjuncts
becoming aware if and when the need for ventilation arises, and delivering it effectively
Oropharyngeal and Nasopharyngeal airways are tubes made of plastic or rubber used to help maintain airway patency by keeping the tongue out of the way from obstructing the upper airway. Whilst in use, patient breathing should be assessed and confirmed so that proper positioning is ensured.
Retrieved from https://twitter.com/myway_rt/status/1472980655696973825?lang=ar-x-fm on 28th October 2022
Complications
gagging
vomiting (may lead to aspiration)
bleeding following trauma to the oral or nasal cavity
airway obstruction caused by the oropharyngeal airway pushing the tongue to the back
laryngospasm – vocal chord spasm which causes temporary difficulties with breathing and speaking
NOTE: The oropharyngeal airway should only be used in unconscious patients with an absent gag reflex.
NOTE: Do not use the nasopharyngeal airway on patients with a fractured skull base.
Oropharyngeal & Nasopharyngeal Airway Insertion
Oral & Nasal Endotracheal Tubes
Oral endotracheal tubes are commonly used in emergency situations. Whilst oral ETTs can be inserted easily, they also facilitate insertion of a larger tube that facilitates breathing and secretion suctioning.
Nasal endotracheal tubes provide less discomfort to the patient since they enable swallowing and oral hygiene, as well as facilitate communication. They can be easily secured and stabilised, minimising the risk of unintentional extubation. Additionally, a nasal ETT is preferred for paediatric use, post-extensive dental or neck surgery, and for patients with a fractured jaw.
Endotracheal tubes are available in many sizes. At the distal end of an endotracheal tube is a cuff which can be inflated by an external pilot balloon using between 15 to 25ml of water. This helps the ETT to stay in place, helps keep ventilated air in the ETT without escaping back up, and may also help prevent aspiration (although micro-aspiration can still pass through). At the proximal end a 15mm adaptor can be attached. This adaptor enables the ETT to be connected to ventilator tubings or to manual resuscitation bags.
NOTE: in paediatrics, the ETT used is usually without a cuff, which means it can be easily coughed out.
The McCoy laryngoscope’s blade has an adjustable hinged tip for improved visualisation of the vocal cords during difficult intubations.
Intubation Drugs
analgesics
sedatives (short-acting) eg. Etomidate or Propofol
muscle relaxants (short-acting) eg. Suxamethonium (Scoline) or Atracurium (Tracrium)
resuscitation drugseg. adrenaline or atropine
NOTE: when ventilating a patient, it is very important to administer sedation first. When sedation effects kick in, a muscle relaxant can then be administered. Baseline parameters are then taken and patient is continuously monitored.
Intubation Procedure
prepare equipment and ensure that all is checked and in working order
position patient in a way which ensures airway patency
suction the patient’s oral cavity and the pharynx
provide patient with 100% oxygen through manual ventilation for a few minutes
attempt intubation – limit attempt/s to 30 seconds
use the BURP technique to increase visibility (apply pressure on thyroid cartilage whilst moving backward, upward, and rightward)
insert tube and inflate cuff
ensure correct tube positioning through auscultation of bilateral breath sounds, visible chest rise, x-ray imaging, and ETCO2 monitor
document size and depth of ETT used
ATTENTION: if the ETT is misplaced into the stomach and not in the trachea, upon ventilating with 100% oxygen, the stomach would inflateinstead of the lungs – chest.
Intubation Complications
vomiting and aspiration
laryngospasm
trauma to the mouth, nose, pharynx, trachea and/or oesophagus
gastric intubation
right main bronchus intubation
hypoxaemia and/or hypercapnia leading to hyper/hypotension and tachy/bradycardia
Right Bronchus Intubation – Retrieved from http://learningradiology.com/archives04/COW%20129-Atelectasis-ETT/atelectasiscorrect.htm on 28th October 2022
Prolonged Intubation Complications
patient discomfort
communication difficulty
patient anxiety
hypersalivation
tube displacement
tube obstruction
aspiration
nasal injury
mucosal lesions
cricoid abscess – causes airway compromise reversible with treatment
sinusitis – causes nasal discharge and undetermined fever
laryngeal stenosis – scarring within the larynx at or above the vocal cords which limits the larynx from opening as it normally does
tracheal stenosis – unusual narrowing of the trachea which restricts normal breathing
tracheo-oesophageal fistula – unusual connection between the trachea and oesophagus which causes swallowed liquids and foods to be aspirated into the lungs
NOTE: An ETT should not be used for more than 12 days. If further ventilation is required, a tracheostomy should be considered instead.
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