Airway management of an elective surgical patient

Airway management is a skill that all healthcare professionals need to learn. This skill is used in two specific areas. First, in emergency situations such as cardiac arrest or respiratory arrest. Second, and the subject of this article, the postanaesthetic patient. This article explores not only the anatomy of the respiratory system but the different techniques and methods employed to manage a patient's airway. Airway management can be divided into three distinct phases. The first phase deals with the management of the airway while the patient undergoes an operation; this is managed by the anaesthetist. While the second phase deals with the patient's airway in the immediate recovery period, it usually occurs in a recover room and is managed by a recovery nurse. The third phase is when the patient returns to the ward, and for the first 24-48 hours after a general anaesthetic. It is only by recognizing the signs and symptoms of respiratory distress and initiating effective treatment that serious consequences can be avoided.

Rapid sequence induction anaesthesia: a guide for nurses in the emergency department

Emergency rapid sequence induction (RSI) anaesthesia is the cornerstone of emergency airway management performed on patients in the emergency department (ED). The Royal College of Anaesthetists has stated that anaesthesia should not proceed without a skilled, dedicated assistant. It is essential that ED nurses are educated, skilled and competent to assist with RSI in the ED.

Emergency oxygen delivery in adults 1: updating nursing practice

The first in this two-part unit discusses new British Thoracic Society guidance on using emergency oxygen in adults. This is the first national guidance on this area and the implications for possible changes to practice are highlighted here. This part outlines the philosophy behind the guideline, the differences between hypoxaemic and hypercapnic patients and essential assessments for critically ill patients who need emergency oxygen. It also discusses using this therapy for patients with lung cancer in acute situations.

[Effects of nurse home visits on compliance to long-term oxygen therapy. 14 months follow-up]

INTRODUCTION

Long-term oxygen therapy (LTOT) is the only treatment improving survival of patients with respiratory failure due to chronic obstructive pulmonary disease (COPD). Benefits of treatment depend mainly on daily duration of oxygen use. The aim of the study was to assess daily use of oxygen and to evaluate influencing factors.

MATERIAL AND METHODS

Consecutive patients qualified to LTOT were included. Eligibility for LTOT was based on the ATS//ERS guidelines. All patients were instructed to use oxygen from oxygen concentrator for 15 hours per day or more. Duration of oxygen therapy was verified every 4 weeks by visiting respiratory nurse using counter clock of oxygen concentrator. The nurses were also encouraging patients to breathe oxygen for at least 15 h/d.

RESULTS

Study group consisted of 30 patients (77% with COPD) aged 67+/-9 yrs, mean FEV, 46+/-18% pred., RV%TLC 64+/-16%, PaO2 50+/-6 mm Hg. Mean duration of oxygen therapy for the group was 12.5+/-4.6 h/d. Eleven (37%) subjects followed prescription during whole follow-up period (mean oxygen use 17.4+/-2.6 h/d). Mean oxygen use in the non-compliant group was 9.6+/-2.7 h/d. In COPD group compliant patients had significantly lower TLC (100+/-19% pred. v. 152+/-36% pred., p=0.001) and lower PaCO2 (38+/-6 mm Hg v. 47+/-8 mm Hg, p<0.05) when compared to the non-compliant group. During the first month of treatment 48% of patients were compliant. From the second month onward percentage of compliant patients fell to 30% and remained stable to the end of the study. Fourteen patients (47% complained of electricity consumption and 7 patients (23%) complained of the noise of working concentrator. Daily oxygen use in the latest group was significantly lower when compared to those who did not complain of the noise (9+/-3.7 h/d v. 13.5+/-4.4 h/d; p=0.02).

CONCLUSIONS

The best compliance to home oxygen therapy is observed at the beginning of treatment. Frequent home nurse visits do not improve compliance. We hypothesize that the use of other oxygen sources eg. liquid oxygen, that are silent and do not increase the cost of electricity, could improve compliance.

Minimal occlusive volume cuff inflation: a survey of current practice

OBJECTIVE

To describe the minimal occlusive volume (MOV) procedure used to monitor cuff inflation and identify practice variation.

RESEARCH METHODOLOGY

Self-administered questionnaire.

SETTING

Adult intensive care unit in an Australian university-affiliated hospital.

RESULTS

Survey response was 71% (80/113). Three methods of MOV were identified. Full cuff deflation, followed by reinflation, removal of 1mL increments of air until a leak was detected, then restoration of cuff seal with 1mL of air was the preferred method (47/80 respondents, 59%) (Method 1). Full cuff deflation followed by incremental addition of air until the MOV was established was used by 25/80 (31%) respondents (Method 2). Two (2.5%) nurses established MOV without full cuff deflation (Method 3), five (6.25%) used more than one method and one (1.25%) nurse did not perform cuff checks. Practice variation was identified for patient positioning, confirmation of cuff seal, and cuff leak management. Consistency of practice was noted in MOV procedure frequency, the number of nurses required, pre-oxygenation and oropharyngeal suctioning prior to cuff deflation.

CONCLUSION

Substantial practice variation for certain aspects of cuff management was noted. Evidence to support the efficacy of MOV procedural elements is required to limit practice variation and reduce risk to patients.

The use of domiciliary oxygen therapy

Carol Kelly and Dave Lynes discuss the evidence and assessment for domiciliary oxygen, as well as considering oxygen therapy in palliative care.

A field-expedient Ohmeda Universal Portable Anesthesia Complete draw-over vaporizer setup

The Ohmeda Universal Portable Anesthesia Complete (U-PAC) draw-over anesthetic system is active in the US Army inventory. It is standard equipment for Certified Registered Nurse Anesthetists assigned to US Army Forward Surgical Teams and Joint Special Operations Command. The purpose of this article is to describe a practical and field-expedient U-PAC draw-over vaporizer setup used during Operation Iraqi Freedom I (February 2003 to July 2003). During the deployment, general anesthesia was administered to 25 patients with penetrating trauma using the Gegel-Mercado setup without system malfunction. This setup strengthens the standard U-PAC draw-over system delivery because it increases fractional inspired oxygen concentrations, promotes hands-free operation, enhances circuit cleanliness reducing cross contamination, and provides an alternate method for draw-over anesthesia administration in austere conditions when a ventilator may not be available or practical. It integrates and builds on the core concepts of draw-over anesthesia delivery in the literature. The Gegel-Mercado setup is combat proven.

Pneumonia 2: effective nursing assessment and management

Part 1 of this two-part unit on pneumonia explored common signs and symptoms of the infection, and explained how nurses can identify those at high risk. This part looks at its nursing assessment and management.

Oxygen: the two-faced elixir of life

Take a moment and consider our planet without oxygen. Imagine the earth some 2.5 billion years ago when oxygen first appeared as a waste product of early anaerobes. Oxygen, as we know it today, is essential for life. Abundant and relatively inexpensive to manufacture, oxygen has widespread use in industry and healthcare. Anesthesia providers routinely administer oxygen in concentrations exceeding that in ambient air to ensure clinical safety and to offset the predictable sequelae associated with patient, drug-related, and procedural factors. Understanding the history of this unique element is critical in evaluating the often contentious body of contemporary research that has illuminated its efficacy (as elixir) and its attendant complications (its "two-faced" nature). Of particular interest is its role in free radical formation as etiogenic in developing complications. Oxygen is a mainstay in the perioperative management of patients, but its administration should be guided by thoughtful and rational goal-directed outcomes to maximize efficacy and minimize complications associated with its use.

Severe allergic reaction: management of anaphylaxis in hospital

Anaphylaxis is an acute, severe, hypersensitivity reaction that can lead to asphyxia, cardiovascular collapse and cardiac arrest. This reaction is sudden, severe, and involves the whole body. Common causes include foods such as nuts, shellfish, dairy products and eggs. Non-food causes include bee/wasp stings, latex and drugs, e.g. penicillin. Common clinical features include urticaria, angioedema, respiratory distress and shock. Summoning expert help, reclining the patient flat, administering high concentration oxygen, and administering intramuscular adrenaline are key aspects of the nursing management of anaphylaxis in hospital. The aim of this article is to understand the management of anaphylaxis in hospital, with particular reference to national consensus guidelines.

Emergency oxygen for respiratory patients

Oxygen is prescribed for hypoxaemic patients to increase alveolar oxygen tension and decrease the effort of breathing. Although principally life saving, in certain circumstances it can be lethal if prescribed and/or administered incorrectly. To ensure safe, effective delivery of oxygen, health professionals dealing with the administration, titration and monitoring of oxygen therapy should understand the principles that underpin its use. Carol Kelly and Anne Riches discuss administering oxygen therapy in the acute situation.

Respiratory assessment in adults

Respiratory disorders are among the most common reasons for admission to critical care units in the U.K. However, anecdotal evidence suggests that nursing assessment of patients' respiratory function is not performed well because it is not considered a priority and the implications of respiratory dysfunction are underestimated. It is essential that nurses are able to recognise and assess symptoms. of respiratory dysfunction to provide early, effective and appropriate interventions, thus improving patient outcomes. This article highlights the role of the nurse in respiratory assessment and discusses the implications of clinical findings.

The effect of education on hypothetical and actual oxygen administration decisions

AIM

This study examined the effect of an education intervention on emergency nurses' decisions related to oxygen administration.

METHOD

A controlled pre-test/post-test quasi-experimental design was used. The intervention was a written self directed learning package. Outcome measures were (i) factual knowledge measured using parallel form multiple choice questions (MCQs) and (ii) clinical decisions measured using parallel form MCQs, parallel form patient scenarios and clinical practice observation.

RESULTS

Eighty-eight nurses from 4 Melbourne EDs participated in the study (control group: n=37 and experimental group: n=51). Subgroups of nurses from the experimental group also participated in the patient scenarios (n=20) and clinical practice observation (n=10). Emergency nurses' knowledge increased as a function of education. Both patient scenario data and clinical practice observation showed decreased selection of nasal cannulae, increased selection of air entrainment masks and a trend towards selection of higher oxygen flow rates following education.

CONCLUSIONS

Evaluation of educational interventions in nursing should focus on identifying strategies that enhance learning in a clinical environment, are valid in terms of the clinical context and culture in which they are being used and most importantly, produce sustained improvements in actual clinical practice.

Dyspnea: applying research to bedside practice

Dyspnea is a common symptom in patients with acute and chronic critical illness as well as in patients receiving palliative care. While dyspnea can be found in a variety of clinical arenas and across many specialties, the mechanisms that cause dyspnea are similar. Although not often the cause for admission to critical care, it may complicate and extend length of stay. This article defines and describes dyspnea and its pathophysiology. Critical care nurses should strive to implement interventions supported by evidence whenever possible. An evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with dyspnea is outlined, using levels of recommendation based on the strength of available evidence. Two case studies are presented to illustrate its application to clinical practice.

Caring for patients receiving oxygen therapy

Although respiratory disease can occur at any age, older people are more likely to suffer both acute and chronic respiratory disease. Without sufficient oxygen, cells fail and die, and extensive cell death causes body systems to fail. This article considers the principles of short-term oxygen therapy and offers guidance to nurses who may be required to administer such treatment in their work with older people.

Experiences of a novice researcher

Karen Clancy, a nurse consultant but a novice researcher reflects on her study of patients with respiratory disease living at home with long-term oxygen therapy. She explores the dual role of researcher and clinician, and concludes with suggestions designed to help other novice researchers.

Oxygen administration: is practice based on evidence?

An audit of oxygen administration to children in the paediatric unit of a district general hospital was carried out following the introduction of new guidelines. The aim of the audit was to review oxygen administration practices against the guidance but also to gather information concerning patients, diagnoses, prescription practices and delivery devices. The notes of 36 infants and children admitted during a two week (winter) period who received oxygen were retrospectively reviewed for the audit. The standards for monitoring the amount of oxygen delivered and oxygenation were found to be high but the prescribing of oxygen was varied. The most common diagnosis of children receiving oxygen was bronchiolitis, and the device used to deliver oxygen most frequently was nasal cannula. Few headboxes were used and experienced team members noted this as a marked change in practice. A further examination of the evidence on the use of nasal cannulae for oxygen delivery in the younger age group led to new practice recommendations.