Special Premie Oxygen Targeting (SPOT): a program to decrease the incidence of blindness in infants with retinopathy of prematurity

Infants born prematurely have a plethora of medical problems. Some have cerebral palsy, resulting in limited mobility, while others require oxygen, hearing aids, and/or glasses for medical problems. Most of these could have been prevented if preterm birth was avoided, but efforts to curb this have been slow. This article discusses how blindness can be prevented in infants born prematurely by accepting lower oxygen saturations when on oxygen in the intensive care nursery.

Early recognition and treatment of shock in the pediatric patient

Pediatric cardiopulmonary arrest is frequently a terminal event of an unrecognized progressive shock state. This article describes predisposing factors and classifications of shock as they relate to pediatric patients. It assists the experienced pediatric nurse as well as the nurse who is less experienced in caring for children in identifying early shock in this population and provides practical advice on the assessment of children. In addition, management and intervention techniques are addressed.

The effects of specific educational preparation on emergency nurses' clinical decisions regarding supplemental oxygen administration

The use of supplemental oxygen by emergency nurses has important implications for patient outcomes, yet there is significant variability in oxygen administration practises. Specific education related to oxygen administration increases factual knowledge in this domain; however, the impact of knowledge acquisition on nurses' clinical decisions is poorly understood. This study aimed to examine the effect of educational preparation on 20 emergency nurses' decisions regarding the assessment of oxygenation and the use of supplemental oxygen. A pre-test/post-test, quasi-experimental design was used. The intervention was a written, self-directed learning package. The major effects of the completion of the learning package included no change in the number or types of parameters used by nurses to assess oxygenation, a significant decrease in the selection of simple masks, a significant increase in the selection of air entrainment masks, fewer hypothetical outcomes of unresolved respiratory distress and more hypothetical outcomes of decreased respiratory distress. As many nursing education programs are aimed at increasing factual knowledge, while experience remains relatively constant, a greater understanding of the relationship between factual knowledge and clinical decisions is needed if educational interventions are to improve patient outcomes.

How long do patients spend weaning from CPAP in critical care?

The purpose of this project was to audit clinical practice and to investigate the time taken to wean patients using continuous positive airway pressure (CPAP) as a method of respiratory support prior to the introduction of a weaning protocol. Data was collected over a two-month period and 43 patients were included in the audit. Criteria for inclusion were that each patient had previously received mechanical ventilation and was subsequently weaned with the aid of CPAP or had received CPAP and was weaning from CPAP alone. The average time taken to wean was 95 hours (3.96 days) and ranged from one to 41 days. There was no correlation between the length of weaning time and the patient's APACHE II Score or the length of time spent on invasive ventilation prior to weaning on CPAP. However, there was a consistency in the time spent on CPAP as a percentage of the total weaning time. The audit identified large variations in the process and time taken to wean patients from CPAP. This might suggest that CPAP is used in a routine or arbitrary manner rather than a selective response to patients' specific needs.

Current management of status asthmaticus in the pediatric ICU

Status asthmaticus (SA) in the pediatric ICU (PICU) can progress to a life-threatening emergency. The goal of management is to improve hypoxemia, improve bronchoconstriction, and decrease airway edema through the administration of continuous nebulized beta2 adrenergic agonist with intermittent anticholinergics, corticosteroids, and oxygen. Adjunctive therapies, such as magnesium, methylxanthines, intravenous beta-agonists, heliox, and noninvasive ventilation should be considered in the child who fails to respond to initial therapies. The restoration of adequate pulmonary functions, resolution of airway obstruction, and avoidance of mechanical ventilation should guide management. This article reviews the pathophysiology, assessment, and management of the child who has SA in the PICU to provide the critical care nurse with current information to facilitate optimal care.

Delivery of high-tech home care by hospital-based nursing units in Quebec: clinical and technical challenges

BACKGROUND

The role that hospital-based nurses should play in the delivery of high-tech home care, and how they should be supported in that role, are topics that remain understudied. Our research objective was to document how hospital-based nursing teams perceive and deal with the clinical and technical challenges associated with the provision of high-tech home care.

METHODS

Four home care interventions were selected: antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. A self-administered survey was sent to all hospital-based units providing these interventions in the province of Quebec, Canada (n = 154; response rate: 70.8%). We used descriptive statistical analyses to derive mean values for scores on either a five- or a six-level Likert scale.

RESULTS

Despite variation across the four interventions, our results indicate that while nursing teams believe these interventions increase patients' autonomy, they also recognize that they generate anxiety and impose constraints on patients' lives. Nurses must increase efforts to deal with both clinical and technical challenges and help patients overcome the barriers to appropriate use of home care technologies.

CONCLUSIONS

While nursing teams generally perceive high-tech home care as beneficial, they still experience significant technical and clinical challenges. Some of these challenges could be addressed by strengthening professional training initiatives, while others require broader home care policy interventions.

Cost-effectiveness and efficacy in long-term oxygen therapy

Changes to the new home oxygen service have raised awareness among health professionals of the potential hazards and benefits of oxygen therapy. Annette Duck reviews the use of long-term oxygen therapy and highlights the importance of assessment in selecting both patients and suitable delivery systems.

Acute life threatening events among infants on home oxygen

BACKGROUND

Chronic lung disease (CLD) of prematurity is associated with significant morbidity, and infants discharged home in oxygen are particularly vulnerable.

AIM

To assess the incidence of acute life threatening events (ALTEs) during 12-month follow-up of CLD infants discharged home receiving supplemental oxygen.

METHOD

All infants discharged over a one-year period were studied. Pre-discharge oxygen requirements were set on clinical grounds. Before discharge, oxygen saturations were recorded blind using a data-logger. Infant's oxygen requirements, hospital attendances, and details of ALTEs were recorded over the subsequent year.

RESULTS

Sixteen infants were studied. Median (range): birth-weight 938 grams (448 - 1,638); gestational age 28 weeks (24 - 32); discharge oxygen requirement 0.20 litres/minute (0.05 - 0.50). Eight infants subsequently had one or more ALTEs. Discharge oxygen saturation profiles were significantly lower in these infant when compared to those not having ALTEs (p < 0.05), despite receiving supplementary oxygen.

CONCLUSIONS

Before discharge home, formal oxygen saturation studies should be performed in infants receiving supplementary oxygen to ensure optimum oxygen delivery.

Nasopharyngeal oxygen (NPO) as a safe and comfortable alternative to face mask oxygen therapy

Nasopharyngeal oxygen (NPO) therapy is an emerging alternative to conventional face mask oxygen administration. It warrants consideration for treating hypoxaemia when face mask therapy is impractical or when patient intolerance or non-compliance regularly interrupt treatment. The effectiveness of the NPO route has been validated in post anaesthetic care and paediatric intensive care units (PICUs), but use in the adult ICU remains minimal. Recent research in the adult ICU setting has shown the nasopharyngeal route to be as effective as face mask oxygen administration in alleviating mild to moderate hypoxaemia, and is significantly more comfortable for patients. Therefore, NPO, administered via a fine catheter advanced into the nasopharynx, should be considered when face masks (FMs) or nasal prongs (NPs) are impractical or poorly tolerated and, because of its effectiveness and improved comfort, in patients for whom traditional non-invasive oxygen therapy is indicated. Implications for resource utilisation and costs also exist.

Rehabilitation for the home care patient with COPD

Assessment techniques and treatment strategies, such as medical management, oxygen management, chest physical therapy, and pulmonary rehabilitation, for patients with chronic obstructive pulmonary disease (COPD) are discussed. Clinically appropriate, evidence-based rehabilitation programs for home care may help to reduce care costs, reduce the impact of this chronic disease on patients with COPD, and prevent emergent care and rehospitalization.

Caring for patients with COPD on long-term oxygen therapy

Long-term oxygen therapy (LTOT) is becoming a mainstay of treatment for people with severe chronic obstructive pulmonary disease (COPD) in the community. This article provides an overview of the fundamental aspects of the therapy, measurement of blood gases and the equipment used in LTOT.

Promoting Physiologic-Physical Adaptation in Chronic Obstructive Pulmonary Disease: Pharmacotherapeutic Evidence-Based Research and Guidelines

Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and evidence-based research include advanced pharmacologic care for patients with chronic obstructive pulmonary disease (COPD). Although clinical trials of medications have not supported evidence that long-term decline in pulmonary function can be prevented, pharmacologic agents can reduce symptoms and prevent complications. High-quality home care services may improve quality of life and prevent hospital admissions because of acute exacerbations.

Effect of Postoperative Supplemental Oxygen on Nausea and Vomiting After Cesarean Birth

Postoperative nausea and vomiting (PONV) has a significant impact on patients and health care providers. Some nonpharmacologic methods may have an effect on PONV. Administration of supplemental oxygen (80%) during and for 2 hours after surgery has been shown to reduce the incidence of PONV from 44% to 22%. However, the effect of limiting supplemental oxygen to the immediate postoperative period on PONV is unknown. The purpose of this study was to test the efficacy of postoperative supplemental oxygen in reducing the incidence of PONV. Patients (n = 106) undergoing cesarean birth were given general anesthesia with 50% oxygen balanced nitrous oxide and in the postoperative period were randomly assigned to 2 groups. Patients in the experimental group received 8 L/min oxygen by a simple face mask for 6 hours. The control group received routine care of oxygen 5 L/min in the PACU and no supplemental oxygen on the ward. Trained nurses evaluated pulse oximetry and PONV after surgery. The incidence of PONV during the first 6 postoperative hours was 28.3% in the experimental group and 24.5% in the control group ( P = .659). There was no statistically significant difference between the 2 groups. In this study, postoperative supplemental oxygen 8 L/min did not prevent PONV in patients undergoing cesarean birth.

Assessment and nursing care of the patient with dyspnoea

Breathlessness is a subjective experience, which has been described as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990). Patients experiencing breathlessness are often described as being dyspnoeic, or having dyspnoea. This is derived from the Greek word, which, when translated, means 'difficulty in breathing'.

[Oxygen therapy care]

Oxygen therapy is administered to patients who require enhanced oxygenation of their arterial blood, patients with, for example, respiratory conditions which have resulted in impaired gaseous exchanges in the lungs, or many conditions that impair oxygen delivery to the tissues, such as myocardial infarction. Generally speaking, oxygen is an effective drug which is used very commonly in clinics. From internal medical problems, to emergency situations, even surgical problems, all of us care for patients receiving oxygen therapy sometimes. Regardless of the nurse's knowledge and skills in relation to oxygen therapy, the key nursing role is to support and reassure the patient and gain his or her confidence in order to maintain compliance with the treatment. This article discusses the pathophysiological changes associated with hypoxia, oxygen delivery devices, and guidelines for caring for patients requiring supplemental oxygen. We expect this article to contribute to improvements in the quality of clinical oxygen therapy.

Omissions and errors during oxygen therapy of hospitalized patients in a large city of Greece

Omissions and errors are commonly found concerning hospital oxygen use and the use of nebulizers. The aim of the study was to record oxygen use in seven hospitals located in a large district city of Greece. Another aim was to record the use of nebulizers in the same hospitals. We included 105 head nurses (HNs) working in seven hospitals of a large city district of Greece. Data were collected after interviewing each HN using a questionnaire and completing an anonymous data form. Data are expressed as percentages and analyzed using the chi-square test. We found that 41% of HN believed O(2) is a gas that improves patient's dyspnea. The majority of the nurses (88.6%) stated that there was no protocol for O(2) therapy in the departments in which they worked. We found that O(2) therapy was commonly started, modified, discontinued by nurses in the absence of a medical order. Oxygen therapy was commonly not guided by arterial blood gas (ABG) analysis. We also found that there are no guidelines to prevent O(2) therapy interruption during intra-hospital transportation, and that few measures were taken to prevent O(2) explosion. In 95.2% of the departments the nebulizers were filled with tap water and were not changed on a daily basis (81.2%). Our results indicate that educational programmes, nursing protocols and guidelines are becoming mandatory in our country in order to ensure the proper use of O(2) therapy and nebulizers.

Principles of post-operative patient care

Surgery causes physiological stress on the body and carries inherent risks such as shock and haemorrhage. This article discusses cardiogenic and hypovolaemic shock and outlines the principles of safe and effective post-operative care, including recognising hypovolaemia, maintaining fluid balance and administering pain control.

Home oxygen therapy after preterm birth in Western Australia

OBJECTIVES

To review our management of infants discharged home receiving supplemental oxygen. Stable preterm infants receive low flow O(2) by nasal cannulae aiming for SaO(2) of > or = 95%. Oxygen-dependent infants must pass an air test (ability to maintain SaO(2) > 80% during 4 h disconnection from oxygen) before discharge home with supplemental oxygen. A sleep study is performed before nocturnal O(2) is ceased.

METHODS

Infants less than 33 weeks gestational age (GA) who were admitted January 1999-June 2001 and discharged home with supplemental oxygen were identified through the databases and medical records of the King Edward Memorial/Princess Margaret Hospitals. The data collected were compared with an audit performed a decade earlier.

RESULTS

Ninety-three infants were discharged home with supplemental oxygen between 1999 and 2001 (10% neonatal intensive care unit admissions less than 33 weeks GA; median GA 26 weeks (interquartile range 25-28). All infants had an air test before discharge: 63% failed the first air test and 30% at least two air tests. The median delay between the first air test and discharge was 2 weeks. The median postmenstrual age at discharge was 40 weeks gestation (interquartile range 38-41). Ninety infants had a sleep study before nocturnal oxygen was ceased and nine failed the first sleep study. Hospital readmission rate was 60%. More preterm infants (less than 33 weeks) were discharged with supplemental oxygen in 1999-2001 (10%, n = 96 in 1999-2001) than in 1987-1992 (2.5%, n = 53) and this was associated with an earlier discharge (40 vs 44 weeks postmenstrual age), lower oxygen requirements at discharge (60 vs 125 mL/min), earlier discontinuation of daytime and nocturnal oxygen (1 vs 4 months postmenstrual age and 2.5 vs 6 months postmenstrual age) and no increase in readmission rate (64% vs 60%). The incidence of bronchopulmonary dysplasia for these infants has remained stable at 20%.

CONCLUSION

Our home oxygen programme, based on an air test predischarge and a sleep study prediscontinuation of nocturnal oxygen, facilitates early discharge home. Our data suggest that over the last decade, bronchopulmonary dysplasia is associated with less impairment in lung function. Further evidence from randomized clinical trials is required to determine optimal target range for oxygen saturation in preterm infants.