Optimising non-invasive mechanical ventilation: Which unit should care for these patients? A cohort study

Respiratory device-related pressure injuries in hospitalised adults: An integrative review

OBJECTIVE

To identify the main ventilatory support medical devices related to the occurrence of pressure injuries in hospitalised adults, as well as the most frequent anatomical localisations of these injuries.

METHODS

The Integrative review was registered at Open Science Framework as per DOI 10.17605/OSF.IO/P3NTZ. Two independent reviewers, in May 2022, searched the databases: PubMed, Embase, Cochrane Database of Systematic Reviews, LILACS and CINAHL; no language or publication year restriction. The review question was: What are the ventilatory support medical devices that cause PIs in hospitalised adults more often? The terms for searching the database were: "adult," "noninvasive ventilation," "artificial respiration." and "pressure injury," and their synonyms. This review followed the PRISMA checklist.

RESULTS

The final sample was 21 articles. Oxygen nasal catheters caused up to 40.7% of the pressure injuries by ventilatory support devices identified, all in the ears. Noninvasive mechanical ventilation oronasal masks presented an incidence of pressure injuries of 63.3%. The nasal bridge was the site most affected by this mask. The Set of Holders for Insight® endotracheal tubes was the device that caused the most pressure injuries, with an incidence of 75%, affecting lip commissure. Tracheostomy cannula accounted for 18.2% of the pressure injuries related to ventilatory support devices; all lesions were in the neck.

CONCLUSION

The ventilatory support devices causing pressure injuries and the most affected sites were, respectively, nasal catheters, ears; masks, nasal bridge; endotracheal tubes, lip commissures; tracheostomy cannulas, neck.

RELEVANCE FOR CLINICAL PRACTICE

Knowing which respiratory devices cause pressure injuries more often in hospitalised adults and which anatomical localisations are more likely to be affected is fundamental for adopting preventive measures and reducing the occurrence of this problem.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution because of the review.

Seznanjenost osebja zdravstvene nege z neinvazivno mehansko ventilacijo

Uvod: Uspešno zdravljenje z neinvazivno mehansko ventilacijo predstavlja velik izziv, saj jo je mogoče učinkovito upravljati v primeru zadostne usposobljenosti vseh članov tima. Namen raziskave je bil oceniti znanje zdravstvenih delavcev, ki se srečujejo s tovrstnim zdravljenjem.Metode: Izvedena je bila kvantitativna presečna opazovalna raziskava. Vanjo je bilo vključenih 68 medicinskih sester, zaposlenih v intenzivnih enotah in na urgenci dveh bolnišnic v severovzhodni Sloveniji. Podatki so bili zbrani s pomočjo vprašalnika ter statistično analizirani in obdelani z uporabo opisne in sklepne statistike.Rezultati: V raziskavi ugotavljamo, da 76,5 % anketirancev meni, da je njihovo znanje o neinvazivni mehanski ventilaciji precej dobro. Znanje o neinvazivni mehanski ventilaciji je 85,3 % anketirancev pridobilo od sodelavcev v službi in 60,3 % od zdravnikov na oddelku. Povprečna vrednost doseženih točk, pridobljena pri vprašanjih o znanju glede uporabe neinvazivne mehanske ventilacije, je bila 23,13 (s = 4.35) od možnih 33. Med delavci, zaposlenimi v urgentnem centru in na oddelkih intenzivne enote, ne obstajajo statistično pomembne razlike v znanju o neinvazivni mehanski ventilaciji (p = 0,456).Diskusija in zaključek: Ugotovili smo, da bi anketiranci potrebovali dodatna usposabljanja s področja neinvazivne mehanske ventilacije. Smiselno bi bilo, da se na državni ravni oziroma ravni posameznih bolnišnic organizirajo izobraževanja s tega področja, na katera se povabi vse zaposlene, ki se srečujejo z neinvazivno mehansko ventilacijo.

Bedside risk stratification for mortality in patients with acute respiratory failure treated with noninvasive ventilation

Our hypothesis was that patients managed with noninvasive ventilation (NIV) on the wards could be risk-stratified with initial pulse oximetry/fraction of inspired oxygen (SpO₂/FiO₂) ratios and tidal volumes (Vte). A prospective study of consecutive patients with acute respiratory failure requiring NIV on the wards was conducted. A multivariate logistic regression model and a negative binomial regression model were used. A total of 403 patients (55.8% women) had a mean age of 65.0 ± 14.9 years with a mean body mass index of 32.1 ± 11.1 kg/m². The 28-day mortality was 14.1%, and the intubation rate was 16.1%. Pneumonia was associated with the highest 28-day mortality (22.5%) and rate of intubation (36.7%) when compared with chronic obstructive pulmonary disease (4.4% and 7.3%) or congestive heart failure (22.2% and 13.4%). The SpO₂/FiO₂ groups were <214 (26.6%), 214 -357 (66.0%), and ≥357 (7.4%). Those in the SpO₂/FiO₂ < 214 group had a higher 28-day mortality rate (odds ratio [OR] = 8.19; 95% confidence interval [CI] 1.02 -65.7), intubation rate (OR = 3.7; 95% CI 1.1 -12.1), intensive care unit admission rate (OR = 2.9; 95% CI 1.2 -7.4), and length of stay (relative risk = 2.0; 95% CI 1.3 -3.0). A Vte/predicted body weight <7.7 mL/kg was associated with increased intubations (OR = 3.1; 95% CI 1.3 -7.4), intensive care unit admissions (OR = 2.5; 95% CI 1.3 -4.6), and 30-day readmissions (OR = 2.9; 95% CI 1.2 -6.8). In conclusion, in patients without acute respiratory distress syndrome who had acute respiratory failure managed with noninvasive ventilation on the wards, severe hypoxemia as assessed by a simple SpO₂/FiO₂ ≤ 214 was associated with poor outcomes.

An observational study on the practice of noninvasive ventilation at a tertiary level Australian intensive care unit

BACKGROUND

Failure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure.

OBJECTIVES

To evaluate NIV failure rate and factors associated with NIV failure.

DESIGN, SETTINGS AND OUTCOMES

Prospective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU.

RESULTS

Amongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m² and median APACHE-II score 17.5 (14.0-23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0-43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3-28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04-24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9-19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91-0.99, p = 0.04).

CONCLUSION

NIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application.

Nurses' and physicians' knowledge and skills in non-invasive ventilation: Equipment and contextual influences

OBJECTIVES

To assess non-invasive ventilation knowledge and skills among nurses and physicians in different contexts: equipment and contextual influences.

METHOD

Cross-sectional, descriptive study in 4 intensive care units (ICU) (1 surgical, 3 medical-surgical), 1 postsurgical recovery unit, 2 emergency departments (ED) and 3 wards, in 4 hospitals (3 university, 1 community) with 407 professionals. A 13-item survey, validated in the setting, was applied (Kappa index, 0.97 (95% CI [.965-.975]).

RESULTS

Nurses (63.7% response); physicians (39% response). The overall percentage of correct responses was 50%. Scored from 1 to 5, with lower scores reflecting more knowledge, nurses scored 3.27±.5 vs 2.62±.5 physicians, respectively (mean difference,.65 (95% CI: .48-.82, P<.001). There were no differences between hospitals or units (P=.07 and P=.09). A notable percentage of respondents incorrectly identified the patient-ventilator synchronization strategy as "covering the expiratory port" (intentional leaks) and pressing the mask against the patient's face (unintentional leaks) (28.2% ICU, 22.5% ED, 8.3% postoperative resuscitation, 61.5% wards), with no difference between nurses and physicians (27.9% vs 23.4%, P=.6). Only 50% of nurse respondents correctly answered a question about measuring mask size and just 11.7% of the nurses knew the "2-finger fit" adjustment.

CONCLUSIONS

There was no difference in nurses' and physicians' knowledge according to the setting studied. The lack of knowledge regarding NIV therapy depended on training received and material available. To reduce the existent confusion between intentional and nonintentional leak, the use of a single type of NIV supply and providing an appropriate level of training for nurses is recommended.

Noninvasive Mechanical Ventilation in Acute Ventilatory Failure: Rationale and Current Applications

Noninvasive ventilation plays a pivotal role in acute ventilator failure and has been shown, in certain disease processes such as acute exacerbation of chronic obstructive pulmonary disease, to prevent and shorten the duration of invasive mechanical ventilation, reducing the risks and complications associated with it. The application of noninvasive ventilation is relatively simple and well tolerated by patients and in the right setting can change the course of their illness.

Prevention and treatment of skin lesions associated with non-invasive mechanical ventilation. Recommendations of experts

INTRODUCTION

In the last two decades, non-invasive mechanical ventilation (NIV) has been consolidated as an initial strategy for the management of respiratory failure in critical adult and paediatric patients.

OBJECTIVES

To identify risk factors and preventive strategies to reduce the incidence of skin lesions associated with clinical devices (LESADIC) related to NIV, as well as the most effective treatment for injuries that cannot be avoided.

METHODOLOGY

Review in the MEDLINE, CINAHL and Cochrane databases of studies published in the last 10years to reach consensus through an expert panel.

RESULTS

Knowledge about how to measure correct mask size and protection of the skin with foam or hydrocolloids dressings are factors related to the incidence of LESADIC, as it conditions the degree of pressure-friction and shear that the interface exerts on the skin. The interface that causes fewer LESADIC and is better tolerated is the face mask. When there are injuries, the first thing is to remove the interface that causes pressure on damaged skin, recommending a Helmet^® hood as an alternative, treating the infection, managing the exudate and stimulating perilesional skin.

CONCLUSIONS

The mask of choice is the facial, always using foam or hydrocolloid dressings on the nasal bridge. Evaluate the condition of the skin under the interface and harness every 4hours (recommended) and 11hours (maximum). Evaluate the rotation strategy of the interface at 24hours if the NIV is still needed on an ongoing basis.