Clinical skills: a care plan approach to nurse-led extubation

Decisions Made By Critical Care Nurses During Mechanical Ventilation and Weaning in an Australian Intensive Care Unit

Background Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries. Organizational interventions, including weaning protocols, may have a variable impact in settings that differ in nursing autonomy and interdisciplinary collaboration.

Objective To characterize the role of Australian critical care nurses in the management of mechanical ventilation.

Methods A 3-month, prospective cohort study was performed. All clinical decisions related to mechanical ventilation in a 24-bed, combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital, a university-affiliated teaching hospital in Melbourne, Victoria, Australia, were determined.

Results Of 474 patients admitted during the 81-day study period, 319 (67%) received mechanical ventilation. Death occurred in 12.5% (40/319) of patients. Median durations of mechanical ventilation and intensive care stay were 0.9 and 1.9 days, respectively. A total of 3986 ventilation and weaning decisions (defined as any adjustment to ventilator settings, including mode change; rate or pressure support adjustment; and titration of tidal volume, positive end-expiratory pressure, or fraction of inspired oxygen) were made. Of these, 2538 decisions (64%) were made by nurses alone, 693 (17%) by medical staff, and 755 (19%) by nurses and staff in collaboration. Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients.

Conclusions In this unit, critical care nurses have high levels of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Revalidation of protocols for ventilation practices in other clinical contexts may be needed.

A nurse's guide to common mechanical ventilation techniques and modes used in infants. Nursing implications

The need for conventional mechanical ventilation (CMV) is a common one in the neonatal intensive care unit (NICU). The goals of CMV are to facilitate adequate gas exchange, minimize the risk of lung injury/damage, decrease the patient's work of breathing, and optimize the patient's comfort. Although time-cycled, pressure-limited ventilation remains the most common CMV modality, volume-cycled ventilation, assist-control ventilation, pressure-support ventilation, and pressure-control ventilation are sometimes used in the NICU. Pressure-regulated volume control, volume-guaranteed ventilation, volume-assured pressure-support ventilation, and proportional-assist ventilation are emerging hybrid modes of CMV. Although CMV is frequently life saving, it can cause complications if improperly used. Nurses are responsible for the ongoing assessment and care of infants undergoing CMV and are becoming frequently more involved in the weaning process of CMV. This article provides an overview of conventional ventilation, with a focus on common modalities, and ventilation-related nursing interventions.

Issues in weaning from mechanical ventilation: literature review

AIM

The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation.

BACKGROUND

Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process.

METHOD

In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations.

DISCUSSION

Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level.

CONCLUSION

Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.