[Noninvasive Mechanical Ventilation in Acute Respiratory Failure]

The non-invasive ventilation (NIV) is widespread in the clinical medicine and has attained meanwhile a high value in the clinical daily routine. The application of NIV reduces the length of ICU stay and hospitalization as well as mortality of patients with hypercapnic acute respiratory failure. Patients with acute respiratory failure in context of a cardiopulmonary edema should be treated in addition to necessary cardiological interventions with continuous positive airway pressure (CPAP) or NIV. In case of other forms of acute hypoxaemic respiratory failure it is recommended the application of NIV to be limited to mild forms of ARDS as the application of NIV in severe forms of ARDS is associated with higher rates of treatment failure and mortality. In weaning process from invasive ventilation the NIV reduces the risk of reintubation essentially in hypercapnic patients. A delayed intubation of patients with NIV failure leads to an increase of mortality and should therefore be avoided. With appropriate monitoring in intensive care NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency. Furthermore NIV can be useful within palliative care for reduction of dyspnea and improving quality of life. The aim of the guideline update is, taking into account the growing scientific evidence, to outline the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.

[Quality assurance concepts in intensive care medicine]

Intensive care medicine (ICM) is characterized by a high degree of complexity and requires intense communication and collaboration on interdisciplinary and multiprofessional levels. In order to achieve good quality of care in this environment and to prevent errors, a proactive quality and error management as well as a structured quality assurance system are essential. Since the early 1990s, German intensive care societies have developed concepts for quality management and assurance in ICM. In 2006, intensive care networks were founded in different states to support the implementation of evidence-based knowledge into clinical routine and to improve medical outcome, efficacy, and efficiency in ICM. Current instruments and concepts of quality assurance in German ICM include core intensive care data from the data registry DIVI REVERSI, quality indicators, peer review in intensive care, IQM peer review, and various certification processes. The first version of German ICM quality indicators was published in 2010 by an interdisciplinary and interprofessional expert commission. Key figures, indicators, and national benchmarks are intended to describe the quality of structures, processes, and outcomes in intensive care. Many of the quality assurance tools have proved to be useful in clinical practice, but nationwide implementation still can be improved.

[Early mobilization. Competencies, responsibilities, milestones]

BACKGROUND

Early mobilization is an evident, interprofessional concept to improve the outcome of intensive care patients. It reduces psychocognitive deficits and delirium and attenuates a general deconditioning, including atrophy of the respiratory pump and skeletal muscles. In this regard the interdisciplinary approach of early mobilization, taking into account different levels of mobilization, appears to be beneficial. The purpose of this study was to explore opinions on collaboration and tasks between different professional groups.

METHOD

During the 25th Bremen Conference on Intensive Medicine and Nursing on 20 February 2015, a questionnaire survey was carried out among the 120 participants of the German Early Mobilization Network meeting.

RESULTS

In all, 102 questionnaires were analyzed. Most participants reported on the interdisciplinarity of the approach, but none of the tasks and responsibilities concerning early mobilization can be assigned to a single professional group. The practical implementation of mobilizing orally intubated patients may require two registered nurses as well as a physical therapist. Implementation in daily practice seems to be heterogeneous.

CONCLUSIONS

There is no consensus regarding collaboration, competencies, and responsibilities with respect to early mobilization of intensive care patients. The approach to date has been characterized by a lack of interprofessional communication, which may lead to an inefficient use of the broad and varied base of knowledge and experienceof the different professions.

[Tolerance of endotracheal tubes in patients on mechanical ventilation]

BACKGROUND

Modern concepts for sedation and analgesia and guidelines recommend light analgesia and sedation, so that patients on mechanically ventilation are more awake, compared to previous concepts. Hence, these patients are more alert and able to experience their situation on the ventilator and their endotracheal tube (ETT).

PROBLEM

There is currently no convincing evidence of how patients tolerate the tube under present conditions, which interventions could help them, or whether they want to be sedated deeper because of the tube. Based upon our own observations, a broad range of reactions are possible.

PURPOSE

The tolerance of the ETT in intensive care patients was explored.

METHOD

A systematic literature research without time constraints in the databases PubMed and CINAHL was performed. Included were quantitative and qualitative studies written in German or English that investigated tolerance of the ETT in adult intensive care patients. Excluded were anesthetic studies including in- and extubation immediately before and after operations.

RESULTS

Of the 2348 hits, 14 studies were included, including 4 qualitative studies about the experience of intensive care, 8 quantitative studies including 2 randomized controlled studies, and 2 studies with a mixed approach. Within the studies different aspects could be identified, which may in- or decrease the tolerance of an ETT. Aspects like breathlessness, pain during endotracheal suctioning and inability to speak decrease the tolerance. Information, the presence of relatives and early mobilization appear to increase the tolerance.

CONCLUSION

Tolerance of the ETT is a complex phenomenon. A reflected and critical evaluation of the behavior of the patient with an ETT is recommended. Interventions that increase the tolerance of the ETT should be adapted to the situation of the patient and should be evaluated daily.

[Methods for endotracheal tube fixation. Results of a survey of intensive care nurses]

There are a wide variety of strategies and methods used in securing and managing the oral endotracheal tube and mouth and oral care in German clinical intensive care nursing for mechanically ventilated patients. There are no nationally recognized guidelines or recommendations on this topic. A survey among intensive care nurses identified the most widely used nursing strategies and methods. Regarding the results of the survey and international literature findings, the commonly used strategies and methods are discussed. Following these discussions, there are recommendations for improving nursing care of orally intubated patients in intensive care, including the aspects of evidence identified, currently used methods and patient needs. Also included are aspects of patient safety, potential complications and quality-orientated nursing care within a system having limited overall nursing care resources.

[Comparison of incomplete (135 degrees ) and complete prone position (180 degrees ) in patients with acute respiratory distress syndrome. Results of a prospective, randomised trial]

BACKGROUND

Ventilation in the prone position is carried out for improvement of pulmonary gas exchange in patients with acute respiratory distress syndrome (ARDS). We compared the effects of an incomplete prone position (IPP, 135( degrees )) with a complete prone position (CPP, 180( degrees )) in patients with ARDS.

PATIENTS AND METHODS

For this trial 59 patients with ARDS were randomly assigned and were positioned in a "cross-over" design: patients of group A were placed in IPP for 6 h and then immediately positioned in CPP for another 6 h. Patients in group B were positioned in reverse order. Blood gases, hemodynamic measurements, quasistatic respiratory compliance and assessments of side effects were performed before begin, 30 min and 6 h after first positioning, then 30 min and 6 h after second positioning and 2 after repositioning.

RESULTS

Turning patients in IPP and CPP resulted in a significant increase in the arterial oxygenation index (p(a)O(2)/F(I)O(2)), but this effect was more pronounced in the CPP (before: 142+/-46 mm Hg, 6 h: 253+/-107 mm Hg) than in the IPP (before: 139+/-54 mm Hg, 6 h: 206+/-75 mm Hg), and compliance was improved only in CPP. The improvement in arterial oxygenation persisted 2 h after repositioning in the supine position in both groups. The oxygenation responder rate was lower during the IPP (70.3%) in comparison with the CPP (84.0%, p<0.05). The incidence of side effects tended to be increased during the CPP.

CONCLUSION

Incomplete prone position improves oxygenation in ARDS patients, but less effectively than a "classic" CPP. In these patients the use of a CPP should be preferred.