The Role of the Nurse In Mechanical Ventilation Weaning Submitted in partial fulfillment of the requirements in the course N451 Clinical Management of Adult Health Nursing III Old Dominion University NORFOLK, VIRGINIA Fall, 2013 Introduction Presenters • Chad del Rosario • Joe Crossman • Amanda Coffin • Vanessa Gonzales Reason for Topic Choice • This semester has been our first time in the critical care unit caring for some patients with severe medical conditions that required mechanical ventilation. While each patient was admitted for different diagnoses, one commonality between most patients on the unit was the use of mechanical ventilation. We were able to witness successful extubations, extubations that resulted in re-intubations, and ET tubes that progressed into tracheostomy ventilation. As nursing students, we wanted to identify the nursing interventions related to weaning in order to achieve successful extubations with limited re-intubations and tracheostomy ventilation. Purpose Goal • The learner will be able to identify the importance of weaning a patient from mechanical ventilation as well as the nursing interventions and desired outcomes required to do so. Learner Objectives • The learner will be given a brief review of what mechanical ventilation entails, followed by a Post Test to evaluate comprehension. • The learner will be able to determine which type of patient will require mechanical ventilation through scenario-based questions following a brief lecture. • The learner will be able to identify possible complications of mechanical ventilation and the nursing interventions necessary for prevention. • The learner will be educated through a lecture on the nursing interventions required in the process of mechanical ventilation weaning based on nursing research and be able to identify the nursing interventions to ensure optimal patient outcomes. Teaching Plan Goal: The learner will be able to identify the importance of weaning a patient from mechanical ventilation as well as the nursing interventions and desired outcomes required to do so. Objectives Content Outline Method of Instruction Time Allotted Resource Method of Evaluation (Met/Unment) The learner will be given a brief review of what mechanical ventilation entails, followed by a Post Test to evaluate comprehension. Review of MV • Definition • Modes • Settings Lecture 2-3 minutes PowerPoint Post Test The learner will be able to determine which type of patient will require mechanical ventilation through scenario-based questions following a brief lecture. Medical Indications for MV • Patient inability (Airway, Gas Exchange, Ventilation) • Surgery Lecture followed with interactive scenariobased questions 2-3 minutes PowerPoint Scenario-based Post Test The learner will be able to identify possible complications of mechanical ventilation and the nursing interventions necessary for prevention. Explanation/Descrip tion of Medical Complications • Pretest • Complication • Prevention Interactive Pre Test with answers provided through lecture 2-3 minutes PowerPoint Pre Test and with answered provided by lecture The learner will be educated through a lecture on the nursing interventions required in the process of mechanical ventilation weaning based on nursing research and be able to identify the nursing interventions to ensure optimal patient outcomes. Research Articles 1 and 2 • Description • Findings • Nursing Interventions Lecture 10 minutes PowerPoint Nurse Driven Protocol Weaning • Interactive Questionnaire Emotional Responses during MV Weaning • Post Test Significance of Mechanical Ventilation to Critical Care • To facilitate: • Airway • Gas Exchange • Ventilation Review: What is Mechanical Ventilation? • Use of an external system to control the movement of air in and out of the lungs • Bag Valve Mask (BVM) • Ventilators • Rescue Breaths • Modes • Volume controlled • Pressure controlled • Fi02 • PEEP (Positive end-expiratory pressure) • Inhalation/Exhalation (I/E) Ratio • Normal 1:2 Mechanical Ventilation Post Test The nurse notices that the patient’s I/E ratio is set to 2:1. What does this mean? Medical Indications: Who needs Mechanical Ventilation? • Patient can no longer control/regulate their own airway or breathing • Airway • Obstructive Apnea, Asthma, COPD • Gas exchange • Atelectasis, Pneumonia, Heart Failure • Ventilation • Spinal injury, Drug overdose, Sedation • Hypoxemia • PaO2 < 55 mmHg • PaCO2 >50 mmHg/ pH < 7.32 • Trauma • Surgery Scenario-Based Post Test • A patient arrives to the ER via ambulance with multiple gunshot wounds. The following clinical signs are noted: RR 34, PaCO2 60, pH 7.20, and use of accessary muscles. The patient is being prepped for the OR. • Should this patient be intubated/ventilated? Complications of Mechanical Ventilation What is a medical complication? • A complication is, “A disease or condition that happens in addition to another disease or condition: a problem that makes a disease or condition more dangerous or harder to treat.” (Merriam-Webster) Complications and Prevention Pre-Test Can you think of possible complications of mechanical ventilation? Can those complications be prevented? Complications • Volutrauma • Volutrauma occurs when high volumes of air are forced into the lungs. Air takes the path of least resistance, avoiding the injured alveoli and concentrating in the healthier alveoli. It is associated with high Tidal Volumes and PEEP. Can lead to overdistention of alveoli, loss of surfactant, and alveolar rupture. • Barotrauma • Barotrauma occurs when pressure inside the lungs exceeds what the alveoli are able to accommodate. This can result in alveolar rupture, causing air to leak into the thorax. Pneumopericardium, subcutaneous emphysema, and pneumothorax are only some of the complications associated with barotrauma. Complications • Ulcerations • Ulcerations can occur on the nose or mouth, depending on where the patient was intubated. The pressure of a tube pressing against the skin can cause breakdown and further complicate the situation. • Infection • Sinus infections are a significant risk for patients who have ventilatory tubes placed through the nares. Infections can cause purulent drainage to leak through the trachea and into the lungs, increasing the risk of Ventilator Associated Pneumonia. Complications • Accidental Extubation/ Displacement • Accidental extubation/ displacement can occur if the patient pulls the ET Tube out, or when it becomes dislodged during routine care. (Turning the patient or transferring him/her to another bed). • Tracheal and Laryngeal Damage • Damage can occur when the patient is unintentionally extubated while the cuff is still inflated. Other causes of damage are laryngoedema from extubation, and cranial nerve damage. Complications • Ventilator Associated Pneumonia (VAP) • Ventilator Associated Pneumonia is an infection of the lungs occurring more than 48 hours after intubation. It is due to pathogens bypassing normal defense mechanisms and entering the pulmonary tissue. The patient’s chest x-ray will show progressive infiltrate that was not present on admission. • VAP has a high mortality rate because it is difficult to treat and further complicates the patient’s disease process. Prevention is Key! • Volutrauma and Barotrauma • Low Tidal Volumes with a higher rate • Ideally PEEP should be kept at 5 • Monitor pressures (Inspiratory, Plateau, Expiratory) • Ulcerations and infections • Mouth care- petroleum jelly • Nurse may switch side of mouth Ventilator is on • Secretions- suction Prevention is Key! • Accidental Extubations/ Displacement • Ensure you have enough slack in the circuit before moving the patient • Monitor sedation. If the patient is grabbing at the ventilator you may need an order for more sedation or light wrist restraints as a reminder to keep their hands away from the vent. • Placement at the lips • No movement in the epigastric area • Tracheal and Laryngeal Trauma • Prevent accidental extubations • Ensure the cuff is fully deflated before extubation • VAP • • • • Head of bed up to at least 30 degrees Mouth care including chlorhexidine, suctioning, and brushing teeth CASS tubes Change the circuit per protocol and PRN Prevention is Key! • The number one way to prevent complications related to ventilators is to wean as early as possible. Get your patient off the vent! Description of the Study: Nurse-Driven Protocol Weaning A comparison of nurse-driven protocol-directed weaning from mechanical ventilation and physician-driven weaning from mechanical ventilation. Background • Usual care • RT staffing • Studies show protocol procedures may shorten the duration of mechanical ventilation and decrease ICU/hospital length of stay. • First study of its kind. Description of the Study: Nurse-Driven Protocol Weaning Purpose • Compare Nurse vs. Physician weaning of mechanical ventilation • Outcomes • South Korean study Study Design • A prospective and nonrandomized study with retrospective historical control. Description of the Study: Nurse-Driven Protocol Weaning Patient Selection • Inclusion • 1. Received mechanical ventilation for longer than 24 hours in the ICU • 2. Vent weaning trial was initiated while in the ICU • 3. 18 years or older • Exclusion • 1. Died before initiation of vent weaning • 2. Terminally weaned from mechanical ventilation before initiation of weaning trial. • 3. Tracheostomy at the time of ICU admission. • 102 (nurse group) 100 (physician group) Nursing Intervention based on Hospital Protocol DAILY NURSE SCREENING -Awake and able to follow simple commands -Vasopressors (equivalent to dopamine ≤ 5 mcg/kg/min) and systolic Blood Pressure ≥ 90 mm Hg -Heart Rate = 55 to 135 beats per minute -Respiratory rate < 35 breaths per minute -PaO2 / FIO2 ratio ≥ 200 -Positive end-expiratory pressure (PEEP) < 5 cm H2O NO Mechanical Ventilation YES ASSESSMENT OF RAPID SHALLOW BREATHING INDEX (BRIEF SPONTANEOUS BREATHING TRIAL) RSBI > 105 -Measure Rapid Shallow Breathing Index (RSBI) after brief 2-3 minutes on Pressure support (PS) = 5-8 cm H2O and continuous positive airway pressure (CPAP) = 0-5 cm H2O -RSBI = Respiratory rate (breaths/min) ÷ Tidal volume (Liters) RSBI < 105 SPONTANEOUS BREATHING TRIAL (SBT): 30-120 minutes -Pressure support (PS) = 5-8 cm H2O and continuous positive airway pressure (CPAP) = 0-5 cm H2O TOLERANCE OF SBT NO -Respiratory Rate < 35 breaths per minute -Heart rate between 55 and 135 beats per minute -Systolic Blood Pressure (SBP) between 90 - 170 mmHg -SpO2 ≥ 92% -Patient showing no signs of diaphoresis, paradoxical respiration, retractions, nasal flaring, agitation, somnolence, or complaining of shortness of breath YES NO Physician approval YES Extubation Findings of the Study: Nurse-Driven Protocol Weaning • Median durations on mechanical ventilation • Nurse 2 days • Physician 4 days • Median duration ICU length of stay • Nurse 5 days • Physician 7 days • Median duration of mechanical ventilation before initiation of weaning trail • Nurse 2 days • Physician 3 days • No significant differences found in hospital length of stay, hospital mortality, rates of VAP, reintubation rate, or disposition. What does this research contribute to Nursing? • • • • • Easy to implement Cost effective Safe Less time on mechanical ventilator Less days in ICU • Danckers, M., Grosu, H., Jean, R., Cruz, R. B., Fidellaga, A., Qifa, H., & ... Khouli, H. (2013). Nurse-driven, protocoldirected weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. Journal Of Critical Care, 28(4), 433-441. doi:10.1016/j.jcrc.2012.10.012 Description of the Study: Emotional Responses to Weaning • A qualitative study which focused on the feelings of the patients’ after successful weaning attempts • The study took place in three separate respiratory critical care facilities and data was collected from all successful attempts at weaning 20 participants from a general adult population. • All participants were on a ventilator for a minimum of three weeks • Ventilator types included: SIMV, pressure support, CPAP, and T-piece • Data was collected over a nine month time frame via interview based questions. The interviews lasted 45-90 minutes and were tape recorded. • The nurse can competently understand and intervene for the patient with knowledge regarding the feelings of the patient during weaning and weaning trials. Findings of the Study: Emotional Responses to Weaning General feelings of uncertainty regarding their preparation for the weaning process and lack of explanation, manifested by three themes: • Bystander • Participants reported feeling as though the decisions were being made for them instead of incorporating them • “I felt that it was too soon to be off and couldn’t imagine not having the ventilator to support me” • Severity of Disease Process related to Safety of Weaning • Participants felt concerned about the severity of their disease process and how that would interfere with the safety of being weaned from the ventilator. • Statements made by the doctor that created these feelings in the participants: • “Your condition is unstable, we will be removing you from the ventilator soon” • “We will be turning off the machine in a few days.” • Loss of control • Being breathless, feeling helpless, not knowing what to expect, feelings of frustration, and wondering whether or not they should give up. Nursing Interventions: How can we as Nurses help? Communication is Key – Establish means of Communication • Bystander • Ask • Include • Severity/Safety: • Explain. • Clarify. • Empathize. • Loss of control: • Establish expectations • Encourage Post Test: What would you do? WW is a ‘frequent flyer’ admitted for an exacerbation of COPD. You have orders for his extubation to take place. JP is a young mother of 3 who has been well on the road to recovery. The doctor has just come out the room after talking with both JP and her family. Mr. P looks very sad because the doctor has stated he’s going to “turn off the machine” today. • How can this situation be avoided? What should you do for both of these patients? Summary Restating the goal • The learner will be able to identify the importance of weaning a patient from mechanical ventilation as well as the nursing interventions and desired outcomes required to do so. Restating the objectives • The learner will be given a brief review of what mechanical ventilation entails, followed by a Post Test to evaluate comprehension. • The learner will be able to determine which type of patient will require mechanical ventilation through scenario-based questions following a brief lecture. • The learner will be able to identify possible complications of mechanical ventilation and the nursing interventions necessary for prevention. • The learner will be educated through a lecture on the nursing interventions required in the process of mechanical ventilation weaning based on nursing research and be able to identify the nursing interventions to ensure optimal patient outcomes. Summary The goal has been met. • The learner successfully completed the evaluation and is able to determine nursing interventions and desired outcomes related with effective ventilator weaning. The objectives have been met. • The learner was educated on each objectives and answered all Post Tests, Pre Tests, and Interactive Questionnaires appropriately. Thank you! Questions?