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Patients receiving mechanical ventilation endure high levels of stress and anxiety due to the invasiveness of the procedure. These critically ill patients are often uncomfortable as a result of their serious conditions and the high-intensity environments in which they are placed. Health care workers heavily sedate these patients to minimize pain and induce a state of relaxation. However, sedatives are known for their wide-ranging, and often deleterious, side effects. Music therapy is an intervention that has been studied in a variety of hospital settings to determine any potential beneficial effects on patients. Many studies have demonstrated a relationship between music therapy and decreased anxiety levels. This thesis reviewed studies on outcomes of music therapy on anxiety in mechanically-ventilated patients. A total of 10 studies that addressed the use of music to decrease anxiety in ventilated patients were analyzed and incorporated into the literature review. The articles were selected from a variety of databases on EBSCOhost, including MEDLINE, PsycINFO, ScienceDirect, and CINAHL. The literature review provides positive evidence for the support of music therapy to help alleviate anxiety in mechanically-ventilated patients.

Holmström, M & Jangvert, M Protokolliserad urträning från respirator. Att ha en plan är viktigare än hur den ser ut och en plan fungerar bara om du använder den. Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Hälsa och samhälle. Utbildningsområde omvårdnad 2011.Respiratorbehandling är en livsavgörande behandlingsinsats för kritisk sjuka in-tensivvårdspatienter. När patienten börjar tillfriskna från sin underliggande sjukdom trappas respiratorbehandlingen ut. Urträning – ”weaning” från respiratorn kan göras på olika sätt. Protokolliserad urträning har i flera studier visats förkorta respiratortiden men används inte överallt. Syftet med denna litteraturstudie var att studera standardiserade protokoll utformade för att underlätta weaning och andra faktorer av betydelse för en fungerande weaning. Vad utmärker de protokoll som visats underlätta weaning? Vad krävs förutom protokoll för att underlätta weaning? Efter att inklusionskriterier och exklusionskriterier utarbetats valdes tio artiklar inom aktuellt område ut - nio kvantitativa och en kvalitativ - från en litteratursökning i PubMed och Cinahl. Artiklarna granskades, analyserades och gemensamma teman för respektive artikel identifierades och omformulerades till rubriker som innehållet infogades under. Resultatet av denna litteraturstudie visade att utformningen av weaningprotokollet verkar vara mindre väsentligt än att det verkligen finns ett protokoll att arbeta efter. Ett protokolliserat arbetssätt är dock inte enda lösningen – målmedveten utbildning krävs för att ett nytt arbetssätt ska fungera. / Holmström, M & Jangvert, M Protocolized weaning from the ventilator. To have a plan is more important than how it is constructed and a plan only works if you use it.Degree Project, 15 Credit Points. Malmö University: Health and Society, Department of Nursing, 2011.Ventilator treatment is lifesaving for the most critically ill patients in an intensive care unit. However, when the patient recovers from illness, ventilator treatment is withdrawn. The process of weaning the patient from the ventilator can be done in different ways. Protocolized weaning has in several studies been shown to shorten the duration of mechanical ventilation but is not the standard of care in all intensive care units. The aim of the present study was to investigate standardized wea-ningprotocols. What parameters define the protocols that can be shown to shorten weaning? Since many factors might be presumed to influence weaning, the aim of the present study was also to determine other possibly important factors than the protocols themselves. Ten studies – nine with a quantitative approach and one with a qualitative approach – were found in a literature search in Pubmed and Cinahl. The studies were analyzed and topics were identified and used for structuring the data from the studies. The conclusion of the present study was that the design of the weaningprotocol seems less important than the existence of protocolized weaning. However, protocolized weaning as such was not enough for success – ambitious education on the usage of the protocol was essential for a suc-cessful weaningprotocol.

A pneumonia associada à ventilação mecânica é uma infecção nosocomial que ocorre em pacientes sob assistência ventilatória mecânica. Apesar dos inúmeros avanços no entendimento desse quadro, sua incidência continua elevada, resultando em altas taxas de mortalidade. Do ponto de vista clínico, a prevenção ainda é a melhor estratégia para reduzir os custos desse quadro, sendo que o emprego de protocolos elaborados juntamente com a equipe tem grande efeito para a prevenção da pneumonia associada à ventilação mecânica. O objetivo do estudo foi elaborar um protocolo de prevenção de pneumonia associada à ventilação mecânica em um hospital privado do sul de Minas Gerais. Trata-se de um estudo de abordagem qualitativa que utilizou como referencial teórico a pesquisa convergente assistencial. Para a coleta de dados foram realizados quatro encontros (uma entrevista individual e três encontros grupais). Para a análise dos dados foi utilizado o referencial de Morse e Field. Os cuidados citados nas entrevistas individuais pelos profissionais das equipes médica, enfermagem e fisioterapia, totalizando 17 profissionais participantes foram organizados de acordo com o nível de evidência sugerido no Guideline da American Thoracic Society. Nos dois encontros grupais seguintes os cuidados foram discutidos de acordo sua relevância na prevenção da pneumonia associada à ventilação mecânica. Com base nos cuidados elencados foi elaborado o protocolo, o qual foi apresentado aos profissionais no quarto encontro. Assim, observa-se que o referencial da pesquisa convergente assistencial possibilitou a elaboração de um protocolo para prevenção de pneumonia associada à ventilação mecânica, com o envolvimento dos profissionais atuantes na UTI, demonstrando a motivação de cada um para agregar conhecimento de sua especialidade no protocolo, além disso, houve interação entre todos os membros das categorias profissionais atuantes no setor. / The pneumonia associated to mechanical ventilation is a nosocomial infection that occurs in patients under mechanical ventilatroy support. In spite of the numerous advances in the understanding of this framework, its incidence remains high, resulting in high mortality rates. From the clinical point of view, prevention is still the best strategy to reduce the cost of this frame, being that the use of protocols designed along with the team has great effect for the prevention of pneumonia associated to mechanical ventilation. The aim of the study was to elaborate a protocol for the prevention of pneumonia associated to mechanical ventilation in a private hospital in the south of Minas Gerais. This qualitative study used the convergent care research as theoretical framework. For data collection, were held four meetings (one individual interview and three group meetings). Data were analyzed based on the Morse and Field theoretical reference. The mentioned care in the individual professionals of the medical, nursing and physiotherapy teams, totalizing 17 professionals were organized according to the level of evidence suggested in the Guideline of the American Thoracic Society. In the following two meetings with the groups, the care were discussed according to their relevance in the prevention of pneumonia associated to mechanical ventilation. Based on the indicated care, the protocol was drawn up and presented to professionals at the fourth meeting. The convergent care research framework made possible the elaboration of a protocol for the prevention of pneumonia associated to mechanical ventilation, with the involvement of professionals that work in the intensive care unit, demonstrating the motivation of each one to add knowledge of their area of expertise in the protocol; in addition, there was interaction between all the members of the professional categories involved in the sector.

The diploma is focused on Ethical aspects of nursing care from the perspective of staff providing nursing care in the intensive care units and long-term intensive care units. We were also interested in respondent?s knowledge in the field of ethical principles in biomedicine and their legislation. The thesis is divided into two parts - theoretical and empirical. The theoretical part describes nursing care of the mechanically ventilated patients, short history of medical ethics and current status of the ethics in biomedicine. The investigative part was implemented by combination of a quantitative and a qualitative research. For the quantitative part of the investigation we used the method of questioning by a questionnaire. The questionnaire consisted of 20 questions, 10 closed questions, 8 half-opened questions and 2 open questions which offered to show a personal opinion. Questionnaires were anonymous. Respondents that were asked were workers providing nursing care in the intensive care units and long-term intensive care units. The first goal of the diploma was to find out respondents point of view on nursing care in patients on long term mechanical ventilation. The second goal was to find out the most important ethical problems in providing nursing care in this category of patients. The last goal of the diploma was to find out respondents knowledge of codes of ethics and legislation. For the quantitative research we had two hypotheses: 1. There are ethical problems related to providing nursing care in patients on long term mechanical ventilation. This hypothesis was verified, because statistically significant majority of respondents said, that there are ethical problems related to providing nursing care in this category of patients. 2. The nurses´ approach to patients on long term mechanical ventilation is different in the intensive care units and long term intensive care units. This hypothesis was verified, because there were statistically significant differences between answers of respondents providing nursing care in intensive care units and long term intensive care units. For the qualitative research we used the technique of half-structured interview offering open questions. Into the research file was involved 10 nurses, 5 from intensive care units and 5 from long term intensive care units. There were set three investigatory questions. 1. What opinion has respondents about nursing care in patients on long term mechanical ventilation? The investigation showed that nurses have the same attitude to long term ventilated paitents as in the case of patients on acute short term mechanical ventilation. 2. What are the most serious ethical problems related to nursing long term mechanical ventilated patients? The research found out the most serious ethical problems related to long term mechanical ventilation from the point view of a nursing staff. These are preservation of human dignity and prolonging medically futile treatment. 3. What awareness of basic ethical principles and their legislation the respondents have? The investigation showed that nurses have poor knowledge of the issue. The results confirm the current situation of this issue. Based on the results of our research, we prepared educational brochure draft, which could help to facilitate orientation in this field.

Introduktion: I dag ska patienter som vårdas på intensivvårdsavdelning vara så lätt sederade som möjligt. Detta kan vid samtidig respiratorvård inge känslor av panik, rädsla och otrygghet. Det är därför av stor vikt att intensivvårdssjuksköterskor vet hur de ska skapa trygghet hos patienterna, då trygghetskänslan även reducerar känslorna av panik och rädsla. Syfte: Syftet med examensarbetet var att belysa hur intensivvårdssjuksköterskor skapar trygghet för lätt sederade patienter vårdade i respirator. Metod: En kvalitativ metod användes och data samlades in genom intervjuer med 14 intensivvårdssjuksköterskor på 3 olika sjukhus. Data bearbetades utifrån Elo och Kyngäs kvalitativa innehållsanalys. Huvudresultat: I resultatet framkom fyra huvudkategorier; Genom att finnas där, Genom upprepad och anpassad information, Genom en bra miljö och yttre resurser samt Genom individanpassad vård. Diskussion: Det framkom att intensivvårdssjuksköterskorna skapade trygghet genom att involvera patienterna och de anhöriga i vården genom en god kommunikation och information. Miljön spelade även en viktig roll i trygghetsskapandet genom att minska störande ljud och inte själva vara stressade. Att skapa trygghet för lätt sederade patienter som vårdas i respirator är viktigt, då trygga patienter kan släppas upp snabbare från sederingen och ändå uppleva välbefinnande. / Introduction: The aim of caring for today’s intensive care patient is to have the patient sedated so light as possible. This can induce a sense of panic, fear and insecurity for the patient, when cared for in a mechanical ventilation. It is therefore very important that the intensive care nurse has the ability to create a sense of security for the patient, thus reducing feelings of fear and panic. Aim: The aim of this study was to illustrate how the intensive care nurses creates a sense of security when caring for light sedated patients in mechanical ventilation. Method: A qualitative method was selected and data collected through interviews with 14 intensive care nurses at 3 different hospitals. The data was processed by using Elo and Kyngäs qualitative content analysis. Main Results: The result of the study presents with four main categories; Being there, Through repeating and adapting information, Through a good climate and outer resources as well as Through individually modified care. Conclusions: It showed that the intensive care nurses created a sense of security through involve the patients and their near ones in the care of the patient through good communication and information. The environment also played a critical role through minimizing distracting noise and not to appear stressed themselves. To create sense of security for light sedated patients in mechanical ventilation is important, as when the patients experience a sense of security they could be more quickly weaned of the sedation and yet still experience a sense of wellbeing.

Formation of atelectasis, defined as reversible collapse of aerated lung, often occurs after induction of anaesthesia with mechanical ventilation. As a consequence, there is a risk for hypoxemia, altered hemodynamics and impaired respiratory system mechanics. In certain situations, the risk for atelectasis formation is increased and its consequences may also be more difficult to manage. Anesthesia for bariatric surgery in morbidly obese patients and surgery requiring one-lung ventilation (OLV) with capnothorax are examples of such situations. In Paper I (30 patients with BMI > 40 kg/m2 scheduled for bariatric surgery) a recruit­ment maneuver followed by positive end-expiratory pressure (PEEP) re­duced the amount of atelectasis and improved oxygenation for a prolonged period of time. PEEP or a recruitment maneuver alone did not reduce the amount of atelectasis. In paper II we investigated whether it is possible to predict respiratory function impairment in morbidly obese patients without pulmonary disease from a preoperative lung function test. Patients with mild signs of airway obstruction (reduced end-expiratory flow) in the preoperative spirometry developed less atelectasis during anaesthesia. In paper III we developed an experimental model of sequential OLV with capnothorax using electrical impedance tomography (EIT) that in real-time detected lung separation and dynamic changes in pulmonary ventilation and perfusion distributions. OLV to the left side caused a decrease in cardiac output, arterial oxygenation and mixed venous saturation. In paper IV we used our model of OLV with capnothorax and applied a CO2-insufflation pressure of 16 cm H2O. We demonstrated that a PEEP level of 12-16 cm H2O is needed for optimal oxygenation and lowest possible driving pressure without compromising hemodynamic variables. Thus, the optimal PEEP was closely related to the level of the capnothorax insufflation pressure. With insufficient PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the non-ventilated lung occurred.

Mechanical ventilation (MV) is the primary form of therapeutic support for patients with acute respiratory failure (ARF) or acute respiratory distress syndrome (ARDS) until the underlying disease is resolved. However, as patient disease state and response to MV are highly variable, clinicians often rely on experience to set MV. The result is more variable care, as there are currently no standard approaches to MV settings. As a result of the common occurrence of MV and variability in care, MV is one of the most expensive treatments in critical care. Thus, an approach capable of guiding patient-specific MV is required and this approach could potentially save significant cost. This research focuses on developing models and model-based approaches to analyse and guide patient-specific MV care. Four models and metrics are developed, and each model is tested in experimental or clinical trials developed for the purpose. Each builds the understanding and methods necessary for an overall approach to guide MV in a wide range of patients. The first model, a minimal recruitment model, captures the recruitment of an injured lung and its response to positive end expiratory pressure (PEEP). However, the model was only previously validated in diagnosed ARDS patients, and was not proven to capture behaviours seen in healthy patients. This deficiency could potentially negate its ability to track disease state, which is crucial in providing rapid diagnosis and patient-specific MV in response to changes in patient condition. Hence, the lack of validation in disease state progression monitoring from ARDS to healthy, or vice-versa, severely limits its application in real-time monitoring and decision support. To address this issue, an experimental ARDS animal model is developed to validate the model across the transition between healthy and diseased states. The second model, a single compartment linear lung model, models the lung as a conducting airway connected to an elastic compartment. This model is used to estimate the respiratory mechanics (Elastance and Resistance) of an ARDS animal model during disease progression and recruitment manoeuvres. This model is later extended to capture high resolution, patient-specific time-varying respiratory mechanics during each breathing cycle. This extended model is tested in ARDS patients, and was used to titrate patient-specific PEEP using a minimum elastance metric that balances recruitment and the risk of lung overdistension and ventilation-induced injury. Studies have revealed that promoting patients to breathe spontaneously during MV can improve patient outcomes. Thus, there is significant clinical trend towards using partially assisted ventilation modes, rather than fully supported ventilation modes. In this study, the patient-ventilator interaction of a state of the art partially assisted ventilation mode, known as neurally adjusted ventilatory assist (NAVA), is investigated and compared with pressure support ventilation (PS). The matching of patient-specific inspiratory demand and ventilator supplied tidal volume for these two ventilation modes is assessed using a novel Range90 metric. NAVA consistently showed better matching than PS, indicating that NAVA has better ability to provide patient-specific ventilator tidal volume to match variable patient-specific demand. Hence, this new analysis highlights a critical benefit of partially assisted ventilation and thus the need to extend model-based methods to this patient group. NAVA ventilation has been shown to improve patient-ventilator interaction compared to conventional PS. However, the patient-specific, optimal NAVA level remains unknown, and the best described method to set NAVA is complicated and clinically impractical. The Range90 metric is thus extended to analyse the matching ability of different NAVA levels, where it is found that response to different NAVA levels is highly patient-specific. Similar to the fully sedated MV case, and thus requiring models and metrics to help titrate care. More importantly, Range90 is shown to provide an alternative metric to help titrate patient-specific optimal NAVA level and this analysis further highlights the need for extended model-based methods to better guide these emerging partially assisted MV modes. Traditionally, the respiratory mechanics of the spontaneously breathing (SB) patient cannot be estimated without significant additional invasive equipment and tests that interrupt normal care and are clinically intensive to carry out. Thus, respiratory mechanics and model-based methods are rarely used to guide partially assisted MV. Thus, there is significant clinical interest to use respiratory mechanics to guide MV in SB patients. The single compartment model is extended to effectively capture the trajectory of time-varying elastance for SB patients. Results show that without additional invasive equipment, the model was able estimate unique and clinically useful respiratory mechanics in SB patients. Hence, the extended single compartment model can be used as ‘a one model fits all’ means to guide patient-specific MV continuously and consistently, for all types of patient and ventilation modes, without interrupting care. Overall, the model-based approaches presented in this thesis are capable of capturing physiologically relevant patient-specific parameters, and thus, characterise patient disease state and response to MV. With additional, larger scale clinical trials to test the performance and the impact of model-based methods on clinical outcome, the models can aid clinicians to guide MV decision making in the heterogeneous ICU population. Hence, this thesis develops, extends and validates several fundamental model-based metrics, models and methods to enable standardized patient-specific MV to improve outcome and reduce the variability and cost of care.

Les ventilateurs ont connu des progrès technologiques considérables grâce à l'application de concepts physiologiques, à l'électronique, à l'informatique et la miniaturisation. Leurs conceptions et performances intrinsèques, en revanche, ont pu rester inégales sur certains points. L'objectif de ce travail a été d'évaluer sur un banc d'essai, avec un protocole, adapté aux problématiques soulevées en pratique clinique, tous les ventilateurs de réanimation, transport et de ventilation non invasive de façon rigoureuse et reproductible. Les résultats montrent que 1) l'erreur sur le volume réellement délivré est très fréquente et correspond facilement à 1ml/kg de volume supplémentaire ; le VT indiqué sur les ventilateurs est inférieur au VT réellement délivré ; 2) les performances des nouveaux ventilateurs ne présentent pas d'améliorations significatives par rapport aux meilleurs ventilateurs testés en 2000; les ventilateurs à turbine sont identiques ou proches des meilleurs ventilateurs conventionnels ; 3) les ventilateurs dédiés à la ventilation non invasive montrent de meilleures performances pour s'adapter à la présence de fuites ; 4) la ventilation par percussion intra-pulmonaire superposée à la ventilation conventionnelle peut réduire l'apport de l'humidification, influencer les volumes administrés et induire une pression expiratoire positive intrinsèque. Les tests sur banc montrent une grande hétérogénéité des performances. Une veille technologique semble indispensable pour évaluer tout nouveau ventilateur / The ventilators have markedly improved thanks to progress in respiratory physiology, in informatics and miniaturization. However, their intrinsic performances remain unequal. The aim was to evaluate ventilators performances on reproducible bench test studies adapted to clinical questions. Tests show that 1) the error of really delivered volume is approximately 1 ml/kg of additional volume; the tidal volume (VT) indicated on the ventilators was lower than the real delivered VT ; 2) Performances of new ventilators are comparable to the best ventilators tested in 2000 ; turbine ventilators are quite similar to best conventional ventilators ; 3) The ventilators dedicated to non invasive ventilation showed better performances to cope with leaks 4) The intrapulmonary percussive ventilation superimposed on conventional ventilation can reduce humidity, increase volumes and can generate intrinsic positive expiratory pressure. The bench tests showed a large heterogeneity of performances. A technological watch seems essential to evaluate all new ventilators

Background: The adverse effects of mechanical ventilation (MV) are a major health concern associated with poor outcomes and economic burden. Some populations, such as those requiring more than one attempt at the gradual removal of MV (weaning), are at risk for longer duration of MV and associated complications. Traumatically injured patients have a higher prevalence of positive illicit drug toxicology then the general population. The traumatically injured, positive for illicit drugs who requires MV, may experience the sequelae of withdrawal syndrome and violate the thresholds that allow weaning, leading to longer durations MV. Methods: A retrospective descriptive analysis of a convenience sample of 52 adult trauma patients from SJHMC admitted between January 1 to December 31, 2014 who presented positive for illicit drugs and required mechanical ventilation. This sample was analyzed to: 1) describe the characteristics of this specific sample, 2) determine the prevalence of a difficult-to-wean subsample, 3) describe the characteristics of this sample during weaning attempts, and 4) determine if the existing weaning protocol necessitates amending. Results: Samples ability to wean; 78.8% (n=41) simple weaning; 15.38% (n=8) difficult weaning; and 5.77% (n=3) prolonged. Zero cases of adverse effects of MV or withdrawal syndrome detected. There was no correlation between stimulant and/or depressant and ability to wean (p=0.662). There was no relationship between injury severity score (ISS) and weaning group (p=0.762). Characteristics identified included; male to female ratio 4:1 and majority with ISS score>24. Variables within weaning protocol were missing 25-84% of data. Conclusion: The ability to wean MV in this sample is similar to what is reported in the general population, suggesting that they are not at risk for difficult weaning or prolonged MV. This sample’s majority was comprised of more traumatically complex, young males than found in the general trauma population. Investigators were unable to analyze or amend the current protocol because of the large amounts of missing data indicating possible gaps in adherence and/or documentation. To our knowledge, this is the first project that describes ability to wean in the traumatically injured positive for illicit drug.