Immobility is one of the factors associated with the accumulation of respiratory secretion in mechanically ventilated patients. Placing patients in a semi-recumbent position between 30° and 45° and frequent manual turning in every two hours are the standard ventilator nursing care practice adopted worldwide. However, the prevalence of pulmonary complications remains high. The use of continuous lateral rotation therapy (CLRT) to improve drainage of secretion within the lung and the lower airways was proposed and has been investigated in numerous studies. The purposes of this dissertation are (1) to perform a comprehensive systematic review for a critical appraisal of the current evidence on the use of CLRT to prevent pulmonary complications in mechanically ventilated patients, (2) to develop an evidence-based guideline and to assess the implementation potential, and (3) to develop an implementation and evaluation plan for translating the guideline to an adult intensive care unit (ICU) of a teaching hospital in Hong Kong. In order to identify studies that compared CLRT with the standard care, four electronic databases, including CINAHL Plus, Medline, British Nursing Index and PubMed, were searched. 94 studies were identified and eight of them met the inclusion criteria. These studies included one randomized controlled trial (RCT), two non-randomized controlled clinical trials, one pretest-posttest clinical trial and four retrospective cohort studies. The quality of these reviewed studies was assessed by using the appraisal instruments of the Scottish Intercollegiate Guidelines Network. Four of the reviewed studies were graded as high quality. No major adverse patient outcome was reported. Instead, beneficial patient outcomes that reached statistical significance were consistently reported in the CLRT group. There were reductions in ventilator-associated pneumonia (VAP), atelectasis, duration of mechanical ventilation and length of stay. However, its effect on health care cost and mortality was inconclusive. The implementation potential, in terms of the transferability, feasibility, and the cost-benefit ratio, was considered as high in the target setting. Based on the synthesized finding, a CLRT guideline is developed and is proposed to translate into practice. The implementation plan includes a communication plan with stakeholders and a pilot test. The guideline will be revised after the trial run of the proposed innovation for one and a half months. A full-scale controlled trial using a quasi-experimental design will be conducted. The primary outcome is to evaluate whether there is a reduction in the prevalence of VAP after the use of CLRT. According to previous studies, the use of CLRT can lead to a 49% reduction in VAP. The proposed innovation will be considered as clinical effective when similar observation is obtained. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Endotracheal suctioning is a procedure performed on a daily basis in hospitals, and is mostly take place in intensive care units (ICUs). (Annapoorna, 2005; Day et al, 2009). It helps removing sputum or secretion out from patients’ trachea. For patients who are under mechanical ventilation, this procedure is vital to maintain their airway patency when they are intubated with endotracheal tube or tracheostomized (Finucane & Santora, 2003). However, the procedure has its own risk and complications such as hypoxaemia, atelectasis, cardiovascular instability and more (Thomson, 2000). There are in general two types of endotracheal suctioning: open and closed system. As disconnection of mechanical ventilation from patients is needed for open endotracheal suctioning (OES), it has a higher risk of complications. However, the cost for OES is much cheaper compared to the closed system. Although OES is widely used in Hong Kong, there is no evidence-based guideline for nurses to follow. The guideline developed by American Association of Respiratory Care (2010) is lack of specificity on the target population and its recommendations were based on mixed literatures targeting on adult and infant patients. Therefore, the aim of this dissertation is to develop an evidence-based guideline for OES in adult patients under mechanical ventilation in ICU. To develop a guideline for OES, search was performed in multiple electronic databases (British Nursing Index, CINAHL, Cochrane Library, Ovid MEDLINE, and PubMed) with keywords related to OES and its complications. A total of 457 studies fulfilled the inclusion criteria and 11 of them were selected. The selected studies were evaluated by quality appraisal checklists, which are developed by Scottish Intercollegiate Guidelines Network (SIGN). Data were extracted for developing the guideline. Evidence have shown that the incidence of post-OES hypoxemia can be reduced by performing hyperoxygenation with 100% oxygen for 4-6 breaths prior and after each open endotracheal suction, accompanying with hyperinflation with 150% of patient’s tidal volume at most 8 breaths/40 seconds delivered by ventilator and prohibiting normal saline instillation into trachea for diluting the sputum. The grades of the recommendations in the guideline were rated with using of the SIGN grading system. The implementation potential was analyzed by the patients’ characteristics, transferability of the findings, feasibility of implementation and cost-benefit ratio. A 12-month implementation program was developed including communication with stakeholders, 4-week pilot testing, and training of ICU staffs, and implementation of OES guideline. The effectiveness of the guideline will be evaluated based on the primary outcome (i.e. oxygen level in blood) for detecting the incidence of hypoxemia. Also, the acceptability of the guideline, compliance of the guideline, financial cost reduction and better quality of service will be used as other evaluation indicators. / published_or_final_version / Nursing Studies / Master / Master of Nursing

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Athletes wear mouthguards to decrease the risk of injuries. However, many athletes resist wearing mouthguards due to problems with speech and breathing during play. Breathing difficulties may suggest limitations with ventilation. The purpose of this study was to examine peak inspiratory and peak expiratory air flow at different ventilatory rates using various types of mouthguards and a no mouthguard condition. Mouthguards were fitted into a dental model and air was ventilated through the model at three flow rates (30, 45, 60 strokes·min-1) using 2 and 3 L syringes. Flows were recorded using a Medisoft Ergocard. Peak flows (L·s -1) were recorded for 10 strokes during each condition. At 180 L·min -1, only bimolar mouthguards impeded air flow compared to the no mouthguard condition. In addition, the Shock Doctor bimolar mouthguard experienced decreased peak values compared to several mouthguards. Results suggest that peak flow is lowered at high ventilation with bimolar mouthguards.

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