Thesis--Wisconsin. / Includes bibliographical references (leaves 82-83).

Ventilator associated pneumonia (VAP) is a nosocomial infection that is acquired in critically ill patients 48 hours or more after intubation. Many interventions have been studied to reduce or prevent patients from acquiring VAP. This integrated literature review examines empirical evidence related to suctioning techniques that reduce or prevent the acquisition of VAP. Oral and subglottic secretion suctioning were examined in depth. It is concluded that the intervention of oral and subglottic secretion suctioning was shown to reduce the incidence of VAP in adult patients.

Ventilator-associated pneumonia (VAP) is the leading healthcare-acquired infection among ventilated patients in intensive care units (ICU). VAP is a serious patient complication that results in increased hospital length of stay, cost, morbidity, and mortality. The accumulation of subglottic secretions above the endotracheal tube (ETT) cuff increases the risk of VAP, as these secretions may leak around the cuff of the ETT resulting in aspiration and an increased risk for infection. An in depth literature review was done to determine the effectiveness of subglottic secretion aspiration (by means of specialized ETT tubes with intrinsic suction lumens) in decreasing the incidence rate of VAP. Evidenced-based data were gathered from the CINAHL Plus with Full Text, PubMed, and Cochrane Database of Systematic Reviews databases for this review. VAP guidelines recommend subglottic secretion aspiration as a means to prevent its occurrence. However, important variables such as suction pressure, frequency, secretion viscosity, and ETT cuff pressure and volume need to be considered. The interaction among these variables determines the effectiveness of subglottic secretion removal. The goal of this review was to highlight these interactions and provide evidenced-based information for critical care nurses to expand their understanding of the dynamics involved in subglottic secretion aspiration and how to efficiently use this practice to prevent VAP.

Neonatal Intensive Care Units have experienced profound advances in technology and treatment modalities over the last two decades. Infants born at the edge of viability are now surviving despite prolonged hospitalizations. These infants born preterm are prone to a high degree of stress from life sustaining and routine interventions. Much focus has been directed toward addressing noxious environmental factors such as noise, light, and infectious disease; however, little has been done to examine the stress experienced by the professional caregiver who work in these environments. Environmental press theory, which focuses on the interplay between human beings and their surroundings, is explored as a way to provide insight into understanding and mitigating the stress experienced by health care providers working in the newborn intensive care. A proposal for a research study with a cross-over design was approved to study the effect of “four handed care” on infants’ physiologic responses (oxygenation, heart rate, and stress) and behavioral responses (state, stress and defense, self-regulatory and approach behaviors) to and recovery from endotracheal suctioning when compared to routine care. Results of this study demonstrated no significant differences were noted when heart rate (HR) or oxygen saturation (SpO2) taken at baseline were compared to HR and SpO2 obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from pre-observation 95.49 to during observation saturation 97.75 (p = 0.001). Salivary cortisol did not differ between groups at baseline or post-suctioning. There was no significant difference in behavior state between the two conditions at any time point. More stress and defense behaviors were seen post-suctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care as opposed to routine care. There was no statistical difference in the number of monitor call-backs post-suctioning. In conclusion, four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. These findings, while based on a small sample, provide modest evidence that the four-handed care intervention for suctioning should receive further testing. Interventions such as four-handed care that are theoretically developmentally supportive of the sick preterm infant, need further research attention before recommending widespread adoption.

Submitted by Livia Mello (liviacmello@yahoo.com.br) on 2016-09-21T13:37:44Z No. of bitstreams: 1 TeseJRFV.pdf: 1887832 bytes, checksum: 38c7ad86f5a7507d3bdab8237dbc37d3 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-09-21T18:36:09Z (GMT) No. of bitstreams: 1 TeseJRFV.pdf: 1887832 bytes, checksum: 38c7ad86f5a7507d3bdab8237dbc37d3 (MD5) / Approved for entry into archive by Marina Freitas (marinapf@ufscar.br) on 2016-09-21T18:36:17Z (GMT) No. of bitstreams: 1 TeseJRFV.pdf: 1887832 bytes, checksum: 38c7ad86f5a7507d3bdab8237dbc37d3 (MD5) / Made available in DSpace on 2016-09-21T18:36:27Z (GMT). No. of bitstreams: 1 TeseJRFV.pdf: 1887832 bytes, checksum: 38c7ad86f5a7507d3bdab8237dbc37d3 (MD5) Previous issue date: 2015-12-16 / Não recebi financiamento / Endotracheal suction (ES) in mechanically ventilated patients is required for maintaining a patent airway. Open circuit endotracheal suction (OCES) may cause greater damage to respiratory mechanics and gas exchange. There is little evidence about the impact of the use of oxygen concentrations below 100% and the expiratory pressure-zero end expiratory pressure (PEEP-ZEEP) technique at increasing oxygenation and maintaining adequate ventilation during the OCES. In addition studies were not found concerning need or not of hyperoxygenation associated with the PEEP- ZEEP and the effectiveness of isolated hyperoxygenation with oxygen concentration 20% above the baseline, thus justifying the studies of this thesis. Study I aimed to evaluate whether the 20% oxygen concentration of inspired oxygen fraction (FiO2) above the baseline avoids hypoxemia compared the offer to 100% and determine the impact of OCES on pulmonary ventilation in critical patients on mechanical ventilatory support. This randomized crossover study involved 68 patients in an adult intensive care unit (ICU), intubated, mechanically ventilated and placed in the two intervention sequences: Hyperoxygenation using 20% above FiO2 (FiO2 20%) and Hyperoxygenation using 100% FiO2(FiO2 100%). Hyperoxygenation was applied 1 min before each of the 5 ES and 1 min after OCES. The studied variables were measured pre, immediately after and 1min, 2 min and 30 min after OCES. There was a significant intra-group increase in immediate post FiO2 20% and 100% on peripheral oxygen saturation (SpO2), carbon dioxide (CO 2) exhaled at the end of expiration (ETCO2), partial pressure of CO2 in the mixed expired air (PeCO2 ), heart rate (HR), mean arterial pressure (MAP), and in the tidal volume of CO2 (VtCO2) only for the FiO2 20%. Intergroup in the immediate post in VtCO 2, ETCO2 and SpO 2 restoring the pre intervention values 30 min after measurement. It was concluded that an oxygen concentration of 20% above baseline FiO2 for patients with need of prior offer  60% effectively avoided hypoxemia and volumetric capnography analysis confirms that changes in pulmonary ventilation in OCES in critical patients are transient and reversible within 30 min. These findings also support the implementation of Study II which aimed to verify behavior of peripheral oxygen saturation (SpO2) and exhaled end- expiratory CO2 (ETCO2), for the OCES procedure, using PEEP-ZEEP baseline FiO2 versus PEEP-ZEEP hyperoxygenation using 20% above FiO 2. This randomized crossover study involved 38 patients in an ICU, intubated, mechanically ventilated and placed in the two intervention sequences: PEEP-ZEEP with baseline FiO2 (PEEP-ZEEP FiO2 baseline) and PEEP-ZEEP with 20% above FiO2 (PEEP-ZEEP hyperoxygenation). Hyperoxygenation was applied 1 min before each of the 5 procedures and 1 min after OCES. PEEP-ZEEP with 3 series before each of the 5 ES. The studied variables were measured pre, immediately after and one, two and 30 min after OCES. There was significant increase in SpO2 on PEEP-ZEEP hyperoxygenation, with maintenance of adequate levels on PEEP-ZEEP FiO2 baseline no change in ETCO2 in both interventions. Significant difference was found in intergroup SpO2 post 1 min of hyperoxygenation, immediate post, post 1and 2 min of OCES. Significant difference was found in intergroup SpO2 post 1 min of hyperoxygenation, immediate post, post 1 and 2 min of OCES. It was concluded that the PEEP-ZEEP technique, when well indicated, associated or not to hyperoxygenation is effective to avoided the fall of SpO2 and maintain levels of ETCO2, minimizing the impairment in the ventilation caused by OCES. / A Aspiração endotraqueal (AE) em pacientes ventilados mecanicamente é necessária para manutenção da permeabilidade das vias aéreas. A AE em sistema aberto (AESA) pode causar maior prejuízo na mecânica respiratória e trocas gasosas. Existem poucas evidências sobre o impacto de concentrações de oxigênio menores que 100% e da técnica de pressão expiratória final positiva - pressão expiratória final zero (PEEP- ZEEP) na oxigenação e ventilação durante a AESA. Também não foram encontrados estudos abordando a necessidade ou não de hiperoxigenação associada à PEEP-ZEEP e sobre a efetividade isolada da hiperoxigenação com concentração de oxigênio de 20% acima da basal em adultos. Justificando assim, a realização dos estudos desta tese. O Estudo I foi realizado com os objetivos de avaliar se a hiperoxigenação com fração inspirada de oxigênio (FiO 2) de 20% acima da basal evita a hipoxemia comparado a oferta de FiO2 à 100%, além de determinar o impacto da AESA na ventilação pulmonar de pacientes críticos em suporte ventilatório mecânico. Estudo, randomizado e cruzado, envolvendo 68 pacientes de uma Unidade de Terapia Intensiva (UTI) adulto, intubados e alocados por sorteio simples em duas sequências de intervenção: Hiperoxigenação com FiO2 de 20% acima da basal (FiO2 20%) e Hiperoxigenação com FiO2 100% (FiO2 100%). A hiperoxigenação foi aplicada 1 min antes de cada um dos 5 procedimentos e 1 min após o procedimento. As variáveis estudadas foram medidas pré, imediatamente após e após 1 min, 2 min e 30 min da AESA. Constatou-se aumento significativo intragrupo no pós imediato nas intervenções FiO2 20% e 100% na saturação periférica de oxigênio (SpO2), dióxido de carbono (CO2) exalado ao final da expiração (ETCO2), pressão parcial mista expirada de CO 2 (PeCO2), frequência cardíaca (FC), pressão arterial média (PAM) e, no volume corrente de CO2 (VtCO2) apenas na FiO2 20%. E intergrupos no VtCO2, ETCO2, e na SpO2, no pós imediato, com restabelecimento aos valores pré intervenção 30 min após. Concluiu-se que a hiperoxigenação com FiO2 de 20% acima da basal evitou a hipoxemia e, a análise de capnografia volumétrica confirmou a ocorrência de alterações transitórias na ventilação pulmonar na AESA, sendo possível observar neste estudo, a reversibilidade em 30 min. Esses achados impulsionaram a realização do Estudo II, com objetivo de analisar o comportamento da SpO2 e do ETCO2 na AESA, utilizando PEEP-ZEEP com FiO2 basal versus PEEP-ZEEP associada a hiperoxigenação com FiO2 de 20% acima da basal. Estudo, randomizado cruzado, envolveu 38 pacientes de uma UTI adulto, intubados e alocados em duas sequências de intervenção: PEEP-ZEEP com a FiO2 em uso (PEEP-ZEEP FiO2 basal) e PEEP-ZEEP com FiO2 de 20% acima da basal (PEEP-ZEEP hiperoxigenação). A hiperoxigenação foi aplicada 1 min antes de cada um dos 5 procedimentos e 1 min após o procedimento e a PEEP-ZEEP com 3 séries de 60 s antes de cada um dos 5 procedimentos de AESA. As variáveis estudadas foram medidas pré, imediatamente após e após 1 min, 2 min e 30 min da AESA. Constatou-se aumento significativo da SpO2 na PEEP-ZEEP hiperoxigenação e com manutenção de níveis adequados na PEEP-ZEEP FiO2 basal, com manutenção do ETCO2 em ambas as intervenções. Observou-se diferença significativa intergrupos na SpO2 no pós 1 min da hiperoxigenação, pós imediato, 1 min e 2 min após intervenção. Concluiu-se que a técnica PEEP-ZEEP quando bem indicada, associada ou não à hiperoxigenação é eficiente para evitar a queda da SpO2 e em manter os níveis do ETCO2, minimizando o prejuízo na ventilação provocado pela AESA.

Introduction: The use of high frequency oscillatory ventilation is increasing in treatment ofacute respiratory distress syndrome over the past decade. The technique of HFOV of ventilatingthe lungs at volumes less than the anatomical dead space calms the clinical concerns surroundingventilating stiff ARDS lungs with high pressures and volumes. This largely reduces theprobability of barotraumas and/or atelectrauma. Purpose: The study was on an in vitro bench model that answered the following researchquestions: 1. The effect of three inline closed suction adapters on delivered tidal volume duringHFOV with varying lung compliance 2. The effect of varying compliance on the amplitudedelivered by HFOV; and 3. The effect of compliance on tidal volume delivered by HFOV. Method: An in vitro bench model using high fidelity breathing simulator (ASL 5000, IngMarMedical) simulating an adult patient with ARDS was set up with 3100B SensorMedic highfrequency ventilator. The simulation included varying the compliance for each lung at 50, 40, 30and 20cmH2O while maintaining fixed resistance of 15 cmH2O/L/sec. The ventilator was set tothe following parameters: power of 6, frequency (f) of 5, inspiratory time (Ti) of 33%, bias flow(BF) of 30 LPM and oxygen concentration of 50%. The breathing simulator was connected withthe high frequency ventilator using a standard HFOV circuit and a size 8.0mm of endotrachealtube. Fourteen French Kimberly Clark suction catheters (with T and Elbow adapters) and Air-Life suction catheters (Y adapter) were placed in-line with the circuit successively to carry outthe study. Each run lasted for 1 minute after achieving stable state conditions. Thisapproximated to 300 breaths. The data was collected from the stimulator and stored by the hostcomputer. Data Analysis: The data was analyzed using SPSS v.11 to determine the statistical significance.A probability value (P value) of ≤ 0.001 was considered to be statistically significant. Results: The data analysis showed that Air-Life Y-adapter suction catheters caused the least lostin tidal volume when placed in line with HFOV and hence proved to be the most efficient. Thestudy also showed a direct relationship between amplitude and lung compliance i.e. an increasein lung compliance caused an associated increase in amplitude (power setting remainingunaltered). Lastly, the study did not show a statistically significant change in tidal volume withchanges in lung compliance. Future studies may be required to further evaluate the clinicalsignificance of the same. Conclusion:1. Many factors affect delivery of tidal volume during high frequency ventilation and thus it isnot constant. Choice of in-line suction system to be placed in line is one of the determinants ofthe same.2. Lung compliance changes lead to associated changes in amplitude delivery by HFOV. Thisshould be adjusted as patient condition improves by altering the power settings to ensure optimalventilation and to avoid trauma to the lungs.

Tracheostomos priežiūros veiksmai bei sekreto išsiurbimo iš tracheostominio vamzdelio technika gali įtakoti komplikacijų dažnumą ir lemti paciento saugumą, pasveikimo galimybę, gydymo trukmę bei gydymo kainą. Svarbu, kad slaugytojai žinotų mokslo tyrimais pagrįstas rekomendacijas apie tracheostomos priežiūrą ir jas pritaikytų klinikinėje praktikoje. Tyrimo tikslas – Išanalizuoti slaugytojų žinias ir įgūdžius atliekant tracheostomos priežiūrą. Tyrimo uždaviniai. 1.Ištirti slaugytojų žinias apie tracheostomos priežiūrą prieš ir po mokymų. 2. Nustatyti slaugytojų įgūdžius atliekant tracheostomos priežiūros veiksmus. 3. Palyginti slaugytojų žinias apie tracheostomos priežiūrą ir jų taikymą praktikoje. Tyrimo metodai: Tyrimas buvo vykdomas 2013.04.20–12.20 LSMUL Kauno Klinikų keturiuose skyriuose bei vienoje iš Slaugos ir palaikomojo gydymo ligoninių. Tyrimo duomenims rinkti buvo naudojamas tyrimo autorių sukurta anketa ir slaugytojų praktikinių veiksmų stebėjimo protokolas. Slaugytojų anketinė apklausa buvo vykdoma du kartus: prieš (n=90, atsako dažnis–96,77 proc.) ir po (n=86, atsako dažnis–92,47 proc.) mokymo. Stebėtos 99 sekreto išsiurbimo iš tracheostomos vamzdelio procedūros. Tyrimui atlikti buvo gautas LSMU Bioetikos centro pritarimas BEC-KS(M)-198. Išvados. 1. Prieš mokymus didžioji dalis slaugytojų teisingai žinojo požymius, rodančius siurbimo poreikį, sekreto išsiurbimo trukmę, kiek giliai įvesti atsiurbimo kateterį, galimas sekreto siurbimo komplikacijas. Po mokymo... [toliau žr. visą tekstą] / Actions of tracheostomy care as well as the technique of secretion suctioning from tracheostomy tube can influence the incidence of complications and determine patient‘s safety, possibility of recovery, the duration of treatment and the cost of treatment. It is critical for nurses to be aware of tracheostomy care recommendations based on scientific research and to apply them in clinical practice. The aim – to analyze nurses’ knowledge and skills in tracheostomy care. Objectives:1.To examine nurses’ knowledge on tracheostomy care prior to training and after the training. 2. To identify nurses’ skills while performing actions of tracheostomy care. 3. To compare nurses’ knowledge on tracheostomy care and their application in practice. Research methods: The research was conducted on 20-04-2013 - 20-12-2013 at the hospital of Lithuanian University of Health Sciences Kauno Klinikos in four departments and in one of the Nursing and supportive care hospital. A questionnaire created by the authors of the research and an observation protocol of nurses’ actions in practice was used to collect the data of the research. A survey on nurses’ was conducted twice: prior to training (n=90, response rate – 96.77%) and after the training (n=86, response rate – 92.47%). We observed 99 procedures of secretion suctioning from tracheostomy tube. The research was conducted with the approval BEC-KS (M)-198 from the center of Bioethics of Lithuanian University of Health Sciences. Conclusions. 1... [to full text]