No description available.

Goal Due to the development of medical technology, implementation of national health insurance (NHI) program and population aging, the increasing of ventilator-dependent patients are significant within these years. Patients with the catastrophic illness certification spent about 26.2% NHI medical resource. Oncology, hemodialysis and ventilator-dependent patients were thought to be the most resource utilized ones. The objective of this study was to find the possible risk of reintubation on those ventilator-dependent patients. So, that we may reduce the reintubation rate and shorten their hospital stays. Method This study was a retrospective study based on the database of a local teaching hospital. During 2005 and 2010, patients aged older than 17 years old and required more than 3 weeks of mechanical ventilation support were selected. Here were total 313 cases include 247 successful weaning and 66 reintubation. Statistical analysis included descriptive statistic, Chi-square test and logistic regression by SPSS® for windows. Risk factors included their demographic features, acute physiology and chronic health evaluation (APACHE) II scoring system as well as laboratory data. Results The ages of successful weaning and reintubation patients were 72¡Ó15 vs. 76¡Ó15, p=0.092 years old, respectively. APACH II score (17¡Ó8 vs. 22¡Ó8, p<0.001), BUN (33.2¡Ó26 vs. 43.0¡Ó33 mg/dL, p=0.033), K+ (3.8¡Ó0.8 vs. 4.2¡Ó0.9 mmol/L, p=0.002), Ca+ (8.0¡Ó0.8 vs. 8.6¡Ó0.9 mmol/L, p=0.007), WBC (13880¡Ó7270 vs. 17720¡Ó9540, p=0.003), Hb (11.8¡Ó2.5 g/dL vs. 10.3¡Ó1.4 g/dL, p<0.001), Platelet (224400¡Ó106310 vs. 284570¡Ó119160,p=0.001). However, Logistic regression found two significant factors were APACHE II (odds ratio [OR], 2.97), Hb (OR, 0.701). By means of ROC curves, we derived the critical values of reintubation risk due to Hb as 11.3 g/dL respectively. Conclusion Based on the results, we inference that the reintubation risk increases up to 1.2 per unit APACHE II score while decreases 45% per unit Hb. It is suggested that if clinical physician could keep Hb of patients above 11.3 g/dL respectively, the reintubation rate may be significantly reduced.

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand / The purpose of this study was to determine the knowledge of nurses working in ICU with respect to evidence based guidelines for prevention of ventilator associated pneumonia. A non experimental, descriptive, correlational and contextual two phase research design was used. The first phase of the study consisted in validating the data collection instrument for applicability to the South African context. The second phase of the study used the instrument validated in phase one to test the knowledge of nurses working in ICU. Data analysis was done by means of descriptive and inferential statistics using frequency distributions, cross-tables, means, standard deviations and Pearson correlation coefficient. The knowledge of 83 nurses working in ICU from two hospitals of the private health sector and one hospital of the public health sector in Gauteng was tested using the data collection instrument validated by ICU nursing experts. Knowledge of ICU trained and non ICU trained nurses working in ICUs of the three hospitals was found to be lacking in the evidence based guidelines for prevention of ventilator associated pneumonia. Of the 83 participants, 18 (21.69%; CI 95% 13.4% ; 32.1%) achieved a pass mark of 70% on the multiple choice part of the questionnaire and were considered to have adequate knowledge on the evidence based guidelines for prevention of VAP. The mean score of participants was 4.25 (SD 1.537 CI 95% 3.92; 4.59) on nine questions. The difference in the mean average score of ICU trained nurses and non ICU trained nurses was very similar demonstrating no statistically significant difference in the knowledge of the two groups of nurses. A weak correlation between years working in ICU and knowledge was found, but this correlation may be clinically insignificant. Recommendations to address this lack of knowledge of ICU nurses were given for clinical nursing practice, nursing education as well as for nursing research.

Patient ventilator dyssynchrony (PVD) occurs frequently, but little is known about the types, frequency and patterns of PVD for longer than 30 minutes. Deeper levels of sedation are associated with PVD. Evaluation of ventilator graphics and the ability to identify PVD should assist clinicians to optimize patient ventilator interactions and promote earlier interventions. The purpose of this study was to identify the different types, frequency and patterns of PVD in critically ill adults and determine the effect of sedation level on PVD. Thirty medical and surgical ICU adult patients were enrolled; 27 were used for analysis. Pressure/time and flow/ time waveform data were collected using the Noninvasive Cardiac Output monitor for up to 90 minutes per subject. Blinded waveform analysis was performed. Sedation level was measured every 20 minutes. A Dyssynchrony Index (DI) and PVD Type Indices were used to describe PVD frequency. Lag analysis was used to detect associated patterns of PVD. PVD occurred during all phases of ventilated breaths and during each of the ventilatory modes used. Heretofore undocumented dyssynchrony in the form of patient gasp PVD, active triggers and combined PVDs were found. The most common type of PVD was Ineffective Trigger (63%), followed by Premature Termination-Flow (17%), Premature Termination (9%), Multiple Trigger (1%), Flow (0.87%) and Delayed Termination (0.09%). The overall frequency of dyssynchronous breaths in the sample was 23% of total breaths analyzed, however 93% of subjects experienced at least one incident of PVD. The overall median DI (Interquartile Range [IQR]) was 4% (1% - 9%) with Ineffective Trigger Index having the highest median index (1.78%). The high DI group (6 subjects, 22%) had a DI (IQR) of 61% (42% - 85%). Seventy seven percent of subjects experienced multiple types of PVD. Premature Termination was followed by Multiple Triggers starting at 3 seconds, but Delayed Termination was followed by Ineffective Triggers, starting at 30 seconds. Clinicians need to recognize PVD, since this is a critical step in evaluating patient ventilator interaction and providing subsequent intervention. PVD interpretation is complex requiring clinicians to clearly understand the operational function of ventilator modes and waveform alterations that occur.

Ventilator-associated events (VAEs) are patients' complications of respiratory conditions including ventilator-associated pneumonia (VAP). Research shows that VAP is the most common hospital-acquired infection among ventilated patients and a leading source of mortality. With greater risk for complications among ventilated- supported patients, nurses working in the ICU must keep abreast of new knowledge and update expertise to develop technical and clinical skills in daily practice. The purpose of this project was to assess whether an educational intervention would increase the ICU nurses' level of knowledge of the evidence-based intervention. Knowles' adult learning theory was chosen for this project. A paired-samples t-test was conducted to examine nurses' knowledge of VAE/VAP using a questionnaire measuring knowledge of VAP; 58 ICU nurses participated an educational intervention. Findings showed that nurses had an increase in knowledge following the education (M = 11.43, SD = .775) compared to nurses prior to education (M = 9.55, SD = .976), t(57) = -26.884, p < .001. Results of this project may guide the use of an evidence-based practice educational intervention to improve the quality and safety of ventilated patients. The implications for positive social change include preventing VAEs/VAP among patients, thus decreasing the length of hospital stay, cost, and deaths related to ventilator infections.

No description available.

Positive pressure mechanical ventilation (MV) has been utilised in the care of critically ill patients for over 50 years. MV essentially provides for oxygen delivery and carbon dioxide removal by the lungs in patient with respiratory failure or insufficiency from any cause. However, MV can be injurious to the lungs, particularly when high tidal pressures or volumes are used in the management of Acute Respiratory Distress Syndrome (ARDS) or similar acute lung injuries. The hallmark of ARDS is extensive alveolar collapse resulting in hypoxemia and carbon dioxide retention. Application of Positive End Expiratory Pressure (PEEP) is used to prevent derecruitment of alveolar units. Hence, there is a delicate trade-off between applied pressure and volume and benefit of lung recruitment. Current clinical practice lacks a practical method to easily determine the patient specific condition at the bedside without excessive extra tests and intervention. Hence, individual patient treatment is primarily a mixture of "one size- fits-all" protocols and/or the clinician's intuition and experience. A quasi-static, minimal model of lung mechanics is developed based on fundamental lung physiology and mechanics. The model consists of different components that represent a particular mechanism of the lung physiology, and the total lung mechanics are derived by combining them in a physiologically relevant and logical manner. Three system models are developed with varying levels of physiological detail and clinical practicality. The final system model is designed to be directly relevant in current ICU practice using readily available non-invasive data. The model is validated against a physiologically accurate mechanical simulator and clinical data, with both approaches producing clinically significant results. Initial validation using mechanical simulator data showed the model's versatility and ability to capture all physiologically relevant mechanics. Validation using clinical data showed its practicality as a clinical tool, its robustness to noise and/or unmodelled mechanics, and its ability to capture patient specific responses to change in therapy. The model's capability as a predictive clinical tool was assessed with an average prediction error of less than 9% and well within clinical significance. Furthermore, the system model identified parameters that directly indicate and track patient condition, as well as their responsiveness to the treatment, which is a unique and potentially valuable clinical result. Full clinical validation is required, however the model shows significant potential to be fully adopted as a part of standard ventilator treatment in critical care.

Surveillance of ventilator-associated pneumonia (VAP) has been the common outcome measurement used for internal and external benchmarking for mechanically ventilated patients; and although not a clinical definition, it is commonly used as an outcome measurement for research studies. Criteria in the VAP definition include both subjective and objective components, leading to questions of validity. In addition, recent legislation has mandated the public reporting of healthcare-associated infections, including VAP, in many states. Infectious disease experts have recently recommended monitoring a new outcome, ventilator-associated events (VAE), that contain specific objective criteria. The Centers for Disease Prevention and Control (CDC) have refined this definition and released a new VAE protocol and algorithm, replacing the VAP surveillance definition, as a result. The VAE protocol assesses for ventilatorassociated conditions (VAC). The primary aims of this study were to determine the incidence of VAC; and to assess four predictors for VAC, including two VAP prevention strategies (use of the subglottic secretion drainage endotracheal-tube [SSD-ETT]), and daily sedation vacation); and two patient-related factors (alcohol withdrawal during mechanical ventilation, and history of COPD). In addition, the incidence for VAE, using a new national algorithm was determined. Using a retrospective study design, electronic medical records of 280 veterans were reviewed to identify cases of VAC using the VAE algorithm. The setting was two intensive care units (ICU) at a large Veterans Administration Healthcare System (VAHCS) from October 2009 to September 2011. In addition to demographic information, variables were collected to determine if cases met event criteria (VAC, infection-related ventilator-associated complication iii [IVAC], and possible or probable VAP). Incidence rates were calculated for VAC and IVAC. Comparative data between those with and without VAC were assessed with independent sample T-test or non-parametric equivalents. The study sample was predominantly male (97.1%), Caucasian (92.1%), non-Hispanic (90.7%); with a mean (SD) age of 67.2 (10.4) years. Twenty patients met the VAC definition resulting in a VAC incidence of 7.38 per 1000 ventilator days. There were no statistically significant differences in demographics or disease characteristics found between the two groups (patients with VAC and patients without VAC). Using logistic regression, the impact of the four predictors for VAC was assessed. None of the four explanatory variables were predictive of the occurrence of VAC. Secondary outcomes (e.g. mechanical ventilation days, ICU days, hospital days, and mortality) of veterans with VAC were compared to veterans without VAC. Results indicated that the VAC group was associated with a significantly longer duration of ICU stay, longer mechanical ventilation period, more likely to have a tracheostomy, and had a higher mortality during hospitalization. Expanding mechanical ventilation quality performance measures to include VAE/VAC provides a better representation of infectious and non-infectious ventilator-associated problems, and provides more accurate morbidity and mortality in this high-risk ICU population. Further research is necessary to explore patient characteristics and prevention strategies that impact the development of all VAC.

Auto-PEEP is auto positive end-expiratory pressure due to excessive amounts of alveolar gas produced by sustained recurrent incomplete exhalation. Incomplete exhalation occurs when the exhaled breath never reaches a flow rate of 0 L/min. The objective of this dissertation is to develop an automated detection system of auto-PEEP through incomplete exhalation as revealed by ventilator graphics for mechanically ventilated adults. Auto-PEEP can cause adverse effects if allowed to linger and if not quickly identified. An automated detection system will be instrumental in helping to quickly identify auto-PEEP. A computerized algorithm was developed to detect incomplete exhalation based on the following three parameters:1) Foi, was used to represent the value of the flow at the onset of inhalation, 2) ∆T, was used to represent the value of time difference between onset inhalation to the 0 L/min mark, and 3) slope threshold, a value set for the slope of change of flow over ∆T. Optimum parameters of the algorithm were achieved for Foi = -3 L/min, ∆T = 0.2 s, and slope threshold = 90 L-s/min. A novel data set was introduced to validate the algorithm, yielding no significant difference in true positive rates (t = 1.5, df = 12.402, p-value = 0.1408) and false positive rates (t = 1.9, df = 16.765, p-value = 0.0725) as outcomes for two-tailed t-tests comparing the novel and old data set. To determine the relationship between auto-PEEP and detection of sustained incomplete exhalation, a correlation of a linear model of the novel data set between auto-PEEP and the percentage of incomplete exhalation detection out of the existing breaths (index) was investigated. A linear model should interpret the index value that corresponds to significant auto-PEEP presence; unfortunately, no significant linear model was found between incomplete exhalation index and auto-PEEP (F1,62 = 1.67, p-value = 0.2010). However, there was a relationship between the intrinsic PEEP values and the incomplete exhalation index as functions of time. The automated detection algorithm produced by this work provides a non-invasive method of automatically detecting auto-PEEP.

Titel: Intensivvårdssjuksköterskors erfarenheter av att bedöma sederade patienter i ventilator: En kvalitativ intervjustudie. Bakgrund: Den kritiskt sjuke intensivvårdspatienten behöver såväl resurskrävande som komplicerad behandling. Sedering administreras till patienter i ventilatorbehandling för att lindra ångest och smärta. Intensivvården bygger på multiprofessionellt samarbete och strävar efter individuellt anpassad sedering för att upprätthålla komfortabel sederingsnivå. Riktlinjer och bedömningsskalor är viktiga hjälpmedel vid bedömning och titrering av sedering. Det är utmaningar i att vårda sederade patienter och det ställer stora krav på intensivvårdssjuksköterskan. Syfte: Syftet var att belysa intensivvårdssjuksköterskors erfarenheter av att bedöma sederade patienter i ventilator på intensivvårdsavdelning. Metod: Studien genomfördes med en kvalitativ design genom individuella semistrukturerade intervjuer med tio intensivvårdssjuksköterskor. Nio av deltagarna var kvinnor och en var man. Data analyserades genom kvalitativ innehållsanalys. Resultat: Studiens resultat frambringade i följande tema Bedömning – En väg av utmaningar som belyste intensivvårdssjuksköterskors erfarenheter av att bedöma sederade patienter i ventilator. Resultatet presenteras under två kategorier: Osäkerhet vid sederingsnivå och Brister vid sedering. Osäkerhet vid sederingsnivå blev påtaglig på grund av otydliga riktlinjer, svårigheter i att upprätthålla en individuell sederingsnivå och utifrån den komplicerade kommunikationen med patienten. Brister vid sedering blev påtaglig på grund av känsla av otillräcklighet och brist på både samarbete och kunskap försvårade ytterligare intensivvårdssjuksköterskans bedömning och titrering av sedering. Slutsats: Studien identifierar utmaningar som bidrar till osäkerhet och brister vid sedering. Dessa utmaningar bör förhindras genom utbildning för att bibehålla patientsäkerheten och möjliggöra god vård. Intensivvårdssjuksköterskan bör få insikt i de samhällsekonomiska vinster som god följsamhet till riktlinjer och bedömningsskalor frambringar.