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O54 Critical Crae patients experience of helmet continuous - Slide 1

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    O54 Critical Crae patients experience of helmet continuous - Slide 1 O54 Critical Crae patients experience of helmet continuous - Slide 1 Presentation Transcript

    • 2
      Critical Care Patients Experience of Helmet Continuous Positive Airway Pressure (CPAP)
      Andrew Dimech
      CNS Cancer Critical Care
    • 3
      Rationale
      The patient experience of health care and health care provision recently become more widely researched.
      Continuous Positive Airway Pressure (CPAP) is a common treatment modality for acute respiratory failure.
    • 4
      Rationale
      Historically a tight fitting mask is used to provide respiratory support.
      Risks to the patient including facial pressure areas, pain and discomfort.
    • 5
      Rationale
      The Helmet CPAP is a new product that provides the same treatment with a different method of delivery.
      Effectiveness between the two approaches is comparable although there is no evidence to date explaining patient perception of the new Helmet modality.
    • 6
      Aim
      To explore critical care patient’s experience of Helmet CPAP.
    • 7
      Helmet CPAP
      High flow oxygen / air mix
      Increased pressure to keep alveoli open (Positive End Expiratory Pressure - PEEP)
    • 8
      Literature Themes
      `
      Healthy Volunteers
      - Helmet versus Face
      Mask
      - Physiological Effects
      - Carbon Dioxide
      Retention / Washout
      - Noise Exposure
      Acutely Unwell
      - Helmet versus Face Mask in Hypoxemic Acute Respiratory Failure
      - Helmet versus Face Mask in Immunocompromised
      CPAP Helmet
      Chronic Conditions (Facial CPAP)
      - Obstructive Sleep
      Apnoea
    • 9
      Research Design
      Qualitative approach
      Descriptive phenomenological methodology.
      Interviews with cues provided the platform for data generation and collection
      A thematic framework was utilised with emergent themes manually analysed
      A constant comparative technique used to express the experiences or phenomena of a particular event or experiences.
    • 10
      Thematic Network(Adapted from Attridge-Stirling 2007)
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Organising Theme
      Organising Theme
      Organising Theme
      Organising Theme
      Global Theme
      Global Theme
      Organising Theme
      Organising Theme
      Organising Theme
      Organising Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
      Basic Theme
    • 11
      Sample
      The study included six patients
      All developed acute respiratory failure upon admission or during their inpatient stay in a critical care unit
      All the patients have been treated with Helmet CPAP
      The patients were introduced to the research via the Critical Care Outreach Team (CCOT) utilising convenience sampling
    • 12
      Findings - Themes
      Entrapment
      Confusion
      Helping me breathe
      Liberation
      Challenges
      Apprehension
      Relief
      Trust
      Endurance
    • 13
      Entrapment
      The overwhelming feeling of entrapment was expressed by patient F with feelings of being locked in somewhere (F31)……, restricted (F45) and there was no escape (F32).
    • 14
      Helping me breathe
      It was easier than…..easier than the mask (B36).Compared to this mask that (Helmet CPAP) regulates the oxygen very well. It’s a……in terms of ah…… other than you’re all tied up and so on……because its part of the ready flow of oxygen its much easier to breath rather than leaking here……leaking there and so on (B59).
    • 15
      Liberation
      Patient D found that he had a reasonable amount of freedom which made his experience more bearable. It wasn’t noisy like nebulisers and ah you were able to speak to people whilst you had it on…… you know it really gives you a great deal of freedom in that point of view you know and I thought that was ah quite outstanding (D35).
    • 16
      Findings
      The overall experience was unique to each patient.
      The patients entrusted the healthcare team which made the experience more tolerable.
      Paradoxical themes were experienced during treatment.
    • Findings
      • Placing Helmet ‘out of sight’ during rest periods
      • Further staff education regarding duration, set up etc
      • No mention of cancer
      • The desire to survive the acute illness proved to be a driving factor.
      17
    • 18
      Conclusion
      The study has provided an insight into the patient’s experience of Helmet CPAP in the critical care setting.
      The findings have provided a basis for policy and guideline development.
      It will also assist in developing future patient focused care.
    • ARDSPast, Present and Future
      Richard Spooner
      Intensive Care Unit
      Medway NHS
      Foundation Trust
    • What is ARDS?
      1st described by Ashbaugh in the 1960’s
      He described 12 adult patients with similar respiratory problems.
      Syndrome can occur in children and adults
      It is the most severe form of acute lung injury
      High mortality rate
      No real definition of syndrome until 1994
    • American-European Consensus Conference Committee
      Recognises severity of the injury
      Simple definition
      Recognises that ALI is a precursor to ARDS
    • Acute Onset
      Bilateral Infiltrates on CXR
      PAWP <18mmHg (if no PAC, then there should be no clinical evidence of LVF)
      PaO2 : FiO2 Ratio (P/F Ratio) < 26.7kpa
      If P/F Ratio < 40kpa, ALI is considered
    • Pathophysiology
      Systemic or pulmonary inflammatory response
      Release of cytokines and other inflammatory molecules
      Alveolar macrophages activated
      Neutrophils recruited to the lungs
      Oxidents, Leukotrienes and proteases released which damage capillary and alveolar epithelium
    • Pathophysiology
      Barriers between capillaries and air spaces are damaged
      Oedema fluid, protein and cellular debris flood the air spaces and interstitium
      Reduced surfactant produced
      Airspace collapse
      Ventilation/perfusion mismatch
    • Causes of ALI/ARDS
      Direct Lung Injury
      Aspiration
      Pneumonia
      Lung contusion
      Drowning
      Embolism
      Gas inhalation
      Indirect Lung Injury
      Sepsis
      Trauma
      Hypovolaemia
      Burns
      Overdose
      Massive blood transfusion
      Pancreatitis
    • Mortality Rate
      Was as high as 40-60%
      Better ventilation strategies, now around 25-40%
      Death often caused by MOF and sepsis
      Variations in rates due to age, severity of disease and presence of other factors
    • Management Options
      Ventilatory strategies
      Proning
      Nitric oxide
      Steroids
      Fluid management
      Surfactants
    • Ventilatory Strategies
      Probable reason for decline in mortality rates
      ARDSnet guidelines
      6ml per kg PBW tidal volume
      High level of PEEP
      High respiratory rate to maintain minute volume
      Plateau pressure management
      Permissive hypercapnoea
      Ph management
    • Oscillatory Ventilation
      Gives sub dead space tidal volumes (1-3mls/kg)
      Higher levels of PEEP
      Reduce risk of alveolar collapse
      Due to high frequencies CO2 levels maintained
      Has often been used as a rescue therapy
      Widely used in treatment of neonates and pre-term infants
    • Proning
      The big nugget
      Does it or doesn’t it work?
      Improves oxygenation, but not outcome
      2006 study prolonged proning (20 hours) may reduce mortality.
      Exact mechanism widely debated
      Theoretical benefit of redistribution of ventilation and perfusion ………
      but
    • There can be Problems
      Very labour intensive
      Risk of dislodging of ETT and lines
      Severe facial oedema
      ‘Ventilator eye’
      Pressure ulceration
      Emergency treatment may be delayed
    • Steroids
      In theory, anti-inflammatory, should work
      No benefit demonstrated
      Some studies have found increased complications and mortality
    • Surfactant
      Introduced via bronchoscopy or inhalation
      No evidence of long term benefit
    • Nitric Oxide
      Acts as a selective pulmonary vasodilator
      Binds to haemoglobin
      Should increase perfusion of better ventilated areas
      No large studies to support wide use
    • Fluid Managaement
      FACTT Trial suggests conservative approach to fluids
      ARDSnet, reducing EVLW, oxygenation improves, but no increase in long term mortality
    • Some Studies
      CESAR
      BALTI II
      OSCAR
      The Future
    • Any Questions?
      Thank you for your time
    • Delirium Management - a Multidisciplinary Education Issue
      Marion L. Mitchell, L. Aitken & J. Abbey
      Griffith University: Research Centre for Clinical and Community Practice Innovation & Princess Alexandra Hospital,Australia.
    • 41
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Overview
      • What is known about delirium in ICU patients
      • Why it is a problem
      • What assessment tools are available
      • The importance of multidisciplinary education
      • How can screening be effectively introduced or compliance rates improved
      • Where to from here
    • 42
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Background – is Delirium a problem in ICU?
      • 92% of patients survive a critical illness (Bagshaw et al., 2009)
      • Up to 2 years after discharge, psychological morbidity & neurocognitive compromise are reported in >50% of ICU patients (Herridge et al., 2003)
      • Delirium has been found in 4 studies to be a predictor of cognitive impairment in non-ICU patients (Jackson et al., 2004)
      • Rates of delirium in ICU patients vary from 11% to 87% of patients (Girard et al., 2008; Shehabi et al., 2008)
    • 43
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      ICU staff’s views on Delirium
      • 92% of Health Care Professionals (n=912) considered delirium to be a very serious problem in ICU (Ely et al., 2004)
      • 86% consider delirium is under diagnosed in ICU
      (Patel et al., 2009)
      • Is there a link between delirium in ICU & long term patient outcomes?
    • 44
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Impact of Delirium on Patients
      • Ely & colleagues (2009) found delirium to be an independent predictor of mortality at 6 months post discharge (n=275)
      • More recently, Girard et al. (2010) found delirium affected cognitive impairment at 3 & 12 months post discharge
      This study found an association between duration (in days) of delirium and poor cognitive function when all other variables were controlled.
    • 45
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Why worry about Delirium?
      • It is not ‘nice’ for the patient, their family & the staff
      • Higher mortality (Ely et al., 2004)
      • Prolonged duration of ICU stay (Ely et al., 2001)
      • Prolonged hospital stay (Thomason et al., 2005)
      • Greater health care costs (Milbrandt et al., 2004)
      • Long-term cognitive impairment (Girard, 2010).
    • 46
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Pre-disposing Factors:
      • Inadequate pain relief
      • Hypoxaemia
      • Acidosis
      • Severe infection
      • Advanced age
      • Immobilisation
      • Frustration
      • Patient/ventilator desynchrony
      • Drug interaction
      • Metabolic & haemodynamic
      instability
      • Drug side effects
      (Borthwick et al., 2006)
    • 47
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Types ofDelirium
      Hyperactive – characterised by agitation, restlessness, emotionally labile
      • These behaviours are outwardly obvious & therefore more easily recognised
      Hypoactive – withdrawal, decreased responsiveness, apathy, misdiagnosed as depressed
      • These behaviours are less obvious & therefore more difficult or not recognised
      3.Mixed – combination of 1) & 2)
    • 48
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Assessment Tools
    • 49
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      CAM - ICU
      Two step process:
      Initial assessment of level of sedation using Richmond Agitation- Sedation Scale (RASS). If score is between -3 (moderate sedation) & +4, go to Step 2
      Assess for acute onset of mental status changes, inattention, altered level of consciousness & disorganised thinking using CAM-ICU
    • 50
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Pre-disposing factors:
      • Inadequate pain relief
      • Hypoxaemia
      • Acidosis
      • Severe infection
      • Advanced age
      • Immobilisation
      • Frustration
      • Patient/ventilator desynchrony
      • Drug interaction
      • Metabolic & haemodynamic
      instability
      • Drug side effects
      (Borthwick et al., 2006)
    • 51
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Who needs to know about Delirium?
      • Multidisciplinary team approach
      Screening is one thing, acting on assessment is another
      • Medical team input with understanding of problem & acknowledgement of short & long-term adverse patient outcomes (i.e. attitudes & beliefs)
      • Nurses are at bed-side, so probably best placed to screen for delirium – but not in isolation….
    • 52
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      How can Delirium Screening be effectively introduced/improved in our ICU?
      • Planned approach to introduction of screening
      All team members need shared understanding & acknowledgement that delirium is problematic for our patients.
      Once screened, shared understanding of possible actions to take is very important.
    • 53
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Strategies to improve Delirium Screening
      • Any new program needs champions
      • Need written policies & procedures
      • Clear instructions on how to record results
      • Easy access to tool – one at each bed-side/flow sheet
      • Planned systematic EDUCATION of medical & nursing staff prior to its introduction
      (Devlin et al., 2007)
    • 54
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      Strategies to improve Delirium Screening
      • Incorporate delirium screening results into all ‘rounds’
      • Continuous quality monitoring to evaluate compliance with the protocol
      Page et al. (2009) in UK unit – 92% compliance using CAM-ICU
      Pun et al. (2005) – in USA - [n=10,037 assessments] – 87% compliance using CAM-ICU
    • 55
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      • Poor outcomes associated with delirium can be overcome with education
      • Education of staff should include the following areas:
      • Understanding of adverse patient outcomes associated with delirium
      • Agitation measured in the SAS and RASS is only one facet of delirium
      • Routine education into the implementation of a validatedinstrument to detect delirium in ICU patients (verbal and non-
      verbal), eg. CAM-ICU
      • Protocols forICUs in the area of analgesia-delirium-sedation
      • Upon detection of delirium strategies include:
      • Earlyintervention to reduce to severity
      • Assessment of sedation andanalgesic medicationsbeing used
      • Early involvement of family members
      • Optimisingpatient communication, using visual and hearing aidswhere required
      • Orientation and reorientation of patients
      • Anxietyreduction, including pre-operative medical assessment where possible and music therapy
      Conclusions
      • Delirium is a widespread problem in ICU that has not universally been
      appropriately recognised or treated
      • There are reliable, valid & feasible tools available
      • Planned education of multidisciplinary team essential
      • Care options need to vary depending on outcome of screening
      • Long term outcomes of ICU care need to be a focus for future research
    • 56
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
      References
      Bagshaw SM. et al. (2009). Very old patients admitted to intensive care in Australia and New Zealand: a multi centre cohort analysis. Crit Care 13,(2)R45. doi:10.1186/cc7768.
      Bergeron N. et al. (2001). Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med, 27(5), 859-64.
      Borthwick M. et al. (2006). Detection, prevention and treatment of delirium in critically ill patient. http://www.ukcpa.org/ukcpadocuments/6.pdf.
      Devlin JW. et al. (2007). Delirium assessment in the critically ill. Intensive Care Med, 33:929-40.
      Ely EW. et al. (2001). Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med, 29(7), 1370-79.
      Ely EW. et al. (2001). The impact of delirium on in ICU on hospital length of stay. Inten Care Med, 27:1892-1900.
      Ely EW. et al. (2009). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA;291(14),173-62.
      Girard TD. Et al. (2008). Delirium in the intensive care unit. Crit Care;12 Suppl 3:S3.
      Herridge MS.et al.(2003). One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med; 348:683-93.
      Immers H E. et al. (2005). Recognition of delirium in ICU patients: a diagnostic study of the NEECHAM confusion scale in ICU patients. BMC Nurs, 4, 7.
      Jackson JC. et al. (2004). The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev; 14:87-98.
      Milbrandt EB. et al.(2004). Costs associated with delirium in mechanically ventilated patients. Crit Care Med, 32:955-62.
      Neelon VJ. Et al. (1996). The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res, 45(6), 324-30.
      Otter H. et al. (2005). Validity and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care, 2(2), 150-58.
      Page V. et al. (2009). Routine delirium monitoring in a UK critical care unit. Crit Care, 13:R16(doi:10.1186/cc7714).
      Thomason JW. et al. (200). ICU delirium is an independent predictor of long term hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 9:R375-R381.
    • 57
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
    • 58
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation
    • 59
      School of Nursing and Midwifery
      Research Centre for Clinical and Community Practice Innovation