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.
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
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.
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.
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
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
Metabolic & haemodynamic
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
Metabolic & haemodynamic
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
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.
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