Respiratory care
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Review
Methods for a Seamless Transition from Tracheostomy to Spontaneous Breathing in COVID-19 Patients.
The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. ⋯ In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.
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Mechanical ventilation is a supportive treatment commonly applied in critically ill patients. Whenever the patient is spontaneously breathing, the pressure applied to the respiratory system depends on the sum of the pressure generated by the respiratory muscles and the pressure generated by the ventilator. Patient-ventilator interaction is of utmost importance in spontaneously breathing patients, and thus the ventilator should be able to adapt to patient's changes in ventilatory demand and respiratory mechanics. ⋯ Asynchronies are relatively frequent during mechanical ventilation in critically ill patients, and they are associated with poor outcomes. This review summarizes the different types of asynchronies and their mechanisms, consequences, and potential management. The development and understanding of monitoring tools are necessary to allow a better appraisal of this area, which may lead to better outcomes for patients.
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The life expectancy of individuals with Duchenne muscular dystrophy has improved considerably with the use of mechanical ventilation to manage respiratory insufficiency. The choice between continuous noninvasive ventilation (NIV) and invasive ventilation is guided both by local logistical considerations and by clinical considerations, but the choice depends largely on patient preference. It is important to know the effects of ventilatory dependence and the method used (ie, continuous NIV or invasive ventilation) on subjects' quality of life. ⋯ Continuous and invasive mechanical ventilation did not affect the perception of quality of life for our subjects with Duchenne muscular dystrophy, apart from more insomnia, which can be explained by the fact that they required frequent repositioning in bed. Different pressure-relief mattresses should be tested and compared to prevent the development of pressure ulcers, which may improve the sleep patterns of these patients.
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The guidelines to conduct and interpret conventional pulmonary function (PFT) tests are frequently reviewed and updated. However, the quality assurance and quality control (QA/QC) guidelines for respiratory oscillometry testing remain limited. QA/QC guidelines are essential for oscillometry to be used as a diagnostic pulmonary function test (PFT) in a clinical setting. ⋯ Although oscillometry requires minimal subject cooperation, application of the principles that govern the conduct and application of a PFT are important for ensuring that oscillometry testing is performed according to acceptability and reproducibility. Specifically, the inclusion of a SOP, a proper training program, a QA/QC checklist, and regular audits with feedback are vital to ensure that oscillometry is conducted accurately and precisely.
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Unplanned extubation (UE) is an important quality metric in the neonatal ICU that is associated with hypoxia, bradycardia, and risk for airway trauma with emergent re-intubation. Initial efforts to reduce UE in our level 4 neonatal ICU included standardized securement of the endotracheal tube (ETT) and requiring multiple providers to be present for ETT adjustments and patient positioning as phase 1 interventions. After an initial decline, the UE rate plateaued; an internal retrospective review revealed that the odds of UE were 2.9 times higher in the setting of an ETT tip at or above T1 (high ETT) on chest radiograph just prior to UE. The team hypothesized that advancing ETT tips to below T1 would reduce UE risk in infants of all gestational ages. ⋯ High ETTs are significantly associated with UEs in the neonatal ICU. Optimizing ETT position may be an underrecognized driver in the provider's toolbox to reduce UEs. Because ETT repositioning carries risk of UE, extra caution should be taken during advancement.