Respiratory care
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Noninvasive ventilation (NIV) has become the preferable modality of respiratory support for spontaneously breathing premature infants in the neonatal ICU (NICU). Whereas NIV support contributes to the prevention of long-term respiratory sequelae from mechanical ventilation, the nasal interfaces used are well known for placing patients at risk for development of NIV device-related pressure injuries (PIs). After implementing clinical practice guidelines promoting the use of sealing NIV interfaces for respiratory support in a level IV NICU, an increase in the frequency of stage 2 or worse and deep tissue injury (DTI) PI was observed. We hypothesized that the implementation of a multifaceted skin care bundle (SCB) would reduce the incidence of NIV device-related PI. ⋯ A collaborative and multidisciplinary team approach was used to promote engagement with clinical staff to address a preventable harm. The implementation of a multifaceted PI prevention bundle contributed to reducing harm while permitting the continued use of appropriate respiratory support to a highly vulnerable patient population in the NICU.
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Randomized Controlled Trial Multicenter Study
Comparison of Two Extubation Techniques in Critically Ill Adult Subjects: The ExtubAR Randomized Clinical Trial.
Two orotracheal extubation techniques are described in the literature: the traditional technique and the positive-pressure technique. Although prior studies reported better clinical outcomes with the positive-pressure extubation technique, its superiority has not been extensively studied yet. This study was to determine whether the positive-pressure orotracheal extubation technique, compared with the traditional orotracheal extubation technique, reduces the incidence of major postextubation complications (up to 60 min) in critically ill adult subjects. ⋯ Despite the trend toward the positive-pressure group, no statistically significant differences were observed. Our findings agree with the literature in that positive-pressure extubation is a safe procedure; therefore, both techniques may be used during extubation in critically ill adult patients.
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Awake prone positioning (APP) has been advocated to improve oxygenation and prevent intubation of patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). This paper aims to synthesize the available evidence on the efficacy of APP. ⋯ APP was associated with improvement of oxygenation but did not reduce the intubation rate in subjects with acute respiratory failure due to COVID-19. This finding is limited by the high heterogeneity and the observational nature of included studies. Randomized controlled clinical studies are needed to definitively assess whether APP could improve key outcome such as intubation rate and mortality in these patients.
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Observational Study
Assessment of Detectable Serum Tobramycin Concentrations in Patients Receiving Inhaled Tobramycin for Ventilator-Associated Pneumonia.
Inhaled tobramycin can be used for empiric or definitive therapy of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. This is believed to minimize systemic exposure and potential adverse drug toxicities including acute kidney injury (AKI). However, detectable serum tobramycin concentrations have been reported after inhaled tobramycin therapy with AKI. ⋯ Detectable serum tobramycin concentrations were frequently observed in critically ill, mechanically ventilated subjects receiving empiric inhaled tobramycin for VAP. Subject age and PEEP were independent predictors for detectable serum tobramycin concentration. Serum monitoring and empiric dose reductions should be considered in older patients and those requiring higher PEEP.