Free Essay About Evidence-Based Nursing Care To Support Breathing In The Critically Ill
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Critical illness is a life threatening state typically preceded by a period of multisystem deterioration (Robertson & Al-Haddad, 2013). Critically-ill patients are intubated and mechanically ventilated if they cannot breathe on their own. Supporting breathing in this manner is a lifesaving intervention. Sedation is a prerequisite to mechanical ventilation. The aim is to facilitate tolerance of intubation, reduce pain levels and anxiety, and enhance synchrony between patient and the ventilator (Hughes, McGrane & Pandharipande, 2012). Mechanical ventilation, however, is not beneficial to the patient’s breathing if it is prolonged unnecessarily.
One complication of mechanical ventilation is ventilator-acquired pneumonia (VAP) or pneumonia that develops at least 48 hours after intubation. As the alveoli fill with fluid and pus causing adventitious breath sounds, there is less space for gas exchange affecting oxygenation and carbon dioxide elimination (Gillespie, 2009). The rate of VAP is associated with the duration or number of days of mechanical ventilation. Prolonged mechanical ventilation was also found to promote atrophy and contractile dysfunction in the diaphragm (Powers, Kavazis & Levine, 2009). The resulting diaphragm weakness leads to a disordered pattern of breathing. Both VAP and diaphragm weakness promote ventilator dependence.
Early ventilator weaning is a common critical care intervention. Promoting independent breathing as soon as the patient is ready makes him or her less prone to nosocomial pneumonia or diaphragm weakness (Morandi, Brummel & Ely, 2011; Powers, Kavazis & Levine, 2009). It optimizes the lifesaving benefits of mechanical ventilation while reducing the risk of unnecessarily prolonging this intervention. Successful ventilator weaning and independent breathing signify stabilization of the patient’s respiratory functioning and improvement in his or her clinical status leading to a reduced risk of mortality and shorter hospital stays.
A relevant protocol for ventilator weaning is the paired spontaneous awakening and spontaneous breathing trial or SAT/SBT (Morandi, Brummel & Ely, 2011). Pairing these interventions recognizes the interrelatedness between sedation and mechanical ventilation and therefore awakening and independent breathing. The latter cannot be achieved without the former. Integrating them into one protocol ensures efficiency in achieving patient liberation from the ventilator. Determining the effectiveness of the SAT/SBT protocol is necessary, and evidence-based practice dictates that nurses conduct systematic literature searches and critical appraisal of available evidence to guide decisions to maintain or modify current protocols (Stevens, 2013).
A systematic search of 6 databases was done to evaluate the evidence supporting paired sedation and ventilator weaning protocols. A search on the CINAHL database using the search string “paired sedation and ventilator weaning protocol” without any limits yielded two articles – one was a randomized controlled trial (RCT) which was retrieved. A search in the Medline database using the same search string yielded only this RCT. In a search of the Academic Search Complete database, the same RCT came up along with 3 articles describing the results of this trial.
More results were obtained when searching the ProQuest database. There were 414 articles and limits were applied, namely only peer reviewed articles in the English language from scholarly journals published between 2008 and the present. This reduced the results to 203 articles. Only one primary study was retrieved. Most of the studies focused on either sedation or weaning protocols but not both or focused on non-breathing related outcomes. On Science Direct, 349 results were filtered by content type and publication date (2008-2015) leading to 171 results. A preview of the abstracts showed the same articles shown in the other databases. As with the ProQuest results, no other articles focused on the effectiveness of paired interventions. There were no results for the search string on the Cochrane library.
Using the search string “spontaneous awakening and breathing trials” yielded 11 articles in Academic Search Complete. One primary study was obtained. The search string yielded 12 articles from CINAHL with retrieval of 2 primary studies and 1 review. On Medline, there were 19 results with no new efficacy studies. On ProQuest, there were 501 results. The same limits used in the previous search string led to 206 articles. The abstract of a primary study was retrieved. Again, the number of studies on paired protocols was limited. Meanwhile, the Science Direct search yielded 2,053 articles. Subsequent filtering included not only the content type and publication date but also publication type. Of the remaining 62 results, no new and relevant primary studies were found.
In summary, the results of the search of 6 databases using two sets of search strings led to the selection of 6 primary studies. The settings of the primary studies were different ICUs and publication dates were from 2008 to 2015. Two pertained to nurse-led initiatives and the rest were by various disciplines in medicine. One was an RCT and 4 were quasi-experimental studies. Once was a secondary analysis of clinical trial results. Four were conducted within the framework of quality improvement.
Evidence Supporting Awakening and Breathing Trials
One of the earliest studies to investigate the efficacy of paired SAT/SBT was Girard et al. (2008). The RCT was conducted in 4 tertiary hospitals using a sample of 336 ICU patients on mechanical ventilation. The underlying assumption was that paired intervention improves practice because it integrated sedation and weaning - interrelated concerns that were considered separately by nurses, physicians, and respiratory therapists. Separate protocols for each intervention have also been developed and investigated. The authors hypothesized that combining SAT with SBT can improve outcomes with a greater magnitude than SBT alone.
The paired protocol entails assessing the patient to ensure that sedative and analgesia discontinuation is safe. The patient is given 4 hours to wake up defined by criteria that include eye-opening in response to verbal stimulus (Girard et al., 2008). If the patient fails to wake up, sedation is resumed at half the dose, and another attempt is made the next day. If the patient wakes and separate criteria are met, an SBT trial is commenced. The patient is permitted to breathe on his own via the ventilator circuit and is given little PEEP and pressure support (Girard et al., 2008). If the patient fails to breathe independently, the protocol is tried again the next day. If the patient passes the trial, he or she is extubated.
The researchers found that the paired intervention participants had a lower likelihood of self extubation compared with the control group (SBT only) at a ratio of 16:6 favoring SAT/SBT (Girard et al., 2008). The intervention group also had more ventilator-free days or days breathing independently within the 28 days of the investigation at 14.7 days compared to the control group (SBT only) at 11.6 days (Girard et al., 2008). The findings are clinically significant as each day a patient is mechanically ventilated is associated with a 3-percent risk in acquiring VAP (Tanios et al., 2009). Mortality within one year was also lower in the SAT/SBT group with one life saved for every 7 patients subjected to paired intervention.
The protocol in the RCT by Girard et al. (2008) has been utilized in single-center quality improvement (QI) initiatives. Almuslim et al. (2010) conducted a quasi-experimental study of paired SAT/SBT in a tertiary level teaching hospital to determine the effect on mechanical ventilator days, reintubation rate, mortality, and ICU length of stay. The intervention was part of a multifaceted QI project that included standardized assessment forms, structured rounds by a multidisciplinary team, and staff compliance monitoring on a daily basis with immediate feedback on performance. Data collection and analysis entailed a comparison with patients prior to and after project implementation. The after group demonstrated a reduced rate of reintubation and time to successful extubation, delayed mortality, and a 5-day average reduction in ICU length of stay.
Meanwhile, Kher et al. (2012) described the process of developing, implementing, and evaluating an SAT/SBT intervention they called Daily Awakening and Spontaneous Breathing Trial. The protocol was piloted in a convenience sample of MICU patients with participating staff taking on the role of project champions. A quasi-experimental before-and-after design was used for the evaluation. Baseline data on staff compliance with protocols, mechanical ventilator days, number of days before successful SBT, self extubation incidence, and dose and days on continuous sedative infusion were obtained in two 10-bed MICUs of a teaching hospital (Kher et al., 2012). The study demonstrated a lower number of mechanical ventilator days compared to baseline.
Another quality improvement project on paired SAT/SBT was conducted by Jones et al. (2014). The development and implementation process was multidisciplinary, team-based, and included staff education and training. The setting of the QI project and study was a 23-bed MICU in a level 2 academic hospital. The before-and-after study again demonstrated reductions in mechanical ventilator days and the ventilator utilization ratio, but no differences were noted in ICU length of stay and the frequency of self-extubation and re-intubation (Jones et al., 2014).
Meanwhile, a feasibility study by Figueroa-Ramos et al. (2013) of paired SAT/SBT in the trauma ICU (TICU) analyzed data from a previous RCT conducted in the same facility. The original RCT focused on the efficacy of paired intervention on delirium outcomes. The outcomes of interest in this substudy by Figueroa-Ramos et al. (2013) were the proportion of patients who passed the SAT, tolerated SBT at the first or second attempt, and were extubated. Within an RCT context, the authors found that 67% of those subjected to SAT passed the criteria, and 18 of the 20 patients passed their SBT. More than 50% were subsequently extubated. These values were higher compared to the control group.
Finally, Klompas et al. (2015) conducted a multicenter QI collaborative in 12 ICUs in 13 teaching and community hospitals analyzed 5,164 mechanical ventilation episodes for ventilator-associated event (VAE) risk following implementation of an SAT/SBT protocol patterned after Girard et al. (2008). Ventilator-associated event (VAE) refers to instances of decline in respiratory status and clinical or laboratory-confirmed infection including VAP. The quasi-experimental study showed an increase in SAT and SBT utilization. There were significant reductions in mechanical ventilation duration, length of stay, and VAE risk per mechanical ventilation episode.
In summary, the results of the studies support a shorter duration of mechanical ventilation or a reduced number of mechanical ventilator days with the implementation of a paired spontaneous awakening and spontaneous breathing trial protocol (Jones et al., 2014; Kher et al. 2012; Klompas et al., 2015). There was an increased rate of and reduced time to planned, successful extubation (Almuslim et al., 2010; Figueroa-Ramos et al., 2013) with a reduced rate of reintubation (Almuslim et al., 2010). There were more ventilator-free days in patients who underwent paired SAT/SBT (Girard et al., 2008).
In addition, the protocol reduced the ventilator utilization ratio or the proportion of days patients are ventilated versus the total number of patient days (Jones et al., 2014; Kher et al. 2012). There was lower risk of ventilator-associated events, including VAP, as well (Klompas et al., 2015). Further, the findings support a lower mortality rate among paired SAT/SBT patients on mechanical ventilation (Almuslim et al., 2010; Girard et al., 2008). Length of stay in the ICU or hospital significantly decreased as well (Almuslim et al., 2010; Klompas et al., 2015).
Based on a high-quality RCT with results validated by a feasibility study and four quality improvement studies employing quasi-experimental methods, a paired SAT/SBT protocol is effective in improving breathing-related outcomes in critically ill patients. Shorter periods that patients are on mechanical ventilation reflect the conduct of timely assessments of readiness for weaning and the efficiency and success of pairing awakening and breathing trials. Shorter durations of mechanical ventilation also mean more days of independent breathing. Moreover, the outcome equates to a lower risk of ventilator associated pneumonia as well as diaphragmatic atrophy and contractile dysfunction with a reduced likelihood of ventilator dependence. A decline in the likelihood of breathing-related complications reduces the chances of death, shortens the length of stay, and the costs of care.
Almuslim, O., Hassan, N., Shorman, M., Adzuara, R., Rayyan, N., & Shukri, K. (2010). Coupling awakening and breathing trials reduced reintubation and mortality in critically ill patients: An observational quality improvement study. Journal of Critical Care, 26(5), e36-e37. doi: http://dx.doi.org/10.1016/j.jcrc.2011.05.032.
Figueroa-Ramos, M.I., Arroyo-Novoa, C.M., Padilla, G., Rodriguez-Ortiz, P., Cooper, B.A., & Puntillo, K.A. (2013). Feasibility of a sedation wake-up trial and spontaneous breathing trial in critically ill trauma patients: A secondary analysis. Intensive and Critical Care Nursing, 29, 20-27. doi: 10.1016/j.iccn.2012.05.001.
Gillespie, R. (2009). Prevention and management of ventilator-associated pneumonia – the Care Bundle approach. South African Journal of Critical Care, 25(2), 44-47. Retrieved from http://www.ajol.info/index.php/sajcc/article/view/52974/41573
Girard, T.D., Kress, J.P., Fuchs, B.D., Thomason, J.W.W., Scheickert, W.D., Pun, B.T, Ely, E.W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. The Lancet, 371(9607), 126-134. doi: 10.1016/S0140-6736(08)60105-1.
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Jones, K., Newhouse, R., Johnson, K., & Seidl, K. (2014). Achieving quality health outcomes through the implementation of a spontaneous awakening and spontaneous breathing trial protocol. AACN Advanced Critical Care, 25(1), 33-42. doi: 10.1097/NCI.0000000000000011.
Kher, S., Roberts, R.J., Garpestad, E., Kunkel, C., Howard, W., Didominco, D., Devlin, J.W. (2012). Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: A quality improvement project. Journal of Intensive Care Medicine, 28(3), 189-197. doi: 10.1177/0885066612444255.
Klompas, M., Anderson, D., Trick, W., Babcock, H., Kerlin, M.P., Lingling, L., Platt, R. (2015). The preventability of ventilator-associated events: The CDC Prevention Epicenters Wake Up and Breathe Collaborative. American Journal of Respiratory and Critical Care Medicine, 191(3), 292-301. doi: 10.1164/rccm.201407-1394OC.
Morandi, A., Brummel, N.E., & Ely, E.W. (2011). Sedation, delirium and mechanical ventilation: The ‘ABCDE’ approach. Current Opinion in Critical Care, 17, 43-49. doi: 10.1097/MCC.0b013e3283427243.
Powers, S.K., Kavazis, A.N., & Levine, S. (2009). Prolonged mechanical ventilation alters diaphragmatic structure and function. Critical Care Medicine, 37(10 Suppl), S347- S353. doi: 10.1097/CCM.0b013e3181b6e760.
Robertson, L.C., & Al-Haddad, M. (2013). Recognizing the critically ill patient. Anaesthesia and Intensive Care Medicine, 14(1), 11-14. doi: http://dx.doi.org/10.1016/j.mpaic.2012.11.010.
Stevens, K.R. (2013). The impact of evidence-based practice in nursing and the next big ideas. The Online Journal of Issues in Nursing, 18(2). Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJI N/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based- Practice.html
Tanios, M.A., de Wit, M., Epstein, S.K., & Devlin, J.W. (2009). Perceived barriers to the use of sedation protocols and daily sedation interruption: A multidisciplinary survey. Journal of Critical Care, 24, 66-73. doi:10.1016/j.jcrc.2008.03.037.
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