Nursing care of the mechanically ventilated patient: what does the evidence say? Part one.

The care of the mechanically ventilated patient is at the core of a nurse's clinical practice in the Intensive Care Unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient is explored with specific focus on patient safety: particularly patient and equipment assessment. Part two of the paper examines the evidence related to the mechanically ventilated patient's comfort, the patient/family unit, patient position, hygiene, management of stressors, pain management and sedation.

Nursing care of the mechanically ventilated patient: What does the evidence say?: Part two

The care of the mechanically ventilated patient is a fundamental component of a nurse's clinical practice in the intensive care unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly, yet is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient was explored with specific focus on patient safety: particularly patient and equipment assessment. This article, part two, examines the evidence related to the mechanically ventilated patient's comfort: patient position, hygiene, management of stressors (such as communication, sleep disturbance and isolation), pain management and sedation.

Part 1. Chemical and Physical Restraints in the Management of Mechanically Ventilated Patients in the ICU: Contributing Factors

Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned

Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: A patient perspective

An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient's experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse–patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient's perspective.

Dust emissions from a tunnel-ventilated broiler poultry shed with fresh and partially reused litter

Dust emissions from large-scale, tunnel-ventilated poultry sheds could have negative health and environmental impacts. Despite this fact, the literature concerning dust emissions from tunnel-ventilated poultry sheds in Australia and overseas is relatively scarce. Dust measurements were conducted during two consecutive production cycles at a single broiler shed on a poultry farm near Ipswich, Queensland. Fresh litter was employed during the first cycle and partially reused litter was employed during the second cycle. This provided an opportunity to study the effect that partial litter reuse has on dust emissions. Dust levels were characterised by the number concentration of suspended particles having diameter between 0.5–20 μm and by the mass concentration of dust particles below 10 μm diameter (PM10) and 2.5 μm diameter (PM2.5). In addition, we measured the number size distributions of dust particles. The average concentration and emission rate of dust was higher when partially reused litter was used in the shed than when fresh litter was used. In addition we found that dust particles emitted from the shed with partially reused litter were finer than the particles emitted with fresh litter. Although the change in litter properties is certainly contributing to this observed variability, other factors such as ventilation rate and litter moisture content are also likely to be involved.

Lung recruitment manoeuvres for reducing respiratory morbidity in mechanically ventilated neonates

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the evidence supporting the use of recruitment manoeuvres in mechanically ventilated neonates and identify the optimal method of lung recruitment. To determine the effects of lung recruitment manoeuvres in neonates receiving ventilatory support on neonatal mortality and development of chronic lung disease when compared to no recruitment. If data are available, subgroup analyses will include: chronological age, gestational age, lung pathophysiology and pre-existing lung disease, mode and length of ventilation, timing and frequency of recruitment techniques.

Lung recruitment and endotracheal suction in ventilated preterm infants measured with electrical impedance tomography

Aims Although suctioning is a standard airway maintenance procedure, there are significant associated risks, such as loss of lung volume due to high negative suction pressures. This study aims to assess the extent and duration of change in end-expiratory level (EEL) resulting from endotracheal tube (ETT) suction and to examine the relationship between EEL and regional lung ventilation in ventilated preterm infants with respiratory distress syndrome. Methods A prospective observational clinical study of the effect of ETT suction on 20 non-muscle-relaxed preterm infants with respiratory distress syndrome (RDS) on conventional mechanical ventilation was conducted in a neonatal intensive care unit. Ventilation distribution was measured with regional impedance amplitudes and EEL using electrical impedance tomography. Results ETT suction resulted in a significant increase in EEL post-suction (P < 0.01). Regionally, anterior EEL decreased and posterior EEL increased post-suction, suggesting heterogeneity. Tidal volume was significantly lower in volume-guarantee ventilation compared with pressure-controlled ventilation (P = 0.04). Conclusions ETT suction in non-muscle-relaxed and ventilated preterm infants with RDS results in significant lung volume increase that is maintained for at least 90 min. Regional differences in distribution of ventilation with ETT suction suggest that the behaviour of the lung is heterogeneous in nature.

Head-of-bed elevation improves end-expiratory lung volumes in mechanically ventilated subjects : a prospective observational study

BACKGROUND: Head-of-bed elevation (HOBE) has been shown to assist in reducing respiratory complications associated with mechanical ventilation; however, there is minimal research describing changes in end-expiratory lung volume. This study aims to investigate changes in end-expiratory lung volume in a supine position and 2 levels of HOBE. METHODS: Twenty postoperative cardiac surgery subjects were examined using electrical impedance tomography. End-expiratory lung impedance (EELI) was recorded as a surrogate measurement of end-expiratory lung volume in a supine position and at 20° and then 30°. RESULTS: Significant increases in end-expiratory lung volume were seen at both 20° and 30° HOBE in all lung regions, except the anterior, with the largest changes from baseline (supine) seen at 30°. From baseline to 30° HOBE, global EELI increased by 1,327 impedance units (95% CI 1,080–1,573, P < .001). EELI increased by 1,007 units (95% CI 880–1,134, P < .001) in the left lung region and by 320 impedance units (95% CI 188–451, P < .001) in the right lung. Posterior increases of 1,544 impedance units (95% CI 1,405–1,682, P < .001) were also seen. EELI decreased anteriorly, with the largest decreases occurring at 30° (−335 impedance units, 95% CI −486 to −183, P < .001). CONCLUSIONS: HOBE significantly increases global and regional end-expiratory lung volume; therefore, unless contraindicated, all mechanically ventilated patients should be positioned with HOBE.

Airborne culturable fungi in naturally ventilated primary school environments in a subtropical climate

There is currently a lack of reference values for indoor air fungal concentrations to allow for the interpretation of measurement results in subtropical school settings. Analysis of the results of this work established that, in the majority of properly maintained subtropical school buildings, without any major affecting events such as floods or visible mould or moisture contamination, indoor culturable fungi levels were driven by outdoor concentration. The results also allowed us to benchmark the “baseline range” concentrations for total culturable fungi, Penicillium spp., Cladosporium spp. and Aspergillus spp. in such school settings. The measured concentration of total culturable fungi and three individual fungal genera were estimated using Bayesian hierarchical modelling. Pooling of these estimates provided a predictive distribution for concentrations at an unobserved school. The results indicated that “baseline” indoor concentration levels for indoor total fungi, Penicillium spp., Cladosporium spp. and Aspergillus spp. in such school settings were generally ≤ 1450, ≤ 680, ≤ 480 and ≤ 90 cfu/m3, respectively, and elevated levels would indicate mould damage in building structures. The indoor/outdoor ratio for most classrooms had 95% credible intervals containing 1, indicating that fungi concentrations are generally the same indoors and outdoors at each school. Bayesian fixed effects regression modeling showed that increasing both temperature and humidity resulted in higher levels of fungi concentration.

Stone baby: An exploration of trembling and its potential for visual art

Informed by Kristeva's formulation of affect and Winnicott's Holding Environment, this practice-led visual art project is an exploration into how sensitivity to the physical sensation of trembling can sustain a creative practice. Building upon this is a further enquiry into what the significance of the affective experience of trembling is for an ethics of affect in contemporary art. I have done this through object and video-based installations informed by my own experience of trembling. This has been further informed by the work of artists like Louise Bourgeois, Dennis Del Favero and Willie Doherty. The creative outcomes contribute to the discourse around ethical responses to affect by extending and developing on the works of these artists.