Fisioterapia respiratoria en la unidad de cuidados intensivos: Revisión bibliográfica

Introduction and aims

Patients in intensive care unit are susceptible to complications due to different causes (underlying disease, immobilisation, infection risk…) The current main intervention in order to prevent these complications is respiratory physiotherapy, a common practice for nurses on a daily basis. Therefore, we decided to carry out this bibliographic review to describe the most efficient respiratory physiotherapy methods for the prevention and treatment of lung complications in patients in intensive care, taking into account the differences between intubated and non-intubated patients.

Technical and contextual barriers to oral care: New insights from intensive care unit nurses and health care professionals

Oral care for intubated patients in the intensive care unit (ICU) is known to reduce bacterial colonization in oropharyngeal cavities decrease development of ventilator associated pneumonia (VAP) and the associated costs of managing this complication (1-4). Provision of oral hygiene by nurses is a fundamental aspect of care in the ICU (5). However, such a basic nursing activity can be devalued or rendered invisible by nurses when there is a greater emphasis on managing and maintaining biotechnology and/or a failure to underpin practice with research evidence that demonstrates the importance of fundamental care (5). A Canadian study by Dale and colleagues (6) to explore clinicians’ knowledge of, and experiences with, delivering oral care in intubated patients is a timely reminder that the complexity of performing oral care in the ICU should not be underestimated or undervalued.     

Smart Bag vs. Standard bag in the temporary substitution of the mechanical ventilation

Objective

To compare in intubated patients manually ventilated in order to mirror the ventilator, the respiratory and hemodynamic effects induced by a bag device equipped with an inspiratory gas flow-limiting valve (Smart Bag, 0-Two Medical Technologies Inc., Mississauga, ON, Canada) and a Standard bag.

Design

Non-randomized crossover study comparing 13?respiratory and eight hemodynamically paired parameters. Eight intubated patients were manually ventilated, each by three different intensive care workers yielding 24 sets of data for comparison. Data were collected during two sessions of manual ventilation, first with the Standard bag and then with the Smart Bag. Between each session, the patient was reconnected to the ventilator until return to the baseline. Patients, included after coronary surgery, were sedated and paralyzed.

Setting

Intensive Care Unit, university hospital.

Results

Compared with Standard bag, the Smart Bag^® provided a decrease of inspiratory flow (23?±?4.7 vs. 47.3?±?16.5?l/min) with a decrease of peak pressure (13.3?±?2.9 vs. 21.9?±?7.3?cmH₂O) and tidal volume (9.4?±?2.8 vs. 12.4?±?2.7?ml/kg). While the expiratory time was similar, the inspiratory time increased (1.83?±?0.58 vs. 1.28?±?0.46?s) with the Smart Bag, limiting the respiratory rate (14?±?5 vs. 17?±?6?cycles/min) and the minute volume (8.8?±?2.9 vs. 14.4?±?4.9?l/min). Finally, it limited the fall of the ETCO₂ (27.9?±?5.1 vs. 24.3?±?5.7?mmHg) and probably the risks of severe respiratory alkalosis. The bags similarly affected hemodynamic states.

Conclusion

In intubated patients manually ventilated, the Smart Bag limits the risks of excessive airway pressure and the fall of the ETCO₂, with hemodynamic effects similar to those of the Standard bag.     

插管保留自主呼吸的复合麻醉在小儿唇腭裂手术中的可行性研究

目的：探讨插管保留自主呼吸的复合麻醉在小儿唇腭裂手术中的可行性。方法：随机选择唇腭裂残疾患儿80例,分A、B两组麻醉。A组以氯胺酮诱导,七氟醚吸入等静吸复合全麻的方法。插管用肌松药,术中控制呼吸。B组采用以七氟醚诱导维持,另加局部麻醉,辅以少量芬太尼并肛纳对乙酰氨基酚栓等联合镇痛,插管不用肌松药,保留自主呼吸。结果：B组患儿完全清醒和气管拨管时间明显早于A组（P〈0.05）,且该组术后并发症的发生率也明显低于A组（P〈0.01）。结论：插管保留自主呼吸的复合麻醉在小儿唇腭裂手术中安全可靠,术中血流动力学稳定。术毕患儿清醒快,气管导管拔除早,术后并发症少。     

Reflection on practice: an intubated patient suffering panic attacks

Panic attacks and respiratory disease have been shown to have probable links; which one is the precursor to the other is unknown. However, what is known is that there is a correlation between high serum carbon dioxide and lactate levels, which are suffocation indicators, and panic attacks. Females are at a higher risk of suffering panic attacks than men, as they have been shown to have a lower tolerance of suffocation indicators. The aim of this paper is to review the relevance of panic attacks within the intensive care unit setting, where a significant number of patients with respiratory disease have an oral endotracheal tube, which limits communication and may add to the feeling of panic. Using a reflective model, I revisited the actual scenario and consider the series of events as I reflect in action, and at the conclusion of the situation, I reflect on action. The results show that suffering from panic attacks did not inhibit the patient with weaning from the ventilator. Effective communication between the patient and myself led to recognition of the problem, for the correct treatment to be being given, and enabling subsequent extubation. In conclusion, once the link is made of the likelihood of a patient with respiratory disease being prone to panic attacks, the nurse can communicate with the patient or family to establish whether the patient has a panic disorder. The treatment of a regular benzodiazepine, such as diazepam, and constant reassurance from the nurse can then be given to the patient to minimize the symptoms. Reducing the effects of panic attacks can decrease the distress experienced by the patient and improve the clinical picture to facilitate extubation.     

非气管插管保留自主呼吸麻醉在电视胸腔镜手术中应用效果的Meta分析

目的 对比非气管插管保留自主呼吸麻醉和传统气管插管全身麻醉在电视胸腔镜手术中的应用效果和安全性。 方法 检索中国知网(CNKI)、万方数据库、维普数据库(VIP)、中国生物医学文献数据库(CBM)、PubMed、Embase、Cochrane Library等中英文数据库中有关比较非气管插管(实验组)和气管插管麻醉(对照组)下胸腔镜手术治疗胸部疾病的研究。对文献质量进行评价后纳入符合标准的文献,提取研究结果,用RevMan5.3软件对手术时间、术中出血量,术中最低血氧饱和度(SpO₂)、术中最高呼气末二氧化碳分压(ETCO₂)、术后胸管留置时间、术后住院天数、术后总并发症发生率等指标进行Meta分析。 结果 共纳入27篇文献、2 019例患者。结果显示:(1)实验组和对照组在手术时间［标准化均数差(SMD)= -0.02,95%CI:-0.26~0.22,P=0.89］和术中最低SpO₂(SMD= -0.10,95%CI:-0.53~0.33,P=0.66)方面差异无统计学意义;(2)在术中出血量(SMD= -0.13,95%CI:-0.24~-0.01,P=0.03)、术后胸管留置时间(SMD= -0.48,95%CI:-0.68~-0.28,P<0.001)、术后住院天数(SMD= -0.69,95%CI:-1.05~-0.33,P<0.001)、术后总并发症发生率［比值比(OR)= 0.42,95%CI:0.25~0.70,P<0.001］等方面,实验组低于对照组;(3)实验组术中最高ETCO₂高于对照组(SMD=1.23,95%CI:0.68~1.78,P<0.001)。 结论 在非气管插管保留自主呼吸麻醉下的胸腔镜手术较传统气管插管全身麻醉具有更短的术后胸管留置时间、更短的术后住院天数、更少的术后总并发症发生率等加速康复优势,该项技术安全可行。     

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: A critical incidents study

IntroductionThe number of interhospital transports with intubated patients or where intubation readiness is required is increasing in Sweden and globally. Specialist nurses are often responsible for these transports, which involve numerous risks for critically ill patients.AimThe aim of this study was to describe nurse anaesthetists’ and intensive care nurses’ strategies for safe interhospital transports with intubated patients or where intubation readiness is required.MethodA qualitative study was conducted using the critical incident technique. During March and April 2020, 12 semi-structured interviews were conducted with nurse anaesthetists and intensive care nurses. Data were analysed according to the critical incident technique, and a total of 197 critical incidents were identified. The analysis revealed five final strategies for safe interhospital transport.ResultsParticipants described the importance of ensuring clear and adequate information transfers between caregivers to obtain vital patient information that enables the nurse in charge to identify risks and problems in advance and create an action plan. Stabilising and optimising the patient’s condition before departure and preparing drugs and equipment were other strategies described by the participants, as well as requesting assistance or support if questions or complications arose during transport.ConclusionTransports with intubated patients or where intubation readiness is required are complex and require systematic patient-safety work to ensure that strategies for increasing patient safety and decreasing risks are visible to the nurses in charge, that they are applied, and that they are, indeed, effective.     

成人经口气管插管口腔护理的最佳证据总结

目的 检索、评价并总结成人经口气管插管口腔护理的最佳证据，为临床实践提供参考。方法 遵循“6S”证据模型，系统检索国内外各数据库及指南网中关于成人经口气管插管口腔护理的所有证据，包括指南、系统评价、证据总结、最佳临床实践信息手册、专家共识、临床决策及高质量的原始研究。检索时限从建库至2022年8月5日。由2名研究人员独立对文献进行整体评价，并提取和汇总相关证据。结果 共纳入文献20篇，包括指南5篇、专家共识2篇、系统评价5篇、证据总结1篇、随机对照6篇、类实验研究1篇。根据相关内容共总结出成人经口气管插管口腔护理的25条证据，涉及口腔评估、口腔护理频次、口腔护理的方法和工具、口腔护理液、声门下吸引、管理和培训6个方面。结论 基于循证方法总结的关于经口气管插管口腔护理干预措施的最佳证据具有较好的科学性和可行性，可为重症患者口腔护理提供科学依据。