Therapy to Prevent Pulmonary Complications - Research Paper Example

PICOT ON PULMONARY COMPLICATIONS Abstract Pulmonary complications accounts for quite a large number of mortality and morbidity in critically ill patients, in which case it is common in patients with intubation and who experiences the mechanical ventilation. Hypoxia, atelectasis, and the nosocomial infections are most frequent complications amongst the critically ill patients. Therefore, the purpose of this paper is to describe the evidence that the continuous lateral rotation is quite effective than no rotation in the prevention of the acute respiratory distress syndrome and lung injury patients who are critically ill. This topic is quite significant as it embarks on the precise delicate and among the dangerous diseases that are common in the society. This is through the review of literature using the PICOT question, in which case it is essential in looking for evidence that supports an intervention (Vollman, 2010). The picot question involves the following elements P – Intubated patients in intensive care unit I – Use of continuous lateral rotation therapy C – Not using the continuous lateral rotation therapy in intubated patients O – Preventing the acute lung injury and ARDS T – Time in demonstrating the outcome Synonyms P- Patients on ventilation support The intubation procedure should involve the gas exchange, the hemodynamic and the neurologic care, in which case they are essential in critically ill patients (Vollman, 2010). The evidence provided is quite of high level and results in answering the PICOT questions. The application of CLRT is quite easier to maintain, and hence, the application of CLRT leads to prevention of atelectasis than it restores the alveolar patency. The inclusion criteria included all the search results, in which case it had to contain continuous lateral therapy and lung injury, lung complications and ARDS (Davis, 2001). PART B Introduction The pulmonary complications are the most frequent in mortality and morbidity in critically ill patients. Studies by the Institute for Healthcare Improvement have had to find that the ventilator-associated pneumonia is leading in the cause of hospital morbidity and mortality. Nurses have even had to implement a two-hour turning of patients in order that they prevent the complications. Despite the continued use of such strategies, there has been no significant improvement in the effectiveness of pulmonary complications. As part of the progressive mobility, the Continuous Lateral Rotation Therapy (CLRT) has been in use in order to reduce the pulmonary complications that have had to result from immobility. The therapy was through continuous motion-bed frames, in which case helps rotate the patient from one side to another. Such strategy is quite effective in improving the pulmonary outcomes in critically ill patients (Dollobich et al, 1998). Synthesize of Evidence In the first article, the study involves the quasi –experiment, the random assignment, and trails with the patients serving as their own controls, among other inclusions. Those who were eligible for study involve the paralyzed, sedated patients that have had to encounter with the acute respiratory distress syndrome. The whole study incorporates randomizing patients in order to receive four turnings and secretion management regimens in a random sequence for about six hours each for a period of twenty-four hours. This involves, routine turning after every two hours from left to right lateral position that includes a 15minutes time of manual postural drainage and percussion. In addition, it includes CLR with a dedicated bed that turns patients from left to right lateral position for two minutes and a 15-minute period of percussion that pneumatic cushions provides every two hours. The results from the nineteen patients entered did not show any statistically difference in the measured cardiovascular variables. The results showed some tendency for the relation of partial pressure of arterial oxygen to the fractional inspired concentration of oxygen. However, there was some statistical difference in an increase in sputum during the time of CLR. Four patients also produced more than 40ml of sputum per day with the P &PD increasing sputum volume (Davis, Et al, 2001). The second article involves placing the patients in a supine on a Biodyne bed and then adjusting the pressures in the cushions to the weight of the patient. Thirteen critically ill patients were in the study, but they were stable and were mechanically ventilated, in which case they were of the age 74years. Then there was the delivering of radio-labeled aerosol by bagging 2-3 minutes and repeating measurements of lung radioactivity by imaging the thorax over the following 3hours. 90-minute rotation of the bed then followed and proceeded by 30degress to either side and followed by two 45-minute control times, and this is when the patient remains supine and stationery on the bed. The results of the patients include the clearance of mucus being slower, unlike the reported normal subjects and in ambulatory patient with COPD. In addition, there was a slight increase in clearance during CLRT and clearance reverted to pre-oscillation levels following therapy (Dolovich, 1998). The third article involves using a CLRT as a replacement for standard manual turning, and this is to decrease the pulmonary complications in critically ill patients. The results include the effectiveness of CLRT that involves decreasing pulmonary complications, but that have serious gaps, for instance when to start and end the therapy (Martin, 2001). The method of the fourth article involves applying the positioning and mobility techniques, for instance, elevation of the head of the bed and procedure moments against gravity. It involves also the manual turning, chair position, ambulation, active and passive range-of-motion exercise and tangling. There was the meta-analysis of 39 randomized trials that examined the influence of bed rest on various 15 medical conditions and the showing of the procedures showed that the bed rest was not so momentous and may be associated with some harm. The results involved the growth of density atelectasis from the formation of depended edema with the patient supine. Amongst the patients, also involve the skin, which does not tolerate prolonged pressure (Vollman, 2010). The last article involves the proposed CLRT as the replacement for the standard manual turning that helps to decrease the pulmonary complications in the critically ill patients. The article seems to reiterate the method that tests the feasibility of two turning protocols. Thereafter, there is studying of procedures for multi-site randomized clinical trial that evaluates efficacy and safety of the horizontal positioning intervention. The research results of this study were quite conflicting, in that there was evidence that the CLRT had some benefits on the pulmonary function. Many researchers have had to report quite a number of investigations as sound scientific evidence that the pulmonary complications reduction takes place in critically ill patients when treated with CLRT. However, there existed several serious gaps in the existing research, for instance, whether the CLRT was advantageous for all the subsets of patients or the limited to some populations, in which case there is the drawing of the conclusion. There include the incidences of pulmonary complications amongst the patients after completing the study participation. In addition, there all-cause mortality and length of stay including the mechanical ventilation duration and turning related adverse events (Sandra, 2012). 2. All articles have their own methods though there exist some similarities and few differences in there procedures. The first article insinuates randomizing the patients to receive four turnings and then followed by several routine turnings. The whole process is manual. The second article involves using supine on a Biodyne bed and then adjusting the pressures in the cushions to the weight of the patient. The process is not manual compared to the first article method. In the third article, it involves using CLRT as a replacement of standard manual turning. This method is not manual also, in which case it is similar to the second article method by not being manual. The fourth method applying techniques of mobility and positioning, in which case it is manual and similar to the first method. The last method involves turnings protocols and studying the procedures, in which case it is also manual like the fist and the fourth methods. Most results are quite different except the third and the last result whereby the patients shows pulmonary complications. 3. The findings in all the articles, to some extent, try to answer the PICOT question. From the evidence table, the findings show some answers to the Intubated patients in intensive care unit, whereby it is quite applicable in almost all the articles. Having the clinical experience suffices to say that there can only be financial consideration problems, in which case it might be too expensive to carry out the non -manual methods such as the use of CLRT. The findings also answer the second PIVOT question whereby it involves the use of continuous lateral therapy. In fact, most people prefer to use lateral therapy because of the financial consideration, which means it is much cheaper that not using the continuous lateral rotation therapy. At the end, one can observe that all articles in one way or the other tries to prevent an acute lung injury and ARDS. Clinical Implications The clinical practice that the evidence supports from all the articles description involves the turning regimes, in which case it is by manual basis. The changes are slightly above the medium. This is because in the first article, the physical turning is the significant element of the custom management of the mechanically ventilated patients. The changes are quite significant as it leads to the reduction of atelectasis, enhances the mobilization of the fluids, prevents the breakdown of the skin, also improves the oxygenation and lastly, it reduces the incidence of the hospital-acquired pneumonias. There is no much risk in the clinical practice while making the changes. This implies that the position changes involve the unilateral lung disease. The process of custom turning steps in tradition and it follows the guidelines of the common senses. Moreover, the practice has the historical precedent. The changes that were significantly observed in practice are enormous to the extent that it was feasible in terms of resources and the economics. It was feasible because the outcomes of the changes were so significant though the whole process was manual. If the changes were made, there would be a tremendous outcome. This is because the practice is somehow efficient and it results in significant changes. Various methods exist that one can employ to implement the clinical change based on the evidence. The methods include, holding seminars and presenting the evidence, getting the evidences to have the approval of various institutions, using the local opinion leaders and authorities, audit and feedback interactive educational sessions and the local consensus building. Because the manual turning of patients has had to create its own problems, there has been the development of specific beds that help in rotating the patients continuously from side to side. The beds are currently in use at many of the intensive care units, and this is to avoid and to treat complications of stillness via the continuous lateral rotation therapy. However, there have been various studies on the immobility, in which case they have had to investigate the benefits of the turning patients, the excellent strategies for turning patients and the values of CLRT against the manual turning. This is where there is no standardized protocol that helps to guide the nurse in identifying the suitable patients for CLRT, the extent of the lateral rotation required or the time of therapy. References: Davis, K. et al ( 2001). The acute effect of body positions strategies and the respiratory therapy in paralyzed patients with acute lung Injury. Crib Care, 5 (5), pp. 81-7 Dolovich, M., Rush brook, J., Churchill, E., Maze, M, Poles, A. (1998). Effects of continuous lateral rotational therapy on lung Mucus transports in mechanically ventilated patients. J Crit Care. 13(3), pp. 119-25. Martin, A.(2001). Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurs, 20 (1), pp. 42-9 Vollman, M.(2010).Progressive mobility in the critically ill, Crit care Nurse, 30 (2) Sandra, K. (2012). Pilot Study of Lateral Rotation Interventions for Efficacy and Safety in ICU Care, Society of Critical Care Medicine SEARCH RESULTS TABLE DATA BASE SEARCH A. Article Citations Davis, K. Johannigman, J. Campbell, R. Marraccini, A. Luchette, F. Frame, S. The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. Crit Care 2001,art No. PMC30713 B. PIMCID number:PMC30713 A. Article Citations Dolovich, M., Rushbrook, J., Churchill, E., Mazza, M, Powles, A. Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. J Crit Care 1998 B. Martin, A. Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurse 2001 A. Article Citation Vollman, M. progressive mobility in the critically ill. Crit care Nurse 2010, ccn2010803 B. PMID number: DOL: 10.4037/ccn2010803. A. Article Citation Sandra, K.. Pilot Study of Lateral Rotation Interventions for Efficacy and Safety in ICU Care, Society of Critical Care Medicine 2012 C. PIMCID number: NCT00542321 TABLE 2: EVIDENCE EVALUATION TABLE Citation Sample/ Setting Research Design Major variables Measurement Data Analysis Findings Level of Evidence Comments Davis, K. et al ( 2001). The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. Crit Care. 5 (5), pp. 81-7 Nineteen patients were to enter into an experiment The study involves prospective, quasi, experiment random assignment, trial with patients that serve as their own controls. Patients randomized to receive four turning and management of secretion regimens in random sequence for six hours each for 24hours. The determination of sequence was by random number table with varying the assignment of the management regimens equally. The regimens included routine turning by the ICU staff every 2 hours from the left lateral to the right lateral position. In addition, routine turning by the ICU staff every 2 hours including the 15minutes time for manual percussion and postural drainage by respiratory therapists. Then there is continual lateral rotation with specialized bed pausing at every position for 2minutes (Davis, 2011). Systolic, diastolic and the mean pulmonary artery pressure and the central venous pressure There is first the calibration of routine cardio -respiratory monitoring in accordance with ICU protocol. Measurement of pulmonary Capillary wedge pressure is then made after every 3 hours. Thereafter, cardiac output determined from the thermo- dilution curves that are iced saline in triplicates. There was drawing of samples, iced and analyzed within five minutes by use of standard blood gas and the co-oximeters. The measurements were with the patient in the supine position in order to assist in preventing positional effects on the results. There was ventilation of patients with Puritan-Bennett 7200ae. Moreover, there were recoding from the ventilator digital display, in which case all patients underwent ventilation by use of pressure control ventilation (Davis, 2011). The data collection and analysis was with commercially available data management and the statistical software. The showing of data is as means ±SD. Analysis of data involves analysis with variance for repeated measures and turkeys test that is for post hoc analysis. There is no statistically significant difference in the measured cardio respiratory variables. There was the probability for PaO2/FIO2 to increase and Vd/Vt to decrease during times of CLR, though there was not significant difference. There were no changes in PaCO2 during the study. In addition, airway pressures showed no change in airway pressures during the study period, and there was no effect in the cardiac output. VO2 and VCO2 showed to be higher during times of P&PD. 1 Whereas PaO2 improves to some extent during the time of rotation, there are no significant increases in exchange of gas between manual turning every 2 hours and CLR. There is no adverse hemodynamic effect of either turning procedure. Continuous rotation increases secretion clearance when compared with manual turning, but adding percussion does not improve removal of secretion. Dolovich, M., Rushbrook, J., Churchill, E., Mazza, M, Powles, A.(1998). Effects of continuous laterals rotational therapy on lung mucus transport in mechanically ventilated patients. J Crit Care. 13( 3), pp. 119-25. Thirteen critically ill patients enrolled, but stable mechanically ventilated patients with the mean age of 74. They were to be in a supine on a bio-dyne bed and pressure in the cushions adjusted to the patient’s weight. The design involves placing supine on a bio-dyne bed and pressure in the cushions adjusted to the weight of the patient. Bio-dyne bed and cushions pressures Measurement involve delivering a radio- labeled aerosol by bagging for 3 to 3 minutes and the measurements repeated of lung radioactivity attained by imaging of the thorax over the next three hours. After rotation of the bed taking 90minutes, there is rotation of 30degrees to either side. This is followed by a two 45minutes control periods, in which case the patient remains supine and stationery on the bed. After that, there is recording of coughs and suctions including obtaining pre and post study blood gases (Dolovich, et al, 1998). This involves recoding the coughs and suctions and then obtaining a pre and post blood gases study. The finding include the mucous clearance was much slower than the reported in normal subjects and ambulatory patient with CORD. In addition, there was some slight increase in the clearance during CLRT, and the clearance had to revert to pre-oscillation levels after therapy. This might be due to too shallow angles of rotation or too short intervention time. I The positional drainage due to short duration CLRT do not appear to stimulate significant mucous removal from the lungs in critical ill patients. However, they do not cause any adverse effects. Martin, A.(2001). Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurse. 20 (1), pp. 42-9 Includes all the genders and all patients. The design involves the replacement for a standard manual turning that decreases the pulmonary complications in critically ill patients (Martin, 2001). The key variables involve the effectiveness of CLRT. The measurements involve finding the effectiveness of the CLRT in decreasing the pulmonary complications. Data analysis involves reviewing and analyzing the research on CLRT and proposing on the directions for future research (Martin, 2001). The findings include the fact that CLRT replaces for the standard manual turning and decrease the pulmonary complication in critically ill patients (martin, 2001). II The CLRT replaces for the standard manual turning and decrease the pulmonary complication in critically ill patients. Vollman, M.(2010).progressive mobility in the critically ill. Crit care Nurse. 30 (2) 39 randomized trials that examine the effect of bed rest on 15 different medical conditions and procedures. The bed rest is not beneficial and maybe related with harm. The design involves the application of positioning and mobility techniques such as elevation of head of the bed, moments against gravity, manual turning, chair position, ambulation, active and passive range-of-motion exercise and dangling among other techniques (Vollman, 2010). This Includes the ventilator-associated pneumonia and the hospital-acquired pneumonia. Also, development of pressure ulcers and the delayed weaning off of mechanical ventilation because of muscles weakness. Long-term measures include the diminished quality of life after discharge (Vollman, 2010). Measurement includes movements in a sequential manner starting at the patient’s current mobility status, and this is with the ambition of persistent to his or her baseline. Data analysis involves the intubation of the study. There are consequences such as development of compression atelectasis from the formation of depended edema with the patient supine and the impaired ability in clearing the lungs. The changes in the cardiovascular system relate to bed rest. The skin also does not tolerate prolonged pressure, hence, immobilized patients on bed rest experience appreciable risk for skin breakdown and delay in wound healing (Vollman, 2010). V The challenges of mobilizing people who are critically ill are quite numerous. Hemodynamic instability might be a crucial barrier in the progression of the mobility protocol. Sandra, K. (2012). Pilot Study of Lateral Rotation Interventions for Efficacy and Safety in ICU Care. Society of Critical Care Medicine The eligibility involves two genders and anybody is eligible as 18 years are not applicable. The design involves testing the feasibility of two turning protocols and studying the procedures for a multisite randomized clinical trial that evaluates efficacy and safety of the horizontal positioning interventions that reduce pulmonary complications in mechanically ventilated critically ill adult patients (Sandra, 2012). The key variables include the turning protocol and study procedures. The measurements involve receiving the mechanical ventilation and then placing the stud protocol within 8 hours of intubation. The measurement involves the exclusion and the inclusion criteria. Data analysis includes the intubation of the study protocol after every 8 hours. The primary outcome involves the incidences of pulmonary complications after completing the study participation and there is time to develop and time to resolution of pulmonary complication. The secondary outcomes involve the ICU all-cause mortality and length of stay including the mechanical ventilation duration and turning-related adverse events. This is after completing the participation of study (Sandra, 2012). III ICUs patients that are on respirators are at high risk for preventing the pulmonary complication, hence, turning patients from one side to another reduces the PPC, but also carry the burden of decreases in the blood pressure and the oxygenation. Read More