Anda di halaman 1dari 11

Intensive and Critical Care Nursing (2007) 23, 4—14

REVIEW

Nursing care of the mechanically ventilated


patient: What does the evidence say?
Part one
Bronwyn A. Couchman a,1, Sharon M. Wetzig b,2,
Fiona M. Coyer c,∗, Margaret K. Wheeler c,3

a Department of Intensive Care Medicine, Royal Brisbane and Women’s Hospital,


Butterfield St., Brisbane, Qld 4029, Australia
b Intensive Care Unit, Princess Alexandra Hospital, Ipswich Rd.,

Brisbane, Qld 4102, Australia


c Queensland University of Technology, Victoria Park Rd.,

Brisbane, Qld 4059, Australia

Accepted 8 August 2006

KEYWORDS Summary The care of the mechanically ventilated patient is at the core of a
Nursing care; nurse’s clinical practice in the Intensive Care Unit (ICU). Published work relating to
Mechanical ventilation; the numerous nursing issues of the care of the mechanically ventilated patient in
Patient assessment; the ICU is growing significantly. Literature focuses on patient assessment and man-
Patient safety;
agement strategies for patient stressors, pain and sedation. Yet this literature is
fragmentary by nature. The purpose of this paper is to provide a single comprehen-
Patient comfort
sive 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.
© 2006 Elsevier Ltd. All rights reserved.


Corresponding author. Tel.: +61 7 3864 3895; fax: +61 7 3863 3814.
E-mail addresses: Bronwyn Couchman@health.qld.gov.au (B.A. Couchman), Sharon Wetzig@health.qld.gov.au (S.M. Wetzig),
f.coyer@qut.edu.au (F.M. Coyer), mk.wheeler@qut.edu.au (M.K. Wheeler).
1 Tel.: +61 7 3636 8534; fax: +61 7 3636 1557.
2 Tel.: +61 7 3240 6268.
3 Tel.: +61 7 3864 9757; fax: +61 7 3864 3814.

0964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.iccn.2006.08.005
Nursing care of the mechanically ventilated patient 5

Introduction or anecdotal comment. This paper presents a sum-


mary of the important principles in the manage-
Mechanical ventilation is indicated for numerous ment of the mechanically ventilated patient. The
clinical and physiological reasons. The nursing focus of this article, the first in a two-part series,
management of the mechanically ventilated is the examination of literature addressing patient
patient is challenging on many levels: from the assessment and safety.
acquisition of highly technical skills; expert knowl-
edge on invasive monitoring; and implementation
of interventions to care for the patient. Each Patient safety
critically ill patient brings the clinical rationale for
mechanical ventilation and additional complexities A useful strategy for promoting the safety of the
associated with their illness. It is recognised that mechanically ventilated patient is to utilise a health
the reason for mechanical ventilation and patient assessment framework. The Emergency Care Cycle
admission impacts on patient assessment and man- is one health assessment framework that facili-
agement. However, there are core evidence-based tates a systematic and comprehensive approach to
collaborative principles which underpin the nursing patient assessment. This framework has two com-
management of such patients in the intensive care ponents: the Primary survey (see Table 1) which
unit (ICU), those being patient safety: patient identifies immediate life-threatening events, and
and equipment assessment; and patient comfort: the Secondary survey (see Table 2) which often
patient position; hygiene; management of stressors utilises a head-to-toe systems approach to assess
and; pain and sedation management. the functional status of each body system (Nettina,
To identify the evidence supporting practice a 2006). The safety considerations in the care of the
thorough review of current literature was under- mechanically ventilated patient will be discussed
taken using the following steps: electronic search utilising this framework (Fig. 1).
conducted of MEDLINE, CINAHL, EMBASE and Psych- Some overall patient safety considerations are
Review databases for articles published between worth noting first. Patients receiving mechanical
1995 and 2006 and; key words used were mechan- ventilation in ICU require continuous observation
ical ventilation, patient assessment, airway man- and monitoring. For this reason a nurse/patient
agement, sedation and comfort. ratio of 1:1 is recommended (ACCCN, 2005). This
Many confounding variables exist in the care of ensures that the patient can be closely monitored
the critically ill mechanically ventilated patient in and that response to any alarms can be rapid
the ICU. Consequently not all practice may be sup- (Winters and Munro, 2004). Promoting safety for
ported by evidence. As evidence-based literature the ventilated patient also involves ensuring emer-
addressing the overarching care of the mechani- gency equipment (see Table 3) is available in the
cally ventilated patient is scant, for the purpose of event of accidental extubation or ventilator failure
this paper common practice is supported by expert (Yeh et al., 2004). Routine safety measures utilised

Table 1 Primary survey


Assessment parameters Relevant numerical data
A: Airway Is the airway patent and secure?
- Listen to air movement
- Observe rise and fall of chest
- Check tube is secure and length is correct
B: Breathing Is the patient breathing? SpO2 , tidal volume, respiratory rate
- Observe chest rise and fall
- Observe patient colour
C: Circulation Does the patient have adequate circulation? Heart rate and rhythm, arterial blood pressure
- Check for a pulse
- Assess strength of pulse
- Observe patient colour
D: Disability What is the patient’s level of consciousness?
E: Exposure What is the patient’s surrounding environment?
Is the patient’s dignity preserved?
6 B.A. Couchman et al.

Table 2 Secondary survey: systems approach for the


ventilated patient
System Assessment parameters
Neurological • Glasgow Coma Score
• Ability to communicate
• Sedation score
• Degree of neuromuscular
blockade
• BIS monitoring
Respiratory Artificial airway:
• Tube placement
• Tube security
• Cuff status
Airway patency:
• Assessment of lung secretions Figure 1 Patient assessment.
(suctioning)
• Adequacy of humidification
monitoring devices and appropriateness of alarm
Breathing:
settings.
• Respiratory rate, volume and
pressure
• ABG analysis
• Pulse oximetry Primary survey
• Capnometry
Cardiovascular • Heart rate and rhythm The Primary survey (see Table 1) is concerned
• Blood pressure with identifying life-threatening circumstances
• Central venous pressure that require immediate attention (Nettina, 2006).
• Peripheral perfusion The pneumonic A: Airway, B: Breathing, C: Circu-
• Chest X-ray interpretation lation, D: Disability and E: Exposure is utilised.
• Measurement of cardiac The assessment is essentially unchanged regard-
output
• Observe for signs of DVT
Gastrointestinal • Abdominal Table 3 Emergency equipment and safety checks
discomfort/distension
Essential equipment required at the bedside
• Presence of bowel sounds
• Self-inflating manual resuscitation bag with
• Amount and characteristics of
appropriately sized face mask
gastric aspirates
• High-flow suction unit with Yankeur sucker and
• Frequency of bowel
endotracheal suction catheters
movement
• Physical strength and body Additional equipment readily accessible to the
weight bedside
• Serum phosphate level • Intubation equipment
• Liver function tests • Oxygen—–wall and portable supplies
• Battery operated suction unit
Metabolic • Temperature
• Blood glucose level Safety checks
• All equipment is present, readily accessible and
Renal • Urine output
in full working order
• Serum electrolytes, urea and
• The ventilator is connected where possible to
creatinine levels
an uninterrupted power supply
Skin integrity • Pressure ulcer risk • Intravenous infusions are being delivered
• Observe for presence of according to a current order with the correct
pressure ulcers rate, composition, time of expiry, point of
administration, etc.
• Patient equipment is functioning properly and
when caring for any critically ill patient should also safe alarm limits are set
be applied. These include checking intravenous • Monitoring devices are connected appropriately
infusions; checking patient equipment and alarm and safe alarm limits are set
settings; ensuring the correct attachment of
Nursing care of the mechanically ventilated patient 7

less of whether or not the patient is mechanically changes, as one of the few indications of a change
ventilated. Particular attention should be given to in the patient’s neurological condition.
ensuring the artificial airway is secure to prevent Many ventilated patients require some form of
dislodgement, and to checking the insertion length sedation to enable them to tolerate this ther-
of the airway for correct placement. As a caution, apy. To reduce the significant risks associated with
the availability of additional numerical data from oversedation (e.g. increased ventilation time and
the mechanical ventilator and monitoring devices increased length of stay, both ICU and hospital),
should not substitute for physical assessment of the a number of tools have been developed to deter-
patient. Used in conjunction with physical assess- mine the patient’s level of sedation (Hogarth and
ment, the numerics provide rapid and valuable Hall, in press; Heffner, 2000). Some of these tools
information, however their validity should be veri- assess degree of sedation as well as degree of agi-
fied by direct patient observation to avoid inaccu- tation. When sedation orders include a target score
rate assessment. on the sedation—agitation scale, this allows the ICU
nurse to titrate sedation doses accordingly (Ely et
al., 2003). This will be expanded further in part two
Secondary survey of this paper.
Neuromuscular blockade is occasionally required
The Secondary survey assesses the function of for ventilated patients in order to allow greater
each body system individually and usually is com- ease of ventilation. When this therapy is used, it
pleted in a head-to-toe format (Hillman and Bishop, is important to ensure that the blockade remains
2004). Acute dysfunction in one or more body sys- partial rather than complete as this is associated
tems is the precursor to initiation of mechani- with an increased risk of critical illness neuropa-
cal ventilation. The addition of artificial respira- thy (De Jonghe et al., 2004). The level of paraly-
tory support further impairs physiological function sis can be easily assessed using a peripheral nerve
by altering physiological homeostasis (Hillman and stimulator, with administration of paralytic agents
Bishop, 2004). Assessing all body systems thor- titrated to achieve the required level. Bispectral
oughly enables early identification of issues and Index Score (BIS) monitoring, which analyses elec-
appropriate intervention to minimise or prevent troencephalography (EEG) waveforms and statisti-
complications. The discussion focuses on the con- cally estimates level of sedation, is becoming more
siderations specific to the mechanically ventilated popular for monitoring sedation in the paralysed
patient. patient (Riker and Fraser, 2001). While used com-
monly during administration of anaesthetics, a sys-
Neurological system tematic review (LeBlanc et al., 2006) showed that
its application in the ICU setting requires further
Neurological assessment of the patient on mechan- investigation.
ical ventilation involves a range of methods. The Assessment of the patient’s conscious state and
Glasgow Coma Score (GCS) remains a widely used communication assists in determining the best
tool for assessing conscious level in terms of arousal approach to use in this area, as will be discussed
and verbal/physical response in many patient pop- further in part two of this paper.
ulations (Fischer and Mathieson, 2001). Adminis-
tration of sedative and/or muscle relaxant agents,
as well as the inability of the ventilated patient Respiratory system
to make a verbal response will impact on the
Effective respiratory assessment is pivotal to ensur-
application and accuracy of the GCS. The limi-
ing the safety of the mechanically ventilated
tations of using the GCS for intubated patients
patient. A helpful way to gather the data is to divide
have been overcome through use of communica-
the assessment into three main areas — the artifi-
tion scoring systems. These subjective tools assess
cial airway, airway patency and breathing.
the patient’s ability to communicate via non-verbal
means, including mouthing words, using letter
boards, writing notes, etc. (Lindgren and Ames, Artificial airway
2005). It is also important to assess pupil size All mechanically ventilated patients have an
and reaction as part of a focused neurological artificial airway in situ to enable delivery of the
assessment (Fischer and Mathieson, 2001). In the respiratory support. Regardless of whether this is
sedated patient, early signs of neurological deteri- an endotracheal tube or a tracheostomy tube, the
oration such as a decrease in level of consciousness aspects of tube placement, tube security and cuff
are masked leaving late signs, such as pupillary status must be addressed.
8 B.A. Couchman et al.

Incorrect tube placement places the patient at movement, be easily applied and removed to
significant risk. Absent or ineffective ventilation, enable adjustment to tube position and attention
aspiration and injury to the airway can result from to hygiene and will minimise trauma to adjacent
oesophageal intubation or from placement that is tissues. Available options include cotton tape,
too high or low in the trachea (Winters and Munro, specifically designed tube holders and non-stretch
2004). Tube placement at the time of insertion adhesive tapes. Although a number of studies
may be assessed in various ways depending on the comparing methods of securing endotracheal
available equipment. Subsequent displacement of tubes exist, a systematic review by Gardner et al.
the tube however may result from head flexion, (2005) indicates that no conclusions regarding the
tension during transport (DeBoer et al., 2003) and benefits of one method over another have been
swelling of surrounding tissues, thus ongoing assess- determined. Assessment includes ensuring the
ment promotes patient safety. method used is properly applied and that the tube
Frequently used strategies to verify placement is secured in the desired position.
include auscultation, end-tidal carbon dioxide mon- The presence of an artificial airway places the
itoring and radiological examination (DeBoer et al., patient at risk of developing complications asso-
2003). Auscultation of breath sounds across the lung ciated with the tube itself. Regular assessment of
fields is a commonly used technique. Stethoscopes the cuff enables effective management to minimise
are readily accessible however referred sounds may the risk of aspiration from underinflation and tra-
be transmitted even with incorrect tube place- cheal mucosal injury from overinflation (Vyas et
ment (DeBoer et al., 2003; Grmec, 2002). End- al., 2002). Evidence to support a single manage-
tidal carbon dioxide monitoring using capnometry ment technique as superior is limited. Crimlisk et
and capnography was determined to be a reliable al. (1996) performed a descriptive study which indi-
method for assessing tube placement in two small cated two primary techniques which were utilised
studies, although influenced by the clinical setting, in the clinical setting: measuring cuff pressures to
availability of equipment and experience of the ensure they remain at 25 mmHg or below; inflating
user (Knapp et al., 1999; Grmec, 2002). The numer- the cuff with the minimum volume of air required
ical and waveform displays provide continuous data to ensure air leak on inspiration (minimal occlusive
on expired carbon dioxide levels, changes to which volume); and inflating the cuff with the minimum
may indicate tube dislodgement or obstruction. A volume of air to allow a small leak on inspiration
concern however is that subtle changes to tube (minimal leak technique). Consideration of infla-
position such as movement into the larynx may not tion pressures, patient head movement and tube
be readily detected (Knapp et al., 1999). Chest diameter to airway diameter ratios should also be
radiograph is often considered as the standard for considered if the desired seal is not achieved (Vyas
assessing tube placement however this technique et al., 2002).
also has limitations. Of note is that the assessment
is at a single point in time and thus does not pro- Airway patency
vide regular or continuous data, delays between the Assessment of airway patency encompasses the
time of imaging to viewing the film can be lengthy, assessment of lung secretions and strategies to
and anatomy or image quality can make assessment manage these. The normal respiratory function
of placement difficult (DeBoer et al., 2003). All of the mechanically ventilated patient is compro-
endotracheal tubes and some tracheostomy tubes mised placing them at risk of complications. Arti-
have distance markings along the length of the ficial airways bypass the humidification and filter-
tube. These assist in assessing placement if mea- ing mechanisms of the upper airways (St John and
sured consistently in relation to a fixed structure Malen, 2004), medical gas is cold and dry and dis-
(for example, the teeth or gums). Given the lack ease processes and therapies can impair the cough
of evidence supporting one method as superior reflex (Jaber et al., 2004). Lung secretions should
and the limitations of any of the methods outlined be assessed for colour, consistency and volume
above, it would seem prudent to utilise two or more (Winters and Munro, 2004). Endotracheal suction-
techniques, one of which is able to be measured ing provides opportunity to assess the secretions
regularly or continuously, to assess tube placement but also to support the patient by removing secre-
in the mechanically ventilated patient. tions. Endotracheal suctioning in itself however is
Tube security supports maintenance of correct potentially hazardous to the patient and should be
tube placement and minimises injury to the airway performed with care.
caused by excessive movement. Techniques to A review by Day et al. (2002) indicates that
secure artificial airways ideally will hold the tube the frequency of suctioning should be determined
firmly in position independent of head and neck by the patient’s need, rather than performed
Nursing care of the mechanically ventilated patient 9

routinely. Physical assessment of the patient includ- (Day et al., 2002). The suction catheter should
ing auscultation and palpation of the chest, and be inserted to the depth of the carina and then
review of the patient’s secretion production over withdrawn by 1 cm prior to commencing suctioning
recent hours will indicate the need for suctioning. (Day et al., 2002). Care should be taken however
Observation of airway pressures and trends in pulse as persistent contact with the carina can result
oximetry and end-tidal carbon dioxide readings are in ulceration and induce haemodynamic changes
also important (Winters and Munro, 2004). Suction- associated with coughing and vagal stimulation.
ing only when needed limits exposure to potential Limiting the duration of the suctioning procedure
complications. to less than 10—15 s reduces the risk of hypoxaemia
Hypoxaemia is the most common complication and atelectasis (Day et al., 2002; Subirana et al.,
noted with suctioning (Demir and Dramali, 2005). 2003). Restricting the number of passes in a suction
Techniques for supplementing oxygenation during episode to three or less also assists in minimising
the suctioning procedure include hyperoxygena- complications. A further consideration is the degree
tion alone or in combination with hyperinflation. of negative pressure applied during the procedure.
A review by Day et al. (2002) and a meta-analysis Evidence is lacking to suggest an exact maximum
by Oh and Seo (2003) indicate that both techniques pressure to be applied, however pressures of
are effective in preventing hypoxaemia, however 200 mmHg or greater have been associated with
both are capable of causing respiratory damage or tracheal damage (Day et al., 2002; Donald et al.,
haemodynamic instability. Perhaps due to variabil- 2000). Recommendations for acceptable suction
ity in application of the interventions, the litera- pressures given in the literature range from 80 to
ture is inconclusive regarding the ideal method of 170 mmHg (Day et al., 2002; Donald et al., 2000).
preventing hypoxaemia (Wynne et al., 2004; Day Of importance also is the use of open versus
et al., 2002; Oh and Seo, 2003). A randomised closed suction systems. The latter are reported to
controlled trial conducted in 2002 by Demir and have the advantages of minimising hypoxaemia,
Dramali (2005) found that patients suctioned using maintaining PEEP and reducing contamination
a closed technique without hyperoxygenation did (Subirana et al., 2003). Two prospective ran-
not demonstrate a significant difference in par- domised controlled trials found that a closed
tial pressure of oxygen or oxygen saturation. The system presented no additional complications for
majority of subjects however had an FiO2 of less 50% the patient although it may not decrease compli-
or less, a positive end expiratory pressure (PEEP) cations associated with suctioning (Zeitoun et al.,
of 8 cm H2 O or less and a mean pre-suction PaO2 2003; Lorente et al., 2005). In particular, a liter-
of 95.49 mmHg, suggesting they may not have been ature review by Grap and Munro (2004) indicates
at high risk of developing hypoxemia. Consideration that closed suction systems offer no advantage in
of the patient’s status prior to suctioning including: the prevention of ventilator associated pneumonia
PEEP; FiO2 ; PaO2 ; heart rate (HR); mean arterial (VAP). However, the closed nature of the systems
pressure (MAP); and observation of the patient’s and ability to leave the system in situ greater
response to suctioning, provide useful data to than 24 h, reduces breaks to the ventilation circuit
guide suctioning practices which promote patient and thus the possibility of contamination from the
safety by minimising the adverse effects caused by environment (Kollef, 1999).
hypoxemia. A further consideration when assessing the phys-
Instillation of normal saline via the endotracheal ical airway is evaluating the adequacy and function
tube prior to suctioning is a common practice in of humidification devices. Inadequate humidifica-
some intensive care units. The theory behind this tion can lead to partial or complete airway obstruc-
practice is that the saline loosens and thins secre- tion and damage to respiratory tissue (Jaber et al.,
tions and stimulates the cough reflex thus facilitat- 2004). Two humidification systems are available:
ing removal of secretions (Blackwood, 1999). While heated humidifiers (HH); and heat and moisture
the theory may seem plausible, two reviews of the exchangers (HME). In a discussion of the litera-
literature do not support the technique and sug- ture by Kelly et al. (2004), it is suggested that
gests that it may actually be harmful to the patient both systems are effective; however both also have
(Blackwood, 1999; Day et al., 2002). potential adverse effects including bacterial con-
Complications are also associated with the suc- tamination and over-hydration (HH), or thick spu-
tioning procedure itself for which general recom- tum and increased work of breathing (HME). The
mendations based on limited studies and accepted humidification system used should take into con-
practice have been made. The size of catheter used sideration factors such as the anticipated duration
should be less than one-half the diameter of the of mechanical ventilation, the degree of sponta-
artificial airway to minimise the risk of atelectasis neous effort by the patient and the amount and
10 B.A. Couchman et al.

consistency of sputum. Whichever system is in use, output, capnometry trends provide an excellent
assessment of the patient is essential (Kelly et al., indication of arterial carbon dioxide levels. Even
2004). Excessively thick or thin secretions, crust- in less stable states, the variation between the
ing in the artificial airway, water in the circuit or end-tidal and arterial carbon dioxide levels pro-
changes in airway pressures may suggest inappro- vides information on dead space and perfusion
priate humidification. A holistic approach involving changes (Soubani, 2001; Frakes, 2001). As with
adequate systemic hydration is also important. any technology however, a sound understanding
of how the data are obtained and the factors that
Breathing influence the measurements is essential to avoid
A comprehensive understanding of the adequacy inappropriate interpretation (Martin and Wilson,
of ventilation and oxygenation in the mechanically 2002). Regardless, if used appropriately, non-
ventilated patient is essential as some if not all of invasive monitoring devices provide a continuous
the respiratory effort is coordinated by the venti- and safe method for assessing gas exchange.
lator. Necessary information is gathered from per-
forming a physical assessment and from analysis of Cardiovascular system
laboratory and patient monitoring data.
Physical assessment provides invaluable infor- The patient receiving mechanical ventilation may
mation concerning the patient’s interaction with experience a marked alteration in cardiovascular
the ventilator. The presence of dyspnoea, dyssyn- function. The increase in intrathoracic pressure
chronous chest and abdominal movement, the use that occurs results in a reduction in preload as
of accessory muscles and agitation may suggest venous return decreases. This is exacerbated in
the ventilation settings are inappropriate for the patients who have high PEEP settings or who are
patient’s requirements (Hillman and Bishop, 2004). on inverse ratio ventilation. The extent of impair-
Physical assessment of the patient may also alert ment depends on the baseline cardiovascular state
the clinician to subtle changes in the patient’s res- of the patient (Pinsky, 2005). It is important that
piratory status which otherwise may have gone the ICU nurse undertakes comprehensive cardio-
unnoticed. Altered breath sounds and asymmetri- vascular assessment of the patient to determine
cal chest movement, for example, may indicate the adequacy of cardiac output and to observe for com-
development of a pneumothorax when other signs plications associated with poor cardiac output. This
such as dyspnoea and rapid, shallow breathing are involves assessment of heart rate and rhythm, blood
masked by sedation and full mandatory ventilation. pressure, central venous pressure, peripheral per-
Monitoring data from the ventilator also aids in fusion, urine output and chest X-ray, as well as
understanding the patient’s respiratory status and serum electrolytes (McGrath and Cox, 1998). Reg-
the appropriateness of the ventilator settings. Res- ular assessment of haemoglobin is also important
piratory rate, tidal volume, minute volume and air- in this group due to the significant impact that
way pressures as absolute values reflect the current anaemia can have on the patient’s oxygen-carrying
delivery of ventilatory support. When analysed as capacity. Measures to conserve blood should be con-
trends over time, such data can provide information sidered to prevent and/or treat anaemia (Fowler
about the status of lung function and the patient’s and Berensen, 2003). Patients receiving mechani-
respiratory effort (Jubran and Tobin, 1996). cal ventilation should have continuous multi-lead
Monitoring of gas exchange is a routine aspect of electrocardiography monitoring to enable timely
caring for a mechanically ventilated patient. Arte- assessment and treatment of cardiac arrhythmias
rial blood gas (ABG) analysis is the gold standard or myocardial ischaemia (Robb, 1997).
for determining arterial carbon dioxide and oxygen A relatively new technique called Pulse Pressure
levels. The complications and costs associated Variation assesses the variation in pulse pressure
with repeated ABG analysis however support the (via an arterial catheter or plethysmograph) with
use of non-invasive monitoring techniques. Pulse respiration, which provides an estimate of fluid
oximetry and capnometry are relatively simple status — the higher the variation, the ‘drier’ the
and effective tools for monitoring gas exchange. A patient is. This method is yet to be substantially
meta-analysis indicated that pulse oximeters are validated, but a prospective clinical investigation
accurate to ±2% for oxygen saturations greater (Cannesson et al., 2005) shows that it could pro-
than 70% (Jensen et al., 1998). Capnometers vide a simple, accurate measurement of fluid status
provide a numerical reading of end-tidal carbon using existing monitoring equipment.
dioxide levels. Reviews by Capovilla et al. (2000) It is well recognised that accurate determina-
and Frakes (2001) suggest that in the context of tion of cardiac output in the most critically ill
stable ventilation/perfusion dynamics and cardiac patients using these basic assessment parameters
Nursing care of the mechanically ventilated patient 11

is difficult. Techniques that endeavour to pro- et al., 2003), best outcomes were found in patients
vide an accurate measurement of cardiac output receiving moderate rather than high caloric intake,
are numerous (Adams, 2004). The so-called ‘gold- around 9—18 kcal/kg/day.
standard’ is the bolus thermodilution method using It is important to note that effective func-
a pulmonary artery catheter (Zink et al., 2004). tioning of the gastrointestinal tract (GIT) can be
Other techniques have sought to provide the same impaired during mechanical ventilation as a result
accuracy in measurement while providing contin- of a reduction in splanchnic blood flow secondary
uous data and/or reducing invasiveness and cost. to decreased cardiac output (Aneman et al., 1999).
These include continuous thermodilution method, The reduction in GIT motility caused by use of seda-
transthoracic/transoesophageal echocardiography, tive and narcotic agents further impairs function-
pulse contour analysis, and oesophageal Doppler ing. Mechanically ventilated patients need to be
(Adams, 2004). regularly assessed for abdominal discomfort and/or
The reduction in preload experienced by venti- distension, presence of bowel sounds, amount and
lated patients can be best managed by maintaining characteristics of gastric aspirates and frequency of
an adequate fluid volume status. It is reported that bowel movement (Bowman et al., 2005).
maintaining adequate filling pressures (e.g. CVP Adequacy of nutrition is particularly important
of 10—12 mmHg) optimises preload and therefore in the weaning phase of mechanical ventilation,
reduces the risk of a reduction in cardiac output where patients are required to breathe with less
(Pinsky, 2005). support from the ventilator (Lindgren and Ames,
The risk of developing deep vein thrombosis 2005). Assessment of the patient’s muscle mass
(DVT) is greatly increased in the ventilated patient or degree of muscle wasting, physical strength
as a result of venous stasis related chiefly to immo- and body weight will provide an indication of the
bility, but also to the decrease in venous return need for increased nutritional support (Sabol, 2004;
described above (Pinsky, 2005). It is important to Flancbaum et al., 1999). Assessment of serum elec-
assess the patient for signs of DVT and to ini- trolytes, particularly phosphate which is impor-
tiate preventative measures early (Yang, 2005). tant in energy production, and supplementation if
Current practice in DVT prophylaxis involves use required is also important to promote muscle func-
of thrombo-embolic deterrent (TED) stockings, tioning (McClave et al., 2002).
sequential compression devices, passive movement Hepatic blood flow via the portal vein may also
exercises and administration of either unfraction- be compromised as a result of decreased car-
ated heparin or low-molecular weight heparin. A diac output associated with mechanical ventilation
review paper (Yang, 2005) indicates that of these (Aneman et al., 1999). It is important to regu-
therapies the mechanical options are not associ- larly measure liver function tests as well as clot-
ated with a decreased risk when used alone, so the ting times to observe for any hepatic impairment
combination of mechanical and pharmacological is (Winters and Munro, 2004).
recommended.
Metabolic system
Gastrointestinal system
Assessment of temperature is a basic yet important
Nutritional status is a vital part of assessment and parameter to monitor as an elevated temperature
care for the mechanically ventilated patient. The can signal the patient’s response to infection
capacity for oral intake is limited in this situation (Winters and Munro, 2004). Ventilated patients
due to the presence of the ETT and the patient’s have a significant risk of developing nosocomial
level of sedation, though it is possible for patients infections as a result of suppressed immune func-
ventilated via tracheostomy. In most critically ill tion and the presence of artificial tubes (e.g.
patients requiring ventilation, early enteral feed- ETT, urinary catheter, central venous catheters)
ing via an oro/nasogastric tube is a well established (Lindgren and Ames, 2005). Other methods that are
practice (Lindgren and Ames, 2005). Use of an commonly used to detect response to infection are
established feeding protocol, where feed absorp- measurement of white blood cell count, C-reactive
tion is closely monitored, feeding rate increased protein (CRP), IL-6 and procalcitonin (PCT) levels.
gradually and prokinetic agents given as required A prospective study (Gaini et al., 2006) has recently
has been shown to provide the best outcomes, shown that CRP and IL-6 are more sensitive markers
when implemented in a pilot study (Bowman et al., of infection than PCT, while PCT is a better indicator
2005). Accurate assessment of caloric requirements of severity. Some ICUs also utilise routine surveil-
in the critically ill patient remains a topic of some lance of high risk patients (e.g. patients ventilated
debate. According to a multi-centre study (Krishnan for 48 h or more) to assist in the early detection of
12 B.A. Couchman et al.

infection and identification of potential infection and renal perfusion pressure to prevent acute renal
control problems (Tablan et al., 2003). failure (Leblanc et al., 2005).
Coupled with the assessment and early detec-
tion of infective processes are measures to min- Skin integrity and mobility
imize the risk of ventilated patients developing
nosocomial infections. The Centre for Disease Con- Ventilated patients are at increased risk of impair-
trol and Prevention and a group representing the ment in skin integrity chiefly through immobility
Canadian Critical Care Trials Group and the Cana- associated with sedation and ventilation (Lindgren
dian Critical Care Society have published guide- and Ames, 2005). Effective pressure ulcer preven-
lines outlining best practice for the prevention tion is essential in reducing the patient’s length
of ventilator-associated pneumonia. The guidelines of ventilation and hospital stay (Wolverton et al.,
suggest a multi-faceted approach to prevention 2005). Although the Braden and Norton scales
which includes oral versus nasal intubation, lim- have been tested for validity and reliability in a
ited interruptions to ventilator circuitry, eleva- prospective multi-centre study (Schoonhoven et
tion of the head of the bed, strategies for the al., 2002), assessment of pressure ulcer risk using
management of respiratory equipment, minimising the Waterlow scoring system best describes the risk
the duration of mechanical ventilation, and effec- for critically ill patients. It includes administration
tive hand hygiene (Tablan et al., 2003; Dodek et of inotropic agents, cytotoxics and high-dose
al., 2004). Such strategies along with strict appli- steroids in its risk assessment, and also has strate-
cation of Standard Precautions should constitute gies for pressure relief/reduction depending on
standard practice for the nursing management of the level of risk (Boyle and Green, 2001).
the mechanically ventilated patient to prevent the Semi-recumbent positioning rather than supine
development of nosocomial infections. positioning has been recommended as a measure to
Blood glucose monitoring and control is not a reduce the risk of ventilator associated pneumonia,
new concept, but one which has certainly been the according to a randomised trial (Drakulovic et al.,
focus of much research in the critically ill patient 1999). Mobility can be enhanced in the longer-term
population recently. Evidence from a randomised- ventilated patient through sitting him/her in a chair
controlled trial (van den Berghe et al., 2006) sug- for periods of time through the day. This improves
gests that maintenance of blood glucose within lung expansion and can reduce the risk of ventilator
tight limits (4.4—6.1 mmol/L) is associated with a associated pneumonia (Safdar et al., 2005).
reduction in mortality. This is of particular signif-
icance in patients who are ventilated as they fre-
quently have an elevated blood glucose level as a Summary
result of initiation of the body’s stress response that
occurs in critical illness (Winters and Munro, 2004). The mechanically ventilated patient presents many
The ‘Surviving Sepsis Guidelines’ recommend that challenges for the intensive care nurse. Nurs-
patients with severe sepsis have a blood glucose ing care and management of the critically ill
level maintained less than 8.3 mmol/L (Dellinger mechanically ventilated patient is demanding and
et al., 2004). necessitates an expert understanding of techno-
logical issues underpinned with a patient focused
Renal system approach. From the discussion above it is clear that
while mechanical ventilation is a necessary ther-
The reduction in cardiac output associated with apeutic intervention for many patients, it brings
positive pressure ventilation may result in reduced with it an array of potential or actual complications
urine output through neural and hormonal mech- which present further challenges for the critically
anisms (i.e. antidiuretic hormone secretion and ill patient. Nursing care based on evidence is piv-
activation of the rennin—angiotensin—aldosterone otal to ensuring quality health outcomes for the
system) (Pinsky, 2005). It is important to closely mechanically ventilated patient.
monitor the urine output of a ventilated patient To support the use of evidence in the practice,
as well as serum levels of urea and creatinine to the concept of a ‘Ventilator Care Bundle’ had been
detect any renal impairment. Ensuring urine output utilised in the United States and the United King-
is greater than or equal to 0.5 mL/kg/h is one way dom. The bundle includes four interventions which
of assessing adequate renal function, according have sound evidence to support their effectiveness
to a recent evidence-based review (Rhodes and in improving outcomes for the mechanically ven-
Bennet, 2004). It is also important to maintain tilated patient: elevation of the head of the bed;
adequate cardiac output, mean arterial pressure management of sedation including daily ‘sedation
Nursing care of the mechanically ventilated patient 13

vacations’; peptic ulcer prophylaxis; deep vein Capovilla J, VanCouwenberghe C, Miller WA. Noninvasive blood
thrombosis prophylaxis (Institute for Healthcare, gas monitoring. Crit Care Nurs Q 2000;23(2):79—86.
Crimlisk JT, Horn MH, Wilson DJ, Marino B. Artificial air-
in press). The concept of Care Bundles provides
ways: a survey of cuff management practices. Heart Lung
a mechanism for highlighting best practice in 1996;25(3):225—35.
a particular area to clinicians. If implemented Crunden E, Boyce C, Woodman H, Bray B. An evaluation of
effectively, Care Bundles support the provision of the impact of the ventilator care bundle. Nurs Crit Care
minimum standards of care for all patients in a sub- 2005;10(5):242—6.
Day T, Farnell S, Wilson-Barnett J. Suctioning: a review of cur-
group (Resar et al., 2005; Crunden et al., 2005) and
rent research recommendations. Intensive Crit Care Nurs
provide indicators to measure the quality of care 2002;18:79—89.
provided (Provonost et al., 2003). As highlighted De Jonghe B, Sharshar T, Hopkinsonb N, Outina H. Pare-
throughout this paper however, much of our nursing sis following mechanical ventilation. Curr Opin Crit Care
practice lacks definitive evidence to support one 2004;10:47—52.
DeBoer S, Seaver M, Arndt K. Verification of endotracheal tube
approach to care over another. The use of evidence-
placement: a comparison of confirmation techniques and
based protocols/guidelines where available, in devices. J Emergency Nurs 2003;29(5):444—50.
conjunction with systematic and comprehensive Dellinger P, Carlet J, Masur H, Gerlach H, Calandra T, Cohen
patient assessment promotes best practice in the J, et al. Surviving sepsis campaign guidelines for manage-
care of the mechanically ventilated patient. ment of severe sepsis and septic shock. Intensive Care Med
2004;30(4):536—55.
This article has presented an overview of the
Demir F, Dramali A. Requirement for 100% oxygen before and
initial management of the mechanically ventilated after closed suction. J Adv Nurs 2005;51(3):254—351.
patient, covering key patient safety issues. Future Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, et al.
research to address deficits in evidence which sup- Evidence-based clinical practice guideline for the preven-
ports nursing practice needs to focus on general tion of ventilator-associated pneumonia. Ann Internal Med
2004;141(4):305—13.
nursing assessment of the mechanically ventilated
Donald KJ, Robertson VJ, Tsebelis K. Setting safe and effective
patient and specifically issues related to ETT secu- suction pressure: the effect of using a manometer in the suc-
rity, closed system suctioning and humidification. tion circuit. Intensive Care Med 2000;26:15—9.
The second paper in this series will address man- Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M.
agement issues related to patient comfort: specif- Supine body position as a risk factor for nosocomial pneumo-
nia in mechanically ventilated patients: a randomised con-
ically the patient/family unit, patient position and
trolled trial. Lancet 1999;354:1851—8.
hygiene, management of stressors, pain manage- Ely W, Truman B, Shintani A, Thomason J. Monitoring sedation
ment and sedation. status over time in ICU patients: reliability and validity. JAMA
2003;289(22):2971—83.
Fischer J, Mathieson C. History of the Glasgow Coma Scale: impli-
cations for practice. Crit Care Nurs Q 2001;23(4):52—8.
References Flancbaum L, Choban P, Sambucco S, Verducci J, Burge J. Com-
parison of indirect calorimetry, the Fick method, and pre-
ACCCN. Position statement on intensive care nursing staffing. diction equations in estimating the energy requirements of
Australian College of Critical Care Nurses; 2005, Available: critically ill patients. Am J Clin Nutr 1999;69(3):461—6.
www.acccn.com.au. Frakes MA. Measuring end-tidal carbon dioxide: clinical applica-
Adams K. Hemodynamic assessment: the physiologic basis for tions and usefulness. Crit Care Nurs 2001;21(5):23—37.
turning data into clinical information. AACN Clin Issues Fowler R, Berensen M. Blood conservation in the intensive care
2004;15(4):534—46. unit. Crit Care Med 2003;31(12):S715—20.
Aneman A, Eisenhofer G, Fandriks L, Olbe L, Dalenback J, Gaini S, Koldkjaer O, Pedersen C, Pedersen S. Procalcitonin,
Nitescu P, et al. Splanchnic circulation and regional sym- lipopolysaccharide-binding protein, interleukin-6 and C-
pathetic outflow during peroperative PEEP ventilation in reactive protein. Crit Care 2006;10(2).
humans. Br J Anaesth 1999;82(6):838—42. Gardner A, Hughes D, Cook R, Henson R, Osborne S, Gardner G.
Blackwood B. Normal saline instillation with endotracheal suc- Best practice in stabilisation of oral endotracheal tubes: a
tioning: primum non nocere (first do no harm). J Adv Nurs systematic review. Aust Crit Care 2005;18(4):158—65.
1999;29(4):928—34. Grap MJ, Munro CL. Preventing ventilator-associated pneu-
Bowman A, Greiner J, Doerschug K, Little S, Bombei C, Comried monia: evidence-based care. Crit Care Nurse Clin N Am
L. Implementation of an evidence-based feeding protocol 2004;16:349—58.
and aspiration risk reduction algorithm. Crit Care Nurs Q Grmec S. Comparison of three different methods to confirm
2005;28(4):324—33. tracheal tube placement in emergency intubation. Intensive
Boyle M, Green M. Pressure sores in intensive care: defining their Care Med 2002;28:701—4.
incidence and associated factors and assessing the utility Heffner J. A wake-up call in the intensive care unit. New Engl J
of two pressure sore risk assessment tools. Aust Crit Care Med 2000;342(20):1520—2.
2001;14(1):24—30. Hillman K, Bishop G. Clinical intensive care and acute medicine.
Cannesson M, Besnard C, Durand P, Bohe J, Jacques D. 2nd ed. Cambridge: Cambridge University Press; 2004.
Relation between respiratory variations in pulse oxime- Hogarth D, Hall J. Management of sedation in mechanically ven-
try plethysmographic waveform amplitude and arterial tilated patients. Curr Opin Crit Care 10(1):40—6, in press.
pulse pressure in ventilated patients. Crit Care 2005;9(5): Institute for Healthcare Improvement. Implement the venti-
R562—8. lator bundle. http://www.ihi.org/IHI/Topics/CriticalCare/
14 B.A. Couchman et al.

IntensiveCare/Changes/ImplementtheVentilatorCareBundle. Riker R, Fraser G. Monitoring sedation, agitation, analgesia, neu-


htm; [retrieved 3rd July 2006]. romuscular blockade, and delirium in adult ICU patients.
Jaber S, Pigeot J, Bodil R, Maggiore S, Harf A, Isabey Semin Respir Crit Care Med 2001;22(2):189—98.
D, et al. Long-term effects of different humidification Rhodes A, Bennet E. Early goal directed therapy: an evidence
systems on endotracheal tube patency. Anaesthesiology based review. Crit Care Med 2004;32(11):S448—50.
2004;100:782—8. Robb J. Physiological changes occurring with positive pressure
Jensen LA, Onyskiw JE, Prasad NGN. Meta-analysis of arterial ventilation: part one 1997;13:293—307.
oxygen saturation monitoring by pulse oximetry in adults. Sabol V. Nutrition assessment of the critically ill adult. AACN Clin
Heart Lung 1998;27(6):387—408. Issues 2004;15(4):595—606.
Jubran A, Tobin MJ. Monitoring during mechanical ventilation. Safdar N, Dezfulian C, Collard H, Saint S. Clinical and economic
Clin Chest Med 1996;17(3):453—73. consequences of ventilator associated pneumonia: a system-
Kelly M, Gillies D, Lockwood C, Todd D. Heated humidification atic review. Crit Care Med 2005;33(10):2184—93.
versus heat and moisture exchangers for ventilated adults Schoonhoven L, Halboom J, Bousema M, Algra A, Grobbee D,
and children (protocol). Cochrane Database Syst Rev 2004(1). Grypdonck M, et al. Prospective cohort study of routine use
Art. No.: CD004711. doi:10.1002/14651858.CD0004711. of risk assessment scales for prediction of pressure ulcers. Br
Knapp S, Kofler J, Stoiser B, Thalhammer F, Burgmann H, Posch Med J 2002;326(7381):165.
M, et al. The assessment of four different methods to verify Soubani AO. Noninvasive monitoring of oxygen and carbon diox-
tracheal tube placement in the critical care setting. Anesth ide. Am J Emergency Med 2001;19(2):141—6.
Analg 1999;88:766—70. St John RE, Malen JF. Contemporary issues in adult tracheostomy
Kollef MH. The prevention of ventilator-associated pneumonia. management. Crit Care Nurs Clin N Am 2004;16:413—30.
New Engl J Med 1999;340(8):627—34. Subirana M, Sola I, Garcia JM, Laffaire E, Benito S. Closed
Krishnan J, Parce P, Martinez A, Diette G, Brower R. Caloric tracheal suctions systems versus ope tracheal systems
intake in medical ICU patients: consistency of care with for mechanically ventilated adult patients (protocol).
guidelines and relationship to clinical outcomes. Chest Cochrane Database Syst Rev 2003(3). Art. No.: CD004581.
2003;124(1):297—305. doi:10.1002/14651858.CD0004581.
LeBlanc J, Dasta J, Kane-Gill S. Role of the bispectral Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.
index in sedation monitoring in ICU. Ann Pharmacother Guidelines for preventing health-care-associated pneumo-
2006;40(3):490—500. nia, 2003: recommendations of CDC and the Healthcare
Leblanc M, Kellum J, Gibney R, Lieberthal W, Tumlin J, Mehta R. Infection Control Practices Advisory Committee. Morbid
Risk factors for acute renal failure: inherent and modifiable Mortal Weekly Rep 2004;53(RR—3):1—38. Available from
risks. Curr Opin Crit Care 2005;11(6):533—6. http://www.cdc.gov/mmwr/PDF/RR/RR5303.pdf.
Lindgren A, Ames N. Caring for patients on mechanical ven- van den Berghe G, Wilmer A, Hermans G, Meersseman W,
tilation: what research indicates is best practice. AJN Wouters P, Weekers F. Intensive insulin therapy in the medical
2005;105(5):50—61. ICU. New Engl J Med 2006;354(5):449—63.
Lorente L, Lecuona M, Martin MM, Garcia C, Mora ML, Sierra Vyas D, Inweregbu K, Pittard A. Measure of tracheal tube cuff
A. Ventilator-associated pneumonia using a closed versus pressure in critical care. Anaesthesia 2002;57:275—7.
an open tracheal suction system. Crit Care Med 2005; Winters A, Munro N. Assessment of the mechanically ventilated
33(1):115—9. patient: an advanced practice approach. AACN Clin Issues
Martin S, Wilson M. Monitoring gaseous exchange: implications 2004;15(4):525—33.
for nursing care. Aust Crit Care 2002;15(1):8—13. Wolverton C, Hobbs L, Beeson T, Benjamin M, Campbell K,
McClave S, DeMeo M, DeLegge M, DiSario J, Heyland D, Mal- Forbes C, et al. Nosocomial pressure ulcer rates in critical
oney J. North American summit on aspiration in the critically care: performance improvement project. J Nurs Care Qual
ill patient: consensus statement. J Parenteral Enteral Nutr 2005;20(1):56—62.
2002;26(6):S80—5. Wynne R, Botti M, Paratz J. Preoxygenation for tracheal
McGrath A, Cox C. Cardiac and circulatory assessment in inten- sunctioning in ventilated adults (protocol). Cochrane
sive care units. Intens Crit Care Nurs 1998;998(14):283—7. Database Syst Rev 2004(4). Art. No.: CD005142.
Nettina SM, editor. Lippincott manual of nursing practice. 8th doi:10.1002/14651858.CD005142.
ed. Philadelphia: Lippincott, Williams and Wilkins; 2006. Yang J. Prevention and treatment of deep vein thrombosis and
Oh H, Seo W. A meta-analysis of the effects of various inter- pulmonary embolism in critically ill patients. Crit Care Nurs
ventions in preventing endotracheal suction-induced hypox- Q 2005;28(1):72—9.
aemia. J Clin Nurs 2003;12:912—24. Yeh S, Lee L, Ho T, Chiang M, Lin L. Implications of nursing care in
Pinsky M. Cardiovascular issues in respiratory care. Chest the occurrence and consequences of unplanned extubation in
2005;128(5):592S—7S. adult intensive care units. Int J Nurs Stud 2004;41(3):255—62.
Provonost PJ, Berenholtz SM, Ngo K, McDowell M, Holzmueller Zeitoun SS, Leite De Barros ALB, Diccini S. A prospective,
C, Haraden C, et al. Developing and pilot testing quality randomised study of ventilator-associated pneumonia in
indicators in the intensive care unit. J Crit Care 2003;18(3): patients using a closed vs. open suction system. J Clin Nurs
145—55. 2003;12:484—9.
Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Zink W, Noll J, Rauch H, Bauer H, Desimone R, Martin E, et
Using a bundle approach to improve ventilator care processes al. Continuous assessment of right ventricular ejection frac-
and reduce ventilator-associated pneumonia. Joint Commis- tion: new pulmonary artery catheter versus transesophageal
sion J Qual Patient Saf 2005;31(5):243—8. echocardiography. Anaesthesia 2004;59:1126—32.