Colorado Cardiac Conference: 2 nd teaching workshop. Proactive Respiratory Therapy in postoperative Cardiac Patients

Transcription

1 Colorado Cardiac Conference: 2 nd teaching workshop Proactive Respiratory Therapy in postoperative

2 Financial Disclosures Donald Fritz, RT Jerrold Judd, RT No relevant financial relationships with any commercial interests. 2

3 Objectives Provide an open forum to discuss the efficacy of proactive Respiratory Therapy and the use of Respiratory Therapy protocols in the Cardiac acute care environment and the potential to improve patient outcome, reduce length of stay and reduce ventilator days. 3

4 There is growing data regarding the use of Respiratory Therapy protocols in the acute care setting. Can this be safely and appropriately applied to the post-operative pediatric cardiac population? 4

5 Rapid weaning to extubation RT-driven protocols vs. Physiciandirected ventilator management 5

6 Critical Care Medicine: April Volume 25 - Issue 4 - pp A randomized, controlled trial of protocol-directed versus physiciandirected weaning from mechanical ventilation Kollef, Marin H. MD, et al. The median duration of mechanical ventilation was 35 hrs for the protocoldirected group compared with 44 hrs for the physician-directed group Conclusion: Protocol-guided weaning of mechanical ventilation, as performed by nurses and respiratory therapists, is safe and led to extubation more rapidly than physician-directed weaning. (Crit Care Med 1997; 25: ) 6

7 Protocol Weaning of Mechanical Ventilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses* Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia Gregory P. Marelich, et al. Conclusions: A VMP designed for multidisciplinary use was effective in reducing duration of mechanical ventilatory support without any adverse effects on patient outcome. The VMP was also associated with a decrease in incidence of VAP in trauma patients. These results, in conjunction with prior studies, suggest that VMPs are highly effective means of improving care, even in university ICUs. (CHEST 2000; 118: ) 7

8 The decision-making processes of nurses when extubating patients following cardiac surgery: an ethnographic study. Hancock HC, Easen PR. OBJECTIVES: This study sought to explore the realities of research and evidence-based practice through an examination of the decision making of nurses when extubating patients following cardiac surgery. RESULTS: The findings indicated that, despite the use of an unwritten physiologically based protocol for weaning and extubation, factors other than best evidence were significant in nurses' decision making. A range of personal, cultural and contextual factors including relationships, hierarchy, power, leadership, education, experience and responsibility influenced their decision making. CONCLUSION: This study revealed, often disregarded, cultural, contextual and personal characteristics which combined to form a complex process of decision making. Providing new insight into research and evidence-based practice, the findings have implications for policy makers, educators, managers and clinicians and for the continued professional development of nursing. 8

9 Effect of Mechanical Ventilator Weaning Protocols on Respiratory Outcomes in Infants and Children A Randomized Controlled Trial Adrienne G. Randolph, MD, MSc; David Wypij, PhD;Shekhar T. Venkataraman, MD; James H. Hanson, MD; Rainer G. Gedeit, MD; Kathleen L. Meert, MD; Peter M. Luckett, MD; Peter Forbes, MA; Michelle Lilley, RRT; John Thompson, RRT; Ira M. Cheifetz, MD; Patricia Hibberd, MD, PhD; Randall Wetzel, MD; Peter N. Cox, MD;John H. Arnold, MD; for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Context: Ventilator management protocols shorten the time required to wean adult patients from mechanical ventilation. The efficacy of such weaning protocols among children has not been studied. Objective To evaluate whether weaning protocols are superior to standard care (no defined protocol) for infants and children with acute illnesses requiring mechanical ventilator support and whether a volume support weaning protocol using continuous automated adjustment of pressure support by the ventilator (ie, VSV) is superior to manual adjustment of pressure support by clinicians (ie, PSV). 9

10 Effect of Mechanical Ventilator Weaning Protocols on Respiratory Outcomes in Infants and Children Results Extubation failure rates were not significantly different for PSV (15%), VSV (24%), and no protocol (17%) (P =.44). Among weaning successes, median duration of weaning was not significantly different for PSV (1.6 days), VSV (1.8 days), and no protocol (2.0 days) (P =.75). Male children more frequently failed extubation (odds ratio, 7.86; 95% confidence interval, ; P<.001). Increased sedative use in the first 24 hours of weaning predicted extubation failure (P =.04) and, among extubation successes, duration of weaning (P<.001). Conclusions In contrast with adult patients, the majority of children are weaned from mechanical ventilator support in 2 days or less. Weaning protocols did not significantly shorten this brief duration of weaning. 10

11 What Change do you suggest? Settings PRVC Rate 24, Vt 8/kg, PS 6(4/kg), PEEP 6, 35% Total respiratory rate 30 ph 7.29 CO2 55 PaO2 40 HCO3 26 BE

12 Timely repositioning, securing of endotracheal tubes Protocol at CHC is to re-secure ETT within 30 minutes of post-op x-ray. In the last two years we have had 285 day and 209 day consecutive runs without an unplanned extubation White board posting days since last event and Muliti-disciplinary vigilance, awareness key factor in success 12

13 Timely repositioning, securing of endotracheal tubes Tape-to-skin technique causing skin breakdown, palate deformities? If rapid extubation is the goal, is re-taping necessary? 13

14 Lung Recruitment Bedside RT can assess for optimal PEEP and proactively provide lung recruitment maneuvers prn Detriment to pulmonary venous return, cardiac output. Inappropriate vent settings can potentially increase need for inotropic support 14

15 Obstacles to Proactive Respiratory Therapy Communication Multi-disciplinary proficiency, knowledge of ventilator modes, available therapies Commitment to protocols/guidelines Consistency of care, adherence to protocols/guidelines 15

16 Innovative strategies for multi-disciplinary respiratory/ventilator management NAVA APRV Non-Invasive, AVAPS 16

17 Conventional Pressure Support

18 NAVA Proactive Respiratory Therapy in postoperative

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20 NAVA Proactive Respiratory Therapy in postoperative Synchronization between ventilator and patient. (less sedation, more comfortable) Patient driven variable tidal volumes. (more like physiologic breathing) Reduce work of breathing Reduce Oxygen requirement Reduce Peak/Mean Airway pressure Reduce Ventilator Time/ICU stay

21 Central nervous system Ideal Technology Phrenic nerve Diaphragm excitation Diaphragm contraction NAVA Trigger Ventilator Breath Chest wall, lung and esophageal response Airway flow, pressure and volume changes Current Technology

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24 Children s Hospital Colorado Cardiac ICU NAVA Trial 8/30/ /1/2011

25 21 Patient Trials What did we observe? Reduced average Peak Inspiratory Pressure Reduced Mean Airway Pressure Increased Patient Synchrony/Comfort Improved Ventilator Weaning/Maintained Strength of Respiratory Muscles Improved venous return secondary to lower pressures

26 24 hour Trend Decrease in Airway Pressure when in NAVA Post-Operative Glenn Physiology After changing to NAVA mode the patient s mean airway pressure decreased thereby improving passive venous circulation from head to pulmonary arteries. Oxygen saturation improved and less oxygen was required to achieve target saturation.

27 A patient with chronic lung disease who had been ventilated in the PICU for 22 days being treated for pneumonia recovered in the CICU after cardiac Surgery for main pulmonary artery reduction to resolve compression on the Left mainstem bronchus, right pulmonary artery plasty and a Lecompte maneuver. The patient was able to be extubated to non-invasive ventilation after 3.5 days on NAVA.

28 A patient with a complex cardiac history of several surgeries requiring intubation Was able to be ventilated more comfortably in NAVA. Excellent patient-ventilator synchrony was noted and the patient was able to progress to extubation faster than previously and required less non-invasive support post-extubation.

29 Conclusions Institution approaches to implementation may vary widely Multi-disciplinary support is necessary Financial benefits? Patient Safety concerns 29

30 References A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation Kollef, Marin H. MD; Shapiro, Steven D. MD; Silver, Patricia MEd; St. John, Robert E. MSN; Prentice, Donna MSN; Sauer, Sharon BSN; Ahrens, Tom S. DNS; Shannon, William PhD; Baker-Clinkscale, Darnetta MBA Critical Care Medicine. April Volume 25 - Issue 4 - pp Protocol Weaning of Mechanical Ventilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses* Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia Gregory P. Marelich, MD, FCCP, Susan Murin, MD, FCCP, Felix Battistella, MD, John Inciardi, PharmD, Terry Vierra, RRT, RCP and Marc Roby, RN, MSN Chest 2000;118; DOI /chest The decision-making processes of nurses when extubating patients following cardiac surgery: an ethnographic study. Hancock HC, Easen PR. Int J Nurs Stud Aug;43(6): Epub 2005 Oct 26. Effect of Mechanical Ventilator Weaning Protocols on Respiratory Outcomes in Infants and Children A Randomized Controlled Trial Adrienne G. Randolph, MD, MSc; David Wypij, PhD;Shekhar T. Venkataraman, MD; James H. Hanson, MD; Rainer G. Gedeit, MD; Kathleen L. Meert, MD; Peter M. Luckett, MD; Peter Forbes, MA; Michelle Lilley, RRT; John Thompson, RRT; Ira M. Cheifetz, MD; Patricia Hibberd, MD, PhD; Randall Wetzel, MD; Peter N. Cox, MD;John H. Arnold, MD; JAMA. 2002;288(20): doi: /jama