The Royal Marsden

2

Critical Care Patients Experience of Helmet Continuous Positive Airway Pressure (CPAP)Andrew DimechCNS Cancer Critical Care

The Royal Marsden3

Rationale

– The patient experience of health care and health care provision recently become more widely researched.

– Continuous Positive Airway Pressure (CPAP) is a common treatment modality for acute respiratory failure.

The Royal Marsden4

Rationale

– Historically a tight fitting mask is used to provide respiratory support.

– Risks to the patient including facial pressure areas, pain and discomfort.

The Royal Marsden5

Rationale

– The Helmet CPAP is a new product that provides the same treatment with a different method of delivery.

– Effectiveness between the two approaches is

comparable although there is no evidence to date explaining patient perception of the new Helmet modality.

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Aim

– To explore critical care patient’s experience of Helmet CPAP.

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Helmet CPAP

– High flow oxygen / air mix

– Increased pressure to keep alveoli open (Positive End Expiratory Pressure - PEEP)

The Royal Marsden8

Literature Themes`

CPAP Helmet

Healthy Volunteers- Helmet versus Face Mask- Physiological Effects- Carbon Dioxide Retention / Washout- Noise Exposure

Acutely Unwell- Helmet versus Face Mask in Hypoxemic Acute Respiratory Failure- Helmet versus Face Mask in Immunocompromised

Chronic Conditions (Facial CPAP)- Obstructive Sleep Apnoea

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Research Design

– Qualitative approach – Descriptive phenomenological methodology.– Interviews with cues provided the platform for

data generation and collection– A thematic framework was utilised with

emergent themes manually analysed– A constant comparative technique used to

express the experiences or phenomena of a particular event or experiences.

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Thematic Network(Adapted from Attridge-Stirling 2007)

Global Theme Global Theme

Organising Theme

Organising Theme

Organising Theme

Organising Theme

Organising Theme

Organising Theme

Organising Theme

Organising Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

Basic Theme

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Sample

– The study included six patients – All developed acute respiratory failure upon

admission or during their inpatient stay in a critical care unit

– All the patients have been treated with Helmet CPAP

– The patients were introduced to the research via the Critical Care Outreach Team (CCOT) utilising convenience sampling

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Findings - Themes

– Entrapment– Confusion– Helping me breathe– Liberation– Challenges– Apprehension– Relief– Trust– Endurance

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Entrapment

– The overwhelming feeling of entrapment was expressed by patient F with feelings of being locked in somewhere (F31)……, restricted (F45) and there was no escape (F32).

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Helping me breathe

– It was easier than…..easier than the mask (B36). Compared to this mask that (Helmet CPAP) regulates the oxygen very well. It’s a……in terms of ah…… other than you’re all tied up and so on……because its part of the ready flow of oxygen its much easier to breath rather than leaking here……leaking there and so on (B59).

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Liberation

– Patient D found that he had a reasonable amount of freedom which made his experience more bearable. It wasn’t noisy like nebulisers and ah you were able to speak to people whilst you had it on…… you know it really gives you a great deal of freedom in that point of view you know and I thought that was ah quite outstanding (D35).

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Findings

– The overall experience was unique to each patient.

– The patients entrusted the healthcare team which made the experience more tolerable.

– Paradoxical themes were experienced during treatment.

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Findings

• Placing Helmet ‘out of sight’ during rest periods

• Further staff education regarding duration, set up etc

• No mention of cancer

• The desire to survive the acute illness proved to be a driving factor.

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Conclusion

– The study has provided an insight into the patient’s experience of Helmet CPAP in the critical care setting.

– The findings have provided a basis for policy and guideline development.

– It will also assist in developing future patient focused care.

ARDSPast, Present and Future

Richard Spooner

Intensive Care Unit

Medway NHS

Foundation Trust

What is ARDS?

1st described by Ashbaugh in the 1960’s He described 12 adult patients with similar

respiratory problems. Syndrome can occur in children and adults It is the most severe form of acute lung injury High mortality rate No real definition of syndrome until 1994

American-European Consensus Conference Committee

Recognises severity of the injury Simple definition Recognises that ALI is a precursor to ARDS

Acute Onset Bilateral Infiltrates on CXR PAWP <18mmHg (if no PAC, then there should be

no clinical evidence of LVF) PaO2 : FiO2 Ratio (P/F Ratio) < 26.7kpa If P/F Ratio < 40kpa, ALI is considered

Pathophysiology

Systemic or pulmonary inflammatory response Release of cytokines and other inflammatory

molecules Alveolar macrophages activated Neutrophils recruited to the lungs Oxidents, Leukotrienes and proteases released

which damage capillary and alveolar epithelium

Pathophysiology

Barriers between capillaries and air spaces are damaged

Oedema fluid, protein and cellular debris flood the air spaces and interstitium

Reduced surfactant produced Airspace collapse Ventilation/perfusion mismatch

Causes of ALI/ARDS

Direct Lung Injury

Aspiration

Pneumonia

Lung contusion

Drowning

Embolism

Gas inhalation

Indirect Lung Injury

Sepsis

Trauma

Hypovolaemia

Burns

Overdose

Massive blood transfusion

Pancreatitis

Mortality Rate

Was as high as 40-60% Better ventilation strategies, now around 25-40% Death often caused by MOF and sepsis Variations in rates due to age, severity of disease

and presence of other factors

Management Options

Ventilatory strategies Proning Nitric oxide Steroids Fluid management Surfactants

Ventilatory Strategies Probable reason for decline in mortality rates ARDSnet guidelines 6ml per kg PBW tidal volume High level of PEEP High respiratory rate to maintain minute volume Plateau pressure management Permissive hypercapnoea Ph management

Oscillatory Ventilation

Gives sub dead space tidal volumes (1-3mls/kg) Higher levels of PEEP Reduce risk of alveolar collapse Due to high frequencies CO2 levels maintained Has often been used as a rescue therapy Widely used in treatment of neonates and pre-term

infants

Proning The big nugget Does it or doesn’t it work? Improves oxygenation, but not outcome 2006 study prolonged proning (20 hours) may reduce

mortality. Exact mechanism widely debated Theoretical benefit of redistribution of ventilation and

perfusion ………but

There can be Problems

Very labour intensive Risk of dislodging of ETT and lines Severe facial oedema ‘Ventilator eye’ Pressure ulceration Emergency treatment may be delayed

Steroids

In theory, anti-inflammatory, should work No benefit demonstrated Some studies have found increased complications

and mortality

Surfactant

Introduced via bronchoscopy or inhalation No evidence of long term benefit

Nitric Oxide

Acts as a selective pulmonary vasodilator Binds to haemoglobin Should increase perfusion of better ventilated areas No large studies to support wide use

Fluid Managaement

FACTT Trial suggests conservative approach to fluids

ARDSnet, reducing EVLW, oxygenation improves, but no increase in long term mortality

Some Studies

CESAR BALTI II OSCAR

The Future

Any Questions?

Thank you for your time

Delirium Management - a Multidisciplinary Education Issue

Marion L. Mitchell, L. Aitken & J. AbbeyGriffith University: Research Centre for Clinical and Community Practice Innovation & Princess Alexandra Hospital, Australia.

41School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Overview • What is known about delirium in ICU patients• Why it is a problem• What assessment tools are available• The importance of multidisciplinary education • How can screening be effectively introduced or

compliance rates improved• Where to from here

42School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Background – is Delirium a problem in ICU?• 92% of patients survive a critical illness (Bagshaw et al.,

2009)

• Up to 2 years after discharge, psychological morbidity & neurocognitive compromise are reported in >50% of ICU patients (Herridge et al., 2003)

• Delirium has been found in 4 studies to be a predictor of cognitive impairment in non-ICU patients (Jackson et al., 2004)

• Rates of delirium in ICU patients vary from 11% to 87% of patients (Girard et al., 2008; Shehabi et al., 2008)

43School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

ICU staff’s views on Delirium

• 92% of Health Care Professionals (n=912) considered delirium to be a very serious problem in ICU (Ely et al., 2004)

• 86% consider delirium is under diagnosed in ICU (Patel et al., 2009)

• Is there a link between delirium in ICU & long term patient outcomes?

44School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Impact of Delirium on Patients• Ely & colleagues (2009) found delirium to be an

independent predictor of mortality at 6 months post discharge (n=275)

• More recently, Girard et al. (2010) found delirium affected cognitive impairment at 3 & 12 months post discharge • This study found an association between duration (in

days) of delirium and poor cognitive function when all other variables were controlled.

45School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Why worry about Delirium?

• It is not ‘nice’ for the patient, their family & the staff

• Higher mortality (Ely et al., 2004)

• Prolonged duration of ICU stay (Ely et al., 2001)

• Prolonged hospital stay (Thomason et al., 2005)

• Greater health care costs (Milbrandt et al., 2004)

• Long-term cognitive impairment (Girard, 2010).

46School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Pre-disposing Factors:• Inadequate pain relief• Hypoxaemia• Acidosis• Severe infection• Advanced age• Immobilisation

• Frustration • Patient/ventilator desynchrony• Drug interaction• Metabolic & haemodynamic

instability • Drug side effects

(Borthwick et al., 2006)

47School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Types of Delirium

1. Hyperactive – characterised by agitation, restlessness, emotionally labile

These behaviours are outwardly obvious & therefore more easily recognised

2. Hypoactive – withdrawal, decreased responsiveness, apathy, misdiagnosed as depressed

These behaviours are less obvious & therefore more difficult or not recognised

3. Mixed – combination of 1) & 2)

48School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Assessment Tools

Instrument

Validated in ICU

Non-Verbal Patients

Validated in ICUVerbal

Patients

CAM-ICU

ICDSC X

DDS

49School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

CAM - ICUTwo step process:

1. Initial assessment of level of sedation using Richmond Agitation- Sedation Scale (RASS). If score is between -3 (moderate sedation) & +4, go to Step 2

2. Assess for acute onset of mental status changes, inattention, altered level of consciousness & disorganised thinking using CAM-ICU

50School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Pre-disposing factors:• Inadequate pain relief• Hypoxaemia• Acidosis• Severe infection• Advanced age• Immobilisation

• Frustration • Patient/ventilator desynchrony• Drug interaction• Metabolic & haemodynamic

instability • Drug side effects

(Borthwick et al., 2006)

51School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Who needs to know about Delirium?• Multidisciplinary team approach

• Screening is one thing, acting on assessment is another

• Medical team input with understanding of problem & acknowledgement of short & long-term adverse patient outcomes (i.e. attitudes & beliefs)

• Nurses are at bed-side, so probably best placed to screen for delirium – but not in isolation….

52School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

How can Delirium Screening be effectively introduced/improved in our ICU?

• Planned approach to introduction of screening• All team members need shared understanding &

acknowledgement that delirium is problematic for our patients.

• Once screened, shared understanding of possible actions to take is very important.

53School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Strategies to improve Delirium Screening• Any new program needs champions• Need written policies & procedures• Clear instructions on how to record results• Easy access to tool – one at each bed-side/flow sheet• Planned systematic EDUCATION of medical &

nursing staff prior to its introduction

(Devlin et al., 2007)

54School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Strategies to improve Delirium Screening• Incorporate delirium screening results into all ‘rounds’• Continuous quality monitoring to evaluate compliance

with the protocol• Page et al. (2009) in UK unit – 92% compliance using

CAM-ICU• Pun et al. (2005) – in USA - [n=10,037 assessments] –

87% compliance using CAM-ICU

55School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

Conclusions

Delirium is a widespread problem in ICU that has not universally been appropriately recognised or treated

There are reliable, valid & feasible tools available

Planned education of multidisciplinary team essential

Care options need to vary depending on outcome of screening

Long term outcomes of ICU care need to be a focus for future research

56School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation

ReferencesBagshaw SM. et al. (2009). Very old patients admitted to intensive care in Australia and New Zealand: a multi centre cohort analysis. Crit Care 13,(2)R45.

doi:10.1186/cc7768.Bergeron N. et al. (2001). Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med, 27(5), 859-64.Borthwick M. et al. (2006). Detection, prevention and treatment of delirium in critically ill patient. http://www.ukcpa.org/ukcpadocuments/6.pdf. Devlin JW. et al. (2007). Delirium assessment in the critically ill. Intensive Care Med, 33:929-40.Ely EW. et al. (2001). Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

Crit Care Med, 29(7), 1370-79.Ely EW. et al. (2001). The impact of delirium on in ICU on hospital length of stay. Inten Care Med, 27:1892-1900.Ely EW. et al. (2009). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA;291(14),173-62.Girard TD. Et al. (2008). Delirium in the intensive care unit. Crit Care;12 Suppl 3:S3.Herridge MS.et al.(2003). One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med; 348:683-93. Immers H E. et al. (2005). Recognition of delirium in ICU patients: a diagnostic study of the NEECHAM confusion scale in ICU patients. BMC Nurs, 4, 7.Jackson JC. et al. (2004). The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev; 14:87-98.Milbrandt EB. et al.(2004). Costs associated with delirium in mechanically ventilated patients. Crit Care Med, 32:955-62. Neelon VJ. Et al. (1996). The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res, 45(6), 324-30.Otter H. et al. (2005). Validity and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care, 2(2), 150-58.Page V. et al. (2009). Routine delirium monitoring in a UK critical care unit. Crit Care, 13:R16(doi:10.1186/cc7714).Thomason JW. et al. (200). ICU delirium is an independent predictor of long term hospital stay: a prospective analysis of 261 non-ventilated patients. Crit

Care 9:R375-R381.

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59School of Nursing and MidwiferyResearch Centre for Clinical and Community Practice Innovation