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What Is the Effective Method of Breathing Assistance, Which Is a Non-Invasive Nursing Intervention, in Critically Ill Patients?

Table of Contents

Introduction.

Search strategy.

Analysis.

Discussion.

Conclusion.

Recommendation.

References.

Introduction

Nurses are an integral part of the healthcare system and the care provision to a person which is such that it is complete and the patient is at the core of the care process (Barratt, 2018). When a person is in critical care the duty of nurses becomes more important and it is such that the patient is comfortable. The patient who is critically ill is the ones who might be present in an intensive care unit based on the critical nature of the disease or illness they are facing. It is the responsibility of a registered nurse to make sure that the clinical condition of the patient is not deteriorated. This also involves in the work which is regarding the betterment of the quality of life by improving the comfort level and various interventions to make sure that response to the treatment is adequate. A patient who is critically ill may one of the following, that is, loss of patent airway, difficulty in proper breathing, improper or inadequate circulation and lastly problems with movement or disability (Bello et al., 2016).

These systems are usually interlinked and inadequacy in one can cause a problem in other. Before proper intervention can be decided or implemented that the patient is recognized as someone who is critically ill. Depending on the system that is affected or is deteriorating the intervention can be decided. The present essay aims to discuss the nursing intervention for non-invasive breathing assistance in patients who are critically ill. This essay will show the search strategy along with the keywords for relevant databases. From the result of the search, relevant articles will be selected for the analysis which will be done as per the CASP guidelines and further discussion will be done and recommendations will be made for evidence-based practice.

As per the requirements of the essay, the research question that is formulated is: What is the effective method of breathing assistance, which is a non-invasive nursing intervention, in critically ill patients?

Search Strategy

From the research question, the keywords are determined for and further MeSH terms are identified which is used for the searching the databases. For the development of search string and search strategy, the PICOs framework is used and the articles selected are such that they fulfil the PICO identified.

Participants: critically ill patients

Intervention: non-invasive nursing intervention

Comparator: none

Outcome: breathing assistance

Keywords

For participants: critically ill patients, ICU patients, patients in ICU, intensive care unit, intensive care and critical care. For intervention: nursing intervention for breathing, non-invasive breathing assistance, non-invasive method for breathing and intervention by nurses for breathing that is non-invasive. For outcome: ease of breathing and breathing assistance.

There are a few words which can be used with different suffixes and to make sure that all the variants are included in the search strategy truncation can be used. Truncation will ensure that all the variable for the last part is included in the search * or $ are suggested tools for the truncation (Shanman, 2017). In the present search keywords, nursing can be truncated for nurses, nursing staff and nurse as nurs*. Boolean operators are simple words which can be used in search strategy which are used as conjunctions between the words to make sure that the search obtained is refined and the large amount of data that is obtained is reduced (Keith Norambuena et al., 2019). The Boolean operators used are AND, OR, and NOT.

The search strategy that is formulated by employing the use of truncation and Boolean operators that aided in the search of the relevant literature is as follows: {(nurs* intervention for breathing OR non-invasive breathing assistance OR non-invasive method for breathing OR intervention by nurs* for breathing that is non-invasive)} AND {(critically ill patients OR ICU patients OR patients in ICU OR intensive care unit OR intensive care OR critical care)} NOT chronic care OR long term illness OR chronic illness)} AND {( ease of breathing OR breathing assistance)}.

There are many databases which are only for the medical and nursing publications and not to restrict the search all the relevant and possible databases were searched for the literature. The databases included and searched were PubMed, Medline Ovid, CINAHL, Google Scholar and BioMed central. The literature search yielded the articles which were many and to narrow down the literature to the recent methods that are being used search limiters were used. Search limiters are the filters that are used in the search criteria which limit the search by certain criteria (Gusenbauer & Haddaway, 2020).

In the present search for the inclusion of recent methods of nursing intervention which are used for the breathing assistance in patients who are critically ill the limit used was the time. Only the articles that have been published in the last ten years were included. The aim to do so is to reduce the amount of literature that is obtained such that it is relevant to the research question. After the search result was obtained, a minimum of ten articles was selected to be included in the present literature review essay for the analysis. Also, for further discussion to form or recommend an evidence-based nursing intervention for breathing assistance in critically ill patients.

Analysis

For the analysis of the relevant searched article data extraction is done first followed by discussion. For the extraction of data, depending on the study design the relevant CASP guidelines is employed for the analysis which will help in identifying the research methodology, study participants, key findings, strengths and limitations of each study.

A randomized controlled trial was conducted by Nava et al. (2011) for the effectiveness of non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure which is a critical illness. In older patients, usually non-invasive breathing assistance is opted as it is more comfortable and less costly. In this study, non-invasive mechanical ventilation was compared with standard medical therapy which reduces the intubation and other comorbidity related to acute hypercapnic respiratory failure. A total of 85 patients from three respiratory units were recruited in the study and were randomized in a non-invasive group and standard medical therapy. The results reflected that endotracheal intubation was lower in the group with non-invasive ventilation compared with standard medical therapy along with mortality rate and this was statistically significant.

Breathing assistance provided by non-invasive ventilation improved arterial blood gases, respiratory rate and dyspnea. The main strength of the study was that it was a multi-centre study which increased the heterogeneity of the study. The main limitation of the study was that as it was a multi-centre study the procedure could not be generalized. Also, the patients were enrolled consecutively and consisted mostly of elderly patients. The authors concluded that intervention with non-invasive ventilation was less intubated compared with standard medical therapy. it can be offered as an alternative to patients who cannot be intubated due to any reason or they have a do not intubate order.

Another study was conducted by Thille et al. (2013) which was aimed to assess the rate and predictive factors of non-invasive ventilation and its related failure in patients who are in intensive care unit for non-hypercapnic acute hypoxemic respiratory failure. The study was an observational cohort which was conducted prospectively over three years from a single setting of a university hospital. A total of 113 patients with non-hypercapnic acute hypoxemic respiratory failure were observed in which 61% of patients had acute respiratory distress syndrome while 35% had non-acute respiratory distress syndrome.

All patients were given non-invasive ventilation and were observed for failure leading to intubation. The factors that affected the failure of non-invasive ventilation were if there was any underlying active cancer, moderate to severe acute respiratory distress syndrome, shock, and a lower score of Glasgow coma scale. The main finding of the study was that the intervention given was nurse-driven which and it improved tolerance to the non-invasive ventilation. The main limitation was that the study was conducted in a single setting which makes the external validity of the results questionable.

A study was conducted by Güntzel Chiappa et al. (2017) with a purpose to examine the effects on spontaneous breathing by the use of conventional T-tube in mechanical ventilation in comparison to pressure-assisted ventilation. These are methods of ventilation which is used for weaning of orotracheal tube in intensive care for critically ill patients. A total of 21 patients were used and they were randomized into TT group or pressure supported ventilation group. The results reflected that breathing was regularized and the heart rate was reduced. In acute care of critically ill patients, T-tube for spontaneous breathing was affected by cardiorespiratory mismatches. The authors further concluded that fore short-term use T-tube was effective but its long-term effectiveness was not determined. The main limitation of the study as stated by the authors is that the effective and change in respiratory rate and heart rate was done by the non-invasive method.

A review was conducted by Osadnik et al. (2017) to compare the efficacy of non-invasive ventilation provided by a nurse in an intensive care unit following critical illness. General intervention that is used for the patient with acute exacerbation of chronic obstructive pulmonary disease which is a critical illness is non-invasive ventilation with bi-level positive airway pressure. The main studies included in the review are a randomized controlled trial. The primary outcome included were hospital admission failure leading to endotracheal intubation. The secondary outcomes included are the length of stay in the hospital, intolerance to treatment, comorbidities, symptoms and changes in arterial blood gas level. The result reflected that the use of non-invasive ventilation decreased the risk of mortality and it was associated with a decrease in a stay at the hospital, reduction in complications, and partial pressure of oxygen increased. the main strength of the study was that this review included randomized controlled trials which and the evidence contributed by them is of higher quality.

Respiratory assistance in critically ill patients is not limited to adult patients but also include pediatric patients. A study was conducted by Ramnarayan et al. (2017) for the feasibility in three centres and the study was conducted for over 12 months. The study aimed to compare the effectiveness of two different modes of respiratory support that is Continuous positive airway pressure and high-flow nasal cannula therapy both of which were non-invasive respiratory support. Further a pilot study was conducted for the randomized controlled trial and the results reflected that the traditional method of Continuous positive airway pressure was more effective in comparison of high-flow nasal cannula and the latter was seen that to have incubation rate more compared to former (Ramnarayan et al., 2018). Since this was just a pilot study a complete randomized control trial is required to extrapolate the results. The main strength was that it is a multi-centre study.

Another literature review was conducted by Lee et al. (2013) to assess the use of high flow nasal cannula which is a routine intervention in a critically ill pediatric patient. In this review the use of the same in respiratory support modality in other subsets of patients like infants and even adults. This high flow nasal cannula is suggested as an alternative to non-invasive positive pressure ventilation. The results of the review reflected that in the adult population the respiratory support and breathing assistance can provide short term relief to the patients and the changes in physiologic status changes in short-term.

The outcome of the same in the long-term towards the escalation of ventilator support is not established. It was seen that high flow nasal cannula is known to generate positive airway pressure but its effectiveness in respiratory distress is not well-established. The authors concluded that high flow nasal cannula was neither superior nor inferior to non-invasive positive pressure ventilation. It was seen that high flow nasal cannula is well tolerated and feasible in different subsets of patients.

Another study was conducted to assess the effectiveness of non-invasive ventilation as a method of breathing assistance provided by the nurses in case of patients who were critically ill as acute exacerbation in chronic obstructive pulmonary disease (Moxon & Lee, 2015). The study was a retrospective observational study and all patients in the emergency department were taken in the study. The result of the present study reflected that non-invasive ventilation initiated by nurses in the emergency department was known to improve the clinical outcomes of the patients. The main limitation was that it was a single centre study but it was seen that the nurses followed the recommended guidelines for breathing assistance.

Gregoretti et al. (2015) conducted a study to explore clinical studies related to intervention related to non-invasive ventilation. There are different modalities of non-invasive ventilation which are administered to patients who are critically ill. These interventions can be either given in an emergency care setting or a critical care unit and it administered the majority by nurses. The results reflected that there was less difference between the types of non-invasive ventilation but when it was compared to mechanical ventilation it was better. It was because native upper respiratory was unaffected and glottis remained unaffected as well.

Another study was conducted with the aim for the assessment of the role of non-invasive positive pressure ventilation as a mode of intervention for breathing assistance in a patient with acute exacerbation of chronic obstructive pulmonary disease (Khilnani et al., 2010). Acute exacerbation of COPD is a critical illness as it has a high mortality rate and the respiratory intervention is given by nurses either in an emergency setting or critical care unit. A total of 40 patients were included in the study and they were randomly enrolled into a non-invasive group or conventional therapy group. The effectiveness was evaluated considering mortality, duration of stay in the hospital and changes in blood gas parameters. The main limitations of the study were that it was conducted in a single centre setting but as the study design was a randomized controlled trial it improved the validity of results. The authors concluded that non-invasive ventilation in patients with acute exacerbation of COPD reduced the mortality and subsequent prevalence of endotracheal intubation.

Discussion

From the literature evidence that has been collected for the research question, it can be seen that non-invasive ventilation is effective in case of respiratory failure in patients who are critically ill. Critical illness can be a result of an ongoing illness or due to acute condition which affects multiple systems and one of them is the respiratory system. For breathing assistance, it is required that airway patency is established or if there is no obstruction to the airflow. Critical care is not limited to a particular subset of patients and can be seen in infants, children, adults and elderly. It can be due to congenital problems in children and infants while in adults it can be due to hypercapnic respiratory failure or acute exacerbation of chronic obstructive pulmonary disorders. Mechanical ventilation is usually given by doctors or specialist but its weaning to non-invasive method or administration of non-invasive respiratory assistance is given by nurses.

The articles selected consisted of different types of articles in terms of study design. The highest level of evidence that was elicited was from the systematic review which was conducted of randomized controlled and various randomised controlled trials. The evidence from both is considered good because of the study design which is robust and the result that is seen does not occur by chance. A systematic review by Osadnik et al. (2017) and other randomized control trials by Ramnarayan et al (2018), Khilnani et al (2010) and Nava et al. (2011) showed that non-invasive ventilation had higher effectiveness. The effectiveness was measured in the form of outcomes like the ultimate requirement of endotracheal intubation, an extended stay in the hospital, hospital-acquired infections and mortality. These parameters were in favour of non-invasive ventilation compared to mechanical ventilators. It was seen that high-flow nasal cannula was effective in adult patients while traditional non-invasive ventilation with positive pressure is better in children

Conclusion

A critically ill patient is the one who is admitted to the hospital care setting in emergency care or an intensive care unit and might be facing multi-system failure. When a patient is admitted to the hospital nurses become an integral part of the care provision team for a patient. It is an essential part of the nursing care that the clinical condition of the patient is not deteriorated and breathing or respiratory assistance is one such method. Breathing assistance can be invasive or mechanical and non-invasive. The review essay was aimed to find the effectiveness of nursing intervention of non-invasive respiratory illness in critically ill patients.

From the research question, PICO was identified and relevant keywords and MeSH terms were identified and with the use of truncation like *, $ and Boolean operators like AND, OR and NOT were used for the formation of the search strategy. The databases used for the search were relevant to the field of medicine and nursing and 10 relevant articles were used for analysis by the use of CASP guidelines. The results reflected that non-invasive ventilation was more effective and there was less association with mortality, infection and stay in hospital.

Recommendation

The main aim of the review was to find the evidence-based nursing practice for breathing assistance in critically ill patients. From the evidence, it can be seen that nursing intervention should comply with the guidelines that are provided by the national policy as well as hospital policies. From the evidence by a systematic review, it is seen that type of non-invasive ventilation varies by the type of illness and also to an extent by the age of the patient (Osadnik et al., 2017). It can be recommended that non-invasive ventilation is effective to reduce the distress in critically ill patients while the type of intervention should be as per the comfort of the patient. As it is seen that difference of effectiveness between different types of interventions is seen to be non-significant it can be recommended that the intervention should be used as per the guideline provided and condition of the patient.

References

Barratt, C. (2018). Developing resilience: the role of nurses, healthcare teams and organisations. Nursing Standard33(7), 43-49. http://dx.doi.org/10.7748/ns.2018.e11231.

Bello, G., Di Muzio, F., & Antonelli, M. (2016). Quality of life and complications after percutaneous tracheostomy. In Percutaneous Tracheostomy in Critically Ill Patients (pp. 131-147). Springer, Cham. https://doi.org/10.1007/978-3-319-22300-1_15.

Gregoretti, C., Pisani, L., Cortegiani, A., & Ranieri, V. M. (2015). Noninvasive ventilation in critically ill patients. Critical Care Clinics31(3), 435-457. https://doi.org/10.1016/j.ccc.2015.03.002.

Güntzel Chiappa, A. M., Chiappa, G. R., Cipriano Jr, G., Moraes, R. S., Ferlin, E. L., Borghi‐Silva, A., & Vieira, S. R. (2017). Spontaneous breathing trial in T‐tube negatively impact on autonomic modulation of heart rate compared with pressure support in critically ill patients. The Clinical Respiratory Journal11(4), 489-495. https://doi.org/10.1111/crj.12363.

Gusenbauer, M., & Haddaway, N. R. (2020). Which academic search systems are suitable for systematic reviews or meta‐analyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research Synthesis Methods11(2), 181-217.

Keith Norambuena, B., Lettura, E. F., & Villegas, C. M. (2019). Sentiment analysis and opinion mining applied to scientific paper reviews. Intelligent Data Analysis23(1), 191-214. https://doi.org/10.3233/IDA-173807.

Khilnani, G. C., Saikia, N., Banga, A., & Sharma, S. K. (2010). Non-invasive ventilation for acute exacerbation of COPD with very high PaCO2: A randomized controlled trial. Lung India: Official Organ of Indian Chest Society27(3), 125. https://doi.org/10.4103/0970-2113.68308.

Lee, J. H., Rehder, K. J., Williford, L., Cheifetz, I. M., & Turner, D. A. (2013). Use of high flow nasal cannula in critically ill infants, children, and adults: A critical review of the literature. Intensive Care Medicine39(2), 247-257. https://doi.org/10.1007/s00134-012-2743-5.

Moxon, A., & Lee, G. (2015). Non-invasive ventilation in the emergency department for patients in type II respiratory failure due to COPD exacerbations. International Emergency Nursing23(3), 232-236. https://doi.org/10.1016/j.ienj.2015.01.002.

Nava, S., Grassi, M., Fanfulla, F., Domenighetti, G., Carlucci, A., Perren, A., ... & Clini, E. (2011). Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: A randomised controlled trial. Age and Ageing40(4), 444-450. https://doi.org/10.1093/ageing/afr003.

Osadnik, C. R., Tee, V. S., Carson‐Chahhoud, K. V., Picot, J., Wedzicha, J. A., & Smith, B. J. (2017). Non‐invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (7). https://doi.org/10.1002/14651858.CD004104.pub4.

Ramnarayan, P., Lister, P., Dominguez, T., Habibi, P., Edmonds, N., Canter, R., ... & Peters, M. J. (2017). FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): Protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children. BMJ Open7(6), e016181. http://dx.doi.org/10.1136/bmjopen-2017-016181.

Ramnarayan, P., Lister, P., Dominguez, T., Habibi, P., Edmonds, N., Canter, R. R., ... & Peters, M. J. (2018). FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): A multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Critical Care22(1), 144. https://doi.org/10.1186/s13054-018-2080-3.

Shanman, R. (2017). Phrase truncation in PubMed searches. Journal of the Medical Library Association: JMLA105(4), 404. https://doi.org/10.5195/jmla.2017.252.

Thille, A. W., Contou, D., Fragnoli, C., Córdoba-Izquierdo, A., Boissier, F., & Brun-Buisson, C. (2013). Non-invasive ventilation for acute hypoxemic respiratory failure: Intubation rate and risk factors. Critical Care17(6), R269. https://doi.org/10.1186/cc13103.

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