What oxygen delivery device should be used on a patient who is not breathing?

DISCHARGE PLANNING

It is often difficult for parents to develop a close attachment to a preterm infant in respiratory failure. The environment in which the infant is given care includes a ventilator, endotracheal tube, various lines and monitors, and a physically inhospitable space, which makes close interaction with the infant difficult. Indeed, parents may become more distant with extended periods of hospitalization and professionals are often required to provide the usual day-to-day care offered by parents of babies who are well.

Parent teaching in preparation for the baby's discharge must begin early in the hospitalization, long before discharge is considered in many cases. In fact, preparing the parents of an infant in the NICU for their baby's discharge is as important as preparing the baby. Early teaching for the parents involves having them handle and provide increasing levels of care for the infant.

The transition from hospital to home can be a crisis for the parents of a baby who has spent a long time in an NICU. The stresses of discharge must be balanced by the benefits, which include decreasing the fatigue of travel, decreasing the financial burdens of prolonged hospitalization, and ending the separation of the parents and siblings from the child. Nonetheless, raising a child who was a VLBW infant, particularly one with significant functional disabilities, is a major stressor on the family in terms of financial burden, familial/social impact, and personal and marital strain.98

The knowledge and skills required to care for a preterm infant with respiratory failure at home are often staggering. The list below identifies many of these items:

Respiratory therapy: oxygen delivery devices, mechanical ventilators and related devices and equipment, suction machines

Medications: dosage, routes of administration, side effects, duration of administration

Nutrition: working on sucking and swallowing skills, various types of tube feeding, formula preparation and delivery

Physical therapy: positioning, percussion, vibration, suctioning; encouraging motor development.

Home monitors: machine monitors, apnea monitoring, trouble-shooting monitors

Instruction in cardiopulmonary resuscitation: can be very stressful for the caregivers99

In most NICU settings, someone is designated as the discharge planner. Often, a nurse or social worker coordinates the efforts of the team to ensure that the discharge plans are carried out.

Prescription, application, and, as appropriate, fabrication of devices and equipment

Two major types of equipment are particularly useful during physical therapy for patients in respiratory failure. An ambulation aid such as a walker, a four-point cane, or a straight cane is often a necessary device as mobility training moves from bed mobility to ambulation and gait training (Fig. 15-4). Supplemental oxygen delivery devices, the second type of equipment, are critically important for the person who cannot otherwise maintain a safe level of oxygen saturation.

Oxygen delivery devices are, of course, of major importance for a patient with respiratory failure. These may include several common devices such as nasal or transtracheal catheters, nasal cannulas, oxygen masks of varied characteristics, and oxygen hoods. The specific device to be used is chosen on the basis of a number of factors, including the percentage of oxygen to be delivered, the need for access to the mouth during meals, and for airway clearance activities such as coughing. One patient may have several different devices to use as appropriate. Supplemental oxygen is almost always humidified because the gas itself can be drying and irritating.

For low levels of supplemental oxygen (low-flow devices), one might see a nasal cannula (prongs), a simple oxygen mask, or a face tent or shield, each of which can supply an FIO2 of from 22% to approximately 40%. A partial rebreathing oxygen mask with a gas reservoir or a Venturi mask enables delivery of up to about 60% oxygen. A nonrebreathing oxygen mask with a gas reservoir can provide for oxygen percentages up to 95%. Figs. 15-5 and 15-6 show some of these various types of devices with a simple humidifier and an aerosol nebulizer. In addition to specific devices as described, it is not uncommon for a patient in long-standing respiratory failure to have a tracheotomy to enable easier mechanical ventilation and airway clearance. In these cases, a supplemental oxygen supply can be attached directly to the tracheotomy site during physical therapy interventions, even while a portable mechanical ventilator is used, as is shown in Fig. 15-3. It is imperative that the physical therapist should employ the proper supplemental oxygen source during interventions because most interventions add significant physical stress that results in greater oxygen demands for the patient.

Patient-Related Instruction

Education and training about the lung disease underlying airway clearance dysfunction is critically important; the American Thoracic Society cites education as one of the four major components of any pulmonary rehabilitation program.31 Patient education and training should be comprehensive and may include the following:

Structure and function of the lung

Information regarding the patient's specific disease

Instruction and participation in

Correct inhaler technique

Airway clearance techniques

Breathing, relaxation, and panic control techniques

Respiratory muscle training

Exercise principles

Activities of daily living and instrumental activities of daily living

Nutritional interventions and considerations

Medications—their effects and adverse effects

Psychosocial interventions and means of coping with stress, anxiety, and depression

Avoidance of environmental irritants

Smoking cessation

Oxygen rationale and proper use of oxygen delivery devices

Travel and leisure activities

Sexuality

End-of-life issues and planning for those with progressive disease

This information may be delivered by many approaches. Individualized teaching or a series of short, interactive lectures are commonly employed. Group sessions may be used to provide peer support from others with airway clearance dysfunction. Videotapes, digital videodisks, and CD-ROMs regarding specific topics are available, as are various Internet websites. Because the patient may feel overwhelmed by the amount of information presented, it is important that each patient be provided with a well-organized notebook that he or she may refer to as needed. Learning is often facilitated in the following ways:

Allotting adequate time for questions

Keeping classes short

Talking in lay terms (i.e., 4th to 7th grade level)

Alternating sitting classes with active classes

Acknowledging the influence on learning of physical and mental defects (e.g., hypoxia, hearing loss, visual problems, fluid and electrolyte imbalance, pain, memory loss, low self-esteem, and depression)

Individualizing the program

Providing support, praise, encouragement, and acceptance

The ultimate goal of patient-related instruction for persons with airway clearance dysfunction is to provide basic knowledge about the disease and its medical management, as well as daily techniques and activities that can enhance quality of life. Instruction also must address limitations imposed by the disease process.

Conclusions

It is clear that resource-limited countries have the highest neonatal and infant mortality from respiratory problems and that there is a great unmet need for respiratory care and ventilatory support. Yet these are the same countries that lack the most essential minimum equipment such as bags and masks for resuscitation, continuous supplies of oxygen, and oxygen delivery devices. It is suggested that the World Health Organization (WHO) designate this life-saving equipment as part of essential equipment, similar to the WHO Essential Drug List.71 Such policies would make a major impact on neonatal survival internationally. Health care workers at primary health care centers and hospitals should be trained in providing basic respiratory care, including clinical assessment using the RDS score, basic principles of care including clearing the airway, bag and mask ventilation, and proper oxygen therapy. The staff at level II units must be routinely trained in providing oxygen therapy and applying CPAP. Staff in level III units should be capable of providing ventilatory support using mechanical ventilation.

Countries with high birth rates and high NMRs require the establishment of regional NICUs with ventilatory support. These centers of excellence must provide nationwide training of health care personnel in basic resuscitation, stabilization with nasal CPAP, and triage and transport to hospitals that can provide higher levels of respiratory care. The market research data also show that developing countries are rapidly acquiring neonatal ventilators; however, there is a lack of concurrent development of respiratory care programs. China has developed a model in which health policies are implemented in a top-down fashion by the government. The NNF of India provides a model in which a professional physician organization has started a major initiative to improve newborn care in the country. Other countries have developed individual NICUs. A combination of varying models may work well for other resource-limited countries.

Because of the large global need, it is important that professionals, organizations, institutions, and government agencies in developed countries extend their services and participate in global programs to accelerate the transfer of knowledge and skills of respiratory care to resource-limited countries. These goals can be achieved through bilateral exchange of medical faculty and nurses between institutions in resource-limited and developed countries. In our own experience, these approaches have made an enormous impact in several countries.

PATIENT HISTORY

The examination must include a comprehensive patient history that can be gathered from the patient's inpatient or outpatient chart, as well as through direct interview with the patient or family members. In addition to general demographics, such as age, gender, and race, it is important to assess the family and caregiver support for the patient. Heart failure is a progressive disease, often characterized by exacerbations that can be kept to a minimum with the support of family and friends reinforcing compliance with the medical regimen.

Employment history should include information about job responsibilities and activities, such as the frequency of stair climbing, heavy lifting, pushing, pulling, or extreme temperature work environments, as these can affect job performance and the clinical status of the patient with heart failure. Home environment and structure should be documented along with any equipment the patient is using or has available for future use. Equipment that may be useful to the patient with heart failure includes motorized wheelchairs, oxygen delivery devices, stair glides, exercise equipment, adaptive bathroom equipment, and home monitoring equipment such as scales, BP units, and HR monitors. The history should also document the health and social habits of the patient, including compliance with medications, diet, exercise routine, medical follow-up, as well as assessment of smoking, drug, and alcohol use.

The history should continue with documentation of the medical and surgical history, current medications, and clinical tests. Commonly used medications in this population and their indications and potential side effects are included in Table 25-1. Clinical tests commonly include echocardiograms, cardiac catheterizations, exercise testing, laboratory tests, electrocardiograms, and radiographic imaging. Additionally, the clinician should determine if the patient has a pacemaker or implanted cardiac defibrillator (ICD) and the settings of these devices, as these may affect the initiation and termination of rehabilitation interventions. Likewise, the history should document any recent arrhythmias with the associated patient symptoms.

Finally, the patient's current functional status, complaints, and symptoms should be thoroughly discussed and documented. The therapist should determine if the patient has symptoms typical for heart failure, including fatigue, shortness of breath, reduced exercise and activity tolerance and peripheral edema; what kind and duration of activity brings on each of these symptoms; how long they last; and what relieves these symptoms. Common signs and symptoms seen in the patient with heart failure are included in Box 25-1.

7 Preparation

Preparation is vital, which includes patient, equipment, drugs and team members – especially if the team is unfamiliar with the environment or their colleagues [28].