1. Kim Fuzzard Clinical Educator Postgraduate Critical Care Nursing Course

2.  Overview of fundamental safety for the intubated, mechanically ventilated adult patient in the Emergency Department.  Launch new BH iLearn module Advanced Life Support for Adults ‘Airway & Breathing’

3.  Endotracheal Intubation ◦ plan and prepare ◦ procedure ◦ tube safety  Mechanical Ventilation ◦ settings ◦ attachment ◦ surveillance & monitoring ◦ issues for ED clinicians  Photo: S. Makepeace

4. Characteristics of patients receiving invasive mechanical ventilation in Aust ED’s:  Altered mental state 59%  Cardiac arrest 14%  Intrapulmonary respiratory failure10%  Other (sepsis, trauma, heart failure) 14%  Airway compromise 3% Ref: Rose & Gerdtz (2009) Sites in study included Bendigo, Alfred, Angliss, Bairnsdale, Ballarat, Box Hill, East Wimmera, Goulburn V, Mildura, Northern, RMH, StV’s and hosps in other states also

5.  Endotracheal intubation and invasive mechanical ventilation are required for the resuscitation of a range of patient presentations, however  Rose & Gerdtz (2007)  Care requires specialist expertise to avoid significant risks and ensure patient safety.  CENA (2013)

6.   Ref: RTIC Severn Emergency induction checklist. Available: http://saferintubation.com/IntubationChecklist.pdf 

7.  Airway and Breathing

11.  Creates a seal  Cuff does not hold the ETT insitu!

12.  Regular observation of length at lip  1:1 care CENA (2013) Photos: Fuzzard, K. (2004)

13.  Hollister TM Anchor Fast Oral Endotracheal Tube Holder

15.  Meticulous preparation for insertion  Safe insertion  Confirm placement in airway- clinical & CXR  Monitor end-tidal CO2  Monitor & maintain lip level  Keep the ETT secure  Provide constant1:1 care

16.  Settings must be based on current scientific principles  Individualised for the patient’s pathophysiology  Photo: Drager Medical

17.  The following are commonly used in Australian ED’s and may be initially suitable for a large proportion of patients, prior to reassessment, review and potential alteration of settings.  Mode: SIMV (Volume Control)  Breath rate: 12-14bpm  Tidal volume: 6-8mL/kg  Pressure support: 10cmH2O  PEEP: 5cmH2O  FiO2: 1.0= 100%  Ref: Rose & Gerdtz (2009)

18.  ETT  Closed suction device  HME ◦ (heat/moisture exchanger/filter)  Continuous capnography  Ventilator circuit

19. ◦ ETT length at lip & security ◦ Respiratory  Observations of ventilator  Observations of patient  Incl. ETCO2 ◦ Cardiovascular ◦ Neurological ◦ Comprehensive patient assessment ◦ Vigilant observation ◦ Photo: S. Evans

20.  Patient re/assessment  Vent alarm setting & troubleshooting  CXR analysis  ABG analysis  Titration of ventilation  Careful positioning  Mouth, eye, pressure care  Psychological support pt & family  Weaning of ventilation  Extubation

21.  There is minimal use of pressure controlled modes despite potential advantages particularly for patients with intrapulmonary disease: ◦ eg. Reduction in peak airway pressures

22.  Evidence – ED nurses have active involvement in decision-making & high levels of responsibility & autonomy Rose & Gerdtz (2009)   Minimum standard- an evidence based competency education program  BUT  Optimum- relevant postgrad qualification CENA (2013) ◦ (Bendigo Health)  Potential issue: ◦ Lack of consistent exposure to ventilated pts Rose & Gerdtz (2009)

23.  ED is not designed to provide ongoing care of the mechanically ventilated pt Marshall & Hodge (2011) Rose & Gerdtz (2009)  Transfer out to ICU asap when safe to do so CENA (2013), Marshall & Hodge (2011) Rose & Gerdtz (2009)  Transporting pts exposes them to additional risks & requires highly trained & skilled clinicians ACEM (2013)

24.  Ventilation modes & parameters  Alarm setting  Sedation  Ongoing care & weaning  Ventilation of special pt populations ◦ eg. raised ICP, lung disease  Advanced ventilation strategies  Patient transport  And much more….

25.  “Mechanical ventilation is a complex and invasive intervention, which can have serious implications if not properly applied or resourced.”  CENA (2013)

26.  Rose & Gerdtz (2009) Use of invasive mechanical ventilation in Australian emergency departments. EMA 21, 108-116  Rose & Gerdtz (2009) Mechanical Ventilation in Australian emergency departments: Survey of workforce profile, nursing role responsibility and education. AENJ 12:38-43  Rose & Gerdtz (2007) Invasive ventilation in the emergency department. Part 1: What nurses need to know. AENJ 10:21-25  Rose & Gerdtz (2007) Invasive ventilation in the emergency department. Part 2: Implications for patient safety. AENJ 10:26-29  CENA (2013) Position Statement: Mechanical ventilation [Accessed online 14/08/2014 http://cena.org.au/CENA/Documents/CENA_Position_Statement_Mechanical_Ventilation. pdf] CENA (2013) Position Statement: Mechanical ventilation [Accessed online 14/08/2014 http://cena.org.au/CENA/Documents/CENA_Position_Statement_Mechanical_Ventilation. pdf  RTIC Severn Emergency induction checklist. Available: http://saferintubation.com/IntubationChecklist.pdf  Bendigo Health (2014) ‘Airway & Breathing’ ALS e-learning module.  Marshall & Hodge (2011) ‘Respiratory emergencies’ in Emergency & trauma care for nurses & paramedics. Eds: Curtis & Ramsden. Mosby: Sydney.  ACEM (2013) Guidelines for transport of critically ill patients. [Accessed online 14/08/2014 https://www.acem.org.au/getattachment/b38ea874-312f-4355-bd66- 977521f194c3/P03-Guidelines-for-Transport-of-Critically-Ill-Pat.aspx ACEM (2013) Guidelines for transport of critically ill patients. [Accessed online 14/08/2014 https://www.acem.org.au/getattachment/b38ea874-312f-4355-bd66- 977521f194c3/P03-Guidelines-for-Transport-of-Critically-Ill-Pat.aspx