Lateral Rotation Therapy for Intubated Patients - Research Paper Example

? PICOT STUDY A. Introduction Pulmonary complications are quite common in critically ill patients, and this is especially so in patients with intubation and who are mechanically ventilated. Among the common complications are atelectasis, hypoxia and nosocomial infections. A study carried out by the Institute for Healthcare Improvement found out that ventilator-associated pneumonia is a leading cause of high hospital morbidity and mortality. Traditionally, nurses have implemented a two hourly turning of patients in order to prevent these complications. In spite of its continued use, no evidence exists as to its effectiveness in improving pulmonary complications (Vollman, 2010). Continuous lateral rotation therapy has been in use as part of progressive mobility and has been employed in an effort to reduce pulmonary complications resulting from immobility. This therapy was delivered through a continuous motion-bed frames that helped rotate the patient from one side to another. Studies have demonstrated the effectiveness of the therapy in improving pulmonary outcomes in critically ill patients (Sahn, 1991). The mobilization of patients is a broadly accepted practice helping reduce the effect of prolonged bed rest. In spite of this, it is usually difficult to mobilize patients during early acute phases of their illness. CLRT can be used to make up for this deficiency by providing early mobility efficiently to those patients whose critical condition or instability makes it hard to use other forms of mobility. There are several criteria which have been proposed in identifying pulmonary patients who could potentially benefit from CLRT. Methods that can be evaluated quickly and simply are preferred owing to ease in their implementation especially in busy critical-care environments. An example of such a method includes calculation of PaO2/ FIO2 ratio. This ratio shows the effectiveness of transfer of oxygen from the lungs to the hemoglobin in the blood. If this ratio is more than 300, the patient is considered to have minor pulmonary insufficiency, but if the ratio is less than 300, the patient is considered to have acute lung injury. The lower the ratio is, the worse the pulmonary function and vice versa. Setting the desired ratio as 300 helps to achieve the goal of early intervention instead of waiting till the patient deteriorates further. Additionally, other criteria include evaluation of the patients’ oxygen and PEEP requirements so as to achieve normal levels of PaO2. A radiograph is useful to assess for the presence of infiltrates and atelectasis. Bedside staff can easily evaluate these criteria. The most important consideration in the evaluation of potential CLRT patients is consistent assessment of the established criteria basing on the established set standards within the institution. The development of clinical practice outlines, standard of care or care bundle enables consistent implementation and helps improve outcomes. All the members of the care team are to participate actively in the identification of patients who would profit from early progressive mobility therapies like CLRT. Continuous education, evaluation and bedside mentoring are required to effect implementation of new or updated standard or practice( Sandra, 2012). When patients have been identified as suitable candidates for CLRT, there are many obstacles that impede the implementation of CLRT. Often times, transferring a patient from one bed to another seems a difficult task, what with the tubing, the branular and equipment that are connected to the patient. Additionally, those caregivers who will physically lift the patient are exposed to physical risk. There is also time lag between the moment when a patient is identified as suitable for CLRT and receipt of a suitable bed for performing a CLRT. This therefore calls for availability of ready beds capable of CLRT in the intensive care units so that there would be no need for multiple transfers from one bed to another. This would in effect minimize delays. In case such types of beds are not available, there should be clearly defined criteria for getting a bed and standard procedures for the transfer of patients to the bed so that time spent for implementation is shortened( Dolovick, 1998). Nursing staff working in the ICU for a long time has been implementing mobility protocols for patients who are hospitalized. Side-to-side turning of patients is a standard care for the prevention of skin related complications. Waiting for doctors’ decision to begin a CLRT for identified suitable patients significantly delays implementation. Guidelines and criteria for identification of patients who need CLRT should be made available so that nursing staff and respiratory therapists may be able to initiate CLRT (especially for spinal injury patients or patients with increased intracranial pressure) basing on written protocol of the hospital without necessarily having to wait for an additional order from the physician( Martin, 2001). How CLRT works Through CLRT, it is much easier to maintain adequate FRC and prevent atelectasis than attempt to restore alveoli patency. The role of CLRT is to reduce atelectasis by means of moving one lung continuously over the other so that secretions are mobilized. In effect, the tendency of alveoli to close is reduced. Additionally, CLRT works by placing the well lung in a dependent position so that gaseous exchange can be optimally realized. Since the flow of blood and distribution of gas is essentially by gravity, more blood will flow to the alveoli in the dependent lung position thus optimizing gaseous exchange, and therefore, generally enhancing oxygenation. Purpose statement In light of the evidence above, this paper aims to further provide evidence that continuous lateral rotation is more effective than no rotation at all in the prevention of acute respiratory distress syndrome and lung injury in patients who are critically ill. This is through review of literature using a PICOT question. A PICOT question is essential in looking for evidence supporting a particular intervention. Due to its use, a PICOT question presents a systematic and accurate way to obtain the best evidence in a time effective manner. This paper will use the four elements of a PICOT study ( Patient population, Intervention, Comparative intervention and Outcome) B. PICOT QUESTION 1. PICOT elements In this study, the four elements of PICO research question will be explained. P – Intubated patients in intensive care unit I – Use of continuous lateral therapy C – Not using continuous lateral therapy in intubated patients O – preventing acute lung injury and ARDS 2. Synonyms for the components include P- Patients on ventilation support 4. Search strategy The first step was to use the keyword. The search word, ‘continuous lateral rotation therapy’ was initially used. This offered several links and websites. In order to narrow down the search, combined searches was used. In addition to ‘CLRT’, ‘intubated patients’ and ‘lung injury and ARDS’. The use of these three items combined by boolean ‘and’, however yielded no results. The next strategy was therefore to reduce the number of search words to be able to yield results. The result search items were the words, ‘clrt’ combined with the Boolean, ‘and’ to ‘lung injury’. This yielded results that are shown in the appendix. Inclusion and exclusion criteria Inclusion criteria included all search results which contained continuous lateral therapy, and lung injury, ARDS or lung complications. In order to select those results which were more specific, filters were used to narrow down to the results. References Davis, K. et al ( 2001). The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. Crit Care, vol. 5 no. 5, pp. 81-7 Dolovich, M., Rushbrook, J., Churchill, E., Mazza, M, Powles, A.(1998). Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. J Crit Care. Vol. 13, no. 3, pp. 119-25. Martin, A.(2001). Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurs, vol 20 no.1, pp. 42-9. Sahn, S. (1991). Continuous lateral rotational therapy and nosocomial pneumonia. Chest, vol. 99, no. 5, pp.1263-7. Swadener-Culpepper L, Skaggs R, Vangilder C. (2008). The impact of continuous lateral rotation therapy in overall clinical and financial outcomes of critically ill patients. Crit Care Nurs Q.vol 31, no. 3, pp. 270-9. Vollman, M.(2010).progressive mobility in the critically ill, Crit care Nurs Vol 30, No. 2, Wanless, S., Aldridge, M.(2012) Continuous lateral rotation therapy - a review. Nurs Crit Car, Vol.1, no. 1, pp. 28-35. doi: 10.1111/j.1478-5153.2011.00458.x. Epub 2011 Jul 20. Review.PMID: 22229679 [PubMed - indexed for MEDLINE] Sandra, K. (2012). Pilot Study of Lateral Rotation Interventions for Efficacy and Safety in ICU Care, Society of Critical Care Medicine. Appendix Search results table Type of evidence Level of evidence Description Systematic reviews Randomized clinical trial Systematic review of qualitative and descriptive studies Controlled trial without randomization Controlled trial without randomization I II V III III Database: pubmed 1. Davis, K. et al ( 2001). The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. Crit Care, vol. 5 no. 5, pp. 81-7 2. Dolovich, M., Rushbrook, J., Churchill, E., Mazza, M, Powles, A.(1998). Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. J Crit Care. Vol. 13, no. 3, pp. 119-25. Martin, A.(2001). Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurs, vol 20 no.1, pp. 42-9 Vollman, M.(2010).progressive mobility in the critically ill, Crit care Nurs Vol 30, No. 2, Database: clinicaltrials.gov Sandra, K. (2012). Pilot Study of Lateral Rotation Interventions for Efficacy and Safety in ICU Care, Society of Critical Care Medicine Martin, A.(2001). Should continuous lateral rotation therapy replace manual turning? Dimens Crit Care Nurs, vol 20 no.1, pp. 42-9. Read More