The role of the nurse in pulmonary rehabilitation

Pulmonary rehabilitation can help patients with chronic obstructive pulmonary disease improve their exercise tolerance and quality of life. Care packages can be devised and managed by respiratory nurses.

A cup full of domesticity: the "Duke-Fingard" vaporizer

This article presents the history of the "Duke-Fingard" domestic medical vaporizer. It considers the emergence of this Canadian device out of Rudolph Duke and David Fingard's larger institutional inhalation treatment system, and seeks to trace and explain the medical, social, commercial and cultural influences that shaped its subsequent sale, use of electricity, and design. What emerges through this synchronic and microhistorical analysis is a more concrete sense of the practice of domestic medicine during a transformative period of Canadian medical history.

Are breathing exercises an effective strategy for people with asthma?

BACKGROUND

The effect of breathing techniques on asthma symptoms and disease control is uncertain.

AIM

To investigate whether physiotherapist-taught breathing exercises can improve asthma control and reduce the condition's impact on patients' quality of life.

METHOD

A randomised controlled trial comparing breathing training with asthma education (control for non-specific effects of healthcare professionals' attention) was carried out.

RESULTS

One month after the intervention, both groups showed similar improvements in asthma quality-of-life questionnaire scores but, at six months, there was a significant difference between groups in favour of breathing training. There was also a significant difference in anxiety and depression scores in favour of breathing training at six months.

DISCUSSION AND CONCLUSION

This study found that adult patients with asthma who were taught breathing exercises showed improvements in quality of life, symptoms and psychological well-being after six months. Breathing exercises may have a role in helping the many people treated for asthma in general practice who have symptoms despite inhaled treatment.

Smoking cessation treatment by Dutch respiratory nurses: reported practice, attitudes and perceived effectiveness

OBJECTIVE

To describe Dutch respiratory nurses' current smoking cessation practices, attitudes and beliefs, and to compare these with a survey from the year 2000, before the national introduction of a protocol for the treatment of nicotine and tobacco addiction (the L-MIS protocol).

METHODS

Questionnaire survey among all 413 registered respiratory nurses in the Netherlands in 2006.

RESULTS

The response rate was 62%. Seventy-seven percent of the respondents reported to have "fairly good" or "good" knowledge of all steps of the L-MIS protocol. Seven out of 10 behavioural techniques for smoking cessation from the protocol were used by more than 94% of the respondents. Seventy-four percent of the respiratory nurses recommended the use of either nicotine replacement therapy (70%) or bupropion (44%). Almost two-thirds (65% of 254) perceived lack of patient's motivation as the most important barrier for smoking cessation treatment; a four-fold increase compared to the year 2000.

CONCLUSION

We conclude that respiratory nurses are compliant with the L-MIS protocol. They offer intensive support and use behavioural techniques for smoking cessation more frequently than evidence-based pharmacological aids for smoking cessation. Perceived lack of patient's motivation forms the most important threat to respiratory nurses' future smoking cessation activities.

PRACTICE IMPLICATIONS

International guidelines acknowledge that respiratory patients have a more urgent need to stop smoking but have more difficulty doing so. They should be offered the most intensive smoking cessation counselling in combination with pharmacotherapy. This kind of counselling may be more feasible for respiratory nurses than for physicians who often lack time. Their efforts could be increased by reimbursing pharmacological aids for smoking cessation and by developing simple tools to systematically assess motivation to quit and psychiatric co-morbidity in smoking patients.

Understanding why we use spirometry: part one

Rachel Booker discusses why spirometry is used and the interpretation of results. In part two she describes the procedure for using spirometry.

Carrying out accurate spirometry testing: part 2

Rachel Booker describes the procedure for using spirometry.

Rehabilitation for the home care patient with COPD

Assessment techniques and treatment strategies, such as medical management, oxygen management, chest physical therapy, and pulmonary rehabilitation, for patients with chronic obstructive pulmonary disease (COPD) are discussed. Clinically appropriate, evidence-based rehabilitation programs for home care may help to reduce care costs, reduce the impact of this chronic disease on patients with COPD, and prevent emergent care and rehospitalization.

Assessment and nursing care of the patient with dyspnoea

Breathlessness is a subjective experience, which has been described as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990). Patients experiencing breathlessness are often described as being dyspnoeic, or having dyspnoea. This is derived from the Greek word, which, when translated, means 'difficulty in breathing'.

Respiratory care in community settings

BACKGROUND

This article reviews the nurse's role in respiratory care in community settings. It aims to identify successful models of community-based respiratory care so that future models and programmes can benefit.

CONCLUSION

From the literature it is evident that the nurse's role could be strengthened by the national standardisation of education and the development of models of care and relevant career paths. Improvements to patient care could include the addition of palliative counselling services, general psychosocial support care, auditing patient satisfaction and implementing individualised care plans.

Protocol-driven ventilator weaning reduces use of mechanical ventilation, rate of early reintubation, and ventilator-associated pneumonia

BACKGROUND

Mechanical ventilation is the defining event of intensive care unit management. To reduce use, a literature-based protocol was introduced to facilitate weaning. The effect of protocol-driven ventilator weaning on ventilator use, ventilator-associated pneumonia (VAP), and intensive care unit (ICU) length of stay (LOS) is described in a survey of 2 years' activity in a multidisciplinary surgical ICU.

METHODS

Data were gathered from April to September 2000 and from April to September 2002 before and after introduction of nurse/therapist-driven weaning. VAP was identified by chest radiography, clinical presentation, Gram's stains, and cultures from tracheal aspirates or bronchoalveolar lavage. Infection control practitioners diagnosed VAP. Failed extubation was defined as reintubation within 72 hours.

RESULTS

Overall, there was a 2:1 ratio of male patients to female patients. The total number of patients and days of mechanical ventilation increased, but the use ratio (ventilator days/ICU days) fell from 0.47 to 0.33. Patients failing extubation fell from 43 (in 2000) to 25 (in 2002). From these patients, 17 cases of VAP occurred in 2000 and 5 in 2002. Mean age (40 years), Injury Severity Score (24), and ICU LOS (5.7-7.4 days; p = not significant) were unchanged in injured patients. ICU discharge was frequently delayed because of the need for subsequent respiratory care.

CONCLUSION

Protocol-driven weaning reduces use of mechanical ventilation and VAP. Injured and general surgical patients show reduction in complications, but shorter ICU LOS depends on resources elsewhere in the health care system.

Inhaled Nitric Oxide Therapy in the Near-Term or Term Neonate with Hypoxic Respiratory Failure

Inhaled nitric oxide (iNO) has altered the management strategy for treating near-term and term infants with hypoxic respiratory failure (HRF) There is a strong relationship between HRF and persistent pulmonary hypertension of the newborn (PPHN). PPHN is characterized by elevated pulmonary resistance, pulmonary vasoconstriction, and altered vascular reactivity. The resulting high pulmonary pressure may lead to HRF, which is defined as a relative deficiency of oxygen in arterial blood and insufficient minute ventilation. iNO improves oxygenation and decreases the need for extracorporeal membrane oxygenation. Although iNO therapy is effective, its efficacy can depend on the fine points of its use and on other care the infant is receiving. Even in NICUs that do not have iNO available, those who care for term infants with HRF must be familiar with its use and know when and how to transfer these infants and how to help families through this difficult period. Because iNO therapy will probably be used more frequently in nurseries over the next few years, more information on the safety and efficacy of its use in the broader neonatal population needs to be available.

[Effects of kinesthetic mobilization in comparison with standard mobilization on respiratory function after coronary artery bypass and other relevant factors]

Presently no relevant nursing data exist in Germany on the effect of mobilization according to kinaesthetic principles on the physiological system, on locomotion and the sensory system. The effect of two different versions of mobilization was measured in a unicentric, open, randomized study with two parallel groups from December 1999 to October 2000 in the intermediate ICU for patients after heart surgery at Ulm University Hospital. The aim was, to show superiority of kinaesthetic mobilization, compared to empirically developed standard mobilization on patients after aortal coronary bypass surgery, with reference to respiratory function. The two protocols of mobilization were carefully coordinated with precise plans of action and timing. A total of 104 subjects were randomized to the two groups. In the kinaesthetic mobilization group (n = 52) median age was 67.5 years, ten (19.2%) were female and 42 (80.8%) were male. In the standard mobilization group (n = 52) median age was 69 years, eight (15.4%) were female and 44 (84.6%) were male. The main outcome variable was the respiratory minute volume 30 minutes after the second mobilization minus the respiratory minute volume prior to the second mobilization. The median change in respiratory minute volume was 0.4 ltr/min. (-5.1 to 3) in the group with kinaesthetic mobilization and median 0.3 ltr/min (-6.0 to +9.1) in the standard mobilization group. Superiority of kinaesthetic mobilization compared to standard mobilization could not be proven (p = 0.38). Also in the secondary outcome variables the kinaesthetic mobilization showed no superiority over standard mobilization. The respiratory minute volume data within points of measure show that subjects in the kinaesthetic group have less extreme results (> 12 ltr.). In the area < 5 ltr. there is a similar tendency. This may point out that regulation between movement of body, respiration and circulatory system occurs more continuous in kinaesthetic mobilization than the standard mobilization. A similar tendency was seen in the secondary outcomes variables. Subjectively nurses noted that kinaesthetic mobilization was less strenuous than standard mobilization, even though subjects in the kinaesthetic group showed more mobility restriction (37%) than in the standard group (15%). From before to after the first mobilization the percentage of subjects needing less pain medication was higher in the kinaesthetic group (35%), compared to the standard group (19%). There were no serious adverse events in either group. The concept of kinaesthetic mobilization showed no negative effect on subjects compared to empirically developed standard mobilization. There was no diagnosis of pneumonia and none of instabile sternum on any of the subjects in this study. Also, there was no negative effect on the sternum due to the light support arms gave to sitting up and rotating movements in the area of thorax and pelvis on subjects in the kinaesthetic group. The subjects early trust in their own varied movement and the possible effects of kinaesthetic mobilization in later phases of recuperation was not explored in this study.

Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions

Spinal cord injury (SCI) is a devastating and challenging condition. The events that lead to SCI, such as road traffic accidents, falls, sports and violence [Top. Spinal Cord Inj. Rehabil. 5 (1999) 83], are also the common aetiologies of traumatic brain injury (TBI). It's not surprising then, that 20-50% of those with cervical SCI have TBI [J. Trauma 46 (1999) 450]. The literature pertaining to the management of either injury in isolation is vast, but lacking where the two conditions are experienced together and require distinct adaptations to interventions. Consequently, a gap in the literature exists. This paper focuses on those patients with SCI of the cervical spine with associated head injury, and pay particular attention to respiratory difficulties, and presents interventions required to minimise and treat the effects of such pulmonary compromise.

Neonatal respiratory therapy in the new millennium: Does clinical practice reflect scientific evidence?

Respiratory therapy has historically been considered the primary role of the physiotherapist in neonatal intensive care in Australia. In 2001 a survey was undertaken of all level three neonatal intensive care units in Australia to determine the role of the physiotherapist and of respiratory therapy in clinical practice. It appears that respiratory therapy is provided infrequently, with the number of infants treated per month ranging from 0 to 10 in 15 of the 20 units who provide respiratory therapy, regardless of therapist availability. The median number of respiratory treatments per month during the week was three, and on weekends it was one. Respiratory therapy was carried out by physiotherapists and nurses in 54.6% of units, by physiotherapists only in 36.4% of units, and by nurses only in the remaining 9% of units surveyed. There was also a diminution of the role of respiratory therapy in the extubation of premature infants. A review of the literature shows that overall the use of respiratory therapy reflects current evidence. The question remains whether it is possible to maintain the competency of staff and justify the cost of training in the current healthcare economic climate. It seems probable that the future role of physiotherapists in neonatal intensive care unit may be in the facilitation of optimal neurological development of surviving very low birth weight infants.

Managing our first breaths: a reflection on the past several decades of neonatal pulmonary therapy

Lung disease has been a leading cause of significant morbidity and mortality since neonates first drew breath. Over the past few decades, many treatment options have evolved to aid us in our ability to support neonatal breathing. The history of neonatal pulmonary care, both its successes and controversies, can teach us a great deal about the future of this dynamic field. As new developments occur, we constantly modify the therapies we offer to preterm and term infants. Understanding traditional therapeutic options and knowing what may be on the horizon can help caregivers to better match treatment plans with individual infants. This article reviews advances in mechanical ventilation, adjuvant therapies, and respiratory drugs through the past few decades and speculates on future directions in this field.

Breathing easy

Patient care models increasingly call for collaborative initiatives between nursing and respiratory care practitioners.

Clinical implications of respiratory system changes in aging

Nurses must consider the many age-related respiratory system changes when assessing and managing respiratory-related symptoms of older individuals. This article reviews upper and lower respiratory tract changes and provides tips for clinical management of the older person. Pertinent respiratory symptom assessment scales are described. Smoking cessation and other health promotion counseling is discussed.

Respiratory care protocols in postanesthesia care

Respiratory care protocols have been developed for specific therapies that include the following: oxygen titration, weaning from mechanical ventilation, sampling arterial blood gases, managing bronchospasm and secretions, treating atelectasis, endotracheal extubation, and managing the postextubation airway. Although relatively little attention has been given to using protocols in postanesthesia care, this environment lends itself to applying protocols. In this context, studies have examined and support the use of protocols for titrating supplemental oxygen, weaning patients from mechanical ventilation, and sampling arterial blood gases. As with other previously mentioned respiratory protocols, these protocols have shown efficacy for improving allocation of respiratory care services, cost savings, and favorable clinical outcomes. On this basis, while recognizing the need for further studies, respiratory care protocols implemented by respiratory therapists can be beneficial in the postanesthesia care setting.

Recent developments in respiratory care pharmacology

Bronchoactive inhaled aerosol drugs target the respiratory tract directly and seek to minimize systemic exposure and reduce side effects. Common delivery devices such as the metered dose inhaler, the small volume nebulizer, or the dry powder inhaler each deliver approximately the same fraction of dose (10%) to the lungs, although their dose amounts are not equivalent. Major respiratory drug groups are reviewed, and include the beta-adrenergic and anticholinergic bronchodilators, mucolytic agents, corticosteroids, mediator antagonists, anti-infective agents, and exogenous surfactants. New agents in each group are identified and briefly described, along with the clinical use and most commonly observed side effects for each class of drugs.