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Background: During the pandemic outbreak, helmet continuous positive airway pressure (CPAP) was widely used as respiratory support for COVID-19 patients, inside and outside of intensive care units. The available literature suggests specific interventions to improve the comfort of patients treated with helmet-CPAP. Few reports are available on the experiences of patients undergoing this treatment. Aim: This qualitative study aimed to explore the views and recollections of COVID-19 patients undergoing helmet-CPAP. Study Design: We conducted semi-structured interviews with thematic analysis. Participants were recruited from the follow-up programme for COVID-19 patients discharged from an Italian general intensive care unit. Participants were interviewed by telephone. Data analysis followed the principles of thematic synthesis approach. Findings: We conducted 29 phone calls in patients eligible for the study. Five participants declared that they did not remember the time spent in hospital on helmet-CPAP. Twenty-four patients were then included. Two themes and six subthemes were generated from their interview data: (1) The helmet-CPAP as a life-saving treatment (subthemes: recognition of the usefulness of treatment and resilience); (2) the negative feelings related to helmet-CPAP application (subthemes: communication problems, entrapment, mental confusion, fear of dying). Each patient's experience was unique, but some discomfort elements such as noise, gas flow turbulence, choking sensation and thirst were found to be very common. Conclusions: The application of helmet-CPAP treatment generated positive and negative memories and feelings in COVID-19 patients during the pandemic. The patients' experience has provided an overview of the main factors of discomfort. This can be a starting point for taking corrective measures to promote greater helmet tolerance and subsequent treatment success. Relevance to Clinical Practice: This study has provided an insight into the patient

The term "system well-being" can move forward a new vision, meaning the result coming from the addition of the well-being of persons belonging to different institutions and organizations, which are all parts of the "health care system." Beginning with this "new definition," with the aim of analyzing the multifaceted issues related to nurses' well-being, we could use the "classical nursing metaparadigm" composed of 4 concepts: "health," "nursing," "environment," and "person." We briefly describe this conceptual map and provide some focused suggestions for further reflection on topics such as physical and psychological well-being, economic gain and career opportunities, work climate, burnout, low job satisfaction, moral distress, compassion fatigue, and a joyful work environment. This view may help organizations to focus on interventions to prevent or eliminate stress, which may be more proactive and effective than interventions to manage stress. Moreover, it offers a multidimensional map to analyze the different aspects influencing the well-being issue, keeping in mind that a concrete solution can be obtained only if all the components of health care systems and society do their part. Some solutions proposed by authors and organizations to increase nurses' well-being are mindfulness based, such as meditation, yoga, acupuncture, gratitude, journaling, choirs, coaching, workload reduction, job crafting, and peer networks. Other reflections on work organization, expected professional behaviors, nurses' retention, and education should be added to the discussion on this multidimensional issue.

Background: The application of Continuous Positive Airway Pressure (CPAP) with a helmet is increasing around the world, both inside and outside of the intensive care unit. Current published literature focus's on indications, contraindications and efficiency of Helmet CPAP in differing clinical scenarios. Few reports, summarising the available knowledge concerning technical characteristics and nursing interventions to improve patient's comfort, are available. Aim: To identify the crucial technical aspects in managing patients undergoing Helmet-CPAP, and what nursing interventions may increase comfort. Methods: A narrative literature review of primary research published 2002 onwards. The search strategy comprised an electronic search of three bibliographic databases (Pubmed, Embase, CINAHL). Results: Twenty-three studies met the inclusion criteria and were included in the review. Research primarily originated from Italy. Nine key themes emerged from the review: gas flow management, noise reduction, impact of gas flow and HME filters on delivered FiO2, filtration of exhaled gas / environmental protection, PEEP monitoring, airway pressure monitoring, active humidification of gas flow, helmet fixation and tips to implement awake prone position during Helmet-CPAP. Conclusions: A Helmet-CPAP check-list has been made of nine key interventions based on the available evidence regarding system set up, monitoring and management. Implementation of this check-list may help nurses and physicians to increase the comfort of patients treated with Helmet CPAP and enhance their compliance with long-term treatment.

BackgroundEndotracheal tube (ETT) clamping before disconnecting the patient from the mechanical ventilator is routinely performed in patients with acute respiratory distress syndrome (ARDS) to minimize alveolar de-recruitment. Clinical data on the effects of ETT clamping are lacking, and bench data are sparse. We aimed to evaluate the effects of three different types of clamps applied to ETTs of different sizes at different clamping moments during the respiratory cycle and in addition to assess pressure behavior following reconnection to the ventilator after a clamping maneuver.MethodsA mechanical ventilator was connected to an ASL 5000 lung simulator using an ARDS simulated condition. Airway pressures and lung volumes were measured at three time points (5 s, 15 s and 30 s) after disconnection from the ventilator with different clamps (Klemmer, Chest-Tube and ECMO) on different ETT sizes (internal diameter of 6, 7 and 8 mm) at different clamping moments (end-expiration, end-inspiration and end-inspiration with tidal volume halved). In addition, we recorded airway pressures after reconnection to the ventilator. Pressures and volumes were compared among different clamps, different ETT-sizes and the different moments of clamp during the respiratory cycle.ResultsThe efficacy of clamping depended on the type of clamp, the duration of clamping, the size of the ETT and the clamping moment. With an ETT ID 6 mm all clamps showed similar pressure and volume results. With an ETT ID 7 and 8 mm only the ECMO clamp was effective in maintaining stable pressure and volume in the respiratory system during disconnection at all observation times. Clamping with Klemmer and Chest-Tube at end inspiration and at end inspiration with halved tidal volume was more efficient than clamping at end expiration (p < 0.03). After reconnection to the mechanical ventilator, end-inspiratory clamping generated higher alveolar pressures as compared with end-inspiratory clamping with halved tidal volu

Background Appropriate levels and patterns of sound and light in an intensive care room help to maintain the patient's normal physiological functions. High sound levels can disrupt the patient's normal sleep architecture, cause hearing deficits, and induce the onset of delirium. Intensive care unit patients frequently report poor sleep, partly due to the environment. Objectives An observational pilot prospective study was designed to record sound pressure and light pollution levels in an Italian intensive care unit, without windows to provide natural light. Method Sound levels were measured in decibel A (dBA) every 10 seconds. Sound data were analyzed for sound peak, defined as the number of times sound levels exceeded 45, 50, 60, 65, 70, 75, 80, and 85 dBA. Light measures were taken every 10 seconds on a continuous basis. Light data were analyzed for light "peaks,"defined as the number of times light levels exceeded 100, 200, 300, 400, and 500 lux. Results The overall median sound level during the study period was equal to 54.60 (interquartile range [IQR], 51.70-57.70) dBA. The daytime median sound level was 56.00 (IQR, 53.00-59.50) dBA, and the nighttime median was 53.00 (IQR, 49.50-55.20) dBA (P <.001). The overall median light level was equal to 114 (IQR, 0-225) lux. The daytime median light level was 184 (IQR, 114-293) lux, and the nighttime median was 0 (IQR, 0-50) lux (P [removed]45 dBA during daytime and nighttime are, respectively, equal to 99.9% and 98.6% of all readings. The Environmental Protection Agency/World Health Organization recommended thresholds for both day (45 dBA) and night (35 dBA). Sound levels reached "toxic levels"when sound-generating activities were performed by nurses and physicians.

Background Awake prone positioning research focuses primarily on improving oxygenation and reducing intubation and mortality rates. Secondary outcomes concerning patient safety have been poorly addressed. Objective To summarize current evidence on the frequency of adverse events during awake prone positioning and the effects on patients’ safety, comfort, and tolerance. Methods This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews. MEDLINE/PubMed and CINAHL databases were the primary sources for the systematic search. Results The review included 19 original studies involving 949 patients who underwent awake prone positioning. No major complications such as death, severe respiratory compromise, or hemodynamic disease were reported. Ten studies reported the following secondary adverse events related to awake prone positioning: skin breakdown (1%-6% of patients), pain (12%-42%), discomfort (35%-43%), vomiting (2%-7%), intolerance (3%-47%), and vascular catheter dislodgment (5%). The duration of awake prone positioning sessions varied widely (0.3-19 hours). Seven studies reported that nurses helped patients during prone positioning maneuvers, including monitoring and surveillance, and 3 studies reported patients placing themselves in the prone position. In 6 studies light or moderate sedation was employed in the procedures. Conclusions Awake prone positioning was not related to cardiorespiratory consequences but was associated with pain, intolerance, discomfort, and patients’ refusal. Patients should receive education regarding awake prone positioning to improve their acceptance. Health care professionals should opti-mize pain control, communication, patient comfort, patient adherence, and correct positioning.

Background: Noninvasive ventilation (NIV) in COVID-19 patients outside of intensive care unit (ICU) settings was a feasible support during the pandemic outbreak. The aim of this study was to assess the effectiveness of an “on the job” NIV training program provided to 66 nurses working in 3 COVID-19 wards in an Italian university hospital. Methods: A quasi-experimental longitudinal before–after study was designed. The NIV Team education program, provided by expert ICU nurses, included: 3 h sessions of training on the job during work-shifts about the management of helmet-continuous positive airway pressure (CPAP) Venturi systems, and NIV with oronasal and full-face masks. An eleven-item “brief skills self-report tool” was administered before and after the program to explore the perception of NIV education program attendees about their level of skills. Results: In total, 59 nurses responded to the questionnaire. There was an improvement in the skill levels of the management of Helmet-CPAP (median before training 2, inter-quartile range (IQR) 0–6; median after training 8, IQR 3–9; p < 0.0001), and mask-NIV (median before training 2, IQR 0–6; median after training 8, IQR 3–9; p < 0.0001). Conclusions: Training on the job performed by expert ICU nurses can be a valuable and fast means to implement new Helmet-CPAP and mask-NIV skills outside of ICUs.

The incidence of COVID-19 gastrointestinal manifestations has been reported to range from 3% to 61%. There are limited data on the incidence rates and risk factors associated with gastrointestinal bleeding (GIB) in patients with COVID-19. A rapid review has been designed to investigate whether there is a relationship between COVID-19 and GIB in adult patients. PubMed, CINAHL, EMBASE, Cochrane Library, and Scopus databases have been analyzed. A total of 129 studies were found; 29 full texts were analyzed, and of these, 20 were found to be relevant to the topic. The key findings of the included studies present an overall GIB rate in COVID-19 patients ranging from 1.1% to 13%. The bleeding involves mucosal damage of the duodenum, stomach, colon, and rectum. The management of gastrointestinal bleeding could be conservative. The use of fecal diversion systems for the management of diarrhea in COVID-19 patients should be minimized and closely evaluated for the risk of rectal mucosal damages and erosions. It is recommended to provide an accurate nutritional assessment; an early setting up of enteral nutrition, if not contraindicated, can help protect the gut mucosa of patients and restore normal intestinal flora. Larger cohort studies are needed to increase the information about this topic.

Summary. Measuring the nursing workload in a medical-surgical high dependency unit through nursing activities score (NAS). a prospective observational study. Introduc-tion. Measuring the nursing staff workload allows adequate delivery of resources within the intensive care unit and high dependency unit to ensure an adequate nurse to patient ratio. Aim. Exploring the nursing workload in the me-dical-surgical high dependency unit (HDU) at Careggi Uni-versity Hospital (Florence, Italy). Methods. Monocentric prospective observational study. We enrolled patients admit-ted in HDU from 11 February to 13 March 2021. Nursing Activity Score (NAS) was measured every 24 hours. Results. Patients included in the study were 75. Three groups ba-sed on their admission diagnosis were identified (medical, surgical, trauma). The median NAS score was 59.7 (IQR: 53.7-68.2; range 34.7-119.7). Statistically significant dif-ferences were found between the median NAS values for the three admission diagnoses: 67.4 (IQR: 54.4-73.4) for medical patients, 60.2 (IQR: 54.4-63.3) for trauma patients and 59.1 (IQR: 55.1-64.7) for surgical patients. These results showed that the items of NAS that mostly affect workload are “monitoring”, “mobilization”, “patient hygiene”, and “ad-mission and discharge procedures”. Conclusions. This study confirms that the NAS scoree can be used in HDUs as well as in intensive care units. The ideal nurse-to-patient ratio was equal to 0.6.

During Continuous Positive Pressure Ventilation delivered through helmet, the patient inhales high flows of gas without adequate conditioning. However, the need to humidify the inspired gas during Helmet-CPAP, has not been sufficiently explored.

Background: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. Aims and objectives: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: ‘armpits strap’ versus ‘counterweights system’. Design: This was a non–randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. Results: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0–10 scale was: 0·5 ± 1·4 at T0 (baseline), 1·5 ± 2·0 at T1 (after 1 h) and 2·6 ± 2·5 at T2 (end of cycle) (p = 0·023). The same analysis was performed for the counterweights fixing option. The mean score was 0·3 ± 0·6 at T0, 0·3 ± 0·2 at T1 and 0·5 ± 0·7 at T2 (p = 0·069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3·0 ± 1·0 and 3·9 ± 2·3 h, respectively (p < 0·001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0·23 ± 0·20 cm2. After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0·27 ± 0·21(p = 0·099) and 0·30 ± 0·25, respectively (p = 0·080). Conclusions: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. Relevance to practice: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight

Background: Caring for patients with COVID-19 requires wearing a full set of personal protective equipment (PPE) to avoid contamination. Personal discomfort has been associated with use of PPE, and anecdotal reports describe pressure injuries related to wearing PPE. Objectives: To investigate the occurrence of device-related pressure injuries due to wearing PPE among Italian nurses caring for patients with COVID-19 in critical care settings. Methods: This descriptive study used an online survey investigating both the demographic characteristics of respondents and complications related to wearing PPE, including the development of pressure injuries. Results: A total of 266 nurses throughout Italy completed the survey; 32% of respondents were men. Nurses' median age was 36 years (range 22-59 years), and the median time spent working in their current clinical setting (an intensive care or high-dependency unit) was 3 years (range 0-32 years). Personal protective equipment was worn for a median duration of 5 hours (range 2-12 hours). While wearing PPE, 92.8% of nurses experienced pain and 77.1% developed device-related pressure injuries, mainly on the nose and forehead. Pain was more frequent among nurses with such injuries. Transparent dressings, emollient cream, and no dressing were associated with development of device-related pressure injury. Conclusions: Pressure injuries related to PPE represent an important adverse effect for nurses caring for patients with COVID-19. This topic deserves study to determine adequate solutions for preventing and treating such injuries and their potential influence on nurses' work tolerance.

Introduction Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required. Purpose The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO. Methods A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study. Results Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni's technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%). The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P <.0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00-100 000], P <.0001), and mouth care score (6 [5-7] vs 8 [7-9], P <.001). Conclusion Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses

BACKGROUND AND AIM: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself. In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. METHODS: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016. RESULTS: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. CONCLUSIONS: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates

Un dispositivo di mappatura continua della pressione di interfaccia tissutale (PIT) può fornire un feedback in tempo reale della posizione da far assumere al paziente per consentire lo scarico delle aree ad alta pressione. Obiettivo. Descrivere i risultati di un sistema di mappatura continua della PIT nei pazienti in terapia intensiva. Metodi. Studio osservazionale prospettico su pazienti adulti ventilati meccanicamente, in una terapia intensiva generale di un ospedale universitario italiano nelle prime 24 ore dopo l'ammissione, utilizzando un sistema di mappatura della pressione (M.A.P. System TM). Nelle prime 24 ore sono state eseguite tre valutazioni ad intervalli di 6 ore, della PIT con il paziente in posizione supina, utilizzando le quattro superfici antidecubito disponibili (Duo2® - Hill-Rom, Proficare®, Nimbus 3® Therakair Visio® - Arjohuntleigh, Getinge Group). Risultati. Sono stati inclusi 27 pazienti (8 femmine), età media 61.2±15.3 anni, indice di massa corporea media di 27±6 (range: 16-43); quattro pazienti erano diabetici. Sono state analizzate 1215 aree di PIT. La pressione media è stata di 26.7±19.6 mmHg (intervallo: 3-78). La regione con la più alta pressione di contatto era quella dorsale (media: 48.7±12.5 mmHg), seguita dall'occipitale (44.7±19.6 mmHg) e dall'osso sacro (44.7±10.7 mmHg). Le tre superfici antidecubito hanno avuto prestazioni significativamente differenti nella distribuzione delle PIT per peso corporeo (p=0.017), altezza (p=0.034), con aumento delle pressioni nei pazienti più alti, e BMI più elevati (p<0.0001). Conclusioni. I valori medi di PIT sono stati superiori ai livelli critici durante il periodo di studio, specialmente nella regione dorsale, occipitale e sacrale., Continuous bedside pressure mapping in a general intensive care unit: a prospective observational study. Introduction. A continuous bedside pressure mapping device (PMD) can provide real-time feedback of ideal body position to allow off-loading of high-pressure areas to prevent pressure ulcers development. Objective. To describe the implementation of a PMD to measure tissue interface pressure (PIT) in Intensive Care (ICU) patients. Methods. Prospective observational study in ICU critically ill mechanically ventilated adults, in an Italian University Hospital. Subjects were enrolled in the first 24 hours after ICU admission. A pressure mapping system (M.A.P. System TM) was used and 3 measurements of PIT with patient in supine position, every 6 hours after admission, were performed. The following anti-decubitus surfaces were used: Duo2® - Hill-Rom, Proficare®, Nimbus 3® or Therakair Visio® - Arjohuntleigh, Getinge Group. Results. 27 patients (8 females) were enrolled; average Body Mass Index 27±6 (range: 16-43); 4 patients (14%) were diabetic. The average pressure of the 1215 areas analyzed was 26.7±19.6 mmHg (range: 3-78); the region with the highest contact pressure was the dorsal region (average: 48.7±12.5 mmHg), followed by the occipital (44.7±19.6 mmHg), and sacrum (44.7±10.7 mmHg). The three anti-decubitus surfaces showed different performances in the distribution of PITs, with statistically significant differences for the following factors: body weight (p = 0.017), patient height (p = 0.034), with increased pressures in taller patients, and higher BMI (p <0.0001). Conclusions. Mean values of PIT were above critical levels, especially in the dorsal, occipital and sacrum region.

Aim: The aim of this study was to assess the noisiness levels produced by different gas source systems, breathing circuits setup, and gas flow rates during continuous positive airway pressure (CPAP) delivered through helmet. Methods: This was a crossover design study. Ten healthy subjects received helmet CPAP at 5 cm H2O in random order with different gas flow rates (60 and 80 L/min), 3 diverse gas source systems (A: Venturi system, B: oxygen and air flowmeters, C: electronic Venturi system), and 3 different breathing circuit configurations. During every step of this study, a heat and moisture exchanger (HME) was placed on the helmet inlet gas port to measure the effects on noise production. Noise intensity level was recorded through a sound-level meter. Participants scored their noisiness perception on a visual analog scale. Results: The noise level inside the helmet ranged between 76 ± 4 and 117 ± 1 Decibel A. The gas source and the gas flow rate always affected the noise level inside and outside the helmet (P < .001). The different "breathing circuit setup" did not change the noise levels inside the helmet (P = .244), but affected the noise level outside, especially when a Venturi system was used (P < .001). An HME filter placed at the junction between the inspiratory limb of the breathing circuit and the helmet significantly decreased the noise intensity inside the helmet (mean dBA without HME, 99.56 ± 13.30 vs 92.26 ± 10.72 with HME; P < .001) and outside (mean dBA without HME, 68.16 ± 12.05 vs 64.97 ± 12.17 with HME; P < .001). The perception of noise inside the helmet was lower when an HME filter was placed on the inspiratory inlet gas port (median, 6 [interquartile range, 4-7] vs 7 [5-8]; P < .001). Conclusions: When helmet CPAP is delivered through gas flow rates up to 50 L/min, an HME placed on the helmet inlet gas port should be used to reduce noise inside the helmet and to improve patients' comfort.

Introduction: In the literature, the change of a syringe pump is described as a dangerous situation, especially in the case of vasoactive drug administration. Methods: Different variables have been studied (central venous pressure, pump displacement in relation to the patient position, utilization of a stopcock, or a neutral displacement needle-free connector between the syringe and the infusion tubing) to understand their influence on medication administration in terms of backflow or bolus creation when changing the syringe. Results: We performed 576 measurements with different combinations. With respect to all the observations, in comparison with “time zero,” we found the following differences expressed in microliters: 0 (±1) at the plunger opening; 0 (±3) at the syringe extraction from the pump; 0 (±7) at the syringe disconnection from the infusion tubing; 0 (±11) at the syringe reconnection to the infusion tubing; 1 (±7) at the syringe insertion in the pump; 3 (±23) at the plunger closing; 8 (±33) at the stabilization at the maneuver end. Conclusion: The syringe change can be a very critical moment given different influencing variables. Syringe pump position, displaced higher than the patient level, always generates a medication bolus that is higher at the lowering of the central venous pressure value. The presence of a neutral displacement needle-free connector reduces the incidence of boluses. When the pump is placed at the patient level, the presence of neutral displacement needle-free connector reduces the establishment of boluses, even in a central venous pressure of −5 mmHg simulations.

Background Early application of prolonged prone positioning has been shown to improve patient survival in moderate to severe adult respiratory distress syndrome (ARDS) patients. Prone position is a key component of lung protective mechanical ventilation in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. Pressure sores are the major prone position complication. The rate of complication is lowering with the increase in center expertise. Aims The aim of this study was to examine the onset of pressure sores and other complications caused by the use of prone position in patients having ARDS. Design This is a single-center, retrospective, observational study. Results One hundred seventy patients were enrolled, with a median age of 49 years (interquartile range [IQR], 38-63). Of all participants, 58% (n = 98) survived the intensive care unit recovery. The total prone position maneuvers were 526, with a median of 2 prone position sessions for each patient (IQR, 1-3). The median length of the prone position session was 9 hours (IQR, 7-12). Twenty-three patients developed pressure sores after prone position (14%). The anatomical positions of pressure sores were as follows: face/chin, 5% (n = 8); face/cheekbones, 6% (n = 11); thorax, 2% (n = 3); trochanter, 1% (n = 1); and other sites, 5% (n = 8). Complications were observed in 1% (n = 6) of all pronation maneuvers (vomit, 2%; respiratory device removal, 0.4%). No removal of intravascular catheter was observed. Conclusions The onset rate of complications given by the use of prone position in ARDS patients is similar to data reported by previous literature. The implementation of a dedicated protocol in specialized centers and the involvement of 5 trained and skilled professionals while moving the patient in the prone position are recommended to prevent the occurrence of similar adverse events.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients’ lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries

Background: Lateral violence and bullying affect nurses’ professional and health status. Worldwide prevalence ranges from 1% to 87%. Aim: To investigate prevalence and risk factors of lateral violence and bullying among Italian nurse peers in different work settings, inside and outside hospitals. Methods: Web survey using the 17-item “Negative Interactions Among Nurses Questionnaire.” Emails were sent to 5,009 nurses in three Tuscan public health care institutions. Results: Response rate was 18.6% (n = 930). Twenty-six respondents were removed as they reported working with no peer colleagues. Negative interactions were experienced by 35.8% (n = 324), 42.3% of whom (n = 137) were bullied. Psycho-physical consequences of negative interactions were reported by 59% (n = 191). Victims who thought of leaving nursing were 21.9% (n = 71). Conclusions: Lateral violence and bullying among nurses are consistently present in all studied settings. Implications for Nursing Management: Nurse managers could play a crucial role in preventing negative interactions among nurses. Strategies could include continuing education programs to promote awareness of this problem; implementation of an anonymous reporting system for bullying; introduction of occupational psychologists in wards with larger numbers of reported negative interactions and bullying; and increasing changes in staff composition within shifts.

Introduction: Tracheal suctioning is recalled by mechanically ventilated patients as the most painful procedure during their stay in the intensive care unit. Aim: The aim of this study was to evaluate whether the implementation of American Association of Respiratory Care suction guidelines positively affects the levels of patients' pain. Materials and Methods: This is a prospective observational study on adult patients admitted to 2 general intensive care units. Pain levels in sedated mechanically ventilated patients were recorded before, during, and after tracheal suctioning, using the Critical Care Pain Observation Tool (CPOT). Results: Forty-seven patients were enrolled, with a mean age of 61.72 (T18.46) years. Median CPOT value was 0 (quartile 1 [Q1] [25%], 0; quartile 3 [Q3] [75%], 0; min, 0; max, 2) during the procedure. The Critical Care Pain Observation Tool reached a median value of 3, while 5 minutes after suctioning. Postprocedural CPOT median score was 0 (Q1 [25%], 0; Q3 [75%], 0; min, 0; max, 2). The median number of passes during suctioning was 1 (Q1, 1; Q3, 2). The sizes of suction catheters used in the recorded procedures were as follows: 12F in 27 cases (57%), 14F in 18 cases (38%), and 10F in 2 cases (5%). The median size of the endotracheal tube was 7.5 mm (Q1, 7.5; Q3, 8). The correct ratio between endotracheal tube diameter and suction catheter was used in 24 procedures (51%). Conclusions: Despite the low number of patients, this study showed that the implementation of the American Association of Respiratory Care 2010 endotracheal suctioning guidelines into practice helps to reduce procedural-induced pain. Therefore, training and continuing education are important for clinical staff performing tracheal suctioning.

This book provides essential insights into how the approach to nursing care in ICU patients has markedly changed over recent years. It shows how the focus has progressively moved away from the technical approach that characterized early ICUs to a wider personalization of patient care that also highlights general problems such as basic hygiene and general comfort. It also demonstrates that, at the same time, the nurses' role has become more professionalized, with increasing competences in assessing and managing patients' problems and measuring related outcomes. It is structured in four units: Unit 1 presents the essential elements of accurate vital-function and basic-needs assessments for ICU patients, using both instrumental monitoring and specially validated assessment tools. Unit 2 addresses basic care in ICU patients, particularly hygiene and mobilization, reflecting recent developments in nursing that focus on the importance of these activities. Unit 3 highlights the main nursing outcomes in ICU patients, particularly focusing on risk prevention and complication management. Lastly, Unit 4 discusses advances in ICU nursing, from clinical, organizational and research perspectives

Respiratory mechanics refers to the expression of lung function through measures of pressure and flow. From these measurements, a variety of derived indexes can be determined, such as volume, compliance, resistance, and work of breathing. Ventilation monitoring plays an important role in the current management of patients with acute respiratory failure, but sometimes there’s a lack of definitions regarding which “signals” and “derived variables” should be prioritized, as well as specifications about the timing and modes of application. New techniques of respiratory monitoring have recently been made available for clinical use, but their use and arrangement are not always well defined. We summarize the current modes of respiratory monitoring and their potential practical applications during invasive and noninvasive ventilation and during extracorporeal membrane oxygenation in patients affected by severe ARDS, needing rescue therapies to maintain blood oxygenation adequate

According to the current literature, Noninvasive Ventilation (NIV) is a well-recognized respiratory support technique for patients affected by Acute Respiratory Failure (ARF). As highlighted by recent meta-analysis, a tight adherence to protocols regarding patients’ selection criteria, relative or absolute contraindications, plus highly skilled and experienced operators, can positively affect the NIV performance and mortality rates. Positive outcome from NIV respiratory support is dependent from: patient’s clinical condition and education needs; confidence of the staff with NIV technology; choice and management of the most suitable interface available prevention of interface complications; nutritional assessment (artificial feeding if required) and conditioning of medical gas. Despite these issues, the air leakage represents the major threat during NIV support. Indeed, to obtain a positive outcome from this treatment, the ‘NIV troubleshooting’ management appears to be crucial. Common issues as air leakage, patient-ventilator asynchrony, interface related pressure ulcers, discomfort, and gastric distention should be promptly detected and solved. The analysis of these current issues reveals a lack of evidence based practice, resulting in bed-side clinical interventions based only on the expert consensus or local opinions. To improve this knowledge gap, more efforts are strongly recommended from medical and nursing research communities. Multicenter randomized controlled clinical trials are needed to achieve adequate knowledge to reach the best patient’s outcome. Further information to identify new areas of nursing research on NIV, can be achieved from qualitative studies performed on patients and healthcare operators.