Optimizing ventilatory support in ARDS: A comprehensive guide for ICU nurses on patient care

Give your patient a “fast hug” (at least once a day ^[15]

The "FAST HUG" mnemonic prompts healthcare providers to review and manage critical areas including,

Feeding (Nutrition): Assessing the patient's nutritional needs to ensure they are met adequately.

Analgesia: Managing pain effectively to ensure patient comfort as ordered.

Sedation: Evaluating the need for sedation to maintain patient comfort and safety as ordered.

Thromboembolic prophylaxis: Implementing measures such as Thrombo Emboli Deterrent Stockings (TEDS) or administering Low Molecular Weight Heparin (LMWH) to prevent blood clots as ordered.

Head-of-bed elevation: Adjusting the bed to an appropriate angle to reduce the risk of aspiration and facilitate better breathing.

Stress Ulcer prevention: Taking steps to prevent the development of stress ulcers in critically ill patients.

Glucose control: Monitoring and managing blood glucose levels to prevent complications.

Vincent and Hatton expanded upon this mnemonic by adding three additional components^[16], ^[17] as follows,

Bowel movement: Monitoring and managing bowel function to prevent complications.

Indwelling catheters: Assessing the necessity of catheters and ensuring their proper management to prevent infections.

Drug de-escalation (BID): Regularly reviewing medication regimens to minimize exposure to unnecessary antibiotics and reduce the risk of resistance.

This expanded "FAST HUG BID" approach ensures a holistic and vigilant care regimen, emphasizing the need for a detailed and routine examination of patients' critical care needs, thereby promoting optimal outcomes in the ICU environment. ^[18]

Nutritional assessment in ARDS patients in the ICU is crucial for optimizing patient outcomes. Enteral nutrition is beneficial in improving oxygenation and extending ventilator-free days in patients with Acute Lung Injury (ALI) and ARDS.^[19] Additionally, high caloric intake with a high ratio of enteral nutrition has been associated with lower hospital mortality in ARDS patients undergoing prone positioning therapy.^[20] It is recommended that nutritional support, preferably enteral, be initiated within 24-48 hours of ICU admission for ARDS patients. ^[21]

In ARDS, a high NUTRIC (Nutrition Risk in Critically Ill) score has been associated with higher mortality in patients requiring mechanical ventilation in the ICU.^[22] Furthermore, a study on nutrition in COVID-19 patients emphasizes the importance of optimizing nutrition management, especially in those with ARDS, to improve patient outcomes. ^[23]

It is essential to consider the nutritional status of ARDS patients, particularly those at high nutritional risk. A study found that energy achievement rate is an independent factor associated with ICU mortality in high-nutritional-risk patients with moderate to severe ARDS requiring prolonged prone positioning therapy. Moreover, immune-enhancing enteral nutrition has shown benefits in terms of oxygenation and mortality in adult ICU patients with ALI/ARDS. ^[24]

Care of invasive lines

The meticulous management of invasive lines, such as IV cannulas, arterial catheters, and central lines, is paramount in patient care, especially to maintain their patency and ensure sterile conditions.^[25], ^[26], ^[27] Precise documentation of the insertion date and time is crucial for timely replacement based on clinical indications or adherence to hospital protocols, thereby minimizing the risk of infection and other complications.^[28], ^[29] Effective care planning and communication in ICUs are essential to prevent overutilization of invasive treatments. ^[30], ^[31]

Particularly challenging is the management of the endotracheal tube, where inadvertent dislodgement can lead to severe consequences including laryngeal swelling, hypoxemia, bradycardia, hypotension, and potentially fatal outcomes. Proactive measures to prevent premature or accidental removal are essential.^[32] Providing adequate sedation and analgesia, coupled with the implementation of standardized protocols, has been shown to reduce the incidence of self-extubation. While the application of soft wrist restraints or mitts may not completely prevent self-extubation, these measures, when used judiciously, can contribute to the overall strategy to mitigate this risk. ^[33]

Regular monitoring and adjustment of cuff pressure are critical to ensure the integrity and functionality of the endotracheal tube. Utilizing a handheld calibrated aneroid manometer every 8 to 12 hours for this purpose, or employing techniques such as the minimal leak volume or minimal occlusion volume method, helps maintain optimal cuff pressure between 18 and 22 mm Hg.^[34], ^[35] This is particularly important during extended periods of intubation, where pressure adjustments may be necessary to secure an adequate seal.

Tracheostomy care warrants diligent attention, with at least tri-daily assessments to prevent infection, a common complication due to the invasive nature of the procedure. The routine replacement of the ventilator circuit and in-line suction tubing, guided by infection control recommendations, further decreases the risk of ventilator-associated infections. ^[36], ^[37]

Moreover, nasotracheal tubes are associated with a higher risk of sinus infections and ventilator-associated pneumonia (VAP), underscoring the need for careful selection and management of airway devices to mitigate these risks. ^[38], ^[39], ^[40]

Such comprehensive care strategies are critical in safeguarding patient health and optimizing outcomes in the critical care setting.

Monitoring vitals

Monitoring vital signs is a cornerstone of patient care, especially in critical care settings, providing essential insights into the patient's physiological state and guiding therapeutic interventions.^[41] Regular and comprehensive monitoring should encompass temperature, pulse, blood pressure (BP), oxygen saturation (SpO2), electrocardiogram (ECG) readings, and pain intensity using a Visual Analogue Scale (VAS). Additionally, assessing skin colour and hemodynamic parameters such as central venous pressure (CVP), arterial blood gas (ABG) values, and random blood sugar levels is crucial for a holistic understanding of the patient's health status.

Auscultation of lung sounds should be performed at least every 2 to 4 hours, ^[42]

To evaluate the adequacy of bilateral air entry, ensuring that ventilation is effectively reaching both lungs. ^[43], ^[44]

To detect the presence or prominence of abnormal breathing sounds, which could indicate complications or changes in the patient's condition.

To follow up on the changes in the abnormal breathing sounds noted on the previous day, whether there has been a reduction or aggravation, providing insight into the progression or improvement of pulmonary issues. ^[45]

Such diligent monitoring is vital for detecting early signs of deterioration or improvement, allowing for timely adjustments in care plans. Healthcare providers need to be adept at interpreting these vital signs and sounds, as they are critical indicators of the patient's overall well-being and the effectiveness of ongoing treatment strategies.

Management of fluid and electrolyte imbalances

Managing fluid and electrolyte imbalances is crucial for patients on mechanical ventilation, particularly those with Acute Respiratory Distress Syndrome (ARDS).^[46], ^[47] Fluid retention is a common complication following 48 to 72 hours of Positive Pressure Ventilation (PPV), especially when Positive End-Expiratory Pressure (PEEP) is utilized. Early recognition of fluid and electrolyte imbalances is key, marked by changes in Central Venous Pressure (CVP), peripheral edema, pulmonary crackles, alterations in blood pressure, irregularities in pulse, and ECG changes. These indicators should prompt immediate communication with the attending intensivist for appropriate management.

In the context of fluid resuscitation, it's imperative to stay informed about current evidence and guidelines, adapting these recommendations to the evolving understanding of disease-specific characteristics, such as the prevalence of heart failure, volume overload, and circulatory failure among ventilated patients. This knowledge aids in tailoring fluid management strategies to optimize patient outcomes. ^[48], ^[49]

Achieving and maintaining specific perfusion targets is fundamental to the management of fluid and electrolyte imbalances. ^[50], ^[51] These targets include maintaining a Mean Arterial Pressure (MAP) greater than 65 mmHg, ensuring a urine output of more than 0.5 ml/kg/hr, achieving a capillary refill time of less than 3 seconds, and closely monitoring the level of consciousness. These parameters serve as critical indicators of adequate organ perfusion and fluid balance, guiding the adjustment of fluid therapy and electrolyte supplementation to support physiological stability and recovery in critically ill patients. ^[52], ^[53]

Administring medications as ordered

Administering medications accurately and safely is a cornerstone of care for patients undergoing mechanical ventilation, especially those diagnosed with Acute Respiratory Distress Syndrome (ARDS). The need for continuous delivery of medications such as analgesics, sedatives, and drugs for hemodynamic support necessitates the use of infusion devices, like syringe pumps or infusion pumps. For ARDS patients, the central venous line is often the preferred route for administration, as it facilitates the effective delivery of inotropes, Total Parenteral Nutrition (TPN), and other critical medications. Additionally, the central line enables precise monitoring of vital hemodynamic parameters, including Central Venous Pressure (CVP).

It is standard practice to provide prophylactic antibiotics and Proton Pump Inhibitors (PPIs), such as Pantoprazole, to patients on mechanical ventilation to prevent infections and stress ulcers, respectively. This approach underscores the importance of preventing complications that could exacerbate the patient's condition or lengthen the ICU stay.

A critical consideration in the care of ventilated patients is the use of neuromuscular blocking agents (paralytics).^[54] These agents should never be administered unless the patient is securely intubated and receiving mechanical ventilation. The rationale behind this guideline is to prevent the administration of paralyzing agents in the absence of adequate ventilation support, which could lead to catastrophic outcomes, including severe hypoxemia and even death. Additionally, when paralytics are used, it is imperative to concurrently administer sedatives. This practice ensures that while the patient is unable to move, they remain unaware and free from the distress of being conscious but immobilized. ^[55], ^[56], ^[57]

Rapid-sequence intubation (RSI) embodies the simultaneous administration of a sedative and a paralytic agent to facilitate emergency airway management, aiming to minimize the risk of aspiration and reduce potential injury to the patient.^[58] This technique highlights the critical balance between ensuring rapid and secure airway control while minimizing the risk of adverse events, reflecting the complex and nuanced care required for patients in critical conditions.

Care bundle for Ventilator-associated pneumonia

Implementing a care bundle for the prevention of Ventilator-associated pneumonia (VAP), which typically develops more than 48 hours after the initiation of mechanical ventilation, is a proven strategy.^[59], ^[60], ^[61] This bundle includes six critical elements, each to be evaluated daily. ^[62]

Head-of-Bed Elevation: Elevate the head of the bed to 30–45° to reduce aspiration risk, except when contraindicated.

Sedation Assessment: Daily assessment of sedation levels to ensure the patient is comfortable; reducing or pausing sedation as needed, using tools like RASS and CAM-ICU for evaluating agitation and sedation levels. ^[63], ^[64], ^[65], ^[66]

Oral Hygiene: Perform oral care using chlorhexidine gluconate (≥ 1–2% gel or liquid) or 1.5% hydrogen peroxide swab every 6 hours. Reposition the endotracheal tube every 24 hours to prevent oral lesions, marking the tube at the lip or teeth level for accurate placement. ^[67]

Subglottic Aspiration: For patients expected to be intubated longer than 72 hours, use a tracheal tube with a subglottic secretion drainage port, aspirating secretions 1- to 2-hourly.

Tube Cuff Pressure: Monitor cuff pressure every 4 hours, maintaining it at 20–30 cmH2O or 2 cmH2O above peak inspiratory pressure to prevent air leak and aspiration.

Stress Ulcer Prophylaxis: Administer stress ulcer prophylaxis according to standard protocols, focusing on high-risk patients.

Adhering to these guidelines can significantly reduce the incidence of VAP, enhancing patient outcomes during mechanical ventilation. ^[68], ^[69]

Positioning

While head elevation is generally recommended for patients on mechanical ventilation to reduce the risk of ventilator-associated complications, the prone position has been identified as particularly beneficial for certain COVID-19 patients with moderate to severe Acute Respiratory Distress Syndrome (ARDS), characterized by a P/F ratio of less than 20 kPa.^[50], ^[70], ^[71], ^[72] This positioning technique, which involves turning the patient onto their stomach, enhances oxygenation by promoting greater expansion of the lung's dorsal regions, thereby optimizing alveolar recruitment.

Evidence suggests that prone positioning, especially when integrated with lung-protective ventilation strategies and applied for at least 12 hours, can significantly improve patient outcomes, including reduced mortality rates. However, the success of prone positioning hinges on careful planning and execution. The use of a checklist during the proning process enhances the safety and efficacy of the maneuver, underscoring the importance of a well-informed and trained healthcare team.^[70]

Notably, prone positioning is not suitable for all patients, and a thorough risk-benefit assessment is essential before its implementation. Adequate staffing is critical to safely turn the patient and adjust their position, ensuring continuous airway protection and appropriate sedation levels. Special care must be taken to prevent complications such as brachial plexus injury, which can occur if the arms are excessively flexed during the process. Following are the steps involved in the proning,^[6]

Explain to the patient, with reassurance, that they will be safe and obtain consent if they can communicate. Close eyes and protect them with gel or pad.

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Place the patient's palms against their thighs, thumbs upwards, elbows straight and shoulders neutral.

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Slide the patient to the edge using a Sliding sheet.

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Roll the patient into the lateral position using the underneath sheet.

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Roll the patient into prone, 'Swimmers position' (position elbow, in which the head is semi-rotated should be flexed to no more than 90° to avoid ulnar nerve stretch, and the other arm internally rotated by the side).

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Ensure that women's breasts or men's genitals are not compressed. Place two pillows under each shin to prevent peroneal nerve stretch, positioning them to avoid knee and toe pressure from the mattress.

Suctioning Patient as indicated

Suctioning in ARDS patients requires a judicious approach, focusing on minimizing potential harm while ensuring patient airways are adequately maintained. Routine, non-indicated suctioning of the airway is discouraged due to the risks of bronchospasm and mechanical trauma to the tracheal mucosa. Instead, the need for suction should be assessed every 2 hours, with the procedure performed only if clinically indicated,^[73] utilizing an inline suction catheter to minimize exposure and contamination risks.

The instillation of normal saline into the airway prior to suctioning is not recommended, as it does not enhance secretion removal and may instead contribute to complications.^[74] Prior to suctioning, it's critical to pre-oxygenate the patient for at least 3 minutes using the ventilator's built-in hyperoxygenation feature, avoiding bag-mask ventilation to reduce aerosol generation. The suctioning process itself should be brief, not exceeding 10-15 seconds at a time, to mitigate the risks of hypoxemia. ^[75]

Performed correctly and cautiously, suctioning is a lifesaving intervention that can significantly reduce the risks of infection, secretion pooling, and prolonged hypoxia, leading to favourable outcomes for most patients. However, it's essential to avoid overly frequent or aggressive suctioning, as it may precipitate hypoxia and cause iatrogenic injuries to the airway.^[76] The suction pressure should ideally be maintained between 100-120 mm Hg, ensuring it does not surpass 120 mm Hg to prevent undue trauma and ensure the procedure's safety and efficacy.

Monitor for complications

Monitoring for complications is crucial in the management of patients on mechanical ventilation, especially those with ARDS, due to their susceptibility to a wide range of complications.^[77], ^[78] These can include, decreased clearance of secretions and ventilator-acquired pneumonia, Central Line Associated Blood Stream Infection (CLABSI), tracheal damage, laryngeal edema, Impaired gas exchange, Ineffective breathing pattern, ET tube kinking, cuff failure, mainstem intubation, Sinusitis, Pulmonary infection, biotrauma, Barotrauma (pneumothorax, tension pneumothorax, subcutaneous emphysema, pneumomediastinum), Decreased cardiac output, Atelectasis, Alteration in GI function (stress ulcers, gastric distention, paralytic ileus), Alteration in renal function, Alteration in cognitive-perceptual status.

Psychosocial spiritual nursing care

Psychosocial and spiritual care emphasizes continuous communication, addressing pain, agitation, and delirium, providing psychological support, aiding patients with artificial airways in communicating, and ensuring scheduled rest and sleep to support overall well-being.

Resuscitation in patients with Suspected and confirmed Covid-19 ARDS

For resuscitating patients with suspected or confirmed COVID-19, adhere to the AHA's Interim Guidance for Basic and Advanced Life Support in adults, children, and neonates (April 2020 update), ensuring safety and efficacy. ^[79]

Other care

For managing patients, especially with COVID-19 induced ARDS, adopt strategies like swollen lip care with ice for inflammation and preferring Metered Dose Inhalers (MDI) over nebulization to minimize aerosol generation.^[80], ^[81], ^[82] Address stress ulcers and gastrointestinal bleeding by administering H2 receptor blockers or Proton Pump Inhibitors (PPIs) and initiate early enteral nutrition within 24-48 hours of admission. Accommodate for potential anosmia by ensuring nutritional needs, including protein and vitamins, are met. Manage symptoms like nausea and loose stools. Exercise caution with aerosol-generating procedures, including oral care, suctioning, and respiratory interventions like intubation and bronchoscopy. Implement dialysis care for those with acute kidney injury (AKI) according to institutional protocols, highlighting a comprehensive approach to patient care amidst the challenges of COVID-19-induced ARDS.

Assist with the weaning process

Weaning from mechanical ventilation to spontaneous breathing involves a Spontaneous Breathing Trial (SBT) for patients ready to transition, lasting 30 to 120 minutes.^[83], ^[84], ^[85] Success is indicated by adequate pulmonary function parameters—tidal volume (VT), vital capacity (VC), and negative inspiratory pressure—demonstrating strong respiratory muscle capacity.^[86] The process includes gradually reducing the Synchronized Intermittent Mandatory Ventilation (SIMV) rate and pressure support until the patient can breathe independently, followed by transitioning to a T-piece or Continuous Positive Airway Pressure (CPAP) system. During extubation, especially in COVID-19 ARDS patients, avoid suctioning to prevent complications. Post-extubation, monitor for airway obstruction or respiratory insufficiency signs, including tracheal or laryngeal edema, hoarseness, or vocal cord paralysis, providing supplemental oxygen and humidification as needed. Emotional support is crucial as patients may feel anxious about breathing independently, requiring reassurance of their readiness and progress.