RESPIRATORY INTENSIVE CARE

RESPIRATORY INTENSIVE CARE

Dr Ludovico Trianni, Specialist in Phthisiology and Diseases of the Respiratory System, Anaesthesiology and Cardiopulmonary Resuscitation

The Respiratory Intensive Care Unit (RICU) is a section of the Pulmonology and Respiratory Rehabilitation departments; it consists of eight beds situated in a suitably well-lit and spacious environment equipped with centrally controlled systems for oxygen delivery, air-suction and air-conditioning.

Patients are usually referred to the RICU from the General Resuscitation departments; these patients (often with a tracheostomy) require constant monitoring and care aimed at complete weaning from a mechanical ventilator or at correcting a severe state of acute respiratory failure.

Diseases and Conditions Treated

Respiratory Intensive Care Units were born as "Areas for monitoring and treating patients suffering from acute respiratory failure (ARF) originally caused by respiratory disease and/or by acute exacerbation of chronic respiratory failure (CRF)". In these units, the monitoring techniques usually employed are prevalently noninvasive, and “noninvasive” ventilation is the preferred option.

Main goals

Respiratory Intensive Care Units aim to provide greater clinical control (constant monitoring of cardiovascular functions), ventilator support, if required, and most especially a greater level of nursing care. They are thus highly specialized facilities requiring highly qualified medical, nursing and rehabilitation personnel suitably trained to offer the patient, through a multidisciplinary approach, the prospect of recovering, even partially, their autonomy, and thereby containing management costs related to long-term stay in areas of general resuscitation.

Target patients are typically those suffering from chronic obstructive pulmonary disease (COPD) and chronic respiratory failure (CRF).

 

Individual Rehabilitation Plan

The Individual Rehabilitation Plan (IRP), developed by the physician in collaboration with the other professionals in the team (nurse, psychologist, rehabilitation therapist, nutritionist-dietician), combines the various components in a mutually enhancing way. It is patient-centred and, as such, is unique to each patient.

 

The IRP:

provides a comprehensive overview of the patient’s functional status and residual capacities, using, wherever possible, scales validated and/or recognized by scientific communities

defines the interventions which can help to achieve the set objectives, focussing on the various ascertained problems

■ involves regular assessment of the results achieved and verification of expected goals

■ is shared with the patient and, if possible, with the family

 

The main areas of IRP intervention are:

  • ComprehensiveDiagnostic Evaluation and Interdisciplinary Assessment
  • Treatment of ARF
  • Weaning from prolonged use of Mechanical Ventilation(MV)
  • Clinical Monitoring
  • Assessment and preparation of patients eligible for Home Mechanical Ventilation (HMV)
  • Medical and Nursing Care

 

Comprehensive Diagnostic Evaluation and Interdisciplinary Assessment

The comprehensive diagnostic evaluation, performed in the first days of hospitalization, analyses not only the clinical variables but also the psychological and social variables affecting the patient during this stage of the illness. The patient approach is developed by the interdisciplinary team which assesses the patient, following and observing their work and therapeutic outcomes.

 

Treatment of ARF

The main applications for effective use of noninvasive ventilation are the treatment of acute exacerbation in patients with COPD and certain clinical conditions characterized by refractory hypoxemia (such as acute pulmonary oedema or pneumonia). The goal is to avoid intubation of the airways and the consequent invasive management more typically used in resuscitation. This goal is achieved in 60-80% of treated cases.

Weaning from Mechanical Ventilation

Weaning from MV is a rehabilitation (i.e. functional recovery) process that takes place during the early stages following ARF and any subsequent intubation of the airways (also after NIV failure). The weaning plan is mainly for patients emerging from this kind of situation, most of whom have undergone a tracheostomy.

Patients who are typically eligible for this process are those with COPD; the goal is to permanently detach the individual from the ventilator and it is achieved in around 50-60% of cases where patients have been treated and survived. At the same time, a percentage of 15-30% of patients who have undergone this process can be defined as unweanable and are thus prepared for/started on Home Mechanical Ventilation (HMV).

Clinical Monitoring

Monitoring consists of constantly updating clinical and physiological (cardio-respiratory) parameters in order to provide an immediate understanding of the illness-related phenomena that can arise in patients at risk of ARF.

In the past, the concept of monitoring was mostly associated with the customary practice of a nurse observing vital signs; nowadays it is performed by technological observation (through sensors and monitors) of many different vital functions.

The goal of this activity is to prevent or predict aggravation, correct conditions of clinical instability and assess the effects of an intervention.

 

Assessment and preparation of patients eligible for Home Mechanical Ventilation (HMV)

When weaning fails, the patient who is unweaned or partially weaned from the ventilator receives preparation for the HMV plan. Those eligible for this course of action are neuromuscular patients (such as patients with myodystrophy) or kyphoscoliotic patients, as well as COPD patients with high clinical instability and/or who do not respond to oxygen therapy. The aim of this is to determine the indication and then prepare the patient for transition to home care or a care facility. During this stage it is crucial to promptly engage the patient and relatives living with them in an education programme that will enable them to gain familiarity with the techniques for home management of the ventilator.

Medical and Nursing Care

Nursing staff and care workers play an essential role in the implementation of the intervention plans developed for the patient and associated monitoring. The role of the medical staff is to ensure that the patient is given the most suitable therapy and that any deterioration or indication for emergency treatment will lead to prompt intervention.

 

Hospital Discharge and Continuum of Therapy and Care

On discharge from hospital, the team assesses the effectiveness of the interventions carried out and verifies whether planned goals have been attained, sharing the information with the patient and/or the patient’s family. Together they agree on the patient’s return home or on the need for a hospital discharge under a continuing care scheme. The doctor fills out the hospital discharge letter, setting down the outcomes of the tests and examinations performed, the recommended drug therapy, any examinations to be carried out at home and the indications that the patient will be required to follow.