Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 1 Emanuele Gouveia de Albuquerque https://orcid.org /0000-0001-9456-8382 Universidade Federal do Rio Grande do Norte, Brasil egouveiaufrn@yahoo.com.br Jéssica Naiara de Medeiros Araújo https://orcid.org /0000-0002-9115-3285 Universidade do Estado do Rio Grande do Norte, Brasil jessicanaiara@uern.br Amanda Barbosa da Silva https://orcid.org /0000-0002-5410-7060 Universidade Federal do Rio Grande do Norte, Brasil amanda.b.silva@animaeducacao.com.br Dase Luyza Barbosa de Sousa Alves https://orcid.org /0000-0003-0462-9220 Universidade Federal do Rio Grande do Norte, Brasil dase.alves@animaeducacao.com.br Barbara Ebilizarda Coutinho Borges https://orcid.org /0000-0001-6922-1475 Universidade Federal do Rio Grande do Norte, Brasil barbara.borges.099@ufrn.edu.br Allyne Fortes Vitor https://orcid.org /0000-0002-4672-2303 Universidade Federal do Rio Grande do Norte, Brasil allyne.vitor@ufrn.br Article Concept Analysis of the Nursing Diagnosis of Impaired Spontaneous Ventilation in Critical Patients Recibido: 15/09/2022 Enviado a pares: 25/11/2022 Aceptado por pares: 15/06/2023 Aprobado: 22/06/2023 DOI: 10.5294/aqui.2023.23.3.7 Para citar este artículo / To reference this article / Para citar este artigo Albuquerque EG, Araújo JNM, Silva AB, Alves DLBS, Borges BEC, Vitor AF. Concept analysis of the nursing diagnosis of impaired spontaneous ventilation in critical patients. Aquichán. 2023;23(3):e2337. DOI: https://doi.org/10.5294/aqui.2023.23.3.7 https://orcid.org/0000-0001-9456-8382 mailto:egouveiaufrn@yahoo.com.br https://orcid.org/0000-0002-9115-3285 mailto:jessicanaiara@uern.br https://orcid.org/0000-0002-5410-7060 mailto:amanda.b.silva@animaeducacao.com.br https://orcid.org/0000-0003-0462-9220 mailto:dase.alves@animaeducacao.com.br https://orcid.org/0000-0001-6922-1475 mailto:barbara.borges.099@ufrn.edu.br https://orcid.org/0000-0002-4672-2303 mailto:allyne.vitor@ufrn.br https://doi.org/10.5294/aqui.2023.23.3.7 https://doi.org/10.5294/aqui.2023.23.3.7 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.6&domain=pdf&date_stamp=2023-07-23 Theme: Epistemology Contribution to the discipline: Concept analyses are types of the- oretical studies that contribute to advances in nursing knowledge. Thus, this study enabled a better understanding of the Nursing Di- agnosis Impaired Spontaneous Ventilation in critically ill patients based on antecedents, critical and consequent attributes. Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 3 Abstract Introduction: In nursing practice, this concept has been identified in studies that address the nursing diagnosis of impaired spontaneous ventilation. Nursing performance facing this unwanted human re- sponse is considered essential for the maintenance and control of vital signs, cardiovascular monitoring, gas exchange and respiratory pat- tern, as well as constant surveillance aimed at signs of hypoventilation and inadequate ventilation. Objective: To analyze the concept of im- paired spontaneous ventilation in critically ill patients in an intensive care unit. Methodology: This study is a concept analysis, according to Walker’s and Avant’s method, conducted using an integrative review. All the referential steps were followed: concept selection, determin- ing the objectives and proposals for concept analysis, identifying the possible uses of the concept, determining the defining attributes, iden- tifying a model case, identifying a contrary case, and identifying the precedents and consequences of the concept. Results: A sample of 38 studies was selected. The following were identified as attributes: distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnormal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia and hypercapnia. An- tecedents: sex, age, oxygen saturation lower than 90%, diseases of the respiratory, cardiovascular, neurological, gastrointestinal, neuromus- cular, and metabolic systems, respiratory infections, trauma, poisons, toxins, and sedatives. Consequences: increased heart rate, decreased partial oxygen saturation, increased use of respiratory muscles, dys- pnea, increased metabolic rate and restlessness. The model case and the contrary case were used to illustrate the attributes, antecedents, and consequences. Conclusion: The study directed the strengthening of evidence about the phenomenon and demonstrated a strong occur- rence in patients who need assistance in intensive care units, thus de- manding critical care. Keywords (Fonte: DeCS) Pulmonary ventilation; respiratory failure; intensive care units; nursing; nursing diagnoses. 4 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 Resumen Introducción: en la práctica de enfermería, este concepto fue iden- tificado en estudios que abordan el diagnóstico de la ventilación es- pontánea deteriorada. La actuación desde enfermería para enfrentar esta indeseada respuesta humana es esencial para el mantenimiento y el control de los signos vitales, el monitoreo cardiovascular, el in- tercambio de gases y el patrón de respiración, así como para la vig- ilancia constante de los signos de hipoventilación y ventilación ina- decuada. Objetivo: analizar el concepto de ventilación espontánea deteriorada en pacientes críticos en una unidad de cuidado inten- sivo. Metodología: Este estudio es un análisis de concepto, de acuer- do con el método de Walker y Avant, conducido usando una revisión integrada. Se siguieron todos los pasos referenciales: selección del concepto, determinación de los objetivos y propuestas para el análi- sis de conceptos, identificación de los posibles usos del concepto, determinar los atributos definitorios, identificación del caso modelo, identificación del caso contrario e identificación de precedentes y consecuencias del concepto. Resultados: se seleccionó una mues- tra de 38 estudios. Se identificaron como atributos: angustia y fatiga, dificultad respiratoria, taquicardia, inestabilidad hemodinámica, es- tado mental alterado, gasometría arterial anormal, disnea, ansiedad, agitación, sudoración, hipoxemia e hipercapnia. Antecedentes: sexo; edad; saturación de oxígeno inferior al 90%; enfermedades de los sistemas respiratorio, cardiovascular, neurológico, gastrointestinal, neuromuscular y metabólico; infecciones respiratorias; traumatis- mos, y venenos, toxinas y sedantes. Consecuencias: aumento del ritmo cardíaco, disminución de la saturación parcial de oxígeno, au- mento del uso de los músculos respiratorios, disnea, aumento del índice metabólico e inquietud. Se utilizaron el caso modelo y el caso contrario para ilustrar los atributos, antecedentes y consecuencias. Conclusión: el estudio dirigió el fortalecimiento de la evidencia so- bre el fenómeno y demostró una fuerte ocurrencia en pacientes que necesitan asistencia en unidades de cuidados intensivos, quienes re- quieren, en consecuencia, de cuidados críticos. Palabras clave (Fuente: DeCS) Ventilación pulmonar; falla respiratoria; unidad de cuidados intensivos; enfermería; diagnósticos de enfermería. Análisis de concepto del diagnóstico de la ventilación espontánea deteriorada en pacientes críticos Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 5 Análise conceitual do diagnóstico de ventilação espontânea prejudicada em pacientes críticos Resumo Introdução: na prática da enfermagem, esse conceito foi identificado em estudos que abordaram o diagnóstico de ventilação espontânea prejudicada. A atuação da enfermagem para enfrentar essa resposta humana indesejável é essencial para a manutenção e o controle dos sinais vitais, da monitorização cardiovascular, das trocas gasosas e do padrão respiratório, bem como para a vigilância constante dos si- nais de hipoventilação e ventilação inadequada. Objetivo: analisar o conceito de ventilação espontânea prejudicada em pacientes graves internados em uma unidade de terapia intensiva. Materiais e mé- todo: este estudo é uma análise conceitual, de acordo com o méto- do de Walker e Avant, realizada por meio de uma revisão integrada. Todas as etapas referenciais foram seguidas: seleção do conceito, determinação dos objetivos e proposições para a análise do concei- to, identificação dos possíveis usos do conceito, determinação dos atributos definidores, identificação do caso-modelo, identificação do contracaso e identificação dos precedentes e consequências do conceito. Resultados: foi selecionada uma amostra de 38 estudos. Os atributos identificados foram angústia e fadiga, angústia respi- ratória, taquicardia, instabilidade hemodinâmica, estado mental alterado, gases sanguíneos arteriais anormais, dispneia, ansiedade, agitação, sudorese, hipoxemia e hipercapnia. Antecedentes: sexo; idade; saturação de oxigênio inferior a 90%; doenças dos sistemas respiratório, cardiovascular, neurológico, gastrointestinal, neuro- muscular e metabólico; infecções respiratórias; trauma; e venenos, toxinas e sedativos. Consequências: aumento da frequência car- díaca, diminuição da saturação parcial de oxigênio, aumento do uso dos músculos respiratórios, dispneia, aumento da taxa metabólica e inquietação. O caso-modelo e o caso oposto foram usados para ilustrar os atributos, os antecedentes e as consequências. Conclu- sões: o estudo teve como objetivo fortalecer as evidências sobre o fenômeno e demonstrou uma forte ocorrência em pacientes que necessitam de assistência em unidades de terapia intensiva e que, consequentemente, requerem cuidados críticos. Palavras-chave (Fonte DeCS) Ventilação pulmonar; insuficiência respiratória; unidade de terapia intensiva; enfermagem; diagnósticos de enfermagem. 6 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 Introduction This research has as its object of study the analysis of the concept of Impaired Spontaneous Ventilation (ISV). In nursing practice, this concept has been identified in studies that address the nursing di- agnosis of impaired spontaneous ventilation, often attributed in clinical practice to patients with a higher level of severity, who are usually assisted in intensive care units and using invasive mechani- cal ventilation (1). The nursing diagnosis (ND) of ISV was added to the taxonomy “NANDA-International Nursing Diagnoses” in 1992, in domain 4, “activity/rest,” and is defined as the “Inability to initiate and/or main- tain independent breathing that is adequate to support life” (2). As a clinical condition that predisposes to ISV, acute respirato- ry failure (ARF) stands out as the main indication for mechanical ventilation. Nursing performance facing this unwanted human response is considered essential for the maintenance and control of vital signs, cardiovascular monitoring, gas exchange and respi- ratory pattern, as well as constant surveillance aimed at signs of hypoventilation and inadequate ventilation, in addition to assess- ing the level of anxiety (3). Therefore, it requires from the nurses, scientific knowledge and sufficient skills for decision-making, from the theoretical-conceptual level to the management of this clinical condition through critical reasoning. Nursing care for patients with ISV in a scenario where there is indis- putably a demand for the implementation of Resolution 358/2009, must be based on the nursing process (NP), a working instrument for nurses that materializes the Systematization of Nursing Care. The use of standardized language systems, such as NANDA-I in the NP, contributes to standardizing the knowledge of the profession, in addition to bringing legitimacy to nursing records (4). Taxonomy II proposed by NANDA-I classifies nursing diagnoses (ND) and guides nurses in clinical decision-making. In the current edition, NANDA-I points out the need to review ND with more recent scientif- ic investigations to raise the level of evidence (LOE) of some diagno- ses present in the taxonomy. For the ND of ISV (00333), there is a need for studies so that it remains in the next edition of the NANDA-I (2). Linked to this, it appears that the diagnosis is regularly inferred in adult patients and several units of the health service, particularly in the intensive care unit. However, there are still gaps in the literature regarding studies focused on this diagnosis. Therefore, it is import- ant to note the diagnosis’s present definition and clinical indicators are still little explored, without contemplating broader and clearer aspects of the individual’s needs. In this perspective, regarding the respiratory function assessment scenario, accurately defining a ND becomes a potential confounder Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 7 due to the existence of several diagnoses with similar character- istics. Therefore, questions converge by relating groups of similar clinical manifestations, related to the same defining character- istics and used in a similar context (1, 2). With that, it becomes essential to favor a precise and accurate evaluation in the recog- nition of the phenomenon as impaired spontaneous ventilation. Thus, understanding concepts that are closely related to nurs- ing practice is necessary to minimize doubts when choosing be- tween one or more diagnoses (2). Because of this and based on the homonymous ND present in NANDA-I, the study aimed to analyze the concept of Impaired Spontaneous Ventilation in pa- tients in the context of an intensive care unit. Methodology This is a concept analysis based on the framework proposed by Walker and Avant (5) and for theoretical composition, an inte- grative literature review was carried out (6). The model chosen as analysis is justified by clarifying ambiguities and clarifying important concepts, with the expectation of favoring the de- velopment of nursing. In addition, the approach comprises the concept with characteristics and attributes capable of defining the corresponding phenomenon. Therefore, it enables the ex- pression of attributes frequently related to the concept, which will allow the researcher to have a broad view of the elements that compose it (5). The ISV concept was chosen to investigate it as an undesirable human response in nursing. Therefore, the decision to study it was based on the researchers’ recognition of clinical practice and previous research, mainly based on previous readings and previous experiences in studies focused on critical care, inten- sive care unit and nursing diagnoses. Thus, it represents a phe- nomenon that demands precise investigation and clarification of the knowledge produced. To this end, this framework suggests the selection of a concept that highlights the researchers’ great- est interest while at the same time approaching their needs (5). The analytical model proposed by Walker and Avant analyzes the concept in eight steps. The first one is the selection of the concept; it should reflect the area of greatest interest to the re- searcher. In the present study, the area of interest was the ND of ISV. The second step is the objective of the analysis, which aims to answer the question of why the analysis will be performed (5). Thus, this study aims to analyze the conceptual core of the ND of ISV. In the third stage, which is the identification of the use of the concept, it is recommended to use all available literature to verify the possibilities of identifying the different attributes of the con- cept (5). In this way, the use of the ISV concept. The fourth step is determining the attributes, which are the characteristics that will determine the presence of the concept (5). Thus, the attributes 8 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 that define the ND of ISV. The fifth one is the identification of a mod- el case, which is an example of using the concept that demonstrates all its attributes or defining characteristics (5). The sixth step is the identification of a contrary case and consists of clear examples that do not represent the concept (5). The seventh step is the identifi- cation of the antecedents and consequences of the phenomenon, which are the events commonly occurring before the identification of the phenomenon and all those events or occurrences that arise as a result of the phenomenon, respectively (5). The eighth step is the definition of empirical references, that is, the empirical references for the attributes, which constitute categories of real phenomena that demonstrate the occurrence of the concept (5). Despite the reference proposing the identification of borderline, re- lated, invented and illegitimate cases, in this study, only the model case and the opposite case were used, as these are believed to be sufficient to clarify the concept. Regarding the integrative literature review, the recommended stages were followed for the systemati- zation of the knowledge produced and available in electronic sourc- es of data on ISV. The stages were the identification of research questions, literature search, data assessment, analysis of results and presentation of the review. The following research questions were elaborated: What are the definitions of ISV? What are the uses of ISV? What are the attributes of the concept of ISV? What are the anteced- ents and consequences of the concept of ISV? What are the empirical references of ISV? The selection of studies was conducted respecting the eligibility cri- teria according to Table 1. It is noteworthy that a time frame was not included for the research to identify the largest number of publica- tions related to the subject under study. Table 1. Eligibility criteria. Natal, RN, Brazil, 2021 INCLUSION EXCLUSION Full articles available in the databases Editorials, abstracts, letters to the editor, reviews, previous notes, and expert opinions. Articles in Portuguese, English or Spanish Articles addressing the theme and objectives of the study, including bibliographic reviews, guidelines, and book chapters. Source: Prepared by the authors. The search was performed from March to September 2021 by a pair of researchers at the same time, using the same internet network and on different machines, in eight data sources: SciELO, Science- Direct, PubMed (MEDLINE), Cochrane, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Virtual Health Library, accessed through the portal of the Co- Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 9 ordination for the Improvement of Higher Education Personnel (CAPES). The following descriptors indexed in the MeSH (Medi- cal Subject Headings) and DeCS (Descriptors in Health Sciences) in Portuguese, English, and Spanish were used: “Pulmonary ven- tilation”, “Respiratory failure” and “Artificial respiration”, using the four crossings: (Ventilação pulmonar OR Pulmonary venti- lation OR Ventilación pulmonar) AND (Insuficiência respiratória OR Respiratory insufficiency OR Insuficiencia respiratoria) AND (Respiração Artificial OR Respiration, Artificial OR Respiración Artificial); (Ventilação pulmonar OR Pulmonary ventilation OR Ventilación pulmonar) AND (Insuficiência respiratória OR Re- spiratory insufficiency OR Insuficiencia respiratoria); (Ventilação pulmonar OR Pulmonary ventilation OR Ventilación pulmonar) AND (Respiração Artificial OR Respiration, Artificial OR Respira- ción Artificial); (Insuficiência respiratória OR Respiratory insuffi- ciency OR Insuficiencia respiratória) AND (Respiração Artificial OR Respiration, Artificial OR Respiración Artificial). After these crossings, other new crossings were conducted to collect more data that could reach the greatest possible number of studies focused on nursing. The following descriptors indexed in MeSH (Medical Subject Headings) and DeCS (Descriptors in Health Sciences), in Portuguese, English and Spanish were used: “Pulmonary ventilation”, “Intensive care units”, “Nursing diag- noses” and “Nursing”, using the three crossings: (Ventilação pulmonar OR Pulmonary ventilation OR Ventilación pulmonar) AND (unidades de terapia intensiva OR Intensive Care Units OR Unidades de Cuidados Intensivo) AND (diagnósticos de enfer- magem OR Nursing Diagnosis OR Diagnóstico de Enfermería) AND (Enfermagem OR Nursing OR Enfermería); (Ventilação pulmonar OR Pulmonary ventilation OR Ventilación pulmonar) AND (unidades de terapia intensiva OR Intensive Care Units OR Unidades de Cuidados Intensivo) AND (diagnósticos de enfer- magem OR Nursing Diagnosis OR Diagnóstico de Enfermería); (Ventilação pulmonar OR Pulmonary ventilation OR Ventilación pulmonar) AND (diagnósticos de enfermagem OR Nursing Di- agnosis OR Diagnóstico de Enfermería) AND (Enfermagem OR Nursing OR Enfermería). A total of 26,014 titles were found in the databases. Considering the inclusion criteria, 1,773 titles were read and selected for the second stage. Of these articles, 1,651 were excluded (1,629 did not meet the inclusion criteria and 22 were duplicated), totaling 122 publications for full reading. The final sample was composed of 38 studies (Figure 1). After obtaining the sample, data extraction began using two in- struments: a worksheet containing items related to concept anal- ysis (uses, definitions, attributes, antecedents, consequents, and empirical references) and other items that made it possible to the characterization of the studies (title, authors, year, journal in which the study was published, country of origin, and method). 10 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 Each sample study was read in detail to extract the elements ad- dressed in the cited instruments, which were recorded on cards. For each study in the sample, a characterization form of the studies was prepared with the elements recommended for the concept analysis and, finally, the final analysis was carried out to compile the results. This study was conducted in public domain databases, which do not require submission to a Research Ethics Committee. Figure 1. Flowchart of the Literature Search and Article Selection According to the PRISMA-ScR Guidelines. Natal- RN, Brazil, 2021 Source: Prepared by the authors. Results The sample comprises 38 studies. Among the different countries identified in the sample, the United States of America (USA) stands out with seven articles (18,4%). Other countries were identified, namely: Brazil, the United Kingdom, Denmark, Canada, Taiwan, France, China, Tunisia, Spain, The Netherlands, India, Austria, Tur- key, England, Sweden, Italy, Egypt, and Mexico. As for the year of publication, the articles date from 1987 to 2020. Of these articles, 26 (68,4%) were published in the last 10 years (2011-2020), indicating greater interest in the subject in the last decade. Regarding the method used by the studies comprising the final sample, observa- tional studies stand out, totaling 22 articles (57,9%), as in Table 2. Studies identi�ed in the data sources (n=26,014). Studies selected by title and abstract (n=1,773) Studies excluded due to duplication (n=22) Studies excluded due to exclusion criteria (n=1,629) Studies excluded due to exclusion criteria (n=84) Studies selected for full reading: (n=122) Studies selected to compose the sample: (n=38) Id en ti � ca ti o n Sc re en in g El ig ib ili ty Se le ct io n Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 11 Table 2. Characterization of Studies According to Authors, Year of Publication, Journal, Country, and Method. Natal, RN, Brazil, 2021 AUTHORS YEAR JOURNAL COUNTRY OF ORIGIN METHOD Perkins GD et al. (7) 2018 JAMA United Kingdom Randomized clinical trial Diaz-Abad M, Brown JE (8) 2014 J Bras Pneumol USA Case report Antonio ACP et al. (9) 2017 Rev Bras Ter Intensiva Brazil Comparative clinical trial Girault C et al. (10) 2011 Am J Respir Crit Care Med Tunisia Randomized multicenter trial Ferreira JC et al. (11) 2017 BMC Pulm Med Brazil Randomized crossover trial Hennus MP et al. (12) 2013 PLoS ONE The Netherlands Case control study Teixeira SN et al. (13) 2015 Respir Care Brazil Prospective randomized, unblinded, controlled trial Figueroa-casas JB et al. (14) 2010 Respir Care USA Prospective randomized controlled study Raurich JM et al. (15) 2008 Respir Care Spain Prospective controlled study Mokhlesi B et al. (16) 2007 Respir Care USA Prospective observational cohort study Gnanapandithana K et al. (17) 2011 Rev Por Pneumologia India Randomized study Putensen C et al. (18) 2001 Am J Respir Crit Care Med Austria Randomized prospective study Ely EW et al. (19) 1996 N Engl J Med. USA Randomized and controlled trial Deslisle S et al. (20) 2011 Respir Care Canada Prospective study Andrade LZC et al. (21) 2012 Acta paul. enferm Brazil Observational study Campbell ML (22) 2018 Am J Crit Care USA Observational study Storm DS, Baumgartner RG (23) 1987 Int J Nurs Stud USA Case study Sørensen D et al. (24) 2013 Int J Nurs Stud Denmark Observational study Sørensen D et al. (25) 2013 Intensive Crit Care Nurs Denmark Qualitative descriptive observational study Manfredini GMSG, Machado RG, Mantovani R (26) 2013 Journal of Nursing UFPE Brazil Study quantitative, exploratory, descriptive Pertab D (27) 2009 Br J Nurs United Kingdom Simple review 12 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 AUTHORS YEAR JOURNAL COUNTRY OF ORIGIN METHOD Yücel ŞÇ et al. (28) 2011 Int J Nurs Pract Turkey Descriptive observational study Pattison N, Watson J (29) 2009 Nurs Crit Care United Kingdom Case study Cools F, Offringa M (30) 2000 Cochrane Database Syst Rev USA Systematic review Greenough A et al. (31) 2008 Cochrane Database Syst Rev England Systematic review Prado PR, Bettencourt ARC, Lopes JL (32) 2019 Rev. Latino-Am. Enfermagem Brazil Observational study Hsu JC et al. (33) 2013 Biomed Eng Online Taiwan Randomized controlled clinical trial Kauppi W et al. (34) 2020 BMC Emerg Med Sweden Retrospective observational study Jellington MO et al. (35) 2016 BMC Nurs Denmark Observational study Tonnelier JM et al. (36) 2005 Crit Care France Prospective study Li W et al. (37) 2016 Exp Ther Med China Retrospective study Yanga L et al. (38) 2019 Medicine China Retrospective study Vitacca M et al. (39) 2014 Respir Care Italy Observational cohort study Rose L, Gerdtz MF (40) 2009 J Clin Nurs Canada Integrative review Belveyre T, Auchet T, Levy B (41) 2019 Respir Med Case Rep France Case report Mohammed H, Abdelatief D (42) 2016 Egyptian Journal of Chest Diseases and Tuberculosis Egypt Simple review Liang YR et al. (43) 2020 Asian Nurs Res (Korean Soc Nurs Sci) Taiwan Prospective study Hernández-Hernández G, Reynoso-García JG (44) 2019 Enferm univ Mexico Case study Source: Prepared by the authors. By analyzing the articles, it was possible to identify the components of the concept, as described below. Identification of Uses of the Concept The main definitions of ISV according to the literature. The defi- nitions, authors, research source and context of use are shown in Table 3. Most definitions were used in the context of mechanically ventilated patients. Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 13 Table 3. Summary of the Main Definitions of ISV According to the Literature. Natal, RN, Brazil, 2021 DEFINITIONS AUTHORS RESEARCH SOURCE CONTEXT OF USE “Failure of the spontaneous breathing trial that makes it difficult to wean from invasive mechanical ventilation” Perkins GD et al. (7) CINAHL Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed. “Inability to tolerate an attempt at spontaneous breathing showing signs of respiratory distress (respiratory rate above 35 breaths per minute, arterial oxyhemoglobin saturation less than 90%, use of accessory respiratory muscles or paradoxical thoracoabdominal ventilation), tachycardia (heart rate > 140 beats per minute), hemodynamic instability (systolic blood pressure < 90 mmHg or 20% above baseline levels) or altered mental status (drowsiness, coma and anxiety)” Antonio ACP et al. (9) Virtual Health Library Adults eligible for mechanical ventilation liberation. “Inability to sustain pulmonary function and protect the airway” Deslisle S et al. (20) Scopus Mechanically ventilated patients recovering from a respiratory failure of various causes. “Inability to initiate and/or maintain adequate independent breathing to support life” Herdman TH, Kamitsuru S, Lopes CT (2) Book Definition of the nursing diagnosis ISV (NANDA- International). Source: Prepared by the authors. Therefore, the synthesis of the definition for ISV can be under- stood as “an inability to maintain spontaneous breathing and sustain pulmonary function to protect the airway.” Identification of Empirical References The Spontaneous Breathing Trial (SBT), Respiratory Distress Observation Scale (RDOS), and arterial blood gas were selected according to the possibility of demonstrating the occurrence of ISV. The latter two are empirical references capable of applica- tion by nurses, which will be described below. 14 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 Spontaneous Breathing Trial (SBT) The spontaneous breathing trial consists of the use of a T-piece by the patient, in which the patient is disconnected from mechanical ventilation, and can be connected to supplemental oxygen, lasting from 30 to 120 minutes. The patient is observed for signs of intol- erance to the trial, such as tachypnea, tachycardia, agitation, or di- aphoresis. If these signals are present during the previously men- tioned time interval of two minutes, the test result is faulty. SBT can also be performed with low levels of pressure support (5 to 7cm- H2O), use of CPAP, Proportional Assisted Ventilation (PAV) and ATC (Automatic Tube Compensation) mode. Although clinical decisions related to the weaning process from me- chanical ventilation are taken by the medical professional, in UK coun- tries, for example, the initiation of SBT and its respective monitoring are performed by nurses together with the respiratory therapist (19). Respiratory Distress Observation Scale (RDOS) The RDOS is an ordinal scale used to measure the respiratory diffi- culty of critically ill or near-death adult patients who are unable to self-report dyspnea, being widely used in patients who are in the intensive care unit (ICU). It consists of 8 items, where each variable is scored from 0 to 2 points, at the end the points are added, and may range from 0 to 16. The scale scores range from 0 to 2, which suggests the absence of respiratory distress, a score of 3 indicates mild distress, a score of 4 to 6 suggests moderate distress, and a score of 7 or more indicates a severe level of distress (22). Arterial Blood Gas Arterial blood gas is constantly used in ICU and emergency depart- ments to check the patient’s respiratory status. Nurses, in turn, are directly related to obtaining and analyzing the results of arte- rial blood gas, and it is essential that nurses working in the ICU are aware of the interpretation to identify ventilation disorders and avoid inappropriate treatments (42). Critical Attributes The attributes found were distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnor- mal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia, and hypercapnia. Distress and Fatigue They are characterized by physiological changes [signs of respirato- ry distress, tidal volume (L) greater than 105 min-¹1-¹, hemodynamic Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 15 instability, tachycardia and cardiac arrhythmias], clinical chang- es (anxiety, depressed mental state, sweating, cyanosis and in- creased respiratory effort – dyspnea, facial expression of distress and use of accessory muscles) and arterial blood gases (partial oxygen less than 8 kPa, FiO2 greater than 0.5 or partial oxygen saturation less than 90%, partial carbon dioxide greater than 6.5 kPa or an increase greater than 1kPa and pH less than 7.32) (7). Respiratory Distress The signs of respiratory distress are respiratory rate above 35 breaths per minute, arterial oxyhemoglobin saturation below 90%, use of accessory respiratory muscles or paradoxical thora- coabdominal ventilation (9). Tachycardia It is characterized as >140 heartbeats per minute (9). Hemodynamic Instability It occurs when systolic blood pressure is less than 90 mmH or 20% above baseline levels (9). Altered Mental Status It is characterized by drowsiness, coma, and anxiety (9). Abnormal Arterial Blood Gas Results It is characterized as abnormal when there are changes in the standardized values for gas exchange, ventilatory disorders and acid-base balance in arterial blood (42). Dyspnea It is characterized by a subjective experience of respiratory dis- tress that presents itself in different sensations and may vary in intensity (22). The other attributes found were anxiety (9, 13, 15, 16, 19, 25, 29), agitation (10, 13, 15, 16, 17), sweating (10, 13, 15), hy- poxemia (11, 27), and hypercapnia (37). Antecedents and Consequences Antecedents Intrinsic factors are male sex and mean age of 53.3 years (old- er age: 71 years; younger age: 90 days), oxygen saturation lower than 90% (16), acute or chronic hypercapnic respiratory failure 16 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 (10) of different etiologies, being more common Chronic Obstruc- tive Pulmonary Disease and Acute Respiratory Distress Syndrome (9, 14, 10, 17, 13). Other comorbidities or clinical conditions predispose the emer- gence of ISV, such as amyotrophic lateral sclerosis (8); congestive heart failure with an ejection fraction less than 45%, left ventricu- lar diastolic dysfunction, kidney replacement therapy, ascites (9); respiratory syncytial virus with infection in the lower respiratory tract (12); head trauma, obesity (13), multiple traumas, neurological urgency (14); imbalance between ventilatory demand and work ca- pacity and work endurance(15); neuromuscular disorders, poisons and toxins (17); use of sedatives such as sufentanil and midazolam (18); pneumonia, gastrointestinal tract diseases, cancer, overdose or ketoacidosis (19); tachypnea, hypertension and hypercapnia (20). Consequences This analysis found some implications, namely: increased heart rate (7, 9, 13, 14, 18), decreased partial oxygen saturation (9, 13, 18), in- creased use of respiratory muscles (9, 18), dyspnea (7), increased metabolic rate (14, 18) and agitation (14). It should be noted that these consequences are in line with the defining characteristics of the ISV diagnosis present in the NANDA-I diagnostics taxonomy (2). Identification of a Model Case and a Contrary Case For this stage, the following fictitious case was constructed: Model case Mr. José, 53 years old, was admitted to the ICU due to respiratory failure. During hospitalization, he had oxygen saturation <90% and was unable to sustain breathing spontaneously, requiring invasive mechanical ventilation. After a week in the ICU, he was screened to perform the SBT but was unsuccessful. At the time of the trial, he presented sweating, agitation, tachycardia, use of accessory mus- cles and dyspnea. He returned to MV, but even so, he developed severe hypoxemia with respiratory acidosis. Contrary Case Lúcia, 25 years old, presented cough, afternoon fever, night sweats, tiredness and fatigue for more than 15 days. She went to the family health unit in her neighborhood and the nurse requested a smear. The examination detected the presence of Koch’s bacillus and Lúcia was referred to a medical consultation to continue the treatment and start the use of tuberculostatic drugs. Despite her tiredness and fatigue, Lúcia was able to breathe spontaneously in ambient oxy- Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 17 gen, saturating at 96% and does not require hospitalization. Her follow-up occurs on an outpatient basis with medical consulta- tions and through home visits by nurses. Discussion The advancement of knowledge on the subject allowed us to identify a strong trend in research on the phenomenon, with emphasis on the last ten years. It is believed that in the current health context, where there is a predominance of diseases with patterns of respiratory tract involvement, the ND of ISV tends to be frequently attributed to patients, which makes it necessary to clarify the concept. The need for clarification regarding the di- agnostic concept of ISV was pointed out by a study that showed this conceptual core caused confusion when confronted with another ND, which could compromise diagnostic accuracy (1). The selected studies identified that the phenomenon of ISV has been strongly associated with critical environments as a care context, especially in patients using MV. This finding corrobo- rates a study that showed that nurses commonly infer the ND of ISV in patients using MV in the ICU (4-1). Added to these consid- erations, factors such as agitation, dyspnea, hypoxemia, irritabil- ity, decreased cooperation, increased heart rate and decreased partial pressure of oxygen and increased use of accessory mus- cles are commonly identified in patients with ISV (21). In addition, patients undergoing deep sedation for surgical procedures may present ISV (45). The literature points to empirical references of ISV that can be measured by other health professionals, in addition to nurses. Among them is pulmonary ultrasound, which can be used during spontaneous breathing attempts to check for impediments to suc- cessful extubation. This imaging method is based on the interpre- tation of artifacts, that is elements resulting from the interaction between air and fluids in the lungs, such as the loss of pulmonary aeration (9). Also noteworthy is the daily screening to assess me- chanical ventilator parameters, cough reflex and use of sedatives and vasopressors. And it can be used together and in a stage pri- or to SBT (19). As in the current health pandemic scenario caused by COVID-19, the role of nurses in critical patients with ISV is essential. This is be- cause the virus named SARS-CoV-2 is responsible for causing acute respiratory distress syndrome (ARDS) in about 70% of patients ad- mitted to the ICU. In addition, among those requiring invasive me- chanical ventilation, there are records of a 97% mortality rate, and of these deaths, 53% are caused by respiratory failure (46). The role of nursing becomes essential for patients who develop ISV. Nurses are responsible for identifying health/disease situa- tions, implementing results, interventions and nursing care (47). 18 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 For the ISV ND contained in NANDA-I, the Nursing Outcomes Clas- sification (NOC) suggests some of the following nursing outcomes: response to mechanical ventilation in adults (alveolar changes and tissue perfusion are expected to be effectively served by the MV); response to weaning from mechanical ventilation in adults (it is ex- pected that there will be a respiratory and psychological adaptation to weaning from mechanical ventilation); drug response (the ther- apeutic effects of prescribed drugs are expected to be achieved); prevention of aspiration (intended to prevent the passage of liquids and solid particles to the lung); pulmonary tissue perfusion (ade- quate blood flow through the pulmonary vasculature must be main- tained to perfuse alveoli/capillary unit); state of psycho-spiritual comfort; and cardiopulmonary status (adequacy of the volume of blood ejected from the ventricles and exchange of carbon dioxide and oxygen at the alveolar level is expected (48). In addition, incorporating the stages of the NP, the sixth edition of the Classification of Nursing Interventions (NIC) brings as interventions for the ISV ND, which can be performed by nurses: medication ad- ministration, emotional support, aspiration of the airways, assistance ventilation, control of invasive and non-invasive mechanical ventila- tion, control of artificial airways and respiratory monitoring (49). Furthermore, the research favors the strengthening of the level of ev- idence of the nursing diagnosis based on the analysis of the concept, and thus allows the solidification of knowledge, presenting the repre- sentativeness of its components, constituting higher and desired lev- els of scientific evidence to promote its permanence in the taxonomy. For this reason, it facilitates the standardization of language among nursing professionals, based on communication and decision- making through the development of taxonomies with the precise and accurate recognition of this human response. Thus, it promotes a solidified classification arrangement, based on evidence, and with conceptual organization resulting from continuous evaluation, clar- ification and refinement, essential aspects for promoting the con- solidation of the nursing process. Conclusion The study found, as essential attributes for the occurrence of the phenomenon, distress and fatigue, respiratory distress, tachycar- dia, hemodynamic instability, altered mental status, abnormal arte- rial blood gas results, dyspnea, anxiety, agitation, sweating, hypox- emia and hypercapnia. The definition identified for the concept specifies the understand- ing of the phenomenon since the analysis reveals the relevance and emphasis of a harmful and disabling condition, which can be avoided through accessible nursing interventions. Thus, understanding this human response represents progress in its study by defining and synthesizing ISV in a typical and predisposed scenario. Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 19 This analysis of the concept of ISV provided the strengthening of evidence about a phenomenon commonly identified in nursing care practice that is little debated regarding the diagnostic con- cept. The antecedents found through the integrative literature review indicate that ISV is not uni-causal and can be triggered by critical and varied pathological processes. Based on the consequences, it is evident that this phenome- non can trigger long periods of hospitalization in critical envi- ronments for the patients, requiring a technological apparatus to maintain life and respiratory function. In addition, this study will strengthen the level of evidence and the feedback of nursing theory and practice, as it allows the recognition of the phenom- enon in clinical practice, through the identification of its attri- butes, antecedents, consequences and empirical references. Furthermore, it allows the standardization of language, by pro- viding the enrichment of nursing taxonomies, facilitating com- munication and decision-making. In this way, it also contributes to the consolidation of the nursing process. Therefore, it is sug- gested the continuity of studies on the subject with research that can understand the phenomenon in the context of the clini- cal practice of nurses in different research designs. As a limitation of the study, the integrative review method cho- sen to operationalize the concept analysis stands out, since the information was restricted to what was in the data sources and published in the previously selected languages. Another limita- tion found refers to the methodological quality of the selected studies, because to cover the maximum amount of information about the selected concept, studies with lower scientific evi- dence were admitted, such as case reports. Conflict of interest: None declared References 1. Seganfredo DH, Beltrão BA , Silva VM, Lopes MVO, Castro SMJ, Almeida MA . Analysis of ineffective breathing pattern and im- paired spontaneous ventilation of adults with oxygen therapy. Rev. Latino-Am Enfermagem. 2017; 25:e2954. DOI: https://doi. org /10.1590/1518-8345.1950.2954 2. Herdman TH, Kamitsuru S, Lopes CT. Diagnósticos de enferma- gem da NANDA-I: definições e classificação 2021-2023. 12a ed. Porto Alegre: Artmed; 2021. 568 p. 3. Debone MC, Pedruncci E da SN, Candido M do CP, Marques S, Kusumota L. Nursing diagnosis in older adults with chronic kid- ney disease on hemodialysis. Rev Bras Enferm. 2017;70(4):800- 805. DOI: https://doi.org /10.1590/0034-7167-2017-0117 4. Canto DF, Almeida MA . Resultados de enfermagem para padrão respiratório ineficaz e ventilação espontânea prejudicada em terapia intensiva. Rev Gaúcha Enferm 2013;34(4):137-45. DOI: https://doi.org /10.1590/S1983-14472013000400018 5. Walker L, Avant KC. Strategies for theory construction in nurs- ing. Boston: Pearson. 2019. 272 p. 6. Hopia H, Latvala E, Liimatainen L. Reviewing the methodology of an integrative review. Scand J Caring Sci. 2016;30(4):662-9. DOI: https://doi.org /10.1111/scs.12327 7. Perkins GD, Mistry D, Gates S, et al. Effect of protocolized weaning with early extubation to noninvasive ventilation vs invasive weaning on time to liberation from mechanical ventilation among patients with respiratory failure. JAMA . 2018;320(18):1881-8. DOI: https://doi.org /10.1001/jama.2018.13763 8. Diaz-Abad M, Brown JE. Use of volume-targeted non-invasive bilevel positive airway pressure ventilation in a patient with amyotrophic lateral sclerosis. J Bras Pneumol. 2014;40(4):443-7. DOI: https://doi.org /10.1590/S1806-37132014000400013 9. Antonio ACP, Teixeira C, Castro PS, et al. Behavior of lung ultra- sound findings during spontaneous breathing trial. Rev Bras Ter Intensiva. 2017;29( 3):279-86. DOI: https://doi.org /10.5935/0103- 507X.20170038 10. Girault C, Bubenheim M, Abroug F, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respirato- https://doi.org/10.1590/1518-8345.1950.2954 https://doi.org/10.1590/1518-8345.1950.2954 https://doi.org/10.1590/0034-7167-2017-0117 https://doi.org/10.1590/S1983-14472013000400018 https://doi.org/10.1111/scs.12327 https://doi.org/10.1001/jama.2018.13763 https://doi.org/10.1590/S1806-37132014000400013 https://doi.org/10.5935/0103-507X.20170038 https://doi.org/10.5935/0103-507X.20170038 20 A Q U IC H A N | eI SS N 2 02 7- 53 74 | A Ñ O 23 - V O L. 2 3 N º 2 - CH ÍA , C O LO M BI A - J U LI O -S EP TI EM BR E 20 23 | e 23 37 ry failure. Am J Respir Crit Care Med. 2011;184(6):672-9. DOI: https://doi.org /10.1164/rccm.201101-0035OC 11. Ferreira JC, Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR. Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial. BMC Pulm Med. 2017;17(1):139. DOI: https://doi.org /10.1186/s12890- 017-0484-5 12. Hennus MP, Vught AJ van, Brabander M, Brus F, Jansen NJ, Bont LJ. Mechanical ventilation drives inflammation in severe viral bronchiolitis. PLoS ONE. 2013;8(12):e83035. DOI: https://doi. org /10.1371/journal.pone.0083035 13. Teixeira SN, Osaku EF, Lima de Macedo Costa CR, et al. Comparison of proportional assist ventilation plus, T-Tube ventilation, and pressure support ventilation as spontaneous breathing trials for extubation: a randomized study. Respir Care. 2015;60(11):1527-35. DOI: https://doi.org /10.4187/respcare.03915 14. Figueroa-casas JB, Montoya R, Arzabala A , Connery SM. Com- parison between automatic tube compensation and continuous positive airway pressure during spontaneous breathing trials. Respir Care. 2010;55(5):549-54. Available from: https://rc.rcjour- nal.com/content/respcare/55/5/549.full.pdf 15. Raurich JM, Rialp G, Ibáñez J, Campillo C, Ayestarán I, Blanco C. Hypercapnia test as a predictor of success in spontaneous breathing trial sand extubation. Respir Care. 2008; 53(8):1012- 8. Available from: https://rc.rcjournal.com/content/resp- care/53/8/1012.full.pdf 16. Mokhlesi B, Tulaimat A , Gluckman TJ, Wang Y, Evans AT, Corbridge TC. Predicting extubation failure after successful completion of a spontaneous breathing trial. Respir Care. 2007; 52(12):1710-7. Available from: https://rc.rcjournal.com/content/ respcare/52/12/1710.full.pdf 17. Gnanapandithan K, Agarwal R, Aggarwal AN, Gupta D. Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: A pilot study. Rev Por Pneumologia. 2011;17(6):244-52. DOI: https://doi.org /10.1016/j.rppneu.2011.06.015 18. Putensen C, Zech S, Wrigge H, Zinserling J, Stüber F, Von Spiegel T, et al. Long-term effects of spontaneous breathing during ven- tilatory support in patients with acute lung injury. Am J Respir Crit Care Med. 2001;164(1):43-9. DOI: https://doi.org /10.1164/ ajrccm.164.1.2001078 19. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335(25):1864-9. DOI: https://doi.org /10.1056/NEJM199612193352502 20. Delisle S, Francoeur M, Albert M, Ouellet P, Bellemare P, Ar- senault P. Preliminary evaluation of a new index to predict the outcome of a spontaneous breathing trial. Respir Care. 2011; 56(10):1500-5. DOI: https://doi.org /10.4187/respcare.00768 21. Andrade LZC, Chaves DBR, Silva VM da, Beltrão BA , Lopes MV de O. Diagnósticos de enfermagem respiratórios para crianças com infecção respiratória aguda. Acta Paul En- ferm. 2012;25(5):713-20. DOI: https://doi.org /10.1590/S0103- 21002012000500011 22. Campbell ML. Ensuring breathing comfort at the end of life: The integral role of the critical care nurse. Am J Crit Care. 2018;27(4):264-9. DOI: https://doi.org /10.4037/ajcc2018420 23. Storm DS, Baumgartner RG. Achieving self-care in the ventila- tor-dependent patient: a critical analysis of a case study. Int J Nurs Stud. 1987;24(2):95-106. DOI: https://doi.org /10.1016/0020- 7489(87)90052-6 24. Sørensen D, Frederiksen K, Groefte T, Lomborg K. Nurse-pa- tient collaboration: a grounded theory study of patients with chronic obstructive pulmonary disease on non-invasive ventilation. Int J Nurs Stud. 2013; 50(1):26-33. DOI: https://doi. org /10.1016/j.ijnurstu.2012.08.013 25. Sørensen D, Frederiksen K, Grøfte T, Lomborg K. Practical wisdom: a qualitative study of the care and management of non-invasive ventilation patients by experienced intensive care nurses. Intensive Crit Care Nurs. 2013 Jun;29( 3):174-8. DOI: https://doi.org /10.1016/j.iccn.2012.10.001 26. Manfredini GMSG, Machado RG, Mantovani R. Prone position in acute respiratory distress syndrome: nursing care. Journal of Nursing UFPE. 2013;7(8):5588-97. DOI: https://doi.org /10.1097/ DCC.0000000000000393 27. Pertab D. Principles of mechanical ventilation--a critical review. Br J Nurs. 2009;18(15):915-8. DOI: https://doi.org /10.12968/ bjon.2009.18.15.43560 28. Yücel ŞÇ, Eşer I, Güler EK, Khorshid L. Nursing diagnoses in patients having mechanical ventilation support in a respiratory intensive care unit in Turkey. Int J Nurs Pract. 2011;17(5):502-8. DOI: https://doi.org /10.1111/j.1440-172X.2011.01959.x 29. Pattison N, Watson J. Ventilatory weaning: a case study of pro- tracted weaning. Nurs Crit Care. 2009;14(2):75-85. DOI: https:// doi.org /10.1111/j.1478-5153.2008.00322.x 30. Cools F, Offringa M. Neuromuscular paralysis for newborn in- fants receiving mechanical ventilation. Cochrane Database Syst Rev. 2000;(4):CD002773. DOI: https://doi.org /10.1002/14651858. CD002773 31. Greenough A , Dimitriou G, Prendergast M, Milner AD. Synchro- nized mechanical ventilation for respiratory support in newborn infants. Cochrane Database Syst Rev. 2008;23(1):CD000456. DOI: https://doi.org /10.1002/14651858.CD000456.pub3 32. Prado PR, Bettencourt ARC, Lopes JL. Fatores preditores do diagnóstico de enfermagem padrão respiratório ineficaz em pacientes de uma unidade de terapia intensiva. Rev LatAm Enfermagem. 2019;27:e3153. DOI: https://doi.org /10.1590/1518- 8345.2902.3153 33. Hsu JC, Chen YF, Chung WS, Tan TH, Chen T, Chiang JY. Clinical verification of a clinical decision support system for ventilator weaning. Biomed Eng Online. 2013;12 Suppl 1(Suppl 1):S4. DOI: https://doi.org /10.1186/1475-925X-12-S1-S4 34. Kauppi W, Herlitz J, Magnusson C, Palmér L, A xelsson C. Char- acteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retro- spective observational study. BMC Emerg Med. 2020;20(1):67. DOI: https://doi.org /10.1186/s12873-020-00363-6 35. Jellington MO, Overgaard D, Sørensen EE. Manoeuvring along the edge of breathlessness: an ethnographic case study of two nurses. BMC Nurs. 2016;15:27. DOI: https://doi.org /10.1186/ s12912-016-0148-4 36. Tonnelier JM, Prat G, Le Gal G, Gut-Gobert C, Renault A , Boles JM, et al. Impact of a nurses’ protocol-directed weaning proce- dure on outcomes in patients undergoing mechanical ventila- tion for longer than 48 hours: a prospective cohort study with a matched historical control group. Crit Care. 2005; 9(2):R83-9. DOI: https://doi.org /10.1186/cc3030 37. Li W, An X, Fu M, Li C. Emergency treatment and nursing of children with severe pneumonia complicated by heart failure and respiratory failure: 10 case reports. Exp Ther Med. 2016; 12(4):2145-9. DOI: https://doi.org /10.3892/etm.2016.3558 38. Yang L, Jiang Q, Guan H, Bo H. Nursing care in an- ti-N-methyl-d-aspartate receptor encephalitis. Medi- cine. 2019;98(46):e17856. DOI: https://doi.org /10.1097/ MD.0000000000017856 39. Vitacca M, Paneroni M, Peroni R, Barbano L, Dodaj V, Piaggi G, et al. Effects of a multidisciplinary care program on disability, https://doi.org/10.1164/rccm.201101-0035OC https://doi.org/10.1186/s12890-017-0484-5 https://doi.org/10.1186/s12890-017-0484-5 https://doi.org/10.1371/journal.pone.0083035 https://doi.org/10.1371/journal.pone.0083035 https://doi.org/10.4187/respcare.03915 https://rc.rcjournal.com/content/respcare/55/5/549.full.pdf https://rc.rcjournal.com/content/respcare/55/5/549.full.pdf https://rc.rcjournal.com/content/respcare/53/8/1012.full.pdf https://rc.rcjournal.com/content/respcare/53/8/1012.full.pdf https://rc.rcjournal.com/content/respcare/52/12/1710.full.pdf https://rc.rcjournal.com/content/respcare/52/12/1710.full.pdf https://doi.org/10.1016/j.rppneu.2011.06.015 https://doi.org/10.1164/ajrccm.164.1.2001078 https://doi.org/10.1164/ajrccm.164.1.2001078 https://doi.org/10.1056/NEJM199612193352502 https://doi.org/10.4187/respcare.00768 https://doi.org/10.1590/S0103-21002012000500011 https://doi.org/10.1590/S0103-21002012000500011 https://doi.org/10.4037/ajcc2018420 https://doi.org/10.1016/0020-7489(87)90052-6 https://doi.org/10.1016/0020-7489(87)90052-6 https://doi.org/10.1016/j.ijnurstu.2012.08.013 https://doi.org/10.1016/j.ijnurstu.2012.08.013 https://doi.org/10.1016/j.iccn.2012.10.001 https://doi.org/10.1097/DCC.0000000000000393 https://doi.org/10.1097/DCC.0000000000000393 https://doi.org/10.12968/bjon.2009.18.15.43560 https://doi.org/10.12968/bjon.2009.18.15.43560 https://doi.org/10.1111/j.1440-172X.2011.01959.x https://doi.org/10.1111/j.1478-5153.2008.00322.x https://doi.org/10.1111/j.1478-5153.2008.00322.x https://doi.org/10.1002/14651858.CD002773 https://doi.org/10.1002/14651858.CD002773 https://doi.org/10.1002/14651858.CD000456.pub3 https://doi.org/10.1590/1518-8345.2902.3153 https://doi.org/10.1590/1518-8345.2902.3153 https://doi.org/10.1186/1475-925X-12-S1-S4 https://doi.org/10.1186/s12873-020-00363-6 https://doi.org/10.1186/s12912-016-0148-4 https://doi.org/10.1186/s12912-016-0148-4 https://doi.org/10.1186/cc3030 https://doi.org/10.3892/etm.2016.3558 https://doi.org/10.1097/MD.0000000000017856 https://doi.org/10.1097/MD.0000000000017856 Co nc ep t A na ly si s of t he N ur si ng D ia gn os is o f I m pa ir ed S po nt an eo us V en ti la ti on in C ri ti ca l P at ie nt s 21 autonomy, and nursing needs in subjects recovering from acute respiratory failure in a chronic ventilator facility. Respir Care. 2014;59(12):1863-71. DOI: https://doi.org /10.4187/respcare.03030 40. Rose L, Gerdtz MF. Review of non-invasive ventilation in the emergency department: clinical considerations and manage- ment priorities. J Clin Nurs. 2009; 18(23):3216-24. DOI: https:// doi.org /10.1111/j.1365-2702.2008.02766.x 41. Belveyre T, Auchet T, Levy B. Spontaneous breathing during extracorporeal membrane oxygenation treatment of sickle cell disease acute chest syndrome. Respir Med Case Rep. 2019;28:100924. DOI: https://doi.org /10.1016/j.rmcr.2019.100924 42. Mohammed H, Abdelatief DA . Easy blood gas analysis: implica- tions for nursing. Egyptian J Diseases Chest and Tuberculosis. 2016;65(1):369-76. https://doi.org /10.1016/j.ejcdt.2015.11.009 43. Liang YR, Yang MC, Wu YK, Tzeng IS, Wu PY, Huang SY, et al. Transitional percentage of minute volume as a novel predictor of weaning from mechanical ventilation in patients with chronic respiratory failure. Asian Nurs Res. 2020;14(1):30-5. DOI: https:// doi.org /10.1016/j.anr.2020.01.002 44. Hernández-Hernández G, Reynoso-García JG. Cuidado de en- fermería posto peración de Tromboend arterectomia Pulmonar Bilateral. Estudio de caso fundamentado en los principios de Henderson. Enferm. univ. 2019;16( 3):322-34. DOI: https://doi. org /10.22201/eneo.23958421e.2019.3.710 45. Walton J. Safe sedation practice for surgeons. Surgery. 2019;37(12):712-4. DOI: https://doi.org /10.1016/j.mp- sur.2019.10.004 46. Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med. 2020; 8(5):506-17. DOI: https://doi.org /10.1016/S2213-2600(20)30161-2 47. Antonucci LAO, Savino MJP. Paciente com ventilação es- pontânea prejudicada: uma revisão integrativa das intervenções de enfermagem no uso da respiração artificial. Rev Saúde Com. 2014;10(1):96-108. Disponível em: https://periodicos2.uesb.br/ index.php/rsc/article/view/289 48. Moorhead S, Johnson M, Mass ML, Swanson E. Classificação dos resultados de enfermagem. 5 ed. Rio de Janeiro: Elsevier, 2016. 49. Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. Clas- sificação das intervenções de enfermagem. 6 ed. Rio de Janeiro: Elsevier, 2016. 640 p. https://doi.org/10.4187/respcare.03030 https://doi.org/10.1111/j.1365-2702.2008.02766.x https://doi.org/10.1111/j.1365-2702.2008.02766.x https://doi.org/10.1016/j.rmcr.2019.100924 https://doi.org/10.1016/j.ejcdt.2015.11.009 https://doi.org/10.1016/j.anr.2020.01.002 https://doi.org/10.1016/j.anr.2020.01.002 https://doi.org/10.22201/eneo.23958421e.2019.3.710 https://doi.org/10.22201/eneo.23958421e.2019.3.710 https://doi.org/10.1016/j.mpsur.2019.10.004 https://doi.org/10.1016/j.mpsur.2019.10.004 https://doi.org/10.1016/S2213-2600(20)30161-2 https://periodicos2.uesb.br/index.php/rsc/article/view/289 https://periodicos2.uesb.br/index.php/rsc/article/view/289