Critical care clinics
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When to intervene and control the airway is the critical decision the physician must make. The technical expertise and confidence of each physician determine the particular airway modality chosen. The medications used depend on each clinical setting and can significantly impact the outcome of airway management. To control the airway and breathing and move on to circulation requires a broad knowledge of alternative airway management techniques and the challenging task of placing each into the appropriate clinical setting.
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Understanding the various delivery systems of the most commonly used therapies in the critical care setting will help avoid iatrogenic problems and enhance ability to deliver effective goal-oriented critical care. Rational use of oxygen is a result of understanding the goals, complications, and risks of oxygen therapy.
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As this article demonstrates, tremendous progress has been made in the techniques of oxygen measurement and monitoring over the past 50 years. From the early developments during and after World War II, to the most recent applications of solid state and microprocessor technology today, every patient in a critical care situation will have several continuous measurements of oxygenation applied simultaneously. Information therefore is available readily to alert personnel of acute problems and to guide appropriate therapy. ⋯ The next generation of devices will attempt to provide information about living tissue. Unlike the devices monitoring arterial or venous oxygen content, no "gold standards" exist for tissue oxygenation, so calibration will be difficult, as will interpretation of the data provided. The application of these devices ultimately may lead to a much better understanding of how disease (and the treatment of disease) alters the utilization of oxygen by the tissues.
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Even routine airway management requires specific skills that are best acquired in a controlled setting, before "trial by fire" in an emergency situation. Furthermore, recognition of a potential difficult airway and appropriate preparation prior to initiating airway intervention are critical steps in avoiding airway catastrophes in the intensive care or emergency setting. Familiarity with a difficult airway algorithm and various alternate techniques for endotracheal intubation is a mandatory requirement for all practitioners involved in airway management, and should be incorporated in critical care curricula. ⋯ In general, "less is more" in the intensive care unit, and techniques that preserve spontaneous ventilation during airway interventions are desirable, particularly in patients with anticipated difficult airways. All intubating sites should have a portable storage unit for equipment for managing difficult airways readily available. Correct ETT placement always should be verified by detection of exhaled CO2, and by chest radiography if prolonged intubation is planned.
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The role of the fiberscope in the management of difficult and failed intubations has been well established and the importance of learning this valuable skill has been emphasized. Nonetheless, the fiberscope is underutilized in anesthesia and critical care practices because of a high rate of intubation failure. The main cause of failure is lack of expertise in maneuvering the fiberscope. ⋯ The fiberscope is best used in patients after learning to perform three simultaneous movements--advancing the fiberscope, coordinated rotation of the insertion cord, and bending the tip of the fiberscope while traversing the airway. After the technical skills of the fiberscope become second nature, the endoscopist can give more attention to patient-related factors to improve the success rate of tracheal intubation. Expert use of the fiberscope can be a life-saving measure through alleviating major airway complications and unnecessary tracheostomies.