Anaesthesia
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Case Reports
Local anaesthesia and sedation for rigid bronchoscopy for emergency relief of central airway obstruction.
We report three experiences that illustrate the use of local anaesthesia for rigid bronchoscopy. All patients were acute emergencies, with life-threatening central airway problems. Instruments were inserted after the airway was anaesthetised using a technique that owes much to mid 20th Century methods for inserting endobronchial blockers. ⋯ Concomitant sedation reduced the unpleasantness of the experience in a way that in the past could only be dealt with by careful attention to the humanitarian elements of detail. Problems of oxygenation were ameliorated by periodically superimposing intermittent jetting with a Sanders injector fed from the oxygen pipeline. A need for developing and refining topical and other local anaesthetic techniques for rigid bronchoscopy is anticipated with the expansion of services for tracheo-bronchial stenting and lasering.
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Aeromedical transport of mechanically ventilated critically ill patients is now a frequent occurrence. However, the performance of the air filled tracheal tube cuff at altitude has not been studied in vivo. ⋯ With air providing the seal in the cuff the mean rise in cuff pressure was 23 cmH2O, which took the pressures above the critical perfusion pressure of the tracheal mucosa. This could lead to tracheal injury.
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Breathing system filters can be used to humidify gases delivered to patients. Performance can be determined by measuring the net moisture loss (the difference between expired and inspired levels of humidity) from a patient model. ⋯ The net moisture loss decreased as the humidity in the breathing system increased and was less for the lower tidal volume. Adequate levels of humidity (>/= 20 g.m-3) will be delivered to patients by most filters provided they are used in conjunction with circle breathing systems and low fresh gas flows.
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Breathing system filters are recommended for use during anaesthesia to protect the patient from inhaling gas-borne particles. Filters placed at the patient connection port of the breathing system can also humidify the inspired gases. ⋯ The moisture content of the end-inspired air at the end of the 3-min period varied from 6.4 to 27.8 and from 4.4 to 25.9 g.m-3 for tidal volumes of 0.5 and 1.0 l, respectively (p < 0.0001 for all pairwise comparisons of the five filters and for the two tidal volumes). Those breathing system filters that have at least an adequate level of performance (at least 20 g.m-3) will generally achieve this level within the 3-min pre-oxygenation period.
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Letter Case Reports
Difficult intubation due to ossification of the anterior longitudinal ligament.