Respiratory care
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The development and evolution of the endotracheal tube (ETT) have been closely related to advances in surgery and anesthesia. Modifications were made to accomplish many tasks, including minimizing gross aspiration, isolating a lung, providing a clear facial surgical field during general anesthesia, monitoring laryngeal nerve damage during surgery, preventing airway fires during laser surgery, and administering medications. In critical care management, ventilator-associated pneumonia (VAP) is a major concern, as it is associated with increased morbidity, mortality, and cost. ⋯ Modifications to the ETT that attempt to prevent bacteria from entering around the ETT include maintaining an adequate cuff pressure against the tracheal wall, changing the material and shape of the cuff, and aspirating the secretions that sit above the cuff. Attempts to reduce bacterial entry through the tube include antimicrobial coating of the ETT and mechanically scraping the biofilm from within the ETT. Studies evaluating the effectiveness of these modifications and techniques demonstrate mixed results, and clear recommendations for which modification should be implemented are weak.
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Visualization of the larynx by direct or indirect means is referred to as laryngoscopy and is the principal aim during airway management for passage of a tracheal tube. This paper presents a brief background regarding the development and practice of laryngoscopy and examines the equipment and techniques for both direct and indirect methods. Patient evaluation during the airway examination is discussed, as are predictors for difficult intubation. Laryngoscope blade design, newer intubating techniques, and a variety of indirect laryngoscopic technologies are reviewed, as is the learning curve for these techniques and devices.
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Endotracheal intubation is a commonly performed operating room (OR) procedure that provides safe delivery of anesthetic gases and airway protection during surgery. The most common intubation technique in the perioperative environment is direct laryngoscopy with orotracheal tube insertion. Infrequently, difficulties that require an alternative intubation technique are encountered due to patient anatomy, equipment limitations, or patient pathophysiology. ⋯ Translating the intubation processes practiced in the OR to intubations outside the perioperative setting should improve patient safety. This paper considers each step in the OR intubation process in detail and proposes ways of incorporating perioperative procedures into intubations outside the OR. Management of the physiologic impact of intubation, lack of readily available specialized equipment and experienced help, and planning for transfer of care following intubation are all challenges during these intubations.
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There is a need to develop simple, noninvasive, and sensitive outcome measures for respiratory therapy. Adventitious respiratory sounds (ie, crackles and wheezes) can be objectively characterized with computerized respiratory sound analysis (CORSA) and have been shown to contribute for diagnosis purposes; however, their potential for use as outcome measures is unknown. Thus, this systematic review synthesizes the evidence on the use of computerized adventitious respiratory sounds as outcome measures. ⋯ Specific variables of each adventitious respiratory sound detected and characterized by CORSA showed high effect sizes and, thus, the potential to be used as outcome measures. Further research with robust study designs and larger samples (both of children and adult populations), and following CORSA guidelines is needed to build evidence-based knowledge on this topic.
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Randomized Controlled Trial
Influence of ambient temperature and minute ventilation on passive and active heat and moisture exchangers.
During invasive mechanical ventilation, inspired gases must be humidified. We previously showed that high ambient temperature greatly impaired the hygrometric performance of heated wire-heated humidifiers. The aim of this bench and clinical study was to assess the humidification performance of passive and active heat and moisture exchangers (HMEs) and the impact of ambient temperature and ventilator settings. ⋯ In this study both passive and active HMEs had stable humidification performance with negligible influence of ambient temperature and minute ventilation. This contrasts with previous findings with heated wire-heated humidifiers. Although there are no clear data demonstrating that higher humidification impacts outcomes, it is worth noting that humidity was significantly higher with the active HME.