Although when it happens, there can be a devastating impact on patients as well as to the multidisciplinary theatre team involved. Consequently, the DAS has produced a consensus set of guidelines for managing failed intubations in adult and paediatric patients, but there are as yet no such nationally-agreed guidelines in obstetrics, therefore each obstetric unit should have their own flowchart with regards to management of failed intubation (Brien and Conlon, 2013). Furthermore, in light of the latest DAS guidelines, several aspects of clinical anaesthetic practise have changed over recent years (Frerk at al, 2015). Amongst the changes are the use of new drugs such as rocuronium and suggamadex and using electronic video-laryngoscopes (Frerk et al, 2015). Further work had also looked at extending the period of apnoea without causing desaturation by optimising the preoxygenation process and adequate patient positioning (Frerk et al, 2015). As a result, updated guidelines for difficult intubations in adult patients were published in 2015; these guidelines provide a flowchart to be used when endotracheal intubation proves difficult or impossible and focus on the central importance of oxygenation while reducing the amount of airway interventions in order to minimize trauma to the delicate airway (Frerk et al, 2015). The main message of the revised guidelines is
The new versus classic BPD features have changed over the years. The approaches to care, including surfactant administration, permissive hypercapnia, and noninvasive ventilation have changed. All these has increased the survival of low birth weight infants as before with classic BPD. The classic BPD was before surfactant and more management techniques, and inflammation and alveolar septal fibrosis. All these changes were associated with oxygen toxicity, infection, and barotrauma.
The main priority for all the pediatric patient was to make sure they are getting enough air. They needed an open airway. Without an open airway nothing else matters. To help with the patients airways we monitored their O2 sats and if they were low we made sure to apply oxygen, and continue to monitor their sats. Once oxygen was applied we worked on
The researchers will submit the research proposal to Douglas College Research Ethics Board for approval. The completed application is attached (see Appendix 1). Although the research involves the medical records of young children deemed to be a vulnerable population, the nature of the research does not imply any contacts with the subjects. Therefore, no consent is required from parents or legal guardians. Since the research does not imply any direct or indirect contacts with the subjects, there are no reasonably foreseeable risks or discomforts pertaining to the research. The researchers will obtain the permission from the provincial Ministry of Health to have an access to the medical records of children
Unlike other OSA treatments, upper airway stimulation (UAS) therapy activates neuromuscular anatomy to increase upper airway caliber without the need for surgical removal or alteration of soft or skeletal tissue (Maurer, 2012). The system works by sensing respiration and applying a small stimulus directly to the hypoglossal nerve which is then synchronized to diaphragmatic movement. This stimulation improves airway patency by activating muscles in the tongue mimicking wakeful function. Multiple studies have shown that a reduction in the tone of the pharyngeal and lingual musculature is associated with a significant increase in airflow resistance and pharyngeal obstruction (Maurer, 2012). The Inspire system targets these muscles and increases muscle tone in a synchronized manner, opening the airway and moving obstructing tissue simultaneously. The system is composed of a stimulation lead, a sensing lead, and an implantable pulse generator (IPG), which together sense respiration patterns and deliver stimulation to the hypoglossal nerve. The article goes on to state that The Inspire UAS system is best used to treat patients with moderate to severe OSA who do not tolerate positive airway pressure treatments. Several clinical investigations of the UAS therapy suggest that it is a valid strategy for reducing OSA.
However, there were no peep values at bedside. We know per our standard of care if there was an emergency and we had to bag our patient and did not apply the same peep we would compromise our end-expiratory pressure which would lead to the collapsing of their alveolars.
Apnoeic oxygenation is increasingly used, especially in critically unwell patients, to provide an oxygen-rich environment in the oropharynx to minimise hypoxia during the apnoeic period of RSI.6 This is provided by an alternative oxygen source, commonly via nasal prongs with oxygen flow at 10 litres per minute or more, or via insertion of
Storage in the GAG can create enlargement of the tongue, adenoids and/or tonsils with the structure of collapsible, space occupying lesions in pharyngolaryngeal walls (Simmons et al 2005). Blockage is frequently worsened by the existence of the swelled secretions around the lower and upper respiratory tracts (Leighton et al 2001). Manifestations of ENT are alongside the first illness-specific manifestation to emerge; it could activate conclusion of MPS and tends to evolve as with time (Muhlebach et al 2011; Wold et al 2010). You’re able to see the effects during Rapid Eye Movement (REM) sleep; it causes a loss of strength in the accessory muscles of respiration and reduction in ventilator CO2 chemo sensitivity (Dempsey et al 2010). Because of the changes that happen alongside sleep, ventilatory compromise generally first manifests as Sleep Disordered Breathing (SDB) and unfamiliar hypoxemia during sleep. SDB happens in 80% of MPS victims (John et al 2011; Leighton et al 2001; Semenza and Pyeritz 1988). It can be classified as Obstructive Sleep Apnoea (OSA) or sustained hypoventilation. Due to the interactions
I would choose pressure controlled - continuous mandatory ventilation (PC-CMV) for this patient. I would set up the ventilator with the following settings: initial PIP of 20 cm H2O and once patient is attached, I would adjust the PIP to 10 cm H2O above the determined plateau pressure, tidal volume at 90 ml (patient’s IBW is 14.5 kg and the recommended VT is 5 - 8 ml/kg), frequency at 30 (recommended is 20 - 35 for a toddler), FiO2 at 100%, PEEP at the recommended pressure of +5 cm H2O, and inspiratory time of 0.6 seconds (recommended is 0.6 - 0.7) (Walsh 335). I would also add heated humidity to the circuit via a heated pass-over humidifier set at 37 degrees Celsius. The alarm settings would be the following: humidifier high temperature alarm at 38 degrees C. and low temperature alarm at 30 degrees C., high pressure alarm set to 10 cm H2O above PIP and low pressure alarm set to 5 - 10 cm H2O below PIP, low exhaled tidal volume alarm set to 80 ml (10 - 15% below set tidal volume), high PEEP set to 7 cm H20 and low PEEP alarm set to 3 cm H2O (2 - 3 cm H2O above and below set PEEP), high respiratory rate alarm set to 42 and low respiratory rate set to 18 (40% above and below the set rate) (Cairo 106-109).
In the study conducted by Ryan, Doherty, Nolan, and McNicholas (2009), the addition of heated humidification or nasal steroids applied to standard CPAP therapy investigated compliance, quality of life and nasal side effects of patients during use. Participants of the study were purposefully selected from the Respiratory Sleep Disorders Unit at St. Vincent’s University Hospital in Dublin, Ireland after undergoing a successful polysomnography test but had not yet received treatment with a CPAP machine. This case study consisted of 125 patients with similar demographic variables and nasal symptoms, assessed by a validated questionnaire and direct interview (Ryan et
The medical field is very fast-paced and new technological discoveries are constantly being made. When one thinks of new medical findings, cancer cures and surgery are common thoughts. However, a very interesting and slightly controversial discovery has been made in the neonatal world. The Neurally Adjusted Ventilatory Assist (NAVA) is “a form of partial ventilator assistance in which the machine delivers assistance in proportion to the electrical activity of the diaphragm (EAdi), as assessed by means of transesophageal electromyography” (Gianmaria Cammarota et al., 2011). It is meant to lower inspiratory pressure and respiratory muscle load in preterm infants (Gianmaria Cammarota et al., 2011). In other words, it helps the patient- whether they be an infant or an adult- breathe when their lungs aren’t able to aid in that process. M. Ferrer and P. Pelosi, authors of “European Respiratory Monograph 55: New Developments in Mechanical Ventilation” say that the signal from the EAdi is used to regulate NAVA, which then causes the airways to receive pressure. “With NAVA, both timing and the magnitude ventilator delivered assistance are controlled by the EAdi” (M. Ferrer & P. Pelosi., 2012, p 116). My research proves that NAVA can work better than pressure support ventilation (PSV) and can be used not only for neonates, but patients in the ICU that are affected by lung-related injury or illness that causes them to have difficulty breathing on their own; though there are
However, its use has since become questionable. N. Bhatia et. al. in “Cricoid pressure where do we stands” contend that its benefits and risks may not be fully understood. For example, the amount of pressure necessary to adequately occlude that esophagus is far from definitive, citing most practitioners description of the required pressure as “enough.” While more scientific assessments of the required amount of pressure ranged from 10 to 40N. Even when the generally accepted amount of pressure was applied to the cricoid cartilage 12% of the patients evaluated still regurgitated stomach contents. Finally, the use of cricoid pressure requires more than a basic understanding of its use and purpose, otherwise, either too much or not enough pressure can be applied, or the trachea can be displaced in an abnormal position making visual laryngoscopy difficulty. In addition, they contend that the proof used in the original article do not meet the basics of scientific proof. The use of cadavers as study subjects and the use of only 26 cases do not meet the minimum standards to adequately prove its overall benefit. However, Stewart et. al. in “Rapid-sequence intubation and cricoid pressure,” argue that despite its difficulties and complications, it is a learnable skill and has a purpose in rapid sequence
The CPAP consists of a small ventilator, from a pipe and a nasal mask or nose buccal. Of course, all these elements are chosen and carefully calibrated, using a procedure defined titration, depending on the patient and the characteristics of his nocturnal respiratory pathology. The greater the attention given to the patient and the medical personnel's experience at this stage, the higher the patient treatment compatibility.
Nasal septal/Turbinates surgery: relationship between nasal obstruction and snoring is complex. Several physiological mechanisms were described to try to explain the relationship between nasal airflow and breathing during sleep and one of the most widely accepted mechanism is the Starling resistor model. According to this the upper airway has been described as resembling a Starling resistor with a collapsible segment in the oropharynx where upper airway narrowing is induced by subatmospheric nasal pressure 104. Recently published data demonstrate that when nasal obstruction due to septal deviation exist in habitual snorers with deviated septum, the snoring can improve after nasal septal surgery, the intensity of snoring can decreases and
Respiratory distress syndrome (RDS) is a common lung disorder that mostly affects preterm infants. RDS is caused by insufficient surfactant production and structural immaturity of the lungs leading to alveolar collapse. Clinically, RDS presents soon after birth with tachypnea, nasal flaring, grunting, retractions, hypercapnia, and/or an oxygen need. The usual course is clinical worsening followed by recovery in 3 to 5 days as adequate surfactant production occurs. Research in the prevention and treatment of this disease has led to major improvements in the care of preterm infants with RDS and increased survival. However, RDS remains an important cause of morbidity and mortality especially in the most preterm infants. This chapter reviews the most current evidence-based management of RDS, including prevention, delivery room stabilization, respiratory management, and supportive care.