Airway Control Research Articles

Successful emergency management of hemorrhagic shock due to carotid artery aneurysm: the role of awake intubation in difficult airway control

We describe the clinical scenario, analyze the decision-making process in airway management, and application of the Difficult Airway Society (DAS) guidelines for awake tracheal intubation (ATI) in a patient involving life-threatening bleeding from an internal carotid artery aneurysm caused by a fistula following radiotherapy for tongue cancer at Hong Ngoc Phuc Truong Minh General Hospital, on March, 2024. A 53-year-old male, diagnosed with tongue cancer, underwent surgery. Days before admission, he experienced pain and bleeding from the right lateral neck due to an internal carotid artery aneurysm. An attempt at tracheal intubation for endovascular intervention at another hospital failed. Upon arrival at our emergency department, he exhibited massive neck hemorrhage, remained conscious, pale, with ongoing bleeding from a right neck fistula, and limited cervical motion due to irritation. A treatment strategy for permanent occlusion of the aneurysm was devised. Awake tracheal intubation using a fiberoptic scope via the nasal route was performed. The patient received light sedation with midazolam, and the airway was topicalized with 10% lidocaine spray over the mouth, tongue, and oropharyngeal mucosa. Continuous monitoring of heart rate, ECG, and oxygen saturation showed no decrease in oxygen levels, and the patient maintained spontaneous breathing throughout. Intensive treatment with crystalloid fluids and blood transfusion, along with right internal carotid embolization with a spring coil, effectively prevented massive hemorrhage. The patient was successfully extubated after three days in the ICU and discharged 15 days post-surgery without any neurological deficits. Keywords: Awake Tracheal Intubation; Difficult Airway Management; Fiberoptic Scope; Emergency Airway Management Citation: Ba NTT. Successful emergency management of hemorrhagic shock due to carotid artery aneurysm: the role of awake intubation in difficult airway control. Anaesth. pain intensive care 2024;28(5):955−959. DOI: 10.35975/apic.v28i5.2572 Received: January 03, 2024; Reviewed: May 05, 2024; Accepted: June 11, 2024

Strategies for prevention and treatment of vascular and nerve injuries in mandibular anterior implant surgery

Important anatomical structures such as mandibular incisive canal, tongue foramen, and mouth floor vessels may be damaged during implant surgery in the mandibular anterior region, which may lead to mouth floor hematoma, asphyxia, pain, paresthesia and other symptoms. In severe cases, this can be life-threatening. The insufficient alveolar bone space and the anatomical variation of blood vessels and nerves in the mandibular anterior region increase the risk of blood vessel and nerve injury during implant surgery. In case of vascular injury, airway control and hemostasis should be performed, and in case of nerve injury, implant removal and early medical treatment should be performed. To avoid vascular and nerve injury during implant surgery in the mandibular anterior region, it is necessary to be familiar with the anatomical structure, take cone-beam computed tomography, design properly before surgery, and use digital technology during surgery to achieve accurate implant placement. This article summarizes the anatomical structure of the mandibular anterior region, discusses the prevention strategies of vascular and nerve injuries in this region, and discusses the treatment methods after the occurrence of vascular and nerve injuries, to provide clinical reference.

Clinical application of submandibular endotracheal intubation in craniomaxillofacial fracture

ObjectiveTo explore the clinical application of submandibular endotracheal intubation in craniomaxillofacial fractures. MethodsThe submandibular endotracheal intubation was used to treat 10 patients with cranio-maxillofacial fractures and contraindications to nasal intubation.Ventilator monitoring data including SPO2(oxygen saturation of blood), Freq,VT,MV,PEEP, PLAT and PEAK were monitored before and after the operation of submandibular endotracheal intubation. The technique of submandibular intubation was assessed intraoperatively and in the postoperative period. The outcomes and complications are presented. ResultsThe study included 10 patients aged between 18 and 63 years(6 males and 4 females). All patients had mandibular fractures, with 6 midface fractures (60 %), 5 nasal bone fractures (50 %), 6 zygomatic bone fractures (60 %). The procedure time ranged from 6 to 10 min (mean, 7.9 min). NO delayed extubation was performed in 10 cases. The technique has proved to be straightforward and satisfactory. A postoperative superficial infection occurred in 1 patients, whereas hypertrophic scars occurred in another 1 patients. ConclusionSubmandibular endotracheal intubation is a safe procedure for intraoperative airway control in maxillofacial trauma patients who present contraindication to nasotracheal intubation.

Anesthesia for an infant with congenital mediastinal mass: a case report

BackgroundGiant anterior mediastinal masses in infants are one of the most challenging cases faced in pediatric anesthesia practice. They can pose unique challenges for resection such as cardiovascular collapse on induction of anesthesia and injury to surrounding structures that maybe compressed or displaced. Principles that must be followed and kept in mind during removal of giant mediastinal mass include appropriate diagnostic imaging to define mass extent, airway control during induction, a multidisciplinary team approach including cardiothoracic for sternotomy, cannulation to institute cardiopulmonary bypass, otolaryngology for rigid bronchoscopy, preservation of neurovascular structure, and complete resection whenever possible. Our patient had a mass that weighed twice his whole body weight.Case presentationHere we present a 3-month-old Middle Eastern infant weighing 3.2 kg with a large congenital teratoma who presented to the emergency room with cyanosis and respiratory distress. During his hospital course, he underwent three procedures, two of them under light-to-moderate sedation: a diagnostic computer tomography scan followed by mass content drainage by interventional radiology (Figs. 1, 2). On the third day, he had a thoracotomy with complete tumor resection under general anesthesia with the help of an epidural for pain control (Fig. 3). The resected tumor weighed 2.5 kg, which was equal to twice the patient’s total body weight (Fig. 4). After the surgery, he was extubated in the operating room and discharged home 3 days later.Fig. 1Anterior–posterior chest x-ray showing the anterior mediastinal mass (AMM)Fig. 2Cross-section computed tomography (CT) showing large anterior mediastinal mass (AMM)Fig. 3Gross anatomy of the tumor before resectionFig. 4Gross anatomy of the removed tumorConclusionAnterior mediastinal mass patients can be challenging for the anesthesiologist. They need meticulous thorough perioperative assessment to determine the extent of compression on major intramediastinal structures and to predict the complications. Planning by multidisciplinary team and discussion with the family is important. These types of cases should be preferably operated on by an experienced team in a well-equipped operation room in tertiary care institutes.

Combined Open Surgery and CO2 Laser for Giant Supraglottic Hemangioma in an Adult: A Case Report.

Laryngeal hemangiomas are rare vascular tumors, mainly in children, and less common in adults. Giant lesions typically require multiple endoscopic procedures and temporary tracheostomy. Open surgery allows single-procedure removal with fewer complications. CO2 laser excision controls bleeding and minimizes tissue damage. This study evaluates this hybrid approach to manage adult giant supraglottic hemangiomas. A 54-year-old woman with a giant supraglottic hemangioma was successfully treated using a combination of open surgery and CO2 laser. Limited data on adult laryngeal hemangiomas result in a lack of established treatment protocols. For giant supraglottic hemangiomas, combining open surgery with CO2 laser resection offers distinct advantages: enhanced lesion visibility, optimal airway control, effective hemostasis, reduced tissue damage, and lower recurrence rates. This hybrid approach also supports rapid recovery and favorable clinical outcomes. Combining open surgical excision with CO2 laser is effective for managing giant supraglottic hemangiomas in adults.

Application of Laryngeal Mask Airway in Airway Management of Patients with A Tracheal Stenosis – A Case Report

Tracheal stenosis is a severe condition that significantly affects patients’ quality of life, with airway reconstruction surgery being the primary treatment. Airway management is critical during general anesthesia, especially when the airway is the surgical site. This report presents clinical concepts and cases of the successful use of laryngeal masks as a supraglottic airway for intraoperative tracheal management in patients with tracheal stenosis. As a transitional device for airway management, a laryngeal mask can provide adequate ventilation and oxygenation and should be incorporated into airway control protocols for individuals with tracheal stenosis.

Landmark based epidural anesthesia in a patient with scoliosis for transabdominal hysterectomy; a case report

We report a case of a 43-years-old female with thoraco-lumbar scoliosis; who was scheduled to undergo an elective total abdominal hysterectomy (TAH). The unique aspect of this case is that the surgery was performed with landmark-guided epidural anesthesia. Regional anesthesia is believed to be a safer alternative to general anesthesia where airway control is uncertain. Keywords: Thoraco-lumbar scoliosis, epidural anesthesia, total abdominal hysterectomy. Citation: Rafiq M, Hussaini, Siraj S, Marium W, Talha S. Landmark based epidural anesthesia in a patient with scoliosis for transabdominal hysterectomy; a case report. Anaesth. pain intensive care 2024;28(4):762−764. DOI: 10.35975/apic.v28i4.2524 Received: February 20, 2024; Reviewed: March 30, 2024; Accepted: April 15, 2024

Rare presence and function of neuroendocrine cells in the nasal mucosa.

There is growing evidence that neurogenic inflammation contributes to the pathophysiology of upper airway diseases, with nasal hyperreactivity (NHR) being a key symptom. The rare neuroendocrine cells (NECs) in the epithelium have been linked to the pathophysiology of bronchial and intestinal hyperreactivity, however their presence in the nasal mucosa and their potential role in NHR remains unclear. Therefore, we studied the presence of NECs in the nasal epithelium of controls, allergic rhinitis patients and chronic rhinosinusitis with nasal polyps patients, and their link to NHR. The expression of typical NECs markers, CHGA, ASCL1 and CGRP, were evaluated on gene and protein level in human samples using real-time quantitative PCR (RT-qPCR), western blot, immunohistochemistry fluorescence staining, RNA scope assay, flow cytometry and single cell RNA-sequencing. Furthermore, the change in peak nasal inspiratory flow after cold dry air provocation and visual analogue scale scores were used to evaluate NHR or disease severity, respectively. Limited gene expression of the NECs markers CHGA and ASCL1 was measured in patients with upper airway diseases and controls. Gene expression of these markers did not correlate with NHR severity nor disease severity. In vitro, CHGA and ASCL1 expression was also evaluated in primary nasal epithelial cell cultures from patients with upper airway disease and controls using RT-qPCR and western blot. Both on gene and protein level only limited CHGA and ASCL1 expression was found. Additionally, NECs were studied in nasal biopsies of patients with upper airway diseases and controls using immunohistochemistry fluorescence staining, RNA scope and flow cytometry. Unlike in ileum samples, CHGA could not be detected in nasal biopsies of patients with upper airway diseases and control subjects. Lastly, single cell RNA-sequencing of upper airway tissue could not identify a NEC cluster. In summary, in contrast to the bronchi and gut, there is only limited evidence for the presence of NECs in the nasal mucosa, and without correlation with NHR, thereby questioning the relevance of NECs in upper airway pathology.

Bimin Kang ameliorates the minimal persistent inflammation in allergic rhinitis by reducing BCL11B expression and regulating ILC2 plasticity

Ethnopharmacological relevanceMinimal persistent inflammation (MPI) is a major contributor to the recurrence of allergic rhinitis (AR). The traditional Chinese herbal medicine known as Bimin Kang Mixture (BMK) have been used in clinics for decades to treat AR, which can relieve AR symptoms, reduce inflammatory response and improve immune function. However, its mechanism in controlling MPI is still unclear. Aim of the studyThis study aims to assess the therapeutic effect of BMK on MPI, and elaborate the mechanism involved in BMK intervention in BCL11B regulation of type 2 innate lymphoid cell (ILC2) plasticity in the treatment of MPI. Material and methodsThe effect of BMK (9.1 ml/kg) and Loratadine (15.15 mg/kg) on MPI was evaluated based on symptoms, pathological staining, and ELISA assays. RT-qPCR and flow cytometry were also employed to assess the expression of BCL11B, IL-12/IL-12Rβ2, and IL-18/IL-18Rα signaling pathways associated with ILC2 plasticity in the airway tissues of MPI mice following BMK intervention. ResultsBMK restored the airway epithelial barrier, and markedly reduced inflammatory cells (eosinophils, neutrophils) infiltration (P < 0.01) and goblet cells hyperplasia (P < 0.05). BCL11B expression positively correlated with the ILC2 proportion in the lungs and nasal mucosa of AR and MPI mice (P < 0.01). BMK downregulated BCL11B expression (P < 0.05) and reduced the proportion of ILC2, ILC3 and ILC3-like ILC2 subsets (P < 0.05). Moreover, BMK promoted the conversion of ILC2 into an ILC1-like phenotype through IL-12/IL-12Rβ2 and IL-18/IL-18Rα signaling pathways in MPI mice. ConclusionBy downregulating BCL11B expression, BMK regulates ILC2 plasticity and decreases the proportion of ILC2, ILC3, and ILC3-like ILC2 subsets, promoting the conversion of ILC2 to ILC1, thus restoring balance of ILC subsets in airway tissues and control MPI.

PULMONOLOGIST’S SATISFACTION WITH THE USE OF I-GEL LARYNGEAL MASK AIRWAY (LMA) FOR BRONCHOSCOPY IN DR. WAHIDIN SUDIROHUSODO MAKASSAR CENTRAL GENERAL HOSPITAL

Bronchoscopy is a type of endoscope used to examine internal organs in the body. This examination is performed by competent physicians, by examining the bronchi or the branches for diagnostic or therapeutic purposes. The use of the LMA for airway management during Fiberoptic Flexible Bronchoscopy (FFB) was first introduced in 1989 and was described as a safe and favorable tool for airway control during bronchoscopy in both adult and pediatric populations. The advantage of an LMA over an endotracheal tube is that it is equipped with a larger diameter tube, allowing for better visibility and flexibility. The I-gel LMA is the most frequently used type of LMA. This study aimed to determine the satisfaction of pulmonologists with the use of LMA I-gel when performing bronchoscopy in Dr. Wahidin Sudirohusodo Central General Hospital Makassar. The research employed probability sampling with an experimental design, using questionnaires for data collection. There were 36 patients underwent bronchoscopy from June ? December 2023. Demographic data were collected (age, sex, body mass index, and American Society of Anesthesiologists physical status), assessment based on the first successful attempt of fiberoptic insertion with a value of p = 0,06, quality of visualization, flexibility of the scope, size of the fiberoptic that can be used, and limitations of performance during bronchoscopy with a value of p &lt; 0,05. It was found that pulmonologists were satisfied with the use of I-gel LMA during bronchoscopy. However, this result was also influenced by the experience of pulmonologists in performing the procedure. Keywords: Bronchoscopy, LMA I-gel, Satisfaction

Polytrauma in Children.

Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room. This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered. Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial. 4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

Obstetrical anesthesia for a patient with multiple sclerosis: case report and literature review

Introduction. Multiple sclerosis is an autoimmune disease characterized by chronic inflammation with progressive demyelination and axonal dysfunction. The disease affects about 1 million young adults, 2/3 of which are women of childbearing age, with all patients develop irreversible neurological dysfunction. There is observed a stagnation of the disease during pregnancy, with the return of exacerbations in the postpartum period. Contemporary specialty textbooks neither confirm nor deny the safety of neuraxial anesthesia in patients with central nervous system diseases. Clinical case. We present the clinical case of a 25-year-old nullipara pregnant (36 weeks and 6 days gestation age), known with relapsing-remitting multiple sclerosis and epilepsy. The woman has relapsing multiple sclerosis symptoms during last 6 days, reason why is urgently consulted by the anesthesiologist for cesarean delivery. Management and outcome. The article describes the technique of epidural anesthesia for the obstetrical patient with multiple sclerosis and the course of the perianesthetic evolution, including 1-year follow-up after cesarean section. Discussions. With the aim of avoiding potential influences on the evolution and progression of the disease, clinical judgment and the choice of anesthetic technique (general vs. neuraxial) depends on several factors: vaginal delivery or caesarean section, the presence of contextual clinical modifiers (native or drug-induced coagulopathy, infection), the urgency of the intervention, and the patient’s cooperation. In case of parturients with multiple sclerosis, all the risks should be rigorously evaluated: on one hand - the additional risk of general anesthesia (risk of aspiration, potential loss of airway control, critical desaturations) and on the other hand - the risk of hypothetical local anesthetic toxicity in the case of neuraxial techniques. Conclusion. Neuraxial epidural anesthesia is a safe technique in obstetric patients with multiple sclerosis.

Capnography-assisted airway management by awake blind nasal intubation in maxillofacial surgeries: An observational study

Background: Maxillofacial surgery patients frequently pose challenges to airway management due to anatomical and functional constraints. While fiber-optic-aided nasotracheal intubation is considered the gold standard, not all medical facilities have access to fiber-optic bronchoscopes, particularly in low-resource settings. In such situations, awake nasal tracheal intubation is often the safest approach for managing patients with known or suspected difficult airways. Aims and Objectives: (1) To assess the technique of capnography-assisted airway management by awake blind nasal intubation (ABNI) in maxillofacial surgeries. (2) To find out any complications encountered by the technique of capnography-assisted airway management by ABNI in maxillofacial surgeries. Materials and Methods: 40 patients undergoing various maxillofacial surgeries and in whom blind nasotracheal intubation was attempted were included in this study. The institutional ethical committee approved the study, and informed consent was obtained from all the patients. The number of attempts for ABNI, successful versus failed ABNI, and complications encountered were studied. SSPS 21.0 software was used for statistical analysis. Results: There were 23 (57.50%) males and 17 (42.50%) females. There was a male preponderance, with the M: F ratio being 1:0.73. The mean age of the patients was 40.97±8.92 years. In 36 (90%) of the patients, the intubation could be successfully done. In 19 (47.50%) patients, blind nasal intubation was successfully done in the first attempt; 2 attempts were required in 15 (37.50%) patients, and 3 attempts were required in 2 (5%) patients. Epistaxis (10%) and sore throats (7.5%) were the most common complications in the studied cases. Conclusion: Capnography-assisted ABNI is an effective technique for airway control in patients undergoing maxillofacial surgeries with an acceptable complication rate.

Video-Laryngoscope For Difficult Paediatric Airway Management In A Case Of Meningomyelocele For Emergency Ventriculo Peritoneal Shunt Surgery

Administering anaesthesia in the pediatric population is challenging because of various physiological and anatomical changes in them compared to adults. It becomes more difficult when associated with congenital anomalies. One of the major anaesthetic challenges in meningomyelocele (MMC) includes securing the airway with proper positioning of the child. The airway becomes a challenge, especially in small babies with associated congenital anomalies, raised intracranial pressure (ICP), and in emergency presentations with upper airway obstruction. Here is a case report of a 5-month-old 6 kg baby with big lumbar MMC and hydrocephalus, raised intracranial pressure with grunting noise indicating upper airway obstruction with respiratory distress for emergency ventriculo-peritoneal shunt placement. Video laryngoscopy (C-MAC)® with pediatric Millers blade was used as the first choice as a difficult airway was anticipated and helped us secure a difficult airway within seconds without any rise in ICP. The baby was placed supine for surgery while avoiding any pressure on the swelling to prevent its rupture, cerebrospinal fluid leak, or increase in ICP. Apart from airway control, intraoperative anaesthetic management in this case of V-P shunt also included proper positioning of large MMC, prevention of any rise in ICP, and prevention of hypothermia. Keywords: Video-laryngoscope, Pediatric millers blade, Difficult pediatric airway, Meningomyelocele, Ventriculo-peritoneal shunt.

Comparison of Efficacy of a Novel Dual Channel Gastro Laryngeal Mask Airway versus Nasal Prongs for Airway Management in Day Care Gastrointestinal Endoscopy Procedures: A Randomised Clinical Study

Introduction: The Gastro Laryngeal Mask Airway (LMA) is a newer supraglottic airway device specifically designed for Gastroinstestinal (GI) endoscopy procedures. Hypoxia is a common complication in endoscopy procedures performed under sedation without securing the airway. The Gastro LMA allows for oxygenation, ventilation, and the passage of a gastroscope through its integrated endoscope channel. Aim: To evaluate the utility of the Gastro LMA compared to nasal prongs in maintaining oxygenation and airway control during upper GI endoscopy procedures. Materials and Methods: The present double-blinded randomised, single-centre clinical study conducted in the Department of Anaesthesiology, GCS Medical College Hospital and Research Centre, Ahmedabad, Gujarat, India included 50 adult patients scheduled for elective GI endoscopy procedures in the supine or lateral position. The patients were divided into two equal groups: Group G (Gastro LMA) and Group N (Nasal prong). Preprocedural heart rate and SpO2 levels were noted. All patients were observed for hypoxia (SpO2 &lt;92%), bradycardia, lowest heart rate and Saturation of Peripheral Oxygen (SpO2 ) levels, conversion to endotracheal intubation, and any other intraoperative adverse events. Postoperatively, patients were observed for four hours for adverse effects and discharged after assessment using the modified Aldrete’s score. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 26.0, and the results were expressed as percentages, mean ± SD, and p-values. Results: Out of the 50 patients, 23 were male and 27 were female, with a median age of 59 years. The preprocedural mean lowest heart rate in Group G was 68/min, and in Group N it was 64/min. The mean lowest SpO2 during the procedure was 94% in Group N and 96% in Group G. In Group N, two patients (8%) required conversion to endotracheal intubation. One patient had a longer duration of the procedure and experienced bronchospasm, while another patient with Chronic Obstructive Pulmonary Disease (COPD) developed bronchospasm. In Group G, one patient (4%) required endotracheal intubation, possibly due to increased intrabdominal pressure caused by air insufflation in an obese patient. Conclusion: In patients undergoing gastrointestinal endoscopy procedures, the Gastro LMA appears to be effective for clinical use. It provides good airway control and enables deeper sedation without respiratory compromise. Ventilation was well maintained with minimal intraoperative and postoperative adverse events.

The placement of four different supraglottic airway devices by medical students: a manikin study

Background and objectives Although endotracheal intubation is the gold standard in airway management, this procedure requires both technical training and experience. Supraglottic airway devices are an alternative to endotracheal intubation and are simpler, less invazive, and require less time for placement compared with endotrakeal intubation. Aim of the study was to evaluate the success rates, ease of use, duration of application, and maneuver performance of different supraglottic airway devices (SADs) used by term-5 medical students on a manikin. Materials and methods This cross-sectional study was conducted in Zonguldak Bülent Ecevit University Hospital, Turkey, between April and June 2022. Term 5 Medical students (n = 111) were asked to place four different SAD [classical laryngeal mask, suprema laryngeal mask, ProSeal laryngeal mask (pLMA), I-gel] on an adult airway manikin. After the students were trained in the use of the devices, the ease of use for each, duration of successful application, success of application and use of optimization maneuvers were recorded. The participants were asked to distinguish the device they felt most confident to place and the most difficult to implement. Results There was a significant difference between the groups in ease and duration of application (p < 0.001). The most difficult and longest application time was with pLMA and the easiest and shortest was with I-gel (p < 0.05). The number of application failure was also highest for pLMA (p < 0.001). It was found that the participants distinguished (41%) I-gel as the most confident device to use, (84%) pLMA as the most difficult device to use for airway control. Conclusions I-gel was found to be superior to others in terms of ease of use, duration and success of application.

Facilitating Lung Collapse for Thoracoscopic Surgery Utilizing Endobronchial Airway Occlusion Preceded by Pleurotomy and One-minute Suspension of Two-lung Ventilation

ObjectivesTo assess when and whether clamping the double-lumen endobronchial tube (DLT) limb of the non-ventilated lung is more conducive to a rapid and effective lung deflation than simply allowing the open limb of the DLT to communicate with the atmosphere. DesignSingle-center, single-blind, randomized, controlled trial. SettingSingle institutional Participants60 patients undergoing elective video-assisted thoracoscopic surgery (VATS). InterventionsPatients were randomized to the open-clamp airway technique group (OCAT Group) or Control Group. Patients in Control Group had one-lung ventilation (OLV) initiated upon being placed in the lateral decubitus position. The OCAT Group had two-lung ventilation (TLV) maintained until the pleural cavity was opened with the introduction of a planned thoracoscopic access port to allow the operated lung to fall away from the chest wall. Thereafter, ventilation was suspended (temporarily ceased) for one (1.0) minute before the DLT lumen of the isolated lung was clamped. The primary and double blind outcome of the trial was the time to complete lung collapse scored as determined from video clips taken during surgery. The secondary outcomes were (1) lung collapse score at 30 minutes after pleural incision, (2) surgeon satisfaction with surgery, and (3) intraoperative hypoxemia. Measurements and Main ResultsThe median time to reach complete lung collapse in the OCAT Group was 10 mins (OR 10.0, 95% CI: 6.3-13.7), which was much shorter than that of Control Group—25 mins (OR 25.0, 95% CI: 13.6-36.4). The difference in complete lung collapse at 30 min between the two groups was significant (P < 0.001). The surgeon satisfaction with surgery was higher in the OCAT Group than in the Control Group (8.5±0.2 vs 6.8±0.2, P<0.001). No difference regarding intraoperative hypoxemia. ConclusionsSuspending ventilation of both DLT limbs for 1 minute after pleural cavity opening, and then clamping the DLT lumen of the isolated lung, resulted in a more rapid deflation of the surgical lung. This open-clamp airway technique is an effective technique for rapid surgical lung collapse during thoracoscopic surgery.

Pemberian Inhalasi Minyak Kayu Putih Untuk Memperbaiki Pola Napas Tidak Efektif Pada Anak Dengan Bronkitis

&lt;p&gt;&lt;em&gt;There are 1.6 million persons who have bronchitis in Indonesia. Coughing, wheezing, sputum buildup, and shortness of breath are common symptoms. We must be mindful of the efficiency of breathing patterns when considering these symptoms. The goal of this study was to identify inefficient breathing techniques used by nurses to provide bronchitis-stricken An. A with nursing care. An. A is the focus of this case study in a scientific journal, and the study's findings include cough and runny nose, RR 32 beats per minute, additional rhonchi noises, SPO2 92%, body temperature 36.8 oC, and pulse 100 beats per minute. Airway control using eucalyptus oil inhalation was the intervention that was used. The major treatment for An's respiratory pattern issues was a straightforward inhalation of eucalyptus oil, and the findings of the case study were achieved following nursing care for airway management for three consecutive days. Increased inspiratory pressure, moderately decreased dyspnea, moderately decreased use of accessory muscles, decreased orthopnea, moderately decreased nasal breathing, improved respiratory rate, and improved respiratory depth are all signs that A can be substantially resolved. This demonstrates how eucalyptus oil can help bronchitis patients breathe more easily.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;strong&gt;&lt;em&gt;Keyword: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;children, bronchitis, ineffective breathing pattern, simple inhalation&lt;/em&gt;&lt;br /&gt;&lt;/strong&gt;&lt;/p&gt;

The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies.

To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.

Strychnine Poisoning: Literature Review

Strychnine poisoning is an quite unusual but a serious poisoning in which convulsions are the major threat to life. Convulsions are predominantly noted at the spinal level, and the key to recognizing this poison is observation of convulsive activity in the awake patient without a postictal phase. Successful treatment requires aggressive airway control and treatment of seizures with benzodiazepines or barbiturates. Neuromuscular blockade may be required. Gastrointestinal decontamination is usually indicated in recent acute ingestions but may precipitate convulsions. Recovery from strychnine poisoning is usually complete and rapid if treatment is aggressive.