Effects Of Positive Pressure Ventilation Research Articles

PEEP trial and effect on hemodynamic in cardiogenic shock

Abstract Funding Acknowledgements None. Introduction Congestion is a paramount pathophysiological driver in patients with cardiogenic shock. Almost half of patients admitted due to cardiogenic shock undertake mechanical ventilation although ventilatory parameter, and their potential hemodynamic effect on the hemodynamic and congestion profile are often neglected. Purpose We sought to evaluate the hemodynamic effect of positive end-expiratory pressure (PEEP) titration on patients admitted to intensive care unit for CS. Methods We perform PEEP titration trial on patients undertaking mechanical ventilation for respiratory failure related to CS. The trial consisted in 3 steps of PEEP increase from 5 to 15 cmH2O. For each step arterial saturation, right atrial -RAP- and systemic blood pressure along with heart rate and respiratory mechanics (tidal volume-TV-, dynamic lung compliance- CLdyn, driving- Δ- and plateau pressure- Ppl) were measured. All the measures were taken at end-expiration; RAP trace was analyzed and systolic, mean and diastolic component collected. The final PEEP was decided based on the best matching between saturation, CLdyn and TV. Descriptive and repeated measures with Bonferroni correction were applied as statistical analysis (IBM SPSS 29). Results Twelve patients were included (10 male, 66 ± 7 years old; 8 acute myocardial infarction and 4 acute heart failure). At baseline the mean RAP was 8.44 (± 2.32) ; SBP 106 (IQR 92-112), HR 94 (IQR 88 - 102) Δ and Ppl pressures respectively 7.42 (± 0.79) and 12.08 (± 0.79, ),VT 427(± 65.42) and CLdyn 58.3 (± 7.1). The right atrial pressure (RAP) differed between AMI and AHDF (8.25 ± 2.25 vs 20.25 ± 1.5; p < 0.001), so HR did (113 ± 3.4 versus 96 ± 3.2 betas per minutes; p 0.015). RAP varied consistently during the PEEP trial (either sRAP, dRAP and mRAP- Table and Figure 1). The TV changed signficnatly between the 1st and 3rd step (p 0.004) and the CLdyn varied consistently throughout the 3 steps of the PEEP trial (p <0.001). A significant difference were observed according to aetiology in RAP (AMI Vs ADHF, eman difference 2.4 versus 4.3 mmHg) and in CLdyn (AMI Vs ADHF mean difference 12.31 vs 8 .65, p < 0.01) but not in the other parameters evaluated (p > 0.05). Conclusion This is the first, small, study evaluating the effect of positive pressure ventilation in CS patients according to etiologies. As previously demonstrated PEEP influences the right side hemodynamic by increasing the RAP, although resulting in better CLdyn. The extent of the effect of PEEP increased may be dependent on the underlying aetiology of CS. Considering that the sample size is extremely limited, these results advocate a wider validation. However, the positive pressures induced by the ventilation in patient with CS should be taken in consideration when the comprehensive evaluation of hemodynamic to define congestion profile and phenotype are performed.Table 1.Hemodynamic parametersGraph PEEP vs RAP

The Effect of Positive Pressure Ventilation on Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome: An Observational Study

Introduction: Acute kidney injury (AKI) is frequent in critically ill COVID-19 patients and is associated with a higher mortality risk. By increasing intrathoracic pressure, positive pressure ventilation (PPV) may reduce renal perfusion pressure by reducing venous return to the heart or by increasing renal venous congestion. This study’s aim was to evaluate the association between AKI and haemodynamic and ventilatory parameters in COVID-19 patients with ARDS. Methods: This is a single-centre retrospective observational study. Consecutive patients diagnosed with COVID-19 who met ARDS criteria and required invasive mechanical ventilation were enrolled. The relationship between respiratory and haemodynamic parameters influenced by PPV and AKI development was evaluated. AKI was defined according to KDIGO criteria. AKI recovery was evaluated a month after ICU admission and patients were classified as “recovered,” if serum creatinine (sCr) value returned to baseline, or as having “acute kidney disease” (AKD), if criteria for AKI stage 1 or greater persisted. The 6-month all-cause mortality was collected. Results: A total of 144 patients were included in the analysis. AKI occurred in 69 (48%) patients and 26 (18%) required renal replacement therapy. In a multivariate logistic regression analysis, sex, hypertension, cumulative dose of furosemide, fluid balance, and plateau pressure were independently associated with AKI. Mortality at 6 months was 50% in the AKI group and 32% in the non-AKI group (p = 0.03). Among 36 patients who developed AKI and were discharged alive from the hospital, 56% had a full renal recovery after a month, while 14%, 6%, and 14% were classified as having an AKD of stage 0, 2, and 3, respectively. Conclusions: In our cohort, AKI was independently associated with multiple variables, including high plateau pressure, suggesting a possible role of PPV on AKI development. Further studies are needed to clarify the role of mechanical ventilation on renal function.

The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study.

Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts. The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO2). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs. Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8mm Hg) and reduced CPP (ΔCPP = -12.8mm Hg) and mean arterial pressure (difference in mean arterial pressure = -5.2mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O2 = 4mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO2 marginally decreased (ΔrSO2 = -0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = -0.1cm; p < 0.001) with a tendency toward increased RV basal diameter (p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP (p = 0.040) and a larger RV basal diameter (p = 0.034) at baseline. In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM's impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.

A study of comparison of outcomes of positive pressure ventilation and face mask oxygen on arterial blood gas parameters in children with congestive heart failure

Aims and objective. To compare the effects of Positive Pressure Ventilation (PPV) and Face Mask oxygen on arterial blood gas (ABG) parameters in children with congestive heart failure. Materials and methods. A prospective, randomized, single-blind, cross-sectional study was undertaken in eastern India’s Dr. B.C. Roy Post Graduate Institute of Pediatric Sciences PICU. From December 2014 to June 2016, single-blind randomization was used to diagnose congestive heart failure in children aged 3 months to 12 years. Results. Patients receiving face mask oxygen had a mean pH of 7.2150, while those receiving NIV had a mean pH of 7.2740 (P value = 0.012, &lt;0.05). After 6 hours, the pH improved more in the NIV group (mean pH = 7.3023) than the face mask oxygen group (mean pH = 7.2503), P value = 0.003 (&lt;0.05). The group receiving face mask oxygen had a mean pCO2 of 54.93 at the start of the study, while the NIV group had 52.83 (P value = 0.395, &gt;0.05). The baseline pCO2 values of the two groups were similar. After 1-2 hours of investigation, the face mask oxygen group had a mean pCO2 of 53.50, whereas the NIV group had 47.77, with a P value of 0.008 (&lt;0.05). After 4-6 hours, the face mask oxygen group had a mean pCO2 of 50.90, while the NIV group had 46.77, with a P value of 0.001 (&lt;0.05). Conclusion. After 6 hours of therapy, NIV improved mean pH more than face mask oxygen. NIV ventilation improved pCO2 readings more than face mask oxygen after 2 hours. The mean pCO2 drop over 4-6 hours in the NIV group was greater than in the face mask oxygen group.

The effect of positive pressure ventilation on serum ischemia-modified albumin levels in obese patients with obstructive sleep apnea syndrome.

Respiratory abnormalities in obstructive sleep apnea syndrome (OSAS) are corrected with positive pressure ventilation treatments. We investigated the effect of positive airway pressure (PAP) treatment on the serum level of ischemia-modified albumin (IMA), an oxidative stress product, in OSAS patients with higher body mass index (BMI) and indication for PAP treatment. Seven consecutive female and 23 male patients with a BMI of ≥30 kg/m2 who were diagnosed as having OSAS according to ICSD3 criteria and were planned for PAP, were included. The Epworth Sleepiness Scale and STOP-Bang Questionnaire were performed. Morning arterial blood gas, hemogram, biochemistry, insulin, and IMA were measured after polysomnography and after three months of PAP. There were no significant changes in lactate, CRP, and serum electrolyte levels measured before and after PAP, except for potassium. When 30 patients were compared in terms of serum IMA levels at baseline and after treatment, the mean baseline value was 0.56 absorbance units (ABSU), and the 3rd-month follow-up IMA value was 0.53 ABSU (p= 0.537). The mean serum fasting insulin level was 15.85 µIU/mL and 11.6 (p= 0.002) and the mean HOMA index was 4.4 and 3.0 (p= 0.001), respectively. Serum IMA levels seem not to be an appropriate marker for the evaluation of PAP treatment in OSAS patients with higher BMI. PAP is associated with a decrease in the fasting insulin level, HOMA index, and hematocrit, but not with serum electrolytes except potassium.

Effect of positive pressure ventilation on lymphatic flow in pediatric patients

Effect of positive pressure ventilation on lymphatic flow in pediatric patients

REPERCUSSÕES DA VENTILAÇÃO NÃO INVASIVA EM RECÉM-NASCIDOS PREMATUROS COM SÍNDROME DO DESCONFORTO RESPIRATÓRIO AGUDO: REVISÃO INTEGRATIVA

Introdução: Neonatos pré-termos apresentam singularidades anatomofisiológicas predispondo-os a complicações respiratórias como a Síndrome do Desconforto Respiratório Aguda. Caracterizada pelo déficit de surfactante pulmonar e consequente insuficiência respiratória, aumentando a necessidade de suporte ventilatório invasivo e não invasivo. Objetivo: Analisar os efeitos da ventilação não invasiva em recém-nascidos prematuros com Síndrome do Desconforto Respiratório Aguda. Metodologia: Trata-se de uma revisão integrativa no qual utilizou-se das bases de dados: SciELO, LILACS, PEDro, MEDLINE e Bireme. Os critérios de inclusão foram estudos relacionados a temática em português, inglês e espanhol; completos e com publicação entre 2015 a 2020. Resultados: Nos 7 estudos sintetizados houve a utilização dos sistemas de suporte ventilatório: pressão positiva em vias aéreas a dois níveis: cânulas nasais aquecidas, umidificadas e de alto fluxo; ventilação de pressão positiva nas vias aéreas nasal, e a ventilação por pressão positiva intermitente nasal. Dois estudos que utilizaram cânulas nasais apontaram efeitos menos benéficos; e um relatou desfechos semelhantes aos demais, além de provocar menor dano nasal. Conclusões: Os recursos analisados obtiveram resultados equivalentes, apontando a eficácia da ventilação por pressão positiva e da pressão positiva intermitente na extubação. Com destaque para a necessidade de pesquisas no uso de cânulas nasais de alto fluxo.

Mechanical ventilation in cardiogenic shock.

Mechanical ventilation is frequently needed in patients with cardiogenic shock. The aim of this review is to summarize and discuss the current evidence and the pathophysiological mechanism that a clinician should consider while setting the ventilator. Little attention has been placed specifically to ventilatory strategies in patients with cardiogenic shock undertaking mechanical ventilation. Lung failure in patients with cardiogenic shock is associated with worsening outcome as well as a delay in mechanical ventilation institution. The hemodynamic profile and cardiogenic shock cause, considering the preload dependency of the failing heart, must be defined to adjust ventilatory setting. Evidence is growing regarding the role of lung failure as adverse prognostic factor and beneficial effect of positive pressure ventilation as part of first-line treatment in patients with cardiogenic failure.

Association Between Fast-Track Extubation After Orthotopic Liver Transplant, Postoperative Vasopressor Requirement, and Acute Kidney Injury.

Acute kidney injury is a significant cause of morbidity after orthotopic liver transplant. Early extubation after liver transplant may have a beneficial effect on postoperative renal function. This may be the result of reduction in vasopressor-mediated vasoconstriction used to counteract the hypotension associated with sedative use and the effects of positive-pressure ventilation. Previous studies explored advantages of early extubation after liver transplant but focused on resource usage rather than clinical benefit. This study was designed to determine the association between fast-track extubation and reduction in postoperative vasopressor requirement and whether this had any association with acute kidney injury incidence or renal replacement therapy requirement. Data were collected from 144 orthotopic liver transplants. A propensity-matched case-control analysis was conducted on a subgroup of 33 patients who were fast-track extubated and with 33 propensity score-matched control patients who were not. The primary outcome was median days of postoperative vasopressor use, and secondary outcomes included incidence of acute kidney injury, renal replacement therapy requirement, and critical care admission duration. The fast-track extubation group had a shorter postoperative vasopressor requirement (0 vs 2 days; P < .01) and a reduced need for renal replacement therapy (3% vs 21.2%; P = .05). Median critical care admission duration (3 vs 4 days; P = .03) and hospital admission duration (14 vs 19 days; P = .04) were shorter in the fast-track extubation group. This is the first study to reveal a significant association between fast-track extubation and reduced postoperative vasopressor requirement. Additionally, this was associated with a trend toward reduced renal replacement requirement after liver transplant. It suggests that early extubation may not just be a resource benefit to an institution but may convey a clinical benefit to patients through a reduction in organ failure and requirement for organ support.

Respiratory Management of Acute Cardiogenic Pulmonary Edema: A Review

Acute cardiogenic pulmonary edema (ACPE) is a common and life-threatening condition among patients with heart failure. The literature contains a large number of reviews discussing the respiratory management aspect of this entity; nonetheless, none of these studies has thoroughly probed into the respiratory management of different cardiac pathologies ending with ACPE, together with the different modes of ventilation and invasive and noninvasive ventilation in the same discussion. The present review seeks to discuss the physiologic bases of lung-heart interactions, the hemodynamic effects of positive pressure ventilation, and the results of studies on the effects of the various modes of ventilation having been used until the writing of this article. Also discussed herein are ACPE in different heart pathologies and their respective ventilator management, as well as the indications, complications, and contraindications of noninvasive positive pressure ventilation and intermittent mandatory ventilation.

The Effect of Positive Pressure Ventilation on Aldosterone Level in Critically Ill Patients; Correlation with Renal Function and the Length of Stay in ICU

Abstract Background: Positive pressure ventilation has been shown to alter a variety of neurohormonal systems including sympa-thetic outflow, the renin-angiotensin axis, nonosmotic vaso-pressin (ADH) release and atrial natriuretic peptide (ANP) production. The end result of all of these neurohormonal pathways is diminished renal blood flow, decreased GFR, and fluid retention (salt and water) with oliguria. Aim of Study: To investigate the effect of positive pressure mechanical ventilator on aldosterone and to study its prognostic value. Patients and Methods: This study was conducted on 50 patients admitted to the intensive care unit (ICU) and needed mechanical ventilation and did not meet any of exclusion criteria and 25 control (critically ill patients who did not need mechanical ventilator). The patients were divided into 2 equal groups; group I with high PEEP (10-15) and group II with physiological PEEP (3-5).Aldosterone level was measured for these patients on first day of using PPV (aldosterone 1) then after 72h (aldosterone 2). Results: Aldosterone levels were increased with use mechanical ventilation and were significantly higher with higher level of PEEP. There were correlations between aldos-terone 2 with urea and Creatinine levels and with length of ICU stay only in patient group (p<0.001). Conclusion: Mechanical ventilation caused elevation of aldosterone levels. Aldosterone levels in mechanically venti-lated patients correlated with kidney function test (urea and Creatinine) and with length of ICU stay.

Effect of Treatment of Central Sleep Apnea/Cheyne-Stokes Respiration on Left Ventricular Ejection Fraction in Heart Failure: A Network Meta-Analysis.

Patients who have experienced heart failure with central sleep apnea/Cheyne-Stokes respiration (CSA/CSR) have an impaired prognosis. Continuous positive airway pressure (CPAP) and adaptive servoventilation (ASV) as well as nocturnal oxygen (O₂) are proposed treatment modalities of CSA/CSR. The goal of the study is to assess whether and how different treatments of CSA/CSR affect cardiac function. Databases were searched up to December 2017 for randomized controlled trials (RCTs) comparing the effect of any combination of CPAP, ASV, O₂ or an inactive control on left ventricular ejection fraction (LVEF) in patients with heart failure and CSA/CSR. A systematic review and network meta-analysis using multivariate random-effects meta-regression were performed. Twenty-four RCTs (1,289 patients) were included in the systematic review and data of 16 RCTs (951 patients; apnea-hypopnea-index 38 ± 3/h, LVEF 29 ± 3%) could be pooled in a network meta-analysis. Compared to an inactive control, both CPAP and ASV significantly improved LVEF by 4.4% (95% confidence interval 0.3-8.5%, P = 0.036) and 3.8% (95% confidence interval 0.6-7.0%, P = 0.025), respectively, whereas O₂ had no effect on LVEF (P = 0.35). There was no difference in treatment effects on LVEF between CPAP and ASV (P = 0.76). The treatment effect of positive pressure ventilation was larger when baseline LVEF was lower in systolic heart failure. CPAP and ASV are effective in improving LVEF in patients with heart failure and CSA/CSR to a clinically relevant amount, whereas nocturnal O₂ is not. There is no difference between CPAP and ASV in the comparative beneficial effect on cardiac function.

IBS26.03 Surgical Technique of Pleurectomy/Decortication

IBS26.03 Surgical Technique of Pleurectomy/Decortication

ネーザルハイフロー施行により両側気胸を来した1例(A case of bilateral pneumothorax induced by nasal high–flow therapy)

要旨ネーザルハイフローセラピー（nasal high–flow therapy: 以下NHF）施行により両側気胸を来した稀な症例を経験した。症例は70歳代の男性，呼吸困難を主訴に前医を受診し胸部CT検査で両側肺炎および肺気腫の所見がみられた。既往歴は腹部大動脈瘤，肺炎，高血圧があった。1日30本を50年間の喫煙歴があった。前医入院後，抗菌薬投与および酸素療法として12L/minリザーバーマスク装着するも酸素化不良があり，NHFをFIO2 1.0・40L/minの条件で開始したところSpO2 95%まで上昇した。第4病日以降，FIO2 0.6・30L/minまで減量できたが第11病日に呼吸困難感が突然悪化し，両側気胸の診断で両胸に胸腔ドレーンを留置し，第12病日に対応不能のため当院に転院となった。右胸腔に2本，左胸腔に1本のドレーンを留置した。肺炎の再燃なく第17病日に抗菌薬投与を終了し，第18病日に左胸腔ドレーンを，第24病日および第30病日に右胸腔ドレーンを抜去したが，気胸の再発はなかった。NHFは呼吸不全患者に対し様々な生理学的効果を持つことから広く普及しつつある。本症例では重症肺炎の治癒過程における肺コンプライアンス低下を背景としてNHFの陽圧換気様効果により両側気胸を発症したと考えた。成人ではNHFで気胸となった報告は稀だが，NHFを行う際には気胸の合併に注意を要すると考えた。

Clinically-relevant cardiopulmonary interactions for the pediatric intensivist.

A thorough understanding of cardiorespiratory interactions is essential when caring for critically ill children. These interactions are linked to changes in intrathoracic pressure and their impact on cardiac preload and afterload. The predominant effect of positive-pressure ventilation in children with normal cardiac function is to decrease preload to the right heart with an eventual decrease in left ventricular stroke volume. This can be anticipated and mitigated by judicious fluid resuscitation. The effect of positive-pressure ventilation on right heart afterload is more complex and variable depending on lung volume. In patients with diminished left ventricular contractility, positive pressure reduces afterload to the left heart, significantly improving stroke volume. Monitoring of cardiorespiratory interactions in critically ill children is beneficial in assessing volume status and predicting fluid responsiveness.

Heart-lung interactions in acute respiratory distress syndrome: pathophysiology, detection and management strategies.

Acute respiratory distress syndrome (ARDS) is the most severe form of acute respiratory failure characterized by diffuse alveolar and endothelial damage. The severe pathophysiological changes in lung parenchyma and pulmonary circulation together with the effects of positive pressure ventilation profoundly affect heart lung interactions in ARDS. The term pulmonary vascular dysfunction (PVD) refers to the specific involvement of the vascular compartment in ARDS and is expressed clinically by an increase in pulmonary arterial (PA) pressure and pulmonary vascular resistance both affecting right ventricular (RV) afterload. When severe, PVD can lead to RV failure which is associated to an increased mortality. The effect of PVD on RV function is not only a consequence of increased pulmonary vascular resistance as afterload is a much more complex phenomenon that includes all factors that oppose efficient ventricular ejection. Impaired pulmonary vascular mechanics including increased arterial elastance and augmented wave-reflection phenomena are commonly seen in ARDS and can additionally affect RV afterload. The use of selective pulmonary vasodilators and lung protective mechanical ventilation strategies are therapeutic interventions that can ameliorate PVD. Prone positioning and the open lung approach (OLA) are especially attractive strategies to improve PVD due to their effects on increasing functional lung volume. In this review we will describe some pathophysiological aspects of heart-lung interactions during the ventilatory support of ARDS, its clinical assessment and discuss therapeutic interventions to prevent the occurrence and progression of PVD and RV failure.

Hemodynamic profile of pulmonary hypertension (PH) in ARDS.

Acute respiratory distress syndrome (ARDS) is a diffuse lung injury that leads to a severe acute respiratory failure. Traditional diagnostic criteria for pulmonary hypertension (PH), in this situation, may be unreliable due to the effects of positive pressure ventilation and vasoactive agents. The aim of this study is to describe the hemodynamic characteristics of PH secondary to ARDS, in relation with respiratory parameters. We assessed the hemodynamic, respiratory function, and ventilator parameters in a cohort of 38 individuals with ARDS-associated PH defined by mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg. Individual characteristics: PaO2/FiO2 = 110 ± 60 mmHg, alveolar-arterial oxygen gradient (A-aO2) = 549 ± 148.9 mmHg, positive end-expiratory pressure (PEEP) = 8.7 ± 3.5 cmH2O, pulmonary static compliance (Cstat) = 30 ± 12.1 L*cmH2O-1, mPAP = 35.4 ±6.6 mmHg, pulmonary artery wedge pressure (PAWP) = 15.6 ± 5.5 mmHg, cardiac index (CI) = 3.4 ± 1.2 L/min/m2, pulmonary vascular resistance (PVR) = 3.3 ± 1.6 Wood units (WU), right atrial pressure (RAP) = 13.4 ± 5.4 mmHg, diastolic pulmonary gradient (DPG) = 12.6 ± 6.5 mmHg, and trans-pulmonary gradient (TPG) = 19.7 ± 7.7 mmHg. The composite marker—DPG >7 mmHg and PVR > 3 WU—is associated with lower CI (P = 0.016), higher mPAP (P = 0.003), and lower pulmonary static compliance (P = 0.028). We confirmed a poor prognosis of ARDS associated with PH, with a 50% survival rate after 17 days. We observed that the survival rate at 28 days was better in the case of improvement in the PaO2/FiO2 ratio in the first 24 h (log rank P = 0.003). ARDS associated with PH is a severe condition with a very poor survival rate. The composite marker DPG > 7 mmHg and PVR > 3 WU seemed to better describe the hemodynamic and respiratory dysfunction. The improvement in PaO2/FiO2 ratio in the first 24 h defined a better survival in our cohort of patients.

An Emergency Case: A Successful Anesthetic Management of Aorta-Trachea Fistula

This report describes 19 year old male with a case with tracheal necrosis and the presence of ascendan aortic fistula with the sign of massive hemoptysis which is diagnosed intraoperatively, although preoperative chest CT has not demonstrated the findings. This emergency case report was to demonstrate the possible ways ofintraoperative management in similar desperate situations. On the first hand, laparotomy is done as planned previously to extract omentum for the support of suspected tracheal injury. Second part of the operation continued with sternotomy and emergently one lung ventilation and later extra corporal circulation. At the end of the operation, the patient was transferred to ICU. He has been discharged from hospital without any haemodynamic or neurological complication. In this case priority is maintaining oxygenation. The inflammatory changes in the surgical anatomic region must be carefully considered. Postoperative ventilation parameters and side effects of positive pressure ventilation make ECMO devices mandatory.

Improvement of Positive Pressure Ventilation by optimizing stairwell door opening area

This technical note presents a strategy to increase the effectiveness of Positive Pressure Ventilation (PPV) tactics in firefighting. It is shown that deployment of a Door Open Area Reducer (DOAR) in an appropriate position, which increases the resistance to the air escaping the stairwell, can significantly improve effectiveness of PPV performance. The simulation results demonstrate that an optimal placement of the fan combined with an optimized DOAR height can increase the pressure significantly yielding higher PPV effectiveness.

Effectiveness of positive pressure ventilation during newborn care unit evacuation

ObjectiveAssess the utility of high fidelity simulation in understanding effectiveness of bag-valve ventilation in a simulated newborn intensive care unit vertical evacuation. ParticipantsA total of 70 participants, (13 teams of 4–6 staff) including physicians, nurses, respiratory therapists and other support personnel participated in a 90-min evacuation sessions. MethodsTwo wireless high-fidelity newborn mannequins (Gaumand ScientificR) provided real-time data of ventilation support during a NICU evacuation exercise. Trained evaluators also recorded data related to performance. Following the exercises, the simulator data were downloaded and analyzed for rate and consistency of respirations. ResultsUsing the data from the simulators and evaluator comments, it was found the infants received proper airway management during the evacuation only 58% of the time. This study highlights the need for ongoing training for NICU staff around safe, effective, coordinated, and timely care of these fragile newborns in the event of an evacuation.