Endotracheal Intubation Time Research Articles

LO08: Effect of an intact “chain of survival” sequence on survival to discharge from out-of-hospital cardiac arrest

Introduction: The “chain of survival” is a 5-link theoretical construct that has been central to cardiac arrest resuscitation for over 40 years. Although the role of each link has been extensively studied, little is known about the impact of performing the chain of survival in sequence. The purpose of this study was to estimate the proportion of out-of-hospital cardiac arrest (OHCA) responses by Emergency Medical Services (EMS) that had an intact chain of survival sequence response, and the effect of this on survival to hospital discharge. Methods: We conducted a prospective cohort study of adult (>age 20 years) OHCA patients using data collected between 2005-2007 by the Resuscitation Outcomes Consortium (ROC). ROC is a research network involving 10 research sites and 264 EMS agencies across North America. Using routinely collected data, we coded cases as receiving an intact or non-intact chain of survival sequence based on EMS cardio pulmonary resuscitation (CPR), rhythm analysis or defibrillation, epinephrine administration or endotracheal intubation, and transport to a hospital with an electrophysiology lab or percutaneous coronary intervention capability, contingent on the patient’s condition when EMS arrived. Multiple variable logistic regression was performed, adjusting for known (Utstein) survival predictors, to estimate the independent effect of intact chain of survival sequence on survival to hospital discharge. REB approval was obtained. Results: We enrolled12,821 OHCA cases, of which, 29.4% (n=3,773) had an intact chain of survival and 7.6% (n=972) survived to hospital discharge. Cases with an intact chain of survival were younger, and more likely to arrest in public, receive bystander CPR, occur in the USA and specific ROC sites, and had faster EMS response times. The adjusted odds ratio of survival to hospital discharge with an intact chain of survival sequence was 2.4 (95% CI: 2.1-2.8). A sensitivity analysis of 4,056 cases with known timing of endotracheal intubation found a similar adjusted odds ratio of 2.1 (95% CI: 1.6-2.8). Conclusion: Our results indicate that OCHA resuscitation with an intact chain of survival occurs in approximately 1/3 of cases, and results in over a two-fold increase in the odds of surviving to hospital discharge. Initiatives to improve EMS teamwork and increase the proportion of OHCA resuscitation with an intact chain of survival appear to be warranted.

Profiling of ARDS pulmonary edema fluid identifies a metabolically distinct subset.

There is considerable biological and physiological heterogeneity among patients who meet standard clinical criteria for acute respiratory distress syndrome (ARDS). In this study, we tested the hypothesis that there exists a subgroup of ARDS patients who exhibit a metabolically distinct profile. We examined undiluted pulmonary edema fluid obtained at the time of endotracheal intubation from 16 clinically phenotyped ARDS patients and 13 control patients with hydrostatic pulmonary edema. Nontargeted metabolic profiling was carried out on the undiluted edema fluid. Univariate and multivariate statistical analyses including principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) were conducted to find discriminant metabolites. Seven-hundred and sixty unique metabolites were identified in the pulmonary edema fluid of these 29 patients. We found that a subset of ARDS patients (6/16, 38%) presented a distinct metabolic profile with the overrepresentation of 235 metabolites compared with edema fluid from the other 10 ARDS patients, whose edema fluid metabolic profile was indistinguishable from those of the 13 control patients with hydrostatic edema. This "high metabolite" endotype was characterized by higher concentrations of metabolites belonging to all of the main metabolic classes including lipids, amino acids, and carbohydrates. This distinct group with high metabolite levels in the edema fluid was also associated with a higher mortality rate. Thus metabolic profiling of the edema fluid of ARDS patients supports the hypothesis that there is considerable biological heterogeneity among ARDS patients who meet standard clinical and physiological criteria for ARDS.

Comparison of endotracheal intubation time in neutral position between C-Mac® and Airtraq® laryngoscopes: A prospective randomised study.

Background and Aims:In the recent past, many novel devices such as AirTraq® and C-MAC® video laryngoscope (VL) have been introduced in an attempt to reduce anaesthetic morbidity and mortality associated with difficult intubation. In this study, we aimed to evaluate and compare C-MAC® VL with a standard Macintosh blade and the AirTraq® optical laryngoscope as a intubating devices with the patient's head in neutral position.Methods:Sixty American Society of Anesthesiologist Physical Status I–II patients were randomly assigned to be intubated with C-MAC® VL (Group CM; n = 30) or AirTraq® (Group AT; n = 30) in the neutral position, with or without the application of optimization manoeuvres. The primary outcomes of this study were the success rate and the time taken to intubate. Glottic view, ease of tracheal intubation and haemodynamic responses were considered as secondary end points.Results:The incidence of successful intubation was similar in both the groups (P = 1.00). However, the time for intubation was significantly less with C-MAC® VL (Group CM = 14.9 ± 12.89 s, Group AT = 26.3 ± 13.34 s; P = 0.0014). There was no significant difference between the two groups in terms of ease of intubation and glottic view. However, the haemodynamic perturbations were much less with C-MAC® VL.Conclusion:We conclude that both the devices were similar in visualising larynx in the neutral position with similar success rates of intubation. However, the C-MAC® VL was better with respect to intubation time and haemodynamic stability.

Abstract PR011

Background & Objectives: There are limited data on outcomes of in-hospital cardiac arrests in a resource-limited setting of low- and middle- income countries like Nepal. Our objective was to find the factors associated with the outcome, primarily the return of spontaneous circulation (ROSC), after cardiopulmonary resuscitation in in-hospital cardiac arrest patients in a resource-limited setting. Materials & Methods: A one-year outcome assessment of in-hospital cardiac arrests were analyzed in a university teaching hospital in Nepal. The study population included all the adult patients (age>18 years) who had in-hospital cardiac arrests. Primary outcomes were return of spontaneous circulation (ROSC). We measured the association of following variables on ROSC after cardiac arrest: witnessed or not witnessed, time of CPR, availability of monitor, time to arrival of monitor, collapse to resuscitation time and attempts of endotracheal intubation. Results: A total of 70 patients who experienced in-hospital cardiac arrests were analyzed. Thirty-seven patients (52.8%) had return of spontaneous circulation, out of which 20 (28.5% p=0.027) were witnessed and 17 (24.3%) were not witnessed arrests. Most of the cardiac arrests happened during the night duty hours (77%). Monitor was available at arrest site in only 24 (34%; p=0.002) of events and there was no monitor available during 8 (11%) events. After monitors were transferred in from another site, the ROSC was seen in 8(21%), 7 (18.4%) and 5(13%) at less than 5, 6 to 10 and more than 10 minutes of monitor arrival respectively. The collapse to resuscitation time was less than 3, 4 to 5 and more than 5 minutes for 40 (57%), 6 (9%) and 24 (34%) patients respectively. Greater number of patients, i.e. 22 (31%), had ROSC when collapse to resuscitation time was less than 3 minutes. Single attempt of successful endotracheal intubation was associated with greater number of ROSC. Conclusion: Returns of spontaneous circulation following CPR were independently associated with the witnessed arrests and the availability of monitor at the arrest site. Disclosure of Interest: None declared

Usefulness of video-laryngoscopy with the Airway Scope for intubation performance and learning: an experimental manikin controlled study.

BackgroundDifferent video-laryngoscopes (VDLs) for endotracheal intubation (ETI) have recently been developed. We compared the performance of the VDL Airway Scope (AWS) with the direct laryngoscopy by Macintosh (DLM) for ETI success, time and learning.Methods We performed an experimental manikin controlled study. Twenty experienced (experts) and 40 inexperienced operators (novices) for DLM-ETI were enrolled. None of them had experience with the use of AWS-VDL. Novices were assigned to start learning with DLM or AWS, and two sub-groups of 20 novices were formed. Experts group constituted the control group. Each participant performed 10 ETI attempts with each device on the same standard manikin. The primary endpoint was the ETI success probability. Secondary endpoints were ETI time, technical validity and qualitative evaluation for each technique. We also assessed the learning order and the successive attempts effects for these parameters.ResultsOverall, 1200 ETI attempts were performed. ETI success probability was higher with the AWS than with the DLM for all operators (98 vs. 81 %; p < 0.0001) and for experts compared to novices using devices in the same order (97 vs. 83 %; p = 0.0002). Overall ETI time was shorter with the AWS than with the DLM (13 vs. 20 s; p < 0.0001) and for experts compared to novices using devices in the same order (11 vs. 21 s; p < 0.0001). Among novices, those starting learning with AWS had higher ETI success probability (89 vs. 83 %; p = 0.03) and shorter ETI time (18 vs. 21 s; p = 0.02). Technical validity was found better with the AWS than DLM for all operators. Novices expressed global satisfaction and device preference for the AWS, whereas experts were indifferent.ConclusionsAWS-VDL permits faster, easier and more reliable ETI compared to the DLM whatever the previous airway ETI experience and could be a useful device for DLM-ETI learning.

Automatic Detection of Endotracheal Intubation During the Anesthesia Procedure.

This paper is concerned with the mathematical modeling and detection of endotracheal (ET) intubation in children under general anesthesia during surgery. In major pediatric surgeries, the airway is often secured with an endotracheal tube (ETT) followed by initiation of mechanical ventilation. Clinicians utilize auscultation of breath sounds and capnography to verify correct ETT placement. However, anesthesia providers often delay timely charting of ET intubation. This latency in event documentation results in decreased efficacy of clinical decision support systems. In order to target this problem, we collected real inpatient data and designed an algorithm to accurately detect the intubation time within the clinically valid range; the results show that we are able to achieve high accuracy in more than 96% of the cases. Automatic detection of ET intubation time would thus enhance better real-time data capture to support future improvement in clinical decision support systems.

Application of new blood-saving extracorporeal circulation circuits in open heart surgery

Objective To explore the blood-saving and conservation effect and clinical prognosis of extracorporeal circulation circuits designed individually by using medical polymeric materials for adults and infants in cardiac surgical procedures. Methods A total of 41 new extracorporeal circulation circuits designed based on the operation requirements, including 20 for adults and 21 for infants, were applied on adults and infants (body weight less than 10 kg), and the results were compared with that of the conventional circuits on adults (20) and infants (19) respectively. Total priming volume, priming and intraoperative blood products consumption, pump pressure, intraoperative blood hemoglobin (Hb) level, free Hb (f-Hb), platelet (Plt) count, mixed venous oxygen saturation (SvO2), colloid osmotic pressure (COP), lactate (Lac) level, Hb level after modified ultrafiltration, endotracheal intubation time and ICU time were all collected in two groups. Results Priming volume, priming and intraoperative blood consumption and f-Hb level in the blood-saving and conservation circuits group were significantly lower than that of conventional circuits group (P 0.05) between the two groups in pump pressure, intraoperative blood Hb level, Plt, SvO2, COP, Lac level, Hb level after modified ultrafiltration, endotracheal intubation time and ICU time. Conclusions The minimized blood conservation extracorporeal circulation circuit plays an important role in reducing priming volume and blood transfusion. It maintains a normal level of hemodynamics, oxygenation and tissue perfusion level during cardiopulmonary bypass in cardiac surgery for adults and infants. Red blood cell destruction can be reduced by improving blood compatibility, and physical data are all stabilized intra and post operation. This new circuit is secure, with its better outcome, expected in application. Key words: Extracorporeal circulation; Infant; Blood-saving circuit

Flexible optical intubation via the Ambu Aura-i vs blind intubation via the single-use LMA Fastrach: a prospective randomized clinical trial

Study ObjectiveThis study was designed to compare the Ambu Aura-i to the single-use LMA Fastrach regarding time to intubation, success rate, and airway morbidity in patients undergoing elective surgery requiring general anesthesia. DesignProspective, randomized controlled trial. SettingAcademic medical center. PatientsSixty-five adult patients scheduled for elective surgery requiring general anesthesia. InterventionsPatients were randomized into 2 groups. Group A (n=33) were intubated using Ambu Aura-i and the Ambu aScope 2, a disposable flexible intubating scope, whereas those in group B (n=33) were blindly intubated using the Intubating Laryngeal Mask Airway (ILMA). MeasurementsFirst-attempt intubation success rate, overall intubation success rate, time to intubation, incidence of airway morbidity. Main resultsThe data demonstrated that time for endotracheal intubation in the ILMA group was significantly shorter than in the Ambu Aura-i group (P<.05). There was no difference in the first-attempt intubation success rate (Aura-i=26/33, 78.8%; ILMA=27/33, 81.8%; P=.757) or the overall intubation success rate (Aura-i=29/33, 87.9%; ILMA=31/33, 93.9%; P=.392) between the groups. Four patients (12%) in the Ambu Aura-i group had a failed intubation; 1 was due to a failure of the aScope monitor, whereas 3 were due to inability to visualize the glottis. Two patients (7%) in the ILMA group had a failed intubation due to esophageal intubation. There was no statistically significant difference in airway morbidity between the 2 groups. ConclusionsThe data suggest that intubation with the ILMA is faster but that first-attempt and overall intubation success rates were comparable in both groups. The results suggest that although the flexible intubating scope–guided Aura-i does not outperform blind intubation via the ILMA, the technique is comparable in terms of first-attempt and overall intubation success rate.

Video Laryngoscopic Techniques Associated with Intubation Success in a Helicopter Emergency Medical Service System

Objectives. Video laryngoscopy (VL) is a technical adjunct to facilitate endotracheal intubation (ETI). VL also provides objective data for training and quality improvement, allowing evaluation of the technique and airway conditions during ETI. Previous studies of factors associated with ETI success or failure are limited by insufficient nomenclature, individual recall bias and self-report. We tested whether the covariates in prehospital VL recorded data were associated with ETI success. We also measured association between time and clinical variables. Methods. Retrospective review was conducted in a non-physician staffed helicopter emergency medical service system. ETI was typically performed using sedation and neuromuscular-blockade under protocolized orders. We obtained process and outcome variables from digitally recorded VL data. Patient characteristics data were also obtained from the emergency medical service record and linked to the VL recorded data. The primary outcome was to identify VL covariates associated with successful ETI attempts. Results. Among 304 VL recorded ETI attempts in 268 patients, ETI succeeded for 244 attempts and failed for 60 attempts (first-pass success rate, 82% and overall success rate, 94%). Laryngoscope blade tip usually moved from a shallow position in the oropharynx to the vallecula. In the multivariable logistic regression analysis, attempt time (p = 0.02; odds ratio [OR] 0.99), Cormack-Lehane view (p < 0.001; OR 0.23), bodily fluids obstructing the view (p = 0.01; OR 0.29), and VL equipment failure (p < 0.001; OR 0.14) were negatively associated with successful attempts. Bodily fluids obstructing the view (p < 0.001; hazard ratio [HR] 0.51), VL equipment failure (p = 0.003; HR 0.42), shallow placement of blade tip within 4 seconds (p < 0.001; HR 0.40), number of forward movements (p < 0.001; HR 0.84), trauma (p = 0.04; HR 0.65), and neurological diagnosis (p = 0.04; HR 0.60) were associated with longer ETI attempt time. Conclusions. Bodily fluids obstructing the view, equipment problems, higher Cormack-Lehane view, and longer ETI attempt time were negatively associated with successful ETI attempts. Initially shallow blade tip position may associate with longer ETI time. VL is useful for measuring and describing multiple factors of ETI and can provide valuable data.

Efficacy of intravenous paracetamol on pressor response in patients undergoing cesarean section under general anesthesia.

Background and Aims:Profound hemodynamic alterations due to stress and pain during endotracheal intubation may cause deleterious effects. The purpose of this study was to evaluate the effect of intravenous (IV) paracetamol on hemodynamic changes due to endotracheal intubation during cesarean section under general anesthesia.Material and Methods:Random allocation of one hundred and ten patients in two groups (Group A - placebo and Group B - paracetamol), was achieved as per computer generated table. The placebo (normal saline) and paracetamol solutions looked identical as both were available in 100 ml piggy bags and were labeled as study drug. Infusion of the drug was given 1 h before surgery. Two baseline readings of heart rate, systolic blood pressure (BP), diastolic BP and mean BP were recorded before induction, and these readings were repeated during intubation. Detrimental effect on neonate was evaluated by Apgar score measured at 1 and 5 min after birth.Results:There were no significant demographic differences found between the two groups. Hemodyamic changes during intubation also did not differ between the two groups.Conclusion:Administration of IV paracetamol 1 h before cesarean section has no significant effect in preventing hemodynamic changes at the time of endotracheal intubation.

Application Effect and Nursing of Non-Invasive Ventilation in Acute Exacerbation of Chronic Obstruction Pulmonary Disease Patients

&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt; To study the application methods, summarize the nursing experience and discuss the clinical effect of non-invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease (COPD). &lt;strong&gt;Methods:&lt;/strong&gt; 152 cases of AECOPD patients, who received treatment in our hospital from January 2011 to December 2013, were selected and divided into the experimental group and control group randomly. Patients in control group received conventional treatment, whereas besides conventional treatment, experimental group received non-invasive positive pressure ventilation and relevant nursing management. The changes in arterial blood gas and clinical indicators before and after treatment for both groups were observed. &lt;strong&gt;Results:&lt;/strong&gt; After 7 days treatment, all the results of blood gas analysis were significantly improved (&lt;em&gt;p&lt;/em&gt; &amp;lt; 0.05). For the respiratory status (based on Borg scale), two groups were significantly improved after treatment, however, experimental group shown better than control group (&lt;em&gt;p&lt;/em&gt; &amp;lt; 0.05). The two groups had statistically significant difference (&lt;em&gt;p&lt;/em&gt; &amp;lt; 0.05) in the aspects of prognosis, endotracheal intubation and hospitalization time. As for the death index, there was no significant difference between two groups. No special treatment was needed for adverse reactions, they would be relieved slowly. &lt;strong&gt;Conclusion:&lt;/strong&gt; Non-invasive positive pressure ventilation able to improve the recovery rate and quality of life of patients with acute exacerbation of COPD.&lt;/p&gt;

Application Effect and Nursing of Non-Invasive Ventilation in Acute Exacerbation of Chronic Obstruction Pulmonary Disease Patients

Objective: To study the application methods, summarize the nursing experience and discuss the clinical effect of non-invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease (COPD). Methods: 152 cases of AECOPD patients, who received treatment in our hospital from January 2011 to December 2013, were selected and divided into the experimental group and control group randomly. Patients in control group received conventional treatment, whereas besides conventional treatment, experimental group received non-invasive positive pressure ventilation and relevant nursing management. The changes in arterial blood gas and clinical indicators before and after treatment for both groups were observed. Results: After 7 days treatment, all the results of blood gas analysis were significantly improved ( p < 0.05). For the respiratory status (based on Borg scale), two groups were significantly improved after treatment, however, experimental group shown better than control group ( p < 0.05). The two groups had statistically significant difference ( p < 0.05) in the aspects of prognosis, endotracheal intubation and hospitalization time. As for the death index, there was no significant difference between two groups. No special treatment was needed for adverse reactions, they would be relieved slowly. Conclusion: Non-invasive positive pressure ventilation able to improve the recovery rate and quality of life of patients with acute exacerbation of COPD.

The relationship between prehospital endotracheal intubation and the postoperative pulmonary infection in patients with traumatic brain injury

Objective To investigate the impacts of prehospital endotracheal intubation on postoperative pulmonary infection in the patients with severe traumatic brain injury. Methods Retrospectively, the clinical data of 284 patients with severe traumatic brain injury admitted in the 97th Hospital of PLA from July 2007 to December 2012 were analyzed. The patients were classified into two groups according to the timing of endotracheal intubation, namely, prehospital intubation group and admission intubation group. The postoperative pulmonary infection incidence, occurrence time, and the duration of treatment of the two groups were studied. Results The incidences of postoperative pulmonary infection in patients intubated before and after admission were 38.0% and 25.2% respectively. Pulmonary infection occurred in the prehospital intubation group was at the (9.9±0.6) d after admission, and in the admission intubation group was at the (11.6±0.3) d after admission. The duration of treatment for postoperative pulmonary infection was (21.2±7.2) days and (14.5±9.0) days respectively. Compared with the patients intubated after admission, patients intubated before admission suffered higher incidence (P <0.05) , earlier onset (P <0.05) , and longer treatment duration of pulmonary infection (P <0.01). Conclusions Severe traumatic brain injury patients with prehospital endotracheal intubation are more susceptible to pulmonary infection. Avoiding the tracheal injury and bacterial contamination in the procedure could reduce the incidence of pulmonary infection. Key words: Trauma; Brain injury; Pulmonary infection; Endotracheal intubation; Prehospital; Postoperation; Complication; Prevention

Risk factors and prognosis of hypotension in postoperative sedation patients

To explore the risk factors and prognosis of hypotension in postoperative sedation patients. A total of 175 patients with postoperative sedation at our department from May 2013 to March 2014 were retrospectively reviewed. Patients with age <18 years, cardiac surgery, pheochromocytoma surgery, hemorrhagic shock, septic shock or cardiogenic shock were excluded. APACHE II, dosage and duration of sedative drug, mean arterial pressure at baseline and after sedation, central venous pressure, fluid balance, dosage and duration of norepinephrine, endotracheal intubation time and length of intensive care unit (ICU) stay were recorded. Blood pressures decreased significantly after administration of sedation (77.2 ± 11.2 vs 82.6 ± 9.3 mmHg, P = 0.000). Compared to those with lower disease severity (APACHEII ≤ 10), the patients with APACHEII.>10 required higher norepinephrine dosage and longer time of infusion. A longer time of norepinephrine infusion was needed for patients with coronary heart disease. Patients undergoing thoracic, abdominal or pelvic surgery, or those with hepatic dysfunction had a higher norepinephrine dosage. Decrement of blood pressure and norepinephrine duration were independent risk factors of endotracheal intubation time. And dosage and duration of norepinephrine were independent risk factors of ICU time. Disease severity, past history of heart disease, surgical site and liver function are risk factors of hypotension in postoperative sedation patients. It is important to pay attention to dosage and administrative route of sedative drug. Norepinephrine duration after sedation is an independent risk factor of endotracheal intubation time and ICU time.

早期循证护理对预防重症急性胰腺炎相关性肺损伤的临床 价值研究

Objective : To investigate the severe acute pancreatitis in patient with early application of evidence-based care,where to improve breathing,reduce mortality and shorten the time of ICU. Methods: 80 patients diagnosed with SAP were randomly divided into two groups,A group(control group) 40 cases,B group(evidence-based nursing group) 40 cases,two groups of baseline have no significant difference( P > 0.05). Results: The treatment of respiratory support,B group significantly reduce the rate of endotracheal intubation and invasive ventilation time( P < 0.05). Conclusion: Early evidence-based nursing,significantly reduced the rate of endotracheal intubation patients with SAP,shorten ICU stay time,but did not reduce mortality.

Comparación de traqueotomía percutánea precoz y tardía en unidad de cuidados intensivos para adultos

Background and objectivesPercutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit. MethodsPercutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0-7th days of endotracheal intubation were grouped as early and after the 7th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18years old, patients with positive end-expiratory pressure above 10cmH2O and those with bleeding diathesis or platelet count under 50,000dL−1 were not included in the study. Durations of mechanical ventilation and intensive care stay were noted. ResultsThere was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p<0.05). ConclusionEarly tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.

Comparação de traqueotomia percutânea precoce e tardia em unidade de terapia intensiva para adultos

Background and objectivesPercutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit. MethodsPercutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0–7th days of endotracheal intubation were grouped as early and after the 7th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18 years old, patients with positive end‐expiratory pressure above 10cmH2O and those with bleeding diathesis or platelet count under 50,000dL‐1 were not included in the study. Durations of mechanical ventilation and intensive care stay were noted. ResultsThere was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p<0.05). ConclusionEarly tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.

Clinical Experience of Noninvasive Positive Pressure Ventilation in Patients with Acute Cardiogenic Pulmonary Oedema Treated in a Community Hospital in Japan

Objective: To review our use of non-invasive positive pressure ventilation (NPPV) for acute cardiogenic pulmonary oedema (ACPO) in the routine clinical management, especially in terms of the timing of endotracheal intubation (ETI) and outcome. Methods: We retrospectively reviewed 61 patients diagnosed with ACPO admitted to our emergency room (ER) or intensive care unit (ICU) and who received NPPV. The reasons for ETI were reviewed, and the intervals between the estimated appropriate time for ETI and the actual time of ETI and in-hospital mortality were recorded. Results: The mortality rate of patients receiving NPPV was 8.2% (five out of 61). Forty-eight patients (78.7%) were successfully weaned off NPPV without ETI, and 13 (21.3%) required ETI. Five of the 13 intubated patients died, but there was no significant difference in the duration of NPPV before ETI between those who survived and those who died. The interval between the estimated appropriate time for ETI and the actual time of ETI was significantly shorter in patients who survived than in those who died (1.9 ± 3.8 hours versus 8.6 ± 5.4 hours, p=0.02). The mortality rate was significantly higher in patients with an interval of longer than 1.8 hours between the estimated appropriate time for ETI and the actual time of ETI (66.7% versus 14.3%, p<0.001). Conclusions: In patients with ACPO receiving NPPV, a delay in performing ETI beyond the appropriate time was significantly associated with increased mortality. The duration of NPPV before ETI was not associated with mortality.

Comparison of early and late percutaneous tracheotomies in adult intensive care unit

Background and objectivesPercutaneous tracheotomy has become a good alternative for patients thought to have prolonged intubation in intensive care units. The most important benefits of tracheotomy are early discharge of the patient from the intensive care unit and shortening of the time spent in the hospital. Prolonged endotracheal intubation has complications such as laryngeal damage, vocal cord paralysis, glottic and subglottic stenosis, infection and tracheal damage. The objective of our study was to evaluate potential advantages of early percutaneous tracheotomy over late percutaneous tracheotomy in intensive care unit. MethodsPercutaneous tracheotomies applied to 158 patients in adult intensive care unit have been analyzed retrospectively. Patients were divided into two groups as early and late tracheotomy according to their endotracheal intubation time before percutaneous tracheotomy. Tracheotomies at the 0–7th days of endotracheal intubation were grouped as early and after the 7th day of endotracheal intubation as late tracheotomies. Patients having infection at the site of tracheotomy, patients with difficult or potential difficult intubation, those under 18 years old, patients with positive end-expiratory pressure above 10cmH2O and those with bleeding diathesis or platelet count under 50,000dL−1 were not included in the study. Durations of mechanical ventilation and intensive care stay were noted. ResultsThere was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit in the group with early tracheotomy was shorter and the difference was statistically significant (p<0.05). ConclusionEarly tracheotomy shortens mechanical ventilation duration and intensive care unit stay. For that reason we suggest early tracheotomy in patients thought to have prolonged intubation.

Intubation by paramedics using the ILMA or AirTraq, KingVision, and Macintosh laryngoscopes in vehicle-entrapped patients

Four devices were compared in a simulated scenario of a vehicle-entrapped patient: standard Macintosh laryngoscope, intubating laryngeal mask (ILMA), AirTraq optical laryngoscope, and KingVision videolaryngoscope. A group of 30 final-year paramedic students intubated a manikin placed in a sitting position under a desk simulating the roof of a car. Time of endotracheal intubation and success ratio were recorded. The baseline time of intubation was measured in a manikin lying down flat on the ground. The mean time to intubation was 13.9±6.6, 24.7±4.7, 25.2±3.7, and 23.9±4.2 s; the first attempt success ratios for devices were 29/30, 18/30, 6/30, and 18/30; and the baseline time of intubation was 14.3±6.5, 16.7±4.7, 22.9±12.6, and 18.1±5.0 s for ILMA, Macintosh laryngoscope, Airtraq, and KingVision, respectively. In emergency situations with very limited access to the patient, ILMA is the most effective device for intubation by paramedics.