Endotracheal Suctioning Research Articles

Manipulating positive end expiratory pressure to recruit lung volume in mechanically ventilated children

Background - Mechanically ventilated children are at risk of chronic de-recruitment with low tidal volume ventilation and acute de-recruitment with each disconnection from the circuit and application of suction. Lung recruitment manoeuvres have demonstrated gain in end expiratory levels (EEL) in both adult and experimental studies. Aim - To quantify the impact of two different methods of manipulating PEEP on EEL and regional gas distribution as measured by electrical impedance tomography (EIT) . Method - A randomised crossover clinical trial in 60 intubated and mechanically ventilated children in a PICU. Forty children underwent two methods of lung recruitment following endotracheal suctioning: a double baseline PEEP manoeuvre – held for two minutes and an incremental PEEP manoeuvre, each step held for one minute. Twenty children acted as controls. EIT measurements to quantify EEL were taken at baseline and at 15 minute intervals throughout the study period. Results - The Double PEEP manoeuvre showed significant and sustained improvement in global EEL from baseline up to 120 min (P < 0.01 ANOVA). Global EEL did not change with the Incremental PEEP manoeuvre or in the control group. The Double PEEP manoeuvre also demonstrated preferential ventilation distribution towards the dependent regions of the lung (P = 0.03 ANOVA). Nil adverse events were observed. Conclusion - Significant increases in EEL were achieved globally with a simple Double PEEP manoeuvre. The magnitude of the dependent ventilation also increased, suggesting genuine alveolar recruitment in dependent regions of the lung that was sustained for up to 120 min.

Landiolol reduces hemodynamic responses to bronchoscopy-assisted suctioning in intubated ICU patients.

Landiolol is an ultra-short-acting β1-selective antagonist developed in Japan that was recently approved for the treatment of tachycardia in intensive care units (ICUs). This study investigated the protective effects of landiolol against the cardiovascular responses during bronchoscopic endotracheal suctioning. This study enrolled 15 patients requiring orotracheal intubation in an ICU. All of the patients required endotracheal suctioning using fiber bronchoscopy while sedated at a Ramsay Scale of 2–3. All subsequent suctioning procedures were assigned randomly to three groups using a cross-over design: saline as a placebo (group C) or 20 or 40 μg kg-1 min-1 landiolol, respectively (groups L20 and L40). The infusion was started 3 min before bronchoscopy and continued for 6 min. The central venous pressure (CVP) heart rate (HR) and arterial blood pressure (BP) were recorded. Fourteen patients completed the investigation, and 30 procedures (n = 10/group) were analyzed. The suctioning significantly increased the CVP, HR, and BP in groups C and L20, although the changes in BP were of shorter duration in group L20. No significant increase in the hemodynamic parameters was observed in group L40. The administration of landiolol 40 μg kg-1 min-1 prevented a harmful hyperdynamic circulatory response to bronchoscopic endotracheal suctioning, without obvious decreases in HR or BP after the intervention.

The effect of facilitated tucking position during endotracheal suctioning on physiological responses and coping with stress in premature infants: a randomized controlled crossover study

Objective: Premature infants respond more intensively to pain compared with term infants. Facilitated tucking position as a non-pharmacological method of pain in infants has been suggested; however, its effect on acute procedural pain such as endotracheal suctioning remains to be studied. This study examined the effect of facilitated tucking position during suctioning on physiological responses and coping with stress in premature infants.Methods: This was a randomized controlled crossover study. Thirty-four premature infants received an order of either suctioning with intervention – suctioning without intervention, or suctioning without intervention – suctioning with intervention. Neonatal Infant Pain Scale (NIPS) was used to collect the data.Results: No statistical significant difference was seen between intervention and non-intervention cases in terms of the average time duration to reach the pain score to one or zero, and also, in the average of changes in oxygen saturation. However, changes in heart rate were less in intervention cases.Conclusion: The effect of facilitated tucking position on coping with stress was not found in this study. This non-pharmacological strategy can be suggested because of its effect on reducing changes in heart rate during painful procedure. It is suggested to replicate the study with larger number of samples.

A COMPARISON OF THE EFFECT OF OPEN AND CLOSED ENDOTRACHEAL SUCTIONING ON HEMODYNAMIC STATUS OF PATIENTS IN THE ICU

Background: If not done properly, suction causes complications such as hypoxia, cardiac arrhythmias or even death. Suction is being used in most hospital wards. Closed Suction appears to have fewer side effects, although studies have reported dissimilar results. Aim: The aim of this study was to compare the effect of open (control) with closed (test) endotracheal suctioning on patients’ Hemodynamic state. Methods: This study was a randomized clinical trial in 86 patients admitted in the ICU of Besat hospital of hamedan in 2013, being divided into two groups: open (control) and closed (test) endotracheal suctioning. Systolic and diastolic blood pressure, mean arterial pressure (MAP), heart rate, arterial O2 saturation (SPO2), respiratory rate and the incidence of disrrythmia were recorded in patients´ questionnaires immediately, and afterwards 2 and 5 minutes after endotracheal suctioning by open and closed methods. Data analysis was performed by Repeated Measure ANOVA, t test, chi-square and Fisher's exact test. Results: A total of 102 patients were included in the study. Sixteen patients were excluded from the study and data from 86 patients were analyzed. No statistically significant differences in age (15/0P =) and sex (33/0P =) were found between the two groups. Hemodynamics index in two groups was similar before the suctioning (P >0.05). In the open group, there was an increase in diastolic blood pressure (P=0.017), mean arterial pressure (P=0.019), heart rate (P=0.003) and respiratory rate (P 0.05). Systolic blood pressure, SPO2 and incidence of disrrythmia were similar in the two groups. Conclusion: Endotracheal suctioning by closed method had lower effects on patients´ Hemodynamic status rather than the open system. Hence, closed endotracheal suctioning is recommended in the ICU.

Effects of Closed Vs. Open Repeated Endotracheal Suctioning During Mechanical Ventilation on the Pulmonary and Circulatory Levels of Endothelin-1 in Lavage-Induced Rabbit ARDS Model

Background: A growing body of evidence demonstrates discretely the difference of open endotracheal suctioning (OES) and closed endotracheal suctioning (CES) on the respiratory and hemodynamic parameters in acute respiratory distress syndrome (ARDS). Endothelin-1 (ET-1), a mediator of vascular inflammation, cell proliferation, and fibrosis in addition to being a potent vasoconstrictor has been potentially implicated in the pathogenesis of ARDS. Here, we investigated the effects of repeated OES vs. CES during mechanical ventilation on circulatory and pulmonary levels of ET-1 in ARDS. Methods: Briefly, 22 Japanese White Rabbits were intubated with a 3.5-mm endotracheal tube. Normal saline was instilled into lung and washed mildly. After instillation, rabbits were ventilated at definite setting; OES and CES duration was for 6 hours and performed every 30 minutes from protocol start. Results: At circulatory level, either OES or CES did not alter plasma ET-1 level compared to the ET-1 level in ARDS before the initiation of endotracheal suctioning (OES 4.7 ± 1.3 pg/ml vs. CES 4.8 ± 1.5 pg/ml, p=0.839). In contrast, pulmonary ET-1 level was significantly higher in CES group compared to OES group after 6 hours of repeated suctioning in ARDS (OES 26.9 ± 2.2 pg/mg vs. CES 29.9 ± 3.3 pg/mg, p=0.018). This change in pulmonary ET-1 level could maintain a parallel relation with PaO2 level. Conclusion: At this moment, we cannot clarify the mechanism and effects of the observed change in ET-1 in a rabbit model of ARDS as well as its clinical impact.

Prolonged Bradycardia, Asystole and Outcome of High Spinal Cord Injury Patients

ABSTRACT High spinal cord injury (HSCI) is one of the devastating traumatic injuries. Majority of these patients are young male and 93% will have major neurological disabilities. The aim of this study was to know the prevalence, risk and precipitating factors for prolonged bradycardia in the HSCI patients. Patients and methods All patients who were admitted to the intensive care unit (ICU) of tertiary hospital, with spinal cord injury above level of dorsal (D4) were enrolled in this study prospectively. Patient's demographic data, mechanism, level and type of spinal injury, associated injuries, injury severity score (ISS), spinal shock, vasopressors used, time of occurrence of bradycardia; precipitating, risk factors and outcome were recorded. Results During the study period, total 138 patients were admitted to the intensive care unit with HSCI. Majority of patients were male. The most frequently associated injury was skeletal fractures (38.4%). Pneumonia in 56 (41%) was the most common complication. Forty-five (33%) patients had prolonged bradycardia; 53.4% had cardiac asystole, 29 (21%) patients had bradycardia during endotracheal suctioning, where, as 27 (20%) patients developed bradycardia at positioning. HSCI patients with prolonged bradycardia had significantly higher, ISS score, ICU and hospitals stay. Multivariate analysis revealed that hypotension on admission; pneumonia and tracheostomy were risk factors for the development of prolonged bradycardia. Conclusion Prolonged bradycardia was associated with significantly higher incidence of asystole. Endotracheal suctioning and positioning of HSCI patients were provocative factors for prolonged bradycardia. Hypotension on admission, pneumonia and tracheostomy were the risk factors for development of prolonged bradycardia. How to cite this article Shaikh N, Raza A, Rahman A, Shabana A, Malstrome F, Al-Sulaiti G. Prolonged Bradycardia, Asystole and Outcome of High Spinal Cord Injury Patients. Panam J Trauma Crit Care Emerg Surg 2014;3(3):87-92.

Open system endotracheal suctioning: practices of intensive care nursing professionals

The purpose of this study was to investigate the practices of nursing professionals working in intensive care units regarding open system endotracheal suctioning (ETS). This quantitative study of 25 subjects was conducted in the State of Mato Grosso do Sul (MS), Brazil. Data was collected from April to September 2011 using a checklist monitoring tool composed of 23 items related to the technique. Data was subjected to descriptive statistical analysis. The mean global adherence rate was 51.33%. Poor adherence to 16 items was observed, these being risk factors for the occurrence of adverse effects, particularly occupational accidents, hypoxemia, infection, and hemodynamic instability. Dissatisfactory performance of ETS was found among the professionals investigated, warranting interventions capable of promoting behavioral changes through continuing education aimed at improving the quality of care.

Frequency and intensive care related risk factors of pneumothorax in ventilated neonates.

Objectives. Relationships of mechanical ventilation to pneumothorax in neonates and care procedures in particular are rarely studied. We aimed to evaluate the relationship of selected ventilator variables and risk events to pneumothorax. Methods. Pneumothorax was defined as accumulation of air in pleural cavity as confirmed by chest radiograph. Relationship of ventilator mode, selected settings, and risk procedures prior to detection of pneumothorax was studied using matched controls. Results. Of 540 neonates receiving mechanical ventilation, 10 (1.85%) were found to have pneumothorax. Respiratory distress syndrome, meconium aspiration syndrome, and pneumonia were the underlying lung pathology. Pneumothorax mostly (80%) occurred within 48 hours of life. Among ventilated neonates, significantly higher percentage with pneumothorax received mandatory ventilation than controls (70% versus 20%; P < 0.01). Peak inspiratory pressure >20 cm H2O and overventilation were not significantly associated with pneumothorax. More cases than controls underwent care procedures in the preceding 3 hours of pneumothorax event. Mean airway pressure change (P = 0.052) and endotracheal suctioning (P = 0.05) were not significantly associated with pneumothorax. Reintubation (P = 0.003), and bagging (P = 0.015) were significantly associated with pneumothorax. Conclusion. Pneumothorax among ventilated neonates occurred at low frequency. Mandatory ventilation and selected care procedures in the preceding 3 hours had significant association.

A Closed-Suction Catheter with a Pressure Valve Can Reduce Tracheal Mucosal Injury in Intubated Patients

Background: Endotracheal suctioning is associated with complications that include bleeding, infection, hypoxemia, cardiovascular instability, and tracheal mucosal injury. Recently, a closed-suction catheter with a pressure valve (Acetrachcare, AceMedical Co., Republic of Korea) was developed. We hypothesized that this new catheter might reduce tracheal mucosal injury compared to a conventional closed-suction catheter (Trachcare, Kimberly-balla RD, USA). Methods: This prospective, randomized study enrolled medical and surgical patients who required mechanical ventilation for more than 48 hours. Patients were randomized into two groups: one group was suctioned with the conventional closed-suction catheter (CCC) and the other group was suctioned with the closed-suction catheter with pressure valve (CCPV). Bronchoscopy was performed 48 hours later, and the severity of tracheal mucosal injury was graded on a 5-point scale, as follows: 0 = normal; 1 = erythema or edema; 2 = erosion; 3 = hemorrhage; and 4 = ulceration or necrosis. Results: A total of 76 patients (37 with CCPV and 39 with CCC) were included. There were no significant differences between the groups regarding demographic characteristics, changes in hemodynamic parameters during suction, incidence of pneumonia, length of intensive care unit (ICU) stay, or ICU mortality. On bronchoscopic evaluation, the use of the CCPV led to a significant decrease in tracheal mucosal injury (median tracheal mucosal injury grade 1 [IQR 0-1] vs. 2 [IQR 1-3], p = 0.001). Conclusions: We conclude that the novel closed-suction catheter with pressure valve may reduce tracheal mucosal injury compared to conventional catheters.

Secondary Insults Related to Nursing Interventions in Neurointensive Care

The patients at a neurointensive care unit are frequently cared for in many ways, day and night. The aim of this study was to investigate the amount of secondary insults related to oral care, repositioning, endotracheal suctioning, hygienic measures, and simultaneous interventions at a neurointensive care unit with standardized care and maximum attention on avoiding secondary insults. The definition of a secondary insult was intracranial pressure > 20 mm Hg, cerebral perfusion pressure < 60 mm Hg and systolic blood pressure < 100 mm Hg for 5 minutes or more in a 10-minute period starting from when the nursing intervention began. The insult minutes did not have to be consecutive. The study included 18 patients, seven women and 11 men, aged 36-76 years with different neurosurgical diagnoses. The total number of nursing interventions analyzed was 1,717. The most common kind of secondary insults after a nursing measure was high intracranial pressure (n = 93) followed by low cerebral perfusion pressure (n = 43) and low systolic blood pressure (n = 14). Repositioning (n = 39) and simultaneous interventions (n = 32) were the nursing interventions causing most secondary insults. There were substantial variations between the patients; only one patient had no secondary insult. There were, overall, a limited number of secondary insults related to nursing interventions when a standardized management protocol system was applied to reduce the occurrence of secondary insults. Patients with an increased risk of secondary insults should be recognized, and their care and treatment should be carefully planned and performed to avoid secondary insults.

Training Nurses About Applying Disinfection Technique For Safe Reuse Of Disposable Suction Catheters For Neonates On Mechanical Ventilation.

AbstractBackground: Endotracheal suctioning is designed to efficiently eliminating broncho-pulmonary secretions from the airway while avoiding the potential hazards of ventilator associated pneumonia (VAP). However, the cost of frequent tracheal suctioning for ventilated neonates admitted to the neonatal intensive care unit (NICU) has become a concern. One major cost component to provide this nursing care in a competent way is the use of a disposable suction catheter each time. The aim of the present study was to train nurses about applying disinfection technique for safe reuse of disposable suction catheters for neonates on mechanical ventilation, and to evaluate whether the repetitive use of disposable suction catheters is cost-effective over the single use. Methods: A quasi-experimental design was used. The disinfection technique was applied on 60 disposable endotracheal suction catheters used by a convenient sample of neonates (n=30) who admitted to the NICU affiliated to El-Mansoura University Children's Hospital suffered from respiratory distress (RD) that required mechanical ventilation. An assessment sheet contained 2 checklists about the steps of suctioning the airway and catheter’s disinfection was used. Results: The studied neonates admission weight was ranged from 905–3600 gm, gestational age was from 26–43 weeks; the period of intubation was between 2–26 days. The applied steps were found to be highly effective, completely (100%) eliminating bacterial growth of catheters seeded with Staphylococcus Aureus, Klebsiella, Pseudomonas, and E-coli. Furthermore, it does not contaminate the catheters that are cultured negative for bacterial growth. Conclusion: Applying the study disinfection technique ensured safe reuse of disposable suction catheters for neonates on mechanical ventilation and reduced NICU΄s financial burden. Recommendation: For safe reuse and cost saving, suction catheters might be disinfected and reused. Further studies to find-out for how long could the nurse reuse the disposable suction catheter after disinfection is needed.

Effects of maintaining intravenous infusion of remifentanil or propofol on anesthesia and palinesthesia during anesthesia and analepsia

When recovering from general anesthesia, upon removal of the endotracheal tube, patients may experience a high dynamic response in the circulatory system, along with choking and restlessness. This study was designed to study the effect of maintaining an intravenous infusion of remifentanil or propofol on the performance of general anesthesia, including on the cardiovascular response, choking and irritability at the end of general anesthesia. We treated 60 patients with combined inhalation and general anesthesia for lower esophageal cancer resection. When the surgery was complete, narcotic drug treatment ceased, oropharynx and endotracheal suctioning was performed with a simple breathing bag, and the patient was quickly sent to the anesthesia recovery room. In the recovery room, patients were randomly divided into three groups (N = 20): the control group (waiting for extubation), the remifentanil group (target-controlled infusion of remifentanil; the target plasma concentration was 3 ng/ mL) and the propofol group (target-controlled infusion of propofol; the target plasma concentration was 2 μg/mL). The results show that maintaining an intravenous infusion of remifentanil or propofol can reduce the hemodynamic response, choking and irritability observed at the end of palinesthesia after administration of general anesthesia upon removing the endotracheal tube. The patients in the remifentanil group were fully awake when extubating, and remifentanil intervention did not extend the recovery time. Therefore, a maintenance infusion of remifentanil during general anesthesia may be a better choice.

Mechanical ventilation and clinical practice heterogeneity in intensive care units: a multicenter case-vignette study

BackgroundObservational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations.MethodsWe conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated.ResultsForty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure.ConclusionsLarge clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.

Acute pulmonary edema due to hypoxia during a difficult intubation in a rheumatoid arthritis patient.

CC We experienced a rheumatoid arthritis (RA) patient who developed acute pulmonary edema by hypoxia in the absence of spontaneous respiratory effort by sufficient muscle relaxation during anesthesia induction. A 61-year-old, 136 cm, 48 kg female patient was treated at our hospital for a bilateral total knee arthroplasty due to RA involving the knee joints. During preoperative evaluation of the patient, her chest radiograph showed a suspicious bronchitis at right lower lobe costophrenic angle area (Fig. 1A), whereas the other laboratory tests showed no specific abnormality. The patient was moved to the operating room to receive bilateral total knee replacement. After normal tidal breathing of 100% oxygen 6 L/min for 3 min using a tightly fitting face mask, anesthesia was induced by injecting 60 mg of propofol and 0.3 μg/kg/min of remifentanil and 30 mg of rocuronium. Under mask ventilation, intubation was performed after 3 min. Intubation was performed using Fiberoptic intubation due to difficulties with endotracheal intubation based on the preoperative cspine radiography finding of atlantoaxial subluxation. Fiberoptic intubation was tried for 3 min but failed, the subsequent mask ventilation was performed for 3 min, during which the patient’s ventilaton was not sufficient but maintained, at that time the SpO2, expired tidal volume and ETCO2 was between 90–95%, 200–400 ml and 40–45 mmHg, respectively. But, a few seconds later, mask ventilation was more inadequate, leading to a decrease in the SpO2 up to 70% and cyanosis. Thus, LMA was immediately inserted for adequate ventilation, and the SpO2 were measured as 90%, the patient’s ventilation was smooth and SpO2 increased to 100%, whereupon LMA-guided fiberoptic intuba tion was successfully performed. Five minutes later, a pinkish foamy secretion was observed in the endotracheal tube, and pulmonary edema was shown by a portable chest radiograph; however, no other abnormality was observed (Fig. 1B). Arterial blood gas analysis (ABGA) at an inspired oxygen fraction of 0.5 showed the following: pH 7.3, PCO2 45 mmHg, PO2 149 mmHg, and BE -2.5 mmol/L. Judging that the pulmonary edema was not serious based on the ABGA and chest radiograph, we proceeded with the surgery as planned and intermittent the endotracheal tube suction for 30 min after initiation of the surgery, until the secretion stopped. The total amount of secretion was

Biting of the Tongue in a Patient with a Tracheostomy during Surgery in the Supine Position.

Biting of the tongue is an unfamiliar perioperative event. However, this complication can occur under some situations such as spinal surgeries with the patient in the prone position3), epileptic seizures6), and rarely in accidental trauma. A bitten tongue may lead to various outcomes ranging from simple laceration to upper airway obstruction by macroglossia or necrosis requiring amputation2). A 24-year-old female was scheduled for cranioplasty. She was delivered to the operating room with stuporous mentality, but was able to breathe spontaneously through the tracheostomy tube. Routine monitorings including ECG, SPO2, EtCO2 and blood pressure were carried out. General anesthesia was induced using 80 mg intravenous propofol and 40 mg rocuronium and was maintained with 1.5-2 vol% sevoflurane and 0.05-0.1 mcg/kg/min remifentanil in an O2-air mixture at a 1 : 1 ratio. The tracheostomy tube was changed for hygienic purposes and connected to a ventilator machine after endotracheal and intraoral cavity suction. The operation lasted about four hours and was uneventful. All the anesthetics were stopped and muscle relaxation was reversed with the administration of glycopyrrolate and pyridostigmine. Her mouth was open less than 1 cm and her tongue was not protruded. She responded gradually upon exposure to verbal and tactile stimuli with the recovery of spontaneous breathing. Suddenly, she bit the anterior third of her tongue and continued to do so more violently as time passed; cyanotic and edematous changes were noted (Fig. 1). At first, we thought she would quit biting her tongue as she would recover from anesthesia further. Then, we decided to withhold giving any anesthetics or neuromuscular blocking agents. Though we attempted to open her mouth manually as safely as possible, the mandible could not be pulled down and we were unable to retract the tongue from her teeth. Further complicating matter was our inability to communicate with this mentally altered patient. There was no space in which to put fingers or a tongue compressor into her mouth. Unfortunately, she continued to bite her tongue harder and marked color changes and bleeding were observed. Although we began to increase the sevofluorane concentration, her jaw muscle did not relax sufficiently to allow us to gain access to her oral cavity, and finally we injected 50 mg succinylcholine intravenously about 3 minutes later. Seconds later, her chin relaxed and her tongue retracted. The color of her tongue gradually returned to normal. After confirming that there was no active bleeding, saline irrigation and wet gauze were applied to the wound. An oral airway was inserted and fixed with tape to ensure it would not be spit out unconsciously. She transferred to recovery room, no other events were observed. Several hours later, the tape and oral airway were removed. Fig. 1 Self-biting injury to the anterior third of tongue during recovery of anesthesia. Tracheostomy is the most common procedure for patients with pulmonary problems or those requiring respiratory support in the neurosurgical field4). Biting of the tongue is a rare complication under general anesthesia, especially in patients with a tracheostomy. However, several cases have been reported in association with the prone position during surgery without a bite blocker1), prolonged re-insertion of dentures in patients without teeth5). and eclamptic seizures. Our case indicates that a patient can bite their tongue even when in a supine position without orotracheal intubation, particularly in patients with brain damage. Although we did not figure out using airway opening instruments such as screw-type or Heister mouth gag in the event, those seem to be a good method of choice worth to be tried in suitable cases. Furthermore, clinicians should seriously consider the routine use of an oral airway in patients with a tracheostomy. One thing that we should keep in mind is that manual attempts to open the mouth carelessly can bring about injuries to the practitioner as well as the patient. Neurosurgeons and anesthesiologists should be aware of the possibility of tongue protrusion and subsequent biting in patients with a tracheostomy.

Three Cases of ALCAPA with Associated Anomalies

There are several potential issues that affect the treatment and diagnostic pattern of anomalous left coronary artery arising from the pulmonary artery. We report three cases of infants who presented with anomalous left coronary artery arising from the pulmonary artery with severe left ventricular dysfunction and severe mitral regurgitation along with associated anomalies. One patient had congenital lobar emphysema of the right midde lobe. Another patient had left main stem bronchus compression, collapse of basal segments of left lower lobe and panlobular emphysema in medial basal segment of right lower lobe. The third patient had cleft lip and palate. All patients underwent successful repair. The hemodynamic stability was compromised when the infant with congenital lobar emphysema had spontaneous pneumothorax after extubation and she needed an intercostal drainage. The infant with lung collapse had to be reintubated on the second day since she became hypoxic due to recollapse of the lung once the airway positive pressure was removed. She needed chest physiotherapy, vigorous endotracheal suctioning and inhaled bronchodilator therapy. The patient who had cleft palate succumbed to aspiration pneumonitis in the postoperative period. Follow-up of other two patients after three months showed very good improvement in left ventricular systolic function.

Repeated open endotracheal suctioning causes gradual desaturation but does not exacerbate lung injury compared to closed endotracheal suctioning in a rabbit model of ARDS

BackgroundAlthough endotracheal suctioning induces alveolar derecruitment during mechanical ventilation, it is not clear whether repeated endotracheal suctioning exacerbates lung injuries. The present study aimed to determine whether repeated open endotracheal suctioning (OS) exacerbates lung injury compared to closed endotracheal suctioning (CS) during mechanical ventilation in an animal model of acute respiratory distress syndrome (ARDS).MethodsBriefly, thirty six Japanese white rabbits were initially ventilated in pressure-controlled mode with a constant tidal volume (6 mL/kg). Then, lung injury was induced by repeated saline lavage. The rabbits were divided into four groups, namely: a) OS; b) CS; c) control with ARDS only; d) and healthy control (HC) without ARDS. Animals in all the groups were then ventilated with positive end expiratory pressure (PEEP) at 10 cm H2O. CS was performed using 6 French-closed suctioning catheters connected to endotracheal tube under the following conditions: a) a suctioning time and pressure of 10 sec and 140 mm Hg, respectively; and b) a suction depth of 2 cm (length of adapter) plus tracheal tube. OS was performed using the same conditions described for CS, except the ventilator was disconnected from the animals. Each endotracheal suctioning was performed at an interval of 30 min.ResultsPaO2/FIO2 (P/F) ratio for CS, control and HC groups remained at >400 for 6 hours, whereas that of the OS group progressively declined to 300 (p < 0.05), with each suctioning. However, no difference was observed either in lung injury score (histology) or in the expression pattern of inflammatory cytokines (tumor necrosis factor-α and interleukin-6) after 6 hours between the OS and CS groups in the circulatory as well as the pulmonary tissues.ConclusionsProgressive arterial desaturation under conditions of repeated endotracheal suctioning is greater in OS than in CS time-dependently. However, OS does not exacerbate lung injury during mechanical ventilation when observed over a longer time span (6 hours) of repeated endotracheal suctioning, based on morphological and molecular analysis.

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Introduction: Endotracheal suctioning is associated with complications including bleeding, infection, hypoxemia, cardiovascular instability, and tracheal mucosal injury. A closed-suction catheter has some advantages, which include minimizing risk of hypoxemia and prevention of infected secretions during suctions. Recently, a closed-suction catheter with pressure valve (Acetrachcare, AceMedical Co., South Korea) was developed. We hypothesized that this new catheter might reduce tracheal mucosal injury compared with conventional closed-suction catheter (Trachcare, Kimberly-balla RD, USA). Methods: The prospective, randomized study included medical and surgical patients requiring mechanical ventilation for more than 48 hours. Patients were randomized into two groups; one group was suctioned with the conventional closed-suction catheter (CCC) and the other group with the closed-suction catheter with pressure valve (CCPV). In CCC group, the wall suction vacuum pressure was kept around 100 mmHg. In CCPV group, the level of pressure used to perform endotracheal suction was adjusted by intensivist according to sputum amount (small, moderate or large). Bronchoscopy was performed 48 hours later, and the severity of tracheal mucosal injury was graded from 0 to 4, as follows: 0 = normal; 1 = erythema or edema; 2 = erosion; 3 = hemorrhage; 4 = ulceration or necrosis. Results: A total of 63 patients (31 with CCPV and 32 with CCC) were included. There were no significant differences between groups about age, sex, diagnosis groups, sputum appearance, mortality, and Acute Physiology and Chronic Health Evaluation II score. No significant difference was found in hypoxemia, hypercapnia, maximal heart rate, arrhythmia, mean arterial pressure and elevated airway pressure during suctioning. On bronchoscopic evaluation, the usage of CCPV led to a significantly reduce tracheal mucosal injury (median tracheal mucosal injury grade 0 [IQR 0–1] vs 2 [IQR 1–2], p<0.05). However, there were no differences in nurse satisfaction, total number of suction for 24 hours, microbial growth and the prevalence of ventilator-associated pneumonia. Conclusions: We conclude that the novel closed-suction catheter with pressure valve may reduce tracheal mucosal injury compared to conventional catheter.

Effects of closed vs. open repeated endotracheal suctioning during mechanical ventilation on the pulmonary and circulatory levels of Endothelin-1 in a lavage induced surfactant depleted Rabbit ARDS model

Effects of closed vs. open repeated endotracheal suctioning during mechanical ventilation on the pulmonary and circulatory levels of Endothelin-1 in a lavage induced surfactant depleted Rabbit ARDS model

Responses to noxious stimuli in sedated mechanically ventilated adults

ObjectiveTo determine the effect of sedation on physiologic responses and comfort before, during and after a noxious stimulus (endotracheal tube suctioning). MethodsThe sample was a subset of a larger, longitudinal descriptive study, blood for endorphins and saliva for alpha-amylase were obtained before and after suctioning. Heart rate (HR), respiration rate (RR), oxygen saturation (SPO2), and arm and leg actigraphy were continuously recorded. Results67 subjects from medical and surgical ICUs were primarily deeply (37%) or mildly sedated (54%) prior to suctioning. Alpha-amylase increased post suctioning (p = 0.04); endorphins did not change (p = 0.58). Neither were modified by sedation. There were no changes in HR, RR or SPO2 post suctioning. Arm (p = 0.007) and leg actigraphy (p = 0.057) changed from baseline and depended on sedation level (p = 0.0005). ConclusionsWhile a stress marker did increase during suctioning, only the measure of patient arm movement was significantly affected by sedation level.