Excessive Secretions Research Articles

Severe Community-Acquired Pneumonia: Noninvasive Mechanical Ventilation, Intubation, and HFNT.

Severe acute respiratory failure (ARF) is a major issue in patients with severe community-acquired pneumonia (CAP). Standard oxygen therapy is the first-line therapy for ARF in the less severe cases. However, respiratory supports may be delivered in more severe clinical condition. In cases with life-threatening ARF, invasive mechanical ventilation (IMV) will be required. Noninvasive strategies such as high-flow nasal therapy (HFNT) or noninvasive ventilation (NIV) by either face mask or helmet might cover the gap between standard oxygen and IMV. The objective of all the supporting measures for ARF is to gain time for the antimicrobial treatment to cure the pneumonia. There is uncertainty regarding which patients with severe CAP are most likely to benefit from each noninvasive support strategy. HFNT may be the first-line approach in the majority of patients. While NIV may be relatively contraindicated in patients with excessive secretions, facial hair/structure resulting in air leaks or poor compliance, NIV may be preferable in those with increased work of breathing, respiratory muscle fatigue, and congestive heart failure, in which the positive pressure of NIV may positively impact hemodynamics. A trial of NIV might be considered for select patients with hypoxemic ARF if there are no contraindications, with close monitoring by an experienced clinical team who can intubate patients promptly if they deteriorate. In such cases, individual clinician judgement is key to choose NIV, interface, and settings. Due to the paucity of studies addressing IMV in this population, the protective mechanical ventilation strategies recommended by guidelines for acute respiratory distress syndrome can be reasonably applied in patients with severe CAP.

Pharmacologic Management of Sialorrhea in Neonatal and Pediatric Patients

Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published ­human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship.

Esophageal atresia with tracheoesophageal fistula: two case reports

BackgroundThe incidence of esophageal atresia with tracheoesophageal fistula is 1 out of 3000–5000 live births. Its incidence in lower middle income countries is not known. The infants usually present with excessive secretions or choking while feeding and are at risk for aspiration. The outcome of these infants in lower middle income countries is not encouraging due to delays in referral, sepsis at presentation requiring preoperative stabilization, postoperative complications such as anastomosis leaks, pneumonia, and pneumothorax.Case presentationWe present two African babies who were term infants at age 2 days (male) and 5 days (female) with diagnosis of esophageal atresia and tracheoesophageal fistula. The 5-day-old infant required preoperative stabilization due to sepsis and delayed surgery with a poor postoperative outcome. The 2-day-old infant was preoperatively stable and had a good postoperative outcome. The challenges faced in management of these two cases have been highlighted.ConclusionOutcome of infants with esophageal atresia and tracheoesophageal fistula in lower middle income countries is not encouraging due to delays in referral and poor postoperative healing attributed to sepsis and recurrent pneumothorax. Timely referral, preoperative condition of the infant, and timely management has shown to be a contributory factor for an improved outcome.

The application of nano-hydrogels and hydrogels in wound dressings.

Wounds and the healing process are one of the main concerns of medical science today. A wound is any loss of integrity, or rupture of the layers of skin (epidermis, dermis, and hypodermis) or subcutaneous tissue caused by physical factors (surgical incision, trauma, pressure, and gunshot wounds) or chemical factors (acid burns). It is observed that soft tissue, muscle, or bone is involved in occurrences of wounds. Lesions and fractures of the skin surface necessitate medical attention, wherein dressings expedite the healing process by establishing a physical barrier between the wound and the external environment, thereby preventing further injury or infection. Hydrogel dressings create a moist environment that facilitates common healing steps, such as granulation hyperplasia, epidermal repair, and removal of excess dead tissue. The limited adhesion of the hydrogel and the hydrated wound bed allows for easy removal of the dressing without secondary damage, thereby significantly reducing the discomfort and risk of infection during dressing changes. These modern, wet dressings foster a moist healing environment by absorbing excess inflammatory secretions and allowing proper passage of steam and air, which expedites the healing process. In this analysis, the utilization of hydrogels as wound dressings is briefly presented.

Study of Organophosphorus Poisoning at a Tertiary Care Teaching Hospital

Introduction: Organophosphate (OP) insecticides inhibit both cholinesterase and pseudo-cholinesterase activities. The inhibition of acetylcholinesterase causes accumulation of acetylcholine at synapses, and overstimulation of neurotransmission occurs as a result of this accumulation. The mortality rate of OP poisoning is high. Early diagnosis and appropriate treatment is often life saving. Treatment of OP poisoning consists of intravenous atropine and oximes. The clinical course of OP poisoning may be quite severe and may need intensive care management. Methods: A retrospective study was performed on the patients with OP poisoning. Fifty patients were included. Diagnosis was performed from the history taken either from the patient or from the patient's relatives about the agent involved in the exposure. Diagnosis could was confirmed with serum and red blood cell anticholinesterase levels. Intravenous atropine and pralidoxime was administered as soon as possible. Other measures for the treatment were gastric lavage and administration of activated charcoal via nasogastric tube, and cleansing the patient's body with soap and water. The patients were intubated and mechanically ventilated if the patients had respiratory failure, a depressed level of consciousness, which causes an inability to protect the airway, and hemodynamic instability. Mechanical ventilation was performed as synchronized intermittent mandatory ventilation + pressure support mode, either as volume or pressure control. Positive end expiratory pressure was titrated to keep SaO2 above 94% with 40% FIO2. Weaning was performed using either T-tube trials or pressure support weaning. The chi-square test was used for statistical analysis. Data are presented as mean ± standard deviation. Results: There were 26 female and 24 male patients. Thirty-five were suicide attempts and 15 were accidental exposure. The gastrointestinal route was the main route in 44 patients. The most frequent signs were meiosis, change in mental status, hypersalivation and fasciculations. Ten patients (20.0%) required mechanical ventilation. Complications were observed in 35 patients. These complications were respiratory failure (14 patients), aspiration pneumonia (10 patients), urinary system infection (6 patients), convulsion (4 patients) and septic shock (1 patient). The duration of the intensive care stay was 5.2 ± 3.0 days. Discussion: Ingestion of OP compounds for suicidal purposes is a major problem, especially in developing countries. Thirty-five of our patients used the OP insecticide for suicide. The average respiratory rate of these patients increased from 22 to 38 breaths/min, which is an important sign of respiratory distress. The nurse to patient ratio was increased after these events. Early recognition of respiratory failure resulting in intubation and mechanical ventilation is a life-saving intervention for patients with OP poisoning. Respiratory failure is the most troublesome complication, which was observed in 35 patients. Patients with OP poisoning may have respiratory failure for many reasons, including aspiration of the gastric content, excessive secretions, pneumonia and septicemia complicating acute respiratory distress syndrome. Conclusions: OP insecticide poisoning is a serious condition that needs rapid diagnosis and treatment. Since respiratory failure is the major reason for mortality, careful monitoring, appropriate management and early recognition of this complication may decrease the mortality rate among these patients.

[Recommendations for the management and rehabilitation of patients with a tracheostomy].

Tracheostomy is a common procedure in critically ill patients who require mechanical ventilation. Tracheostomies have several advantages over endotracheal tubes, including less sinusitis or pharyngeal injuries, fewer sedative drugs, improved oropharyngeal hygiene, easier communication, more comfort, preservation of vocal cord function, and so on. However, patients with a tracheostomy require high quality care and often suffer from dysphagia, dysphonia, tracheal stenosis, or excessive airway secretions, etc. In China, there are currently no comprehensive evidence-based clinical guidelines or consensus documents on the management and rehabilitation of patients with a tracheostomy. Approaches to tracheostomy care are inconsistent among different institutions and clinicians. Therefore, a group of top experts specialized in this field in China were gathered to draft this document to reduce variations in practice in the management of patients with a tracheostomy and to minimize complications. Panel members were asked to complete surveys on various aspects of adult tracheostomy care, followed by a conference at which the results were presented and a number of themes outlined for a formal literature review and a preliminary draft. Several conferences were then held to discuss the differences of opinion among the panel members. In general, the panel reached a consensus and a total of 9 issues were covered in the document. At first, the importance of a standardized management protocol, pathophysiological characteristics, indications, complications, contradictions, and techniques used for tracheostomies were discussed. Then, more emphasis was placed on post-operative care such as airway clearance therapy, tube changes, and decannulation criteria, etc. In addition, the most important topic was elaborated, namely the methods used to promote the rehabilitation and decannulation of patients with a tracheostomy, including respiratory and other skeletal muscle training, dysphagia and verbal communication intervention, ventilation support, chest physiotherapy, and specifically the traditional Chinese medical therapies that were excellent in this area, such as acupuncture, moxibustion, and herbal medicine, etc. Finally, a flow chart was created to summarize the suggestions for managing and promoting rehabilitation or decannulation of patients with a tracheostomy. Proposed by Respiratory Equipment Committee of China Association of Medical Equipment, Young and Middle-Aged Pulmonary Rehabilitation Group of Pulmonary Rehabilitation Committee of China Association of Rehabilitation of Disabled Person, and Critical Illness Rehabilitation Group of China Association of Rehabilitation Medicine, and sponsored by several national or provincial natural science research projects, this work is expected to provide clear guidance for the general treatment of adult patients with a tracheostomy in China in the future.

Clinical application of intrapulmonary percussive ventilation: A scoping review.

Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.

Safety of removal of ProSeal laryngeal mask airway in children in the supine versus lateral position in a deep plane of anesthesia: A randomized controlled trial.

When a ProSeal laryngeal mask airway (PLMA) is removed with the child in a deep plane of anesthesia, the upper airway muscle tone and protective upper airway reflexes may be obtunded. To determine whether the supine or lateral position is safer for the removal of a PLMA in deeply anesthetized children by comparing the incidence of upper airway complications. This randomized single-blind comparative trial was conducted at a tertiary care hospital between January 2020 and September 2020. Forty children of the American Society of Anesthesiologists class I/II of ages 1-12 years age undergoing surgery under general anesthesia with PLMA used as the definitive airway device were recruited. Patients were randomly allocated to lateral group or supine group for PLMA removal in a deep plane of anesthesia in the lateral or supine position. The primary outcome was the number of patients experiencing one or more upper airway complications and the secondary outcomes were incidence of individual respiratory adverse effects and of severe airway complications. The incidence of airway complications was 30% in the supine group and 20% in the lateral group (P = 0.6641). Incidence of laryngospasm, immediate stridor, and excessive secretions were similar. Early stridor and oxygen desaturation were higher in the supine group (P = 0.0374, P = 0.0183 respectively). The overall incidence of upper airway complications was similar with the removal of a PLMA in the supine or lateral position in deeply anesthetized children. The incidence of oxygen desaturation and stridor were higher with PLMA removal in the supine as compared to the lateral position.

Abstract P227: Resistant Hypertension In Young Patient- A Case Of Conn’S Syndrome

Abstract: Resistant hypertension (HTN) is defined as elevated blood pressure (BP) while being on three different antihypertensive medications at maximum recommended doses which include diuretics or BP that requires four different antihypertensives. One of the secondary causes of resistant HTN is Conn's Syndrome (CS). CS is mainly due to excessive secretions of aldosterone (aldo), Aldo is a mineralocorticoid hormone that maintains sodium and potassium homeostasis. Excessive secretion can result in hypernatremia and hypokalemia. This is a case of a young patient who presented with resistant hypertension and low potassium. Case: A 47-year-old African American with a known history of HTN presented with a seizure-like episode due to elevated BP and low potassium (K) of 2.6 with a creatinine of 2.2 (baseline creatinine 1.2). He was non-compliant with BP medication hydrochlorothiazide. During hospitalization, BP remained elevated with low K even with K supplementation. BP regimen was broadened to amlodipine, carvedilol, hydralazine, losartan, and spironolactone. Further evaluation showed elevated plasma aldo and low renin with a ratio >30. CT abdomen with contrast confirmed a right adrenal gland adenoma measuring 1.8 cm x 2.0 cm. Ultimately, the patient underwent robot-assisted right adrenalectomy, and adrenal vein sampling (AVS) confirmed CS. The right AVS showed an aldo level >3000 ng/dl and the left adrenal aldo level was 37.6 ng/dl. After successful surgery, BP medicines were cut down to spironolactone. A few months later, BP improved, and all medications were discontinued. Discussion: Aldosterone poses proinflammatory, prothrombotic, and profibrotic changes that in the long-term cause end-organ damage. For these reasons, diagnosing hyperaldosteronism early in young patients is crucial to avoid further complications. Adrenalectomy is a treatment of choice in most cases, many patients could also benefit from pharmacotherapy, especially with newer medications that are not anti-androgenic and nonsteroidal like finerenone. Hyperaldosteronism can be simply diagnosed by checking serum morning aldo level and renin level. Therefore, screening for hyperaldosteronism should be done frequently in young patients with resistant HTN.

Implementation of AIRVO™ System for Postoperative Tracheostomy Care in Head and Neck Free Flaps.

Effective postoperative tracheostomy management after free flap surgery is critical but can offer challenges including difficulty with humidification delivery and contraindications toward neck instrumentation. The purpose of this project was to establish a multidisciplinary team and implement the AIRVO™ tracheostomy humidification system for those undergoing free flap surgery and determine its effect on respiratory secretions and related events. A retrospective cohort study of head and neck free flap surgery patients prior to implementation of AIRVO™ (Jan 2021-May 2021) and after (August 2021-December 2021) were analyzed with a 2 month (June 2021-July 2021) implementation phase. Main variables analyzed included excessive tracheal secretions, necessity of supplemental oxygen above baseline for a day or greater, respiratory rapid response calls, elevation to intensive care units (ICU), and length of hospital stay. A total of 82 patients (40 pre-AIRVO™ and 42 with AIRVO™) met criteria for the study. A significant reduction in excessive tracheal secretions (40% pre-AIRVO™, 11.9% with AIRVO™, P = .01) and necessity of supplemental oxygen above baseline (25% pre-AIRVO™, 7.1% with AIRVO™, P = .04) were observed. No significant difference in hospital length of stay (P = .63) was observed. No respiratory rapid responses or elevation to ICU care were seen in either groups. The AIRVO™ system provided an efficient, portable, free of neck instrumentation, and easy to use device that resulted in a reduction in excessive tracheal secretion events and necessity of supplemental oxygenation needs in free flap tracheostomy patients.

The diagnostic workup of patients with a primary complaint of post-nasal drip

Background: Post-nasal drip (PND) is likely multifactorial in etiology which may be attributed to excessive sinonasal secretions or an increase in mucous viscosity from chronic sinusitis or allergic rhinitis. Increased throat sensitivity due to inflammatory changes have been postulated as a possible cause, which may be secondary to laryngopharyngeal reflux (LPR). Methods: Patients presenting with a primary complaint of post-nasal drip were prospectively enrolled into the cohort study. All patients underwent nasal endoscopy, flexible laryngoscopy, in-vitro allergy testing, and computed tomography (CT) imaging. Patients were also asked to fill out a SNOT-22 questionnaire and a reflux severity index (RSI) form.   Results: 33 patients were enrolled in the study of which 22 completed all necessary procedures. In our cohort of patients the average SNOT score was 43±22, and the average RSI was 22±7. Twenty-one of the 22 patients had RSIs consistent with LPR. Reflux finding scores (RFS) as evaluated and averaged between two laryngologists found that all patients in the cohort met criteria for LPR with an average RFS of 12.6±2.1. Fourteen of the 22 patients had a positive RAST. Seventeen of the patients in the cohort had CT scans that were normal. The average Lund Kennedy score was 0.9±1.4 with 14 of the 22 patients having unremarkable nasal endoscopies. Conclusions: Patients with PND benefit from consideration of empiric treatment with PPIs, dietary modification given the high rates of LPR. Consideration should also be given to allergy testing prior to any consideration for CT imaging.

Direct activation of Airway Sensory C-fibers by SARS-CoV-2 Spike protein

Activation of sensory nerves, in particular nociceptive C-fibers, is a feature of most respiratory viruses. Evidence of such activation is found in the classical consequences of C-fiber activation including sneezing, sore throat, coughing, and reflex secretions. As well as causing the troubling symptoms of viral infection, the activation of these nerves allows viruses to escape the body and be transmitted to other hosts, i.e. nociceptor activation amplifies spread in a community. In addition, activation of airway vagal C-fibers can lead to strong reflex bronchoconstriction and excessive secretions that likely contribute to the exacerbation of asthma particularly in children. In theory, viral infection leads to C-fiber activation by two general mechanisms. The first is that viral infection of epithelial cells leads to the production of a mediator(s) that stimulates the C-fiber terminals. The second is that the virus itself directly activates the nerves. We used three orthogonal approaches to address our hypothesis that the coronavirus spike protein directly activates (evokes action potential discharge) vagal C-fibers in mouse airways. We used male C57/BL6 mice to evaluate whether coronavirus spike protein interacts; directly with C-fiber terminals in an isolated vagus-trachea/lung preparation. Action potentials were recorded using extracellular electrodes positioned near the relevant cell bodies in the vagal sensory nodose/jugular ganglion complex. Spike protein S1 (4ug/ml) was perfused through the mouse trachea into the receptive field of an identified C-fiber (c.v. <1 m/s). 40% of C-fibers (12 out of 30) responded acutely to the S1 protein with action potential discharge. In the same type of ex-vivo experimental set-up, two-photon imaging technique was also used to evaluate the % of fibers activated by spike protein. Consistent with our electrophysiological studies we found that 45% of the C-fibers (241 fibers out of 538 fibers in 4 experiments) were stimulated by the S1protein. To determine whether spike protein was indirectly activating C-fibers in the lung, i.e. requiring other cells within the airway tissue, we evaluated its effect on neurons dissociated from the vagal ganglia with Fura-2 calcium imaging. Again, ~ 40% of the isolated neurons (65 out of 163 neurons) responded to spike protein. These data support our hypothesis that the spike protein can directly activate neurons independently of airway tissue. This supports the hypothesis that some of the nerve-related effects of SARS CoV-2 infection may involve the direct activation of sensory C-fibers. R35 HL144887 This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

One-stage tracheostomy during surgery reduced early pulmonary infection and mechanical ventilation length in complete CSCI patients.

Complete cervical spinal cord injury (CSCI) is a devastating injury that usually requires surgical treatment. Tracheostomy is an important supportive therapy for these patients. To evaluate the effectiveness of early one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery, and to identify clinical factors for one-stage tracheostomy during surgery in complete cervical spinal cord injury. Data from 41 patients with complete CSCI treated with surgery were retrospectively analyzed. Ten patients (24.4%) underwent one-stage tracheostomy during surgery, thirteen (31.7%) underwent tracheostomy when necessary after surgery, and eighteen (43.9%) did not have a tracheostomy. One-stage tracheostomy during surgery significantly reduced the development of pneumonia at 7 days after tracheostomy (p = 0.025), increased the PaO2 (p < 0.05), and decreased the length of mechanical ventilation (p = 0.005), length of stay (LOS) in the intensive care unit (ICU) (p = 0.002), hospital LOS (p = 0.01) and hospitalization expenses compared with necessary tracheostomy after surgery (p = 0.037). A high neurological level of injury (NLI) (NLI C5 and above), a high PaCO2 in the blood gas analysis before tracheostomy, severe breathing difficulty, and excessive pulmonary secretions were the statistically significant factors for one-stage tracheostomy during surgery in the complete CSCI patients, but no independent clinical factor was found. In conclusion, one-stage tracheostomy during surgery reduced the number of early pulmonary infections and the length of mechanical ventilation, ICU LOS, hospital LOS and hospitalization expenses, and one-stage tracheostomy should be considered when managing complete CSCI patients by surgical treatment.

Vitamin C modulates adrenaline-augmented gastric injury via cardiac troponin/creatine kinase pathway in Wistar rats.

Vitamin C has anti-oxidant benefits in the gastrointestinal tract and heart. This study investigated the effect of vitamin C on some gastric parameters in myocardial injury in rats. Thirty Wistar rats were divided into five groups (n = 6). Group 1 was the control and Group 2 (ADR) received 1 mg/kg of adrenaline subcutaneously on days 13 and 14. Group 3 received vitamin C (200 mg/kg) orally for 14 days. Group 4 received adrenaline (1 mg/kg) on days 1 and 2 and vitamin C from days 1 to 14. Group 5 received vitamin C till day 14 and adrenaline on days 13 and 14. All animals were sacrificed after 2 hr of pyloric ligation. Gastric secretion parameters were assessed while a blood sample was obtained for biochemical analysis. Gastric juice volume, total gastric acidity, pepsin activity, cardiac troponin 1, creatine kinase-MB, and lactate dehydrogenase levels increased (P<0.05) in ADR only group relative to the control. Pre- and post-vitamin C treatment reduced (P<0.05) these markers to near normal. However, treatment with vitamin C reduced (P<0.05) ulcer score, and increased (P<0.05) pepsin activity, mucus weight, and serum vitamin C levels when compared with the ADR-only group. Pre-treatment with vitamin C resulted in a marked decrease (P<0.05) in gastric juice volume, pepsin activity, and total gastric acidity compared with post-treatment in the adrenaline-induced injury group. Vitamin C pretreatment reduces excessive gastric secretions, ulcer scores, and attenuates cardio-inflammatory responses in adrenaline-augmented myocardial injury in rats.

Effects of Normal Saline Instillation on Haemodynamic Parameters and Oxygen Saturation after Suctioning of Mechanically Ventilated Patient

When patient is critically ill the function of removal of secretions may be compromised leading to excessive pulmonary secretions. Airway suction is one of the most popular methods of clearing airway secretion. This study aimed to assess effects of normal saline instillation on haemodynamic parameters and oxygen saturation before and after suctioning and to find out the association with demographic variable. Pre-experimental (one group pre-test post-test) study design was used; 52 patients were enrolled using convenient sampling from Intensive Care Units. Observation checklist was used to collect needed data on haemodynamic parameters and oxygen saturation before 5 min and after 5, 10 and 15 min of suctioning. As a part of intervention normal saline was instilled during suctioning. Paired t test values with regard to blood pressure (t=11.41), heart rate (t=1.50), systolic blood pressure (t=8.43) and respiratory rate (t=13.64) were found significant (p'lt;0.05) after suctioning with normal saline. Repeated measures of analysis of variance F test suggest that there was significant difference in respiratory rate (F=10.98) and oxygen saturation (F=62.16) among patients was significant at level p'lt;0.05. Chi-square test concluded that level of consciousness was found significant with level of heart rate and age was significant with systolic blood pressure at p-value 'lt;0.05. The study findings revealed that saline instillation should not be used as a routine clinical practice as it increases the heart rate, respiratory rate and systolic blood pressure also there was no change in oxygen saturation.

Adequacy of Reversal of Neuromuscular Blockade with or without Train-of-Four Monitoring: A Randomised Controlled Study

Introduction: Adequate reversal of Neuromuscular Blockade (NMB) is essential when using muscle relaxants to avoid residual paralysis postoperatively. Reversal can be achieved using clinical parameters or, alternatively, by Train-of-Four (TOF) monitoring. Aim: To evaluate the adequacy of successful NMB reversal using clinical parameters-based endpoints compared to using TOF monitoring. Materials and Methods: The hospital-based randomised controlled study conducted in the Department of Anaesthesiology, SDM Medical College, Dharwad, Karnataka, India for a peroid of two years from November 2019 to December 2021. Consisted of 120 subjects divided into two groups: Group-C (Clinical parameters) and group T (TOF monitoring), aged 18-60 years of either sex with American Soceity of Anaesthesiologists (ASA) physical status I and II, undergoing elective surgery under general anaesthesia requiring intubation. Extubation was achieved in group C using clinical parameters like return of spontaneous respiratory efforts, adequate Tidal Volume (TV) (≥5 mL/kg), obeying simple commands, absence of excessive secretions, and in group T using TOF monitoring. The t-test was used to compare the difference between the groups. The Chi-square test was done for contingency data. A p-value of less than or equal to 0.05 (p-value≤0.05) indicates statistical significance. Results: In the study, both group C and group T were comparable in terms of age {(41.15±10.23 years, 41.03±11.9 years) p-value=0.95}, sex (m/f) {(46.6%/53.3% and 63.3%/36.6%) p-value=0.06}, and Basal Metabolic Index (BMI) {≤25=59.1%, 25- 30=33.3%, ≥30=7.5%, p-value=0.57}, respectively. Five patients in group C had residual paralysis, whereas none in group T. Reversal-extubation time in minutes (min) in group C {5.9± 2.2, 5.4 (2-15.2)} and group T {6.6± 1.9, 6.24 (3.3-12.2)} (p-value=0.07), TOF value at the time of extubation in group C {72.1±11.6, 72 (41-91)}, group T {72.75±2.74, 72 (70-79)} (p-value=0.69). TOF value after 10 minutes of extubation in group C {92.5±7.1, 94 (66- 100)} and group T {95.6±2.7, 96 (90-100)} (p-value=0.006). Conclusion: The TOF monitoring is better compared to a clinical parameters-based reversal strategy in reducing the incidence of residual paralysis and resulting complications whenever Neuromuscular Blocking Agents (NMBAs) are used. Hence, it is desirable to use Neuromuscular Monitoring with the use of NMBAs.

574: SAFE AND EFFECTIVE VOCALIZATION IN MECHANICALLY VENTILATED PATIENTS WITH TRACHEOSTOMY

Introduction: As many as 10-15% of patients admitted to the intensive care unit (ICU) will require a temporary tracheostomy. Verbal communication, however is still difficult and often ineffective. Certain tracheostomy tubes have added a subglottic port similar to endotracheal tubes for suctioning above the cuff. This above the cuff (ACV) port can also be used for vocalization by instilling air through this port which passes through the larynx and vocal cords to allow for phonation. Studies have been limited with very small sample sizes and ACV remains an underutilized modality for communication in patients with tracheostomy. Methods: An IRB approved retrospective review was performed in all adult patients admitted to any ICU requiring tracheostomy from November 2019 to October 2021. All patients receiving tracheostomy were identified. Patients with a tracheostomy tube with an above the cuff suction port were then evaluated 48 hours after surgery and underwent ACV. Major and minor complications and level of phonation achieved were recorded. Speech effectiveness was stratified by no voice, whisper, word level and sentence level performance with ACV. Major and minor complications were recorded. Results: 48 patients underwent 139 interventions. 100% of patients identified were able to attempt ACV. 20 patients (42%) achieved word-level speech and 10 (21%) reached sentence-level speech. Word-level speech was achieved in 52% of all interventions and sentence-level in 17.5%. 95.7% reported no complications and there were no major complications. Comparison to a hypothetical 1% major complication rate using a one-sample binominal test was significant. (P < 0.000) The most common minor complications was excessive oral secretions occurring in 2 patients (1.4%). Conclusions: ACV is a valuable procedure that can result in effective communication for patients with tracheostomy still requiring mechanical ventilation. The procedure is simple and safe to perform and tolerated very well by patients even early after tracheostomy.

The anatomical landmarks for positioning of double lumen endotracheal tube using flexible bronchoscopy: A prospective observational study

BackgroundTo examine the tracheobronchial anatomy and its common variations after double-lumen tube (DLT) placement, and to determine the anatomical landmarks that can be easily identified by practitioners for DLT positioning. MethodIn total, 200 patients with American Society of Anesthesiologists I–II, who were aged 20–75 years and scheduled for video-assisted thoracic surgery (VATS), were prospectively enrolled. The types of DLT position in each patient was recorded [Type I, the DLT bronchial end was in the left main bronchus (LMB), and the primary carina could be observed; Type Ⅱ, the DLT bronchial end was in the right bronchus intermedius (RBI); and Type III, an unidentified trachea or bronchus wall was observed from the DLT tracheal lumen] and the main tracheobronchial tree images were collected using Flexible bronchoscopy (FB). ResultFive patients were excluded due to excessive bronchus secretions impacting image collection. Type Ⅰ, II, and III positions of DLT were detected in 134 (68.7%) patients, 28 (14.4%) patients, and 33 (16.9%) patients, respectively. Examples of the tracheobronchial tree, common features, and variations in each lung lobe were demonstrated using FB. Furthermore, image analysis showed that each superior segment orifice of the right lower lobe (RLL) and the left lower lobe (LLL) was less variable and recognizable, determining it an important anatomical landmark for DLT positioning. ConclusionThe tracheobronchial tree and its common variations after DLT placement were described. The superior segment orifice of the RLL and LLL can be considered as an important landmark for DLT positioning.

ODP048 Large Bilateral Adrenal Lesions Abutting Right Hemidiaphragm in a Man from Texas

Abstract Sporadic cases of disseminated histoplasmosis (DHI) have been reported in several regions of the US, mainly inimmunocompromised patients where involvement of the adrenal gland, either unilaterally or bilaterally, is often being the only demonstrable site of active fungal disease in the setting of nonspecific clinical complaints. While DHI is not immediately life-threatening, adrenal involvement might be the most concerning complications due to potential risk of the gland destruction by the expanding infection or its treatment; it is considered that adrenal insufficiency is one of the most common causes of death in patients with DHI. We present a case of 78-year-old immunocompetent gentleman with history of hypertension, ischemic heart disease, atrial fibrillation and 30 pack-years of cigarette smoking who presented with low-grade fever, anorexia and 30 lbs weight loss. As a part of diagnostic evaluation, CT abdomen was performed and bilateral adrenal lesions were reported: right adrenal mass measured 4.6×3.4 cm, and the left adrenal mass 4.1×3.2 cm in maximal axial dimensions. Of note, the right adrenal mass abutted the crus of the right hemidiaphragm and undersurface of the liver. Hormonal evaluation was performed and did not show any excess secretions. GI consult was called for evaluation of adrenal gland access and biopsy: endoscopic ultrasound guided FNA biopsy access was performed and revealed findings compatible with adrenal histoplasmosis and no malignant cells. ID consult was sought: evaluation and prompt start of antifungal therapy were undertaken: IV Amphotericin B, followed by oral Itraconazole for total of 12 months. Patient has remained stable during initial evaluation: due to his age and comorbid conditions, he was admitted to the hospital during which Cosyntropin stimulation test was performed: results have revealed 12.9 at baseline and 17.6 after stimulation. Interdisciplinary discussion was held and resulted in decision to start steroid replacement therapy due to rather mild response to stimulation and significant risk of collateral damage to the remaining adrenal tissue during the antifungal therapy. Patient has responded to therapy well, though had some worsening of his cardiac function which required optimization of diuretic therapy. Patient's vital signs have remained stable, he has reported improved appetite and started to regain some of the lost weight; his electrolytes remained stable. Six-month interval imaging has shown reduction of the size of the adrenal gland sizes and no evidence of gland hemorrhage; notably, adrenal gland improvement has generally paralleled imaging improvement in other involved organs. Steroid therapy is being continued for total of 12 months. DHI still remains a serious problem in certain regions of the US and the world and has to remain an essential part of the differential diagnosis of the adrenal lesions allowing earlier treatment, gland preservation and avoidance of life-threatening complications. Presentation: No date and time listed

Mucopenetration study of solid lipid nanoparticles containing magneto sensitive iron oxide

In most chronic respiratory diseases, excessive viscous airway secretions oppose a formidable permeation barrier to drug delivery systems (DDSs), with a limit to their therapeutic efficacy for the targeting epithelium. Since mucopenetration of DDSs with slippery technology (i.e. PEGylation) has encountered a reduction in the presence of sticky and complex airway secretions, our aim was to evaluate the relevance of magnetic PEGylated Solid Lipid Nanoparticles (mSLNs) for pulling them through chronic obstructive pulmonary disease (COPD) airway secretions. Thus, COPD sputum from outpatient clinic, respiratory secretions aspirated from high (HI) and low (LO) airways of COPD patients in acute respiratory insufficiency, and porcine gastric mucus (PGM) were investigated for their permeability to mSLN particles under a magnetic field. Rheological tests and mSLN adhesion to airway epithelial cells (AECs) were also investigated. The results of mucopenetration show that mSLNs are permeable both in COPD sputum and in PGM, while HI and LO secretions are always impervious. Parallel rheological results show a different elastic property, which can be associated with different mucus mesostructures. Finally, adhesion tests confirm the role of the magnetic field in improving the interaction of SLNs with AECs. Overall, our results reveal that mesostructure is of paramount importance in determining the mucopenetration of magnetic SLNs.