Rate Of Endotracheal Intubation Research Articles

Brief report: Tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway

The Bonfils intubation fibrescope (BIF), a rigid, straight and reusable fibreoptic device, is being used increasingly to facilitate endotracheal intubation after direct laryngoscopy has failed. We tested the hypothesis that, with the BIF compared to direct laryngoscopy, the rate of failed endotracheal intubation could be reduced in patients with a difficult airway, simulated by means of a rigid cervical immobilization collar. Seventy-six adults undergoing elective gynecological surgery under general anesthesia were randomly assigned to have endotracheal intubation, facilitated with either a standard size 3 Macintosh laryngoscope blade, or the BIF. A rigid cervical immobilization collar was used to simulate a difficult airway, by reducing mouth opening and limiting neck extension. If endotracheal intubation could not be achieved within two attempts, the cervical collar was removed, and direct laryngoscopy was performed thereafter, using a Macintosh blade in all subjects. The success rate of endotracheal tube placement was the primary outcome variable. Patient characteristics were similar in the two groups. After neck immobilization, the inter-incisor distance was reduced to 2.6 +/- 0.7 cm (Macintosh) and 2.6 +/- 0.8 cm (BIF). Tube placement was successful in 15/38 (39.5%) patients with a Macintosh blade, and in 31/38 patients with the BIF (81.6%; P = 0.0003). Time required for tube placement was 53 +/- 22 sec (Macintosh) and 64 +/- 24 sec (BIF; P = 0.15). The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.

NIPSV for acute cardiogenic pulmonary oedema does not increase the risk of myocardial infarction compared to CPAP

Acute cardiogenic pulmonary oedema (ACPO) can be managed with either non-invasive pressure support ventilation (NIPSV) or non-invasive continuous positive airway pressure (CPAP). Does management with NIPSV increase the risk of myocardial infarction compared to management with CPAP? Randomised controlled trial with concealed allocation. High-dependency unit of a hospital emergency department in Turin, Italy. 52 adults with severe ACPO, defined as acute dyspnoea, > 30 breaths per minute, use of accessory respiratory muscles, oxygen saturation (SpO 2 ) < 90% with F i O 2 60%, and radiological signs of ACPO. Patients with signs of acute coronary syndrome (ACS) on hospital admission were excluded from the study. All patients received standard medications (diuretic, nitroglycerin, morphine) and oxygen. NIPSV was applied by a Pulmonetics Systems LTV 1000 ventilator. CPAP was administered by means of a flow generator (Whisper-Flow) with an expiratory (PEEP) valve. Patients randomised to NIPSV (n = 25) received sufficient inspiratory pressure (IPAP) to generate a tidal volume of ∼7 mL/kg, and oxygen to maintain SpO 2 at ∼93%, via an oronasal mask. Expiratory pressure (EPAP) was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Those randomised to CPAP (n = 27) commenced at 5 cmH 2 O via an oronasal mask with oxygen to maintain SpO 2 at ∼93%. The CPAP was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Treatment failure was defined as cardiac arrest, respiratory distress and arterial blood gas deterioration for > 60 min, PaO 2 /F i O 2 < 100 mmHg, coma or psychomotor agitation, haemodynamic instability, or life-threatening arrhythmias. Otherwise, treatment continued until the participant met objective criteria of recovery. The primary outcome was the rate of acute myocardial infarction (AMI). Secondary outcomes included rate of endotracheal intubation, death, duration of ventilatory assistance, and lengths of stay in the hospital and high-dependency unit. In the NIPSV group, the average EPAP and IPAP applied were 7 ± 1 and 15 ± 3 cm H 2 O, respectively. In the CPAP group, the mean pressure applied was 9 ± 2 cm H 2 O. AMI occurred in four patients on NIPSV and eight patients on CPAP, which was not significantly different, absolute risk reduction (ARR) 0.14, 95% CI –0.10 to 0.34. Also not significantly different were the number of intubations with only one in the NIPSV group, ARR –0.04, 95% CI –0.20 to 0.09, and the number of deaths with three in the NIPSV group and two in the CPAP group, ARR –0.05, 95% CI –0.23 to 0.13. The lengths of stay in hospital and in the high-dependency unit also did not significantly differ between the groups. This study demonstrated no significant difference in AMI among patients with ACPO managed with NIPSV versus CPAP.

A comprehensive telemedicine system for remote guidance of emergency airway management

We developed a Tele-Airway Management System (TAMS) which contained two high quality videocameras which were set up to view the frontal and lateral parts of the patient. Another endoscopic camera, a videolaryngoscope, was used to view the anatomy of the airway. One patient monitor was used to view the vital signs and there was also a PC terminal. A study was conducted in two separate emergency departments with 33 novice intubators (medical students and interns of the department). Remote consultation was provided by a board certified emergency physician. The time taken to complete endotracheal intubation for the TAMS group was 82.1 s (SE 4.9) and was 103.8 s (SE 7.9) in the videolaryngoscope-only group. The difference was significant (P = 0.03). The success rate of endotracheal intubation within 2 min was 94% for the TAMS group and 63% in the videolaryngoscope-only group (P = 0.04). With a wireless communication system, the TAMS could be installed in an ambulance, which might allow paramedics to perform safe and effective airway management in the field.

Noninvasive Ventilation Using a Mouthpiece in Patients with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure

Background: Noninvasive positive pressure ventilation (NPPV) delivered via a mouthpiece (mNPPV) has been successfully used in stable chronic restrictive respiratory insufficiency, but not in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF). Objectives: The purpose of this matched case-control study was to compare the usefulness of mNPPV to noninvasive ventilation using a nasal or oronasal mask (nNPPV) or standard medical treatment (SMT) in COPD patients with ARF. Methods: Twenty-nine patients receiving mNPPV were matched with 29 patients receiving nNPPV and 29 patients receiving SMT regarding age, SAPSII, admission PaCO₂ and pH. Results: In the mNPPV group, admission PaCO₂ and pH were 78.6 ± 12 mm Hg and 7.30 ± 0.04, respectively. mNPPV and nNPPV avoided the need for endotracheal intubation in 27 and 25 patients, respectively (nonsignificant) whereas SMT resulted in a higher mechanical ventilation rate (13 patients). At the end of the treatment protocol, PaCO₂ was lower in the mNPPV group (62.2 ± 9.6 mm Hg) than in the SMT group (72.4 ± 20.4 mm Hg, p < 0.018) leading to a significantly higher pH. No significant differences were observed between the mNPPV and nNPPV groups. Conclusions: In case of moderate respiratory acidosis, noninvasive ventilation using a mouthpiece significantly reduces the endotracheal intubation rate in comparison with SMT and therefore appears to be a second-line alternative to noninvasive ventilation delivered via a mask, especially when poorly tolerated.

Is there a role for noninvasive ventilation in acute respiratory distress syndrome? A meta-analysis

The role of noninvasive ventilation (NIV) in the management of acute respiratory distress syndrome (ARDS) is controversial. The aim of this study was to assess the effect of NIV on the rate of endotracheal intubation and intensive care unit (ICU) mortality in patients with ARDS. We searched the MEDLINE database for relevant studies published from 1980 to September 2005, and included studies if (a) the design was a randomized controlled trial; (b) patients had ARDS irrespective of the underlying etiology; (c) the interventions compared NIV and medical therapy with medical therapy alone; and (d) outcomes included need for endotracheal intubation and/or ICU survival. The addition of NIV to standard care in the setting of ARDS did not reduce the rate of endotracheal intubation (absolute risk reduction (RR) 13.5%, 95% confidence interval (CI) -5.2% to 31.3%), and had no effect on ICU survival (absolute RR 4.8%, 95% CI -12.8% to 22.1%). However, the trial results were significantly heterogeneous. Thus, current evidence suggests that patients with ARDS are unlikely to have any significant benefits on outcome when NIV is added to standard therapy. However, this analysis is limited by the presence of significant heterogeneity; hence large randomized controlled trials are required to settle this issue.

The LMA CTrach™, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients

The LMA CTrach is a new laryngeal mask system consisting of an LMA CTrach Airway with integrated fibreoptic channels, and a detachable LMA CTrach Viewer. This system enables viewing of the larynx and aids endotracheal intubation through a laryngeal mask airway. Method. We used and evaluated this system in 100 adult patients undergoing general anaesthesia for elective surgery. Our primary outcomes were the success rates of LMA CTrach Airway insertion and endotracheal intubation with this system. We were able to insert the LMA CTrach Airway in and to ventilate all 100 patients. We were successful in endotracheal intubation, either under vision or blind, in 96 patients. We were able to view the larynx in 84 patients, but the quality of the best view obtained was very variable. The median (inter quartile range) time for the complete intubation process was 166 (114-233) s. The system allowed nearly continuous ventilation and oxygenation during the process. The LMA CTrach system has potential advantages over the LMA Fastrach system, including the ability to align the LMA outlet with the larynx and a high first intubation attempt success rate. However, it was difficult to view the larynx with the LMA CTrach compared with direct laryngoscopy, and expectations must be moderated.

Non-invasive ventilation as a first-line treatment for acute respiratory failure: “real life” experience in the emergency department

Objective: To describe our experience with non-invasive ventilation (NIV) for patients with acute respiratory failure (ARF) in the emergency department (ED). Methods: A prospective/retrospective, observational study on 190 patients with...

Noninvasive positive pressure ventilation on air medical transport: Effects on endotracheal intubation rates

Noninvasive positive pressure ventilation on air medical transport: Effects on endotracheal intubation rates

Airway Management by US and Canadian Emergency Medicine Residents: A Multicenter Analysis of More Than 6,000 Endotracheal Intubation Attempts

We determine success rates of endotracheal intubation performed in emergency departments (EDs) by North American emergency medicine residents. During 58 months, physicians performing intubations at 31 university-affiliated EDs in 3 nations completed a data form that was entered into the National Emergency Airway Registry 2 database. Included were all patients undergoing endotracheal intubation in the ED. The data form included patients' age, sex, weight, indication for intubation, technique of airway management, names and dosages of all medications used to facilitate intubation, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We queried this prospectively gathered, observational data to analyze intubations done by US and Canadian emergency medicine residents. Enrollment was incomplete (eg, 85% at the main study center), so the study sample did not include all consecutive patients. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the United States and Canada. The first intubator was successful in 90% (5,193/5,757; 95% CI 89% to 91%) of cases, including 83% (4,775/5,757; 95% CI 82% to 84%) on the first attempt. Success rates on the first attempt were as follows: postgraduate year 1 = 72% (498/692; 95% CI 68% to 75%), postgraduate year 2 = 82% (2,081/2,544; 95% CI 80% to 83%), postgraduate year 3 = 88% (1,963/2,238; 95% CI 86% to 89%), postgraduate year 4+ = 82% (233/283; 95% CI 77% to 87%), and attending physician = 89% (689/772; 95% CI 87% to 91%). Success rates by the first intubator were as follows: postgraduate year 1 = 80% (553/692; 95% CI 77% to 83%), postgraduate year 2 = 89% (2,272/2,544; 95% CI 88% to 90%), postgraduate year 3 = 94% (2,105/2,238; 95% CI 93% to 95%), postgraduate year 4+ = 93% (263/283; 95% CI 89% to 96%), and attending physician = 98% (755/772; 95% CI 96% to 99%). Rapid sequence intubation technique was used in 78% (4,513/5,768; 95% CI 77% to 79%) of initial attempts: it resulted in 85% (3,843/4,513; 95% CI 84% to 86%) success on the first attempt and 91% (4,117/4,513; 95% CI 90% to 92%) success by the first intubator. The overall rate of cricothyrotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). When an initial intubator failed, 40% (385/954; 95% CI 37% to 44%) of rescue attempts were performed by emergency medicine residents. Among emergency medicine residents, success on the first rescue attempt was 80% (297/371; 95% CI 76% to 84%), and success by the first rescue intubator was 88% (328/371; 95% CI 85% to 91%). Success of initial intubation attempts increased over the first 3 years of residency. This large multicenter study demonstrates the success of airway management by emergency medicine residents in North America. Using rapid-sequence intubation predominantly, emergency medicine residents achieved high levels of success.

An Evaluation of Out-of-hospital Advanced Airway Management in an Urban Setting

To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.

The intubating laryngeal mask airway: Rocuronium improves endotracheal intubating conditions and success rate

Study objectiveTo assess intubating conditions without neuromuscular blocking drugs, to determine the relation between the dose of rocuronium and the probability of achieving excellent or at least good (good or excellent) intubating conditions with the intubating laryngeal mask airway (ILMA), and finally, to determine the relationship between rocuronium use and the success rate of endotracheal intubation. DesignProspective, randomized, double-blinded, placebo-controlled study. SettingUniversity-affiliated medical center. PatientsSixty American Society of Anesthesiologists physical status I and II patients undergoing elective surgery. InterventionsAnesthesia was induced with propofol 2.5 mg/kg and fentanyl 1 μg/kg. One minute after loss of consciousness, patients received rocuronium 0.2 mg/kg or saline. In the rocuronium group, if intubating conditions were scored as poor, rocuronium dose in the next patient was increased by 0.05 mg/kg. If intubating conditions were scored as good, no change was made, but if conditions were scored as excellent, the dose was decreased by 0.05 mg/kg. One minute after rocuronium or saline administration, an ILMA was used to intubate the trachea. If intubation was unsuccessful, a second attempt was made using the ILMA. MeasurementsWe recorded intubating conditions and the success rate of tracheal intubation. Main resultsWithout rocuronium, the probability of achieving at least good intubating conditions with the ILMA was 30%. A rocuronium dose of 0.2 mg/kg resulted in a probability of 80% to achieve at least good intubating conditions. Rocuronium significantly increased the success rate of the second intubation attempt. ConclusionTo achieve good or excellent intubating conditions with the ILMA, a rocuronium dose lower than the standard intubating dose of 0.6 mg/kg can be used. Neuromuscular blockade increases the success rate of intubation if a second attempt is necessary.

Sustained pressure-controlled inflation or intermittent mandatory ventilation in preterm infants in the delivery room? A randomized, controlled trial on initial respiratory support via nasopharyngeal tube

To prove the hypothesis that sustained pressure-controlled inflation compared to intermittent mandatory ventilation for lung recruitment via nasopharyngeal tube after delivery is more effective in reducing the rate of endotracheal intubation and mechanical ventilation in very preterm infants. The study was designed as a randomized, controlled trial. The setting was the delivery room and neonatal intensive care unit of a university hospital in Germany. Subjects were 61 infants (25.0-28.9 wk of gestation) with signs of respiratory distress immediately after birth. The infants were randomized in the delivery room to two different respiratory interventions: either to sustained pressure-controlled inflation (15 s) or to intermittent mandatory ventilation (rate 60 min(-1)). This respiratory support was given by a nasopharyngeal tube. The inflation pressure or peak inspiratory pressure was increased stepwise (20-25-30 cm H2O) according to the response of heart rate and oxygenation. The main outcome measure was treatment failure, i.e., endotracheal intubation and mechanical ventilation according to given intubation criteria. Treatment failure occurred in 61% (95% CI, sustained pressure-controlled inflation: 42-78) and 70% (95% CI, intermittent mandatory ventilation: 51-85) (p = 0.59). The rates of mortality (3/61), severe intraventricular haemorrhage (5/61) and chronic lung disease (10/58) were not different between groups. Sufficient spontaneous breathing within the first 48 h of life without endotracheal intubation and mechanical ventilation was achieved in about 30% with both methods of initial respiratory support.

Review of treatment of bronchiolitis related apnoea in two centres

Aims: To determine whether the use of negative pressure ventilation (NPV) was associated with a lower rate of endotracheal intubation in infants with recurrent apnoea secondary to acute bronchiolitis. Methods:...

Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema*

To compare the effects of oxygen, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (bilevel-PAP) on the rate of endotracheal intubation in patients with acute cardiogenic pulmonary edema. Randomized, controlled trial. Tertiary hospital emergency room. We randomly assigned 80 patients with severe cardiogenic acute pulmonary edema into three treatment groups. Patients were followed for 60 days after the randomization. Oxygen applied by face mask, CPAP, and bilevel-PAP. The rate of endotracheal intubation as well as vital signs and blood gases was recorded during the first 24 hrs. Mortality was evaluated at 15 days, at 60 days, and at hospital discharge. Complications related to respiratory support were evaluated before hospital discharge. Treatment with CPAP or bilevel-PAP resulted in significant improvement in the PaO2/FiO2 ratio, subjective dyspnea score, and respiratory and heart rates compared with oxygen therapy. Endotracheal intubation was necessary in 11 of 26 patients (42%) in the oxygen group but only in two of 27 patients (7%) in each noninvasive ventilation group (p = .001). There was no increase in the incidence of acute myocardial infarction in the CPAP or bilevel-PAP groups. Mortality at 15 days was higher in the oxygen than in the CPAP or bilevel-PAP groups (p < .05). Mortality up to hospital discharge was not significantly different among groups (p = .061). Compared with oxygen therapy, CPAP and bilevel-PAP resulted in similar vital signs and arterial blood gases and a lower rate of endotracheal intubation. No cardiac ischemic complications were associated with either of the noninvasive ventilation strategies.

Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review

The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. In duplicate and independently, we abstracted data to evaluate methodological quality and results. The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10-35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1-3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8-26%). However, trial results were significantly heterogeneous. Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.

The feasibility of treating severe acute congestive heart failure with bolus intravenous nitroglycerin

Study objectives: Bolus intravenous nitroglycerin is a potential innovation for the management of severe acute decompensated heart failure (ADHF) but has undergone limited clinical evaluation. Although previous studies have demonstrated improved outcomes, the effect of adding bolus intravenous nitroglycerin to standard American Heart Association (AHA) treatment of severe ADHF has not been defined. Our primary objective is to evaluate the feasibility of using this novel therapeutic approach in the management of severe ADHF. Secondary objectives include an assessment of the safety and efficacy of bolus intravenous nitroglycerin. Methods: This study was designed as an unblinded pilot intervention trial of the addition of bolus intravenous nitroglycerin to standard AHA treatment for ADHF. The eligible study population included all adult patients (age ≥18 years) presenting to the emergency department of Detroit Receiving Hospital (Detroit, MI: annual census ∼85,000) or Sinai-Grace Hospital (Detroit, MI: annual census ∼62,000) with a clinical diagnosis of ACPE. The prespecified goal was to enroll 30 patients. The main inclusion criterion was a systolic blood pressure of 160 mm Hg or greater or a mean arterial pressure of 120 mm Hg or greater. Patients with a suspected or proven right ventricular infarction, known or suspected pregnancy, or a history of intolerance to nitroglycerin and those requiring immediate intubation or cardiopulmonary resuscitation were excluded. The study was approved by the institutional review board of Wayne State University, and written informed consent was obtained from all patients (or proxy) before initiation of the protocol. On enrollment, baseline hemodynamic values and a serum brain natriuretic peptide level were obtained. Initial treatment of all patients consisted of 100% oxygen (by NRB), 3 doses of sublingual nitroglycerin (0.4 mg), and intravenous furosemide (60 to 100 mg). Administration of morphine sulfate (3 to 5 mg) was permitted but not encouraged. Patients without improvement were then started on the intervention protocol, which included initiation of a nitroglycerin infusion (0.3 to 0.5 μg/kg per minute) with concurrent administration of a dose of bolus intravenous nitroglycerin (2 mg). Titration of the infusion (≤400 μg/min) and repeated dosing of bolus intravenous nitroglycerin (2 mg) was allowed every 3 to 5 minutes, up to a total of 10 doses, at the discretion of the treating physician. Ventilatory assistance with endotracheal intubation or biphasic positive airway pressure and administration of additional pharmacologic therapy was permitted at any point at the discretion of the treating physician. The primary efficacy endpoint was rate of endotracheal intubation. Secondary efficacy endpoints included the need for ICU admission and total hospital length of stay. Primary safety endpoints included the incidence of cardiac or neurovascular complications and symptomatic hypotension. Descriptive statistics are provided. Results: Twenty-eight patients were enrolled. Mean age was 61.57 years (±15.01 years); 89.3% were black and 64.3% were men; 89.3% had a history of heart failure, 92.9% had hypertension, and 35.7% had coronary artery disease; 76.5% were noted with New York Heart Association heart failure classification III or IV, and the median brain natriuretic peptide level was 1,849 pg/mL. Baseline vital signs (mean±SD) were as follows: mean arterial pressure 155.11 mm Hg (±23.49 mm Hg); pulse rate 114.93 beats/min (±24.85 beats/min), and respiratory rate 31.07 breaths/min (±6.77 breaths/min). Mean protocol intervention time was 18.21 minutes (±14.97 minutes). Symptom improvement was reported in 24 patients (85.7%). Mean dosing of bolus intravenous nitroglycerin was 6.50 mg (±3.47 mg). Mean nitroglycerin infusion rate was 38.82 μg/min (±28.04 μg/min), and mean intravenous furosemide was 85.00 mg (±24.11 mg). Other administered medications included morphine (11 patients), angiotensin-converting enzyme inhibitors (10 patients), and β-blockers (3 patients). Patients were monitored for a mean period of 75.46 minutes (±69.84). During this time, significant reductions from baseline vital signs were noted (mean Δ [95% confidence interval (CI)]: pulse rate 20.96 beats/min [95% CI 14.49 to 27.44], and respiratory rate 8.59 breaths/min [95% CI 5.49 to 11.69]). Four patients (14.3%) required endotracheal intubation, and 2 (7.1%) needed biphasic positive airway pressure. Four patients (14.3%) had acute myocardial infarction. There were no neurovascular complications. One patient (3.6%) developed symptomatic hypotension. Ten patients (35.7%) were admitted to the ICU. The median length of stay was 4.06 days (range 14.31). Conclusion: Treatment of ADHF with bolus intravenous nitroglycerin is feasible. Addition of bolus intravenous nitroglycerin to standard AHA therapy results in dramatic hemodynamic and respiratory improvement without the development of excess adverse events. A decrease in the need for endotracheal intubation and ICU admission, as well as hospital length of stay, may also be associated, but comparison trials are needed.

Effect of prenatal diagnosis on outcomes in D-transposition of the great arteries.

By decreasing preoperative morbidity, prenatal diagnosis could improve neurodevelopmental outcomes in infants with critical congenital heart disease. We explored the impact of prenatal diagnosis on perinatal and perioperative variables and on outcomes at 1 year of age. We analyzed a database of children enrolled in prospective studies on surgical support techniques from 1988 to 2000. Selection criteria included a diagnosis of D-transposition of the great arteries with intact ventricular septum or ventricular septal defect, no extracardiac congenital anomalies, birth weight >2.3 kg, and repair by arterial switch procedure. Of 346 patients at enrollment, 25 had a prenatal diagnosis, and 321 did not. Children with prenatal diagnosis, compared with those without, had a lower likelihood of birth by spontaneous labor, lower birth weights, lower Apgar 5 scores, a higher rate of preoperative endotracheal intubation, and surgery at a younger age. They tended to have a lower incidence of fetal distress during labor. At 1 year of age, 272 patients were tested with the Psychomotor Development Index and Mental Development Index of the Bayley Scales. Mean z scores were similar in those with and without prenatal diagnosis for both Psychomotor Development Index (-0.92 +/- 0.93 vs -0.88 +/- 1.05) and Mental Development Index (-0.29 +/- 1.13 vs -0.41 +/- 0.93). Infants with D-transposition of the great arteries with and without prenatal diagnosis differed with respect to perinatal and perioperative variables, but their development at 1 year of age was similar. Future studies should include a greater number of children with prenatal diagnosis and a variety of congenital heart lesions.

Changes in Resuscitation Practice at Birth

The investigators, in the course of an ongoing monitoring program, prospectively collected information on neonatal resuscitation covering 17,885 infants born in a 4-year period in 1993 through 1997. In early 1995, T-piece circuits and facemasks were introduced in the maternity unit, and all medical and midwifery staff received practical training in their use. After 6 months, the previously used 500-mL self-inflating bags and masks were removed. Mean maternal age increased by approximately 6 months during the period under study. Forceps deliveries and cesarean sections (elective and emergency) declined significantly, whereas ventouse extractions and vaginal deliveries through meconium increased. Although medical staff electively attended progressively fewer deliveries during the 4-year study period, the number of infants seen after delivery by a pediatrician did not change significantly. Rates of early neonatal encephalopathy and meconium aspiration syndrome did not change significantly, but neonatal convulsions became markedly less frequent. The intubation rate fell significantly throughout the study period. The crude rate of endotracheal intubation fell 51%, and that of ventilatory resuscitation by any method decreased from 11% to 8.9%. The proportion of infants who received ventilatory support at birth but were not intubated rose from 76% to 86%. Intubation rates declined for infants of 30 weeks gestation and above. Rates of mask ventilation and intubation were 3.7% and 0.6%, respectively, for infants born by normal vaginal delivery. In contrast, 8.3% of infants born by elective cesarean section and 19.1% of those born by emergency section received mask ventilation. There was no independent association between the advent of T-piece ventilation and a lower intubation rate. No consistent change in 5-minute Apgar scores was evident during the period under review. Intubation rates fell substantially in this population with no decline in neonatal status. T-piece ventilation appears to be an effective and safe alternative to bag-valve-mask ventilation for resuscitating newborn infants. Education in the use of noninvasive airway support could help account for declining rates of intubation.

Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema

Background: Continuous positive airways pressure (CPAP) and bilevel non-invasive ventilation may have beneficial effects in the treatment of patients with acute cardiogenic pulmonary oedema. The efficacy of both treatments was...

Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema.

Noninvasive ventilation may reduce the endotracheal intubation rate in patients with acute cardiogenic pulmonary edema. However, criteria for selecting candidates for this technique are not well established. We analyzed a cohort of patients with severe acute cardiogenic pulmonary edema managed by conventional therapy to identify risk factors for intubation. These factors were used as guide for indications for noninvasive ventilation. Observational cohort registry in the ICU and emergency and cardiology departments in a community teaching hospital. . 110 consecutive patients with acute cardiogenic pulmonary edema, 80 of whom received conventional oxygen therapy. Physiological measurements and blood gas samples registered upon admission. Twenty-one patients (26%) treated with conventional oxygen therapy needed intubation. Acute myocardial infarction, pH below 7.25, low ejection fraction (<30%), hypercapnia, and systolic blood pressure below 140 mmHg were independent predictors for intubation. Conversely, systolic blood pressure of 180 mmHg or higher showed to be a protective factor since only two patients with this blood pressure value required intubation (8%)], both presenting with a pH lower than 7.25. Considering systolic blood pressure lower than 180 mmHg, patients who showed hypercapnia presented a high intubation rate (13/21, 62%) whereas the rate of intubation in patients with normocapnia was intermediate (6/23, 26%). All normocapnic patients with pH less than 7.25 required intubation. No patient with hypocapnia was intubated regardless the level of blood pressure. Patients with pH less than 7.25 or systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for noninvasive ventilation. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation.