Terms Of Ventilation Research Articles

Síndrome ROHHAD (obesidad de rápida progresión, disfunción hipotalámica, hipoventilación y disregulación autonómica). Presentación de un caso y revisión de la literatura

IntroductionROHHAD syndrome (rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation) is a rare and complex disease, presenting in previously healthy children at the age of 2-4 years. Up to 40% of cases are associated with neural crest tumours. DevelopmentWe present the case of a 2-year-old girl with symptoms of rapidly progressing obesity, who a few months later developed hypothalamic dysfunction with severe electrolyte imbalance, behaviour disorder, hypoventilation, and severe autonomic dysregulation, among other symptoms. Although the pathophysiology of this syndrome remains unclear, an autoimmune hypothesis has been proposed for ROHHAD. Therefore, after obtaining a limited response to intravenous immunoglobulins, we decided to test the response to a high dose cyclophosphamide (low dose was not effective either). Unfortunately our patient experienced many severe complications (among them central pontine myelinolysis, from which the patient recovered, and failure to wean from the ventilator requiring tracheostomy and long term ventilation) that required a prolonged ICU stay. Although her behaviour improved, our patient unfortunately died suddenly at home at the age of 5 due to respiratory pathology. ConclusionsROHHAD syndrome is a rare and little-known disease which requires a multidisciplinary approach because it involves complex symptoms and multiple organ system involvement. Alveolar hypoventilation should be identified early and appropriate treatment should be started promptly for the best possible outcome. Immunomodulatory treatment with immunoglobulins, cyclophosphamide, or rituximab has previously resulted in symptom improvement in some cases. Because of the low incidence of the syndrome, multi-centre studies must be carried out in order to gather more accurate information about ROHHAD pathophysiology and design an appropriate therapeutic approach.

Assisted Ventilation in Patients With Acute Respiratory Distress Syndrome

BACKGROUND: In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of patient of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient-ventilator interaction. METHODS: Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient-ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume. RESULTS: During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 +/- 0.7, 11.2 +/- 0.7, and 9.4 +/- 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient-ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001. CONCLUSION: In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient-ventilator interaction and preserves respiratory variability.

Surgery for Patients With Spontaneous Deep Supratentorial Intracerebral Hemorrhage: A Retrospective Case-Control Study Using Propensity Score Matching.

Spontaneous intracerebral hemorrhage (sICH) is one of the most dangerous cerebrovascular diseases, especially when in deep brain. The treatment of spontaneous deep supratentorial intracerebral hemorrhage is still controversial. We conducted a retrospective case-control study using propensity score matching to compare the efficacy of surgery and conservative treatment for patients with deep surpatentorial hemorrhage.We observed the outcomes of consecutive patients with spontaneous deep supratentorial hemorrhage retrospectively from December 2008 to July 2013. Clinical outcomes of surgery and conservative treatments were compared in patients with deep sICH using propensity score matching method. The primary outcome was neurological function status at 6 months post ictus. The second outcomes included mortality at 30 days and 6 months, and the incidence of complications. Subgroup analyses of 6-month outcome were conducted.Sixty-three (22.66%) of the 278 patients who received surgery had a favorable neurological function status at 6 months, whereas in the conservative group, 66 of 278 (23.74%) had the same result (P = 0.763). The 30-day mortality in the surgical group was 19.06%, whereas 30.58% in the conservative group (P = 0.002). There was significant difference in the mortality at 6 months after ictus as well (23.38% vs 36.33%, P = 0.001). The subgroup analyses showed significantly better outcomes for the surgical group when hematoma was >40 mL (13.33% vs 0%, P = 0.005) or complicated with intraventricular hemorrhage (16.67% vs 7.27%, P = 0.034). For complications, the risk of pulmonary infection, gastrointestinal hemorrhage, urinary infection, pulmonary embolus, and need for tracheostomy/long term ventilation in the surgical group was higher than the conservative group (31.29% vs 15.47%, P < 0.001; 6.83% vs 3.96%, P = 0.133; 2.88% vs 1.80%, P = 0.400; 1.80% vs 1.08%, P = 0.476; 32.73% vs 23.38%, P = 0.014).Surgery could reduce the short-term mortality as well as long-term mortality in patients with spontaneous deep supratentorial hemorrhage. Moreover, surgery might improve the functional outcome in patients with large hematoma or with IVH compared with conservative treatment. Surgery might be a beneficial choice for part of the patients with spontaneous deep supratentorial hemorrhage, but further detailed research is still needed.

Study of bathroom ventilation fan performance trends for years 2005 to 2013—Data analysis of loudness and efficacy

Whole-house ventilation, which is defined as systems that supply and exhaust or relieve ventilation air for a residence, has been a mandatory provision since the announcement of IECC 2012. As a result, an increasing numbers of publications and standards are now addressing residential ventilation in terms of performance and efficiency. In addition, loudness is increasingly addressed in standards and guidelines, especially in the last decade as it is now considered to be a significant factor for certified performance ratings of ventilation fans. Because of the above interest in fan performance, this paper provides statistics of bathroom ventilation fan tests and their results for an almost decade-long period from 2005 to 2013. Also, the paper interprets these statistics with regards to the recent development of residential ventilation standards and guidelines.In order to investigate year-to-year changes, this paper first evaluates changes in loudness ratings for the test period 2005–2013, and its relevance to applicable standards, including ASHRAE 62.2. Then, noticeable transitions in loudness and efficacy in specific time frames are investigated. The test results of DC-motor high-efficiency bathroom fans are also compared to AC-motor fans. Relationships between performance variables and loudness are investigated, and formulated by developing regression models.

Colonization and infection in tracheostomized patients at tertiary care hospital in Eastern Nepal

Introduction: Tracheostomy is a life saving emergency procedure and provides many benefits for long term ventilator dependent patients. However, colonization and infection of airways after tracheostomy is one of the serious complications increasing patient morbidity and mortality. Objective: To find out the colonizing agent in the trachea of tracheostomized patients and the type and frequency of post tracheostomy infection. Methods: Study was conducted in 30 consecutive, adult patients requiring either elective or emergency tracheostomy at BPKIHS, Nepal. First and second tracheal swab was obtained immediately after tracheostomy and on the seventh day. Micro-organisms isolated from the culture of tracheal swab were noted. Patients were observed for infectious complications after tracheostomy. Results: Eighteen (60%) tracheostomies were performed electively and 12(40%) as an emergency. Sixty-eight isolates were grown from the culture of tracheal swabs. Out of 60 tracheal swabs, nine showed sterile culture. Single micro-organism was isolated from 35(58.33%) tracheal swabs and polybacterial isolation was seen in 16(26.66%) swabs. Pseudomonas aeroginosa was the commonest micro-organism isolated. After Pseudomonas, Staphylococcus aureus in the first culture and Acinetobacter anitratus in the second culture was the commonest organisms isolated. Five (16.6%) patients developed stomal infection and three (10.0%) developed pneumonia as a complication of tracheostomy. Conclusion: Trachea of the tracheostomized patients is heavily colonized by Pseudomonas aeruginosa, Acinetobacter anitratus and Staphyloccus aureus . Stomal infection and pneumonia are the infectious complication occurring within seven days of tracheostomy.Health Renaissance 2014;12(2): pp. 68-73

The effects of inverse ratio ventilation on cardiopulmonary function and inflammatory cytokine of bronchoaveolar lavage in obese patients undergoing gynecological laparoscopy

BackgroundHigh peak airway pressure (Ppeak) and high end-tidal carbon dioxide tension (PETCO2) are the common problems encountered in the obese patients undergoing gynecological laparoscopy with conventional volume-controlled ventilation. This study was designed to investigate whether volume-controlled inverse ratio ventilation (IRV) with inspiratory to expiratory (I:E) ratio of 2:1 could reduce Ppeak or the plateau pressure (Pplat), improve oxygenation, and alleviate lung injury in patients with normal lungs. MethodsSixty obese patients undergoing gynecological laparoscopy were enrolled in this study. After tracheal intubation, the patients were randomly divided into the IRV group (n = 30) and control group (n = 30). They were ventilated with an actual tidal volume of 8 mL/kg, respiratory rate of 12 breaths/min, zero positive end-expiratory pressure and I:E of 1:2 or 2:1. Arterial blood samples, hemodynamic parameters, and respiratory mechanics were recorded before and during pneumoperitoneum. The concentrations of tumor necrosis factor-α, and interleukins 6 and 8 in bronchoalveolar lavage fluid were measured immediately before and 60 minutes after onset of CO2 pneumoperitoneum. ResultsIRV significantly increased arterial partial pressure of oxygen, mean airway pressure, and dynamic compliance of respiratory system with concomitant significant decreases in Ppeak and Pplat compared to conventional ventilation with I:E of 1:2 (p < 0.05). Additionally, the levels of tumor necrosis factor-α, and interleukins 6 and 8 were significantly lower than those in control group (p < 0.05). ConclusionVolume-controlled IRV not only reduces Ppeak, Pplat, and the release of inflammatory cytokines, but also increases mean airway pressure, and improves oxygenation and dynamic compliance of respiratory system in obese patients undergoing gynecologic laparoscopy without adverse respiratory and hemodynamic effects. It is superior to conventional ratio ventilation in terms of oxygenation, respiratory mechanics and inflammatory cytokine in obese patients undergoing gynecologic laparoscopy.

Factors related to persisting perforations after ventilation tube insertion

ObjectiveOver a million ventilation tubes are placed annually in the United States, making this one of the most commonly performed procedures in the field of medicine. Certain factors increase the risk of persistent tympanic membrane perforation following the extrusion of short term ventilation tubes. Persistent perforations may fail to heal on their own, necessitating surgical closure to avoid conductive hearing loss. It is important to detect factors that may predict children who are at increased risk for persistent perforations. Methods, outcomes data and statistical analysisThis study was a retrospective chart review that involved 757 patients between 2003 and 2008. The patients studied were within the age of 2 months–17 years, and all had short term tubes placed. The chart data also included demographic information, comorbidities, and information related to tube insertion and follow-up care. Chi-square, t-test, and multivariate logistic regression were conducted to compare variables between patients with perforations and those without. ResultsData from 757 patients was analyzed, showing that perforation rate is associated with rhinorrhea, operative tube removal, aural polyps, and otorrhea (OR 1.72, 8.16, 4.69, and 1.72 respectively). The absence of otorrhea decreased the likelihood of TM perforations and no significant differences were found in gender, total number of sets of tubes, type of tube, use of nasal steroids, adenoidectomy, or nasal congestion. ConclusionOur findings suggest that children with rhinorrhea, otorrhea, aural polyps, or prolonged intubation requiring operative tube removal should be identified clinically as children at risk of persisting perforation.

Lung Damage and Thrombocytopenia

Hematological changes in patients with lung damage were common and included thrombocytopenia (55%) (Yang et al, Int J Mol Med. 2004; Hon et al, Lancet. 2003). A number of potential mechanisms have been investigated. The lungs of patients who died of lung infection show diffuse alveolar damage with pulmonary congestion, edema, formation of hyaline membrane, and fibrosis. Viral infection, oxygen toxicity and/or barotrauma contribute to the lung damage. The lung tissue and pulmonary endothelial cell damage result in platelet activation, aggregation, and thrombi formation at the site of the injury. All these mechanisms may induce the consumption of platelets and megakaryocytes (MK). The association between lung injury and thrombocytopenia was investigated by comparing the MK and platelet counts, and platelet activation using P-selectin as a marker, between the prepulmonary (right atrial) and postpulmonary (left atrial) blood in rats with and without hyperoxic lung injury. In the healthy controls, the postpulmonary blood had lower megakaryocyte count, higher platelet count, but similar P-selectin expression. In contrast, the lung-damaged animals did not show any such differences in either MK or platelet count, but P-selectin expression was greater in the postpulmonary blood. Peripheral platelet and intra-pulmonary MK counts in the lung-damaged rats were significantly lower than those in their respective controls. Intra-pulmonary thrombi or platelet aggregation were detected in the lung-damaged rats but not in the controls. These findings showed that lung damage reduced circulating platelets through (i) failure of the lungs to retain and fragment MK to release platelets, (ii) and platelet activation leading to platelet aggregation, thrombi formation and platelet consumption. The number and morphology of circulating MK were also investigated before, during and after cardiopulmonary bypass (CPB) in 22 patients undergoing routine cardiac surgery. Results showed that: (i) The total number of MK in central venous was higher than those of peripheral arteries during normal circulation (P<0.01). There was significant decrease of Type-4 MK (mature and large MK) number in peripheral arteries compared with that in central venous (P<0.001); and (ii) During CPB, the total MK and Type-4 MK of central venous and peripheral arteries were significant increased when compared with that in normal circulation (P<0.01). Our observation supports that the lungs may remove large MK during normal circulation. This physiological effect would be lost on CPB. On the other hand, the lungs may be the sites of platelet release from mature MK. The inflammation, the long term ventilation and/or oxygen therapy may result in pulmonary fibrosis and other pathological changes. The reduced or morphologically altered pulmonary capillary bed would affect the MK fragmentation in the lung. The increased consumption of platelet and/or the decreased production of platelet may lead to thrombocytopenia. DisclosuresYang:National Natural Science Foundation of China(81270580): Research Funding.

설계초기단계에 적용 가능한 초고층건축물의 패시브디자인 계획요소에 관한 연구

High-rise buildings may have problems of negative effects on the environment through excessive energy consumption and CO2 emission. Therefore, the purpose of this study is to establish the passive design elements that can be applied in the initial architectural design phase and to analyze them through some specific high-rise building examples that had acquired LEED green building certification. The findings of this study are as follows; The cooling and lighting are major factors for energy consumption for high-rise buildings. The major factors for reducing the energy consumption in the early design stage are Daylight, Solar heat, Curtain wall facade design, and Solar shades in terms of solar radiation, and Renewable Solar energy, Design for wind load, Natural Ventilation, and Renewable wind energy in terms of air flow. It is necessary to select appropriate strategies for the passive design according to divers climate characteristics. From the twelve buildings of green building certification, applications of passive design method are characterized according to the climatic zones, mass orientations, floor plans, forms and facade design elements.

Assisted Ventilation in Patients with Acute Respiratory Distress Syndrome: Lung-distending Pressure and Patient-Ventilator Interaction.

In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of "patient control" of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient-ventilator interaction. Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient-ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume. During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 ± 0.7, 11.2 ± 0.7, and 9.4 ± 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient-ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001. In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient-ventilator interaction and preserves respiratory variability.

Long term non-invasive ventilation in children: impact on survival and transition to adult care.

BackgroundThe number of children receiving domiciliary ventilatory support has grown over the last few decades driven largely by the introduction and widening applications of non-invasive ventilation. Ventilatory support may be used with the intention of increasing survival, or to facilitate discharge home and/or to palliate symptoms. However, the outcome of this intervention and the number of children transitioning to adult care as a consequence of longer survival is not yet clear.MethodsIn this retrospective cohort study, we analysed the outcome in children (<17 years) started on home NIV at Royal Brompton Hospital over an 18 year period 1993-2011. The aim was to establish for different diagnostic groups: survival rate, likelihood of early death depending on diagnosis or discontinuation of ventilation, and the proportion transitioning to adult care.Results496 children were commenced on home non invasive ventilation; follow-up data were available in 449 (91%). Fifty six per cent (n=254) had neuromuscular disease. Ventilation was started at a median age (IQR) 10 (3-15) years. Thirteen percent (n=59) were less than 1 year old. Forty percent (n=181) have transitioned to adult care. Twenty four percent (n=109) of patients have died, and nine percent (n=42) were able to discontinue ventilatory support.ConclusionLong term ventilation is associated with an increase in survival in a range of conditions leading to ventilatory failure in children, resulting in increasing numbers surviving to adulthood. This has significant implications for planning transition and adult care facilities.

G395(P) Experiences of patients on long term ventilation transferring to adult services

Aims Medical advances mean that more children with serious illnesses are surviving into adulthood. Recent legislation and guidelines stress the importance of delivering improved joined-up services for children undergoing transition to adult services. 1,2 A qualitative study was performed to explore the experiences of patients receiving long-term ventilation (LTV). Methods Questionnaire-based telephone interviews were conducted with 21 patients (14 males, median age 26 years, range 14–57) on LTV or their carers. All had previously been within children’s services and were now under adult respiratory care at a UK teaching hospital. The underlying causes for LTV included: Duchenne muscular dystrophy (9), other muscular dystrophies (6), congenital central hypoventilation syndrome (4) and other (2). Results Thematic analysis of the data identified 3 main themes: Variability : the age at which transition occurred varied (17–25), as did the option to attend combined clinics, which was only given to 3 of the 21 patients. There were discrepancies in the provision of community services, which was described as being “post-code dependent”. Unfamiliarity : patients expressed concerns about the unfamiliarity of adult doctors with their background and condition, which was often interpreted as insensitivity or lack of knowledge. They expressed frustration at having to repeat their story to numerous health care professionals. Separation of services : care under children’s services was reported as being more holistic when compared with the single organ approach in adult services. However, the thoroughness of adult physicians in patient management was appreciated. Conclusion Our study highlights the gap that needs to be bridged between children and adult services for patients on LTV. Early transition planning should occur to alleviate the unfamiliarity commonly experienced. This should include information about adult care and the differences in service provision. The utilisation of health care passports can do much to avoid physician unfamiliarity with the patient’s situation. These changes need to be uniformly adopted in order to improve patient satisfaction, care and long term outcome. References Care Act 2014 Care Quality Commission. From the pond into the sea: Children’s transition to adult healthcare services. June 2014

Role of dexmedetomidine in early extubation of the intensive care unit patients.

Background and Aims:Patients on ventilatory support in intensive care unit (ICU) require sedation and analgesia to facilitate mechanical ventilation and endotracheal tube tolerance. The selection of the agent should be such that it does not interfere with the early extubation of the patients. We compared the efficacy of dexmedetomidine with midazolam to facilitate extubation of patients from mechanical ventilation in terms of the sedative properties, cardiovascular responses, ventilation, and extubation characteristics and safety profile.Materials and Methods:A total of 40 adult, mechanically ventilated patients of either sex, aged 18-60 years, meeting the standard criteria for weaning, randomized into 2 groups of 20 patients each, received intravenous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h) or midazolam (0.04-0.2 mg/kg/h) as needed for Ramsay sedation scale 2-4. Extubation following standard extubation protocol was done. Time for extubation and vital parameters were regularly recorded.Results:The time to extubation in the dexmedetomidine group was significantly lower than in the midazolam group. Heart rate and blood pressure was significantly lower in dexmedetomidine group than the midazolam group at most of the times.Conclusions:Dexmedetomidine has clinically relevant benefits compared with midazolam in facilitating extubation due to its shorter time to extubation, more hemodynamic stability, easy arousability, and lack of respiratory depression.

The dual mode of ventilation ′pressure-controlled ventilation-volume guaranteed′ does not provide anymore benefit in obese anesthetized patients

Background Ventilatory strategies aim at the prevention of atelectasis and the improvement of oxygenation, but yet none is optimal. On comparing pressure-controlled ventilation (PCV) with volume-controlled ventilation (VCV) with the same tidal volume and inspiratory time, PCV tends to produce higher mean airway pressures, and thereby improves oxygenation. However, volume-targeted ventilators (VTV) allow to set the tidal volume directly. In order to deliver that volume. We compared PCV and pressure-controlled ventilation volume guaranteed (PCV-VG) with regard to the airway pressures produced when aiming to achieve the same tidal volume. Patients and methods Thirty obese ASA I-III patients scheduled for abdominal surgery were ventilated with PCV for 45 min; then, the PCV-VG mode was applied to all patients with the same parameters, targeting the same tidal volume of conventional PCV during the first phase. The plateau pressure and the mean airway pressure were recorded and compared between both modes. Vital signs, EtCO 2 , SpO 2 , arterial blood gases, and the oxygenation index were compared. Results No difference was observed between both modes of ventilation in terms of the plateau airway pressure (34.2 ΁ 1.8 vs. 34.1 ΁ 2.9 cmH 2 O, P = 0.484) and the mean airway pressure (13.4 ΁ 1.6 vs. 13.2 ΁ 1.8 cmH 2 O, P = 0.326). No significant difference was observed between PCV and PCV-VG with regard to the hemodynamics, EtCO 2 , and SpO 2 . No significant change was observed in the arterial blood gas analysis including pH (7.39 ΁ 0.3 versus 7.4 ΁ 0.2 with P value 0.204), PaCO 2 (30.8e 0.204) change in 0.2 with P value 0.06), PaO 2 (155.8 0.06)) change in0.2 with blood P value 0.316) and oxygenation index (4.34 oxygenation index.2 with bP value 0.176). ConclusionNo significant difference was observed between both modes of ventilation (PCV vs. PCV-VG) in obese patients.

Prolonged Middle Ear Ventilation by Cartilage-Grommet Tympanoplasty

In 1994, the American Otological Society reported favourable experience with composite cartilage shield tympanoplasty. The tragal cartilage with a grommet inserted in it was used for tympanoplasty in our patient with unilateral CSOM, supposedly because of severe chronic eustachian tube dysfunction. The marriage of cartilage tympanoplasty with grommet insertion was aimed to add the advantages and abolish the disadvantages of both the procedures. In 1990 Lary Hall first introduced the “long term ventilation of the middle ear” with a T-tube placed in the tragal cartilage perichondrium composite island graft. T-tube insertion in the cartilage has been described. But insertion of the Indian Sheperds grommet (ventilation tube) in the cartilage graft as described in this case and its technique are possibly the first of its kinds in literature. The report is aimed to ignite innovation of newer and better techniques of cartilage tympanoplasty.

Automated weaning and spontaneous breathing trial systems versus non-automated weaning strategies for discontinuation time in invasively ventilated postoperative adults.

Automated systems use closed-loop control to enable ventilators to perform basic and advanced functions while supporting respiration. Selected automated systems can now not only measure selected respiratory variables and adapt ventilator output to individual patient needs by operationalizing predetermined algorithms but also automate the conduct of spontaneous breathing trials (SBTs). To summarize the evidence comparing automated weaning and SBT systems to non-automated mechanical ventilation strategies on time to mechanical ventilation discontinuation in adult postoperative patients. In secondary objectives we ascertained differences between automated weaning and SBT systems and non-automated mechanical ventilation discontinuation strategies on clinical outcomes (time to successful extubation, time to first SBT and first successful SBT, mortality, total duration of ventilation, intensive care unit (ICU) and hospital lengths of stay, use of non-invasive ventilation (NIV) following extubation, and adverse events). We searched CENTRAL (The Cochrane Library 2013, Issue 5); MEDLINE (OvidSP) (1966 to May 2013); EMBASE (OvidSP) (1988 to May 2013); CINAHL (EBSCOhost) (1982 to May 2013), Evidence Based Medicine Reviews and Ovid Health Star (1999 to May 2013), conference proceedings, trial registration websites, and contacted authors and content experts to identify potentially eligible trials. Randomized and quasi-randomized trials comparing automated weaning and SBT systems to non-automated mechanical ventilation discontinuation strategies in intubated adults in the postoperative setting. Two review authors independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses were planned to assess the impact of the type of (i) clinician primarily involved in implementing the automated weaning and SBT systems, (ii) intensive care unit (ICU), and (iii) non-automated discontinuation (control) strategy utilized on selected outcomes. We identified one randomized controlled trial of high quality, involving 300 patients , comparing SmartCare™ to a written protocol. In this trial, SmartCare™ had no effect on discontinuation time. While SmartCare™ significantly reduced the time to the first SBT (mean difference (MD) -0.34 days, 95% CI -0.60 to -0.08; P = 0.01) it did not reduce the time to the first successful SBT (MD -0.25 days, 95% CI -0.55 to 0.05; P = 0.10) and other clinically important outcomes. SmartCare™ did not demonstrate beneficial effects on most clinically important outcomes including time to successful extubation, total duration of mechanical ventilation, ICU and hospital lengths of stay, and the requirement for tracheostomy. Moreover, SmartCare™ did not favourably impact reintubation, mortality, self-extubation, and the proportion of patients undergoing protracted mechanical ventilation, with a small numbers of events in this single trial. There is a paucity of evidence from randomized controlled trials to support or refute use of automated weaning and SBT systems in discontinuing invasive mechanical ventilation in adult postoperative patients. In a single large trial of high methodologic quality, while the use of SmartCare™ to adjust ventilator settings and conduct SBTs shortened the time to undergoing the first SBT, it did not reduce the time to the first successful SBT or the rate of tracheostomy compared to a written protocol implemented by physicians. SmartCare™ did not demonstrate beneficial effects on clinically important outcomes including time to mechanical ventilation discontinuation, time to successful discontinuation, total duration of mechanical ventilation, and ICU and hospital lengths of stay. Additional well-designed, adequately powered randomized controlled trials are needed to clarify the role for SmartCare™ on important outcomes in patients who predominantly require short term ventilation and in specific postoperative patient populations.

G165(P) The Impact of a Multi-Disciplinary Neuro-Respiratory Clinic on the Respiratory Monitoring of Children with Duchenne’s Muscular Dystrophy

AimsDuchenne’s muscular dystrophy (DMD) is a progressive degenerative muscular disorder that leads to respiratory failure in early adulthood. Our aim was to assess the impact of the development of a...

G167(P) The Multi-Disciplinary Paediatric Tracheostomy Clinic

AimsTo present our experience of managing children with a tracheostomy in a Multi-Disciplinary Team clinic consisting of an ENT Consultant, Paediatric Respiratory Consultant, a Nurse Specialist and Speech and Language...

Research Priorities for Medical Toxicology in Low and Middle Income Countries

In the editorial by Dr. Reza Afshari “What is the best research for low income countries” (1), some important issues have been raised, highly relevant to developing countries. In most developing countries including India, emergency medicine is not well established and clinical toxicology is even further a low priority in view of both research and clinical management. The number of poison control and treatment centers is few and if they exist, they are mainly in metro cities. Moreover, we are faced with lack of required resources for such research. Dr. Afshari’s suggestion about the need for epidemiological studies should be regarded as highly important (1). These studies should be prospective and community-based rather than hospital or poison centre based. Unless we know the pattern of poisonings, it will not be possible to formulate the guidelines for treatment and research as poisonings vary in different countries and in different areas of a country (2). Depending on pattern, the treatment and research guidelines can be devised and scarce resources can be allocated. The acute poisonings in developing countries are very often due to toxic chemicals. This is because there is a lack of control on availability of chemicals as laws do exist but implementation is lacking (2). Although specific antidote is available for majority of them, mortality remains high because treatment is often delayed due to non-availability of proper centres and lack of antidotes. Therefore, it is necessary to train health care professionals and to provide better awareness in general public regarding risks of poisonings. Furthermore, not only resources are lacking, western textbooks or literature is only available for management of poisonings and local guidelines are limited. In high income countries, both knowledge and money are available but poisoned patients are in limited number while in developing countries it is other way round. We must pay the most careful attention to the role of gastric lavage which due to legal reasons in some countries such as India, it is mandatory (3). It is also crucial to carefully investigate the venomous snakes where more species are required to be identified and antivenoms should be developed. There is a great need to develop low-priced diagnostic kits and cheaper analytic methods for poisons. More access to information in developing world and South-South collaboration is a highly welcomed idea. We need a standardized format to record, uniform protocols to manage poisonings and low cost healthcare technologies such as self-inflating bag in saving patients with respiratory arrest following snakebite or OPC poisoning or where short term ventilation is required.

Submental Intubation in Maxillofacial Surgery: A Prospective Study

We designed a prospective study with the objective to evaluate the efficacy, indications and our experience of submental intubation in different types of maxillofacial surgeries. From May 2008 to August 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. All the patients were managed well with this technique of intubation with no significant difference in intubation and extubation time. We did not face any uneventful complication. There was only one reported complication that is rupture of the bulb of cuffed flexometallic tube but was managed well by changing tube. We found skull base access surgery as a new indication for submental intubation. The submental route for endotracheal intubation may be utilized as an alternative to blind nasal intubation or tracheostomy in the surgical management of patients involving complex maxillofacial surgeries. We hypothesized that the submental intubation should not be used where long term ventilation support is needed. We did a technique modification to deliver the endotracheal tube out from the submental region to avoid pilot cuff damage. Our study proposes that skull base access surgery is a safe and potential indication for submental intubation. In our experience submental intubation is a simple, secure and effective procedure for operative airway control in major maxillofacial surgeries.