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   2014| January  | Volume 3 | Issue 1  
    Online since July 21, 2017

 
 
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CONTINUING EDUCATION ARTICLE
Essentials of ventilator graphics
Ruben D Restrepo, Felix Khusid
January 2014, 3(1):396-404
Respiratory function monitoring involves the integration of information such as airway pressures, flow and volume to evaluate changes in pulmonary mechanics. Ventilator graphics are an essential and valuable tool in the care of mechanically ventilated patients. Clinicians responsible for both setting up the ventilators and managing the patients should have a thorough understanding of the different waveforms to be able to recognise mechanical and/or clinical abnormalities. The scalar graphics allow the assessment of each variable (pressure, flow and volume) over time. Despite the ability to customise graphics on modern ventilators, scalars are typically displayed together in the same screen. There are an innumerable number of changes that can be detected in the scalars that may facilitate the management of the mechanical ventilator, and thus optimise the care of the ventilated patient. The loops provide a two-dimensional view of two variables plotted against each other. Understanding how the patient and the ventilator interact must be considered a critical component of the overall assessment of patients undergoing any type of mechanical ventilation since detection and management of asynchrony impacts important clinical outcomes in the ICU.
[ABSTRACT]   Full text not available  [PDF]
  1,402 386 -
CASE REPORTS
An unusual case of multiple failed extubations in a neurosurgical patient
Gana Boban Thadathil, Jithendra , Mathew George, Jithin K Sree, PJ Binu, Jeevan Lal
January 2014, 3(1):418-420
A 41 year old woman, ASA PS1, an operated case of Chiari type 1 malformation, syringomyelia and syringobulbia, was posted for right syringopleural shunt. After a routine on-table extubation, immediately postoperatively, she lost consciousness, became progressively hypoxaemic requiring emergent reintubation. Blood gases revealed severe respiratory acidosis. The patient was systematically evaluated for likely causes of respiratory failure considering the sites of surgery and her preoperative surgical condition, i.e., brainstem, chest and larynx. She failed three trials of extubation, at different stages of her evaluation. Suspecting an undiagnosed neurological condition, the neurologist's evaluation discovered a three-month history of easy fatiguability, dysphagia and ptosis. Nerve conduction studies also pointed to the diagnosis of myasthaenia gravis. After initiating steroids and neostigmine, the patient made a steady recovery and was successfully weaned off the ventilator.
[ABSTRACT]   Full text not available  [PDF]
  1,503 128 -
ORIGINAL ARTICLES
Arterial blood gas tensions - Effect of storage time and temperature
Rajamanickam Rajasekaran, Henry Sadhanandham Arthur, John Victor Peter
January 2014, 3(1):350-356
Introduction: Arterial and venous blood gas analysis provide vital information on pH, oxygenation, ventilatory and acid-base status that guide clinician interventions. Factors such as syringe material, sampling technique, type of anticoagulant, storage time and temperature, and analysis may influence the accuracy of results. Aim: To determine the effect of storage time and temperature on blood gas analysis. Method: Nine 1-ml samples of arterial blood were collected by convenient sampling method involving 25 subjects in a single attempt from an in-dwelling arterial line. Four samples were stored in separate ice bags and four at room temperature. One sample was analysed immediately (‘reference’). One sample from each storage group was analysed at 15-min intervals for 60-min. The agreement of the ‘reference’ value with values of samples taken at 15-, 30-, 45- and 60-min were determined using Lin's concordance correlation and Bland and Altman's 95% limits of agreement (LOA). Results: The rate of decay of pH and PaCO2 values over time were similar for samples stored at room temperature and ice. The average difference (95% LOA) in PaO2 on samples stored at room temperature at 15, 30, 45 and 60 min when compared with baseline were 1.80 (-18 to 21.7), 3.84 (-20.5 to 28.2), 3.40 (-18.8 to 25.6) and 4.36 (-17.5 to 26.2) respectively. The decay in PaO2 was less pronounced in samples stored in ice with differences of -2.04 (-18.3 to 14.2), -2.64 (-14.2 to 9.0), -3.08 (-20.0 to 13.5) and -2.40 (-12.2 to 7.4) at 15, 30, 45 and 60 min respectively. Conclusion: PaO2 values reduce with time. The changes are more pronounced when samples are stored in room temperature than in ice. The wide LOA would imply that blood gas samples should, as far as possible, be processed immediately.
[ABSTRACT]   Full text not available  [PDF]
  989 145 -
REVIEW ARTICLES
Rapid sequence induction-intubation and cricoid pressure – Facts and fallacies
Shreepathi Krishna Achar, Nanda Shetty
January 2014, 3(1):374-381
Rapid sequence induction-intubation (RSII) is ‘the standard of care’ practice since decades while anaesthetising a full stomach patient or during emergency airway management. Cricoid pressure (CP), an important manoeuvre, labelled as the ‘linchpin of rapid sequence induction-intubation’, when not performed properly can lead to catastrophic results. The purpose of this review of literature is to discuss if rapid sequence induction and application of cricoid pressure is a safe and effective technique in managing a full stomach patient. Literature from multiple sources was searched for key words, subject headings and text entries on rapid sequence induction, rapid sequence induction and intubation, and cricoid pressure. Outcomes such as prevention of aspiration and prevention of other airway complications such as airway trauma could not be evaluated based on the literature available at present. There is lack of clear cut evidence from randomised controlled trials on the safety and effectiveness of rapid sequence induction-intubation and cricoid pressure. Despite wide acceptance of RSII, its role in emergency airway management is still debated. CP as an essential skill, lacks in its uniformity among clinicians, technicians and nurses, and simulation based training hold promise in this regard.
[ABSTRACT]   Full text not available  [PDF]
  846 135 -
SURVEY
Initial rhythm and outcome of in-hospital adult cardiac arrest in a tertiary care hospital
Saumy Johnson, Anitha Nileshwar
January 2014, 3(1):421-425
Introduction: Successful cardiopulmonary resuscitation after in-hospital cardiac arrest depends on basic and advanced life support systems, the ability to immediately defibrillate the arrested heart, and the quality of the CPR intervention. Aim: To determine the frequency of different cardiac arrest rhythms during the cardiac arrest event and also their effect on outcome. Methodology: This was a prospective study conducted in patients who sustained cardiac arrest in a tertiary hospital over 20 months. Tools used to collect data were Modified Utstein style Format for standard reporting of In-hospital cardiopulmonary resuscitation and Modified Early Warning Score chart. Results: There were a total of 1135 patients in the Pre MEWS group and there were 820 patients in the Post MEWS group. A total of 279 (14.27%) patients sustained VF/VT, 570 (29.15%) had pulseless electrical activity and 1106 (56.57%) had asystole. Survival to hospital discharge was significantly higher with VF/VT (18.27%) as compared to asystole (7.14%) and PEA (11.75%). There was no difference in the frequency of any cardiac arrest rhythm in various age groups, gender or degree of illness (APACHE II score). Furthermore, the cerebral performance category was significantly better if the initial rhythm was VF/VT. Survival to hospital discharge was higher if the initial rhythm was VF/VT (18.2%) as compared to asystole (7.14%) and pulseless electrical activity (11.75%). In the Pre MEWS period, 8.5% of the patients sustained VF/VT as compared to 23.7% sustaining VF/VT in the Post MEWS period. Conclusion: First monitored rhythm as VF/VT has significant association with the survival. Modified early warning score helps the nurses and the physicians to identify patients at risk of In-hospital adult cardiac arrest and this improves the survival of the patients.
[ABSTRACT]   Full text not available  [PDF]
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ORIGINAL ARTICLES
Graded oxygen delivery using low flow rotameter during positive pressure ventilation using self-inflating bag with a leak - An experimental study
Swathy Mohan, Tisha Ann Skariah, Eribaweimon Shilla, Leslie Lewis
January 2014, 3(1):370-373
Introduction: Bag-mask ventilation does not always guarantee 100% seal around airway opening and hence delivered fraction of oxygen (FDO2) may vary. Aim: To determine the FDO2 via a standard neonatal self-inflating bag with and without application of leak, without a reservoir bag with flow rates of 0.1, 0.2, 0.4, 0.6, 0.8, 1, 2, 4 and 6 L/min. Method: A test lung with a three way rotator to produce 0%, 30%, 50% and 75% leak was connected to a 3.5 mm ID endotracheal tube (ETT) connected to a VBM standard preterm self-inflating bag of 250 mL without a reservoir. The ETT was connected to ENVENTEC oxygen analyser and the bag inlet to a 100% oxygen source. Ventilation was done to a peak pressure of 15-20 cm H2O, at 40 bpm. FDO2 was recorded every 30 s, until the difference between two consecutive values was ≤ 1%. Result: The change in FDO2 was maximum when compared between 0.1 L/min and 6 L/min. For all leak percentages, the delivered oxygen showed an increasing trend from 0.1 to 0.6 L/min, a plateau from 0.6 to 1 L/min after which it increased. The change in FDO2 was different for different flow rates among various leak percentages. The highest delivered oxygen without leak was 56.15 ± 3.45% with 4 L/min flow. The oxygen delivered with 70% leak was considerably lower when compared to values with different leaks with respective flow rates. Conclusion: FDO2 increases with oxygen flow rates greater than 1 L/min. Leak around the mask has no effect of FDO2. Equilibration of FDO2 is achieved with in 60-90 s.
[ABSTRACT]   Full text not available  [PDF]
  839 110 -
Comparison of the C-MAC™ ‘D’ blade with AirTraq® for endotracheal intubation in patients with simulated limitation of cervical movements
Madhu Rao, Anitha Nileshwar, N Nandeesha
January 2014, 3(1):357-363
Background: Direct laryngoscopy and tracheal intubation with manual in-line stabilisation is the standard practice for trauma victims while securing the airway when cervical injury/instability is suspected. The use of videolaryngoscopes eliminates the need to align the three axes, avoids movement at cervical joints, allows viewing around the corner and improves glottic view. Aim: Comparison of C-MAC™‘D’Blade and AirTraq® for endotracheal intubation in patients with simulated limitation of cervical movements. Methodology: This was a prospective, randomised study conducted on 52 consenting patients requiring intubation. They were assigned to undergo intubation using C-MAC™‘D’Blade (n=26) or AirTraq® (n=26) by an anaesthesiologist experienced in the use of both laryngoscopes while MILS was provided. Results: Laryngoscopic view was similar in the two groups: grade 1 in 16 (61.5%) and 21 patients (81.8%) in the ‘D’blade and AirTraq® groups respectively with the remaining having a grade 2 view.The median time for laryngoscopy was less (13 s) in the ‘D’ blade compared to AirTraq® group (19.6 s) and was statistically significant (p= 0.036) but clinically insignificant.The intubation time was comparable (p=0.094). Most patients in both groups were intubated successfully in the first attempt. Requirement of airway manipulation to optimise view, postoperative sore throat and blood on the endotracheal tube was comparable. Good overall satisfaction score was obtained in bothgroups. Conclusion: Both C-MAC™ ‘D’Blade and AirTraq® when used for intubation in patients with simulated limitation of cervical movements provide similar videolaryngoscopic view, time for laryngoscopy and intubation, and overall satisfaction score.
[ABSTRACT]   Full text not available  [PDF]
  794 133 -
REVIEW ARTICLES
Multidisciplinary approach to pulmonary rehabilitation – An overview
Mohan K Manu, Saumy Johnson, Johnson Alex
January 2014, 3(1):388-395
Chronic respiratory diseases cause significant morbidity and lead to poor quality of life. Along with regular medications, pulmonary rehabilitation is an integral part in the management of such conditions to alleviate the suffering. This paper is an attempt to give an overview of the programme and its benefits. There is description about various components, staffing, setting, details about preprogramme evaluation, the programme per se and postprogramme follow up. This review is oriented largely towards how to run the programme in a resource poor setting.
[ABSTRACT]   Full text not available  [PDF]
  762 137 -
Respiratory care therapists in chronic respiratory care: The need of the hour
Komalkirti Apte, Sundeep Salvi
January 2014, 3(1):382-387
Chronic respiratory diseases are one of the main causes of morbidity and mortality, not only in the world at large, but also in India. The healthcare infrastructure at present remains insufficient to cope with the present and rising burden of chronic respiratory diseases. Insufficient and lack of skilled assistance has played a key role in the poor management of cases of chronic respiratory diseases. However, a second tier of healthcare providers, empowered with sufficient knowledge and skill sets for chronic respiratory disease management, can help in managing these patients better. Respiratory care therapists have made a significant difference in the management of acute and critical care in respiratory medicine. With chronic respiratory diseases comprising the greater burden, respiratory care therapists are in a position to make a greater impact in the management of these cases. This article is an endeavour to highlight the growing burden of chronic respiratory diseases and a possible solution to tackle the issue with efficient disease management. This is an extensive, raw and untapped opportunity for respiratory care therapists; an opportunity to unite with physicians in making lungs the heart of their scope of work. Together with physicians, respiratory care therapists can create this much pivotal change in efficient delivery of respiratory healthcare in India. This will help improve survival and therefore ensure a better quality of life for patients suffering from chronic respiratory diseases.
[ABSTRACT]   Full text not available  [PDF]
  741 133 -
ORIGINAL ARTICLES
Tracheal intubation with rocuronium bromide using the ‘timing principle‘ – A comparison with succinylcholine for rapid sequence induction
I Shajahan, Ramkumar Venkateswaran
January 2014, 3(1):364-369
Background: Rapid sequence induction and intubation aims to secure the airway at the earliest possible time to protect the airway. Succinylcholine is the most popular drug for this but rocuronium is an alternative when succinyl choline is contraindicated. Aim: We aimed to compare intubating conditions following intravenous rocuronium bromide (0.6 mg/kg and 1.0 mg/kg) using the ‘timing principle’ with that following intravenous succinylcholine hydrochloride (2 mg/kg). Methods: Sixty patients, ASA I or II, undergoing elective surgery were randomly assigned to one of three groups: Roc 0.6 (n=20) and Roc 1.0 groups (n=20) received rocuronium 0.6 mg/kg and 1.0 mg/kg respectively and anaesthesia induced at the onset of clinical weakness with thiopentone 5 mg/kg. Sch 2.0 group received thiopentone 5 mg/kg followed by succinylcholine hydrochloride 2.0 mg/kg. Intubating conditions were assessed 60 seconds after administration of thiopentone and were graded as excellent, good or poor. Results: Excellent intubating conditions were obtained in 70% of patients in Roc 0.6 and Sch 2.0 groups, and in 55% of patients in Roc 1.0 group. Conclusion: Rocuronium bromide administered in a dose of 0.6 mg/kg using the timing principle seems to be a suitable alternative to succinylcholine when a rapid onset of neuromuscular blockade is desired.
[ABSTRACT]   Full text not available  [PDF]
  742 114 -
CASE REPORTS
Multiple myeloma mimicking acute respiratory distress syndrome
G Gokul Krishna, Suresh G Nair
January 2014, 3(1):411-414
Multiple myeloma involves lungs rarely but when it does, it may be difficult to differentiate it from other more common primary lung parenchymal, pleural diseases, tumours or metastatic diseases. This is a case report of a patient who developed clinical features of acute respiratory distress syndrome secondary to multiple myeloma with involvement of lung parenchyma by neoplastic plasma cells.
[ABSTRACT]   Full text not available  [PDF]
  727 118 -
EDITORIAL
Cardiopulmonary resuscitation in acute respiratory distress syndrome– is it time to focus?
Ramesh Unnikrishnan, Abraham Samuel Babu, HM Krishna
January 2014, 3(1):347-349
[ABSTRACT]   Full text not available  [PDF]
  734 111 -
CASE REPORTS
Nocturnal hypoventilation-A case report
M Indu, Hari Lakshmanan
January 2014, 3(1):415-417
Nocturnal hypoventilation is commonly seen in disorders affecting the function of the diaphragm or central respiratory drive mechanisms. The consequences of nocturnal hypoventilation such as sleep disturbances, poor gas exchange, day time sleepiness and effect on daily activities are similar irrespective of the precipitating underlying disorder. Here we report a rare case of nocturnal hypoventilation which posed a diagnostic and therapeutic challenge.
[ABSTRACT]   Full text not available  [PDF]
  716 117 -
A case study of polymicrobial pneumonia
M Puneetha, T Mohankumar
January 2014, 3(1):408-410
A 34-year old woman, presented with high grade fever and productive cough for 10 days. She had history of recurrent lower respiratory tract infections for past four years. Her serial chest X-ray showed evidence of fleeting pneumonitis. She was tachypnoeic at rest but general examination was otherwise normal. Chest X-ray showed homogenous opacity in right lower zone. She was treated with piperacillin-tazobactam, clindamycin, azithromycin, bronchodilators and other supportive measures. Computerised tomography scan of the thorax showed multifocal areas of ground glass attenuation with inter lobular septal thickening in both lungs. Bronchial wash specimen for PCR analysis was positive for Staphylococcus aureus, Enterococcus species, Herpes simplex nuis, Cardida species, E coli and Pseudomonas arrogia. She was then started on acyclovir and voriconazole for one week. Repeat chest X-ray after one week showed radiological clearance. Patient became afebrile and improved symptomatically.
[ABSTRACT]   Full text not available  [PDF]
  717 103 -
Bulla or pneumothorax? - A radiological dilemma
Krishnamurthy Narasimha Prasad, A Amjad, Indu Priyadarshini
January 2014, 3(1):405-407
Diagnosing and treating pneumothorax can be an emergency life-saving situation. However, differentiating pneumothorax from bulla may be difficult in some circumstances and requires careful attention to details on the chest radiograph. We report a case of loculated hydropneumothorax which initially presented like a bulla. We wish to highlight the atypical radiographic presentation of pneumothorax empasising the importance of careful interpretation of chest radiograph. Follow up radiologic imaging or computed tomogram/magnetic resonance imaging would be required in such cases if the clinical and radiographic diagnosis do not match.
[ABSTRACT]   Full text not available  [PDF]
  714 101 -