Airway Management

Background: Minimising interruptions in chest compressions is associated with improved survival from cardiac arrest. Current in-hospital guidelines recommend continuous chest compressions after the airway is secured on the premise that this will reduce no flow time. The aim of this study was to determine the effect of advanced airway use on the no flow ratio and other measures of CPR quality. Methods: Consecutive adult patients who sustained an in-hospital cardiac arrest were enrolled in this prospective observational study. The quality of CPR was measured using the Q-CPR device (Phillips, UK) before and after an advanced airway device (endotracheal tube [ET] or laryngeal mask airway [LMA]) was inserted. Patients receiving only bag-mask ventilation were used as the control cohort. The primary outcome was no flow ratio (NFR). Secondary outcomes were chest compression rate, depth, compressions too shallow, compressions with leaning, ventilation rate, inflation time, change in impedance and time required to successfully insert airway device. Results: One hundred patients were enrolled in the study (2008)(2009)(2010)(2011). Endotracheal tube and LMA placement took similar durations (median 15.8 s (IQR 6.8-19.4) vs LMA median 8.0 s (IQR 5.5-15.9), p = 0.1). The use of an advanced airway was associated with improved no flow ratios (endotracheal tube placement (n = 50) improved NFR from baseline median 0.24 IQR 0.17-0.40) to 0.15 to (IQR 0.09-0.28), p = 0.012; LMA (n = 25) from median 0.28 (IQR 0.23-0.40) to 0.13 (IQR 0.11-0.19), p = 0.0001). There was no change in NFR in patients managed solely with bag valve mask (BVM) (n = 25) (median 0.29 (IQR 0.18-0.59) vs median 0.26 (IQR 0.12-0.37), p = 0.888). There was no significant difference in time taken to successfully insert the airway device between the two groups. Conclusion: The use of an advanced airway (ETT or LMA) during in-hospital cardiac arrest was associated with improved no flow ratio. Further studies are required to determine the effect of airway devices on overall patient outcomes.

Background: With advances in technology, intubation using video laryngoscopy has been gaining popularity, particularly
in patients with difficult airways or as rescue devices in failed intubation attempts. Their routine use is, however, an uncommon occurrence. This clinical trial was carried out to support their use in elective airway management.
Objective: To evaluate the effectiveness of kingvision video laryngoscope (KVL) in comparison with the Truview video
laryngoscope (TVL) in routine airway management.
Methods: We studied 60 subjects requiring orotracheal intubation during general anaesthesia for elective surgeries. They were randomly assigned into two groups to undergo tracheal intubation using either a TVL (n=30) or KVL (n=30). Characteristics and consequences of airway management were evaluated. The primary outcomes were the percentage of glottic opening (POGO) and ease of intubation and secondary outcomes were Cormack and Lehane (CL) grading, TTI (time taken for intubation) and successful placement of endotracheal tube (ETT).
Results: Both the VLs were comparable with respect to primary and secondary outcomes except TTI which was more
with KVL.
Conclusion: We opine that both TVL and KVL provide a better laryngoscopic view in routine airway management, but
KVL does not have an extra benefit over TVL otherwise, further indicating the need for more experience with the use
of a KVL.
Keywords: Laryngoscopes; Airway Management; Intubation.

The use of diagnostic ultrasound by physiotherapists is not a new concept; it is frequently performed in musculoskeletal physiotherapy. Physiotherapists currently lack accurate, reliable, sensitive and valid measurements for the assessment of the indications and effectiveness of chest physiotherapy. Thoracic ultrasound may be a promising tool for the physiotherapist and could be routinely performed at patients’ bedsides to provide real-time and accurate information on the status of pleura, lungs and diaphragm; this would allow assessment of lung aeration from interstitial syndrome to lung consolidation with much better accuracy than chest X-rays or auscultation. Diaphragm excursion and contractility may also be assessed by ultrasound. This narrative review refers to lung and diaphragm ultrasound semiology and describes how physiotherapists could use this tool in their clinical decision-making processes in various cases of respiratory disorders. The use of thoracic ultrasound semiology alongside typical examinations may allow for the guiding, monitoring and evaluating of chest physiotherapy treatments. Thoracic ultrasound is a potential new tool for physiotherapists.

SUMMARY: Airway management in the ICU scenario is a real challenge due to instability imposed by illness severity. Some of these patients may also suffer from other diseases associated to difficult airway. Rheumatoid arthritis represents a special condition because not only can limit access to the hypopharynx, but also can hamper laryngoscopy. Among many options for difficult airway management, only a few can be safely applied to intubate the trachea while preserving physio-logic stability in an emergency setting. We chose awake fiberoptic intubation as the first and safest approach for this combined difficult patient. This approach requires not only individual skills but also a plan in advance and a well coordinated team to be successful. A case is presented as an example of difficulties imposed by physiologic instability added to anatomic difficult.

RESUMEN: El manejo de la vía aérea en la UCI representa un desafío debido a la inestabi-lidad derivada de la severidad de la patología. Además, algunos de estos pacien-tes pueden presentar condiciones preexistentes asociadas a vía aérea difícil. La artritis reumatoide representa una condición especial debido a que no sólo limita el acceso a la hipofaringe, sino que también puede dificultar la laringoscopía. Entre las diferentes opciones para manejar la vía aérea, sólo algunas pueden ser aplicadas para intubar la tráquea de manera segura y al mismo tiempo preservar la estabilidad fisiológica en un contexto de urgencia. Este abordaje requiere no sólo habilidades individuales, sino que también trabajo en equipo coordinado y planificación. Se presenta un caso como ejemplo de dificultades impuestas por la inestabilidad fisiológica agregada a dificultad anatómica.

Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syn...