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The increased polarity of evidenced-based medicine has changed the approach to evaluation of medical interventions and treatments, either placing them on firm scientific foundations or suggesting that evidence is inadequate to strongly support current or innovative practices. Airway management devices and techniques are essential and common components of clinical care. It is the purpose of this review to identify the levels of evidence that support common and novel techniques in airway management. Very few airway management techniques are supported by large, prospective randomized trials. In resuscitation, defibrillation should take priority over airway management. This is supported by animal studies and several reported series of patient experiences and will never be subjected to a prospective randomized trial. Substantial evidence supports the use of noninvasive ventilation, subglottic endotracheal tube secretion removal, changing ventilator circuits no more frequently than every 7 days, and the use of selective digestive decontamination with systemic antibiotics to reduce the incidence of ventilator-associated pneumonia. Little evidence supports using other measures such as elevating the head of the bed to 30% (but this costs nothing and is intrinsically attractive), use of heat and moisture exchangers, kinetic bed therapy, early tracheotomy, or lung secretion removal techniques to reduce ventilator-associated pneumonia. Percutaneous tracheotomy currently can only be recommended over open surgical tracheotomy based on cost, convenience and late stomal complications; it may be associated with a slightly higher morbidity and mortality.

Background: Inspired gases can be warmed and humidified in a variety of ways. The effect of a chemically-reactive heated heat and moisture exchanger/hygroscopic condenser humidifier (HME/HCH) on secretions, rate of core body warming, blood loss, and time to extubation was studied in hypothermic post-cardiac surgery patients., Methods: Fifty patients with normal ventricular function, undergoing coronary bypass grafting, were randomized to receive either a conventional HME (Gibeck, Humid-Vent 1 [PN 11112], Hudson RCI, Temecula, California) or a chemically-heated HME (Thermax HCH Filter [PN 9302], Enternet Medical, Las Vegas, Nevada) following surgery or on arrival in the ICU. Effects on secretions, core temperature, postoperative bleeding, duration of intubation, and added resistance were measured. The Thermax weighs 67 g and adds 79 mL of dead space. The Humid-Vent 1 weighs 9.4 g and adds 10 mL of dead space., Results: There was no significant difference between the 2 devices in time to extubation, blood loss, or quality or quantity of secretions. Use of the Thermax device, however, resulted in a more rapid rise in body temperature (0.299 degrees C/h with the Thermax vs 0.073 degrees C/h with the Humid-Vent 1, p = 0.001) and more added resistance (0.0672 cm H(2)O/L/s with the Thermax vs 0.0123 cm H(2)O/L/s with the Humid-Vent 1, p = 0.00000172)., Conclusions: The Thermax chemically-heated HME results in more rapid warming of mildly hypothermic patients following cardiopulmonary bypass than does a conventional passive HME.

Background: Indwelling arterial lines are commonly used in critical care. To standardize and improve the placement of these devices, we developed and implemented a respiratory therapist-based line placement service. As a measure of the quality of the service, we assessed the success and complications encountered in the first 119 line placement attempts of this new service., Methods: The following were recorded for each artery on which cannulation was attempted: the number of the attempt on which cannulation was successful; if a different person was able to cannulate the artery after initial failure; and whether any complications occurred. Success rate compared to the number of attempts was tested with chi-square., Results: Respiratory therapists were successful in placing 80% of attempted lines on the first try, including all 18 of 18 dorsal pedis attempts. Ninety-seven percent (115 of 119) of attempted arteries were ultimately cannulated. Success on second attempts by the same person was less than if a different, more experienced, person attempted the placement (p = 0.024). No complications were identified during the study., Conclusions: Initiation of a respiratory therapist-based arterial line placement service resulted in an acceptable cannulation success rate, without complications. Increased experience of the person attempting cannulation correlates with improved success.

We investigated the effects of establishing a blood gas analysis service controlled by respiratory care practitioners (RCPs) on the appropriateness of arterial blood gas (ABG) sampling. An ABG analyzer was placed outside the surgical intensive care unit (SICU) and only RCPs were permitted to process samples on it. In 1-month and 1-year follow-up audits of appropriateness of ABG analysis, the nursing staff improved from 42% appropriate to 73% appropriate in both follow-up periods. RCPs maintained a high degree of appropriateness in all periods (90%, 87%, and 91%), although the percentage of the total ABGs performed by RCPs increased. Additional benefits included a better mutual understanding of each caregiver's role and work load, more collaboration among caregiver groups, and caregiver's perception of improved patient care.