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The obstruction of the endotracheal tube is a complication that can occur at any time during a general anesthesia and requires prompt recognition. We report a case of partial obstruction of the endotracheal tube in a 55 years old patient who underwent mamma tumorectomy plus sentinel node biopsy. The procedure was performed under general anaesthesia and during the surgery an increase in airway pressure was detected due to a kinking of the endotracheal tube at the oral cavity., A obstrução do tubo endotraqueal é uma complicação que pode acontecer em qualquer altura durante uma anestesia geral e requer de um rápido diagnóstico da situação. Apresentamos um caso de obstrução parcial do tubo endotraqueal numa doente de 55 anos submetida a tumorectomia de mama mais biópsia de gânglio sentinela. Foi realizada uma anestesia geral e, no decurso da intervenção foi detetado um aumento da pressão na via aérea devido ao kinking do tubo endotraqueal na cavidade oral.

Airway management in obstetrics remains a true challenge for several reasons. The anatomical and physiological modifications related to pregnancy are responsible for hypoxemia as well as an increase of the risk of inhalation of gastric contents. The emergency context increases the risks of difficulties with airway management, which justify the classification of the obstetric population as potential difficult airway. The evolution of the practices, with the considerable rise of the regional analgesia/anesthesia limits the training and the maintenance of competences for intratracheal intubation in obstetrics. For limiting the risk of difficult airway on this population is important to give priority to regional analgesia/anesthesia and perform a careful evaluation of the predictive criteria of difficult intubation or ventilation. The adapted material and algorithm for difficult intubation must be available in the labor wards and operatory rooms. The training per simulation appears particularly interesting on the subject. Our objective with this article is reviewing problems related to the airway management in obstetrics, taking into account the recent evolutions and propose an obstetric failed intubation algorithm., A abordagem da via aérea na população obstétrica continua a ser um verdadeiro desafio para o anestesiologista por várias razões. As alterações anatómicas e fisiológicas associadas à gravidez são responsáveis pelo desenvolvimento rápido de hipoxemia em caso de apneia. Existe ainda risco aumentado de regurgitação e aspiração do conteúdo gástrico. As situações de urgência ou emergência em obstetrícia aumentam o risco de dificuldade na abordagem na via aérea, em doentes já potencialmente portadores de via aérea difícil. A evolução da prática anestésica, com o aumento no recurso à anestesia/analgesia loco-regional, entre outros condicionantes, tem vindo a limitar a manutenção das aptidões em intubação endotraqueal na população obstétrica. Para limitar o risco de via aérea difícil nesta população é importante conceder prioridade à anestesia loco-regional e efetuar uma avaliação cuidadosa da via aérea , no sentido de detetar as situações previsivelmente difíceis. A existência de material adequado e algoritmos de via aérea difícil é essencial nas unidades obstétricas. O treino através das técnicas de simulação assume um papel de grande interesse para o aperfeiçoamento e manutenção das competências neste contexto particular. O nosso objetivo com este artigo é realizar uma revisão sobre os problemas associados à gestão da via aérea na população obstétrica, em função da evolução recente das práticas em anestesia obstétrica, e propor um algoritmo de via aérea difícil em obstetrícia.

Justificativa e objetivo: especialistas recomendam a intubação traqueal para o manejo das vias aéreas em procedimentos cirúrgicos laparoscópicos. A máscara laríngea (ML) pode ser uma boa opção à intubação endotraqueal. Nesta série de casos, o nosso objetivo foi analisar o uso damáscara laríngea SupremeTM (MLS) na prática cirúrgica laparoscópica. Métodos: o estudo foi conduzido com 60 pacientes, entre 18 e 60 anos, submetidos à cirurgia laparoscópica. Os valores de saturação periférica de O2 (SpO2) e dióxido de carbono no fim da expiração (EtCO2) foram registrados nos minutos um, 15, 30, 45 e 60. A frequência cardíaca e a pressão arterial média (PAM) dos pacientes também foram registradas. Consideramos o tempo de inserção da MLS; a taxa de aplicabilidade da sonda gástrica; a ocorrência de náusea, vômito, tosse e dor de garganta uma hora após a cirurgia. Resultados: a média inicial de EtCO2 foi menor do que aos 15, 30, 45 e 60 minutos (p < 0,0001) e a média de EtCO2 aos 15 minutos foi menor do que nos outros tempos registrados. Observamos que a frequência cardíaca média inicial foi maior do que as subsequentes à inserção da MLS e as anteriores e posteriores à remoção da MLS. A frequência cardíaca média após a inserção da MLS foi acentuadamente menor do que a anterior à remoção da MLS (p = 0,013). A PAM após a inserção da MLS foi menor do que a inicial e também menor do que as anteriores à remoção da MLS (p = 0,0001). Conclusão: a MLS pode ser uma opção adequada para intubação em procedimentos cirúrgicos laparoscópicos em um grupo seleto de pacientes. Background and objectives: In laparoscopic surgical procedures, experts recommend tracheal intubation for airway management. Laryngeal mask airway (LMA) can be a good alternative to intubation. In this case series, we aimed to examine the use of the SupremeTM LMA (SLMA) in laparoscopic surgical practice. Methods: We planned the study for sixty patients between the ages of 18 and 60, who would undergo laparoscopic surgery. We recorded one, 15, 30, 45, and 60-minute peripheral O2 saturation (SpO2) and end-tidal carbon dioxide (EtCO2) values, heart rate and mean arterial blood pressure (MAP). We observed the duration of SLMA insertion, the rate of gastric tube applicability, whether nausea, vomiting, and coughing developed, and whether there was postoperative1-hour sore throat. Results: The initial EtCO2 mean was lower than the EtCO2 means of 15, 30, 45, and 60 minutes (p < 0.0001) and the 15-minute EtCO2 mean was lower than other measured EtCO2 means. We observed the initial heart rate mean to be higher than the ones following the SLMA insertion, prior to the SLMA removal, and after the SLMA removal. The heart rate mean after the SLMA insertion was remarkably lower than the heart rate mean prior to the SLMA removal (p = 0.013).The MAP after the SLMA insertion was lower than the initial MAP means, as well as the MAP averages prior to after the removal of SLMA (p = 0.0001). Conclusion: SLMA can be a suitable alternative to intubation in laparoscopic surgical procedures in a group of selected patients. Justificativa y objetivo: expertos recomiendan la intubación traqueal para el manejo de las vías aéreas en procedimientos quirúrgicos laparoscópicos. La mascarilla laríngea (ML) puede ser una buena opción a la intubación endotraqueal. En esta serie de casos, nuestro objetivo fue analizar el uso de la mascarilla laríngea SupremeTM (MLS) en la práctica quirúrgica laparoscópica. Métodos: el estudio fue llevado a cabo con la participación de 60 pacientes de entre 18 y 60 anos, sometidos a la cirugía laparoscópica. Los valores de saturación periférica de O2 (SpO2) y de dióxido de carbono al final de la espiración (EtCO2), fueron registrados en los minutos 1, 15, 30, 45 y 60. La frecuencia cardíaca y la presión arterial promedio (PAP) de los pacientes también fueron registradas. Consideramos el tiempo de inserción de la MLS; así como la tasa de aplicabilidad de la sonda gástrica, el aparecimiento de nóusea, vómito, tos y dolor de garganta una hora después de la operación. Resultados: el promedio inicial de EtCO2 fue menor que a los 15, 30, 45 y 60 minutos (p < 0,0001) y el promedio de EtCO2 a los 15 minutos fue menor que en los otros tiempos registrados. Observamos que la frecuencia cardíaca promedio inicial fue mayor que las posteriores a la inserción de la MLS y a las anteriores, y posteriores a la retirada de la MLS. La frecuencia cardíaca promedio después de la inserción de la MLS fue acentuadamente menor que la anterior a la retirada de la MLS (p = 0,013). La PAP después de la inserción de la MLS fue menor que la inicial y también menor que las anteriores a la retirada de la MLS (p = 0,0001). Conclusiones: la MLS puede ser una opción adecuada para la intubación en los procedimientos quirúrgicos laparoscópicos en un grupo selecto de pacientes.

Objective: Endotracheal intubation (ETI) and laryngeal mask airways (LMA) can cause various laryngeal symptoms and changes in the acoustical characteristics of the voice in the postoperative period. In this study, we aimed to compare the effects of ETI, classical LMA, proseal LMA and I gel LMA on laryngeal symptoms and acoustic analysis parameters of the voice. Material and Methods: Eighty patients who underwent lower abdomen and extremity surgery, which do not effect the formation of the voice, were included in the study. A clinical survey sheet that included questions about hoarseness, globus pharyngeus, need for clearing throat, sore throat, loss of voice, unpleasant voice and cracking voice, was filled by the patients preoperatively, and on postoperative 2nd and 24th hours. All patients had acoustic analyses in an isolated room in the Otorhinolaryngology polyclinic. Acoustic analysis included parameters of basic frequency, jitter (measures of the cycle-to-cycle variations of fundamental frequency), shimmer (measures of the cycle-to-cycle variations of fundamental amplitude), harmonic/noise ratio and normalized noise energy. Results: The increase was statistically significant in group ETI preoperatively and on postoperative 2nd hour when compared to the other groups (p=0.005). In ETI group, hoarseness and need to clearing throat were significantly higher. In classical LMA group, need to clearing throat was significantly higher. No differences were found between T2 and T24 time periods for loss of voice parameters (p=0.179, p=1.000). These clinical evaluations were present in the early postoperative period, and they decreased to normal values on the postoperative 24th hour. In acoustic analysis, only the jitter parameter in the proseal LMA group changed significantly on the 2nd postoperative hour. Other acoustic parameters did not change significantly. Conclusion: We suppose that ETI and classical LMA may have effects on voice functions in the early postoperative period, and newly developed LMAs, especially gel structured laryngeal mask airways, which are not dilated with air, have minimal effects on voice functions and laryngeal complaints. © 2014 by Türkiye Klinikleri.

BACKGROUND: Pulmonary coagulopathy is a hallmark of lung injury following inhalation trauma. Locally applied heparin attenuates lung injury in animal models of smoke inhalation. Whether local treatment with heparin benefits patients with inhalation trauma is uncertain. The present trial aims at comparing a strategy using frequent nebulizations of heparin with standard care in intubated and ventilated burn patients with bronchoscopically confirmed inhalation trauma. METHODS: The Randomized Controlled Trial Investigating the Efficacy and Safety of Nebulized HEParin versus Placebo in BURN Patients with Inhalation Trauma (HEPBURN) is an international multi-center, double-blind, placebo-controlled, two-arm study. One hundred and sixteen intubated and ventilated burn patients with confirmed inhalation trauma are randomized to nebulizations of heparin (the nebulized heparin strategy) or nebulizations of normal saline (the control strategy) every four hours for 14 days or until extubation, whichever comes first. The primary endpoint is the number of ventilator-free days, defined as days alive and breathing without assistance during the first 28 days, if the period of unassisted breathing lasts for at least 24 consecutive hours. DISCUSSION: As far as the authors know, HEPBURN is the first randomized, placebo-controlled trial, powered to investigate whether local treatment with heparin shortens duration of ventilation of intubated and ventilated burn patients with inhalation trauma. TRIAL REGISTRATION: NCT01773083 (http://www.clinicaltrials.gov), registered on 16 January 2013.Recruiting. Randomisation commenced on 1 January 2014

Backgound and objective A postal survey was conducted in order to investigate current practice in airway management amongst Dutch anaesthetists and to investigate the role of recent training and the role of an 'Access to the Airway' airway management course. Methods A questionnaire containing 27 questions was sent to all practising anaesthetists in The Netherlands. Questionnaires were returned anonymously and were analysed using the Pearson chi (2)-test (P

Colonization of the intestinal tract has been assumed to be important in the pathogenesis of ventilator-associated pneumonia (VAP), but relative Impacts of oropharyngeal, gastric, or intestinal colonization have not been elucidated. Our aim was to prevent VAP by modulation of oropharyngeal colonization, without influencing gastric and Intestinal colonization and without systemic prophylaxis. In a prospective, randomized, placebo-controlled, double-blind study, 87 patients received topical antimicrobial prophylaxis (gentamicin/ colistin/vancomycin 2% in Orabase, every 6 h) in the oropharynx and 139 patients, divided over two control groups, received placebo (78 patients were studied in the presence of patients receiving topical prophylaxis [control group A] and 61 patients were studied In an intensive care unit where no topical prophylaxis was used [control group B]). Baseline characteristics were comparable in all three groups. Topical prophylaxis eradicated colonization present on admission in oropharynx (75% in study group versus 0% in control group A [p

End-tidal CO2 monitoring is an exciting non-invasive technology that is more commonly used in the emergency department, intensive care unit and in the prehospital setting. Its main use has been in verifying endotracheal tube position, during mechanical ventilation and cardiopulmonary resuscitation, but it is being studied and used for other purposes as well. The new American Heart Association guidelines require secondary confirmation of proper tube placement in all patients by exhaled CO2 immediately after intubation and during transport. This article covers the clinical applications of end-tidal CO2 monitoring with special reference to the paediatric patient.

AIMS: To evaluate the intraocular pressure and haemodynamic changes subsequent to insertion of laryngeal mask airway and endotracheal tube. SUBJECTS AND METHODS: The study was conducted in 50 adult patients. A standard general anaesthesia was administered to all the patients. After 3 minutes of induction of anaesthesia baseline measurements of heart rate, non-invasive blood pressure and intraocular pressure were taken following which patients were divided into two groups: laryngeal mask airway was inserted in group 1 and tracheal tube in group 2. These measurements were repeated at 15-30 second, every minute thereafter up to 5 minutes after airway instrumentation. RESULTS: A statistically significant rise in heart rate, systolic blood pressure, diastolic blood pressure and intraocular pressure was seen in both the groups subsequent to insertion of laryngeal mask airway or endotracheal tube. Mean maximum increase was statistically more after endotracheal intubation than after laryngeal mask airway insertion. The duration of statistically significant pressure responses was also longer after endotracheal intubation. CONCLUSION: Laryngeal mask airway is an acceptable alternative technique for ocular surgeries, offering advantages in terms of intraocular pressure and cardiovascular stability compared to tracheal intubation.

Difficult airway management represents a challenge in anaesthesia. In the last decades airway difficulty awareness has improved as a result of better anticipation and decision-making. Airway algorithms and protocols have a more prominent role in training and in clinical anaesthesia practice. In addition, several new instruments and therefore new techniques have been developed. These have improved possibilities for the clinician to secure the airway. Clinicians should become familiar with this equipment and techniques by using them on a regular basis in elective cases. The instruments available must be selected by the characteristics of the patient population, the local circumstances and the experience of the anaesthesiologist. The aim of this paper is to provide some practical guidelines with respect to airway difficulty predictors and airway instrument choice.

AIMS: To evaluate the ink impression made by the palm of the dominant hand as a screening tool for difficult laryngoscopy in diabetic patients. SUBJECTS AND METHODS: In this prospective study, airway of 50 adult diabetic patients, undergoing elective surgery under general anaesthesia, was assessed preoperatively using the common clinical indices such as Modified Mallampati test, thyromental distance, degree of head extension and a specific index- the palm print test. Following induction of anaesthesia and neuromuscular relaxation, laryngoscopy was performed and the laryngoscopic view scored. The sensitivity, specificity and positive predictive value of each airway evaluation index were calculated. RESULTS: The incidence of difficult laryngoscopy was 16%. The palm print test had the highest sensitivity (75%) of all the indices. The thyromental distance less than six cm had the highest specificity (95.2%) but was least sensitive (25%). 87% of patients with difficult laryngoscopy had two or more indices abnormal. CONCLUSION: Though the palm print test was the most sensitive index of the four indices studied, a better prediction of difficult laryngoscopy can be achieved by evaluating all the four airway indices preoperatively.

The management of endotracheal tubes and nasal cannulae covers a large part of work time of nurses involved in the care of very preterm infants. These procedures, although continuously performed, have not yet been scientifically demonstrated. In fact, there is limited evidence regarding several points such as the frequency of endotracheal suctioning, the level of suction pressure, the duration of suctioning, the depth of catheter insertion, the sterility, and the use of normal saline during endotracheal suction. With regard to the nasal cannulae, there is a more recent use of this device consisting in delivering end-expiratory pressure or gas flow to reduce the frequency of apneas and desaturations in preterm infants or for the management of RDS. This approach is defined high-flow nasal cannulae (HFNC). In this article, we review the literature on the airway management of intubated patients as well as of infants managed with nasal-CPAP or nasal cannulae. Potential fields of research on this topic are suggested.

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.

To assess a new technique for intubation via the laryngeal mask airway (LMA) in which a lighted stylet is used to optimise the position of the LMA before intubation.In 114 patients, following LMA insertion, the lighted stylet (Trachlight Wand) with mounted tracheal tube (TT) was advanced 1.5 cm beyond the mask aperture bars and the anterior neck observed for a distinct central point of light at the cricothyroid membrane (CTM). If this was not seen, the LMA was repositioned in the pharynx, depending on the location of the light, by manually advancing, withdrawing or rotating the device, manipulating the head/neck or trying an alternative size. Tracheal intubation was attempted only when transillumination was correct. The TT with lighted stylet was advanced until the supra-sternal notch was transilluminated.In 89 patients (78%) the CTM was transilluminated without repositioning, in 12 (10%) a single positional adjustment was required, and in 10 (9%) a change of LMA size was required. In three patients (3%) transillumination of the CTM was impossible. In the 97% of patients in whom transillumination was correct, tracheal intubation was successful in all at the first attempt without the need for further repositioning or size change.The lighted stylet is useful in facilitating intubation via the LMA in anaesthetised adult patients when used as a guide to optimal LMA position.

A case of severe ankylosing spondylitis involving the entire spine was to be operated for lumbar osteotomy. She had fixed rigidity of the cervical spine with minimal rotational movement, inability to lie down supine and severe restrictive lung disease with hypoxemia (pO2 = 65 mmHg). An awake intubation was performed and the patient was operated under general anaesthesia in the prone position. Intraoperative "wake-up" test was performed to judge whether extent of straightening was excessive. Postoperatively, she was electively ventilated and extubated uneventfully after 24 hours.

This prospective study was carried out over a period of 6 months in the Paediatric Intensive Care Unit (PICU) of a tertiary care teaching hospital. The aim of the study was to determine the organisms causing catheter related nosocomial infections in the PICU and to study their antimicrobial susceptibility pattern. Patients with endotracheal intubation, indwelling urinary catheters and central venous catheters (CVC)/venous cutdown catheters were included in the study. Colonization of the endotracheal tube, urinary catheter related infections (UCRI) and colonization of the CVC/venous cutdown catheters was studied. E. coli was the commonest organism colonizing the endotracheal tube tip with maximum susceptibility to cefotaxime and amikacin. E. coli was also was the commonest organism causing UCRI with maximum susceptibility to nitrofurantoin and amikacin. Acinetobacter was the commonest organism colonizing the CVC/venous cutdown catheters with maximum susceptibility to ciprofloxacin. All these sites of catheter related infections considered together, E. coli and Klebsiella were the commonest nosocomial organisms. Both had maximum susceptibility to amikacin. Methicillin resistant Staphylococcus aureus (MRSA) was isolated only from one culture. All the organisms had a poor susceptibility to cefazolin and amoxycillin. A knowledge of the resident microbial flora and their antimicrobial susceptibility pattern is necessary for formulating a rational antibiotic policy in an ICU.

ANTECEDENTES: El establecimiento del bloqueo neuromuscular determina el tiempo entre la inducción anestésica y la intubación traqueal, y es parcialmente influenciado por el flujo sanguíneo muscular y el gasto cardiaco. La efedrina puede aumentar el gasto cardiaco y el flujo sanguíneo muscular. El objetivo es evaluar la efectividad y la seguridad de la efedrina para obtener condiciones de intubación excelentes durante la laringoscopia directa. MÉTODOS: Fueron incluidos experimentos controlados aleatorizados en pacientes sometidos a intubación traqueal con laringoscopia directa. Se comparó la efedrina contra placebo o no intervención. Se realizaron búsquedas en bases de datos (MEDLINE, CENTRAL, EMBASE, LILACS, ISI, CINAHL y mRCT), en bola de nieve y en fuentes de literatura gris. RESULTADOS: Se incluyeron 25 estudios (2.029 pacientes). Seis fueron considerados de riesgo de sesgo bajo. La inconsistencia fue considerable (I2 50%). La efedrina podría aumentar la probabilidad de condiciones de intubación excelentes (odds ratio [OR] 5,32; intervalo de confianza [IC] 95%, 3,20 a 8,85) y de condiciones de intubación aceptables. También podría disminuir el tiempo de intubación y dolor a la inyección. No se observaron diferencias en taquicardia, hipertensión y arritmias entre los grupos. CONCLUSIONES: El uso de efedrina podría ser útil para aumentar la probabilidad de condiciones de intubación excelentes. Sin embargo, la inconsistencia entre estudios no hace posible recomendar el uso rutinario de esta intervención. Estudios adicionales con riesgo de sesgo bajo se requieren para evaluar este tema. Abstract. BACKGROUND: The onset of neuromuscular blockade usually determines the period from anesthetic induction to tracheal intubation, and is partially determined by muscle blood flow and cardiac output. Ephedrine can increase cardiac output and muscle blood flow. The aim of this study is to assess the effectiveness and safety of ephedrine to obtain excellent intubating conditions during direct laryngoscopy in adults METHODS: The review included randomized controlled trials conducted in patients requiring tracheal intubation with direct laryngoscopy. The intervention studied was ephedrine compared with placebo or no intervention. After conducting database searches (MEDLINE, CENTRAL, EMBASE, LILACS, ISI, CINAHL and mRCT), additional snowballing and grey literature searches were done. RESULTS: Were included 25 studies (2.029 patients). Six were considered to a have a low risk of bias. The inconsistency between studies was considerable (I2 50). Ephedrine could increase the likelihood of excellent intubating conditions (risk ratio [OR] 5.32; 95% confidence interval [CI], 3.20 a 8.85) and acceptable intubating conditions. Also could decreases the time of tube placement, and pain at injection. No differences were observed between groups in tachycardia, hypertension and arrhythmias. CONCLUSIONS: The use of ephedrine could be useful to increase the likelihood of excellent intubation conditions. However, the presence of inconsistency does not make possible to recommend the routine use of this intervention. Additional studies with low risk of bias are required to address this issue Maestría

Introduction Critically ill patients can develop acute respiratory failure requiring endotracheal intubation. Swallowing dysfunction after liberation from mechanical ventilation, also known as post-extubation dysphagia, is common and deleterious among patients without neurologic disease. However, the risk factors associated with the development of post-extubation dysphagia and its effect on hospital lengthofstay in critically ill patients with neurologic disorders remains relatively unexplored. Methods We conducted a retrospective, observational cohort study from 2008 to 2010 of patients with neurologic impairment who required mechanical ventilation and subsequently received a bedside swallow evaluation (BSE) by a speech-language pathologist. Results A BSE was performed after mechanical ventilation in 25% (630/2,484) of all patients. In the 184 patients with neurologic impairment, post-extubation dysphagia was present in 93% (171/184), and was classified as mild, moderate, or severe in 34% (62/184), 26% (48/184), and 33% (61/184), respectively. In univariate analyses, statistically significant risk factors for moderate/severe dysphagia included longer durations of mechanical ventilation and the presence of a tracheostomy. In multivariate analysis, adjusting for age, tracheostomy, cerebrovascular disease, and severity of illness, mechanical ventilation for >7 days remained independently associated with moderate/severe dysphagia (adjusted odds ratio = 4.48 (95%confidence interval = 2.14 to 9.81), P

Proposals to use a helmetlike interface for noninvasive positive pressure ventilation (NIV) can be traced back to more than a century ago. Among the earliest descriptions, Brauer and Petersen,1 in 1904, developed a helmetlike positive pressure ventilation “cabinet” to be placed around the patient’s head, with an air-tight seal formed via a soft neck collar. This prescient invention garnered little attention at the time. Instead, negative pressure ventilation via the “iron lung” gained widespread use to treat respiratory failure from polio and was superseded by endotracheal intubation for invasive mechanical ventilation by the 1960s. Although the physics of various mechanical ventilation devices is similar (pressure difference between airway opening and alveolus drives airflow), the interface used can have important implications for features of mechanical support possible, access of health care personnel to the patient, and comfort of the patient that may influence efficacy.

OBJETIVO: identificar e analisar evidências oriundas de ensaios clínicos controlados e randomizados sobre os cuidados relacionados à aspiração de secreções endotraqueais em pacientes adultos, em estado crítico, intubados e sob ventilação mecânica. MÉTODO: a busca foi realizada nas bases de dados Pubmed, Embase, Central, Cinahl e Lilacs. Das 631 referências encontradas, 17 estudos foram selecionados. RESULTADOS: identificaram-se evidências quanto a seis categorias de intervenções relacionadas à aspiração endotraqueal, as quais foram analisadas segundo desfechos referentes a alterações hemodinâmicas e dos gases sanguíneos, colonização microbiana, infecção nosocomial, dentre outros. RESULTADOS: as evidências obtidas são relevantes para a prática da aspiração endotraqueal, entretanto, os riscos de viés dos estudos selecionados comprometem a sua confiabilidade. OBJETIVO: identificar y analizar evidencias oriundas de ensayos clínicos controlados y hechos aleatorios sobre las atenciones relacionados a la aspiración de secreciones endotraqueales en pacientes adultos, en estado crítico, intubados y bajo ventilación mecánica. MÉTODO: la busca fue realizada en las bases de datos PUBMED, EMBASE, CENTRAL, CINAHL y LILACS. De las 631 referencias encontradas, 17 estudios fueron seleccionados. RESULTADOS: se identificaron evidencias en cuanto a seis categorías de intervenciones relacionadas a la aspiración endotraqueal, las cuales fueron analizadas según los resultados referentes a alteraciones hemodinámicas y de los gases sanguíneos, colonización microbiana, infección nosocomial, entre otros. RESULTADOS: las evidencias logradas son relevantes para la práctica de la aspiración endotraqueal, mientras, los riesgos de bies de los estudios seleccionados comprometen su confiabilidad. AIM: identify and analyze in the literature the evidence of randomized controlled trials on care related to the suctioning of endotracheal secretions in intubated, critically ill adult patients undergoing mechanical ventilation. METHOD: the search was conducted in the PubMed, EMBASE, CENTRAL, CINAHL and LILACS databases. From the 631 citations found, 17 studies were selected. RESULTS: Evidence was identified for six categories of intervention related to endotracheal suctioning, which were analyzed according to outcomes related to hemodynamic and blood gas alterations, microbial colonization, nosocomial infection, and others. CONCLUSIONS: although the evidence obtained is relevant to the practice of endotracheal aspiration, the risks of bias found in the studies selected compromise the evidence's reliability.

JUSTIFICATIVA E OBJETIVOS: A indução da anestesia geral em pacientes com estômago cheio pode resultar em regurgitação do conteúdo gástrico e aspiração pulmonar. A indução em sequência rápida (ISR) tem a função de minimizar o intervalo de tempo entre a perda dos reflexos protetores da via aérea e intubação traqueal com um tubo com balonete. O objetivo desse estudo foi avaliar a execução da indução em sequência rápida entre os anestesiologistas do Hospital São Paulo. MÉTODO: Os participantes responderam o questionário de forma voluntária e anônima, após esclarecimento e livre consentimento. O questionário continha 60 questões acerca dos pontos fundamentais da ISR. As questões se dividiam em pré-oxigenação, circuitos, drogas utilizadas na indução (opioides, hipnóticos, bloqueadores neuromusculares), técnicas de pressão cricoide, intubação e intubação difícil. RESULTADOS: Foram aplicados 75 questionários, sendo 22 descartados por preenchimento incompleto. Todos anestesiologistas declaram sempre realizar pré-oxigenação e administrar opioide, hipnótico e bloqueador neuromuscular. A maioria utiliza fentanila (83%), propofol (74,5%) e succinilcolina (68,6%). Todos anestesiologistas realizam pressão cricoide. A maioria não soube a pressão correta a ser aplicada na cartilagem cricoide. As falhas de intubação já ocorreram com 71,7% dos anestesiologistas e com 40% a regurgitação. Diante de uma intubação difícil e inesperada, 35,5% dos anestesiologistas solicitam máscara laríngea. CONCLUSÕES: Este estudo mostrou uma ampla variedade individual na técnica da ISR, fato já relatado por diversos autores. A dificuldade em se estabelecer um protocolo de ISR pode ser atribuída às constantes evidências que a ciência proporciona, fazendo da atualização parte da boa prática médica ao longo dos tempos. BACKGROUND AND OBJECTIVES: The induction of the general anesthesia in patients on a full stomach can result in regurgitation of the gastric content and pulmonary aspiration. The function of the rapid sequence induction (RSI) is to minimize the time interval between the loss of the airway protection reflexes and tracheal intubation tube balloon. The objective of this study was to evaluate the rapid sequence induction among the anesthesiologists of the São Paulo Hospital. METHODS: The participants answered the questionnaire voluntarily and anonymously, after signed consent. The questionnaire consisted of 60 questions about the fundamental points of the RSI. The questions were divided in pre-oxygenation, circuits, drugs used in the induction (opioids, hypnotics, neuromuscular blockers), cricoid pressure techniques, intubation and difficult intubation. RESULTS: Seventy-five questionnaires were applied and 22 were discarded due to incomplete answering. All anesthesiologists always declare doing pre-oxygenation and administering opioid, hypnotic, and neuromuscular blocker. Most use fentanyl (83%), propofol (74.5%) and succinylcoline (68.6%). All anesthesiologists apply cricoid pressure. Most did not know the correct pressure to be applied on the cricoid cartilage. Intubation failures have already occurred with 71.7% of anesthesiologists and with 40%, the regurgitation. When faced with an unexpected difficult intubation, anesthesiologists ask for the laryngeal mask (35.5%). CONCLUSIONS: This study showed a broad individual variety of the RSI technique, a fact already reported by different authors. The difficulty in establishing a RSI protocol can be attributed to constant evidence that science provides us, where updating over the years becomes good medical practice. JUSTIFICATIVA Y OBJETIVOS: La inducción de la anestesia general en pacientes con estómago lleno puede resultar en una regurgitación del contenido gástrico y en la aspiración pulmonar. La inducción en secuencia rápida (ISR), tiene la función de minimizar el intervalo de tiempo entre la pérdida de los reflejos protectores de la vía aérea y la intubación traqueal con un tubo con balón. El objetivo de este estudio, fue evaluar la ejecución de la inducción en secuencia rápida entre los anestesiólogos del Hospital São Paulo. MÉTODO: Los participantes respondieron al cuestionario de forma voluntaria y anónima, con la pertinente clarificación y con la posterior firma del Término de Consentimiento Informado. El cuestionario contenía 60 preguntas sobre los puntos fundamentales de la ISR. Las preguntas se dividían en preoxigenación, circuitos, fármacos utilizados en la inducción (opioides, hipnóticos, bloqueantes neuromusculares), técnicas de presión cricoide, intubación y desentubación difícil. RESULTADOS: Se aplicaron 75 cuestionarios y de ellos, 22 se descartaron porque fueron rellenados de forma incompleta. Todos los anestesiólogos siempre realizan una preoxigenación y siempre administran opioide, hipnótico y bloqueante neuromuscular. La mayoría utiliza fentanila (83%), propofol (74,5%) y succinilcolina (68,6%). Todos los anestesiólogos realizan presión cricoide. La mayoría no tuvo conocimiento respecto de la presión correcta que sería aplicada en el cartílago cricoide. Los fallos de intubación ya ocurrieron con un 71,7% de los anestesiólogos y con un 40% la regurgitación. Frente a una intubación difícil e inesperada los anestesiólogos solicitan mascarilla laríngea (35,5%). CONCLUSIONES: Este estudio mostró una amplia variedad individual en la técnica de la ISR, hecho que ya fue relatado por diversos autores. La dificultad en establecer un protocolo de ISR puede ser atribuida a las constantes evidencias que la ciencia nos proporciona, haciendo con que la actualización forme parte de la buena práctica médica a lo largo de los tiempos. Universidade Federal do Paraná Hospital do Trabalhador SAMMEDI CET Hospital do Servidor Público Estadual de São Paulo Universidade Federal de São Paulo (UNIFESP) UNIFESP, EPM SciELO

AIM: identify and analyze in the literature the evidence of randomized controlled trials on care related to the suctioning of endotracheal secretions in intubated, critically ill adult patients undergoing mechanical ventilation. METHOD: the search was conducted in the PubMed, EMBASE, CENTRAL, CINAHL and LILACS databases. From the 631 citations found, 17 studies were selected. RESULTS: Evidence was identified for six categories of intervention related to endotracheal suctioning, which were analyzed according to outcomes related to hemodynamic and blood gas alterations, microbial colonization, nosocomial infection, and others. CONCLUSIONS: although the evidence obtained is relevant to the practice of endotracheal aspiration, the risks of bias found in the studies selected compromise the evidence's reliability. OBJETIVO: identificar e analisar evidências oriundas de ensaios clínicos controlados e randomizados sobre os cuidados relacionados à aspiração de secreções endotraqueais em pacientes adultos, em estado crítico, intubados e sob ventilação mecânica. MÉTODO: a busca foi realizada nas bases de dados Pubmed, Embase, Central, Cinahl e Lilacs. Das 631 referências encontradas, 17 estudos foram selecionados. RESULTADOS: identificaram-se evidências quanto a seis categorias de intervenções relacionadas à aspiração endotraqueal, as quais foram analisadas segundo desfechos referentes a alterações hemodinâmicas e dos gases sanguíneos, colonização microbiana, infecção nosocomial, dentre outros. RESULTADOS: as evidências obtidas são relevantes para a prática da aspiração endotraqueal, entretanto, os riscos de viés dos estudos selecionados comprometem a sua confiabilidade. OBJETIVO: identificar y analizar evidencias oriundas de ensayos clínicos controlados y hechos aleatorios sobre las atenciones relacionados a la aspiración de secreciones endotraqueales en pacientes adultos, en estado crítico, intubados y bajo ventilación mecánica. MÉTODO: la busca fue realizada en las bases de datos PUBMED, EMBASE, CENTRAL, CINAHL y LILACS. De las 631 referencias encontradas, 17 estudios fueron seleccionados. RESULTADOS: se identificaron evidencias en cuanto a seis categorías de intervenciones relacionadas a la aspiración endotraqueal, las cuales fueron analizadas según los resultados referentes a alteraciones hemodinámicas y de los gases sanguíneos, colonización microbiana, infección nosocomial, entre otros. RESULTADOS: las evidencias logradas son relevantes para la práctica de la aspiración endotraqueal, mientras, los riesgos de bies de los estudios seleccionados comprometen su confiabilidad.

Lesion of the recurrent laryngeal nerves as a consequence of thyroid surgery results in bilateral vocal fold paralysis and respiratory obstruction. The initial treatment involves ensuring an adequate airway and it ranges from tracheostomy to endo-extralaryngeal laterofixating operations in general anesthesia. Subglottic high frequency jet ventilation (HFJV) is an alternative ventilatory approach in airway surgery. HFJV offers optimal endolaryngeal working conditions, immobility of vocal cords, adequate oxygenation and ventilation. The HFJV was prospectively studied in 20 consecutive female patients with bilateral vocal fold paralysis. Ventilation was performed as subglottic HFJV via jet catheter inserted through the vocal cord. Anesthesia was administered as total intravenous anesthesia. At the end of the procedure, the jet catheter was exchanged with LMA laryngeal mask until spontaneous breathing was established. Subglottic HFJV was used in 20 patients undergoing endo-extralaryngeal laterofixating operations with suspension microlaryngoscopy. The mean duration of surgery was 32.25 minutes, mean age 47.35 (SD 9.75) years, and mean body mass index 26.39 kg m(-2) (SD 5.03). The mean arterial PaCO2 5 min before surgical procedure was 5.39 (SD 0.86) kPa, at 5 min of starting jet ventilation 6.19 (SD 0.91) kPa, and at the end of surgical procedure 5.93 (SD 0.99) kPa. There was significant correlation between PaCO2 obtained 5 min before starting jet ventilation and PaCO2 at 5 min of starting jet ventilation (p0.05). No complications secondary to the ventilation technique were observed. No perioperative tracheotomy was necessary. It is concluded that subglottic HFJV is an easy and safe way to ventilate patients with bilateral vocal fold paralysis when endoscopic intervention is performed.

Place: France; International audience; We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.

Background and objectives: In our study we aimed to investigate the effect of esmolol, lidocaine and fentanyl on P-wave dispersion (Pwd), QT and corrected QT (QTc) durations and hemodynamic responses to endotracheal intubation during propofol induction. Methods: A total of eighty adult patients, American Society of Anesthesiologists (ASA) Physical Status I or II aged 18 to 60 years were included in this prospective, randomised, double-blind study. All patients had control electrocardiograms (ECGs) done before anesthesia induction. The patients were randomised into four equal groups. The control group (Group C) received saline 5 mL, the esmolol group (Group E) received esmolol 0.5 mg.kg-1, the fentanyl group (Group F) received fentanyl 2 μg.kg-1 and the lidocaine group (Group L) received lidocaine 1.5 mg.kg-1 before anesthesia induction. Anesthesia was induced with intravenous propofol. ECGs for all patients were performed during the 1st and 3rd minutes of induction, 3 minutes after administration of muscle relaxant, and at 5 minutes and 10 minutes after intubation. Pwd and QT intervals were measured on all ECGs. QTc intervals were determined using the Bazett formula. Heart rate (HR) and mean arterial pressure (MAP) were recorded before and after induction of anesthesia, immediately after intubation, and 1, 3, 5, 7 and 10 minutes after intubation. Results: Compared with control, HR significantly increased in Group C, Group L and Group F after intubation. However, in Group E, there was no significant difference in HR values between control and after intubation. Compared with control, MAP significantly increased in Group C and Group L after the intubation. However, in Group E and Group F, there was no significant difference in MAP values between control and after the intubation. Compared with control, Pwd significantly increased in Group C after intubation. In Group L, Group F and Group E, there was no significant difference in Pwd values between control and after the intubation. Compared with control, QTc duration significantly increased in Group C and L after the intubation. In Group F and Group E, there was no significant difference in QTc durations between control and after the intubation. Conclusion: We concluded that administration of esmolol before intubation prevents tachycardia and an increase in MAP, Pwd and QTc duration caused by laryngoscopy and tracheal intubation. Keywords: Electrocardiography, Intubation, Intratracheal, Anesthesia, Propanolamines/esmolol, Lidocaine, Fentanyl, Propofol.

The experience in performing intubation procedures gained by a single operator has been previously reported for adult, but not for neonatal patients.In order to evaluate the process of skill acquisition, we reviewed the first 150 neonatal tracheal intubations performed by a pediatric trainee.For logbook purposes, a pediatric trainee prospectively recorded all neonatal tracheal intubation procedures that she performed during a 5-year training period.During the study period, Nicoletta Doglioni performed for 152 intubation procedures. Of the 152 procedures, the author was successful on 120 (79%) occasions. Of these, 77 (64%) were performed on the first attempt, and 43 (36%) on the second attempt. Author successful intubation improved by the training year 1 (67%) to training year 2 (79%), 3 (77%), 4 (80%) and 5 (91%), respectively.Intubation success rate progressively improved with training year experience. A recommended level of proficiency, defined as 90% of procedure success, was obtained after 100 attempts suggesting that a significant amount of experience is needed for obtaining proficiency in neonatal intubation.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:58:15Z No. of bitstreams: 1 S0102-86502011000500006.pdf: 2182675 bytes, checksum: 53361d811109c0ccbffb1b45725b54c5 (MD5) Made available in DSpace on 2013-08-22T18:58:15Z (GMT). No. of bitstreams: 1 S0102-86502011000500006.pdf: 2182675 bytes, checksum: 53361d811109c0ccbffb1b45725b54c5 (MD5) Previous issue date: 2011-10-01 Made available in DSpace on 2013-09-30T19:53:48Z (GMT). No. of bitstreams: 2 S0102-86502011000500006.pdf: 2182675 bytes, checksum: 53361d811109c0ccbffb1b45725b54c5 (MD5) S0102-86502011000500006.pdf.txt: 29826 bytes, checksum: 2db49231adb089bd47ec2c7a514a756e (MD5) Previous issue date: 2011-10-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T15:13:59Z No. of bitstreams: 2 S0102-86502011000500006.pdf: 2182675 bytes, checksum: 53361d811109c0ccbffb1b45725b54c5 (MD5) S0102-86502011000500006.pdf.txt: 29826 bytes, checksum: 2db49231adb089bd47ec2c7a514a756e (MD5) Made available in DSpace on 2014-05-20T15:13:59Z (GMT). No. of bitstreams: 2 S0102-86502011000500006.pdf: 2182675 bytes, checksum: 53361d811109c0ccbffb1b45725b54c5 (MD5) S0102-86502011000500006.pdf.txt: 29826 bytes, checksum: 2db49231adb089bd47ec2c7a514a756e (MD5) Previous issue date: 2011-10-01 OBJETIVO: Avaliar as alterações morfológicas no epitélio traqueal de cães expostos à inalação de gases pouco condicionados, sob ventilação com tubo traqueal (TT) ou máscara laríngea (ML). MÉTODOS: Doze cães adultos foram divididos aleatoriamente em dois grupos: grupo TT (n-6) e grupo ML (n-6), submetidos à anestesia venosa e ventilação mecânica, em sistema sem reabsorção de CO2. Foram registrados parâmetros hemodinâmicos e ventilatórios, temperatura timpânica, temperatura, umidade relativa e absoluta do ar ambiente e dos gases inalados durante 3 horas. Ao término do experimento, os animais foram submetidos a eutanásia e realizadas biópsias ao longo do segmento traqueal para estudo morfológico. Três cães saudáveis foram utilizados para controle morfológico. RESULTADOS: A temperatura dos gases inalados manteve-se entre 24ºC e 26ºC, a umidade relativa entre 10% e 12%, e umidade absoluta entre 2 -3 mg H2O.L-1 sem diferença significativa entre os grupos. em ambos os grupos a análise histológica evidenciou processo inflamatório epitelial e congestão no córion, e a microscopia eletrônica de varredura mostrou agrupamento e desorganização ciliar. A microscopia eletrônica de transmissão detectou maiores alterações no grupo TT do que no ML, como alargamento das junções intercelulares, desorientação ciliar, vacuolização citoplasmática, alterações nucleares como pcinose e condensação da cromatina. CONCLUSÃO: A máscara laríngea determinou alterações menos pronunciadas no epitélio traqueal de cães expostos à inalação de gases pouco condicionados. PURPOSE: To study morphological findings in the tracheal epithelium of dogs exposed to the inhalation of poorly conditioned gases under use of an endotracheal tube (ET) or laryngeal mask airway (LMA). METHODS: Twelve dogs randomly were allocated to two groups: ET group (n-6) and LMA group (n-6), anaesthetized and mechanically ventilated, without CO2 reabsorption. Haemodynamic and ventilatory parameters, tympanic temperature, temperature, relative and absolute humidity of the ambient and inhaled gases were analyzed during three hours. The animals were submitted to euthanasia and biopsies were carried out along the tracheal segment to morphological study. Three healthy dogs were used to morphological control. RESULTS: Inhaled gas temperature was maintained between 24ºC and 26ºC, relative humidity between 10% and 12%, and absolute humidity between 2 - 3 mg H2O.L-1 with no significant differences between groups. In both groups, histological analysis showed epithelial inflammation and congestion in the corion and scanning electron microscopy showed ciliary grouping and disorganization. Transmission electron microscopy showed higher alterations in ET group than LMA group as widening of cell junctions, ciliary disorientation, cytoplasmic vacuolization, nuclear abnormalities, picnosis and chromatin condensation. CONCLUSION: LMA determined less pronounced changes in the tracheal epithelium in dogs exposed to the inhalation of poorly conditioned gases. UNESP Botucatu Medical School Department of Otorhinolaryngology, Ophthalmology and Head and Neck Surgery UNESP Botucatu Medical School Department of Anaesthesiology UNESP Botucatu Medical School Department of Pathology UNESP Institute of Biosciences Department of Biostatistics UNESP Botucatu Medical School Department of Otorhinolaryngology, Ophthalmology and Head and Neck Surgery UNESP Botucatu Medical School Department of Anaesthesiology UNESP Botucatu Medical School Department of Pathology UNESP Institute of Biosciences Department of Biostatistics

La introducción del sugammadex en la práctica clínica podría mejorar el perfil de seguridad de los relajantes neuromusculares; sin embargo, su uso en pacientes con nefropatía es cuestionable, pues, en razón del mecanismo de eliminación del fármaco, este podría ser problemático. Este artículo se basa en un caso en el cual se administró sugammadex a una paciente con nefropatía, quien presentó rápida reversión de la relajación neuromuscular sin que se observaran efectos adversos. The introduction of sugammadex in clinical practice could improve the safety profile of muscle relaxants, however, its use in patients with renal diseases is questionable when considering its clearance mechanism, as this could generate some problems. This case report describes a patient with renal disease in whom sugammadex was administered with a quick neuromuscular block reversal without any adverse effects.

Background and objectives: : We report a case of pneumothorax caused by a bronchial perforation during a reintubation using an airway exchange catheter (AEC) in a patient with a head and neck cancer. Case report: : A 53 year old man with oropharynx carcinoma was admitted to ICU for severe pneumonia and severe acute respiratory distress syndrome (ARDS). The patient was recognized as a difficult-to-intubate patient and an endotracheal tube (ETT) was inserted through a bronchoscope. After one week of treatment, it was observed an endotracheal cuff perforation. Exchanging the endotracheal tube was necessary to achieve satisfactory pulmonary ventilation. An AEC Cook 14 was used to perform the reintubation. After reintubation, the patient presented a worsening in oxygen saturation and a chest radiography (CXR) revealed a large pneumothorax. A chest tube was inserted and we observed immediate improvement in oxygen saturation. A repeat CXR confirmed correct positioning of the chest tube and reexpansion of the right lung. A bronchoscopy performed showed a posterior laceration in the right main bronchus. The patient was extubated the following day. After four days, the chest tube was removed. A CXR performed a day after chest tube removal revealed a small right upper pneumothorax, but the patient remained asymptomatic. Conclusions: : Airway exchange catheter is a valuable tool to handle with difficult-to-intubate patients. Although the physicians generally focus their attention in avoid barotrauma - caused by oxygen supplement or jet ventilation through AEC - concern for insertion technique can minimize life threatening complications and increase the safety of AEC. Keywords: Intubation, Intratracheal, Airway Management, Intensive Care, Anesthesia

Background: Patients with major burns accompanied with airway edema need more attention for airway management. Although the Pentax-AWS has an advantage in managing endotracheal intubation more easily, its usefulness cannot be assured if it does not maintain hemodynamic stability in burn patients. The aim of this study was to compare cardiovascular responses and general efficacy of the Pentax-AWS and Macintosh laryngoscopes in burn patients. Methods: American Society of Anesthesiologists physical status 2 or 3 adult patients with major burn injury were randomly assigned to group P (AWS, n = 50) or group M (Macintosh, n = 50). Fifty-nine patients assigned to the Macintosh group and no patient to AWS group were excluded because of failure to first intubation. Hemodynamic data at baseline, just before and after intubation as well as 3, 5 and 10 minutes after intubation and grade of sore throat were recorded in two groups. Intubation time, success rate of intubation, number of intubation attempts and the percentage of glottic opening (POGO) scores were also observed and analyzed in all patients. Results: A statistically significant increase in heart rate just after laryngoscopy was seen in group M. The success rate of the first attempt in group P (100%) was greater than with the group M (46%). POGO scores were higher in group P (97 ± 4%) than in group M (48 ± 29%) Conclusions: The use of Pentax-AWS offers a reduced degree of heart rate elevation compared with the Macintosh laryngoscope and better intubation environments in major burn patients. (Korean J Anesthesiol 2012; 62: 119-124)

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]). Refereed/Peer-reviewed

Negative-pressure pulmonary edema is an unusual complication mainly associated with general anesthesia. It is caused by excessive negative intrathoracic pressure following a deep inspiration against an acute airway obstruction. The resultant decreased intrathoracic pressure amplifies venous return to the right heart and increases pulmonary capillary wedge pressure that can be further amplified by massive sympathetic discharge due to hypoxia. The combination of increased venous return and pulmonary capillary wedge pressure favours the shift of fluid into the pulmonary interstitium with resultant pulmonary edema. Conversely, spontaneous pneumomediastinum (SP) results from alveolar rupture following an excessive positive intrathoracic pressure. The air leaks out of the alveoli and along the perivascular space toward the mediastinum. We experienced a case of negative pulmonary edema which presented in association with SP. Pneumomediastinum is probably caused by an excessive positive intrathoracic pressure for a subsequent expiration against a closed airway. In the present case, both complications resolved with conservative management.

Background Since the discovery of the human CFTR gene in 1989 various mouse models for cystic fibrosis (CF) have been generated and used as a very suitable and popular tool to approach research on this life-threatening disease. Age related changes regarding the course of disease and susceptibility towards pulmonary infections have been discussed in numerous studies. Methods Here, we investigated CftrTgH(neoim)Hgu and Cftrtm1Unc-Tg(FABPCFTR)1Jaw/J CF mice and their non-CF littermates during an acute lung infection with Pseudomonas aeruginosa for age dependent effects of their lung function and immune response. Mice younger than three or older than six months were intratracheally infected with P. aeruginosa TBCF10839. The infection was monitored by lung function of the animals using non-invasive head-out spirometry and the time course of physiological parameters over 192 hours. Quantitative bacteriology and lung histopathology of a subgroup of animals were used as endpoint parameters. Results Age-dependent changes in lung function and characteristic features for CF like a shallower, faster breathing pattern were observed in both CF mouse models in uninfected state. In contrast infected CF mice did not significantly differ from their non-CF littermates in susceptibility and severity of lung infection in both mouse models and age groups. The transgenic Cftrtm1Unc-Tg(FABPCFTR)1Jaw/J and their non-CF littermates showed a milder course of infection than the CftrTgH(neoim)Hgu CF and their congenic C57Bl/6J non-CF mice suggesting that the genetic background was more important for outcome than Cftr dysfunction. Conclusions Previous investigations of the same mouse lines have shown a higher airway susceptibility of older CF mice to intranasally applied P. aeruginosa. The different outcome of intranasal and intratracheal instillation of bacteria implies that infected CF epithelium is impaired during the initial colonization of upper airways, but not in the subsequent response of host defense.