Peter Young

Paramedic laryngoscopy in the simulated difficult airway: comparison of the Venner A.P. Advance and GlideScope Ranger video laryngoscopes.

OBJECTIVESnThis study assesses intubation times and potential trauma with two new portable video laryngoscopes, the GlideScope Ranger (GSR) and the Venner A.P. Advance (APA), in a simulated difficult prehospital airway. The GSR has a hockey stick shape and is inserted by a different (midline) technique compared with direct laryngoscopy and requires the use of a stylet. The APA has a handle similar to a direct laryngoscope, but with an angulated difficult airway blade. The APA is designed to have an intuitive insertion technique somewhat similar to that of direct laryngoscopy (lateral tongue displacement) and has a guiding mechanism that foregoes the need for a stylet.nnnMETHODSnThirty qualified paramedics received a short demonstration of each device and were asked to intubate a modified Grade III difficult laryngoscopy mannequin in a random order (closed envelope technique). Optimal view and tracheal intubation times were recorded, and potential trauma assessed by the number of additional discrete forward advances and by visual analog scale (VAS). Direct laryngoscopy was used as a comparator. The Wilcoxon rank sum test was used for intubation times, optimal view times, percentage of glottis opening (POGO) seen, and objective trauma assessment. Students paired t-test was used for subjective trauma assessment and a Bonferroni correction was used for the primary outcome measures.nnnRESULTSnParticipants declared a median of 60 (range 20 to 300) previous intubations. Time to achieve optimal view between APA and GSR was not different (20 seconds vs. 19 seconds; p = 0.19), but tracheal intubation was significantly faster with the APA (25 seconds vs. 46 seconds; p < 0.0001). Intubation success was ultimately 97% in both groups. Participants judged subjective trauma to be less for the APA than GSR on a VAS (1.6 cm vs. 3.3 cm; p < 0.001). More than three additional forward advances were required in 43% of GSR and 0% of APA intubations.nnnCONCLUSIONSnFollowing a brief demonstration to paramedics naïve to video laryngoscopy, the APA demonstrated earlier intubation, fewer additional discrete forward advances of the tube, and less participant-judged subjective trauma when compared to the GSR in this simulation model.ACADEMIC EMERGENCY MEDICINE 2011; 18:692–698

The LoTrach system: its role in the prevention of ventilator-associated pneumonia.

OBJECTIVESnTo discuss the development of the LoTrach system in light of current evidence around the prevention of ventilator-associated pneumonia (VAP) and its practical application in the intensive care setting.nnnBACKGROUNDnVAP causes substantial morbidity and mortality in ventilated patients in the Intensive Care Unit (ICU), increases length of stay in ICU and is extremely costly. Strategies are needed to reduce the risk of VAP.nnnMETHODnWe examine the need for an endotracheal tube (ETT) specifically designed for the critically-ill patient, the development of the LoTrach system from conception to production, and the role of the various components of the system in preventing VAP. Early issues in implementing this revolutionary equipment into ICU are explored and three case studies highlight advantages of this system.nnnCONCLUSIONnThe LoTrach system has been designed to facilitate the provision of a number of evidence-based interventions that have been shown to reduce VAP. Pulmonary aspiration is ubiquitous with conventional cuffs but prevented by the cuff of the LoTrach system when held at a constant and safe pressure against the tracheal wall with a cuff pressure controller. Other aspects incorporated in the ETT are aimed at clearing the secretions from the subglottic space, preventing tube occlusion and accidental extubation, and avoiding damage to the airway. In this way the LoTrach system employs a multifactorial approach to the prevention of VAP and the cost savings from LoTrach rather than a standard ETT will be considerable because of an average 3 day reduction in ICU length of stay related to this. It thus has the potential to be a very useful tool in the ICU setting in the prevention of VAP.

Increasing positive end expiratory pressure at extubation reduces subglottic secretion aspiration in a bench‐top model

AIMnTo estimate the ability of simulated tracheal suction, adjusting the positive end expiratory pressure (PEEP) settings on the ventilator or compressing a self-inflating bag to minimize aspiration during cuff deflation and extubation in a bench-top model.nnnBACKGROUNDnDuring intubation, colonized secretions accumulate in the subglottic space above the endotracheal tube (ETT) cuff. Consequently, during cuff deflation and extubation, there is a risk of aspiration of the secretions. This may result in pneumonitis or pneumonia. There are a number of techniques used during cuff deflation and extubation to prevent secretion aspiration.nnnMETHODnA model trachea was intubated and the proximal end of the ETT was attached to a mechanical ventilator. Ten millilitres of water was placed above the inflated cuff and then nine test protocols were implemented in a random order to simulate tracheal suction, adjusting the PEEP settings on the ventilator or compressing a self-inflating bag. The volume of water aspirated by the model was determined by weighing the apparatus pre- and post-extubation. Statistical analysis was performed using regression analysis and heteroscedastic t tests with a Bonferroni correction.nnnRESULTSnThe level of PEEP was negatively correlated with the volume of fluid aspirated [co-efficient -0.24 (99% confidence interval -0.31 to -0.17), R(2) = 0.75]. Significantly less fluid was aspirated when a PEEP of 35 cmH(2)O was applied when compared with competing techniques.nnnDISCUSSION AND CONCLUSIONSnThis study suggests that applying PEEP during cuff deflation and extubation is protective against aspiration. We conclude that unless there is a contraindication, the application of PEEP should be considered when extubating patients.

Disinfecting the iPad: evaluating effective methods.

BACKGROUNDnTablet computers are increasingly used in healthcare, but they may carry nosocomial pathogens. There are few data available on how to clean an iPad effectively for use in the clinical setting.nnnAIMnWe aimed to identify the most effective method of decontaminating the Apple iPad, without causing damage, and establish the duration of any residual effect.nnnMETHODSnFollowing contamination with a microbial broth (meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE) and Clostridium difficile), we examined efficacy of iPad disinfection in the laboratory using six different disinfectant wipes: Sani-Cloth CHG 2% (chlorhexidine 2%/alcohol 70%), Clorox, Tristel, Trigene, soap and water, and plain cloth. Following cleaning, iPads were recontaminated to examine residual activity. After 480 Sani-Cloth CHG 2% disinfecting episodes, functional and visual analysis of iPads was performed by blinded subjects.nnnFINDINGSnWith the exception of Clostridium difficile, Sani-Cloth CHG 2% and Clorox wipes were most effective against MRSA and VRE, and they were significantly better than the Apple-recommended plain cloth (Pxa0≤xa00.001). A substantial residual antimicrobial effect was seen for >6h after wiping the iPad with Sani-Cloth CHG 2% despite repeated recontamination and without further disinfection. The functionality or visual appearance of the iPad was not damaged by repeated use of Sani-Cloth CHG 2% wipes.nnnCONCLUSIONSnSani-Cloth CHG 2% wipes effectively disinfect the iPad against MRSA and VRE, with a residual antibacterial effect and without causing damage.

Preoxygenation and apneic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for emergency intubation.

PURPOSEnHypoxia is one of the leading causes of anesthesia-related injury. In response to the limitations of conventional preoxygenation, Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) has been used as a method of providing both preoxygenation and apneic oxygenation during intubation.nnnMATERIALS AND METHODSnIn this prospective, observational study, THRIVE was introduced in a critical care unit (CCU), operating room (OR), and emergency department (ED) during emergency intubation of patients at high risk of hypoxia. Linear regression analysis tested for correlation between apnea time or body mass index and hemoglobin saturation (Spo2).nnnRESULTSnAcross 71 sequential patients, the interquartile range for apnea time and decrease in Spo2 were 60 to 125 seconds and 0% to 3%, respectively. Significant desaturation occurred in 5 (7%) patients. There was no evidence of correlation between apnea time or body mass index and Spo2 (R2=0.04 and 0.08 for CCU/ED and OR and 0.01 and 0.04 CCU/ED and OR, respectively). There were no complications reported from using THRIVE.nnnCONCLUSIONSnThis study demonstrated that preoxygenation and apneic oxygenation using THRIVE were associated with a low incidence of desaturation during emergency intubation of patients at high risk of hypoxia in the CCU, OR, and ED. THRIVE has the potential to minimize the risk of hypoxia in these patient groups.

Extubation in intensive care units in the UK: an online survey

AIMnTo determine the current practice among critical care nurses in the UK with regard to airway management during cuff deflation and extubation.nnnBACKGROUNDnThere are a number of techniques used by clinicians to prevent aspiration during cuff deflation and extubation of patients. There are no published clinical studies comparing the different manoeuvres available to clinicians at the time of extubation nor any data to suggest which technique is most commonly used.nnnMETHODSnAll members of the British Association of Critical Care Nurses with an email address were invited to participate in an online survey.nnnRESULTSnA total of 533 (29%) nurses from 184 (84%) intensive care unit (ICUs) in the UK completed the survey. Just under half of the sample (n = 258, 48.4%) had more than 10 years of critical care experience and the vast majority (n = 427, 80.1%) worked in general ICUs. The majority of respondents (n = 461, 86.5%) suction the trachea during cuff deflation and extubation. A further 304 (57%) respondents ask patients to cough as part of extubation. Respondents increase the positive end expiratory pressure setting on the ventilator infrequently as part of routine procedure for extubation (n = 7, 1.3%).nnnCONCLUSIONnThe majority of UK critical care nurses either suction the trachea during cuff deflation and extubation of patients and/or simply ask the patient to cough. Further clinical trials are required to identify the most appropriate and safe technique for critically ill patients.

Emergency capnography monitoring: comparing ergonomic design of intensive care unit ventilator interfaces and specific training of staff in reducing time to activation

Modern ventilators provide capnography monitoring in patients with tracheal tubes, in compliance with national and international recommendations. This technology is often not used when patients’ lungs are non‐invasively ventilated; however, it should be accessed immediately following tracheal intubation to confirm tube placement. This study assessed the effect of ventilation interface design on the speed with which capnography can be activated by comparing the Dräger Evita 4 and Dräger V500 before and after a specific training episode. We configured the V500 to have a capnography activation button on the front screen in contrast to the Evita 4 which requires a sequence of actions to access capnography monitoring. We used a randomised crossover design, measuring time to monitoring activation, and repeated the study after 3u2003months. Survival analysis showed significantly quicker activation associated with ventilator choice (V500, pu2003<u20030.0001) and training (pu2003=u20030.0058). The training improved activation speed with both machines, though this was only significant for the Evita 4 (pu2003=u20030.0097).

Keyboard cleanliness: A controlled study of the residual effect of chlorhexidine gluconate

A controlled trial of once daily cleaning of computer keyboards in an intensive care unit was performed comparing 2% chlorhexidine gluconate-70% isopropyl alcohol (CHG) and a chlorine dioxide-based product used as a standard in our hospital. A study before and after the introduction of once daily keyboard cleaning with CHG in the wider hospital was also completed. Cleaning with CHG showed a sustained and significant reduction in bacterial colony forming units compared with the chlorine dioxide-based product, demonstrating its unique advantage of maintaining continuous keyboard cleanliness over time.

Superiority of chlorhexidine 2%/alcohol 70% wipes in decontaminating ultrasound equipment.

Ultrasound equipment is known to act as a reservoir for potentially pathogenic organisms. The aims of these studies were to establish current cleaning practices, to review the extent of bacterial contamination of ultrasound equipment in our hospital, to establish an effective cleaning regimen and to ensure that cleaning does not cause damage. A questionnaire was sent to all acute NHS hospitals in England to establish current cleaning practices. A review of our current practice was performed to establish the extent of bacterial contamination of ultrasound equipment currently in use. Laboratory studies compared cleaning the probes with soap and water with decontaminating with a chlorhexidine 2% and alcohol 70% wipe, including quantifying the residual effect. Accelerated aging was performed on the probe and staff surveyed to establish potential problems with using the wipes on the probe. The survey revealed that a variety of cleaning methods were used to decontaminate ultrasound probes; 57% of our ultrasound machines were contaminated with bacteria. The laboratory studies showed superiority of the chlorhexidine and alcohol wipes over soap and water due to a residual effect, both immediately after cleaning and after 24 hours. The staff survey demonstrated no apparent change in function of the probe after cleaning with the chlorhexidine wipes. Cleaning ultrasound probes with chlorhexidine and alcohol wipes is effective and provides additional protection against bacterial contamination due to its residual effect, and appears in the short term to have no detrimental effect on the probe.

The LoTrach™: A Tracheal Tube for Critical Care

The LoTrach: A Tracheal Tube for Critical Care How many times have your nursing colleagues pointed out to you that the stuff they are sucking out of the tracheal tube looks the same as the nasogastric aspirate? Pulmonary aspiration is so commonplace during mechanical ventilation that we no longer see it as a complication but as a necessary evil associated with intubation. A recent paper examined the presence of pepsin in tracheobronchial aspirates as a marker of gastric regurgitation and pulmonary aspiration. This study showed that 89% of intubated and mechanically ventilated patients, managed to the highest standards, aspirated a portion of their stomach contents at some stage during their critical care stay. The number of times pepsin was detected in the pulmonary secretions was also the most significant independent risk factor for the development of ventilator-associated pneumonia (VAP). This supports the causative link between “microaspiration” and VAP that has been established for many years.