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   2013| July  | Volume 2 | Issue 2  
    Online since July 21, 2017

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Comparison of five weaning indices in predicting successful weaning from mechanical ventilation
J Praveen Jacob John, Saumy Johnson, Anitha Shenoy
July 2013, 2(2):299-306
Introduction: Mechanical ventilation is a life-supporting modality used in patients with respiratory failure. Most patients are extubated early but weaning can be prolonged in some. Aim: Comparison of accuracy of prediction of success of a spontaneous breathing trial (SBT) using CORE, CROP, RSBI, RSBI rate and minute ventilation recovery. Methods: This is a prospective observational study. 62 adult patients admitted to Multidisciplinary Intensive Care Unit during April 2012 - January 2013 were studied. All patients, orotracheally intubated and mechanically ventilated for at least 24 hours and ready for weaning were enrolled. The patients underwent SBT using pressure support ventilation (5 – 8 cm H2O), PEEP of 5 - 8 cm H2O, and 40% oxygen. The weaning indices were measured at 30 min and correlated with weaning success. Results: The mean (± SD) age was 49.7 (± 18.3) years. There were 46 male and 16 female patients. The threshold values were as follows: CORE index: ≥ 6, CROP index: ≥ 13, RSBI < 105 b/min/L, RSBI rate ≤ 20%. The sensitivity (%), specificity (%) and AUC of ROC curve were as follows: CORE (96, 66, 0.74), CROP (95, 33, 0.61), RSBI (89, 46, 0.2), RSBI rate (85, 28, 0.52) and minute ventilation recovery (higher than baseline minute ventilation at 25 min of rest on initial ventilator settings after 30 min of SBT) (n = 26) (92.3, 100, 0.93). Conclusion: CORE and RSBI are moderately accurate while CROP and RSBI rate are inaccurate. Minute ventilation recovery predicted weaning failure accurately.
[ABSTRACT]   Full text not available  [PDF]
  1,736 285 -
Newer techniques of humidification and secretion clearance
Brent Kenney, Felix Khusid, Emma Fisher
July 2013, 2(2):262-276
This paper begins with a review of airway anatomy, physiology of airway secretions, alterations in disease, and the importance of the mucociliary escalator, especially in airway disease states (asthma, COPD, cystic fibrosis, bronchiectasis etc). Alternatives to treating mild to moderate hypoxemia with high flow nasal cannula oxygen (HFNCO) such as Vapotherm are mentioned. A relatively new technique called Intrapulmonary Percussive Ventilation (IPV®) seems very effective in secretion removal. A newer device called CoughAssist™ assists cough by mechanical insufflation-exsufflation and is very useful in neurological disease. The review then focuses on High Frequency Percussive Ventilation (HFPV), otherwise known as Volumetric Diffusive Ventilation (VDR®). Lastly, the use of biphasic cuirass ventilation for secretion removal has been described.
[ABSTRACT]   Full text not available  [PDF]
  1,648 188 -
Plagiarism - The dark art of scientific writing
Goneppanavar Umesh
July 2013, 2(2):255-257
Plagiarism is a serious form of scientific misconduct that may bring significant disrepute not only for the author in question but also to the concerned institution. Lack of appropriate knowledge on the part of the authors is the major contributor to plagiarism. Educational institutions should take lead role to educate their students and faculty members regarding scientific misconduct and its repercussions.
[ABSTRACT]   Full text not available  [PDF]
  1,243 192 -
Efficacy of recruitment manoeuvre with or without antiderecruitment strategy in ARDS patients: A prospective study
Heera Lal Mahto, Vishal Shanbhag, Anitha Shenoy
July 2013, 2(2):284-291
Introduction: Lung recruitment manoeuvre (RM) opens up collapsed segments of the ARDS lung but the collapse may reappear once the RM is complete and pre-RM positive end-expiratory pressure (PEEP) is applied. Aim: Evaluation of the outcome of setting PEEP using decrement PEEP titration (antiderecruitment manoeuvre - ADRM) after an alveolar recruitment manoeuvre (RM) in ARDS patients. Methods: Twenty four mechanically ventilated adult patients with ARDS were enrolled. This was a randomised, prospective study. After recording baseline parameters, on pressure control ventilation and stabilisation, RM was performed. The responders were randomly assigned to one of two groups: ‘Antiderecruitment RM’ (ADRM) group and ‘Only RM’ (RM) group. ADRM group received RM using volume control ventilation and optimal PEEP was set after RM using decremental PEEP titration method. The RM group patients were returned to baseline ventilator settings after manoeuvre. Results: Of the 24 patients, 13 were males and 11 female. The mean (± SD) age was 43 (± 13.43) years. Twelve patients responded to the initial recruitment manoeuvre of which six were assigned to RM group and six to ADRM group. There was no difference in survival rate between the groups. The ICU and hospital stay were shorter in patients in ADRM group as compared to only RM group. Conclusion: Only half of the patients with ARDS respond to recruitment manoeuvres with an improvement in oxygenation. In most responders, the improvement is sustained irrespective of whether RM only or ADRM was used. Mortality is high if the baseline P/F ratio is below 90.
[ABSTRACT]   Full text not available  [PDF]
  1,195 183 -
Gloriosa superba poisoning - A case report
CBG Akhila, Ramesh Unnikrishnan
July 2013, 2(2):336-338
The genus of ten species in plant family colchicaceae is gloriosa. Gloriosasuperba is a species of flowering plant in the family colchicaceae. In Karnataka it is known as gowri gedde (Hindi: Kalihari, Gujarathi: Dudhio, Sanskrit: Agnimukhi, Marathi: Indai). This ornamental plant is distributed in both Asian and African continent, it is often known as a poison, a noxious weed and a medicine. In India, Gloriosa superba is commonly distributed in the Western Ghats. Colchicine a pseudoalkaloid extracted from the plant, a useful drug with a narrow therapeutic index. This is a case report of an adult male with history of accidental consumption of colchicine and subsequent fatal toxicity.
[ABSTRACT]   Full text not available  [PDF]
  1,180 176 -
Diffuse pulmonary calcification syndrome - A case report
Monu Yadav, R Gopinath, Shantveer G Uppin, C Sundaram
July 2013, 2(2):332-335
Diffuse pulmonary calcification can be (1) metastatic, in which the calcium deposits occur in normal tissues, or (2) dystrophic, in which calcification occurs on injured lung tissue. The pathogenesis of these abnormalities is not fully understood, but hypercalcemia, hyperphosphatemia, alkalosis, and lung damage predispose to calcification and ossification. Standard digital radiography and high resolution computed tomography (HRCT) offer excellent diagnostic sensitivity in the detection of small calcifications inside the lung. We describe the case of a 35 year old male admitted with acute respiratory failure due to acute on chronic lung pathology. His blood culture and bronchial wash cultures were sterile throughout the illness. Bronchial wash culture was negative for acid fast bacilli (AFB), on Gram staining and for any fungal growth. Smears were negative for malignancy. CT scan of the chest showed multiple nodules bilaterally. As all the cultures were sterile, in view of history of unexplained fever, weight loss and unexplained finding of pulmonary nodular lesions, the patient was further investigated on the lines of vasculitic syndromes and the possibility of these syndromes was also ruled out. Postmortem biopsy revealed a diagnosis of diffuse pulmonary calcification syndrome. Diffuse pulmonary calcification is a progressive, normally asymptomatic disease but can lead to critical and fulminant respiratory failure.
[ABSTRACT]   Full text not available  [PDF]
  1,179 162 -
Comparison of two techniques of airway anaesthesia for awake fibreoptic nasotracheal intubation in patients with anticipated difficult airway
B Rakesh Rai, U Kailasnath Shenoy
July 2013, 2(2):313-319
Introduction: The success of awake fibreoptic assisted intubation often depends on the adequacy of anaesthesia of the airway and patient comfort for the procedure. Aim: To compare the standard technique (nerve block) of airway anaesthesia with simple aspiration of lignocaine. Methods: Thirty patients in whom difficult airway was anticipated were randomly allocated into either Group A (Aspiration) and Group B (Nerve block). In Group A, 0.2 mL/kg of 1.5% lignocaine was trickled on to the dorsum of the tongue while the patient was encouraged to breathe through the mouth. In Group B, superior laryngeal nerve block and intratracheal injection of lignocaine was used. Fibreoptic bronchoscopy was then carried out by a consultant anaesthesiologist, who was blinded to the local anaesthetic technique used. The patient responses to instrumentation of pharynx, glottis and trachea, and tolerance of the endotracheal tube were noted. Results: Two cases were excluded from the study because of bleeding resulting in subsequent loss of visualisation of glottis through bronchoscope. There was no statistical or clinical difference in the patient responses between the two groups (P > 0.05) due to fibreoptic bronchoscope in the pharynx, larynx and endotracheal tube in the trachea or with regard to the use of rescue medications. Conclusions: Aspiration of 1.5% lignocaine (0.2 mL/kg) provides clinically comparable conditions for intubation as the nerve block technique for awake fibreoptic nasotracheal intubation in patients with anticipated difficult airway.
[ABSTRACT]   Full text not available  [PDF]
  1,167 172 -
Comparison of pressure support ventilation and proportional assist ventilation plus for weaning from mechanical ventilation in critically ill patients
Sanjay Sasikumar, Vishal Shanbhag, Anitha Shenoy
July 2013, 2(2):292-298
Background: Pressure support ventilation (PSV) is a widely used weaning mode that provides varying amount of support with changing lung characteristics. Proportional-assist ventilation plus (PAV+) is a new mode that automatically adjusts to changes in the respiratory system. Aim: This study compared PSV and PAV+ for weaning from mechanical ventilation. Methods: This was a prospective, randomised, control study enrolling 23 adult patients, mechanically ventilated for at least 48 h after passing SBT criteria and a PSV trial of 30 min. They were randomised to receive either PAV+ (Group 1) or PSV (Group 2). A washout time of 30 min was given for patients in either of the group in order to nullify the effect of the previous PSV mode. Two arterial blood gas samples were taken, during the assessment of SBT readiness, and after 60 min on the randomised weaning mode. Clinical signs of respiratory distress and objective weaning criteria were noted. Success and duration of weaning, rapid shallow breathing index (RSBI), rapid shallow breathing index rate (RSBI rate), haemodynamic and respiratory parameters were noted. Results: 13 patients were randomised to PAV+ group; 10 patients to PSV group. Demographic data were similar in both groups. RSBI, RSBI rate, arterial blood gas analysis, peak and mean inspiratory pressure were not different in either group. The average length of ICU stay, duration to wean and days to extubate were almost similar in both groups. Conclusion: Both PAV+ mode and PSV can be used with equal efficiency in patients ready for weaning.
[ABSTRACT]   Full text not available  [PDF]
  1,152 168 -
Comparison of the safety and effectiveness of dexmedetomidine with a combination of midazolam and fentanyl for sedation during awake fibreoptic nasotracheal intubation
Tajammul Sayeed, Anitha Shenoy, Umesh Goneppanavar
July 2013, 2(2):320-327
Introduction: Several drugs have been used to enhance patient comfort during awake nasal fibreoptic intubation (AFOI) process. Most of these can cause dangerous airway or haemodynamic compromise. This study compared combination of midazolam and fentanyl against dexmedetomidine. Methods: Thirty two adults undergoing AFOI were randomly allocated into group MF (1mg midazolam and 1 μg/kg fentanyl) or group D (dexmedetomidine 1μg/kg over 10 minutes). Following standard airway topicalisation technique, the study drugs were administered and AFOI was performed. Results: The demographic data, patient comfort score, post intubation score, endoscopy and intubation times were comparable. The endoscopy was observed to be easy in all patients except 2 in MF group while intubation was easy in all (group D) versus 12 patients in group MF (P value 0.03). Significant haemodynamic response was observed in group MF while patients were more stable in group D. Postoperatively, 10 and two patients in groups D and MF respectively felt sedation was excellent (P value 0.02) while increased need for sedation was felt by one and three patients in groups D and MF respectively (P value 0.028). AFOI was remembered by six and one patients in groups D and MF respectively (P value 0.003). Two in group D and three in group MF had moderate discomfort. None experienced severe discomfort. The overall satisfaction score was comparable. There were no serious adverse events during the study. Conclusions: Dexmedetomidine provides better intubating conditions and patient satisfaction without adversely affecting the airway or haemodynamic stability during AFOI.
[ABSTRACT]   Full text not available  [PDF]
  1,131 160 -
Anaesthetic management of a huge mediastinal tumour with tracheobronchial compression
Anitha Shenoy, Shyamsunder Kamath
July 2013, 2(2):328-331
A 20 year old man diagnosed to have multiple neurofibromatosis presented with 2 months history of orthopnoea and cough with moderate expectoration since 1 month. Chest Xray and CT scan showed a huge mediastinal mass with compression of the trachea and superior vena cava. In view of the anticipated airway problems, an awake intubation in the sitting position was achieved. Cardiopulmonary bypass was not considered because of the possibility of excessive bleeding after heparinization. Despite this, the patient bled about 4,500 mL. Tracheomalacia was suspected intraoperatively. A larger endotracheal tube was inserted at the end of the procedure and the patient ventilated electively overnight. He was successfully extubated 24 hours later.
[ABSTRACT]   Full text not available  [PDF]
  1,135 151 -
Practical approach to sleep disordered breathing
Anup Bansal, Arun Samuel Ponnish, Nagarajan Ramakrishnan
July 2013, 2(2):277-283
It is not uncommon to have occasional difficulty in falling asleep or have fatigue and day time sleepiness. However, when sleep disturbances persist for over a month and are associated with significant daytime dysfunction for at least two weeks, it may be a warning of an underlying sleep disorder requiring further evaluation and treatment. The combination of snoring, nonrefreshing sleep and daytime sleepiness is usually a hallmark of Obstructive Sleep Apnea (OSA) which is the most common sleep related breathing disorder. This review article aims to provide a practical and comprehensive approach to the diagnosis and management of sleep related breathing disorders with a focus on OSA.
[ABSTRACT]   Full text not available  [PDF]
  1,119 159 -
Respiratory therapists' role in research: Results of a National survey
Richard Rice, James K Stoller
July 2013, 2(2):339-345
Background: While research is essential to respiratory therapy, little attention has been given to the role of respiratory therapists (RTs) in conducting research. To better understand the prevalence and spectrum of roles of RTs in research, a survey of RTs was designed and administered. Methods: The study was deemed exempt by the Cleveland Clinic Institutional Review Board. An invitation to participate in the survey was sent electronically to members of the American Association for Respiratory Care (AARC) via ‘AARConnect’ (the AARC's social and professional networking site) on May 21, 2012 and the survey remained open until August 16, 2012. A second, similar survey was sent via ‘Listserve’ to 6,431 RTs in the state of Ohio and remained open from May 31, 2012 to August 16, 2012. Results: Response rates to the national and state-wide surveys were 0.16% and 13%, respectively. Eighty two individuals responded to the AARConnect survey, while the Ohio survey attracted 849 respondents. Of the 81 active AARConnect RT respondents, 31 (38%) reported being currently involved in research activity: 29 (36%) had been involved in research in the past but not currently, and 21 (26%) reported never being involved in any research activity. In contrast, fewer of the Ohio survey respondents reported research experience or involvement. Conclusions: To our knowledge, this represents the first survey of RTs to assess research roles. Limitations of this study include possible biases related to small sample size, self-selection of respondents, and self-reported data. Overall, these results both suggest that a minority of RTs have research experience and that additional study is needed to better characterise the prevalence and level of research experience of RTs.
[ABSTRACT]   Full text not available  [PDF]
  1,108 167 -
Evaluation of ‘tuskmask’ as an oxygen delivery system
P Thajunnisa, U Kailasnath Shenoy
July 2013, 2(2):307-312
Introduction: Conventionally either partial rebreathing mask or nonrebreathing mask can be used to deliver oxygen concentrations of up to 60%. A simple modification of the partial rebreathing mask using two pieces of respiratory tubing, or ‘tusks’ has been shown to deliver a high FIO2. Aim: This study aimed to evaluate the efficiency of the ‘tuskmask’. Methods: This was a prospective study. Twenty patients of either gender, 18-70 years, ASA PS I or II and scheduled for elective surgery requiring arterial blood pressure monitoring intraoperatively were studied. On the day of surgery, in the operating room, after establishing standard monitoring, an intravenous access was secured. The radial artery was cannulated using a 20 G cannula and hep-locked. A baseline arterial blood gas (ABG) sample was drawn on room air and three more samples taken after breathing oxygen through a 60% Venturi mask, polymask (10 L/min) or tuskmask (10 L/min) for ten minutes each with a ten minutewashout period in between. The ABG samples were analysed at the end of study. Results: The mean age (SD) in years was 53.65 (17.10). There were 15 female and five male patients. The PaO2 obtained with tuskmask was significantly higher with tuskmask compared to polymask and 60% Venturi mask but PaCO2 was similar with all three masks. The mean (95% confidence interval) derived FIO2 of tuskmask was 0.924 (0.872 to 0.97). Conclusion: The tuskmask when used with oxygen flow of 10 L/min, consistently delivers a very high concentration (FIO2 ≥ 0.85) without causing rebreathing.
[ABSTRACT]   Full text not available  [PDF]
  1,052 154 -
The end of life issues - Part 2
Ian McLellan
July 2013, 2(2):258-261
Full text not available  [PDF]
  883 179 -
Are intensive care units safe?
Venkateswaran Ramkumar
July 2013, 2(2):251-254
Full text not available  [PDF]
  847 183 -