This review deals with several grey areas in mechanical ventilation. Noninvasive ventilation for acute respiratory failure may be useful but careful choice of patients, identification of early signs of its failure and changeover to invasive ventilation is essential to improve outcome. Preservation of spontaneous ventilation during mechanical ventilation is currently being investigated. High frequency ventilation is useful in refractory cases. Rapid shallow breathing index corrected to weight needs to be studied. The ideal timing of tracheostomy is not known and is best to individualise the intervention.

Neonatal and paediatric ventilation is highly challenging in respiratory care. Management of the ‘little ones’ on ventilator is a difficult task. A strong knowledge about basic respiratory physiology and lung mechanics of newborns, gives us the easier application of providing both noninvasive and invasive ventilation. Respiratory distress is mainly assessed by Downes\' score, clinical conditions and arterial blood gases. Different modes of ventilation describe the easier ability for gentler ventilation and lung protective strategy. Humidification is essential as the upper airway is bypassed and it can prevent hypothermia. This review will explore the ventilatory support in neonates and paediatric age group.

Transportation of a critically ill patient is a challenging task necessitating development of safety guidelines that can be universally followed to minimise problems during transit. This not only requires trained personnel with good communication skills but also necessitates a well-equipped transportation facility such as ambulance and modification of traffic rules to suit preferential allowance of such vehicles. It is also vital that the trained personnel are experts in handling emergencies, trained in cardiopulmonary resuscitation and airway management. The transport vehicle (ambulance) should be spacious enough to allow resuscitation that may require multiple personnel to be around the patient. Furthermore, the vehicle should have advanced communication equipment so as to be in constant communication with the hospital personnel to which the patient is getting shifted.

Background: Noninvasive ventilation (NIV) is increasingly used for acute respiratory failure although its effectiveness is unclear. Methods: This study was conducted to analyse clinical outcome in patients with acute respiratory failure treated with NIV and to identify the determinants predicting success and failure of this technique. This prospective study included acute respiratory failure patients eligible for NIV admitted to Multidisciplinary Intensive Care Unit from August 2006 to September 2007. All patients received NIV using oronasal masks. Arterial blood gases, chest radiograph, duration of NIV, ICU and hospital stay were compared. NIV was considered successful or failed according to the need for endotracheal intubation. Results: A total of 41 patients were enrolled. NIV was successful in 26 (63.4%) patients while failed in 15 patients (36.6%). The overall mortality was 34.1%. Patients managed successfully with NIV showed a significant increase in PaO2 at 1 and 6 h and their duration of ICU stay was shorter as compared to those who failed NIV. Changes in PaCO2, pH and hospital stay were similar between the groups. Conclusions: An improvement in PaO2 after 1-2 and 6 h of NIV is associated with a successful outcome. NIV when successful is associated with shorter ICU stay and failure is associated with high mortality. Effectiveness of NIV in improving PaO2 in the initial hours could be used to predict whether the patients with acute respiratory failure could be successfully treated with NIV.

Introduction: Patients with heart failure developing acute pulmonary oedema benefit from immediate administration of noninvasive respiratory support such as continuous positive airway pressure (CPAP) or Biphasic positive airway pressure (BIPAP). Objective: To quantify the most advantageous positive end-expiratory pressure (PEEP) required to improve patient's oxygenation and to evaluate outcome of noninvasive respiratory support in patients with cardiogenic pulmonary oedema. Methods: This was a nonrandomised interventional study. Patients admitted with acute cardiogenic pulmonary oedema to the cardiac intensive care unit were initiated on CPAP/ BIPAP mode of ventilation noninvasively. They were evaluated for the most advantageous PEEP that improved their symptoms. Results: A total of thirty two patients were studied. Twenty four patients were included in the CPAP group [mean (± SD) age of (63.66 ± 11.18) years)] and eight in BIPAP group [mean (± SD) age of (67.25 ± 12.6) years]. Most advantageous PEEP (mean (± SD) in CPAP group was 5.62 ± 1.24 cm H₂O and in BIPAP group was 7.125 ± 1.8 cm H₂O (P = 0.0125). Lower serum bicarbonate levels were found at baseline in the BIPAP group (14.4 ± 6.3 mmol/L) compared to CPAP group (19.4 ± 5.59 mmol/L, P < 0.041). Patients in BIPAP group needed a longer hospital stay (19.62 ± 14.9 days) compared to CPAP group of 8.12 ± 6.58 days (P 0.0047). Conclusions: Most patients of cardiogenic pulmonary oedema can be managed noninvasively with CPAP but patients with metabolic acidosis are likely to require BIPAP and a longer duration of hospital stay.

Background: Continuous Positive Airway Pressure (CPAP) is a noninvasive, gentle method of providing respiratory support to spontaneously breathing neonates. Objective: To compare the effectiveness of bubble CPAP (B-CPAP) over conventional CPAP (C-CPAP) in view of improvement in the severity of respiratory distress in preterm neonates with hyaline membrane disease (HMD). Methods: The targeted populations were all preterm and late preterm neonates admitted in neonatal intensive care unit (NICU) with HMD and respiratory distress, requiring noninvasive ventilation. Neonates who met the inclusion criteria were randomly allocated to either B-CPAP or C-CPAP using random table method. CPAP was started at the earliest signs of respiratory distress and postextubation. Result: Respiratory distress was assessed before and after initiation of CPAP based on Downe's score. The decrease in Downes score was statistically significant in the B-CPAP group compared to C-CPAP group. Primary CPAP failure was 23% (7/30) in the B-CPAP group compared to 10% in the C-CPAP group (3/30) (p = 0.16). The number of days on CPAP, oxygen therapy and NICU stay showed no significant difference. Complications of CPAP were not significantly different. Conclusions: B-CPAP is as effective as C-CPAP in improving respiratory distress. However, CPAP failure rates are higher in B-CPAP group with preterm of extreme low birth weight babies (<1000 g). B-CPAP is one of the most effective and economical mode of noninvasive respiratory support for preterm neonates with HMD.

Background: Cricoid pressure is used in rapid sequence intubation in patients with full stomach. Intubation may become difficult with adverse consequences with this manoeuvre, as laryngeal view may be altered. We used a cricoid device to standardise the cricoid pressure. Aim: To study the effectiveness of cricoid pressure delivered by a mechanical device in occluding the oesophagus (by visual assessment using a fibreoptic bronchoscope) and to assess the quality of laryngeal view after the application of cricoid pressure using a Macintosh laryngoscope. Patients and methods: 41 patients of ASA I and II, posted for elective surgery were enr olled in this prospective crossover study. They were randomly allocated to one of two interventions Intervention: A (with cricoid pressure) followed by Intervention B (without cricoid pressure) or intervention B followed by intervention A. Assessment of oesophageal opening and laryngeal grading was done. Assessor was blinded whether cricoid pressure was applied or not (cricoid device was designed to conceal the weight applied). Results: Oesophageal opening was occluded in 95% (39/41) of patients, with cricoid pressure and 88% (36/41) patients without cricoid pressure. 51% (21/41) of patients with cricoid pressure had worsening of laryngeal view. Whereas there was no change in 32% (13/41) of patients, there was improvement in 17% (7/41), with cricoid pressure. Conclusion: Irrespective of the cricoid pressure administered oesophageal opening appeared occluded in majority of the cases. Cricoid pressure delivered by cricoid device alters the quality of the laryngeal view.

Introduction: Extubation failure is said to be associated with increased morbidity and mortality. Patients and methods: This was a prospective, observational study of extubation failure among all patients who have been intubated and required ventilatory support in the Multi-Disciplinary Intensive Care Unit (MICU) of Kasturba Hospital, Manipal from 1st September 2007 to 30th September 2008. Criteria for considering extubation failure were similar to those used to evaluate need for intubation. Results: Of 167 patients who received invasive ventilation through an oral endotracheal tube, 145 were extubated successfully and 22 patients failed extubation. They were managed either with noninvasive ventilation (NIV) or reintubation as decided by the physician. The incidence of extubation failure was 13.1%. Only one patient could be managed with NIV. One was discharged against medical advice. Of the twenty patients who were reintubated, seven patients could be reextubated, seven required tracheostomy and six died. A mortality rate of 33% was observed in these patients. Extubation failure was mainly due to respiratory causes (15/21 patients), most of whom (11/15 patients) survived. Those due to nonrespiratory causes (6/15 patients) had 50% survival. The mean duration of mechanical ventilation prior to extubation was significantly lower among survivors (56 ± 25.1 hours) but the total duration of mechanical ventilation and ICU stay were not very different. Conclusions: Extubation failure is associated with high mortality. Extubation failure occurs most often due to respiratory causes and noninvasive positive pressure ventilation is not useful for patients who fail extubation.

Background: Organophosphorus insecticides are one of the most important causes of accidental and suicidal poisoning in India. There is a high mortality associated with this condition. Methods: The aim of this study was to find out the frequency, need for artificial airway and ventilation, evaluate the management and to determine the clinical outcomes of organophosphorous poisoning patients in a tertiary hospital in Udupi district. A total of 177 patients were included in this retrospective study over 3 years (Jan 2005 to Dec 2007). Results: Majority of the patients had normal respiratory rate while 44 were tachypnoeic. Out of the 49.15% patients requiring tracheal intubation, 40.1% required mechanical ventilation while 17.24% eventually required tracheostomy. The duration of ICU stay ranged between 1 – 28 days with an average of 6.51 days. The duration of hospital stay ranged between 1 – 63 days with an average of 11.9 days. The in hospital mortality rate was 18.6%. The management of organophosphorous poisoning in this hospital consisted of gastric wash and atropine. The use of pralidoxime, glycopyrrolate and activated charcoal was not uniform. Conclusion: Organophosphate poisoning has significantly high rate of requirement for tracheal intubation and mechanical ventilation. Despite appropriate management, it carries a high risk of in-hospital mortality. Mainstay of management of these patients is gastric wash, atropine and mechanical ventilation.

Airway pressure release ventilation is a novel mode of positive pressure ventilation that has advantages over low tidal volume, assist control ventilation in patients with acute respiratory distress syndrome (ARDS). It also helps to meet the goals of ventilatory management of patients with ARDS such as lung protection strategy. We report a patient with trauma who developed fat embolism syndrome (FES) followed by severe life-threatening ARDS and successfully managed with airway pressure release ventilation.

Prone position ventilation is widely used in treating patients with acute respiratory distress syndrome (ARDS) and severe refractory hypoxaemia. However, its use in patients who have undergone pneumonectomy is rare. We report a 57-year-old woman, a case of right pneumonectomy, who later presented with left lung pneumonia. She was ventilated with conventional lung protective strategy to improve oxygenation. When unsuccessful, ventilation in prone position was carried out. This case report gives you a sequential representation of how she was treated successfully for severe refractory hypoxemia with prone position ventilation.