Indian Journal of Respiratory Care

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2012 | July-December | Volume 1 | Issue 2

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EDITORIAL

Umesh Goneppanavar

Communication in the intensive care unit

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:4] [Pages No:83 - 86]

   DOI: 10.5005/ijrc-1-1-83  |  Open Access |  How to cite  | 

180

REVIEW ARTICLE

Umesh Goneppanavar

Prevention of nosocomial infections – role of the health care personnel

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:7] [Pages No:87 - 93]

Keywords: Hand hygiene, health care workers, micro-organisms, vectors

   DOI: 10.5005/ijrc-1-1-87  |  Open Access |  How to cite  | 

Abstract

Hospitalised patients are usually more susceptible for development of infections while the hospitals are turning out to be hideouts for various micro-organisms. Hence, incidence of nosocomial infections is on the rise worldwide, more so in the developing countries. This contributes to significant increase in healthcare costs and an unnecessary as well as unacceptable increase in morbidity and mortality. Patients in the intensive care unit are the most susceptible hosts for development of nosocomial infections due to poor protective airway reflexes, invasive monitors and procedures, lack of immunity as a result of their primary disease process, broad spectrum antibiotic therapy, poor nutrition, etc. Although development of newer antibiotics, proper antibiotic regimen and better detection modalities to control infection are desirable, there are several other means by which one can contain the spread of nosocomial infections. These include physical precautions and education to help contain the health care worker (HCW) from becoming a potential vector for transmission of infective organisms by instituting measures such as hand hygiene, use of personal protective equipment, cleaning and disinfection, appropriate disposal and disinfection of health care wastes among others. ‘Hand and mind hygiene’ practice from the HCW can contain the nosocomial infections to a large extent.

220

REVIEW ARTICLE

HM Krishna

Nosocomial pneumonia

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:7] [Pages No:94 - 100]

Keywords: Nosocomial pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia

   DOI: 10.5005/ijrc-1-1-94  |  Open Access |  How to cite  | 

Abstract

Nosocomial pneumonia encompasses hospital-acquired pneumonia, healthcare-associated pneumonia and ventilator-associated pneumonia. It is a major infectious problem in the hospitals. Though predominantly caused by endogenous bacteria colonised in the oropharynx and stomach, polymicrobial aetiology is not uncommon. The problem with multidrug resistant strains has been increasing. Hospital environment, equipment and staff are the sources, fomites and carriers of this infection from patient to patient. Diagnosis of nosocomial pneumonia has been simplified by the guidelines. Preventive measures to reduce the incidence of nosocomial pneumonia are simple, effective and economical. They just need to be followed. Empirical antibiotic therapy and de-escalation measures form the back bone of the treatment of nosocomial pneumonia.

269

REVIEW ARTICLE

Vandana Iyengar

Protective lung ventilation in Acute Respiratory Distress Syndrome: What is new?

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:11] [Pages No:101 - 111]

Keywords: Acute respiratory distress syndrome, protective lung ventilation, positive end-expiratory pressure, recruitment manoeuvre

   DOI: 10.5005/ijrc-1-1-101  |  Open Access |  How to cite  | 

Abstract

Acute respiratory distress syndrome (ARDS) is associated with high mortality and morbidity. Traditional ventilation with large tidal volumes aimed at normalisation of blood gases is usually associated with significant injury to the lungs. Protective lung ventilation (PLV) with smaller tidal volumes, higher levels of positive end-expiratory pressure (PEEP) and control of plateau pressures is the accepted mode of ventilation in patients with ARDS. Recruitment manoeuvres have been part of the protocol in PLV. However, considerable controversy surrounds the optimal PEEP that may be applied to these patients. Similarly, there is no consensus on the usefulness of recruitment manoeuvres in these sick patients. This review tries to find some answers to the best way to use PLV, PEEP and recruitment manoeuvres in patients with ARDS.

189

REVIEW ARTICLE

Susan P Pilbeam

Monitoring electrical activity of the diaphragm and the ventilation mode NAVA (Neurally Adjusted Ventilatory Assist)

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:12] [Pages No:112 - 123]

Keywords: Neurally adjusted ventilatory assist, ventilation, electromyography, diaphragm

   DOI: 10.5005/ijrc-1-1-112  |  Open Access |  How to cite  | 

Abstract

While it is possible to monitor the electrical activity of the heart using an electrocardiogram (ECG), the ability to monitor the electrical activity of the diaphragm (EAdi) in the clinical setting has not been possible until recently. A specialised nasogastric tube is now available which can monitor EAdi in the intensive care units (ICU). The EAdi signal can also be used to control a mechanical ventilator. The mode associated with the EAdi is referred to as neurally adjusted ventilator assist (NAVA). It can be used in spontaneously breathing patients. A NAVA ventilator breath is triggered (beginning of breath), delivered and cycled (end of breath) by the patient’s neural control of breathing. This is markedly different from all other modes of ventilation which rely on a pneumatic trigger (flow or pressure change), and where breath delivery and breath termination are generally determined by how the clinician sets the ventilator’s controls. This article will include a discussion of patient-ventilator asynchrony, monitoring the electric activity of the diaphragm (EAdi) with a specialised catheter and will provide an explanation of how NAVA operates.

580

REVIEW ARTICLE

Eribaweimon Shilla, Pushpa Kini

Paediatric mechanical ventilation

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:11] [Pages No:124 - 134]

Keywords: Paediatric, mechanical ventilation, airway, ventilatory care, monitoring

   DOI: 10.5005/ijrc-1-1-124  |  Open Access |  How to cite  | 

Abstract

Knowledge of paediatric mechanical ventilation is moving forward at an interesting pace. There are no clear or consistent guidelines despite several years of mechanical ventilation on a large number of paediatric populations. Although, the basic principles of physics and gas flow apply to all age groups, anatomical and physiological differences in children play a significant role in selecting the type of ventilator as well as the ventilatory modes and settings. Requirement for respiratory support in children admitted to ICU is common. Respiratory failure or impending failure is usually due to lung pathology or other systemic disease contributing to respiratory compromise. Monitoring vital signs, blood gases, pulse oximeter and end-tidal carbon dioxide are essential to provide optimal care. Positive pressure ventilation with improper settings may result in barotrauma and it is essential to prevent or detect these complications at the earliest.

1,073

Original Article

Sneha Ratti, Jayashree Purkayastha, Ramesh Bhat

An addition of tidal volume (volume guarantee) to synchronised intermittent mandatory ventilation in neonates with respiratory distress syndrome – A randomised controlled trial

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:5] [Pages No:135 - 139]

Keywords: Respiratory distress syndrome, synchronised intermittent mandatory ventilation, volume guarantee, preterm, weaning

   DOI: 10.5005/ijrc-1-1-135  |  Open Access |  How to cite  | 

Abstract

Background: Volume guarantee is a synchronised mode with time-cycled, pressure-limited ventilation, developed to maintain minimal preset mechanical tidal volume. Objective: To compare the effects of synchronised intermittent mandatory ventilation plus volume guarantee (SIMV+VG) with conventional synchronised intermittent mandatory ventilation (SIMV) in preterm neonates with respiratory distress syndrome (RDS). Method: This prospective study included preterm neonates admitted in Neonatal Intensive Care Unit (NICU) from October, 2010 to March, 2011. A total of 28 neonates were randomised in the study with the SIMV and SIMV+VG during initial ventilation and weaning phase. The outcome measures were to compare peak inspiratory pressure (PIP), mean airway pressure (MAP), oxygenation (PaO2/FiO2) and ventilation in both the groups. Result: During the initial ventilation, the oxygenation (based on PaO2/FiO2 ratio) was considerably better in the SIMV+VG (285.6±154) as compared to the SIMV group (156.8±92.9) and it was statistically significant (p=0.025).The compliance in SIMV+VG group was higher than SIMV group but it did not reach statistically significant difference. During the weaning phase, the SIMV+VG group showed hypocarbia (33 mm Hg) whereas the SIMV group showed normocarbia (44 mm Hg); (p=0.025). The compliance was better in the SIMV+VG (2.7 ± 1.8 ml/mbar) as compared to the SIMV (0.7 ± 0.6 ml/mbar). This was statistically significant (p value=0.042). Conclusion: The SIMV+VG is relatively better for weaning from ventilatory support and it enhances the spontaneous respiratory effort.

207

Original Article

Saumy Johnson, Elna Eldo, Ashley Varghese

Comparison of FDO2 at different flow rates in an adult manual resuscitator with and without reservoir bag: A manikin study

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:4] [Pages No:140 - 143]

Keywords: Manual resuscitator, delivered oxygen concentration, oxygen flow rate

   DOI: 10.5005/ijrc-1-1-140  |  Open Access |  How to cite  | 

Abstract

Background: Manual resuscitators are used to manually assist or provide positive pressure breaths during cardiopulmonary resuscitation, suctioning and intrahospital transport. However, the fraction of delivered oxygen (FDO2) through these devices with different flow rates varies. Aim: To study the FDO2 with manual resuscitator under different conditions. Methods: An adult manikin was intubated with 8 mm ID endotracheal tube and ventilated using an adult manual resuscitator. An oxygen analyser was connected between endotracheal tube and the manual resuscitator. The variables included with or without reservoir bag (RB), manual ventilation at 12 or 20 breaths/min and use of one or two hands while the FDO2 was measured with oxygen flow rates at 2, 4, 6, 8, 10, 12 and 15 (L/min). Results: The maximum FDO2 delivered was 95.3% and 97.6% with RB using one hand and two hands respectively. At . 10 L/min flow, FDO2 was >90% with RB. At 2 . 4 L/min flow, the FDO2 was <60% with RB and 25-40% without RB. FDO2 was slightly higher with ventilation at 12 bpm than with 20 bpm. The effect of one- or two-handed ventilation was variable. Conclusion: With the use of a reservoir bag along with the manual resuscitator at an oxygen flow rate above 10 L/min, FDO2 > 90% can be consistently delivered irrespective of single or both handed breath delivery or the ventilator rate. Without the use of reservoir bag, irrespective of other conditions, it is not possible to deliver FDO2 > 60% with a manual resuscitator.

175

Original Article

Shyamsunder Kamath

Comparison of the ‘D blade’ with the conventional blade of C-MAC® for endotracheal intubation in patients with simulated limitation of cervical movements

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:5] [Pages No:144 - 148]

Keywords: C-MAC®, D blade, videolaryngoscope, cervical immobilisation

   DOI: 10.5005/ijrc-1-1-144  |  Open Access |  How to cite  | 

Abstract

Background: The C-MAC® videolaryngoscope enables better visualisation of glottis for rapid and successful endotracheal intubation. Aim: The present study is aimed at comparing the conventional C-MAC® blade with new ‘D’ blade in patients with simulated cervical spine immobilisation. Methods: This was a prospective, randomised and crossover study. Eighty patients were randomised to one of two groups: Group CD or Group DC (CD - Conventional blade first, DC-D blade first). Patients in each group had laryngoscopy performed with both the blades in random order following which the patient’s trachea was intubated using the blade used for second laryngoscopy. Results: The mean (± SD) age was 39.4 (± 12.4) years. There were 33 male and 47 female patients. The average weight was 57.2 kg. No patient had a grade 3 or 4 view at initial laryngoscopy (without cervical spine immobilisation) with Macintosh blade and hence not excluded. 75 patients had a grade 1 view and 5 patients with grade 2 view with D blade whereas 63 patients had a grade 1 view and 17 patients had a grade 2 view with the conventional blade. The difference was clinically and statistically very significant. The time taken for laryngoscopy and intubation, and the overall satisfaction score did not differ between the groups. Conclusions: The D blade of C-MAC® videolaryngoscope enables better visualisation of glottis as compared to the conventional blade, for endotracheal intubation in patients with simulated limitation of cervical movements. The time taken for laryngoscopy, endotracheal intubation and the overall satisfaction score did not differ between the two blades.

300

Original Article

KN Prasad, Prabhu Manjunath, Shailza Khara

Comparison of two techniques of laryngeal mask airway insertion – is reverse technique better than standard?

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:7] [Pages No:149 - 155]

Keywords: LMA, standard technique, reverse technique, fibreoptic view, sore throat

   DOI: 10.5005/ijrc-1-1-149  |  Open Access |  How to cite  | 

Abstract

Background: Standard technique of Laryngeal Mask Airway (LMA) insertion has been routinely and successfully employed in adults. This technique has failed in certain instances prompting evaluation of alternative techniques. ‘Reverse technique’ is one which is studied and employed successfully in paediatric population. However, this has not been widely studied in adults. Materials and methods: In this randomised, prospective, single blinded study, we compared the standard technique and reverse technique of LMA insertion with respect to success rate, time taken for successful insertion, confirming the final position of LMA by performing a fibreoptic evaluation of the glottic view and incidence of postoperative sore throat in 60 adult patients undergoing surgery under general anaesthesia. Statistical analysis used: Using SPSS 11.5TM software, Independent samples’ test and Chi-square test was applied to the results where appropriate. A p value of < 0.05 was considered as statistically significant. Results: LMA insertion was successful in all patients using standard technique and all but one patient using reverse technique. Insertion was complete with in 30 seconds with the longest being 24.08 seconds in reverse technique group. Grade 1 or 2 glottic view on fibrescopy was obtained in 90.3% patients in the standard technique group as against 100% patients in reverse technique group. There was no significant difference in immediate or delayed incidence of sore throat. Conclusions: Reverse technique of LMA insertion has a comparable success rate with the standard technique in adult patients undergoing general anaesthesia.

202

Original Article

Anil Kalarickal

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) IV and Simplified Acute Physiology Score (SAPS) II in a Tertiary Care Hospital ICU in India

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:5] [Pages No:156 - 160]

Keywords: SAPS II, APACHE IV, ICU scoring systems, mortality

   DOI: 10.5005/ijrc-1-1-156  |  Open Access |  How to cite  | 

Abstract

Background: APACHE IV and SAPS II are ICU scoring systems used to predict mortality in critically ill patients in the ICU. Aim: To compare mortality prediction using APACHE IV and SAPS II in an Indian ICU. Methods: This prospective study included 225 patients. SAPS II and APACHE IV scoring and predicted mortality were obtained for each patient using online calculators and correlated with actual mortality and length of stay. Results: 183/225 of these admissions were due to medical causes. The mean±SD SAPS II score was 37.97 (±15.85) and APACHE IV score was 64.15 (±20.04). The median SAPS II predicted mortality rate was 19.6% and by APACHE IV was 17.4%. Actual mortality was 25.33%. Area under the curve (AUC) for SAPS II was 0.723 and APACHE IV was 0.701. AUC for SAPS II and APACHE IV for medical admissions were 0.712 and 0.681 respectively and for surgical admissions was 0.803 and 0.811 respectively. The best cut off value of SAPS II was 37 and APACHE IV was 70.5 for surgical patients. The mean predicted mortalities for patients with SAPS II score <37 and .37 were 4.95±3.87% and 37.15±16.5% respectively and APACHE IV score <70.5 and .70.5 were 16.82±11.48% and 40.6±15.72% respectively. There was no correlation between predicted and actual length of stay. Conclusions: Both APACHE IV and SAPS II ICU scoring systems are inaccurate in predicting overall mortality in our ICU. APACHE IV is not reliable in predicting length of stay of all patients in our ICU.

284

SURVEY

Rahul Magazine, Bharti Chogtu, L Muthukumaran, A J Saisree Reddy, Nimisha Srivastava, Aswini Kumar Mohapatra

Knowledge, attitude and practice of nurses regarding pulmonary tuberculosis in a tertiary care hospital

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:6] [Pages No:161 - 166]

Keywords: Tuberculosis, nurses, tertiary care hospital

   DOI: 10.5005/ijrc-1-1-161  |  Open Access |  How to cite  | 

Abstract

Background: Knowledge, attitude and practices of nurses can have a significant effect on the delivery of health services to pulmonary tuberculosis patients. Information regarding this can help in modifying and improving the training programs for nurses working in various health facilities. Objectives: To study the knowledge, attitude and practices of nurses regarding pulmonary tuberculosis in an academic hospital. Methods: A cross sectional questionnaire based study was conducted over a period of one month at Kasturba Hospital, Manipal, Karnataka. 202 (89.8%) out of the 225 nurses who were approached agreed to take part in the study and were included in the analysis. The data was analysed using SPSS 16.0., p values were calculated using chi- square test. Results: 79 (39.1%) respondents were worried about getting tuberculosis from patients. 37 (63.8%) subjects who had work experience in a tuberculosis ward as compared to 58 (40.3%) who had never worked in a TB ward were able to write the expanded form of DOTS (p = 0.002). Only 4.5% of respondents collected sputum in an open area. Regarding the measures taken to reduce transmission of TB infection in the ward it was found that 143 (70.8%) respondents followed the correct practices. It was noted that only 86 (42.6%) subjects displayed satisfactory level of awareness. Conclusion: Majority of the respondents were not choosing the right location for sputum collection. With less than fifty per cent of the respondents having satisfactory level of awareness there is a need to further strengthen the training and skill monitoring programs.

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CASE REPORT

Saumy Johnson, Eldo Vijo

Role of noninvasive ventilation for acute respiratory failure due to snakebite

[Year:2012] [Month:July-December] [Volume:1] [Number:2] [Pages:2] [Pages No:167 - 168]

Keywords: Noninvasive ventilation, Snake bite, Acute respiratory failure

   DOI: 10.5005/ijrc-1-1-167  |  Open Access |  How to cite  | 

Abstract

Introduction: Noninvasive ventilation (NIV) has revolutionised the management of diverse forms of respiratory failure.1 Case report: An 18 year old male patient presented to the emergency department with a history of an Indian krait snake bite on his left upper limb about seven hours ago. He had signs and symptoms of local and systemic envenomation, left upper limb cellulitis and suspected acute tubular necrosis of the kidneys. He was administered anti-snake venom and given supportive care. He was shifted to the intensive care unit where a noninvasive ventilator was used for supporting his respiratory system via a full face mask. He received NIV for thirteen days intermittently alternating with 60 percent oxygen via a Venturi mask. Progressively, he showed significant improvement and was weaned off NIV. He was discharged from hospital with no neurological sequelae. Conclusion: NIV can be used in selected patients with acute neuromuscular respiratory failure while awaiting improvement from specific therapies.

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