Indian Journal of Respiratory Care

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2014 | July-December | Volume 3 | Issue 2

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Acute coronary syndromes in India – Call for help?

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:4] [Pages No:427 - 430]

Keywords: Acute coronary syndrome, emergency medical services

   DOI: 10.5005/ijrc-3-2-427  |  Open Access |  How to cite  | 


Original Article

Harshan Arul, Jasvinder Kaur

A comparative study of paediatric endotracheal tubes available in the Indian market – a bench study

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:9] [Pages No:431 - 439]

Keywords: Cuff, margin of safety, paediatric endotracheal tubes

   DOI: 10.5005/ijrc-3-2-431  |  Open Access |  How to cite  | 


Introduction: A variety of paediatric endotracheal tubes (ETT) are available in India. Aim: Comparison of paediatric cuffed and uncuffed ETT with respect to dimensions, depth markings, cuff characteristics and cost. Methods: 65 cuffed and 38 uncuffed paediatric ETT (3.0-7.0 mm ID) from 12 different manufacturers were evaluated. The outer diameter, position of depth markings, length and position of cuff, largest diameter of cuff inflated at 20 cm H2O of the ETTs were measured and compared with dimensions of trachea. Results: Outer diameters of similar ID ETTs varied between manufacturers and between cuffed and uncuffed ETTs from the same manufacturer. 26 tubes studied did not have a depth marking. In many tubes the distances from depth marking to tube tip were greater than half the age-related minimum tracheal length. If the tube tips were placed in midtrachea, many cuffs were placed within the larynx. If cuffs were placed 0.5 cm below cricoid level, many tube tips lay too close to the carina. Diameters and cross-sectional area of the cuff at 20 cm H2O pressure mostly covered maximal internal age related tracheal diameters and cross sectional areas. Conclusion: Most paediatric ETTs are poorly designed. ETTs from Kimberly Clark and Parker tubes for children suit paediatric tracheal dimensions. All cuffed tubes including Kimberly Clark tubes need close cuff pressure monitoring.


Original Article

Lincy Devasia, Heera Lal Mahto

Effect of oxygen injection sites on fraction of delivered oxygen (FDO2) during noninvasive ventilation – An experimental lung model study

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:4] [Pages No:440 - 443]

Keywords: Delivered oxygen concentration, noninvasive ventilation, oxygen injection site

   DOI: 10.5005/ijrc-3-2-440  |  Open Access |  How to cite  | 


Introduction: The two-level noninvasive positive pressure ventilation (NPPV) is the most commonly used mode of ventilation in the treatment of early respiratory failure. During NPPV, the inspired oxygen fraction (FiO2) could be influenced by various factors such as the inspiratory positive airway pressure (IPAP), the expiratory positive airway pressure (EPAP), the O2 flow rate and the site where O2 is added to the circuit. Aim: To investigate the effect of IPAP, EPAP, O2 flow rate, leak and the O2 injection sites on the fraction of delivered oxygen (FDO2). Methodology: A lung model was constructed to simulate noninvasive ventilation with bilevel positive airway pressure (BiPAP) without leak and with 10% leak, the oxygen analyser was placed proximal to the ventilator to measure FDO2 when oxygen was injected at three different sites. The portable BIPAP device was set to spontaneous/timed mode. Inspiratory and expiratory pressures of the BIPAP device were set at 10/5, 15/5, 15/10 and 20/10 cm H2O. Results: This study revealed that there is a variation in the FDO2 with a change in the position of connection of oxygen tubing, leak in the system and the oxygen flow rate. Conclusion: During NPPV, the FDO2 varies significantly with O2 flow rate and presence of leak. Higher O2 flow rates and lower amounts of leak provide a higher FDO2. Higher FDO2 is achieved if the oxygen tubing is connected proximal to the patient whereas the effect of ventilator settings on FDO2 is not significant.


Original Article

Elna Eldo, Tisha Ann Skariah

Clinical outcome of high frequency ventilation in neonates in neonatal intensive care unit

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:5] [Pages No:444 - 448]

Keywords: High frequency ventilation, neonates

   DOI: 10.5005/ijrc-3-2-444  |  Open Access |  How to cite  | 


Background: Pulmonary disease is a major cause of mortality and morbidity in neonates. Some of them may require mechanical ventilation with high mean airway pressures to maintain adequate gas exchange. More unconventional modalities such as inverse ratio ventilation, high frequency ventilation or extracorporeal membrane oxygenation (ECMO) may be needed. Objective: To study the clinical outcome of neonates managed with HFV for past 5 years in Neonatal Intensive Care Unit (NICU). Methods: A retrospective study conducted at NICU from January 2007 to June 2013. All neonates who were managed with HFV were included in the study. Result: There were 39 neonates who were ventilated with HFV during that period. The survival rate was 20.5% (8 out of 39 subjects). 18 developed pulmonary hypertension, 5 of whom survived. Six (15.4%) presented with primary pulmonary hypertension (PHN) and 12 (30.8%) developed secondary PHN. In the survived group, 12.5% developed chronic lung disease and periventricular leukomalacia and in the expired group, 25.8% developed pulmonary haemorrhage. Conclusions: When HFV is instituted in infants who fail to show improvement with conventional ventilation, statistically significant improvement in arterial oxygen tension may occur without any change in oxygenation index. A longer period of conventional ventilation prior to HFV could be one of the factors that could interfere with the successful management with HFV.


Original Article

G Umesh, U Kailasnath Shenoy, KM Deepak

Comparative evaluation of the effect of magnesium sulphate with lignocaine on the haemodynamic response to orotracheal intubation

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:6] [Pages No:449 - 454]

Keywords: Laryngoscopy, Lignocaine, Magnesium sulphate, Orotracheal intubation

   DOI: 10.5005/ijrc-3-2-449  |  Open Access |  How to cite  | 


Introduction: Magnesium sulphate inhibits the release of catecholamines from adrenal medulla whereas lignocaine blocks conduction of nerve impulses. Both these drugs may suppress adverse haemodynamic responses to laryngoscopy and intubation. Aim: The purpose of the study was to evaluate the effect and safety of an intravenous bolus dose of 2%lignocaine (1.5 mg/kg) or 50%magnesium sulphate (40 mg/kg) on the haemodynamic response to laryngoscopy and intubation in anaesthetised and paralysed adults. Patients and Methods: This was a prospective, randomised, double-blind study. Sixty four adults, belonging to ASA PS 1 and 2, were randomised to one of two groups: Group M and Group L. Heart rate, systolic, diastolic and mean arterial blood pressures were recorded every minute from injection of study drug upto 5 minutes post-intubation. Serum magnesium levels were measured before and after giving magnesium in Group M patients. Results: Heart rate was significantly higher and diastolic blood pressure significantly lower at 30 seconds in magnesium group whereas systolic and mean arterial pressures were comparable in both groups at all time intervals. Total muscle relaxation time was highly significant in magnesium group as compared to lignocaine. Post-study magnesium levels in Group M were statistically significant but not clinically significant as all values were within normal therapeutic range. Conclusion: Intravenous bolus dose of magnesium sulphate (40 mg/kg) can be used safely as a substitute for lignocaine for attenuation of haemodynamic responses to laryngoscopy and orotracheal intubation.


Original Article

Tenzin Phakdon, Eribaweimon Shilla

Clinical features, management and outcome in patients admitted with liver cirrhosis to the ICU - A retrospective study

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:5] [Pages No:455 - 459]

Keywords: Cirrhosis, Fibrosis, Hepatic, Portal hypertension, Sepsis

   DOI: 10.5005/ijrc-3-2-455  |  Open Access |  How to cite  | 


Background: Hepatic cirrhosis is an important cause of morbidity and mortality in the intensive care unit (ICU). Objective: To determine the precipitating factors, presenting complaints, course of the disease and predictors of mortality in patients with liver cirrhosis admitted to the ICU. Methods: This retrospective study was conducted mat Multidisciplinary ICU at tertiary care hospital from April 2013 to March 2014. A total of 107 patients diagnosed with liver cirrhosis were admitted to the ICU. Of these, 17 were discharged against medical advice. The remaining 90 patients were included in the study. Their case notes were examined for data such as severity of disease, precipitating events and their course in the ICU. The survivors were followed up telephonically to assess survival at six months. Results: There were 30 survivors and 60 nonsurvivors. The stage of cirrhosis (based on modified Child-Pugh criteria) had significant association with hospital mortality and disease outcome. Mortality was significantly higher in patients presenting with sepsis and septic shock (P=0.022) and hepatic encephalopathy (P=0.007). Interventions such as mechanical ventilatory support (P=0.002), inotropes (P=0.001) and vasopressors (P=0.048), variceal banding (P=0.005), need for transfusion of fresh frozen plasma (P=0.001) and packed cell transfusion (P=0.036) showed significant association with clinical outcome. Conclusion: Overall mortality rate of patients admitted in the ICU with liver cirrhosis is high (66.7%). Mortality rate is higher in those with Stage C cirrhosis, sepsis and septic shock and hepatic failure. Among the patients who survive, one third may not survive beyond six months after hospital discharge.



M Koutra, R Curtis, Baikady R Rao

Cardiopulmonary Exercise Test

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:9] [Pages No:460 - 468]

Keywords: Anaerobic threshold, cardiopulmonary testing, oxygen pulse

   DOI: 10.5005/ijrc-3-2-460  |  Open Access |  How to cite  | 


Cardiopulmonary exercise testing (CPET) allows the objective measurement of patients’ exercise capacity. In contrast to traditional and static investigations for limited exercise tolerance, CPET can provide a global and dynamic evaluation of both cardiovascular and respiratory systems and their functional interactions. There is increasing literature to support the use of CPET in various clinical settings. Its role has been established for the evaluation of chronic heart failure especially for prognosis, measurement of response to treatment and assessment of suitability for heart transplantation. CPET has also been used for assessment of patient’s suitability for lung resection. There is currently a lot of interest in the use of CPET as a tool for the preoperative evaluation of patients for noncardiac surgery. Poor fitness levels as measured by CPET variables are shown to be associated with perioperative morbidity and mortality. It can therefore be very useful in risk stratification, preoperative optimisation, patient informed consent process for surgery and allocation of healthcare resources. In this article we review the basic physiological principles behind its use and the conduct of testing. We also summarise the latest evidence relevant to its current clinical applications, with emphasis on management of chronic heart failure, assessment of patient’s suitability for lung resection and preoperative stratification of surgical risk.



Robert L Chatburn

Recognising, describing and comparing modes of mechanical ventilation

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:10] [Pages No:469 - 478]

   DOI: 10.5005/ijrc-3-2-469  |  Open Access |  How to cite  | 



Sagar S Haval

Extracorporeal Membrane Oxygenation Therapy - A review

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:9] [Pages No:479 - 487]

Keywords: Cardiac failure, extracorporeal membrane oxygenation, respiratory failure

   DOI: 10.5005/ijrc-3-2-479  |  Open Access |  How to cite  | 


Since the first successful case of Extracorporeal Membrane Oxygenation (ECMO) in early 1970’s till date, there has been quite a change in clinical approach and technology. The recent H1N1 flu pandemic led to a wider use of ECMO therapy worldwide, proving its superiority in supporting respiratory failures with better outcomes. More over centres applied it as a rescue therapy for refractory hypoxaemia and refractory circulatory failures understanding its benefits and limitations. Understanding and execution of the ECMO therapy can be quite challenging and may have a greater learning curve. Initiating the ECMO program in the hospital with an organised and planned approach may shorten the learning curve and improve outcomes. Multiple factors are responsible for successful and smoother functioning of the ECMO program, which should be identified and worked upon. There are many indications where ECMO therapy can be applied and understanding its potential in the hospital is of utmost importance. Along with this, forming an ECMO team with trained members, forming policies and protocols, and taking the right decisions at the right time are important. An in-depth review of every aspect of its successful institution has been discussed in this article.



Devaraj Acharya

Percutaneous dilatational tracheostomy

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:9] [Pages No:488 - 496]

Keywords: Complications, intensive care unit, percutaneous, tracheostomy

   DOI: 10.5005/ijrc-3-2-488  |  Open Access |  How to cite  | 


Tracheostomy is one of the oldest surgical procedures and its technique has evolved over time. Nearly half of all tracheostomies are performed in the ICU. Most of these tracheostomies are temporary. Percutaneous dilatational tracheostomy (PDT) has become a standard practice in intensive care unit (ICU). However, many aspects of its practice are not yet clear. This bedside procedure when performed by experienced intensivists is reasonably safe but has known complications. In this review, the basics of tracheostomy, indications, contraindications, various techniques, complications, the assisting aids for PDT and the operator competence required are discussed. Finally PDT is compared with surgical tracheostomy and the feasibility of PDT in patients with coagulopathy, obesity and on high PEEP is reviewed.



A rescue technique for LMA Classic insertion in unanticipated limitation of mouth opening

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:3] [Pages No:497 - 499]

Keywords: Insertion technique, LMA Classic™ Supraglottic device, Difficult airway

   DOI: 10.5005/ijrc-3-2-497  |  Open Access |  How to cite  | 


Sudden unanticipated limitation in mouth opening can cause serious problems in airway management. We report a case in which mouth opening became restricted after induction of anaesthesia resulting in inability to insert LMA Classic by standard insertion technique. An alternative technique consisting of LMA insertion without intraoral manipulation was used in this case as a rescue technique and LMA could be inserted successfully.



Nayana Nemani, Laxmi Shenoy, Priyanka Kini, Nithin Mathews

Missed post-traumatic haemopneumothorax under general anaesthesia – A case report

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:4] [Pages No:500 - 503]

Keywords: General anaesthesia, haemopneumothorax, positive pressure ventilation, trauma

   DOI: 10.5005/ijrc-3-2-500  |  Open Access |  How to cite  | 


Chest trauma is an important factor that determines the morbidity and mortality in patients admitted with polytrauma. Impeccable clinical examination and chest x-ray is a must in all trauma patients to rule out major chest injuries. We present a case of undiagnosed haemopneumothorax in a haemodynamically stable child without obvious symptoms or signs of chest trauma posted for emergency lower limb surgery after road traffic accident.



Sethulakshmi Prasad, Pawan Nanjangud, Manjunath Prabhu

Anaesthetic management of a child with mediastinal tumour, superior vena caval obstruction and thrombocytopenia

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:5] [Pages No:504 - 508]

Keywords: Mediastinal tumour, superior vena caval obstruction, thrombocytopaenia

   DOI: 10.5005/ijrc-3-2-504  |  Open Access |  How to cite  | 


A 4 year old girl presented with swelling of left half of face, fever, hurried breathing and a mass over the left forearm. A computerised tomography (CT) scan revealed a large mediastinal mass compressing the superior vena cava, encasing trachea, both main bronchi and pulmonary trunk with infiltration into left upper lobe of lung. Haematological investigations revealed anaemia and thrombocytopenia. As part of clinical evaluation, she was posted for left ulnar mass biopsy. The case was successfully managed with an ultrasound guided brachial plexus block without any respiratory or haemodynamic compromise.



Patient-ventilator interaction: Unusual ventilator graphics and management using Positive End Expiratory Pressure – A case report

[Year:2014] [Month:July-December] [Volume:3] [Number:2] [Pages:3] [Pages No:509 - 511]

Keywords: Cardiogenic oscillation, dysynchrony, patient-ventilator interaction, positive end expiratory pressure, ventilator graphics

   DOI: 10.5005/ijrc-3-2-509  |  Open Access |  How to cite  | 


Approximately 25% of patients receiving mechanical ventilation have significant patient ventilator asynchrony which is associated with prolonged duration of mechanical ventilation. Here we report an unusual presentation of ventilator graphics “saw tooth” appearance in both pressure-time and flow-time graphs. An increase in the applied PEEP level resolved the saw tooth pattern in the graphics. The possible explanation for the graphics displayed is heart-lung interaction which is cardiogenic oscillation. If this is true, then this pattern can be used as a clinical tool to apply lung inflation manoeuvres.


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