Despite the decline in overall asthma mortality, acute severe asthma continues to be a significant challenge to clinicians. Patients with acute severe asthma present unique clinical features that require early recognition and aggressive treatment. The aim of this review is to describe the most current evidence that supports diagnostic and therapeutic approaches in the management of patients with acute severe asthma in the clinical setting.

Biphasic positive airway pressure (BIPAP) and Airway pressure release ventilation (APRV) are two commonly used modes of ventilation. BIPAP is widely used as a ‘universal mode of ventilation’ for both invasive and noninvasive mechanical ventilation. Understanding the functioning of this mode helps in ventilation with this mode alone for all levels of support. APRV is a variant of BIPAP and offers benefits for protective lung ventilation. Allowing patient's spontaneous respiration unhindered at all phases of ventilation is the hallmark of these modes. The ventilatory characteristics, difference from the conventional pressure controlled ventilation (PCV), ventilatory settings, technique of weaning, indications, contraindications, advantages and disadvantages of these two modes of ventilation are described in this article.

Electrical Impedance Tomography (EIT) is a relatively new noninvasive tool in the management of patients on mechanical ventilators. It is a simple, user-friendly and radiation-free investigation to study the regional ventilation and distribution of ventilation particularly in patients with Acute Respiratory Distress Syndrome (ARDS). It empowers the clinician to take necessary steps for the management of collapsed, non-aerated regions of the lungs, to prevent regional overdistension of lungs which results in Ventilator Induced Lung Injury (VILI) and for early detection of pneumothorax. This is a short review focusing the basic principles, clinical applications and current evidence in the effectiveness of this modality in the routine respiratory care.

Introduction: Acute respiratory distress syndrome (ARDS) is a major contributor to mortality and morbidity of adult patients admitted to intensive care units (ICU). Numerous scoring systems have been developed for critically ill patients with the goal of more accurately predicting clinical outcomes. However, the variability in these scores among individual patients, and consequently, their individual predictive ability is quite limited. Aim: To evaluate the role of initial oxygenation as an early predictor of mortality in ARDS patients. Methodology: One hundred and six mechanically ventilated adult patients with ARDS were enrolled retrospectively. Baseline parameters from the day of ICU admission were recorded. The details of ventilation, inspired oxygen fraction required, positive end-expiratory pressure and number of days on ventilation along with duration of hospital stay were recorded. Similarly, the status of oxygenation was assessed using PaO₂/FiO₂ (P/F) ratio. Survival of the patients was correlated with the baseline status of oxygenation. Results: Of the 106 patients, 65 were males and 41 female. The mean (± SD) age was 44 years (16.08). The difference in the P/F ratio between survivors and nonsurvivors was statistically significant. The ROC curve showed a cutoff value for P/F ratio of 108. Among survivors, the ICU stay was shorter in patients in pulmonary group compared to extrapulmonary group. Conclusion: Mortality is high if the baseline P/F ratio at admission is below 108. There is no difference in mortality due to lung injury caused by pulmonary or extrapulmonary aetiologies. ICU stay is longer among survivors if cause of ARDS is extrapulmonary.

Introduction: An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. When obtaining an arterial blood sample via percutaneous puncture, there is a risk of accidentally obtaining venous blood. Conventional methods of confirming arterial blood at the bedside such as blood colour and pulsatile return can be misleading in patients with low blood pressure or hypoxaemia. The blood of patients with hypoxaemia can show a dark colour similar to venous blood and patients with low blood pressure may have very low pulsatile action. Aim: The purpose of this study was to determine if the arterial sampler filling time can be an accurate predictor of obtaining arterial blood sample in adults. Methodology: Forty patients were enrolled prospectively who required arterial blood sample or venous sample in medical and surgical intensive care unit. During the arterial and venous puncture procedures the amount of time it took to fill the sample tube was measured with the help of stop watch in s/ml was measured. Results: Twenty patients were in the arterial group and 20 patients in venous group. The mean ± SD filling time was 12 ± 3 s/ml for the arterial group and 112±21 s/ml for the venous group. Conclusion: There is a statistically significant difference between arterial and venous filling times using an arterial blood sampler in human subjects. There is no relationship between mean arterial pressure (MAP) and arterial sampler filling times.

Introduction: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Aim: The present study was undertaken to assess the effectiveness of breathing exercises in the reduction of dyspnoea among the COPD patients. Methods: A quantitative research approach, quasi experimental pre-test and post-test control group design was used in the study. The study was theoretically supported by the frame work based on goal attainment theory of Imogen King. The study was conducted in pulmonology wards of a teaching institute in South India. A total of 60 subjects were selected. The samples were selected by using convenient sampling technique. BODE index was used to grade dyspnoea. The data collected were analysed using descriptive and inferential statistics. Results: 63% of patients were having BODE index score between 4 and 7. In the experimental group the mean pre-test value was 6.13 and the mean post-test value was 2.96 and significant at p value 0.001 level. The post interventional level of dyspnoea of both groups was analysed by using Mann Whitney test, and showed a p value of 0.001. There is significant reduction in the level of dyspnoea after practising breathing exercises compared with control group. Conclusion: There is significant reduction in the level of dyspnoea among COPD patients with breathing exercises.

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Ventilatory failure may result from dysfunction of any part of the respiratory pathway. Muscle weakness preexisting or acquired should be considered in all patients. Case Report: A 52-year-old smoker presented in extremis with type II respiratory failure. She was treated with bronchodilators, steroids and antibiotics. Weaning ventilatory support was difficult and so a tracheostomy was performed.. Two weeks later, she was transferred to a respiratory ward where she was decannulated before discharge home. After discharge, her breathlessness and weakness progressed until she was readmitted in extremis 1 week later. On readmission, she deteriorated despite treatment for COPD. Mandatory ventilation was initiated after recannulation of the tracheostomy. The patient gradually improved over the next few days and was transferred to a respiratory ward where she was weaned onto nocturnal NIV and the tracheostomy was decannulated. Flow volume loops excluded air flow obstruction but spirometry confirmed severe inspiratory muscle weakness. The patient reported progressive weakness over several years. On examination all muscle groups were weak and deep tendon reflexes were absent but there was no fatigability or fasciculation. Sensation was intact. The diagnosis of acid maltase deficiency (AMD) was confirmed by analysis of peripheral blood lymphocytes, muscle biopsy and enzyme assay.

Acute pulmonary embolism (PE) is a life-threatening condition, requiring immediate management. This case report summarises the evaluation and management of a patient who presented with a saddle pulmonary embolus. Since the patient had features suggestive of significant right heart dysfunction, he was thrombolysed with streptokinase but developed cardiogenic shock while on the streptokinase infusion. Therefore, catheter fragmentation and thrombectomy was performed with a view to break and remove the clot. Despite this, his condition deteriorated and unfortunately he died in the ICU. The thrombophilia screen sent before death showed significantly elevated serum levels of homocysteine, which could potentially have caused a hypercoagulable state. This case re-emphasises the mortality associated with major PE and the need for a detailed thrombophilia screen in patients with deep vein thrombosis or PE without any major clinical risk factors.

A 31 year old man with spina bifida and a ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt in situ presented with sudden onset dyspnoea and pleuritic chest pain. He reported a nine month history of increasing breathlessness. Clinical signs of right heart strain were present. Echocardiography estimated the pulmonary artery pressure to be 86 mm Hg. Computed tomography pulmonary angiogram confirmed acute pulmonary embolism (PE) and chronic pulmonary thromboembolic disease. He was anticoagulated but unfortunately had a cardiac arrest and succumbed. VA CSF shunts were used for the treatment of hydrocephalus between the 1950s and 1980s. Although most VA shunts sited for hydrocephalus in childhood have been removed, some may remain in situ in adults. These patients are at risk of PE and development of chronic thromboembolic pulmonary hypertension (CTEPH). Removal of the VA shunt should be considered when patients are shown to be shunt independent. We advise the regular screening of patients with VA CSF shunts for pulmonary hypertension with pulse oximetry, electrocardiography, chest radiography and echocardiography as it is preventable, detectable and treatable.

A 56 year old female patient belonging to American Society of Anaesthesiologists Physical Status (ASA-PS) 1 underwent emergency laparoscopic appendectomy. Surgery was uneventful. After reversal of the neuromuscular blockade and extubation, patient sustained acute upper airway obstruction due to laryngospasm and developed negative pressure pulmonary oedema, which resolved after a period of about 15 hours of mechanical ventilation.

Laryngomalacia is one of the commonest causes of congenital stridor in neonates. The treatment depends on the severity of the stridor. We present a case of 12 day old neonate with a history of stridor who was diagnosed to have laryngomalacia on clinical examination and confirmed by flexible fibreoptic bronchoscopy. The neonate underwent excision of excessive aryepiglottic fold under general endotracheal anaesthesia with controlled ventilation as the definitive surgery.

Introduction: Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia that develops within 48 hours or more of mechanical ventilation. It is also associated with significant morbidity including increased ventilatory days, intensive care unit (ICU) stay and higher medical cost that leads to high mortality rate in ICU. Aim: To evaluate the clinical outcome of the patients diagnosed with VAP and also to identify the risk factors for VAP. Methodology: This retrospective study included 27 patients admitted in Medical and casualty ICU's from August 2013 to April 2014 who were diagnosed with various diseases and later developed VAP. The patient's demographic data and diagnosis based on Centres for Disease Control and prevention (CDC) criteria were collected. Results: Among 27 patients, 20 were male patients and 7 were female patients. The order of organism according to the frequency in the current study was found to be Acinectobacter, Klebsiella, Pseudomonas aeruginosa, methicillin resistant Staphylococcus aureus, Streptococcus pneumonia, Hemophilus influenza, Enterobacter sp. Twenty two patients had late onset VAP and five patients had early onset VAP. Overall the survival was 52%. Conclusion: The incidence and the mortality of VAP are high in the current ICU setup. The mortality rate in the current study was 48% and the patients who survived had a longer ICU stay due to ventilator dependence.