Patient ventilator asynchrony (PVA) is a prevalent phenomenon seen in almost 25% of our intensive care unit patients. PVA can be trigger asynchrony, flow asynchrony, cycle asynchrony or mode asynchrony. Ineffective triggering is the most commonly occurring asynchrony. The best way to identify PVA is via the ventilator graphics. Corrective steps and manipulating the ventilator on the conventional mode to suit the patient's needs can help reduce the incidence of PVA. Recent advances have given rise to newer modes of ventilation such as Neurally Adjusted Ventilatory Assist and Proportional Assist Ventilation with the goal of reducing the frequency of PVA. Many new methods to reduce asynchronies are being studied; however additional large scale trials are needed to come to conclusive results. This article is an attempt to simplify the various asynchronies for better application to all healthcare professionals.

Airway management in critically ill patients is often difficult and is associated with complications. Knowledge of airway anatomy, its change during laryngoscopy and physiology of oxygen transport is essential for predicting difficult airway and in planning the management. Optimal assessment of the airway anatomy to predict difficulty, formulating a plan of action, and an alternate plan, assembling the required equipment and personnel, keeping the difficult airway trolley ready, preparation of the patient by preoxygenation and proper positioning are some of the measures to decrease complications. Adequate training to develop cognitive and procedural skill for managing difficult airway is very important. All physicians involved in airway management should update their skills by involving in simulation excercises and workshops.

Refractory hypoxaemia is a problem in patients with acute respiratory distress syndrome (ARDS). Although mechanical ventilation is the mainstay of management of ARDS, this therapy itself can cause damage to the lungs due to high tidal volume and high airway pressures. Lung protective strategies are used to reduce damage to the lungs due to mechanical ventilation. Use of small tidal volumes can cause alveolar derecruitment and arterial hypoxaemia. Lung recruitment manoeuvre (RM) opens up collapsed segments of the ARDS lung but the collapse may reappear once the RM is complete. Although RM has been shown to improve oxygenation there is still no clear data showing improvement in clinical outcome. This review summarises the different techniques used for RM, physiological effects of RM on lung mechanics along with monitoring RM at the bedside.

Trial registration has become an important part of clinical trials and various databases exist across the world. In India, the Clinical Trial Registry India (CTRI) was established in 2007 to promote registration of clinical trials in the country. This initiative which was part of a move to promote transparency in clinical trials has now become a requirement for publication of clinical trials across most journals. This article discusses the importance of clinical trial registration and describes the steps required to complete the registration of a clinical trial in the CTRI database.

ARDS is a clinical syndrome characterised by severe refractory hypoxaemia associated with significant mortality and morbidity. Low tidal volume ventilation and restricting plateau pressure has got maximum survival benefit. Various others measures to tackle refractory hypoxaemia in patients with ARDS have been studied. Prone ventilation is one such rescue therapy which has shown promising results. This article is intended to discuss the benefits of prone ventilation and to clarify some of the common queries one has in practising prone ventilation.

Noninvasive ventilation (NIV) is the term used when patients are mechanically ventilated without using an invasive artificial airway. NIV is widely used to provide ventilator support for patients with acute or chronic respiratory failure. This article deals with the indications and contraindications of NIV, various interfaces, their advantages and disadvantages, selection of interface and weaning of patients from NIV.

Capnography has become an essential monitoring tool in perioperative and critical care setting. It helps monitor dynamic physiological processes more precisely and promptly, compared to other monitoring modalities. Methods to measure and display carbon dioxide concentrations in respired gases include infrared spectrography, mass spectrography, Raman spectrography, photoacoustic analysers or colorimetry. It is used to confirm correct endotracheal tube placement, ensure effective and consistent chest compression, detect return of spontaneous circulation and diagnose alterations in haemodynamics and ventilation of critically ill patient. It helps to optimise fluid resuscitation and monitor shock progression by providing insight into adequacy of tissue perfusion. Thus, a detailed study and interpretation of capnographic waveform is essential.

Trauma constitutes a large proportion of the number of lives lost, especially in the productive age group. Trauma-related deaths have a trimodal distribution: First, at site or on transfer due to severity of trauma injuries. The injury could be so severe that nothing can be done to save the life of that trauma victim. Second phase of deaths is usually due to hypovolaemia and are often treatable and avoidable. Timely and appropriate intervention at this stage can reduce the effects of trauma and prevent morbidity secondary to the injury. The third phase includes those patients who die of complications of trauma such as infection, embolism, sepsis, ARDS and septic shock. A well-managed second phase is likely to reduce the incidence of the third phase. A systematic approach to a victim of trauma is very necessary so that any life-threatening injury is not missed. The approach to trauma must be done in the following steps: Primary survey and resuscitation, secondary survey and definitive care. This article outlines the various steps of the initial management of trauma.

Patients with complex medical and surgical issues are often admitted to the intensive care unit (ICU). In such patients, prompt administration of broad spectrum empirical antibiotics is mandatory to control the infection. Antibiotic therapy should be instituted as soon as possible after the relevant culture specimens of blood, urine, endotracheal secretions or cerebrospinal fluid are sent. Ideally, empirical antibiotic therapy should be initiated within the first hour of admission of patients with suspected sepsis in ICU. While selecting the empirical antibiotic therapy, the patient's clinical history along with the probable source of infection, previous antibiotic history and most likely pathogens according to the prevalence in the particular intensive care unit (ICU) should be taken into account. A delay in initiating empirical antibiotic therapy is associated with a higher risk of progression to severe sepsis, more days on ventilator and ultimately an adverse outcome. However, empirical therapy should be de-escalated as soon as the culture and sensitivity reports are available to the clinician.

Comparison of many clinical signs to commonly encountered objects is useful as memory aid. Similarly, radiological sign in chest imaging can be compared to a particular object or pattern for easier recognition. In this article, we discuss 23 classic thoracic radiological roentgenographic signs commonly used in chest imaging and serves as an educational review for respiratory therapists and physicians for better assessment and rapid interpretation.

Introduction: The six minute walk test (6MWT) is a practical and reliable measure of exercise tolerance that is widely used to assess the functional status of the patients with a variety of cardiac and pulmonary diseases, including heart failure, pulmonary hypertension, and Chronic Obstructive Pulmonary Disease (COPD). Objective: To evaluate the reliability validity and responsiveness of the six minute walk test and to measure the minimal clinically important difference (MCID) in South Indian IPF patients. Methods: The study population consisted of 30 patients diagnosed as IPF. Six minute walk test distance and other parameters were measured at baseline and at 18 week interval using a standard protocol. Correlation coefficients were used to evaluate the association between six minute walk distance and measures of dyspnea using Borg Scale rate of perceived exertion and Quality of Life questionnaire using St George Respiratory Questionnaire. The distribution based method was used to quantify the MCID. Results: The relationship between 6MWD with dyspnea and St George Respiratory Questionnaire showed good reliability (coefficient = 0.69 p<0.05). There was strong correlation between increase in 6MWD and decrease in Borg Scale of rate of perceived exertion and also decreased St George Respiratory Questionnaire indicating improvement in quality of life. The calculated MCID was 15 m. The decline in 6MWD indicated the prognosis of the disease. Conclusions: The six minute walk test is a clinically helpful measure of status of the disease and the prognosis in South Indian patients with IPF.