Evaluating respiratory mechanics during dynamic conditions without interrupting ongoing ventilation and flow, adds to the information obtained from the mechanics derived from static (= no flow) conditions, i.e., the flow signal has the potential to provide information on the properties of the respiratory system (including the tubing system). Hence monitoring the changes in the flow signal during ongoing mechanical ventilation would give information about the dynamic mechanics of the respiratory system. Any change in the mechanics of the respiratory system including the endotracheal tube (ETT) and the ventilatory circuit would affect the shape of the flow signal. Knowledge of the airway pressure distal to the ETT at the carina level (= tracheal pressure) is required for calculating the extra resistive load exerted by the endotracheal tube in order to compensate for it. In a porcine model, the flow signal was used to non-invasively calculate tracheal pressure. There was good agreement between calculated and measured tracheal pressure with different modes of ventilation. However, calculation of tracheal pressure assumes that the inner diameter of the ETT is known, and this assumption is not met if the inner diameter is narrowed by secretions. Flow that passes a narrowed tube is decelerated and this is most pronounced with the high flow of early expiration, yielding a typical time constant over expiratory volume pattern that is easy to recognize during mechanical ventilation. This pattern reliably detected partial endotracheal obstruction during volume and pressure controlled mechanical ventilation. A change in compliance of the respiratory system modifies the elastic recoil and this also affects the rate of the expiratory flow and the shape of its signal. In a porcine model, lung volume gains on the flow signal generated by the heartbeats (cardiogenic oscillations) provided information about the compliance of the respiratory system during ongoing mechanical ventilation In conclusion analyzing the flow signal during ongoing ventilation can be a cheap, non-invasive and reliable tool to monitor the elastic and resistive properties of the respiratory system including the endotracheal tube.

En démontrant sa capacité d’identifier les pneumothorax, de différencier les différentes causes d’insuffisance respiratoire chez les patients dyspnéiques et de confirmer la position d’un tube endotrachéal lors d’une intubation endotrachéale, l’échographie pulmonaire a pris une place prépondérante dans la prise en charge des patients de soins critiques. La majorité des études, notamment celles sur l’intubation endotrachéale, ont évalué la performance de cliniciens possédant une expérience considérable en échographie pulmonaire et souvent dans un cadre idéal permettant des examens d’une durée prolongée. Considérant la disponibilité grandissante de l’échographie ciblée lors des situations de stabilisation et de réanimation des patients de soins critiques, nous voulions évaluer la capacité d’un groupe de clinicien hétérogène en termes de formation échographique à identifier la présence ou l’absence de glissement pleural sur de courtes séquences (comparable à la durée probable d’un examen lors de condition de réanimation) d’échographie pulmonaire enregistrées chez des patients intubés. Un total de 280 courtes séquences (entre 4 et 7 secondes) d’échographie pulmonaire démontrant la présence ou l’absence de glissement pleural chez des patients intubés en salle d’opération ont été enregistrées puis présentées de façon aléatoire à deux groupes de cliniciens en médecine d’urgence. Le deuxième groupe avait la possibilité de s’abstenir advenant une incertitude de leur réponse. Nous avons comparé la performance selon le niveau de formation académique et échographique. Le taux moyen d’identification adéquate de la présence ou l’absence du glissement pleural par participant était de 67,5% (IC 95% : 65,7-69,4) dans le premier groupe et 73,1% (IC 95% : 70,7-75,5) dans le second (p<0,001). Le taux médian de réponse adéquate pour chacune des 280 séquences était de 74,0% (EIQ : 48,0-90,0) dans le premier groupe et 83,7% (EIQ : 53,3-96,2) dans le deuxième (p=0,006). Le taux d’identification adéquate de la présence ou absence d’un glissement pleural par les participants des deux groupes était nettement supérieur pour les séquences de l’hémithorax droit par rapport à celles de l’hémithorax gauche (p=0,001). Lorsque des médecins de formation académique et échographique variable utilisent de courtes séquences d’échographie pulmonaire (plus représentatives de l’utilisation réelle en clinique), le taux d’identification adéquate de la présence ou l’absence de glissement pleural est plus élevé lorsque les participants ont la possibilité de s’abstenir en cas de doute quant à leur réponse. Le taux de bonnes réponses est également plus élevé pour les séquences de l’hémithorax droit, probablement dû à la présence sous-jacente du cœur à gauche, la plus petite taille du poumon gauche et l’effet accru du pouls pulmonaire dans l’hémithorax gauche. Considérant ces trouvailles, la prudence est de mise lors de l’utilisation de l’identification du glissement pleural sur de courtes séquences échographique comme méthode de vérification de la position d’un tube endotrachéal lors d’une intubation endotrachéale, et ce, particulièrement pour l’hémithorax gauche. Aussi, une attention particulière devrait être mise sur la reconnaissance du pouls pulmonaire lors de l’enseignement de l’échographie pulmonaire. / The field of targeted lung ultrasound in critical care is in constant expansion. Its many proven use include pneumothorax diagnosis, differentiation of the different causes of acute dyspnoea and endotracheal intubation confirmation. These studies on endotracheal intubation evaluated sonographers with extensive ultrasound training using sometimes lengthy exam. Hence, with the growing presence of bedside lung ultrasound we devised a study to evaluate the capacity of a heterogeneous group of physicians, with different levels of ultrasound training, to correctly identify lung sliding on random short sequences of recorded thoracic ultrasound. 280 short ultrasound sequences (4 to 7 seconds) of present and absent lung sliding of intubated patients recorded in the operating room were randomly presented to 2 groups of physicians. Descriptive data, mean accuracy of each participant, as well as the rate of correct answers for each of the sequences was measured and compared for different subgroups. Participants in the second group where instructed that they could abstain from answering in uncertain cases. Mean accuracy was 67.5% (95%CI: 65.7-69.4) in the first group and 73.1% (95%CI: 70.7-75.5) in the second (p<0.001). When considering each sequence individually, median accuracy was 74.0% (IQR: 48.0-90.0) in the first group and 83.7% (IQR: 53.3-96.2) in the second (p=0.006). The rate of correct answer was higher for right hemithorax sequences (p=0.001). Accuracy in lung sliding identification is better when participants have the possibility to abstain themselves from answering in uncertain cases. It is also improved in the right hemithorax, probably owing to the presence of the heart and the lung pulse artefact in the left hemithorax. Considering our results, caution should be taken when using short ultrasound sequences for identifying lung sliding as a mean of confirming endotracheal intubation, particularly in the left hemithorax. Emphasis should also be put on knowledge and identification of the Lung pulse artefact when teaching chest ultrasound curriculum.

Introdução: O gênero Acinetobacter representa um importante patógeno relacionado a infecções hospitalares, principalmente, à pneumonia associada à ventilação mecânica (PAV). O aumento de isolados de Acinetobacter baumannii resistentes aos carbapenêmicos (ABRC) representa um problema mundial, pois limita drasticamente as opções terapêuticas. A produção da carbapenamase OXA-23, uma β-lactamase da classe D de Ambler, representa o principal mecanismo responsável por esta resistência em nosso país. Objetivo: O presente estudo tem como objetivo padronizar a técnica de PCR em tempo real (qPCR) para a detecção do gene blaOXA-23 diretamente de aspirados traqueais (ATs) de pacientes com suspeita de pneumonia associada à ventilação mecânica (PAV) de unidades de tratamento intensivo (UTIs). Métodos e resultados: O DNA das amostras de ATs coletadas de pacientes em ventilação mecânica foi analisado pela técnica de qPCR, utilizando o SYBR green, para a detecção do gene blaOXA-23. Dentre os 20 ATs analisados, ABRC foi isolado em 10, A. baumannii sensível aos carbapemêmicos (ABSC) em 3 e 7 foram negativos na culura bacteriológica. O gene blaOXA-23 foi detectado tanto na colônia quanto no AT em 8 das 10 amostras de ABRC. Em uma amostra não houve detecção do gene por qPCR em nenhum dos materiais e em outra amostra houve detecção só no AT. Dos ABSC, em duas amostras não houve detecção do gene na colônia e no AT enquanto que em uma amostra o gene foi detectado somente no AT. Em nenhuma das amostras de ATs negativas na cultura foi detectado o gene. Conclusão: O estudo sugere que a técnica qPCR pode ser aplicada para a detecção do gene blaoxa-23 diretamente de amostras de AT, reduzindo assim, o tempo para o início de uma terpia antimicrobiana adequada e melhorando, consequentemente, o desfecho clínico deste pacientes. / Background: The genus Acinetobacter is an important pathogen associated with nosocomial infections mainly ventilator-associated pneumonia (VAP). The increasing of carbapenemresistant Acinetobacter baumannii (CRAB) isolates is a worldwide concern since it limits drastically the range of therapeutic alternatives. The OXA-23 producing, a carbapenemhydrolysing class D β-lactamase, is the major mechanism responsible for CRAB in our country. Objective: The study objective is to develop a real time PCR (qPCR) to detect the Acinetobacter baumannii blaOXA-23 gene directly in endotracheal aspirate (ETA) of patients under mechanical ventilation, with suspected ventilator-associated pneumonia (VAP). Methods and Results: DNA extracted from ETA samples from patients under mechanical ventilation was analyzed by qPCR, using SYBR green, for the presence of blaOXA-23 gene. Among the 20 ETAs examined, CRAB isolates were recovered in 10 quantitative cultures; carbapenem-susceptible A. baumannii (CSAB) in 3 and 7 cultures were negative to A. baumanni. Of the 10 CRAB, 8 were positive for blaOXA-23 on both the colony and ETA. In one blaOXA-23 qPCR was negative in colony and directly from ETA, while the other showed a qPCR negative result in the colony and positive in the ETA. In 3 CSAB, 2 samples showed negative results in colony and ETA and one showed a blaOXA-23 positive result only from the ETA. None of the 7 negative ETAs were positive for blaOXA-23 gene in the qPCR of the ETA. Conclusion: Our study suggests that qPCR can be applied to detect the presence of blaOXA-23 gene directly from ETAs reducing the time to an earlier initiation of appropriate therapy improving, consequently, the clinical outcomes for these patients.

Introdução: O gênero Acinetobacter representa um importante patógeno relacionado a infecções hospitalares, principalmente, à pneumonia associada à ventilação mecânica (PAV). O aumento de isolados de Acinetobacter baumannii resistentes aos carbapenêmicos (ABRC) representa um problema mundial, pois limita drasticamente as opções terapêuticas. A produção da carbapenamase OXA-23, uma β-lactamase da classe D de Ambler, representa o principal mecanismo responsável por esta resistência em nosso país. Objetivo: O presente estudo tem como objetivo padronizar a técnica de PCR em tempo real (qPCR) para a detecção do gene blaOXA-23 diretamente de aspirados traqueais (ATs) de pacientes com suspeita de pneumonia associada à ventilação mecânica (PAV) de unidades de tratamento intensivo (UTIs). Métodos e resultados: O DNA das amostras de ATs coletadas de pacientes em ventilação mecânica foi analisado pela técnica de qPCR, utilizando o SYBR green, para a detecção do gene blaOXA-23. Dentre os 20 ATs analisados, ABRC foi isolado em 10, A. baumannii sensível aos carbapemêmicos (ABSC) em 3 e 7 foram negativos na culura bacteriológica. O gene blaOXA-23 foi detectado tanto na colônia quanto no AT em 8 das 10 amostras de ABRC. Em uma amostra não houve detecção do gene por qPCR em nenhum dos materiais e em outra amostra houve detecção só no AT. Dos ABSC, em duas amostras não houve detecção do gene na colônia e no AT enquanto que em uma amostra o gene foi detectado somente no AT. Em nenhuma das amostras de ATs negativas na cultura foi detectado o gene. Conclusão: O estudo sugere que a técnica qPCR pode ser aplicada para a detecção do gene blaoxa-23 diretamente de amostras de AT, reduzindo assim, o tempo para o início de uma terpia antimicrobiana adequada e melhorando, consequentemente, o desfecho clínico deste pacientes. / Background: The genus Acinetobacter is an important pathogen associated with nosocomial infections mainly ventilator-associated pneumonia (VAP). The increasing of carbapenemresistant Acinetobacter baumannii (CRAB) isolates is a worldwide concern since it limits drastically the range of therapeutic alternatives. The OXA-23 producing, a carbapenemhydrolysing class D β-lactamase, is the major mechanism responsible for CRAB in our country. Objective: The study objective is to develop a real time PCR (qPCR) to detect the Acinetobacter baumannii blaOXA-23 gene directly in endotracheal aspirate (ETA) of patients under mechanical ventilation, with suspected ventilator-associated pneumonia (VAP). Methods and Results: DNA extracted from ETA samples from patients under mechanical ventilation was analyzed by qPCR, using SYBR green, for the presence of blaOXA-23 gene. Among the 20 ETAs examined, CRAB isolates were recovered in 10 quantitative cultures; carbapenem-susceptible A. baumannii (CSAB) in 3 and 7 cultures were negative to A. baumanni. Of the 10 CRAB, 8 were positive for blaOXA-23 on both the colony and ETA. In one blaOXA-23 qPCR was negative in colony and directly from ETA, while the other showed a qPCR negative result in the colony and positive in the ETA. In 3 CSAB, 2 samples showed negative results in colony and ETA and one showed a blaOXA-23 positive result only from the ETA. None of the 7 negative ETAs were positive for blaOXA-23 gene in the qPCR of the ETA. Conclusion: Our study suggests that qPCR can be applied to detect the presence of blaOXA-23 gene directly from ETAs reducing the time to an earlier initiation of appropriate therapy improving, consequently, the clinical outcomes for these patients.

Introdução: O gênero Acinetobacter representa um importante patógeno relacionado a infecções hospitalares, principalmente, à pneumonia associada à ventilação mecânica (PAV). O aumento de isolados de Acinetobacter baumannii resistentes aos carbapenêmicos (ABRC) representa um problema mundial, pois limita drasticamente as opções terapêuticas. A produção da carbapenamase OXA-23, uma β-lactamase da classe D de Ambler, representa o principal mecanismo responsável por esta resistência em nosso país. Objetivo: O presente estudo tem como objetivo padronizar a técnica de PCR em tempo real (qPCR) para a detecção do gene blaOXA-23 diretamente de aspirados traqueais (ATs) de pacientes com suspeita de pneumonia associada à ventilação mecânica (PAV) de unidades de tratamento intensivo (UTIs). Métodos e resultados: O DNA das amostras de ATs coletadas de pacientes em ventilação mecânica foi analisado pela técnica de qPCR, utilizando o SYBR green, para a detecção do gene blaOXA-23. Dentre os 20 ATs analisados, ABRC foi isolado em 10, A. baumannii sensível aos carbapemêmicos (ABSC) em 3 e 7 foram negativos na culura bacteriológica. O gene blaOXA-23 foi detectado tanto na colônia quanto no AT em 8 das 10 amostras de ABRC. Em uma amostra não houve detecção do gene por qPCR em nenhum dos materiais e em outra amostra houve detecção só no AT. Dos ABSC, em duas amostras não houve detecção do gene na colônia e no AT enquanto que em uma amostra o gene foi detectado somente no AT. Em nenhuma das amostras de ATs negativas na cultura foi detectado o gene. Conclusão: O estudo sugere que a técnica qPCR pode ser aplicada para a detecção do gene blaoxa-23 diretamente de amostras de AT, reduzindo assim, o tempo para o início de uma terpia antimicrobiana adequada e melhorando, consequentemente, o desfecho clínico deste pacientes. / Background: The genus Acinetobacter is an important pathogen associated with nosocomial infections mainly ventilator-associated pneumonia (VAP). The increasing of carbapenemresistant Acinetobacter baumannii (CRAB) isolates is a worldwide concern since it limits drastically the range of therapeutic alternatives. The OXA-23 producing, a carbapenemhydrolysing class D β-lactamase, is the major mechanism responsible for CRAB in our country. Objective: The study objective is to develop a real time PCR (qPCR) to detect the Acinetobacter baumannii blaOXA-23 gene directly in endotracheal aspirate (ETA) of patients under mechanical ventilation, with suspected ventilator-associated pneumonia (VAP). Methods and Results: DNA extracted from ETA samples from patients under mechanical ventilation was analyzed by qPCR, using SYBR green, for the presence of blaOXA-23 gene. Among the 20 ETAs examined, CRAB isolates were recovered in 10 quantitative cultures; carbapenem-susceptible A. baumannii (CSAB) in 3 and 7 cultures were negative to A. baumanni. Of the 10 CRAB, 8 were positive for blaOXA-23 on both the colony and ETA. In one blaOXA-23 qPCR was negative in colony and directly from ETA, while the other showed a qPCR negative result in the colony and positive in the ETA. In 3 CSAB, 2 samples showed negative results in colony and ETA and one showed a blaOXA-23 positive result only from the ETA. None of the 7 negative ETAs were positive for blaOXA-23 gene in the qPCR of the ETA. Conclusion: Our study suggests that qPCR can be applied to detect the presence of blaOXA-23 gene directly from ETAs reducing the time to an earlier initiation of appropriate therapy improving, consequently, the clinical outcomes for these patients.

En démontrant sa capacité d’identifier les pneumothorax, de différencier les différentes causes d’insuffisance respiratoire chez les patients dyspnéiques et de confirmer la position d’un tube endotrachéal lors d’une intubation endotrachéale, l’échographie pulmonaire a pris une place prépondérante dans la prise en charge des patients de soins critiques. La majorité des études, notamment celles sur l’intubation endotrachéale, ont évalué la performance de cliniciens possédant une expérience considérable en échographie pulmonaire et souvent dans un cadre idéal permettant des examens d’une durée prolongée. Considérant la disponibilité grandissante de l’échographie ciblée lors des situations de stabilisation et de réanimation des patients de soins critiques, nous voulions évaluer la capacité d’un groupe de clinicien hétérogène en termes de formation échographique à identifier la présence ou l’absence de glissement pleural sur de courtes séquences (comparable à la durée probable d’un examen lors de condition de réanimation) d’échographie pulmonaire enregistrées chez des patients intubés. Un total de 280 courtes séquences (entre 4 et 7 secondes) d’échographie pulmonaire démontrant la présence ou l’absence de glissement pleural chez des patients intubés en salle d’opération ont été enregistrées puis présentées de façon aléatoire à deux groupes de cliniciens en médecine d’urgence. Le deuxième groupe avait la possibilité de s’abstenir advenant une incertitude de leur réponse. Nous avons comparé la performance selon le niveau de formation académique et échographique. Le taux moyen d’identification adéquate de la présence ou l’absence du glissement pleural par participant était de 67,5% (IC 95% : 65,7-69,4) dans le premier groupe et 73,1% (IC 95% : 70,7-75,5) dans le second (p<0,001). Le taux médian de réponse adéquate pour chacune des 280 séquences était de 74,0% (EIQ : 48,0-90,0) dans le premier groupe et 83,7% (EIQ : 53,3-96,2) dans le deuxième (p=0,006). Le taux d’identification adéquate de la présence ou absence d’un glissement pleural par les participants des deux groupes était nettement supérieur pour les séquences de l’hémithorax droit par rapport à celles de l’hémithorax gauche (p=0,001). Lorsque des médecins de formation académique et échographique variable utilisent de courtes séquences d’échographie pulmonaire (plus représentatives de l’utilisation réelle en clinique), le taux d’identification adéquate de la présence ou l’absence de glissement pleural est plus élevé lorsque les participants ont la possibilité de s’abstenir en cas de doute quant à leur réponse. Le taux de bonnes réponses est également plus élevé pour les séquences de l’hémithorax droit, probablement dû à la présence sous-jacente du cœur à gauche, la plus petite taille du poumon gauche et l’effet accru du pouls pulmonaire dans l’hémithorax gauche. Considérant ces trouvailles, la prudence est de mise lors de l’utilisation de l’identification du glissement pleural sur de courtes séquences échographique comme méthode de vérification de la position d’un tube endotrachéal lors d’une intubation endotrachéale, et ce, particulièrement pour l’hémithorax gauche. Aussi, une attention particulière devrait être mise sur la reconnaissance du pouls pulmonaire lors de l’enseignement de l’échographie pulmonaire. / The field of targeted lung ultrasound in critical care is in constant expansion. Its many proven use include pneumothorax diagnosis, differentiation of the different causes of acute dyspnoea and endotracheal intubation confirmation. These studies on endotracheal intubation evaluated sonographers with extensive ultrasound training using sometimes lengthy exam. Hence, with the growing presence of bedside lung ultrasound we devised a study to evaluate the capacity of a heterogeneous group of physicians, with different levels of ultrasound training, to correctly identify lung sliding on random short sequences of recorded thoracic ultrasound. 280 short ultrasound sequences (4 to 7 seconds) of present and absent lung sliding of intubated patients recorded in the operating room were randomly presented to 2 groups of physicians. Descriptive data, mean accuracy of each participant, as well as the rate of correct answers for each of the sequences was measured and compared for different subgroups. Participants in the second group where instructed that they could abstain from answering in uncertain cases. Mean accuracy was 67.5% (95%CI: 65.7-69.4) in the first group and 73.1% (95%CI: 70.7-75.5) in the second (p<0.001). When considering each sequence individually, median accuracy was 74.0% (IQR: 48.0-90.0) in the first group and 83.7% (IQR: 53.3-96.2) in the second (p=0.006). The rate of correct answer was higher for right hemithorax sequences (p=0.001). Accuracy in lung sliding identification is better when participants have the possibility to abstain themselves from answering in uncertain cases. It is also improved in the right hemithorax, probably owing to the presence of the heart and the lung pulse artefact in the left hemithorax. Considering our results, caution should be taken when using short ultrasound sequences for identifying lung sliding as a mean of confirming endotracheal intubation, particularly in the left hemithorax. Emphasis should also be put on knowledge and identification of the Lung pulse artefact when teaching chest ultrasound curriculum.

Introduktion: Anestesisjuksköterskor arbetar inom flera olika delar av sjukvården. Tack vare deras kunskaper om luftvägar och omhändertagande av kritiskt sjuka patienter så anställs anestesisjuksköterskor inom olika prehospitala verksamheter så som exempelvis resursenheter. Vid plötsliga hjärtstopp är upprättandet av en fri luftväg kritiskt. Detta görs vanligen genom användandet av olika medicintekniska hjälpmedel som larynxmask eller endotrachealtub. De respektive hjälpmedlen har olika styrkor och svagheter som är väl studerade, men upplevelser av att använda dessa metoder finns det lite forskning om. Syfte: Syftet med studien var att studera anestesisjuksköterskans upplevelser av att använda larynxmask och endotrachealtub vid plötsliga hjärtstopp utanför sjukhuset. Metod: En kvalitativ induktiv enkätstudie med öppna semistrukturerade frågor genomfördes för att fånga användarnas upplevelser av skillnader mellan dessa metoder av luftvägshantering. 14 anestesisjuksköterskor med minst två års erfarenhet samt erfarenhet av att arbeta prehospitalt deltog i studien. Deltagarna arbetar i tre regioner vilka har stora skillnader i resurser och arbetsrutiner. Resultat: Larynxmask var mest använt, trots att nästan alla deltagare föredrog att ha patienten intuberad. Orsaken till att laynxmasken användes trots att deltagarna föredrog att patienten skulle ha en endotrachealtub varierade något men hade flera gemensamma faktorer så som tidsåtgång och enkel användning. / Introduction: Nurse anesthesias work in different parts of healthcare. In various prehospital activities and different resource units these specialist nurses are often hired for their knowledge of the airways and critical patients. In case of sudden cardiac arrest, the establishment of a free airway is critical. This is usually done using various medical aids such as a laryngeal mask or endotracheal tube. These have their different strengths and weaknesses that are well studied, but there is little research on experiences of using these methods. Aim: The aim of the study was to study anesthesia nurses' experiences of using a laryngeal mask and endotracheal tube in sudden cardiac arrest outside the hospital. Method: A qualitative inductive survey with open semistructural questions, was done to capture the users’ experiences of the differences between these methods of airway management. This study included 14 nurse anesthetists, with at least 2 years of experience and experience of working in a prehospital setting. Participants from three regions participated, those regions differ in resources and ways of working routines. Result: The laryngeal mask is most commonly used, even though almost all participants prefer to have an intubated patient. The reasons for that varies between the participants but have several common factors such as time of application and ease of use.

Bakgrund: Dagligen drabbas mer än 25 personer av hjärtstopp utanför sjukhus där ungefär 500 av dessa räddas årligen. Luftvägshanteringen är en av de viktigaste faktorerna under hjärt-och lungräddning och en obehandlad hypoxi i samband med hjärtstopp ökar risken för att patienten kan erhålla neurologiska skador. Enligt Erikssons omvårdnadsteori kan olika former av lidande upplevas, men när kroppen, själen och anden är i balans uppnås hälsa. För att hantera luftvägen kan ambulanspersonal använda sig utav mask-och blåsa eller larynxmask. Endotrakeal intubation är även ett alternativ, men kräver särskild kompetens i Sverige vilken främst specialistsjuksköterska inom anestesisjukvård innehar. Studier visar på en låg procentuell framgång för antal lyckade försök gällande utövandet av endotrakeal intubation prehospitalt och att larynxmask numera används i stället av ambulanspersonalenför att den kan appliceras snabbt och enkelt. Syfte: Syftet var att belysa om förekommande luftvägshjälpmedel vid hjärtstopp utanför sjukhus kan påverka patientens utfall vid återkomst av spontan cirkulation. Metod: Litteraturöversikt med systematisk ansats. Cinahl plus och PubMed har använts som databassökning. Totalt 15 artiklar av kvantitativ metod inkluderades. Artiklarna har därefter analyserats genom integrerad analys. Resultat: De signifikanta huvudfynden som framkom med var att luftvägshantering med mask-och blåsa påvisade en hög prevalens för gynnsamt neurologiskt utfall och överlevnad medan endotrakeal intubation påvisade en högre prevalens för återgång av spontan cirkulation. Slutsats: Utifrån resultatet visade sig användning av mask-och blåsa ge mest utdelning för att uppnå ett gynnsamt neurologiskt utfall och ökad chans till överlevnad för patienten. Däremot framkom det att användning av endotrakealtub vid prehospitalt hjärtstopp medförde störst chans till återkomst av spontan cirkulation. Av de tre förekommande luftvägshjälpmedlen att använda sig av vid prehospitalt hjärtstopp kan det förekomma skillnader i utfallet för patienten. Det förekommer däremot inte tillräckligt med stora skillnader och resultatet bördärmed tolkas med försiktighet då det anses behövas fler studier inom området. / Background: Every day more than 25 people suffer from out-of hospital cardiac arrest, of which approximately 500 rescued annually. Airway management is one of the most important factors in cardiopulmonary resuscitation and an untreated hypoxia in conjunction with cardiac arrest increases the patient’s risk of receiving neurological damage. According to Eriksson's nursing theory, various forms of suffering can be experienced, and a state of health can only be achieved when the body, soul and spirit are in balance. To manage the airway, the ambulance clinician can use a bag-valve mask or laryngeal mask. Endotracheal intubation is also an alternative, but in Sweden, it requires specific competence that mainly specialist nurses in anesthesia care possess. Studies shows a low success rate regarding the practice of performing a prehospital endotracheal intubation and that laryngeal mask nowadays more used instead by ambulance staff because it’s applied quickly and easily. Aim: The purpose was to shed light on whether the available respiratory aids in out-of-hospital cardiac arrest can affect the patient outcomes on the return of spontaneous circulation. Method: Literature overview with systematic approach. Cinahl plus and PubMed has been used as database search. A total of 15 articles of quantitative method were included. The articles were analyzed through integrated analysis. Results: The significant main findings that emerged were that airway management with bag-valve mask correlated with a high prevalence for favorable neurological outcome and survival while endotracheal intubation showed a higher prevalence for return of spontaneous circulation. Conclusion: Based on the results, the use of bag-valve mask found to be the best option to achieve a favorable neurological outcome and increased chance of survival for the patient. However, the use of endotracheal tube in out-ofhospital cardiac arrest for increasing the chance of the patient regaining return of spontaneous circulation. Out of the three available airway aids to use in out-of-hospital cardiac arrest, there may be differences in the outcome for the patient. However, there are not enough significant differences, and the result therefore should be interpreted with caution as it is considered that more studies in the subject required.

The continuous emergence of drug-resistance pathogens is a global concern. As a result, substantial effort is being expended to develop new therapeutics and mechanisms for controlling microbial growth to avoid entering a "post-antibiotic" era in which commonly used antibiotics are no longer effective in treating infections. In this work, we investigate the efficacy and application of ceragenins as non-peptide mimics of antimicrobial peptides (AMPs). First, this work examines the susceptibility of drug-resistant Gram-negative bacteria. The susceptibility of colistin-resistant clinical isolates of Klebsiella pneumoniae to ceragenins and AMPs suggests that there is little to no cross-resistance between colistin and ceragenins/AMPs. Furthermore, Lipid A modifications are found in bacteria with modest changes in susceptibility to ceragenins and with high levels of resistance to colistin. Next, we investigated the potential for cross resistance between chlorhexidine, colistin, AMPs and ceragenins as repeated exposure of bacteria to chlorhexidine might result in cross resistance with colistin, AMPs or ceragenins. Furthermore, a proteomics study on the chlorhexidine-resistant strains showed that chlorhexidine resistance is associated with upregulation of proteins involved in the assembly of LPS for outer membrane biogenesis and virulence factors in Pseudomonas aeruginosa.Second, this dissertation describes the antifungal activity of ceragenins against an emerging multidrug-resistant fungus, Candida auris. We found that lead ceragenins displayed activities comparable to known antifungal agents against C. auris isolates. We also found that fungal cell morphology was altered in response to ceragenin treatment, that ceragenins exhibited activity against sessile organisms in biofilms, and that gel and cream formulations including CSA-44 and CSA-131 resulted in a significant log reduction against established fungal infections in ex vivo mucosal tissues. Finally, a hydrogel film containing CSA-131 was generated on endotracheal tubes (ETTs). ETTs provide an abiotic surface on which bacteria and fungi form biofilms that cause serious infections. In this study, the eluting ceragenin prevented fungal and bacterial colonization of coated ETTs for extended periods while uncoated tubes were colonized by bacteria and fungi. Coated tubes were well tolerated in intubated pigs. The ability of ceragenins to eradicate established biofilms make them attractive potential therapeutics for persistent infections in the lung, including those associated with cystic fibrosis. In ex vivo studies, we initially found that this ceragenin, at concentrations necessary to eradicate established biofilms, also causes loss of cilia function. However, by formulating CSA-131 in poloxamer micelles, cilia damage was eliminated and antimicrobial activity was unaffected. These findings suggest that CSA-131, formulated in micelles, may act as a potential therapeutic for polymicrobial and biofilm-related infections in the lung and trachea.

A research report submitted in partial fulfilment of the requirements for the degree Master of Science in Medicine in the Field of Emergency Medicine in the Division of Emergency Medicine, University of the Witwatersrand / Introduction: Control over the patient bears time-critical importance in emergency medicine. In the entrapment situation after a Motor Vehicle Collision (MVC), emergency care including airway management may need to be initiated before extrication and thus with restricted access. Objective: This manikin study aimed at answering the question of which advanced airway device can be inserted the fastest and most reliably by paramedics in the simulated entrapped patient. Methods: Paramedics were asked to insert four airway devices (endotracheal tube with the Macintosh laryngoscope, endotracheal tube with the Airtraq® optical laryngoscope, Laryngeal Mask Airway - SupremeTM, and Laryngeal Tube Suction - DisposableTM) in randomised order into a manikin seated in the driver seat of a light motor vehicle. Time to first successful ventilation and number of attempts required for successful insertion were measured. Following each insertion, participants were asked by means of a questionnaire to rate the degree of insertion difficulty (scale 1 – 10) and provide reasons for this rating. Finally, participants were asked which device they preferred and why. Results: Prospectively collected data from 26 paramedics were analysed. The LMA-SupremeTM had the shortest mean time to first successful ventilation (16.7 seconds (CI [0.95]; 14.9 - 18.6)), followed by the LTS-DTM (19.4 seconds (CI [0.95]; 18.0 - 20.8)), ETI using the Macintosh laryngoscope (37.7 seconds (CI [0.95]; 31.8 - 43.5)) and ETI using the Airtraq® (41.2 seconds (CI [0.95]; 36.7 - 45.6)). Both face-to-face ETI with the Macintosh laryngoscope and the insertion of the LMA-SupremeTM had 100% first-attempt success. Five participants required a second attempt to successfully intubate the manikin using the Airtraq® and one participant had to re-insert the LTS-DTM for correct placement. In terms of insertion difficulty, the LMA-SupremeTM received the lowest mean score (1.7/10 (CI [0.95]; 1.2 - 2.1)) followed by the LTS-DTM (2.5/10 (CI [0.95]; 1.8 – 3.2)), face-to-face ETI using the Macintosh laryngoscope (3.7/10 (CI [0.95]; 2.9 - 4.5)), and ETI with the Airtraq® (4.5/10 (CI [0.95]; 3.7 - 5.3)). Most participants chose the Macintosh laryngoscope for ETI as their preferred device (10/26; 38%) followed closely by the LMA-SupremeTM (9/26; 35%). These participants stated clinical experience and ease of insertion respectively as the primary reasons for their preference. Conclusion: Besides ETI, Supraglottic Airway Devices are beneficial alternative airway devices to be considered by paramedics in the entrapped patient after a MVC. The LMA-SupremeTM was the fastest and least difficult airway device to insert. Face-to-face endotracheal intubation with the Macintosh laryngoscope remains an important definitive airway that was shown to be performed competently by participating paramedics. The Airtraq® can be used for face-to-face ETI and enables improved laryngoscopy.