The purpose of this study was to compare the cost-effectiveness between the 2 types of general anesthesia, namely, laryngeal mask (LMA) and endotracheal intubation (ETT). The study included 353 patients who received general anesthesia during operation in a medical center in Kaohsiung City. Of these, 183 patients were assigned to the LMA group, while the remaining 170 were assigned to the ETT group. The norm of cost adopted by this study was calculated as the average expense per hour incurred by using the anesthetic and hygienic materials for medicinal use. The indices of effectiveness were physical reactions that were tracked at 2 h and 8¡V10 h postoperatively; these indices were acute pain, dizzyness, sore throat, nausea, and vomiting. These 5 indices were rated on a scale of 0¡V10. A low score was considered to represent lesser side-effects and greater effectiveness of the anesthetic. Besides, the shorter the recovery time of the patient was, the higher the effectiveness would be. The conclusion showed that the cost of the average expense per hour produced by the anesthesia and hygienic materials of medicinal use in the LMA group was 531 dollars while in the ETT group was 1,017 dollars. In the LMA group, at 2 h postoperatively, the mean tracking score for acute pain was 2.9 ¡Ó 2.6; for dizzyness, 1.4 ¡Ó 1.9; for sore throat, 0.4 ¡Ó 1.1; for nausea, 0.5 ¡Ó 1.4; and for vomiting, 0.2 ¡Ó 0.9. In the LMA group, at 8¡V10 h postoperatively, the mean tracking score for acute pain was 0.9 ¡Ó 1.5; for dizzyness, 0.6¡Ó1.3; for sore throat, 0.2 ¡Ó 0.7; for nausea, 0.1 ¡Ó 0.6; and for vomiting, 0.07 ¡Ó 0.4. In the ETT group, at 2 h postoperatively, the mean tracking score for acute pain was 4.9 ¡Ó 3.2; for dizzyness, 2.6 ¡Ó 2.5; for sore throat, 2.0 ¡Ó 2.1; for nausea, 1.3 ¡Ó 2.4; and for vomiting, 0.7 ¡Ó 1.9. In the ETT group, at 8¡V10 h postoperatively, the mean tracking score for acute pain was 2.82¡Ó 2.5; for dizzyness, 1.9 ¡Ó 1.9; for sore throat, 1.3 ¡Ó 1.9; for nausea, 1.1 ¡Ó 2.1; and for vomiting, 0.7 ¡Ó 1.9. The mean postoperative recovery time of the patients in the LMA group was 11.5¡Ó13.2 min and that for the patients in the ETT group was 25.9¡Ó16.0 min. T-test was performed to examine the hypothesis that LMA is more cost-effective than ETT when the same variables as those mentioned above are used; the results of all variables support the hypothesis that the p-value of every index was .000. Results of stepwise regression showed that LMA plays a significant positive role in every cost-effectiveness index.

Endotracheal intubation is still the gold standard in airway management. For medical students and young professionals, it is often difficult to train personal skills. We tested a high-fidelity simulator with an additional quantitative feedback integration to elucidate if competence acquisition for airway management is increased by using this feedback method. In the prospective trial, all participants (n = 299; 4th-year medical students) were randomized into two groups—One had been trained on the simulator with additional quantitative feedback (n = 149) and one without (n = 150). Three simulator measurements were considered as quality criteria—The pressure on the upper front row of teeth, the correct pressure point of the laryngoscope spatula and the correct depth for the fixation of the tube. There were a total of three measurement time points—One after initial training (with additional capture of cognitive load), one during the exam, and a final during the follow-up, approximately 20 weeks after the initial training. Regarding the three quality criteria, there was only one significant difference, with an advantage for the control group with respect to the correct pressure point of the laryngoscope spatula at the time of the follow-up (p = 0.011). After the training session, the cognitive load was significantly higher in the intervention group (p = 0.008) and increased in both groups over time. The additional quantitative feedback of the airway management trainer brings no measurable advantage in training for endotracheal intubation. Due to the increased cognitive load during the training, simple airway management task training may be more efficient for the primary acquisition of essential procedural steps.

Bakgrund Endotrakeal intubation används i många olika situationer där det finns ett behov av att skapa en säker luftväg. Den manipulation av luftvägarna som krävs i samband med en intubation kan bland annat orsaka postoperativ halssmärta och heshet, vilket kan ha negativa konsekvenser för patienten. För att försöka undvika komplikationer vid intubering har det utvecklats olika intubationshjälpmedel, där ett av hjälpmedlen är videolaryngoskop, som minskar den kraft som behövs för att skapa en fri insyn i larynx. Syfte Syftet med studien var att jämföra Macintosh direktlaryngoskopi mot McGrath videolaryngoskopi, för att undersöka om någon av metoderna ger minskad förekomst av halssmärta och heshet postoperativt. Metod För att besvara syftet antogs en kvantitativ ansats. Studien utfördes sedan som en förberedande undersökning med en induktiv metod. Datainsamlingen utfördes på en operationsavdelning i Västra Götaland, totalt deltog 24 patienter, varav 12 patienter intuberades med direktlaryngoskopi och 12 patienter intuberades med videolaryngoskopi. Deltagarna fick postoperativt svara på validerade enkätfrågor, och gradera eventuell förekomst av halssmärta och heshet enligt validerade fyrgradiga skalor. Resultat Resultatet visade att det eventuellt kan finnas en viss skillnad gällande postoperativ halssmärta beroende på om man intuberas med Macintosh direktlaryngoskopi eller McGrath videolaryngoskopi. Presenterat i absoluta och relativa mått visar det på att endast 1 deltagare (8%) som videolaryngoskoperades graderade lindrig halssmärta postoperativt, medan det var 3 deltagare (25%) som direktlaryngoskoperades som graderade lindrig halssmärta. Dock var skillnaden inte signifikant (p=0,56). Skillnaderna gällande heshet var större, där 9 deltagare (75%) som videolaryngoskoperades graderade sig helt besvärsfria postoperativt och 3 (25%) graderade en lindrig heshet. Ingen av deltagarna som direktlaryngoskoperades graderade sig som besvärsfri postoperativt, 9 (75%) graderade lindrig heshet och 3 (25%) graderade måttlig heshet. Skillnaden mellan grupperna var signifikant (p=0,001). Slutsats Skillnad verkar föreligga gällande framför allt heshet beroende på vilken intubationsmetod som används. Det kan även finnas en eventuell skillnad gällande halssmärta, dock är denna ej signifikant i pilotstudiens resultat. Studiepopulationen är begränsad i sitt antal, och det finns få studier att jämföra resultatet med. Det finns ett behov av fler och större studier för att finna evidens för den bästa metoden. / Background Endotracheal intubation is used in many different situations where there is a need to create a safe airway. The airway manipulation force that is required when an endotracheal intubation is needed may cause postoperative sore throat and hoarseness. This can adversely affect the patient. To avoid complications of an endotracheal intubation, different intubation aids have been developed, one of which is a videolaryngoscope, which reduces the force needed to create a free laryngeal insight. Aim The purpose of the study was to compare Macintosh direct laryngoscopy to McGrath videolaryngoscopy, to investigate whether either method reduces the incidence of sore throat and hoarseness postoperatively. Method To answer the purpose, a quantitative approach was adopted. The study was then conducted as a preliminary study with an inductive method. The data collection was carried out in an operation theatre in Västra Götaland, Sweden. A total of 24 patients participated, where 12 patients were intubated with direct laryngoscopy and 12 patients with videolaryngoscopy. Postoperatively the participants responded to validated questionnaires, and evaluated any occurrence of sore throat and hoarseness according to validated four-dimensional scales. Result There was a difference in postoperative sore throat depending on intubation with Macintosh direct laryngoscopy or McGrath videolaryngoscopy. Presented in absolute and relative terms, the result show that only 1 participant (8%) that was intubated with videolaryngoscopy graded mild sore throat postoperatively, while there 3 participants (25%) who were intubated with the use of direct laryngoscopy graded mild sore throat. However, the difference was not significant (p=0.56). The differences in hoarseness were greater, where 9 participants (75%) that was intubated with the use of videolaryngoscopy graduated no hoarseness post-operatively and 3 (25%) graded a mild hoarseness. None of the participants who were intubated with the use of direct laryngoscopy graded no hoarseness, 9 (75%) participants graded mild hoarseness and 3 (25%) graded moderate hoarseness. The difference between the groups was significant (p=0.001). Conclusions A difference exists in advance of hoarseness depending on the intubation method that is used. There may also be a difference regarding sore throat, but this result remained non-significant. However, in this pilot study the population was limited in its number, and there are few other studies in this field available for comparison. Therefore, more, and larger studies are needed to find evidence for the best intubation method.

Pacientes internados em Unidade de Terapia Intensiva (UTI) intubados em ventilação mecânica podem apresentar uma higiene bucal inadequada, foco de colonização propício à pneumonia associada à ventilação mecânica (PAVM). Entretanto, o conhecimento sobre esse assunto é limitado, sendo frequente a ausência deste conteúdo na formação dos profissionais, razão pela qual, na prática clínica, muitas vezes, a higiene bucal não é priorizada. O uso de tecnologias educacionais possibilita à equipe de enfermagem buscar conhecimento, a fim de melhorar a assistência ao paciente crítico. As diferentes maneiras de pensar o cuidado oral avançam para a aplicação de referenciais teórico-conceituais e de taxonomias, na prática clínica, no ensino de enfermagem e na pesquisa, garantindo efetivamente a aplicação do Processo de Enfermagem. Objetivo: Propor um objeto de aprendizagem, vídeo educativo, para o cuidado oral de pacientes entubados em ventilação mecânica, para a equipe de enfermagem. Método: pesquisa de desenvolvimento de objeto de aprendizagem, estudo metodológico de delineamento transversal. Adotou-se como referencial teórico os pressupostos de Vygotsky. A proposta de construção do vídeo educativo está fundamentada na literatura e constou das seguintes fases: Fase 1 pré-produção, Fase II produção e Fase III pós- produção. A estrutura do vídeo foi baseada no modelo científico do cuidar, por meio do Processo de Enfermagem e a aplicação dos sistemas de classificações NANDA-I ®, NOC e NIC. Análise: constou de duas fases: síntese da revisão integrativa e análise descritiva da validação do roteiro/script e storyboard de três peritos. O projeto foi aprovado pelo Comitê de Ética em Pesquisa conforme Resolução 466/2012. Resultado: a construção do vídeo educativo constou das seguintes fases: I Pré-produção: construção do roteiro / script e storyboard; II Produção: validação do roteiro / script e storyboard, ensaio com os atores, filmagem das cenas, desenvolvimento de imagens, narração / gravação de áudio; III Pós-produção: edição. A construção do vídeo foi fundamentada no modelo científico do cuidar em enfermagem e proporcionou a estrutura de compreensão, para a dinâmica das fases do Processo de Enfermagem e classificação da linguagem NANDA-I ®, NOC e NIC. Uma revisão integrativa da literatura sobre o tema \"cuidado oral do paciente adulto entubado em ventilação mecânica\" foi realizada e assegurou que a construção do roteiro/script e storyboard estejam atualizadas, com base em evidência científica. Os artigos foram agrupados de acordo com o nível de evidência, sendo: cinco estudos do nível II, um do nível IV, nove do nível VI e um nível VII. A edição do vídeo foi feita por um técnico áudio-visual e pesquisador; foi utilizado software Adobe ® Premiere; finalizado em 18 minutos de gravação. Conclusão: o vídeo educativo para o cuidado oral de pacientes intubado em ventilação mecânica pode proporcionar a equipe de enfermagem conhecimento científico capaz de modificar seu comportamento, por meio da educação crítica e reflexiva. Este estudo pode contribuir para o desenvolvimento de protocolos de higiene oral e assim, contribuir com estratégias para reduzir a incidência de PAVM na UTI. Os passos adotados na construção do vídeo educativo mostraram-se adequados e passíveis de serem utilizados em diversas temáticas / Hospitalized patients in Intensive Care Units (ICU) intubated for mechanical ventilation may be subject to inadequate oral hygiene, a colonization focus conducive to ventilator-associated pneumonia (VAP). However, the knowledge on this subject is limited as professional training often lacks such topic, which often leads, in clinical practice, to oral hygiene being neglected.The use of educational technology could enable the nursing staff to gain the knowledge to improve the care of critically ill patients. The different approaches to oral care have advanced to the application of theoretical and conceptual frameworks and taxonomies, both in clinical practice and in nursing education and research, effectively ensuring the application of the nursing process. Objective: To propose a learning tool, consisting of an educational video that teaches the nursing staff the oral care of intubated patients receiving mechanical ventilation. Method: To research the development of a learning tool through a methodological cross-sectional study with the assumptions of Vygotsky being adopted as the theoretical reference. The proposal to make an educational video was based on the literature and consisted of three phases: Phase 1 - Pre-production; Phase 2 - Production; and Phase 3 - Post-production. The structure of the educational video was based on the scientific model of care through the nursing process and the implementation of NANDA-I ®, NOC and NIC classification systems. Analysis: Consisted of two phases: A summary of the integrative review and a descriptive analysis of three experts on the validation of the script and storyboard. The project was approved by the Research Ethics Committee according to Resolution 466/2012. Results: The production of the educational video consisted of three phases: Phase 1 - Pre-production: Development of the script and storyboard; Phase 2 - Production: Validation of the script and storyboard, actors rehearsal, shooting the scenes, image development, recording of the audio and narrative; Phase 3 - Post-production: Editing. The production of the educational video was based on the scientific model of nursing care and provided a structure to understand the dynamics of the phases in the nursing process and the NANDA-I®, NOC and NIC classification systems. An integrative review of the literature on the topic of oral care of intubated adult patients receiving mechanical ventilation was performed and assured that the development of the script and storyboard is updated and based on scientific evidence. The articles were grouped according to the level of evidence, as follows: five level 2 studies; one level 4 study; nine level 6 studies and one level 7 study. The editing was executed by a video and audio technician and researcher. The \"Adobe ® Premiere ®\" software was used, resulting in an 18-minute-long video. Conclusion: The educational video of the oral care of intubated adult patients receiving mechanical ventilation can provide the nursing staff with scientific knowledge able to change their behavior through critical and thoughtful education. This study can contribute to the development of oral hygiene protocols and strategies to reduce the incidence of VAP in the ICU. The steps taken to produce the educational video are applicable to several other themes

Pacientes internados em Unidade de Terapia Intensiva (UTI) intubados em ventilação mecânica podem apresentar uma higiene bucal inadequada, foco de colonização propício à pneumonia associada à ventilação mecânica (PAVM). Entretanto, o conhecimento sobre esse assunto é limitado, sendo frequente a ausência deste conteúdo na formação dos profissionais, razão pela qual, na prática clínica, muitas vezes, a higiene bucal não é priorizada. O uso de tecnologias educacionais possibilita à equipe de enfermagem buscar conhecimento, a fim de melhorar a assistência ao paciente crítico. As diferentes maneiras de pensar o cuidado oral avançam para a aplicação de referenciais teórico-conceituais e de taxonomias, na prática clínica, no ensino de enfermagem e na pesquisa, garantindo efetivamente a aplicação do Processo de Enfermagem. Objetivo: Propor um objeto de aprendizagem, vídeo educativo, para o cuidado oral de pacientes entubados em ventilação mecânica, para a equipe de enfermagem. Método: pesquisa de desenvolvimento de objeto de aprendizagem, estudo metodológico de delineamento transversal. Adotou-se como referencial teórico os pressupostos de Vygotsky. A proposta de construção do vídeo educativo está fundamentada na literatura e constou das seguintes fases: Fase 1 pré-produção, Fase II produção e Fase III pós- produção. A estrutura do vídeo foi baseada no modelo científico do cuidar, por meio do Processo de Enfermagem e a aplicação dos sistemas de classificações NANDA-I ®, NOC e NIC. Análise: constou de duas fases: síntese da revisão integrativa e análise descritiva da validação do roteiro/script e storyboard de três peritos. O projeto foi aprovado pelo Comitê de Ética em Pesquisa conforme Resolução 466/2012. Resultado: a construção do vídeo educativo constou das seguintes fases: I Pré-produção: construção do roteiro / script e storyboard; II Produção: validação do roteiro / script e storyboard, ensaio com os atores, filmagem das cenas, desenvolvimento de imagens, narração / gravação de áudio; III Pós-produção: edição. A construção do vídeo foi fundamentada no modelo científico do cuidar em enfermagem e proporcionou a estrutura de compreensão, para a dinâmica das fases do Processo de Enfermagem e classificação da linguagem NANDA-I ®, NOC e NIC. Uma revisão integrativa da literatura sobre o tema \"cuidado oral do paciente adulto entubado em ventilação mecânica\" foi realizada e assegurou que a construção do roteiro/script e storyboard estejam atualizadas, com base em evidência científica. Os artigos foram agrupados de acordo com o nível de evidência, sendo: cinco estudos do nível II, um do nível IV, nove do nível VI e um nível VII. A edição do vídeo foi feita por um técnico áudio-visual e pesquisador; foi utilizado software Adobe ® Premiere; finalizado em 18 minutos de gravação. Conclusão: o vídeo educativo para o cuidado oral de pacientes intubado em ventilação mecânica pode proporcionar a equipe de enfermagem conhecimento científico capaz de modificar seu comportamento, por meio da educação crítica e reflexiva. Este estudo pode contribuir para o desenvolvimento de protocolos de higiene oral e assim, contribuir com estratégias para reduzir a incidência de PAVM na UTI. Os passos adotados na construção do vídeo educativo mostraram-se adequados e passíveis de serem utilizados em diversas temáticas / Hospitalized patients in Intensive Care Units (ICU) intubated for mechanical ventilation may be subject to inadequate oral hygiene, a colonization focus conducive to ventilator-associated pneumonia (VAP). However, the knowledge on this subject is limited as professional training often lacks such topic, which often leads, in clinical practice, to oral hygiene being neglected.The use of educational technology could enable the nursing staff to gain the knowledge to improve the care of critically ill patients. The different approaches to oral care have advanced to the application of theoretical and conceptual frameworks and taxonomies, both in clinical practice and in nursing education and research, effectively ensuring the application of the nursing process. Objective: To propose a learning tool, consisting of an educational video that teaches the nursing staff the oral care of intubated patients receiving mechanical ventilation. Method: To research the development of a learning tool through a methodological cross-sectional study with the assumptions of Vygotsky being adopted as the theoretical reference. The proposal to make an educational video was based on the literature and consisted of three phases: Phase 1 - Pre-production; Phase 2 - Production; and Phase 3 - Post-production. The structure of the educational video was based on the scientific model of care through the nursing process and the implementation of NANDA-I ®, NOC and NIC classification systems. Analysis: Consisted of two phases: A summary of the integrative review and a descriptive analysis of three experts on the validation of the script and storyboard. The project was approved by the Research Ethics Committee according to Resolution 466/2012. Results: The production of the educational video consisted of three phases: Phase 1 - Pre-production: Development of the script and storyboard; Phase 2 - Production: Validation of the script and storyboard, actors rehearsal, shooting the scenes, image development, recording of the audio and narrative; Phase 3 - Post-production: Editing. The production of the educational video was based on the scientific model of nursing care and provided a structure to understand the dynamics of the phases in the nursing process and the NANDA-I®, NOC and NIC classification systems. An integrative review of the literature on the topic of oral care of intubated adult patients receiving mechanical ventilation was performed and assured that the development of the script and storyboard is updated and based on scientific evidence. The articles were grouped according to the level of evidence, as follows: five level 2 studies; one level 4 study; nine level 6 studies and one level 7 study. The editing was executed by a video and audio technician and researcher. The \"Adobe ® Premiere ®\" software was used, resulting in an 18-minute-long video. Conclusion: The educational video of the oral care of intubated adult patients receiving mechanical ventilation can provide the nursing staff with scientific knowledge able to change their behavior through critical and thoughtful education. This study can contribute to the development of oral hygiene protocols and strategies to reduce the incidence of VAP in the ICU. The steps taken to produce the educational video are applicable to several other themes

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.

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.

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.

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.

Introduction: The most appropriate airway management technique for use by paramedics in out-of-hospital cardiac arrest is yet to be determined and evidence relating to the influence of airway management strategy on outcome remains equivocal. In cases where return of spontaneous circulation (ROSC) occurs following out-of-hospital cardiac arrest, patients may undergo direct transfer to a specialist heart attack centre (HAC) where the post resuscitation 12 lead ECG demonstrates evidence of ST elevation myocardial infarction. To date, no studies have investigated the role of airway management strategy on outcomes in this sub-set of patients. The AMICABLE (Airway Management In Cardiac Arrest, Basic, Laryngeal mask airway, Endotracheal intubation) study therefore sought to investigate the influence of prehospital airway management strategy on outcomes in patients transferred by the ambulance service directly to a HAC post ROSC. Methods: Adults with ROSC post out-of-hospital cardiac arrest who met local criteria for transfer to a HAC were identified prospectively. Ambulance records were reviewed to determine prehospital airway management approach and collect physiological and demographic data. HAC notes were obtained to determine in-hospital course and quantify neurological outcome via the Cerebral Performance Category (CPC) scale. Neurologically intact survivors were contacted post discharge to assess quality of life via the SF-36 health survey. Statistical analyses were performed via Chi-square, Mann Whitney U test, odds ratios, and binomial logistic regression. Results: A total of 220 patients were recruited between August 2013 and August 2014, with complete outcome data available for 209. The age of patients ranged from 22-96 years and 71.3% were male (n=149). Airway management was undertaken using a supraglottic airway (SGA) in 72.7% of cases (n=152) with the remainder undergoing endotracheal intubation (ETI). There was no significant difference in the proportion of patients with good neurological outcome (CPC 1&2) between the SGA and ETI groups (p=.286). Similarly, binomial logistic regression incorporating factors known to influence outcome demonstrated no significant difference between the SGA and ETI groups (Adjusted OR 0.725, 95% CI 0.337-1.561). Clinical and demographic variables associated with good neurological outcome included the presence of a shockable rhythm (p < .001), exposure to angiography (p < .001), younger age (p < .001) and shorter time to ROSC (p < .001). Due to an inadequate response rate (25.4%, n=15) analysis of SF36 data was limited to descriptive statistics. Limitations: The study only included patients who achieved ROSC and met the criteria for direct transfer to a HAC. Results are therefore not generalisable to more heterogenous resuscitation populations. Accuracy of clinical decision making and ECG interpretation were not assessed and therefore some patients included in the study may have been inappropriately transferred to a HAC. The low SF-36 survey response rate limited the level of neurological outcome analysis that could be undertaken. Conclusion: In this study, there was no significant difference in the proportion of good neurological outcomes in patients managed with SGA versus ETI during cardiac arrest. Further research incorporating randomised controlled trials is required to provide more definitive evidence in relation to the optimal airway management strategy in out-of-hospital cardiac arrest.