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Thesis (MMed)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Case Report - A case is described of central oxygen pipeline failure that occurred at a large academic hospital and its subsequent implications for managing the situation. Literature review - The literature review undertaken focused on the current state of affairs with regards to anaesthetic staff's knowledge of and preparedness for the management implications of central oxygen pipeline failure. The events I describe below demonstrate a significant deficiency in the staff’s understanding of and training for the crisis, which should be remedied to improve patient safety. Specific measures are suggested in the literature to prevent such incidents and guidelines are available to manage central oxygen pipeline failure. These are reviewed in this study. Recommendations - This study attempts to bring together the most critical aspects that need to be addressed to safely manage similar future incidents. Prevention should include measures to implement clearly stated disaster management plans and increased awareness with regards to the medical gas pipeline system (MGPS), simulation training, efficient alarm systems, personally conducted routine evaluations of equipment and emergency backup systems by anaesthesiologists and effective communication between hospital staff. Careful planning and successful coordination during maintenance and modification of the medical gas pipeline system, using piston-type or air-driven, rather than oxygen-driven, ventilators and optimal design of the hospital bulk oxygen system can contribute to reduce risks. In the event of central oxygen pipeline failure a specific sequence of actions should be taken by the anaesthesiologist and a clear institutional operational policy is described. / AFRIKAANSE OPSOMMING: Gevalsbeskrywing - 'n Geval van sentrale suurstoftoevoerversaking, wat plaasgevind het by 'n groot opleidingshospitaal, word bespreek. Daar word ook gekyk na die praktiese gevolge met betrekking tot die hantering van die situasie. Literatuurstudie - 'n Literatuurstudie is aangepak met die doel om te fokus op die huidige toedrag van sake betreffende narkosepersoneel se kennis en paraatheid in die hantering van sentrale suurstoftoevoerversaking. 'n Wesenlike gebrek aan begrip en opleiding aangaande hierdie onderwerp is geïdentifiseer – areas wat, met die nodige aandag, verbeter kan word ten einde die welstand van pasiënte te verseker. Spesifieke voorkomende maatreëls en hanteringsriglyne word voorgestel deur die literatuur en word gevolglik hersien in hierdie studie. Aanbevelings - Hierdie studie poog om kernaspekte aan te raak ten einde soortgelyke toekomstige voorvalle veilig en optimaal te kan hanteer. Voorkomende maatreëls behels onder meer die daarstelling van duidelik verstaanbare noodplanne, verbeterde bewustheid aangaande die mediese gaspypsisteem, simulasie-opleiding, doeltreffende alarmstelsels, effektiewe kommunikasie tussen hospitaalpersoneel, sowel as narkotiseurs wat self roetine-evaluasies van hul narkosetoebehore en -noodtoerusting uitvoer. Noukeurige beplanning en neweskikking tydens herstelwerk of werk aan die mediese gaspypsisteem, die gebruik van suierventilators (of dan lugaangedrewe in plaas van suurstofaangedrewe ventilators) en die optimale uitleg van 'n hospitaal se suurstoftoevoer, kan bydra om die risiko's te beperk. In die geval van sentrale suurstoftoevoerversaking behoort die narkotiseur stapsgewyse aksie te neem. 'n Duidelike institusionele noodbeleid word ook omskryf.

Orientador: José Roberto Fioretto / Banca: Eduardo Mekitariam filho / Banca: Marcelo Braciela Brandão / Banca: Mário ferreira Carpi / Banca: Regina Grigoli César / Resumo: Comparar os efeitos agudos do óxido nítrico inalatório (Noi) sobre a oxigenação durante ventilação oscilatória de alta frequência (VAF) e ventilação mecânica convencional (VMC) em crianças com insuficiência respiratória hipoxêmica aguda (IRHA). Crianças com IRHA, com idade entre 1 mês e 14 anos, em VMC com pressão expiratória final positiva (PEEP) maior ou igual a 10cmH2O foram aleatorizadas para VMC (GVMC, n=14) ou VAF (GVAF, n=14), em estudo randomizado e cruzado. Foram registrados índices de oxigenação e variáveis hemodinâmicas à inclusão (Tind), 1 hora após iniciar VMC (T0) e a cada 4h (T4...T24). A relação PaO2/FiO2 aumentou significantemente depois de 4 horas comparada com a inclusão em ambos os grupos [(GVMC- Tind: 111,95 ± 37 < T4h: 143,88 ± 47,5mmHg, p<0,05; GVAF- Tind: 123,76 ± 33 < T4h: 194,61 ± 62,42mmHg, p<0,05)], sem diferença estatística entre eles. Em T8h, a relação PaO2/FiO2 foi maior no GVAF comparado com GVMC (GVAF: 227,9 ± 80,7 > GVMC: 171,21 ± 52,9mmHg, p < 0,05). A FiO2 pode ser reduzida após 4h no GVAF ( GVAF- T4h: 0,53 ± 0,09 < Tind: 0,64 ± 0,2; P < 0,05), mas somente após 8 horas no GVMC. Comparando os grupos em T8h, observou-se que a diminuição da FiO2 foi maior para o GVAF (GVAF: 0,47 ± 0,06 < GVMC: 0,58 ± 0,1; p < 0,05). Tanto a VAF como VMC, associadas com a administração precoce de NOi, melhoram a oxigenação. A VAF possibilita redução da FiO2 e aumento da relação PaO2/FiO2 mais precoces quando comparada com VMC, em 8h. Entretanto, ao final de 24h de observação, não houve diferença significante na melhora clínica devido a aplicação da VAF associada com NOi quando comparada com VMC associada com o gás. Nossos resultados precisam ser confirmados por uma base mais ampla de casos em estudo randomizado / Abstract: To compare the acute oxygenation effects of high-frequency oscillatory ventilation (HFOV) plus inhaled nitric oxide (iNO) with conventional mechanical ventilation (CMV) plus iNO in acute hypoxemic respiratory failure (AHRF) children. Children with AHRF, aged between 1 month and 14 years under CMV with PEEP ≥ 10 cmH2O were randomly assigned to CMV (CMVG, n = 14) or HFOV (HFVG, n = 14) in a crossover design. Oxygenation indexes and hemodynamic variables were recorded at enrollment (Tind), 1 hr after CMV start (T0) and then every 4 hr (T4h, etc.). PaO2/FiO2 significantly increased after 4 hr compared to enrollment in both groups [(CMVG -Tind: 111.95 ± 37 < T4h: 143.88 ± 47.5 mmHg, p < 0.05; HFVG-Tind: 123.76 ± 33 < T4h:194.61± 62.42 mmHg, p < 0.05)] without statistical differences between groups. At T8h, PaO2/FiO2 was greater for HFVG compared with CMVG (HFVG: 227.9 ± 80.7 > CMVG: 171.21 ± 52.9 mmHg, p < 0.05). FiO2 could be significantly reduced after 4 hr for HFVG (HFVG-T4h: 0.53 ± 0.09 < Tind: 0.64 ± 0.2; P < 0.05) but only after 8 hr for CMVG. Comparing groups at T8h, it was observed that FiO2 decrease was greater for HFVG (HFVG: 0.47 ± 0.06 < CMVG: 0.58 ± 0.1; p < 0.05). CBoth ventilatory techniques with iNO improve oxygenation. HFOV causes earlier FiO2 reduction and increased PaO2/FiO2 ratio compared to CMV at 8 hr. However, at the end of the protocol, there was no significant difference and no clinical improvement derived from the application of both ventilatory strategies with iNO. It is not possible to say what would have happened if a different conventional ventilatory mode had been used, given the fact that our study has a limited number of patients included in each group / Doutor

In spite of the substantial repository of literature about respirators, little is known about the practicalities of their use. The focus of this research was about the practical aspects of using respirators in New South Wales workplaces. Two self-administered postal surveys were used to assess the level of implementation of respirator programs in 1996 and 2001. After five years, six elements improved. The most improvement was seen in the area of documentation including written procedures, keeping training records, recording respirator tasks, and maintenance records. The second survey investigated respirator maintenance and found little automated cleaning. Thorough washing was scarce with more than 50% of organisations relying on moist towelettes. For the third portion of the research methodology 485 used, half facepiece reusable respirators from 36 different sites were examined to determine the most common respirator defects. Maintenance and cleaning procedures were primitive and probably inadequate. Disinfection or sanitisation was common practice indicating concern about infectious diseases. The 2001 survey found that physical inspection of respirators in the workplace usually checked for the common types of defects found in the examination of used respirators. Weight, breathing resistance, heat and tightness were reported as causes of discomfort. The key outcomes from the research were that respirator programs were poorly implemented in a group of organisations that were expected to have more expertise than most and that the most common defects could be corrected by good respirator cleaning programs. / Doctor of Philosphy (PhD)

Made available in DSpace on 2014-06-11T19:32:12Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-09-25Bitstream added on 2014-06-13T21:03:37Z : No. of bitstreams: 1 000739125.pdf: 8253955 bytes, checksum: 0020aaeb461490f20e4ed55bb6a089f5 (MD5) / Comparar os efeitos agudos do óxido nítrico inalatório (Noi) sobre a oxigenação durante ventilação oscilatória de alta frequência (VAF) e ventilação mecânica convencional (VMC) em crianças com insuficiência respiratória hipoxêmica aguda (IRHA). Crianças com IRHA, com idade entre 1 mês e 14 anos, em VMC com pressão expiratória final positiva (PEEP) maior ou igual a 10cmH2O foram aleatorizadas para VMC (GVMC, n=14) ou VAF (GVAF, n=14), em estudo randomizado e cruzado. Foram registrados índices de oxigenação e variáveis hemodinâmicas à inclusão (Tind), 1 hora após iniciar VMC (T0) e a cada 4h (T4...T24). A relação PaO2/FiO2 aumentou significantemente depois de 4 horas comparada com a inclusão em ambos os grupos [(GVMC- Tind: 111,95 ± 37 < T4h: 143,88 ± 47,5mmHg, p<0,05; GVAF- Tind: 123,76 ± 33 < T4h: 194,61 ± 62,42mmHg, p<0,05)], sem diferença estatística entre eles. Em T8h, a relação PaO2/FiO2 foi maior no GVAF comparado com GVMC (GVAF: 227,9 ± 80,7 > GVMC: 171,21 ± 52,9mmHg, p < 0,05). A FiO2 pode ser reduzida após 4h no GVAF ( GVAF- T4h: 0,53 ± 0,09 < Tind: 0,64 ± 0,2; P < 0,05), mas somente após 8 horas no GVMC. Comparando os grupos em T8h, observou-se que a diminuição da FiO2 foi maior para o GVAF (GVAF: 0,47 ± 0,06 < GVMC: 0,58 ± 0,1; p < 0,05). Tanto a VAF como VMC, associadas com a administração precoce de NOi, melhoram a oxigenação. A VAF possibilita redução da FiO2 e aumento da relação PaO2/FiO2 mais precoces quando comparada com VMC, em 8h. Entretanto, ao final de 24h de observação, não houve diferença significante na melhora clínica devido a aplicação da VAF associada com NOi quando comparada com VMC associada com o gás. Nossos resultados precisam ser confirmados por uma base mais ampla de casos em estudo randomizado / To compare the acute oxygenation effects of high-frequency oscillatory ventilation (HFOV) plus inhaled nitric oxide (iNO) with conventional mechanical ventilation (CMV) plus iNO in acute hypoxemic respiratory failure (AHRF) children. Children with AHRF, aged between 1 month and 14 years under CMV with PEEP ≥ 10 cmH2O were randomly assigned to CMV (CMVG, n = 14) or HFOV (HFVG, n = 14) in a crossover design. Oxygenation indexes and hemodynamic variables were recorded at enrollment (Tind), 1 hr after CMV start (T0) and then every 4 hr (T4h, etc.). PaO2/FiO2 significantly increased after 4 hr compared to enrollment in both groups [(CMVG -Tind: 111.95 ± 37 < T4h: 143.88 ± 47.5 mmHg, p < 0.05; HFVG-Tind: 123.76 ± 33 < T4h:194.61± 62.42 mmHg, p < 0.05)] without statistical differences between groups. At T8h, PaO2/FiO2 was greater for HFVG compared with CMVG (HFVG: 227.9 ± 80.7 > CMVG: 171.21 ± 52.9 mmHg, p < 0.05). FiO2 could be significantly reduced after 4 hr for HFVG (HFVG-T4h: 0.53 ± 0.09 < Tind: 0.64 ± 0.2; P < 0.05) but only after 8 hr for CMVG. Comparing groups at T8h, it was observed that FiO2 decrease was greater for HFVG (HFVG: 0.47 ± 0.06 < CMVG: 0.58 ± 0.1; p < 0.05). CBoth ventilatory techniques with iNO improve oxygenation. HFOV causes earlier FiO2 reduction and increased PaO2/FiO2 ratio compared to CMV at 8 hr. However, at the end of the protocol, there was no significant difference and no clinical improvement derived from the application of both ventilatory strategies with iNO. It is not possible to say what would have happened if a different conventional ventilatory mode had been used, given the fact that our study has a limited number of patients included in each group

Medical certification of workers for respirator use is an important activity of occupational medicine health professionals. Spirometry is a diagnostic tool to evaluate respiratory distress/insufficiency that may affect respirator use. In this study, we analyzed the pulmonary function data of 337 workers from different occupations which required medical evaluation to wear a respirator. The American Thoracic Society and National Fire Protection Association criteria were used to evaluate employees. Of 337 workers who were cleared for respiratory use on the basis of medical questionnaires for respirator compliance, 14 (4.15%) failed to pass respirator compliance on the basis of NFPA criteria and 5 (1.48%) failed to pass respirator compliance criteria on the basis of ATS criteria. We compared the use of different Spirometric equations to evaluate these criteria and we found the Crapo equation cleared more workers for respirator use as compared to the Knudson and NHANES III equations. We also measured repeated Forced Expiratory Volume in 1st Second (FEV1) and Forced Vital Capacity (FVC) and compared the results longitudinally over time. Age was the only significant factor affecting the reduction in the lung function in longitudinal analysis. Longitudinal spirometry results suggested that workers were protected while using a respirator in the workplace, but age is the significant factor in reducing their lung function. As some workers were able to qualify for respirator use based on questionnaire alone but failed respirator clearance subsequent to pulmonary function testing, it is recommended that spirometry be used to evaluate clearance for all workers who will use a respirator in the workplace. As well, using different Spirometric equations can affect the outcome on passing or failing clearance for respirator use, and this should be considered in a respiratory medical certification program.

M.Cur. / Neonates born with respiratory distress require supplementary oxygen. In some cases it is necessary to ventilate these neonates in order to obtain adequate tissue oxygenation. Due to the potential complications of mechanical ventilation it is necessary to extubate the neonate as soon as possible after intubation and administer supplementary oxygen by an alternate method. Any form of oxygen therapy carries the risk of oxygen toxicity. It is therefore essential that the method of oxygen therapy opted for after extubation will result in the infant being weaned in the shortest time possible. In the two NICUs from which the sample was taken for this study, neonates are currently extubated and placed either in a head box, on nasal CP AP or on a nasal cannula, these being the methods used to administer oxygen to a neonate. The decision regarding the method of choice is currently directed by customary practices rather than physiological variables as indicators/criteria of effectiveness. The questions that arise from the research problem are as follows: • Which physiological variables should be considered when faced with the decision regarding the method of oxygen therapy to initiate after extubation of a neonate? • Are there any differences in the effectiveness of the two methods of oxygen therapy, namely headbox and nasal cannula, after extubation of a neonate? The purpose of this study was to compare two methods of oxygen therapy, after extubation of the neonate with respiratory distress syndrome, in an attempt to formulate guidelines; based on physiological variables as criteria/indicators of effectiveness. After analyzing the data, as described in Chapter 4, it became evident that it would not be possible to formulate guidelines. Therefore only a comparison was done between the two methods of oxygen therapy (headbox and nasal cannula,) based on both biographical and physiological variables as criteria/indicators, to determine whether there were any significant differences in the effectiveness of the two methods after extubation of the neonate.

Mechanical ventilation (MV) is one of the most frequently used treatment modalities in the intensive care unit (ICU) (Burns, 2005:14). Up to 90% of critically ill patients in ICUs globally are connected to a mechanical ventilator. Although mechanical ventilation is a lifesaving intervention, it is expensive and is associated with diverse complications (Mclean, Jensen, Schroeder, Gibney & Skjodt, 2006: 299). Ventilator-associated pneumonia (VAP) accounts for 25% of all infections in ICU, with global crude mortality figures estimated at 20-70% (Craven, 2006:251). Minimising the time that a patient is connected to a mechanical ventilator to the absolute minimum can have considerable benefits in terms of decreased mortality and morbidity, as well as a decreased length of ICU stay and lower hospital costs. Critically ill patients therefore need to be weaned from the mechanical ventilator as soon as their condition that warranted the need for mechanical ventilation is stabilized. The process of weaning the critically ill patient from mechanical ventilation constitutes a significant proportion of total ventilator time. As professional nurses attend to the mechanically ventilated patient 24 hours a day, they have a vital role to play in the collaborative management of the patient requiring weaning from mechanical ventilation. The objectives of this study were to explore and describe the professional nurses’ knowledge regarding weaning the critically ill patient from mechanical ventilation. Based on the results, recommendations in the form of a protocol were made in order to improve the professional nurses’ knowledge and enhance the care of the mechanically ventilated patient. A quantitative design, which was exploratory, descriptive and contextual in nature, was utilised for the study. The data collection instrument of choice was a self-administered questionnaire. Convenience, non-probability sampling was the sampling method chosen for the purpose of this study. Collected data were analysed with the assistance of a statistician using descriptive and inferential statistics. Results were displayed in the form of graphs and tables. The results obtained in the study, combined with data from the literature review, were used to develop recommendations to enhance vi professional nurses’ knowledge regarding weaning the critically ill patient from mechanical ventilation. The recommendations were presented in the form of a protocol based on the available evidence. Ethical principles as they relate to conducting research were adhered to throughout the study.

Background: Spinal Cord Injuries (SCIs) are traumatic, life-changing injuries that can affect every aspect of an individual's life and can lead to death if not treated timeously and appropriately. Respiratory complications occur frequently after the SCI and are the leading cause of mortality and morbidity. Respiratory complications are predictable based on the neurological level of impairment of the spinal cord lesion; the higher the neurological injury, the more severe the respiratory complication. Changes in pulmonary function, poor cough, hypersecretion, immobility and bronchospasm all contribute to the development of respiratory complications. If the patient is unable to protect his/her airway or if respiratory failure occurs, mechanical ventilation is often required. Many patients require prolonged ventilation and subsequently need to go for tracheostomies. The critical care nurse plays an important role in the early identification of complications and can, therefore, act to limit and prevent these complications, which may be a direct result from the injury or treatment modality such as mechanical ventilation. Respiratory management has been promoted in preventing and treating respiratory complications and is associated with better prognosis in the SCI patient. Design and method: The research study aims to explore and describe existing literature and to make recommendations for the respiratory management of a mechanically ventilated spinal cord injured patient in a critical care unit (CCU). A systematic review was undertaken with clear inclusion and exclusion criteria. Ethical principles were maintained throughout the study. The quality of the study was ensured by critically appraising data that was utilized in the systematic review. It is envisaged that the results from this systematic review will improve the respiratory management of the SCI patient and prevent any variations in practice. Results: Were presented under the following themes: priorities of care for the SCI patient in the acute phase, during the critical care phase and preventative care. Conclusion: The SCI patient regardless of the neurological level or completeness of injury should be admitted to the CCU for intensive ventilatory, cardiopulmonary support and hemodynamic monitoring in order to detect and prevent respiratory complications. The use of larger tidal volumes is associated with improved comfort and less dyspnea however if a patient has acute lung injury or ARDS the use of low tidal volumes 6ml/kg is recommended. Prevention and early identification of respiratory complications is associated with improved outcomes for the SCI patient.

Methicillin-resistant Staphylococcus aureus (MRSA) was originally recognized as a hospital acquired infection. However, it is now recognized that MRSA infections are frequently acquired in the community setting as well. As epidemiological studies and surveillance of MRSA continued over the past decade, agricultural sources of MRSA have also been recognized. Although direct person-to-person transmission of MRSA has been recognized as a major known route of transmission, a preliminary study has shown that aerosol exposures may also be an important mechanism of transmission, both occupationally to workers inside animal feeding operations and environmentally via exhaust ventilation to the outside e. In this study I aimed to 1) determine the concentration of viable MRSA inside and outside swine buildings known to be positive for MRSA, 2) determine the efficiency of the N95 respirator at protecting workers inside swine buildings, and 3) determine the efficiency of a biofilter unit at mitigating emissions of MRSA from a swine building. I hypothesize that remediation and control of airborne MRSA in animal feeding operations can be achieved by the appropriate use of N-95 respirators to protect workers and the addition of biofilters to the exhaust ventilation system to mitigate transmission of this emerging environmental contaminant to the outdoor environment. The results of the study indicate that MRSA in the respirable size range can be detected inside a swine building and 215 m downwind of the swine building. Aim 2 results indicated that the N95 respirator was efficient at protecting workers exposed to MRSA particles greater than 5 μm but not as effective with MRSA particles less than 5 μm. The results of aim 3 indicated that hardwood chips and western red cedar chips are efficient biofilter media for mitigating the emission of MRSA from a swine building. These studies showed that workers inside swine buildings and the outdoor environment can be protected against the transmission of MRSA with a respiratory program which includes the use of N95 respirators and biofilters as mitigation control measures.