Made available in DSpace on 2014-06-11T19:27:58Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-07-14Bitstream added on 2014-06-13T20:36:40Z : No. of bitstreams: 1 santos_il_me_jabo.pdf: 445425 bytes, checksum: 8eabdcdd56ae9af7bcf160cad345bd86 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / O vírus da bronquite infecciosa aviária (VBIG) permanece como um dos principais problemas para a avicultura industrial. Para a imunoprofilaxia dessa virose existem vacinas “vivas” atenuadas ou inativadas, mas elas não são efetivas para o controle dessa doença infecciosa a longo prazo, especialmente contra estirpes variantes desse vírus. A função primordial das vacinas usuais contra o VBIG são estimular as respostas imunes sistêmicas e locais, mediadas por anticorpos ou por células T efetoras. Com a finalidade de investigar os mecanismos envolvidos na imunidade protetora, os níveis de anticorpos locais e sistêmicos e a expressão de genes associados a respostas de linfócitos T citotóxicos, tais como o CD8 e a granzima A foi avaliada na mucosa traqueal, após a imunização primária de pintinhos de 1 dia de idade com vacinas atenuadas contra o VBIG seguida do desafio 42 dias depois. Proteção ao desafio foi avaliada por meio da ciliostase traqueal, histopatologia e detecção de vírus pela técnica de RT-PCR em tempo real na traquéia. Os níveis de anticorpos no soro e na secreção lacrimal foram mensurados pelo Sandwich- Concanavalina A – ELISA. A expressão dos genes de CD8 e de granzima A foram avaliadas pela técnica de RT-PCR em tempo real. Os resultados demonstraram que a proteção contra a infecção pelo VBIG em aves vacinadas se correlacionou com os níveis de anticorpos anti-virais específicos dos isótipos IgG, IgM e IgA na secreção lacrimal e com os níveis de expressão de CD8 e de granzima A. Concluindo, os resultados possibilataram definir o perfil cinético do desenvolvimento das respostas imunes de memória contra o VBIG na mucosa que é o sítio primário de replicação viral e indicaram que os mecanismos de imunidade humoral e celular podem ser muito importantes para a proteção de hospedeiros naturais contra a infecção pelo VBIG. / Avian infectious bronchitis (IBV) remains a major problem in the poultry industry. Live and inactivated vaccines are available, but they are not effective long term in controlling IBV infection, specially against variant strains. The essential function of existing IBV vaccines is to elicit, ideally, local and systemic specific antibodies, as well as cell-mediated immunity to this virus. To investigate the mechanisms of protective immunity, the levels of systemic and local specific antibodies and the expression of genes responsible for cytotoxic T cell killing such as CD8-marker and granzyme-A at tracheal mucosa was evaluated after the primary immunization of 1- day-old chicks with an attenuated avian infectious bronchitis virus (IBV) and challenge 42 days later. Challenge protection was evaluated by tracheal ciliostasis, histopathology and virus detection by real time RT-PCR. The serum and lachrymal anti-IBV antibody levels of IgG, IgM and IgM isotypes were measured with a Sandwich-ELISA Concanavalina-A method. The expression of CD8 and granzyme A genes were evaluated by real time RT-PCR. The results showed protection against challenge with the M-41. Lachrymal IgG, IgM and IgA anti-IBV specific antibodies and the levels of expression of CD8 and granzyme A genes correlated significantly with the protection to challenge. Overall, the results provided the kinetics on the development of memory mucosal immune responses against IBV at the primary replication site and indicate that tracheal humoral and cellular immune mechanisms may be very important in protecting natural hosts against IBV infection.

Em contraste com a vasta descrição na literatura científica dos biofilmes bacterianos, poucos trabalhos focam o estudo da formação e as estratégias de inibição da constituição do biofilme fúngico. Este trabalho objetiva a caracterização do potencial antifúngico e antibiofilme do sal imidazólico 1-metil-3-octilimidazol cloreto (C16MImCl), e das frações (F70 e F90) purificadas de saponinas mate (Ilex paraguariensis A. st. Hil.), frente a células de biofilme de seis isolados clínicos de Candida tropicalis. A Concentração Inibitória Mínima (CIM) do C16MImCl foi de 0,014μg/mL frente às células planctônicas, ao passo que as Frações de Saponinas da Erva Mate (FSEM) não apresentaram atividade antifúngica. Utilizando o cateter traqueal (CT) como corpo de prova, foi utilizado para avaliar a capacidade de inibição e remoção do biofilme. Avaliou-se também a Concentração Mínima de Erradicação do Biofilme (CMEB) para remoção do biofilme pré-formado pelo método da microplaca. Para a atividade antibiofilme foi observado que o C16MImCl, apresentou melhor resultado quando comparado ao fluconazol. As FSEM também apresentaram atividade antibiofilme quando comparados ao fluconazol, entretanto menores do que o tensoativo sintético Pela análise dos resultados de CMEB, o C16MImCl foi o composto com maior capacidade de erradicar o biofilme pré-formado, na concentração de 0,9 μg/mL (92% a 100% de remoção do biofilme). Os demais compostos testados (fluconazol, FEM e a água) não apresentaram atividade removedora, observando-se valores menores que 80% de remoção. Tanto as concentrações nas quais C16MImCl inibiu as células planctônicas (0,014 μg/mL) como as de biofilme (0,028 -0,225 μg/mL) foram mais baixas que as obtidas pelo fluconazol. Os resultados obtidos demonstram a potencialidade destes tensoativos, principalmente o C16MImCl, que demonstrou baixa toxicidade e provável mecanismo de ação sobre a síntese do ergosterol. Assim, é possível afirmarmos que estes tensoativos representam uma potencial alternativa para o controle químico de fungos leveduriformes, especialmente as ocasionadas por células de biofilme por C. tropicalis. / In contrast to the extensive description in the literature of bacterial biofilms, few works focus on the study of the formation and strategies for inhibiting the formation of fungal biofilms. This work aims to characterize the antifungal potential and antibiofilm the imidazole salt 1 - methyl - 3 - octilimidazol chloride (C16MImCl), and fractions (F70 and F90) purified saponins mate (Ilex paraguariensis A. st. Hil.), against to biofilm cells of six clinical isolates of Candida tropicalis. The Minimum Inhibitory Concentration (MIC) of C16MImCl was 0.014 mg / mL to planktonic cells, whereas the Saponin Fractions of Yerba Mate (SFYM) showed no antifungal activity. Using the tracheal catheter (CT) as a specimen was used to evaluate the ability of the biofilm inhibition and removal. We also assessed the Minimum Biofilm Eradication Concentration (MBEC) to remove the preformed biofilms by the microplate method. For antibiofilm activity was observed that C16MImCl, showed better results when compared to fluconazole. The SFYM also had antibiofilm activity when compared to fluconazole, however smaller than the synthetic surfactant. By analyzing the results MBEC, the compound C16MImCl was capacity to eradicate pre- formed biofilm in a concentration of 0.9 mg / mL (92% to 100% biofilm removal) The other tested compounds (fluconazole, SFYM and water) showed no activity remover, observing less than 80 % removal values. Both concentrations at which they inhibit planktonic cells C16MImCl (0.014 μg/mL) and the biofilm (0.028 -0.225 μg/ml) were lower than those obtained by fluconazole. The results obtained demonstrate the potential of these surfactants, especially C16MImCl, which demonstrated low toxicity and probable mechanism of action on the synthesis of ergosterol. Thus, it is possible to assert that these surfactants are a potential alternative to chemical control of yeasts, especially those caused by biofilm cells of C. tropicalis.

Base teórica: Muitos pacientes internados em Unidade de Terapia Intensiva (UTI) necessitam da instituição da ventilação mecânica invasiva (VM). Porém esta pode trazer efeitos deletérios como: alteração na higiene brônquica e pneumonia associada à ventilação mecânica (PAV). Devido a isso, faz-se necessária avaliação de técnicas de higiene brônquicas eficazes e o menos deletérias possíveis. Objetivos: Comparar a eficácia das técnicas em estudo: vibrocompressão (VB) (G1), hiperinsuflação com o ventilador mecânico (HMV) (G2) VB + HMV (G3) na quantidade de secreção aspirada (SEC), no tempo de VM, na incidência de PAV, na reintubação orotraqueal (Re-IoT) e na mortalidade de pacientes em VM. Método: Ensaio clínico randomizado, realizado no Centro de Terapia Intensiva do Hospital de Clínicas de Porto Alegre (HCPA). Foram incluídos no estudo 93 pacientes (29 G1, 32 G2 e 32 G3) em VM por mais de 24 horas. Foram aplicadas as seguintes técnicas: aspiração isolada (ASP), VB, HMV e VB + HMV. Foram medidas as seguintes variáveis: frequência cardíaca (FC), frequência respiratória (FR), pressão arterial média (PAM), saturação arterial periférica de oxigênio (SpO2), pressão inspiratória de pico (PIP), volume corrente (VC), complacência dinâmica (Cdyn), peso da SEC; tempo de VM, Re-IoT, incidência de PAV e mortalidade na VM. Conclusão: O grupo 3 foi o único que apresentou aumento significativo da SEC, quando comparado à ASP (0,7 g (0,1-2,5) vs 0,2 g (0,0-0,6) – p = 0,006). Em comparação com os demais grupos, o grupo 2 apresentou aumento significativo na incidência de PAV (22% - p = 0,003) e Re-IoT (21,9% - p = 0,048), demonstrando assim, na amostra estudada, que VB + HMV é mais eficaz quanto à quantidade de SEC e exerce efeito protetor, juntamente com a VB, na incidência de PAV e Re-IoT. / Background: Many patients admitted to the Intensive Care Unit (ICU) require the institution of invasive Mechanical Ventilation (MV). However, this can bring harmful effects such as changes in mucociliary transport and cough capacity, leading to bronchial obstruction and Ventilator Associated-Pneumonia (VAP). Objective: To compare the efficacy of the techniques: Vibrocompression (G1), Hyperinflation with Mechanical Ventilation (G2) Vibrocompression + Hyperinflation with Mechanical Ventilation (G3) in the amount of Aspirated Secretions (AS), MV time, the incidence of VAP, Re-intubation tracheal (Re-IoT) and mortality of patients on MV. Method: Randomized clinical trial, conducted at the Intensive Care Unit, of the Hospital de Clinicas de Porto Alegre (HCPA). 93 patients were included in the study (29 G1, 32 G2 and 32 G3) in mechanical ventilation for more than 24 hours. The following techniques were applied: Isolated Aspiration (ASP), Vibrocompression (VB), Hyperinflation with Mechanical Ventilation (HMV) Vibrocompression + Hyperinflation with Mechanical Ventilation (HMV + VB). The following variables were measured: Heart Rate (HR), Respiratory Rate (RR), Mean Arterial Pressure (MAP), Peripheral Arterial Oxygen Saturation (SpO2); Peak Inspiratory Pressure (PIP), Tidal Volume (TV); Dynamic Compliance (Cdyn); weight of the AS; VM time; Re-IoT; VAP incidence and mortality in the VM. Conclusion: The HMV + VB (G3) was the only group that showed significant increase in the AS (0.7 g (0.1-2.5) vs 0.2 g (0.0-0.6) – p = 0.006) when compared to ASP. Compared with the other groups G2 showed a significant increase in the incidence of VAP (22% - p = 0.003) and Re-IoT (21.9% - p = 0.048). Thus demonstrating in the sample, which HMV + VB is more effective as the amount of secretion aspirated and has a protective effect, along with the VB, the incidence of VAP and Re-IoT.

Nous avons développé un nouveau ballonnet pour l'occlusion trachéale fœtale par endoscopie (FETO) qui permet une levée de l'occlusion facile, par contrôle externe et non-invasive. Ce ballonnet "Smart-TO" permet d'éviter les problèmes liés au rétablissement des voies aériennes. La solution technique est basée sur une valve magnétique dont l'ouverture est contrôlée par le champ de fuite d'une IRM. L'ouverture de la valve provoque la vidange du ballonnet, qui est ensuite expulsé par les sécrétions pulmonaires. Les tests d'imperméabilité, d'occlusion et de fonctionnement sont prometteurs. Une toute première expérimentation sur le modèle du singe a montré la bonne fonctionnalité et fonctionnement du ballonnet "Smart-TO". D'autres tests in vitro ainsi que d'autres tests animaux sont prévus. Un brevet a été déposé en 2016. Une analyse de risques préliminaire, une exploration des chemins réglementaires et une étude de marché ont été initiés mais sont encore en cours. / We developed a new balloon for Fetal Endoscopic Tracheal Occlusion (FETO) which allows an easy, remotely controlled, and non-invasive reversal occlusion. This "Smart-TO" balloon to overcome issues related to the airway reestablishment. The technology is based on a magnetic valve whose opening is actuated by the fringe field of an MRI scanner. The opeing of the valve induces the deflation of the balloon, which is then washed out by the fluid coming out from the lungs. The impermeability, occlusion and operation tests are promising. A very first experimentation on the monkey model showed appropriate functionality and operation of the "Smart-TO" balloon. Further in vitro and animal tests are planned. A patent has been filed in 2016. Preliminary risk analysis, regulatory routes exploration, and market study have been started but are still ongoing.

L’hypertension artérielle pulmonaire (HTAP) correspond à une augmentation des résistances artérielles pulmonaires, avec dans les formes les plus graves, une défaillance cardiaque droite. L’HTAP persistante du nouveau-né (HTAPP) est estimée à 2/100 naissances en France. L’adaptation cardio-respiratoire à la naissance implique le déclenchement simultané de plusieurs phénomènes non complètements compris. Notre travail avait pour but d’approfondir les connaissances sur la régulation pulmonaire périnatale et d’envisager de nouvelles possibilités thérapeutiques. Ainsi, nous avons mis en évidence in vivo une vasoconstriction pulmonaires chez le fœtus lors du tabagisme passif maternel, par blocage de la voie du NO. De même, nous avons pu montrer l’effet vasoconstricteur de l’apeline sur les artères pulmonaires de fœtus de brebis. Cet effet semble dose dépendant, inhibé par l’action des inhibiteurs calciques. Au contraire nous avons mis en évidence un effet vasodilatateur de la Déhydroépiandrostérone (DHEA). Cette action est médiée par la voie du NO. Parallèlement, nous avons montré que les acides gras poly insaturés ω 3 (AGPIω3) entrainaient une vasodilatation pulmonaire, se prolongeant au delà d’une heure après l’arrêt de la perfusion. Cet effet est médié par l’ouverture des canaux potassiques et indépendant de la voie du NO. Parmi les AGPIω3, nous avons établi que l’acide eicosapentaénoïque (EPA) qui induit cette réponse sans effet délétère sur la circulation systémique, ni l’oxygénation tissulaire. Enfin, nous avons établi que l’occlusion trachéale (OT) anténatale, traitement proposé pour certaine hypoplasie pulmonaire malformative, n’altère pas le débit pulmonaire, en favorisant la dilatation pulmonaire. Mais en cas d’OT prolongée, ces effets sont en partie masqués par les effets mécaniques de la pression intraluminale. Ainsi grâce à ces travaux, nous avons avancé dans la compréhension de l’adaptation de la circulation pulmonaire de la vie intra à la vie extra utérine. Ils permettent aussi de proposer de nouvelles thérapeutiques comme la supplémentation en AGPIω 3 des femmes attendant un enfant à risque d’HTAP, et d’envisager de nouvelles voies de recherche thérapeutique comme la voie de l’apeline. / Persistent pulmonary hypertension (PPH) corresponds to an increase in pulmonary arterial resistance, with in the most severe forms, right heart failure. The persistent pulmonary hypertension of the newborn (PPHN) is estimated at 2/100 births in France. The cardiorespiratory adaptation at birth involves the simultaneous triggering of several phenomena including non completions. Our work aimed to increase knowledge on the regulation of perinatal pulmonary and consider new therapeutic possibilities. Thus, we have demonstrated in vivo pulmonary vasoconstriction in the fetus when maternal passive smoking, by blocking the NO pathway. Similarly, we demonstrated the vasoconstrictor effect of apelin infusion on the pulmonary arteries of fetal sheep. This effect appears dose dependent, inhibited by the action of calcium channel blockers. Instead we have shown a vasodilatory effect of dehydroepiandrosterone (DHEA). This action is mediated by the NO pathway. In parallel, we have shown that polyunsaturated fatty acids ω 3 (AGPIω3) would cause pulmonary vasodilation, extending beyond an hour after stopping the infusion. This effect is mediated by the opening of potassium channels and independent of the NO pathway. Among AGPIω3, we found that eicosapentaenoic acid (EPA) that induces this response without deleterious effect on the systemic circulation or tissue oxygenation. Finally, we established that the antenatal tracheal occlusion (TO), treatment proposed for some malformative pulmonary hypoplasia, does not alter pulmonary blood flow, promoting lung expansion. But in case of prolonged OT, these effects are partly masked by the mechanical effects of intraluminal pressure. And through this work, we have made progress in understanding the adaptation of the pulmonary circulation of the intra to extrauterine life. They also suggest new therapeutic, like supplementation as AGPIω for women expecting a child at risk for PAH, and to consider new possibility of therapeutic research like the way of apelin.

Bronchiolitis obliterans syndrome (BOS), a form of chronic lung allograft dysfunction, represents a major cause of mortality after lung transplantation. This disease is associated with a progressive fibro-obliteration of small airways (known as obliterative bronchiolitis) which leads to respiratory impairment and graft failure. The mechanisms behind airway occlusion remain unclear, and no curative treatment is available at the moment. Myofibroblasts are considered central effectors in this fibrotic process, but their origin is controversial. They can arise either from donor cells (resident fibroblasts and epithelial cells) or recipient cells (bone marrow-derived cells).The purpose of this project was to identify the precursors of mesenchymal cells responsible for post-transplant airway fibro-obliteration. Lineage-tracing tools were used to track or deplete potential sources of myofibroblasts in the heterotopic tracheal transplantation model, which produces a surrogate of obliterans bronchiolitis. Confocal analysis showed that myofibroblasts in the allografts were mostly recipient-derived, even though immunosuppression with tacrolimus induced a mild increase of donor-derived myofibroblasts. Occasional epithelial-to-mesenchymal transition was detected, but only in tacrolimus-treated recipients. On the other hand, fate-mapping techniques demonstrated that myeloid cells gave rise to the majority of mesenchymal cells in occluded airways. Accordingly, specific ablation of Cx3cR1+ mononuclear phagocytes significantly decreased allografts fibrosis. In parallel, single-cell RNA-sequencing unveiled surprising similarities between myeloid-derived cells (i.e. fibrocytes and macrophages) from the allografts and both murine and human samples of pulmonary fibrosis. Finally, analysis of BOS lesions from transplanted patients allowed us to translate our results to a clinical level. Indeed, confocal microscopy revealed that myofibroblasts expressing the macrophage marker CD68 were increased in BOS explants when compared to controls, and their numbers seemed correlated with the intensity of fibrosis.Collectively, these findings indicate that recipient mononuclear phagocyte system constitutes a clinically relevant source of mesenchymal cells infiltrating the airways after allogeneic transplantation. Therefore, therapies targeting migration and differentiation of mononuclear phagocytes and fibrocytes could prevent fibrotic remodelling of small airways and improve long-term outcomes after lung transplantation. / La bronchiolite oblitérante (bronchiolitis obliterans syndrome, BOS), une forme de dysfonction chronique du greffon, représente une des majeures causes de mortalité après transplantation pulmonaire. Cette pathologie est associée à une oblitération progressive et irréversible des petites voies aériennes par de la fibrose, qui mène à une perte de fonction respiratoire jusqu’à la défaillance du greffon. Les mécanismes impliqués dans la fibroproliferation ne sont pas encore bien compris, et il n’existe pas de traitement efficace de la BOS à l’heure actuelle. Les myofibroblastes joueraient un rôle majeur dans le développement de la fibrose, mais leur origine reste controversée. Ils pourraient dériver des cellules du donneur (fibroblastes in situ ou cellules épithéliales) ou bien du receveur (à partir de la moelle osseuse). L’objectif de cette étude était d’identifier les précurseurs des cellules mésenchymateuses responsables de l’obstruction des voies aériennes après transplantation allogénique. Nous avons utilisé des techniques de lineage tracing pour identifier les sources potentielles de myofibroblastes dans un modèle de transplantation hétérotopique de trachée, lequel permet d’obtenir une maladie fibro-oblitérante du greffon qui simule histologiquement la bronchiolite oblitérante. Les analyses par microscopie confocale ont montré que les cellules du receveur constituent la source principale de myofibroblastes dans les allogreffons, malgré une faible augmentation de la proportion de cellules mésenchymateuses dérivées du donneur lors du traitement immunosuppresseur. En plus, une minime fraction de myofibroblastes d’origine épithéliales a également été détectée, mais seulement dans les greffons traités par tacrolimus. D’autre part, nous avons établi que la lignée myéloïde produit la plupart des cellules mésenchymateuses détectés dans les voies aériennes oblitérées. Par ailleurs, la délétion spécifique de phagocytes mononucléaires Cx3cR1+ était associée avec une diminution significative du nombre de myofibroblastes et de la fibrose endoluminale dans les allogreffons. En parallèle, l’utilisation des techniques de séquençage en single cell a permis de révéler des ressemblances inattendues entre des populations de cellules d’origine myéloïdes (macrophages et fibrocytes) retrouvés dans les greffons et celles impliqués dans le développement de la fibrose pulmonaire chez l’homme et la souris. In fine, l’analyse par microscopie confocale des lésions pulmonaires de patients atteints de BOS nous a permis de transposer en clinique nos résultats expérimentaux. En effet, nous avons observé que la fraction de myofibroblastes positifs pour le CD68, un marqueur typiquement exprimé par les macrophages, était significativement augmentée dans les greffons avec bronchiolite oblitérante par rapport aux contrôles. De plus, leur nombre était corrélé avec la sévérité de la fibrose. L’ensemble de ces résultats indique que le système phagocytaire mononuclée constitue une source significative de cellules mésenchymateuses et contribue à la fibro-oblitération des voies aériennes après transplantation. L’utilisation de thérapies ciblant la migration et la différenciation des phagocytes mononuclées et des fibrocytes pourrait bloquer la destruction du greffon pulmonaire et améliorer la survie à long terme des patients transplantés. / Doctorat en Sciences médicales (Médecine) / info:eu-repo/semantics/nonPublished

Effects of various levels of L-ascorbic acid (L-AA) (12 and 25 mg) in ovo injected at 17 and 18 days of incubation, on embryonic and posthatch physiological variables in Ross 708 broilers were investigated. There were no significant treatment effects on the hatchability or serum concentrations of L-AA in the broilers. Eye L-AA concentrations were higher, and plasma nitric oxide levels were lower in male chicks treated in ovo with 12 mg of L-AA. While exposed to elevated atmospheric NH3 levels, the in ovo injection of 12 mg of L-AA increased the body weight gain and decreased the feed conversion ratio of the broilers from 0 to 28 days of age (doa). Decreased tracheal attenuation incidence was also experienced at 0 doa in the in ovo injected L-AA groups, and tracheal inflammation was significantly reduced at 28 doa in response to the in ovo injection of 12 mg of L-AA.

Bakgrund Bristfällig kuffhantering kan leda till skador på slemhinnan, bidra till ineffektiv ventilation och mikroaspirationer som kan leda till ventilatorassocierad pneumoni (VAP). I dagsläget skiljer sig handhavandet åt och det finns inget standardiserat handhavande av kuffen hos patienter med endotrakealtub eller trakealtub. Specialistsjuksköterskor inom intensivvård ansvarar för säkerställandet av ett evidensbaserat yrkesutövande som stärker patientsäkerhet. Syfte Syftet var att sammanställa kunskapsläget gällande kuffhantering hos vuxna patienter på intensivvårdsavdelningar för att bidra till ökad patientsäkerhet. Metod Systematisk litteraturöversikt av kvantitativa studier med en induktiv ansats. 16 vetenskapliga studier inkluderades och kvalitetsgranskades med hjälp av en granskningsmall för kvantitativa studier. Deskriptiv syntes med narrativ analys användes för resultatet. Resultat Resultatet redovisades utifrån två huvudteman; mätmetoder ochomvårdnadsåtgärder som påverkar kufftrycket. Sex subteman skapades till de två temana. Resultatet visade att meningsskiljaktigheter råder huruvida kontinuerlig mätning anses vara mer fördelaktigt än intermittent mätning. Vidare pekade resultatet på att olika omvårdnadsåtgärder kontribuerar till förändringar av kufftrycket. Slutsats Resultatet tyder på att kuffhantering är komplext. Kufftrycket påverkas av flera faktorer och bör följas regelbundet, en exakt definition på hur ofta går dock ej att fastställa. För att intensivvårdspatienter skall erhålla evidensbaserad vård, och därmed öka patientsäkerheten, behövs ytterligare forskning inom kuffhantering eftersom evidensen i nuläget är begränsad. Dock pekar uppsatsens resultat på att kontinuerlig mätning kan vara fördelaktigt utifrån ett patientsäkerhetsperspektiv, eftersom på-och avkoppling av manometer sågs vara ett riskmoment. / Background Inadequate cuff-management can lead to mucosal damage, contribute to ineffective ventilation and microaspirations that can lead to ventilator-associated pneumonia (VAP). At present, there are differences in practice and no standardized practice of cuff-management in patients with endotracheal tubes or tracheal tubes. Specialist nurses in intensive care are responsible for ensuring evidence-based professional practice that enhances patient safety. Aim The aim was to summarize the current state of knowledge on cuff-management in adult patients in intensive care units to contribute to improved patient safety. Method Systematic literature review of quantitative studies with an inductive approach. 16 articles were included and quality reviewed using a review template for quantitative studies. Descriptive synthesis with narrative analysis was used for the results. Result The results were presented using two main themes; measurement procedures and nursing interventions that influence cuff pressure. Six subthemes were created for the two themes. Opinions are divided as to whether continuous measurement is considered more beneficial than intermittent measurement. Furthermore, nursing-interventions were found to influence the cuff pressure. Conclusion Cuff-management is a complex topic. Cuff pressure is influenced by several factors and should be monitored regularly, however, how often is not possible to determine. For intensive care patients to receive evidence-based care and thereby increase patient safety, further research in cuff-management is required as the evidence is currently limited. However, continuous measurement may be beneficial from a patient safety perspective, as switching on and off the manometer is considered a risk factor.

Inadvertent tracheal tube misplacement and particularly endobronchial intubation are well-known complications of emergency endotracheal intubation (ETI) in pediatric trauma patients, which require repositioning of the tube to avoid impairment of gas exchange. The main aim of study was to identify the frequency of tube misplacement and associated factors of pediatric trauma patients who received ETI either by prehospital physician-staffed emergency medical service (EMS), or at emergency department (ED) admission to a single level-1 trauma center. Sixty-five patients (median age 14 years and median injury severity score 29) were included. Of these, 30 underwent helicopter EMS ETI, 29 ground EMS ETI, and 6 ED ETI. Seventeen cases (26%) of tracheal tube misplacement were recognized. After multivariable analysis, tracheal tube misplacement was independently negatively associated with body weight (OR 0.86; 95% CI, 0.76–0.99; p = 0.032) and helicopter EMS ETI (OR 0.20; 95% CI, 0.04–0.97; p = 0.036). Two of nineteen patients received tube thoracostomy due to endobronchial intubation. Mortality and length of stay were comparable in patients with misplaced tubes and correctly placed tubes. The results suggest that particularly small children require attention to avoid tracheal tube misplacement, which emphasizes the need for special training. Helicopter EMS physicians’ expertise might be beneficial in prehospital pediatric trauma patients requiring advanced airway management.

: Bakgrund och problemformulering: Extubation är ett avgörande moment inom anestesi. När patienten har tillfredsställande andningsmönster så kan trakealtuben tas ut ur patientens luftväg. Inga hundraprocentiga kriterier finns för hur extubationens utfall blir, utan utförs ofta utefter situation. Det är en komplex process som kräver noga övervakning och anpassning till varje patients individuella behov. Att bedöma, etablera och kontrollera luftvägen kräver att anestesisjuksköterskan har kunskap och erfarenhet av multidisciplinärt samarbete och etisk medvetenhet. För att undvika patientlidande är personcentrerad vård nödvändigt och kräver ett förhållningsätt baserat på omtanke. Riskerna för komplikation har inte tydligt minskat under åren och det upplevs svårt att planera och utföra en extubation. Syfte: Syftet var att undersöka anestesisjuksköterskan och anestesiologens erfarenheter av extubation. Metod: En systematisk litteraturöversikt med integrativ metod baserat på kvalitativa och kvantitativa artiklar. Artikelsökningen utfördes i databaser och webbsökning. Totalt inkluderades nio artiklar publicerade mellan år 2006–2022. Kvalitetsgranskning genomfördes utifrån CASP checklista av kvalitativa och randomiserad kontrollerad studie. Resultat: I resultatet framkommer det att erfarenhet är en betydande roll som ger bättre förutsättning för extubationen. Kommunikationsbrist, tidspress och bristande respekt påverkade anestesipersonal under utförandet. Planering och förberedelser är två viktiga faktorer för att underlätta handhavandet av extubation. Diskussion: Erfarenhet har en betydande roll för att skapa förutsättningar för trygghet, respekt och evidensbaserad vård. Anestesisjuksköterskor och anestesiologer har olika erfarenheter om extubation. Genom att öka kunskap gällande upplevelser av anestesipersonalens erfarenheter kan praktiska och teoretiska momentet kring extubering förbättras. / Background and Problem Statement: Extubation is a crucial step in anaesthesia. When the patient has a satisfactory breathing pattern, the tracheal tube can be removed from the patient's airway. There are no one-hundred- precent criteria for the outcome of extubation; it is often preformed based on the situation. It is a complex process that requires careful monitoring and adaptation to each patient’s individual needs. Assessing, establishing and controlling the airway require that the anaesthesia nurse possesses knowledge and experience with multidisciplinary collaboration and ethical awareness. To avoid patient suffering, person-centred care is necessary, which requires an approach based on compassion. The risk of complications has not clearly decreased over the years, and planning and preforming an extubation are often perceived as challenging. Aim: The aim was to examine the anesthesia nurse and the anesthesiologist's experiences with extubation. Method: A systematic literature review using an integrative method based on qualitative and quantitative articles. Articles searches were conducted in the databases Cinahl, PubMed and Scopus, as well through web searches. A total of nine articles published between 2006 and 2022 were included. Quality assessment was preformed using CASP checklist for qualitative and randomised controlled studies. Results: The results indicate that experience is a significant factor that provides better conditions for successful extubation. Communication problems, time pressure and lack of respect affected anaesthesia personnel during the procedure. Planning and preparing are two important factors that facilitate the management of extubation. Discussion: Experience plays a significant role in creating conditions for safety, respect and evidence-based care. Anaesthesia nurses and anaesthesiologist have mixed options about extubations. By increasing knowledge about the experiences of anaesthesia personnel, both the practical and theoretical aspects of extubation can be improved.