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Regional lung ventilation during supraglottic and subglottic jet ventilation: A randomized cross-over trial
Test the hypothesis that the center of ventilation, a measure of ventro-dorsal atelectasis, is posterior during supraglottic ventilation indicating better dependent-lung ventilation. Secondarily, we tested the hypothesis that supraglottic ventilation improves oxygenation and carbon dioxide elimination.
Supraglottic and subglottic jet ventilation are both used during laryngotracheal surgery. Supraglottic jet ventilation may better prevent atelectasis and provide superior ventilation.
Randomized, cross-over trial.
Operating rooms.
Patients having elective micro-laryngotracheal surgery.
Patients were sequentially ventilated for 5 min with one randomly selected type of jet ventilation before being switched to the alternative method.
Regional ventilation distribution was estimated using electrical impedance tomography, with arterial oxygenation and carbon dioxide partial pressures being simultaneously evaluated.
Thirty patients completed the study. There were no statistically significant or clinically meaningful differences in the center of ventilation with supraglottic and subglottic ventilation. However, ventilation with the supraglottic approach was about 4 % higher in the ventromedial lung region and about 4 % lower in the dorsal lung. Surprisingly, arterial blood oxygenation was considerably worse with supraglottic (173 [156, 199] mmHg) than subglottic ventilation (293 [244, 340] mmHg). Arterial carbon dioxide partial pressure was near 40 mmHg with each approach, although slightly lower with supraglottic jet ventilation.
The center of ventilation distribution, a measure of atelectasis, was similar with supraglottic and subglottic jet ventilation. Subglottic jet ventilation improved the dorsal-dependent lung region and provided superior arterial oxygenation. Both techniques effectively eliminated carbon dioxide, with the supraglottic approach demonstrating slightly superior efficacy.
•In a cross-over trial, we compared supraglottic and subglottic jet ventilation during open-airway laryngeal surgery.•Jet ventilation did not significantly shift the overall center of ventilation as determined by EIT.•Supraglottic jet ventilation worsened ventilation in dorsal lung regions compared to subglottic jet ventilation by 4 %.•Oxygenation was substantially better with subglottic than supraglottic jet ventilation.•Either type of jet ventilation appears suitable for open-airway laryngeal surgery.
Journal Article
A29 UPDATES IN CONTROL OF BREATHING: Volitional Initiated Breaths Do Mimic Automatic Breathing And Allow Paco2 Homeostasis
In the present study, we have re-analyzed data collected from one of our previous studies (J Appl Physiol 110:854-856, 2011) in order to develop a model accounting for the regulatory properties that are retained by the respiratory control system, wherein the spontaneous automatic rhythmic activity is replaced by a volitionally paced rhythm. If we assume that the cortical-spinal pathway does not involve the central pattern generator of breathing during volitional breathing, the site of mediation of this interaction must be the (spinal) respiratory moto-neurons, This suggests that the medullary neurons involved in the response to CO2 or exercise send signals to the respiratory moto-neurons independently of the inputs originating from the central pattern generator.
Journal Article
At your best as an HVAC/R tech : your playbook for building a successful career and launching a thriving small business as an HVAC/R technician
\"The only series of step-by-step guides to succeeding in the skilled trades and achieving the American dream. At Your Best as an HVAC/R Tech is your playbook for learning if a career as an electrician is right for you, progressing from pre-apprentice to journeyman to master technician, and launching your own small business. Learn: What does a career as an HVAC/R tech look like? Why should you consider becoming an HVAC/R tech? How do you become a successful craftsman as an HVAC/R tech? How much can you make as an HVAC/R tech? What are your career options once you become an HVAC/R tech? How long does it take to be successful at each stage in a HVAC/R tech's career? How and where do you find work as an HVAC/R tech? What does it take to strike out on your own? What does it take to launch and build a successful small business? At Your Best is the only step-by-step handbook to finding if a career in the trades is right for you, educating yourself and earning the proper certifications, establishing yourself as an excellent apprentice and journeyman in the industry, and moving on to start your own small business in the trades. At each step of the way, your At Your Best playbook and its companion, www.AtYourBest.com, provide the information, recommendations, outside resources, and concrete actions needed for taking the next successful step in You, Inc. Whether you are beginning your first career, changing careers, or ready to move up and start your own business as a carpenter, plumber, HVAC/R tech, or other tradesman, this is the book that will tell you how. There currently over 6.5 million unfilled jobs in the skilled trades in the US. Despite being well-paying and secure, these jobs remain open because enough qualified candidates with the skills, attitude, and experience required do not exist. Moreover, plenty of opportunity exists for established tradespeople to start their own business, but they have no guidance. The At Your Best Playbooks series and www.AtYourBest.com change that.\" -- ONIX annotation.
Book
Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial
PurposeNoninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure.MethodsHighly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early or standard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality.ResultsWe enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0–7.0) vs. 5.5 (4.0–9.0) days, respectively, p = 0.004], while ICU LOS was not significantly different [8.0 (6.0–12.0) vs. 9.0 (6.5–12.5) days, respectively (p = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p = 0.001), and hospital LOS, 20 (13–32) vs. 27(18–39) days (p = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies.ConclusionsIn highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.
Journal Article
Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial
Purpose
Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation.
Methods
A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality.
Results
In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (
P
= 0.66), the asynchrony index was 14.7 vs. 26.7 % (
P
< 0.001), the ventilator-free days at day 7 were 1.0 day [1.0–4.0] vs. 0.0 days [0.0–1.0] (
P
< 0.01), the ventilator-free days at day 28 were 21 days [4–25] vs. 17 days [0–23] (
P
= 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (
P
= 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (
P
< 0.01).
Conclusions
NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient–ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation.
Trial Registration.
clinicaltrials.gov Identifier: NCT02018666.
Journal Article