Physiopathological rationale of using high-flow nasal therapy in the acute and chronic setting: A narrative review

Chronic lung disease and admissions due to acute respiratory failure (ARF) are becoming increasingly common. Consequently, there is a growing focus on optimizing respiratory support, particularly non-invasive respiratory support, to manage these conditions. High flow nasal therapy (HFNT) is a noninvasive technique where humidified and heated gas is delivered through the nose to the airways via small dedicated nasal prongs at flows that are higher than the rates usually applied during conventional oxygen therapy. HFNT enables to deliver different inspired oxygen fractions ranging from 0.21 to 1. Despite having only recently become available, the use of HFNT in the adult population is quite widespread in several clinical settings. The respiratory effects of HNFT in patients with respiratory failure may be particularly relevant for clinicians. In this narrative review, we discuss the main pathophysiological mechanism and rationale for using HFNT in the acute and chronic setting

Role of physiotherapy for adult patients with critical illness

Turin, Italy, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. Critical illness can last from hours to months, depending on the underlying pathophysiology and response to treatment. It carries high morbidity and mortality rates, and the associated care is a major determinant of healthcare costs. The evolution of intensive care medicine and integrated team management has greatly improved the survival of critically ill patients. In view of the high costs associated with ICU, every attempt should continue to be made to prevent complications and appropriately treat the primary underlying pathophysiology to minimize length of stay in ICU. There are common complications particularly associated with a prolonged ICU stay, including deconditioning, muscle weakness, dyspnoea, depression and anxiety, and reduced health-related quality of life. Chronic critical illness is associated with prolonged immobility and intensive care unit (ICU) stay and accounts for 5–10% of ICU stays, a proportion that appears to beincreasing . Because of these detrimental sequelae of long-term bed rest, there is a need for rehabilitation throughout the critical illness and thereafter , to address these effects. The amount of rehabilitation rehabilitation performed in ICUs is often inadequate, A strategy for whole-body rehabilitation-consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care

Multimodal analgesia in trauma patients in ICU

Turin, Italy, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Treatment of the trauma patient has evolved rapidly in the past decade. Nevertheless, the treatment of pain as part of overall trauma management has been relatively neglected. Although recent publications suggest that the assessment and treatment of pain in trauma have improved, most studies still document inadequate analgesia..Following the initial resuscitation of trauma patients, the pain experienced may be divided into a ‘background’ pain and a ‘breakthrough’ pain associated with painful procedures in ICU (e.g. tracheal suctioning, chest tube positioning, staple removal and wound-dressing, bathing in major burn patients.) Background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/ or less potent oral opioids, epidural analgesia or with continuous regional blocks, The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium and activation of inflammatory response During painful procedures the most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with propofol or benzodiazepines. Adjuvant drugs such as clonidine, low dose ketamine, magnesium and paracetamol (acetaminophen) have also been used to realize a multimodal drugs approach both in the treatment of background pain as well as during procedural pain. Patients in spontaneous breathing may only receive ketamine will usually maintain spontaneous breathing. This is an important feature in patients with heat trauma (major burn) who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. However, it must bear in mind that trauma patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Educating the staff to perform early routine assessment of pain and to be familiar with the administration of analgesia are key elements to improved pain management in trauma.. Further developments are needed in order to provide safer and more effective analgesia to the trauma patient

Grain‐energy release governs mobility of debris flow due to solid–liquid mass release

Debris flows often exhibit high mobility, leading to extensive hazards far from their sources. Although it is known that debris flow mobility increases with initial volume, the underlying mechanism remains uncertain. Here, we reconstruct the mobility–volume relation for debris flows using a recent depth‐averaged two‐phase flow model without evoking a reduced friction coefficient, challenging currently prevailing friction‐reduction hypotheses. Physical experimental debris flows driven by solid–liquid mass release and extended numerical cases at both laboratory and field scales are resolved by the model. For the first time, we probe into the energetics of the debris flows and find that, whilst the energy balance holds and fine and coarse grains play distinct roles in debris flow energetics, the grains as a whole release energy to the liquid due to inter‐phase and inter‐grain size interactions, and this grain‐energy release correlates closely with mobility. Despite uncertainty arising from the model closures, our results provide insight into the fundamental mechanisms operating in debris flows. We propose that debris flow mobility is governed by grain‐energy release, thereby facilitating a bridge between mobility and internal energy transfer. The initial volume of debris flow is inadequate for characterizing debris flow mobility, and a friction‐reduction mechanism is not a prerequisite for the high mobility of debris flows. By contrast, inter‐phase and inter‐grain size interactions play primary roles and should be incorporated explicitly in debris flow models. Our findings are qualitatively encouraging and physically meaningful, providing implications not only for assessing future debris flow hazards and informing mitigation and adaptation strategies, but also for unravelling a spectrum of earth surface processes including heavily sediment‐laden floods, subaqueous debris flows and turbidity currents in rivers, reservoirs, estuaries, and ocean

Choosing a ventilator for home mechanical ventilation

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Effect of high-flow nasal therapy on dyspnea, comfort, and respiratory rate

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management of blast and inhalation injury

Key points All patients with facial burns may be suspected of having 'difficult-to-control' airways owing to smoke inhalation injury (SII). Many of them either have an incorrect diagnosis, or mild-to-moderate injury with unrecognised aggravating respiratory failure. For a diagnosis of inhalation injury, it is necessary to follow the patient closely for >48 h. Inhalation injury is a condition with different clinical presentations. Clinical follow-up is necessary to improve patient care, to help guide treatment and to provide clues for therapeutic interventions. Notwithstanding intensive care treatment including airway intubation and mechanical ventilation, many patients with severe inhalation injury remain under-treated. Educational aims To discuss the initial approach and assessment of a patient with SII. To help the reader recognise different clinical pictures of inhalation injury. To outline management and discuss treatment. Summary "Inhalation injury" describes a variety of insults caused by the aspiration of superheated gases, steam or noxious products of incomplete combustion. Inhalation injury involves the entire respiratory system. Early diagnosis based on history and physical examination, in addition to careful monitoring for respiratory complications, is mandatory. As there is no specific treatment for inhalation injury, management involves providing the necessary degree of support required to compensate for upper airway swelling and impairment in gas exchange. Airway intubation and mechanical ventilation may be required while the endobronchial and alveolar mucosa are regenerating. Primary blast injury (BI) is caused by immediate pressure variations, which are the product of rapid sequences of compression and decompression. Secondary and tertiary BI include lesions caused when the subject is thrown against rigid structures or is hit by flying objects. Its diagnosis and therapy follows guidelines for emergency care

Efficacy and Safety of Using High-Flow Nasal Oxygenation in Patients Undergoing Rapid Sequence Intubation.

Objective: To assess the efficacy and safety of high-flow nasal oxygen (HFNO) therapy in patients undergoing rapid sequence intubation (RSI) for emergency abdominal surgery. Methods: HFNO of 60 L.min\ue2\u88\u921at an inspiratory oxygen fraction of 1 was delivered 4 min before laryngoscopy and maintained until the patient was intubated, and correct intubation was verified by the appearance of the end-tidal CO2(EtCO2) waveform. Transcutaneous oxygenation (SpO2), heart rate and non-invasive mean arterial pressure were monitored at baseline (T0), after 4 min on HFNO (T1) and at the time of laryngoscopy (T2) and endotracheal intubation (ETI) (T3). An SpO2of <3% from baseline was recorded at any sampled time. The value of EtCO2at T3 was registered after two mechanical breaths. The apnoea time was defined as the time from the end of propofol injection to ETI. RSI was performed with propofol, fentanyl and rocuronium. Results: Forty-five patients were enrolled. SpO2levels showed a statistically significant increase at T1, T2 and T3 compared with those at T0 (p<0.05); median SpO2% (interquartile range) was 97% (range, 96%-99%) at T0, 99% (range, 99%-100%) at T1, 99% (range, 99%-100%) at T2 and 99% (range, 99%-100%) at T3. Minimal SpO2was 96%; no patient showed an SpO2of <3% from baseline; mean EtCO2at the time of ETI was 36\uc2\ub14 mmHg. Maximum apnoea time was 12 min. Conclusion: HFNO is an effective and safe technique for pre-oxygenation in patients undergoing rapid sequence induction of general anaesthesia for emergency surgery