Pathogenetische Faktoren der Reflux-assoziierten chronischen Erkrankung der Lunge : die Magenentleerungszeit

Ein gastroösophagealer Reflux, der keine gastroenterologischen Symptome wie Erbrechen oder saure Regurgitation zeigt, kann im Kindesalter chronische Erkrankungen der Lunge auslösen. Typische Krankheitsbilder sind hierbei zum Beispiel Asthma bronchiale oder rezidivierende Bronchitiden. Die Inzidenz hierfür beträgt 1 : 300 bis 1 : 500. Für die Entstehung eines gastroösophagealen Reflux wird ein multifaktorielles Geschehen diskutiert. So kann zum Beispiel ein verminderter Druck des unteren Ösophagussphinkters, eine verminderte Leistung der Clearancefunktion des Ösophagus, eine pathologische Magensäuresekretion und auch eine verlängerte Entleerung des Magens ursächlich sein. Studien haben einen Zusammenhang zwischen einer pathologischen Magenentleerungszeit und einem symptomatischen gastroösophagealen Reflux beschrieben. Ein primärer Defekt wird hierbei in einer Motilitätsstörung vermutet, da ein signifikanter Zusammenhang zwischen pathologischen Magenentleerungszeiten und Dysrhythmien (abnormen elektrischen Potentialen) des Magens beschrieben ist. Bisher ist kein diagnostisches Verfahren bekannt, dass mit hoher Sensitivität und Spezifität das Vorliegen eines gastroösophagealen Reflux beweist. Vielmehr umfasst die derzeitige Diagnostik lediglich Teilaspekte der Erkrankung und liefert uneinheitliche Bilder. Bei insgesamt 25 Kindern mit Lungenproblemen bedingt durch einen gastroösophagealen Reflux wurde die Magenentleerungszeit, eine 2 Punkt-pH Metrie, eine obere Magendarmpassage sowie eine quantitative Bestimmung von fettbeladenen Alveolarmakrophagen im Rahmen einer Bronchoskopie erhoben. Im Gegensatz zur bisher üblichen Bestimmung der Magenentleerungszeit per Szintigraphie konnten im Rahmen dieser Arbeit die Werte mit einem 13C-Acetat- Atemtest gemessen werden. Eine pathologische Magenentleerungszeit wurde bei ungefähr der Hälfte der Patienten dargestellt. Obwohl ein Zusammenhang zwischen der Magenentleerungszeit und anderen Untersuchungsbefunden vermutet wurde, konnte keine signifikante Korrelation aufgezeigt werde. Alle Testverfahren lieferten unterschiedliche Ergebnisse. Bei keinem Kind mit klinisch gesichertem gastroösophagealen Reflux waren alle erhobenen Parameter pathologisch. Die Verteilung der Ergebnisse erfolgte auch im grenzpathologischen Bereich nicht signifikant. Als Grund hierfür kann vermutet werden, dass der gastroösophageale Reflux bei Kindern unterschiedliche Ursachen hat. So könnte eine pathologische Magenentleerungszeit bei einem Teil der Kinder ursächlich sein oder im Vordergrund stehen, während andere pathologische Korrelate das gleiche Krankheitsbild verursachen. Die Diagnosestellung eines gastroösophagealen Reflux bei Kindern mit pulmonaler Symptomatik kann somit nur mit hinweisenden Untersuchungen erfolgen, bei denen auch Widersprüche geduldet werden müssen.Gastro-oesophageal reflux without gastroenterological symptoms such as vomiting or sour regurgitation can cause chronical illness of the lung in the childhood. Typical examples are asthma bronchiale or recurrent bronchitis, the overall incidence of lung problems related to gastro-oesophageal reflux is 1: 300 to 1: 500. To explain the pathophysiological process of gastro-oesophageal reflux multiple factors are being discussed. The pressure of the lower oesophageal sphincter, a decreased oesophageal clearance, a pathological gastric secretion, and delayed gastric emptying can be responsible. Different studies have described the relation between a pathological gastric emptying time and a gastro-oesophageal reflux with lung diseases, but its pathophysiologic role has not yet been established. Motility disorders are seen as important factors because significant relations between delayed gastric emptying and dysrhythmia (abnormal electric potentials) of the stomach have been described. Until present no diagnostic procedures with a high sensitivity and specificity to prove a gastro-oesophageal reflux are known. Present diagnostic techniques only cover some aspects of the illness and generate non-uniform results. 25 children suffering from gastro-oesophageal reflux related lung diseases were included into the study. In all of these gastric emptying time tests, a 24h oesophageal pH-monitoring, an upper stomach intestine passage and a quantitative testing of lipid laden alveolar macrophages were performed. In contrary to previous studies the gastric emptying time was measured with a 13Cacetate breath test. In half of the patients delayed gastric emptying was documented. Although a relation between the gastric emptying time and other tests was assumed, no statistical significance was found. All test procedures supplied different results. No patient with gastro-oesophageal reflux had a pathological result in all performed tests. The distribution of results was also non-significant in the border pathological range. It can be assumed that there are different reasons for gastro-oesophageal reflux in children. In some children a pathological gastric emptying time causes the problems whereas other pathological disorders may cause similar symptoms. Diagnostics of gastro-oesophageal reflux in children with pulmonal symptoms can only take place with referring examinations. Contradictions have to be accepted

Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics

<p>Abstract</p> <p>Background</p> <p>Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath^®Series 5 and GlideScope^®Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics.</p> <p>Methods</p> <p>Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated.</p> <p>Results</p> <p>Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath^®compared to the GlideScope^®and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath^®device (p < 0.001) compared to using the Macintosh blade.</p> <p>Conclusions</p> <p>The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath^®and GlideScope^®devices by paramedics.</p

Rigid fibrescope Bonfils: use in simulated difficult airway by novices

<p>Abstract</p> <p>Background</p> <p>The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade.</p> <p>Methods</p> <p>30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK) with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany) or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques.</p> <p>Results</p> <p>In normal airway all intubations were successful using laryngoscope (100%) vs. 82% using the Bonfils (p < 0.05). In the scenario "tongue oedema" success rate using the Macintosh laryngoscope was 67% and 83% using the Bonfils. In the scenario "decreased cervical range of motion with jaw trismus", success rate using the Macintosh laryngoscope was 84% vs. 76%. In difficult airway scenarios time until airway was secured did not differ between the two devices. Use of Bonfils was rated "easier" in both difficult airway scenarios.</p> <p>Conclusion</p> <p>The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.</p

Orogastric tube insertion using the new gastric tube guide : first experiences from a manikin study

Abstract Background Orogastric tube placement is a common procedure routinely used in clinical anesthesiology and intensive care medicine. Nevertheless high failure rates and severe complications have been reported. We conducted this study to evaluate if the usage of the new gastric tube guide would speed up the placement of orogastric tubes and ease the procedure. Methods Thirty one professionals were given a hands-on-training in orogastric tube placement in a simulation manikin without and with the gastric tube guide. Afterwards they performed both methods in randomized order. We recorded the placement time, counted the required attempts and asked the participants to rate their experience with both methods. Results The median placement time using the gastric tube guide was 14 s compared to 25 s without the device. In addition all participants were able to place the orogastric tube when using the gastric tube guide compared to 26/31 (84%) without it. Furthermore 26/31 (84%) users preferred the gastric tube guide over the standard method. Conclusion Our results show that using the gastric tube guide to place orogastric tubes in a manikin led to a significant shorter placement time and a higher overall success rate

Orogastric tube insertion using the new gastric tube guide: first experiences from a manikin study

Abstract Background Orogastric tube placement is a common procedure routinely used in clinical anesthesiology and intensive care medicine. Nevertheless high failure rates and severe complications have been reported. We conducted this study to evaluate if the usage of the new gastric tube guide would speed up the placement of orogastric tubes and ease the procedure. Methods Thirty one professionals were given a hands-on-training in orogastric tube placement in a simulation manikin without and with the gastric tube guide. Afterwards they performed both methods in randomized order. We recorded the placement time, counted the required attempts and asked the participants to rate their experience with both methods. Results The median placement time using the gastric tube guide was 14 s compared to 25 s without the device. In addition all participants were able to place the orogastric tube when using the gastric tube guide compared to 26/31 (84%) without it. Furthermore 26/31 (84%) users preferred the gastric tube guide over the standard method. Conclusion Our results show that using the gastric tube guide to place orogastric tubes in a manikin led to a significant shorter placement time and a higher overall success rate

Vergleich der Anwendung verschiedener extraglottischer Atemwegshilfen durch Laien am Phantom

Background!#!Supraglottic airways (SGA) are an established method of airway management both in prehospital medicine and clinical settings. Endotracheal intubation is the gold standard, but SGA offer advantages in terms of faster application learnability.!##!Objectives!#!In the present study it was investigated whether the time until the first sufficient ventilation in the three examined SGAs applied by bystander differed significantly.!##!Materials and methods!#!A total of 160 visitors to a shopping mall were assigned to one of the three SGA after permutative block randomization. The primary endpoint of the present study was the required placement time until the first sufficient ventilation.!##!Results!#!Participants managed to place the i‑gel laryngeal mask airway (i-gel, Intersurgical Beatmungsprodukte GmbH, Sankt Augustin, Germany) after a median time of 11 s, whereas the median time until the first sufficient ventilation using a classic laryngeal mask airway (LMA; 26 s) or a laryngeal tube (LT; 28 s) was significantly longer. Thus, the time savings when using the i‑gel compared to the LT and LMA were each significant (p &amp;lt; 0.001), whereas the times between LT and LMA did not differ significantly (p 0.65).!##!Conclusion!#!The results show that laypersons are able to successfully apply various supraglottic airways to the phantom after a short learning period. The i‑gel laryngeal mask could be placed with the highest success rate and speed

Bonfils intubation fibrescope : use in simulation-based intubation training for medical students in comparison to MacIntosh laryngoscope

BACKGROUND: A variety of instruments are used to perform airway management by tracheal intubation. In this study, we compared the MacIntosh balde (MB) laryngoscope with the Bonfils intubation fibrescope as intubation techniques. The aim of this study was to identify the technique (MB or Bonfils) that would allow students in their last year of medical school to perform tracheal intubation faster and with a higher success probability. Data were collected from 150 participants using an airway simulator [‘Laerdal Airway Management Trainer’ (Laerdal Medical AS, Stavanger, Norway)]. The participants were randomly assigned to a sequence of techniques to use. Four consecutive intubation ‘trials’ were performed with each technique. These trials were evaluated for differences in the following categories: the ‘time to successful ventilation‘, ‘success probability’ within 90 s,’time to visualisation’ of the vocal cords (glottis), and ‘quality of visualisation’ according to the Cormack and Lehane score (C&L, grade 1–4). The primary endpoint was the ‘time to successful ventilation‘in the fourth and final trial. RESULTS: There was no statistically significant difference in the ‘time to successful ventilation’ between the two techniques in trial 4 (‘time to successful ventilation’: median: MB: 16 s, Bonfils: 14 s, p = 0.244). However, the ‘success probability’ within 90 s was higher when using a Macintosh blade than when using a Bonfils (95 vs. 87 %). The glottis could be better visualised when using a Bonfils (C&L score of 1 (best view): MB: 41 %, Bonfils: 93 %), but visualisation was achieved more rapidly when using a Macintosh blade (median: ‘time to visualisation’: MB: 6 s, Bonfils: 8 s, p = 0.003). CONCLUSIONS: The time to ventilation using the MacIntosh blade and Bonfils mainly did to differ, however success probabilities and time to visualisation primary favoured the MacIntosh blade as intubation technique, although the Bonfils seem to have a steeper learning curve. The Bonfils is still a promising intubation technique and might be easier to learn as the MB, at least in a manikin

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia : the randomised multicentre EMMA trial study protocol

Introduction The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. Methods and analysis The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. Ethics and dissemination The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings