OZLJEDE DIŠNOG PUTA KOD TRAUME DIŠNOG PUTA

Upper airway trauma patients have to be treated as diffi cult airway patients in pre-hospital and hospital settings. Airway management is included in the prehospital trauma care and advanced trauma care. The aim of this article is to present clinical observations that pertain to airway management in upper airway trauma patients, including clinical approach to traumatized upper airway, diffi culties in airway management in these patients, defi nition of failed airway, algorithm for failed airway, anticipation and decision-making. Clinical approach to upper airway is the fi rst step that clinicians usually do. Traumatized airway is by the book diffi cult airway that does not need the same procedure of prediction that we use evaluating the airway. Diffi culties in airway management in trauma patients include diffi culties in laryngoscopy and intubation, diffi cultbag-mask ventilation and diffi culties in the use of supraglottic devices. In the severely upper airway traumatized patients, a clear defi nition of airway failure is necessary, as well as an action plan to follow when this occurs. According to Diffi cult Airway Society guidelines for management of unanticipated diffi cult intubation in adults, failed airway exists when there have been three failed attempts by an experienced anesthetist, or there has been one failed attempt by an experienced anesthetist combined with inability to maintain adequate oxygen saturation. Repeated attempts of intubation carry the risk of traumatizing the already traumatized upper airway. The time and ability to think clearly are limited in this situation, so airway algorithm can be used in these situations. On the other hand, there are many failed airway algorithms developed by the societies. The most important points in those algorithms are anticipation and decision-making, decision driven by whether there is suffi cient time to consider alternatives. If ‘cannot intubate, cannot oxygenate’ scenario arises, the pathway leads to the front open neck access (FONA). It is perfectly appropriate to attempt rapid placement of laryngeal mask airway (LMA) simultaneously with preparation for FONA. The attempt of LMA placement must not delay the initiation of the defi nitive airway and must be accomplished in parallel with the preparations for FONA. Reasons for diffi cult FONA can be penetrating or blunt neck trauma. Trauma-related diffi culty in these situations is distorted or disrupted airway. Cricothyroid membrane could be accessible or injured. Low tracheotomy is a solution for airway establishing in this situation.Bolesnici s ozljedama gornjeg dišnog puta moraju biti tretirani kao bolesnici s teškim dišnim putem, u predbolničkom i bolničkom okruženju. Upravljanje dišnim putem uključeno je u predbolničku skrb i naprednu skrb. Cilj ovog rada je prikazati klinička opažanja koja se odnose na liječenje dišnog puta u bolesnika s ozljedama gornjeg dišnog puta, uključujući klinički pristup traumatiziranim gornjim dišnim putovima, poteškoće u uspostavljanju dišnog puta kod takvih pacijenata, defi niranje neuspjelog dišnog puta, algoritam za neuspjeli dišni put, predviđanje i odlučivanje. Klinički pristup gornjem dišnom putu je prvi korak koji kliničari obično rade. Traumatizirani dišni put zahtijeva istu procjenu predviđanja teškoća pri tretmanu, koji koristimo i za procjenu netraumatiziranog dišnog puta. Teškoće u uspostavljanju dišnog puta kod bolesnika s traumom su: poteškoće u laringoskopiji i intubaciji, otežana ventilacija pomoću maske i poteškoće u upotrebi supraglotičkih uređaja. Kod pacijenata s ozbiljno traumatiziranim gornjim dišnim putem neophodna je jasna defi nicija zatajenja uspostavljanja dišnog puta, kao i akcijski plan koji će nakon toga slijediti. Prema smjernicama Diffi cult Airway Society za upravljanje neočekivanom teškom intubacijom kod odraslih, neuspješnom intubacijom se smatra nakon tri neuspjela pokušaja iskusnog anesteziologa ili nakon jednog neuspjelog pokušaja iskusnog anesteziologa u kombinaciji s nemogućnošću održavanja dovoljne zasićenosti kisikom. Ponovljeni pokušaji intubacije nose rizik od traumatizacije već traumatiziranog gornjeg dišnog puta. Vrijeme i sposobnost jasnog razmišljanja u ovoj situaciji ograničeni su pa se u tim situacijama treba koristiti DAS-ovim algoritmom. S druge strane, postoji puno propalih algoritama dišnog puta koje su propisala nacionalna stručna društva. Ono što je najvažnije u tim algoritmima i u svima isto, jest predviđanje i donošenje odluka. Odluke su vođene s obzirom na to ima li dovoljno vremena za razmatranje alternativa. Ako se u bilo koje vrijeme ne može intubirati i ne može dati kisik, nastaje scenarij CICO (ne može se intubirati, ne može se oksigenirati) i jedino rješenje je otvaranje prednjeg pristupa vratu (FONA). Odgovarajuće je pokušati brzo postaviti laringealnu masku (LMA) istovremeno s pripremanjem za FONA. Pokušaj postavljanja LMA ne smije odgoditi inicijaciju konačnog dišnog puta i mora se učiniti paralelno s pripremama za FONA. Razlozi za tešku FONA mogu biti unutarnje ili otvorene ozljede vrata. Teškoće vezane uz povredu u takvim situacijama su iskrivljeni ili poremećeni dišni put. Krikotireoidna membrana može biti dostupna ili ozlijeđena. U takvoj situaciji rješenje za uspostavu dišnog puta je traheotomija

Nove tehnike i uređaji za obradu poteškoća u disanju

The purpose of this review is to compare old conventional techniques and devices for difficult airway management and new sophisticated techniques and devices. Recent techniques and devices are defined as the American Society of Anesthesiology (ASA) practice guidelines for the management of difficult airway, published in 1992, reviewed in 1993 and updated in 2003. According to ASA, the techniques for difficult airway management are divided into techniques for difficult intubation and techniques for difficult ventilation. Awake fiberoptic intubation is the technique of choice for difficult airway management prescribed by the World Health Organization document for patient safety in the operating theater. Conventional techniques for intubation used direct visualization. The new generation of devices does not require direct visualization of the vocal cords for endotracheal tube placement. They allow better glottis view and successful endotracheal placement of the tube with indirect laryngoscopy. New intubation devices such as video laryngoscopes facilitate endotracheal intubation by indirect visualization of glottis structures without aligning the oral, pharyngeal and laryngeal axes in patients with cervical spine abnormality. Video laryngoscopes such as V-Mac and C Mac, Glide scope, McGrath, Airway Scope, Airtraq, Bonfils and Bullard laryngoscope are widely available at the market. Airway gadgets are lighted stylets and endotracheal tube guides. The principal conclusion of this review is that utilization of these devices can be easily learned. The technique of indirect laryngoscopy is currently used for managing difficult airway in the operating room as well as for securing the airway in daily anesthesia routine.Cilj ovog osvrta je usporediti stare konvencionalne tehnike i uređaje za obradu poteškoća u disanju i nove sofisticirane tehnike i uređaje. Dosadašnje tehnike i uređaje propisala je ASA (Američko udruženje anesteziologa) kao praktične smjernice u obradi poteškoća u disanju, iste su objavljene 1992., revidirane 1993. i ažurirane 2003. godine. Prema ASA tehnike za obradu poteškoća u disanju podijeljene su na tehnike za poteškoće pri intubaciji i poteškoće pri ventilaciji. Budna fiberoptička intubacija kao tehnika izbora u obradi poteškoća u disanju propisana je dokumentom Svjetske zdravstvene organizacije o sigurnosti bolesnika u operacijskoj dvorani. Konvencionalne tehnike intubacije koriste direktnu vizualizaciju. Nova generacija uređaja ne zahtijeva direktnu vizualizaciju glasnih žica pri postavljanju endotrahealnog tubusa. Oni omogućavaju bolju vizualizaciju i uspješnu endotrahealnu intubaciju putem indirektne laringoskopije. Novi uređaji za intubaciju, kao video laringoskop, olakšavaju endotrahealnu intubaciju indirektnom vizualizacijom struktura grla bez premještanja oralne, faringealne i laringealne osi bolesnika s abnormalnostima vratne kralježnice. Video laringoskopi kao V-Mac i C-Mac, Glide skop, McGrath, Airway skop, Aertracq, Bonfils i Bullard lako su dostupni na tržištu. Naprave za disanje su svjetleće sonde i endotrahealni vodiči (ili vodiči endotrahealnog tubusa). Zaključak ovog osvrta je da se primjena ovih uređaja može lako naučiti. Tehnika indirektne laringoskopije već se koristi u obradi poteškoća u disanju, kao i u svakodnevnoj anesteziološkoj praksi

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise. The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included.Peer reviewe