Objectives: Critical care teams are encouraged to follow best practice protocols to help wean mechanically ventilated patients from the ventilator to reduce ventilator-associated events including ventilator-associated conditions, probable ventilator-associated pneumonias, and infection-related ventilator-associated conditions. Providers monitor for alerts suggestive of possible ventilator-associated events and advise when patients should undergo spontaneous breathing trials. Compliance with protocols in most units is suboptimal. Design: Retrospective review of clinical data over 24 months. Setting: St. Joseph Mercy Hospital Candler Hospital Medical-Surgical ICU. Patients: All mechanically ventilated patients. Interventions: The Respiratory Knowledge Portal was implemented in our ICU. For 13 months, Respiratory Knowledge Portal data were ported to ICU workstations (control). For the following 11 months, Respiratory Knowledge Portal data were also presented on tablet computers (intervention) for use during multidisciplinary rounds. We performed a retrospective review of Respiratory Knowledge Portal data from before and after the implementation of the tablet computers. Measurements and Main Results: Data were collected from 337 patients (187 control group, 150 intervention group). A decrease in the occurrence of ventilator-associated events was observed during the intervention group compared with the control group. Only 2.0% of patients in the intervention group experienced any category of ventilator-associated event, while 11.2% of patients in the control group experienced one event ( p = 0.003). Intervention patients experienced less ventilator-associated conditions ( p = 0.002), infection-related ventilator-associated conditions ( p = 0.026), and probable ventilator-associated pneumonias ( p = 0.036) than control patients. Twenty-one of the 24 patients with any ventilator-associated events were in the control group. There was no significant difference between the days spent on ventilation nor hospital length of stay in the control compared with intervention group patients. Conclusions: Fewer ventilator-associated events, ventilator-associated conditions, infection-related ventilator-associated conditions, and probable ventilator-associated pneumonias were seen during the period when Respiratory Knowledge Portal monitoring data was presented on tablet computers. There was no difference in time on ventilator nor overall length of stay.
Background: SuperNO 2 VA TM Et Nasal Mask (Vyaire Medical, Inc., United States) is a new nasal mask with an integrated sampling hood to capture exhaled gases and enable accurate measurements of end tidal carbon dioxide (EtCO 2). The authors hypothesized that the SuperNO 2 VA Et design would measure EtCO 2 more accurately than a predicate EtCO 2 sampling line, the Smart CapnoLine® Plus, Adult/Intermediate CO 2 Oral-Nasal Set (Medtronic, United States). Methods: A simulated patient setup enabled comparison of the accuracy of CO 2 measurements within the SuperNO 2 VA Et and a predicate device for eight condition combinations of input CO 2 ; breath rate and tidal volume (VT); and O 2 flow rates. These tests were repeated with simulating Nasal Breathing and Oral Breathing. Results: Testing demonstrated that measurements of 1% and 5% input CO 2 within the SuperNO 2 VA Et were accurate for a range of respiratory rates, VT, O 2 flows, and CO 2 concentrations. CO 2 measurement errors were significantly larger for the Oral-Nasal Set compared to the SuperNO 2 VA Et for both 1% Input CO 2 (−0.12%vol vs. −0.01%vol, p = 0.0005) and 5% Input CO 2 (−0.93%vol vs. −0.08%vol, p < 0.0001). At 5% Input CO 2 , eight of the 12 trials for the Oral-Nasal Set failed to meet the ISO accuracy specification, while all SuperNO 2 VA Et measurements met the specification. The accuracy of CO 2 measurement within the Super-NO 2 VA were not different for Oral and Nasal Breathing trials for both CO 2 concentration (1%: p = 0.33, 5%: p = 0.064). With the Oral-Nasal Set, CO 2 measurements were lower during Oral compared to Nasal Breathing (1%: p = 0.
Upper airway obstruction during anesthesia is the leading cause of complications during sedation, intubation, and emergence. Devices to support oxygenation and ventilation are costly, require capital equipment, and cannot be used during transport. We present a 46-year-old man with sleep apnea and anticipated difficult airway undergoing a cardiac ablation under general endotracheal intubation. The SuperNO2VA nasal mask provided high-flow nasal oxygen and positive pressure during awake fiberoptic intubation and on extubation, maintaining airway patency in the operating room, during transport, and in recovery. The SuperNO2VA is inexpensive and portable and should be considered for high-risk patients with difficult airways.
Postoperative pulmonary complications are common after major neck surgery, with airway compromise a leading cause for hypoxemia, hypercarbia, and reintubation. There are advantages to tracheal extubation upon emergence from anesthesia when appropriate. Recognizing that reintubation in the setting of upper airway obstruction or respiratory compromise may be challenging with presence of a cervical collar or anatomic changes following surgery. We present a 42-year-old man who underwent emergent cervical decompression and fusion with corpectomy following blunt force trauma. Upon emergence, a deep extubation was performed directly to the SuperNO2VA nasal mask connected to a Mapleson C circuit. This is a nasal positive pressure device used to maintain upper airway patency and provide ventilatory support during emergence. While in the intensive care unit, the patient was weaned to nasal cannula. However, mental status remained poor; and upper airway obstruction ensued leading to hypoxemic respiratory insufficiency, as shown by arterial blood gas. The SuperNO2VA was replaced with normalization of respiratory function and blood gas analysis. After 14 hours, including the use of SuperNO2VA during transport to and use inside the computed tomography scanner, the patient’s mental status recovered and ventilatory support was downgraded to nasal cannula without further events. Nasal positive pressure via the SuperNO2VA device as described may offer an inexpensive, transportable option for providing airway and ventilatory support in high-risk patients with anticipated difficult airways.
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