High-flow via a tracheostomy tube and speaking valve during weaning from mechanical ventilation and tracheostomy

Background

Weaning from mechanical ventilation and tracheostomy after prolonged intensive care consume enormous resources with optimal management not currently well described. Restoration of respiratory flow via the upper airway is essential and early cuff-deflation using a one-way valve (OWV) is recommended. However, extended OWV use may cause dry airways and thickened secretions which challenge the weaning process. High-flow therapy via the tracheostomy tube (HFT-T) humidifies inspired air and may be connected via an in-line OWV (HFT-T-OWV) alleviating these problems. We aim to provide clinical and experimental data on the safety of HFT-T-OWV along with a practical guide to facilitate clinical use during weaning from mechanical ventilation and tracheostomy.

Methods

Data on adverse events of HFT-T-OWV were retrieved from a quality register for patients treated at an intensive care rehabilitation center between 2019 and 2022. Benchtop experiments were performed to measure maximum pressures and pressure support generated by HFT-T-OWV at 25–60 L/min flow using two different HFT-T adapters (interfaces). In simulated airway obstruction using a standard OWV (not in-line) maximum pressures were measured with oxygen delivered via the side port at 1–3 L/min.

Results

Of 128 tracheostomized patients who underwent weaning attempts, 124 were treated with HFT-T-OWV. The therapy was well tolerated, and no adverse events related to the practice were detected. The main reason for not using HFT-T-OWV was partial upper airway obstruction using a OWV. Benchtop experiments demonstrated HFT-T-OWV maximum pressures <4 cmH₂O and pressure support 0–0.6 cmH₂O. In contrast, 1–3 L/min supplemental oxygen via a standard OWV caused pressures between 84 and 148 cmH₂O during simulated airway obstruction.

Conclusions

Current study clinical data and benchtop experiments indicate that HFT-T-OWV was well tolerated and appeared safe. Pressure support was low, but humidification may enable extended use of a OWV without dry airway mucosa and thickened secretions. Results suggest the treatment could offer advantages to standard OWV use, with or without supplementary oxygen, as well as to HFT-T without a OWV, for weaning from mechanical ventilation and tracheostomy. However, for definitive treatment recommendations, randomized clinical trials are needed.     

丙泊酚复合瑞芬太尼喉罩全麻的效果分析与研究

目的 探讨丙泊酚复合瑞芬太尼喉罩全身麻醉(全麻)的效果。方法 62例腹腔镜、泌尿科、骨科、肛肠科、妇科等手术治疗的患者,随机分为实验组和对照组,每组31例。对照组采用常规气管插管静脉复合全麻,实验组给予靶控输注丙泊酚复合瑞芬太尼喉罩全麻。比较两组患者插入喉罩(插管)、插管1 min、插管3 min、拔出喉罩(拔管)1 min、拔管3 min时心率(HR)和平均动脉压(MAP)水平;不良反应发生情况、麻醉效果;全麻起效时间、维持全麻时间、术后苏醒时间。结果 实验组插管时、插管1 min、插管3 min、拔管1 min、拔管3 min的HR水平分别为(77.52±6.36)、(73.26±5.56)、(72.01±4.69)、(75.35±7.63)、(72.34±6.79)次/min,均低于对照组的(92.34±7.85)、(87.97±5.25)、(78.85±5.20)、(95.69±9.21)、(85.63±7.43)次/min,差异均具有统计学意义(P<0.05)。实验组插管时、插管1 min、插管3 min、拔管1 min、拔管3 min的MAP水平分别为(90.25±6.73)、(87.65±7.98)、(88.79±7.65)、(88.09±5.61)、(88.52±5.16)mm Hg(1 mm Hg=0.133 kPa),均低于对照组的(109.51±7.85)、(103.27±12.43)、(102.52±8.21)、(106.74±7.68)、(104.62±7.71)mm Hg,差异均具有统计学意义(P<0.05)。实验组不良反应发生率3.23%低于对照组的19.35%,差异具有统计学意义(P<0.05)。实验组麻醉总有效率96.77%均高于对照组的80.65%,差异均具有统计学意义(P<0.05)。实验组全麻起效、维持全麻、术后苏醒时间分别为(1.61±0.23)、(100.59±6.72)、(17.99±3.52)min,均短于对照组的(2.93±0.41)、(123.61±7.85)、(36.87±4.16)min,差异均具有统计学意义(P<0.05)。结论 针对腹腔镜等手术患者应用丙泊酚复合瑞芬太尼喉罩全麻对血液动力学影响小,不良反应发生率低,麻醉效果良好,降低对机体损伤,值得推广应用。     

Exercise-induced laryngeal obstruction: From clinical examination to continuous laryngoscopy during exercise

The diagnosis of exercise-induced laryngeal obstruction (EILO) should be suspected when exercise triggers inspiratory stridor. EILO is common in adolescent populations and has a significant impact on sports. Identification of laryngeal obstruction during continuous laryngoscopy during exercise (CLE) is the gold standard diagnostic tool for this disorder, which is not widely known in France. The challenge faced by otolaryngologists is to identify, among patients referred by pulmonologists or sports physicians, those with exercise-induced inspiratory symptoms or poorly controlled exercise-induced asthma, in whom a diagnosis of EILO is strongly suspected. Laryngoscopy at rest may reveal a laryngeal, glottic or supraglottic abnormality predictive of obstruction at increased inspiratory airflow. When pulmonary function tests are normal or in the case of failure of treatment of exercise-induced asthma, the otolaryngologist must complete the examination by a CLE test to confirm the diagnosis of EILO and identify the site of obstruction. This examination is well tolerated, minimally invasive and allows identification of the site of airflow obstruction, allowing specific conservative or surgical treatment. This technical note describes in detail clinical examination and CLE testing in patients with suspected EILO.     

Proseal喉罩在妇科腹腔镜手术麻醉中的应用研究

目的探究分析Proseal喉罩在妇科腹腔镜手术麻醉中的具体应用和临床价值。方法此项研究的考察对象为本院妇科于2017年7月—2019年7月期间医治的80名腹腔镜手术患者,经随机方式把这些患者归入参照组(n=40)、试验组(n=40)。前者在手术麻醉中安排气管插管,试验组患者在手术麻醉中安排Proseal喉罩,对比两组腹腔镜手术患者的生命体征(心率HR、平均动脉压MBP)的变化、术中并发症发生率和术后不良反应率。结果试验组腹腔镜患者插罩前和取罩后的生命体征无明显变化,差异无统计学意义(P>0.05),对照组患者插管前和拔管后的生命体征有明显变化,且试验组患者的术中并发症发生率与术后不良反应率相较参照组皆偏低(P<0.05)。结论Proseal喉罩在妇科腹腔镜手术麻醉中的应用相对于气管插管具有更高的稳定性和安全性,能够保证患者血流动力学平稳,且并发症的发生率更低。     

预注右旋美托咪啶用于喉显微手术麻醉的研究

目的研究分析预注右旋美托咪啶用于喉显微手术麻醉中的临床效果。方法选取2017年12月—2018年12月本院收治的80例行喉显微手术治疗的患者为观察对象,并将其随机分为普通组与观察组,每组各40例,普通组中患者行常规诱导麻醉,观察组中患者行预注右旋美托咪啶诱导麻醉,比较两组麻醉应用效果。结果在T1、T4、T5时段,观察组患者HR、MAP水平均低于普通组,其血流动力学稳定,且不良反应发生率相比普通组降低,两组间比较差异有统计学意义(P<0.05)。结论对行喉显微手术患者在应用预注右旋美托咪啶麻醉,能改善患者血流动力学指标水平,减少患者不良反应。     

甲状腺癌术后复发再手术中甲状旁腺和神经保护

甲状腺癌是一种十分常见的恶性肿瘤，其病理类型大多数为分化型甲状腺癌，经规范化治疗，预后较好，但仍有部分病人复发，且长期随访，可有高达30%以上的复发或转移率。因此，再次手术是甲状腺外科医师不可避免的问题，甚至在未来一段时间会成为一个临床常见情况。再次手术，尤其是Ⅵ区淋巴结复发的再次手术，往往有较高的手术难度和风险，需要谨慎地选择手术时机和入路，术中应用神经监测与传统显露技术相结合以保护喉返神经，运用传统识别和保护手法，选择性应用纳米炭、甲状旁腺素试纸、近红外自体荧光显像等技术以保护甲状旁腺功能。     

CrkⅡ表达水平对喉癌细胞Hep-2增殖、迁移及侵袭的影响

目的探讨CrkⅡ表达水平对喉癌细胞Hep-2增殖、迁移及侵袭的影响。方法采用免疫组化法检测CrkⅡ在108例喉癌患者喉癌组织及癌旁正常组织中的表达情况,分析不同临床特征喉癌患者喉癌组织中CrkⅡ蛋白的阳性表达情况。构建并验证CrkⅡRNA干扰质粒,将培养后的Hep-2细胞分为空白对照组(未转染质粒)、阴性对照组(转染阴性对照质粒)和实验组(转染CrkⅡ干扰质粒),细胞转染后行实时聚合酶链反应(PCR)扩增。采用蛋白质印迹法(Western blot)检测转染后Hep-2细胞中CrkⅡ的表达水平,噻唑蓝(MTT)法检测细胞的增殖情况,Transwell实验检测细胞的侵袭和迁移能力,细胞划痕实验检测细胞的迁移情况。结果喉癌组织中CrkⅡ蛋白的阳性表达率明显高于癌旁正常组织(P﹤0.01)。临床分期为Ⅲ~Ⅳ期、组织分化程度为中低分化、有淋巴结转移喉癌患者喉癌组织中CrkⅡ蛋白的阳性表达率均高于临床分期为Ⅰ~Ⅱ期、组织分化程度为高分化、无淋巴结转移的喉癌患者(P﹤0.05)。实验组喉癌细胞Hep-2中CrkⅡmRNA和蛋白的相对表达量均低于阴性对照组、空白对照组(P﹤0.05)。实验组穿过基质膜至下室的细胞数目低于阴性对照组和空白对照组(P﹤0.05)。转染48 h时,实验组细胞的迁移率低于阴性对照组、空白对照组(P﹤0.05)。细胞培养24、48、72 h时,实验组Hep-2细胞的光密度(OD)值均低于空白对照组和阴性对照组(P﹤0.05)。结论喉癌细胞Hep-2中CrkⅡ的表达下调可降低细胞的增殖、迁移和侵袭能力,CrkⅡ有可能成为喉癌临床治疗的新靶点。     

Poor prognostic factors in post-traumatic endophthalmitis following open globe injury

The use of personal protective equipment (PPE) for ophthalmologists caring for asymptomatic patients remains controversial. This commentary reviews the latest emerging evidence. This is paramountly important in shaping health policies in countries which is not currently recommended.