RESUMEN
Allied health personnel and nonanesthesiologist physicians often undergo training in tracheal intubation but then may actually use the skill relatively infrequently. This study assessed retention of skills one year after initial training and identified specific areas of knowledge critical to successful performance of intubation. Eleven respiratory therapists on the staff of a 253-bed hospital, each of whom had been trained one year previously in airway management, were evaluated. Prior to returning to the operating room for skills assessment and recertification, each respiratory therapist took a 21-question written exam. Therapists then went to the operating room and a trained observer (anesthesiologist) monitored the intubations performed to see whether critical steps were followed, while a second observer monitored a checklist of skills performed. The attending anesthesiologist recertified the therapist only when all steps were correctly performed and the intubation was successful. There was a poor correlation (r = -0.25, p > 0.1) between the number of intubations performed by the therapists for emergencies in the previous year and the number of intubations needed to be recertified. There was a negative correlation (r = -0.8, p < 0.05) between the score on the written test and the number of intubations required for recertification-a higher score meant fewer intubations were needed to achieve recertification. First-pass success occurred significantly more frequently if all skills tested were performed correctly (50/75 first-pass successes had all skills performed correctly vs 10/28 for failed first-pass, p < 0.01). The most common errors were levering the blade on the upper teeth (12/91) and tube not inserted from the right side of the mouth (28/104). When the blade was levered, 8 of 10 intubations failed. When the tube was not inserted from the right side of the face, 6 of 12 failed. The useful findings of this study are: (1) occasional performance of intubation did not ensure skill maintenance; (2) cognitive and procedural abilities correlated, suggesting benefits to study as well as to practical training; and (3) two specific mistakes were associated with a high incidence of failure.
Asunto(s)
Técnicos Medios en Salud/normas , Certificación , Competencia Clínica , Intubación Intratraqueal/normas , Servicio de Terapia Respiratoria en Hospital , Humanos , Washingtón , Recursos HumanosRESUMEN
OBJECTIVE: To determine the occurrence and nature of sleep-related breathing disorders in adults with traumatic brain injury (TBI). DESIGN: Prospective, observational, consecutive sample enrollment of subjects admitted for rehabilitation after TBI. SETTING: Inpatient rehabilitation and subacute rehabilitation units of a tertiary care university medical system. PARTICIPANTS: Subjects (n = 28) included adults with TBI and a Rancho Los Amigos Scale level of 3 or greater who were less than 3 months postinjury and admitted for comprehensive inpatient rehabilitation. INTERVENTIONS: Overnight sleep study using portable 6-channel monitoring system. MAIN OUTCOME MEASURE: Respiratory disturbance index (RDI), which is the number of apneic and hypopneic episodes per hour of sleep. RESULTS: Evidence of sleep apnea was found in 10 of 28 (36%) subjects as measured by a RDI level of 5 or greater and in 3 of 28 (11%) subjects as measured by a RDI level of 10 or greater. This rate of sleep apnea is significantly (p =.002) higher than would be predicted based on population norms. No correlation was found between the occurrence of significant sleep apnea and measures of TBI severity or other demographic variables. Sleep-related breathing disorders were primarily central though obstructive apneas were also noted. CONCLUSION: In this preliminary investigation, sleep-related breathing disorders as defined by a respiratory disturbance index of 5 or greater appears to be common in adult subjects with TBI.
Asunto(s)
Lesiones Encefálicas/complicaciones , Síndromes de la Apnea del Sueño/epidemiología , Adulto , Lesiones Encefálicas/rehabilitación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Síndromes de la Apnea del Sueño/etiología , Washingtón/epidemiologíaRESUMEN
OBJECTIVE: To determine the prevalence of sleep apnea in a sample of persons with chronic spinal cord injury (SCI) of varying injury levels and degrees of impairment. DESIGN: Cross-sectional study. SETTING: Inpatient SCI rehabilitation unit. PARTICIPANTS: Twenty men with SCI (motor complete and incomplete; American Spinal Injury Association classes A-D) of at least 1 year's duration, randomly selected from patients with SCI undergoing elective hospitalization. MAIN OUTCOME MEASURES: Apnea index, determined by sleep study (including chest wall movement, airflow, oxygen saturation), and daytime sleepiness, determined by Epworth sleepiness score. RESULTS: Eight subjects (40%) had sleep apnea, manifested by elevated apnea index (mean +/- SD, 17.1 +/- 6.9) and excessive daytime sleepiness. Sleep apnea was commonly diagnosed in motor-incomplete injuries. A trend (p = .07) existed toward a greater prevalence of sleep apnea with tetraplegia. Age and body mass index were not associated with sleep apnea. CONCLUSION: The prevalence of sleep apnea in men with chronic SCI admitted for nonrespiratory elective hospitalization is high relative to the general population.
Asunto(s)
Síndromes de la Apnea del Sueño/epidemiología , Traumatismos de la Médula Espinal/complicaciones , Adulto , Anciano , Estudios de Casos y Controles , Estudios Transversales , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Síndromes de la Apnea del Sueño/etiología , Síndromes de la Apnea del Sueño/fisiopatología , Síndromes de la Apnea del Sueño/terapia , Traumatismos de la Médula Espinal/rehabilitación , Estadísticas no Paramétricas , Resultado del Tratamiento , Washingtón/epidemiologíaRESUMEN
SUBJECT: It is occasionally desirable for patients with a tracheostomy tube to breathe through their native airway. We hypothesized that capped tracheostomy tubes with cuffs deflated would create substantial additional resistance to airflow without fenestration but would provide minimal resistance to airflow when the tube had a fenestration. METHODS: Two tracheal models were tested simulating a large (26 mm) and an average (18 mm) trachea. Tests were carried out with fenestrated and nonfenestrated tracheostomy tubes of sizes ranging from No. 4 to No. 10. Negative pressure inspiration was simulated using suction. RESULTS: With a large trachea or small tubes, the suction required to generate flows of 40 L/min or greater remained less than 5 cm H2O with or without a fenestration. However, with an average-sized trachea and no fenestration, the pressure required to generate flows of 40 L/min or greater exceeded 5 cm H2O and with No. 8 or No. 10 tubes exceeded 20 cm H2O. A fenestration routinely reduced the required pressure to less than 5 cm H2O. CONCLUSION: The effort required to move gas across the native airway in the absence of a fenestration may be substantial. If a patient is to breathe through a native airway, a fenestrated tube should be used unless the tracheostomy tube is a No. 4.
Asunto(s)
Intubación Intratraqueal , Traqueostomía , Diseño de Equipo , Gases , Humanos , Modelos Estructurales , PresiónRESUMEN
After documenting that the measured flow from a portable liquid oxygen device was different from the set flow and that this difference caused hypoxemia in a patient with chronic obstructive pulmonary disease, we compared the measured and set flows from 23 portable devices supplied by 2 different providers. Nine of 13 devices (69%) from Provider A gave measured flows that differed from the set flows at 14 of 65 (21%) settings (13 devices times 5 flow settings). Three of 10 devices (30%) supplied by Provider B gave measured flows that differed from the set flow in only 5 of 50 (10%) possible settings (10 units times 5 flow settings). Oxygen delivery may be inaccurate from portable liquid systems serviced by some suppliers. This problem may cause patients to become hypoxemic despite using the devices in the prescribed fashion.