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Traditionally, Scandinavian anaesthesiologists have had a very broad scope of practice, involving intensive care, pain and emergency medicine. European changes in the different medical fields and the constant reorganising of health care may alter this. Therefore, the Board of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) decided to produce a Position Paper on the future of the speciality in Scandinavia. The training in the various Scandinavian countries is very similar and provides a stable foundation for the speciality. The Scandinavian practice in anaesthesia and intensive care is based on a team model where the anaesthesiologists work together with highly educated nurses and should remain like this. However, SSAI thinks that the role of the anaesthesiologists as perioperative physicians is not fully developed. There is an obvious need and desire for further training of specialists. The SSAI advanced educational programmes for specialists should be expanded and include formal assessment leading to a particular medical competency as defined by the European Union of Medical Specialists (UEMS). In this way, Scandinavian anaesthesiologists will remain leaders in perioperative, intensive care, pain and critical emergency medicine.

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The use of noninvasive ventilation (NIV)/ventilatory assistance has in its modern form experienced a resurgence during the last two decades, primarily in the adult population. During the last few years, NIV, predominantly in the form of positive-pressure ventilation/ventilatory assistance, has also become an option in the paediatric population. Although the technique is increasingly being applied, data in this often very heterogeneous group of patients are still very limited, and are usually derived from case series and not randomised controlled studies. Available experience indicates that the technique is useful for children with a wide spectrum of hypercapnic and/or hypoxaemic respiratory disorders, in the acute as well as in the chronic setting. Results have shown improvements in survival and arterial blood gases, and have indicated better quality of life. Adverse effects are generally minor, although the impact on facial bony structures should be monitored closely during long-term ventilation. Considering the paucity of data, the area badly needs research, which preferentially should include: 1) short- and long-term effects and adverse effects in various conditions and age groups; 2) techniques, in particular interfaces and triggering mechanisms; 3) comprehensive plans for training of attendants, discharge and follow-up; and 4) quality of life measurements. As many of the conditions suited for noninvasive ventilation are very rare, much of the research would probably benefit from multicentre studies, or even studies on a European level.

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The objective of this study was to compare sound reflections in a flexible tube (flextube reflectometry) with pressure-catheter recordings (ApneaGraph) for identifying the predominant obstructive level of the upper airway during sleep. Seventeen males with suspected obstructive sleep apnoea syndrome (OSAS) were included in the study. The mean (standard deviation = SD) number of flextube narrowings per hour recording was 50.2 (20.4) and the mean (SD) RDI (respiratory disturbance index = apnoeas and hypopnoeas per hour recording) determined by the ApneaGraph was 45.7 (20.2). The mean difference (SD) between the number of flextube narrowings per hour recording and the RDIs determined by the ApneaGraph was not statistically significantly different from 0. There was no statistically significant correlation between the percentage of retropalatal narrowing of the total narrowing (retropalatal and retrolingual narrowing) measured by flextube reflectometry and the percentage of retropalatal ("upper") obstructive apnoeas and hypopnoeas of the total number ("upper", "intermediate" and "lower") measured by ApneaGraph (Spearman's correlation coefficient r = 0.24, p = 0.36, N = 17). In conclusion diverging results were found in flextube reflectometry studies and pressure-recordings performed on different nights regarding the level distribution of obstructions during sleep. Possible explanations of this discrepancy are discussed.

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The aim of this study was to examine an acoustic reflection method using a flexible tube for identifying the obstructive site of the upper airway in snorers and patients with obstructive sleep apnoea (OSA). As a preliminary study it was performed n models and subjects in the awake state. Flextube narrowing was produced in a model of the nose and pharynx and three blinded observers assessed the obstructive level. The correlation between pharyngeal narrowing assessed by endoscopy and by acoustic measurement during Müller manoeuvres was also examined in 10 OSA patients and 11 healthy non-snoring, adults. Three blinded observers dentified the level of 176 of 180 random cases of flextube narrowing in a polycarbonate model correctly The level of narrowing was always correctly evaluated within 1.9 mm. Pharyngeal area decrease was measured by the flextube method during the Müller manoeuvre but it was not closely related to the findings by endoscopy. In conclusion the flextube reflectometry method was able to demonstrate narrowng in a model of the nose and pharynx in a precise way. Narrowing was also observed during Müller manoeuvres. Flextube reflectometry may be a promising method to detect upper airway narrowing but further evaluation during sleep is required.

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The aim of this study was to examine a new technique based on sound reflections in a flexible tube for identifying obstructive sites of the upper airway during sleep. There was no significant difference between two nights in seven obstructive sleep apnoea (OSA) patients regarding the level distribution of pharyngeal narrowings, when the pharynx was divided into two segments (retropalatal and retrolingual). We also compared the level distribution determined by magnetic resonance imaging (MRI) with the level distribution found by flextube reflectometry in seven OSA patients. There was no significant difference between flextube and MRI level distributions during obstructive events, but due to few subjects the power of the test was limited. We found a statistically significant correlation between the number of flextube narrowings per hour of sleep and the number of obstructive apnoeas and hypopnoeas per hour of sleep determined by polysomnography (PSG) in 21 subjects (Spearman's correlation coefficient r = 0.79, P < 0.001). In conclusion, the flextube reflectometry system seems to be useful for level diagnosis in OSA before and after treatment.

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The Swedish Society of Chest Medicine has started a national register of patients on home mechanical ventilation, to establish reliable national prevalence data and to accurately document patient and treatment characteristics to enable a scientific evaluation of this treatment. In this first collection of retrospective register data, covering patients on home mechanical ventilation at the register start on 1 January 1996, we found 541 patients, corresponding to 6.1/100000 inhabitants, using home mechanical ventilation. Non-invasive ventilation, night-time ventilation and volume controlled ventilation dominated. We found four diagnosis categories of approximately equal size, namely post-polio, chest wall deformities, neuromuscular diseases and 'other diseases'. The age distribution was bimodal, with one small peak in the 20-29 year group and a large peak in the 60-69 year group. A survey of Danish patients on home mechanical ventilation showed that they were considerably younger and that almost half of them suffered from neuromuscular diseases. Further work will be done to follow the situation in Sweden and in Denmark to elucidate the obvious differences in the selection of patients for home mechanical ventilation.

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Ten patients without cardiac disease or pulmonary dysfunction were exposed to an inspiratory pressure of 0, 10 and 20 cmH2O, in random order, via a nasal mask during the first postoperative day after scoliotic surgery. These patients were in the supine position, and a BiPAP respiratory assist device was used. Arterial oxygen saturation increased significantly during the application of 10 and 20 cmH2O, while none of the haemodynamic parameters (cardiac output, central venous pressure, right ventricular ejection fraction, right ventricular end diastolic volume, mean pulmonary artery pressure, pulmonary artery wedge pressure, pulmonary vascular resistance) changed significantly, contrary to the findings during continuous positive airways pressure treatment. In addition, the BiPAP was generally well tolerated by the patients.

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INTRODUCTION: Positive expiratory airway pressure seems to dilate narrowed or collapsed airways, but this may be accompanied by a maintained and harmful increase in resting lung volume in obstructive pulmonary disease. PURPOSE: To evaluate the influence of inhaled terbutaline and positive expiratory pressure (PEP) on airway resistance (Raw) and functional residual capacity (FRC) in bronchial asthma. DESIGN: Randomized crossover design, single blind with regard to inhaled medication, open with regard to PEP (PEP can be felt). MATERIAL AND METHODS: Ten patients with bronchial asthma inhaled placebo and terbutaline in doses of 0.125 mg, 0.5 mg, and 1.5 mg by cone spacer combined with a facemask giving 0, 10, or 15 cm H2O PEP on separate days. FRC and Raw were measured by body plethysmography before and after inhalations. Data were analyzed by analysis of variance with terbutaline dose and PEP as factor levels. RESULTS: The effect of terbutaline: Raw decreased significantly (p < 0.0001) after 0.125 mg and 1.5 mg. The FRC did not change significantly. The effect of PEP: Raw decreased, but significantly only when the dose of 1.5 mg terbutaline was excluded from the analysis. Raw decreased with PEP 10 and 15 cm H2O, mean 0.6 (95 percent CI: -1.1, -0.2) and 0.9 (95 percent CI: -1.3, -0.4) cm H2O/L/s. The FRC did not change significantly with the PEP level. CONCLUSION: PEP only had influence on Raw when insufficient doses of terbutaline were inhaled, whereas once an efficient dose of terbutaline was administered, significant bronchodilation was achieved with or without PEP. Positive expiratory pressure did not increase FRC.

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The purpose of this study was to evaluate the in- and expiratory pressures achieved by the use of different continuous positive airway pressure (CPAP) delivery systems. The study was performed on ten healthy adults breathing spontaneously with: 1) "simple CPAP", consisting of a fresh gas flow around 40 l/min and reservoir balloons of 2, 6 and 10 l and expiration against a water column, 2) a high-flow system CR60 CPAP, designed for home treatment and 3) another high-flow system Down's CPAP. Both high-flow systems used a venturi device (Downs Flow Generator, Vital Signs) giving flows around 90 and 170 l/min in our set-up, and the same PEEP valves (Vital signs) were used. All systems were tested with expiratory pressures set at 5, 10 and 20 cm H2O. Individual responses were found, but in general the simple CPAP with a 10 l latex balloon reservoir gave optimal CPAP. The high-flow systems were not found to provide better CPAP, however, CR60 CPAP was found also to be optimal with 5 and 10 cm H2O. Down's CPAP provided 3-5 cm higher expiratory pressure than the intended CPAP level. We recommend measurement of the pressure during the CPAP treatment to ensure that the intended CPAP is achieved.

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The influence of positive expiratory pressure (PEP) applied during inhalation of a beta 2-agonist in treatment of bronchial asthma was investigated in a randomized crossover study with two-week treatment periods. In one period, two puffs (0.5 mg) of terbutaline was given from a metered dose inhaler and inhaled through a device consisting of a conespacer connected to a facemask giving PEP (10 to 15 cm H2O). In a second period, terbutaline 0.5 mg was inhaled similarly but without PEP, and in a third period placebo spray was inhaled with PEP. Treatments were given three times daily. Peak expiratory flow (PEF) was measured before and after each inhalation and symptom scores for dyspnea, cough, and mucus production were noted in a diary. All treatments increased PEF significantly (p less than 0.0001). The mean increase was 32 L/min during treatment with terbutaline and PEP. This was greater than the increase of 25 L/min during terbutaline treatment (p = 0.005). The increase in PEF during terbutaline treatment was significantly higher than the achieved 18 L/min during PEP (p = 0.026). The study showed improved bronchodilation when PEP was combined with inhalation of beta 2-agonist compared with beta 2-agonist alone.

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In a randomized, double-blind, controlled study, 153 patients with claudication were each given either 20 infusions of Na2EDTA or 20 infusions of saline. Walking distances and ankle/brachial indices were measured before, during, and after treatment. In 30 patients, angiograms and transcutaneous oxygen tensions were obtained before, during, and after treatment. The patients' subjective evaluations of the effect of treatment were also recorded. It is concluded that EDTA chelation therapy has no effect in patients with intermittent claudication in the legs caused by arteriosclerosis.

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The effect of positive expiratory pressure (PEP) and inhaled terbutaline was evaluated in ten patients with chronic obstructive pulmonary disease in a randomized cross-over study with three 2 weeks periods. In one period 5 mg terbutaline was inhaled 3 times daily from a nebulizer combined with PEP. In a second period 5 mg terbutaline was inhaled similarly but without PEP and in a third period placebo inhalations were combined with PEP. Symptom score and peak expiratory flow (PEF) measured before and after each inhalation was noted in a diary. The treatment with nebulized terbutaline combined with PEP gave the best relief in symptoms. All treatments increased PEF significantly. PEP alone gave the least increase in PEF (25 1/min), and there was no difference between the increase in PEF after terbutaline inhaled with PEP (28 1/min) compared to terbutaline alone (29 1/min).

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Immunotherapy (IT) in venom-allergic patients has been demonstrated to provide a highly efficient protection from severe reactions to a re-sting. It is not known whether this protection will persist after IT is stopped in patients with remaining venom sensitivity. In 25 adult patients with a previous severe systemic reaction to a Hymenoptera insect sting, 28 in-hospital sting challenges after stopping IT resulted in no systemic reactions. The mean duration of venom IT was 42.8 months (range, 36 to 83 months), and the mean time interval from the time IT was stopped until sting challenge was, in mean, 25.2 months (range, 12 to 36 months). The mean venom-specific IgE after stopping IT was 2.4 PRU/ml (range, 0 to 16.9 PRU/ml), at the day of sting challenge, 2.7 PRU/ml (range, 0 to 22 PRU/ml), and 2 weeks later, 2.4 PRU/ml (range, 0.02 to 27.8 PRU/ml). These changes in IgE were not significant. Venom-specific IgG concentration when IT was stopped was 64 PU/ml (range, 20 to 144 PU/ml), decreasing significantly to the day of sting challenge to 41.1 PU/ml (range, 13 to 84 PU/ml), and 2 weeks later, a significant increase to a mean of 53.5 PU/ml (range, 12 to 117 PU/ml) was found. Our results suggest that venom IT may be stopped after 3 years, regardless of the level of specific antibodies. To confirm this finding, a larger number of patients should be studied.

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The aim of this study was to determine the effects of postural changes on lung function in pregnant women during the first, second, third trimester and post partum. A significant decrease in FRC, PEF and FEV1 was observed as a result of the postural changes. Arterial oxygenation, MVV and DLCO remained largely the same.

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In a prospective study of traumatic lesions of the volar fibrocartilage of the PIP joint, 56 patients were randomized to treatment by immobilization for 3 weeks and 56 patients, to purely analgetic treatment without immobilization. Seventy-eight patients were reexamined 6 months later and 77 patients, in a follow-up study 2-3 years after the injury. No difference was found between the two groups with respect to subjective complaints or objective signs.

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