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ABSTRACT BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

RESUMO JUSTIFICATIVA E OBJETIVOS: A incidência de via aérea difícil chega a 10% das intubações de emergência. Ainda que poucos estudos abordem o emprego de guia introdutor artesanal no ambiente de emergência e terapia intensiva, há descrições de guias produzidas de forma artesanal disponíveis na internet. Nosso objetivo é descrever uma série de casos sobre o uso de um guia introdutor (Bougie) artesanal para intubação de emergência em pacientes com Via Aérea Difícil. RELATO DE CASO: O guia introdutor artesanal foi utilizado em cinco pacientes consecutivos com via aérea difícil, instabilidade clínica e falta de outro método imediato para a obtenção de uma via aérea. Essa técnica proporcionou sucesso na intubação e não houve complicações. CONCLUSÕES: A utilização do guia introdutor artesanal pode ser uma opção útil para o manejo de via aérea difícil.

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BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

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BACKGROUND AND OBJECTIVES: The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway. CASE REPORT: The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications. CONCLUSIONS: The use of the handmade introducer guide can be a useful option for the management of difficult airways.

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OBJECTIVE: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. METHODS: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). RESULTS: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. CONCLUSIONS: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.

OBJETIVO: O ultrassom pulmonar (USP) à beira do leito é uma técnica de imagem não invasiva e prontamente disponível que pode complementar a avaliação clínica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar à beira do leito em situações de emergência) demonstrou elevado rendimento diagnóstico em pacientes com insuficiência respiratória aguda (IRpA). Recentemente, um programa de treinamento em USP à beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acurácia do USP baseado no protocolo BLUE, quando realizado por médicos com habilidades básicas em ultrassonografia, para orientar o diagnóstico de IRpA. MÉTODOS: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Após treinamento, 4 operadores com habilidades básicas em ultrassonografia realizaram o USP em até 20 minutos após a admissão na UTI, cegados para a história do paciente. Os diagnósticos do USP foram comparados aos diagnósticos da equipe assistente ao final da internação na UTI (padrão-ouro). RESULTADOS: Foram inclusos na análise 37 pacientes (média etária: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnóstico do USP demonstrou concordância com o diagnóstico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogênico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnóstico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogênico, respectivamente. CONCLUSÕES: O USP baseado no protocolo BLUE foi reproduzível por médicos com habilidades básicas em ultrassonografia e acurado para o diagnóstico de pneumonia e de edema pulmonar cardiogênico.

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Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema. .

Objetivo: O ultrassom pulmonar (USP) à beira do leito é uma técnica de imagem não invasiva e prontamente disponível que pode complementar a avaliação clínica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar à beira do leito em situações de emergência) demonstrou elevado rendimento diagnóstico em pacientes com insuficiência respiratória aguda (IRpA). Recentemente, um programa de treinamento em USP à beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acurácia do USP baseado no protocolo BLUE, quando realizado por médicos com habilidades básicas em ultrassonografia, para orientar o diagnóstico de IRpA. Métodos: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Após treinamento, 4 operadores com habilidades básicas em ultrassonografia realizaram o USP em até 20 minutos após a admissão na UTI, cegados para a história do paciente. Os diagnósticos do USP foram comparados aos diagnósticos da equipe assistente ao final da internação na UTI (padrão-ouro). Resultados: Foram inclusos na análise 37 pacientes (média etária: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnóstico do USP demonstrou concordância com o diagnóstico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogênico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnóstico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogênico, respectivamente. Conclusões: O USP baseado no protocolo BLUE foi reproduzível por médicos com habilidades básicas em ultrassonografia e acurado para o diagnóstico de pneumonia e de edema pulmonar cardiogênico. .

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OBJECTIVE: In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. METHODS: A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Student's t-test and chi-squared analysis. RESULTS: Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. CONCLUSION: Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization.

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Objetivo: O desmame da ventilação mecânica é acompanhado, na prática clínica em terapia intensiva, de concomitante mobilização precoce do paciente. O objetivo deste estudo foi comparar o sucesso da extubação realizada com pacientes sentados em uma poltrona à extubação de pacientes na posição supina. Métodos: Foi realizado um estudo retrospectivo, observacional e não randomizado em uma unidade de terapia intensiva de 23 leitos, que atende pacientes clínicos e cirúrgicos. O desfecho primário do estudo foi o sucesso da extubação, definido como a tolerância da remoção do tubo endotraqueal por, pelo menos, 48 horas. As diferenças entre os grupos do estudo foram avaliadas utilizando-se o teste t de Student e o qui quadrado. Resultados: Foram incluídos 91 pacientes no período compreendido entre dezembro de 2010 e junho de 2011. A população do estudo tinha uma média de idade de 71 anos ± 12 meses, escore APACHE II médio de 21±7,6 e duração média da ventilação mecânica de 2,6±2 dias. A extubação foi realizada em 33 pacientes enquanto permaneciam sentados em uma poltrona (36%) e 58 pacientes mantidos em posição supina (64%). Não houve diferenças significantes entre os grupos em termos de idade, escore médio APACHE II ou duração da ventilação mecânica. Foi observada uma taxa de sucesso da extubação similar entre os grupos sentado (82%) e em posição supina (85%), com p>0,05. Além disso, não se encontraram diferenças significantes entre os dois grupos em termos de disfunção respiratória pós-extubação, necessidade de traqueostomia, duração do desmame da ventilação mecânica, ou tempo de permanência ...

Objective: In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. Methods: A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Student's t-test and chi-squared analysis. Results: Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. Conclusion: Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization. .

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