Best practice in stabilisation of oral endotracheal tubes : a systematic review

Mechanical ventilation of patients in intensive care units is common practice. Artificial airways are utilised to facilitate ventilation and the endotracheal tube (ETT) is most commonly used for this purpose. The ETT must be stabilised to optimise ventilation and avoid displacement or unplanned extubation. Tube movement is a major factor in causing airway trauma. A destabilised tube can cause fatal complications. A systematic review was conducted to identify and analyse the best available evidence on ETT stabilisation to determine which stabilisation method resulted in reduced tube displacement and the least amount of unplanned or accidental extubations. The types of stabilisations included one or a combination of the following methods: twill or cotton tape, adhesive tape, gauze, or a manufactured device. All relevant randomised controlled and quasi-experimental studies of ETT stabilisation practices, identified through electronic and hand searching, were assessed for inclusion in the study. One published randomised controlled trial and six published quasi-experimental studies met the inclusion and exclusion criteria and were retrieved. Data were extracted independently by two reviewers. Results of the systematic review showed that no single method of ETT stabilisation could be identified as superior for minimising tube displacement and unplanned or accidental extubations. Rigorous randomised controlled trials with clearly identified and described ETT stabilisation methods are required to establish best practice. In addition, comparative research to evaluate cost effectiveness and nursing time requirements would also be of significant benefit to critical care nursing practice.

Trajectory of sedation assessment and sedative use in intubated and ventilated patients in intensive care: a clinical audit

Background: Sedation is crucial for the recovery of patients in intensive care units (ICUs). Maintaining comfort and safety promotes optimal care for critically ill patients. Purpose: To examine sedation assessment and management undertaken by health professionals for mechanically ventilated patients in one Australian ICU. Methods: A retrospective clinical audit was undertaken of medical records of all eligible, mechanically ventilated patients admitted to an ICU of an Australian metropolitan, teaching hospital over a 12-month period. A Sedation Audit Tool was used to collect data from the day of intubation to 5 days after intubation. Findings: Data were extracted from medical records of 150 patients. The Riker Sedation-Agitation Scale (SAS) was the scoring system used. Patients were unarousable or very sedated between 57% and 81% at some point during the study period, while between 5% and 11% were agitated, very agitated or extremely agitated across this time. Patients' sedation scores were not documented in between 3.3% and 23.3% of patients. Medications commonly used were propofol, midazolam, morphine, and fentanyl. There were 135 situations of adverse events, which related to patients pulling endotracheal tubes leading to malpositioning, patients biting endotracheal tubes causing desaturation, patient experiencing excessive agitation requiring restraint use, patients experiencing increased intracranial pressure above desired limits, patients self-extubating, and patients experiencing over-drowsiness leading to delays in extubation. Conclusions: Many patients were either very sedated or agitated at some point during the study period, and some patients experienced adverse outcomes associated with sedation practices. The findings inform future quality initiatives to improve sedation practices.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Objective: The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. Methods: This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. Results: There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. Conclusion: The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

The transition from pediatric to adult health care services for young adults with a disability : an ethical perspective

Young children with disabilities and their carers or parents tend to form a long-term dependent relationship with a paediatrician throughout childhood At some stage when the young person with a disability reaches early adulthood, the relationship is severed This paper draws upon recent research undertaken by the authors that describes the difficulties experienced by young people with disabilities as they go through the transition from paediatric care to adult mainstream health care services. The purpose of this article is to present the argument that the dependent, paternalistic relationship that tends to exist between young people with disabilities (and/or their carers) and paediatricians throughout childhood does not facilitate the successful negotiation of adult mainstream health care services, nor optimally promote the well-being of these young people with disabilities. It is proposed that the promotion of autonomy (or self-determination) via a well planned transition program will increase the likelihood that young adults with disabilities and/or their carers will be empowered to successfully negotiate the current mainstream health care system in Australia, and will enhance the well-being of young adults with disabilities.

Preliminary validation of the Chinese version of the pediatric quality of life inventory

The Pediatric Quality of Life Inventory (PedsQL) is a scale for assessing health-related quality of life of children and adolescents aged 2-18 years. Three reports of PedsQL for the age ranges 2-4 years and 5-7 years were translated into Chinese and their validities were examined. A total of 186 children and parents were involved in the study. Content validity, test-retest reliability, internal consistency reliability and construct validity were assessed. The correlation of parents' and children's reports was also examined. The results showed that the internal consistency is generally good, test-retest reliability ranged from moderate to good, differences between disabled and non-disabled individuals are significant in total scores and in all subscales except for the physical functioning subscale for the children's self-report for the age ranges of 2-4 years and 5-7 years and the correlation between the reports of the parents and children for the age range of 5-7 years is moderate to high. This suggests that the newly translated Chinese PedsQL for children aged 2-4 years and 5-7 years seems to be reliable and valid to be used as a measure of health-related quality of life in Chinese pediatric research and clinical applications.

Crushing simulation of foam-filled aluminium tubes

A numerical study is presented in this paper to investigate the energy absorption of foam-filled aluminium tubes during crushing. The post-buckling mode of the foam-tube structures has been successfully simulated. The predicted compressive load-displacement is in a good agreement with experimental results. The energy absorption ability of the composite structure due to plastic deformation in a crushing process is evaluated by comparison with the tube structure without foam. The results indicate that the energy absorption of a foam-filled tube structure is superior to the tube without foam. The influences of the friction and the geometric parameters of the structure on the energy absorption have also been investigated. Results from this study will assist automotive industry to design crashworthy components based on foam-filled tubes.

Diesel exhaust particulate matter induces multinucleate cells and zinc transporter-dependent apoptosis in human airway cells

The cellular effects of biodiesel emissions particulate matter (BDEP) and petroleum diesel emissions particulate matter (PDEP) were compared using a human airway cell line, A549. At concentrations of 25 µg/ml, diesel particulate matter induced the formation of multinucleate cells. In cells treated with a mixture of 80% PDEP:20% BDEP, 52% of cells were multinucleate cells compared with only 16% of cells treated with 20% PDEP:80% BDEP with a background multinucleate rate of 7%. These results demonstrate a causal relation between the formation of multinucleate cells and exposure to exhaust particulate matter, in particular diesel exhaust. Exposure of A549 cells to PDEP induced apoptosis, seen by active caspase-3 expression and the presence of cleaved pancytokeratin. PDEP exhaust was a much stronger inducer of cellular death through apoptosis than BDEP. There was an eightfold increase in the expression of SLC30A3 (zinc transporter-3 or ZnT3) in cells exposed to 80% PDEP:20% BDEP compared to untreated cells. The increase in ZnT3 expression seen in apoptotic cells following PDEP suggests a role for this zinc transporter in the apoptotic pathway, possibly through controlling zinc fluxes. As exposure to diesel exhaust particles is associated with asthma and apoptosis in airway cells, diesel exhaust particles may directly contribute to asthma by inducing epithelial cell death through apoptotic pathway.

Crushing modes of aluminium tubes under axial compression

A numerical study of the crushing of circular aluminium tubes with and without aluminium foam fillers has been carried out to investigate their buckling behaviours under axial compression. A crushing mode classification chart has been established for empty tubes. The influence of boundary conditions on crushing mode has also been investigated. The effect of foam filler on the crushing mode of tubes filled with foam was then examined. The predicted results would assist the design of crashworthy tube components with the preferred crushing mode with the maximum energy absorption.

Strain rate effects on the energy absorption of rapidly manufactured composite tubes

As a result of recent increases in fuel prices and the growing number of accident fatalities, the two major concerns of the automotive industry and their customers are now occupant safety and fuel economy {1, 2]. Increasing the amount of energy and optimizing the manner in which energy is absorbed within vehicle crush zones can improve occupant survivability in the event of a crash, while fuel economy is improved through a reduction in weight.  Axial crush tests were conducted on tubular specimens of Carbon/Epoxy (Toray T700/G83C) and Glass/Polypropylene (Twintex). This paper presents results from the tests conducted at quasi-static rates at Deakin Unniversity, Victoria Australia, and intermediate rate tests performed at the Oak Ridge National Laboratory, Tennessee  USA.   The quasi-static tests were conducted at 10mm/min (1.67x10-4m/s) using 5 different forms of initiation. Tests at intermediate rates were performed at speeds of 0.25m/s, 0.5m/s, 0.75m/s 1m/s, 2m/s and 4m/s. Quasi-static tests of tubular specimens showed high specific energy absorption (SEA) values with 86 kJ/kg for Carbon/Epoxy specimens. The SEA of the Glass/Polypropylene specimens was measured to be 29 kJ/kg. Results from the intermediate test rates showed that SEA values did not fall below 55kJ/kg for carbon specimens or 35kJ/kg for the Glass/Polypropylene specimens. When compared with typical steel and aluminium, SEA values of 15 kJ/kg and 30kJ/kg respectively, the benefits of using composite materials in crash structures is apparent.                                                                     

Modelling factors of square tubes in high speed bending situations

Accurate finite element crash simulations of side impact depend upon a thorough understanding of dynamic tube bending. There is a need to understand the dynamic bending mode of square sections (equivalent of automotive structural parts) to obtain a greater confidence in CAE. This work varied strain rate and material definitions, such as Cowper-Symonds vs Zerilli-Armstrong, as well as initial velocity and yield strength. The results show that most of the plastic work is done between strains rates of 30 ¿ 300/s and strains up to 0.3. Peak strain rates were marginally above 1000/s with maximum strain greater than 1. When the strain rate definition and material model were modified, it was shown that a higher yield stress produced a higher reaction force. These results would suggest that the strain rate sensitivity needs to be carefully identified for accurate crash simulations.

Energy absorption and crushing behaviour of foam-filled aluminium tubes

The crushing behaviour and energy absorption of foam filled aluminium tubular structures were investigated using the quasi-static compressive tests. The crushing behaviour of the tubular structures changed due to foam filling. The energy absorption of the foam filled tubular structures was improved significantly. Foam filling caused an interaction effect between the tube and the foam during progressive crushing, leading to an increase in the mean crushing load compared to that of the foam or tube itself. This interaction effect might be affected by several parameters such as the density of the foam, the properties of both the foam material and tube material, and the thickness and outer diameter of the tube. In particular, the interaction effect essentially depended on the ratio of the mean crushing force of the foam to that of the tube.