Efficacy of high flow nasal cannula as an alternative to continuous positive airway pressure therapy in surgical patients with suspected moderate to severe obstructive sleep apnea.

PURPOSE: To compare the efficacy of High flow nasal cannula (HFNC) as an alternative to Continuous Positive Airway Pressure (CPAP) therapy on the first postoperative night in patients with suspected moderate to severe obstructive sleep apnea (OSA). METHODS: This is randomised controlled trial conducted in a tertiary hospital which included elective surgical patients with STOP-BANG score of 5 and above. Forty patients were randomised into one of the four postoperative treatment groups: CPAP, or HFNC at three different flow rates (20 L/min, 30 L/min and 40 L/min). The primary outcome measured was the number of recorded drops in baseline SpO2 of >4%. Secondary outcomes measured included the need for supplemental oxygen or other interventions and the total number of hours of usage of the device. Patient satisfaction, preference for device and reasons for their preference were also collected. RESULTS: CPAP was used for a significantly fewer number of hours compared to HFNC (at all flow rates) during the first postoperative night. There was no significant difference in the primary outcome or in the requirement for other interventions between the four treatment groups. 73.3% of patients in the HFNC group preferred the use of HFNC to the use of CPAP. Reasons for user preference for HFNC include device comfort, ease of use, reduced noise levels and perception of efficacy. CONCLUSIONS: HFNC could be an useful alternative to CPAP as it is not inferior to CPAP in the perioperative management of OSA and is better tolerated.

Early Experience of a Multidisciplinary Group Pain Program with Cognitive Behavioural Strategies, Physiotherapy and Peer Support for Patients with Chronic Noncancer Pain.

BACKGROUND: Chronic non-cancer pain affects about 20% of the population worldwide. The effect of medical treatment in isolation is often limited. A multidisciplinary approach has been strongly advocated to help manage patients' pain more effectively. AIMS: The primary purpose was to reduce pain severity, pain interference on patients'daily activities and improve their levels of self-efficacy despite pain. The secondary aim was to evaluate the possible changes in patients' depression, anxiety, and stress symptoms after amultidisciplinary group pain program. The program content and structure were also evaluated. DESIGN: This scholarly project used within-subject pre- and post-test design. SETTINGS/SUBJECTS: Fifty-six patients were recruited from the project center pain clinic. METHODS: An evidence-based eight-hour multidisciplinary group pain program was implemented. Data was collected before and 3 months after the program. INTERVENTIONS: The program covered pain physiology, cognitive behavioural strategies, demonstration of various exercises, self-management skills, medication management, and peer support. RESULTS: Three months postprogram, there was a statistically significant improvement in patients' pain severity (ß = -0.9, 95% CI: -1.73 to -0.14, p = .023) and self-efficacy (ß = 5.6, 95% CI: 0.85 to 10.41, p = .023). Pain interference on their daily activities was also significantly reduced (ß = -2.0, 95% CI: -2.90 to -0.83, p = .001). Patients provided positive and encouraging feedback about the program. CONCLUSION: Initial improvements in patients' ability to cope with pain and to perform daily activities were demonstrated following participation in the brief multidisciplinary group pain program. Future randomized controlled trials are needed to confirm that the results are due to patients' participation in the program.

Experiential learning in simulated parapharyngeal abscess in breathing cadavers.

PURPOSE: Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways. METHODS: Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements-the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models. RESULTS: The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%). CONCLUSIONS: Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.

A randomized controlled trial to compare the interface pressures of alternating pressure overlay with gel pad versus gel pad alone during prolonged surgery.

INTRODUCTION: Prolonged surgery is a known risk of pressure ulcer formation. Pressure ulcers affect the quality of life, are a significant cause of morbidity and mortality, and pose a burden on the healthcare system. This study aimed to compare the effectiveness of an alternating pressure (AP) overlay with Gel pad against the Gel pad in reducing interface pressure (IP) during prolonged surgery. METHODS: A total of 180 participants from a tertiary hospital were randomized to AP overlay with Gel pad group (n = 90) and Gel pad group (n = 90). Patients were placed supine on the pressure redistributing surfaces, and IP data under the sacrum and ischial tuberosities were collected at an interval of 30 min from 0 min up to a maximum of 570 min. RESULTS: Based on data from 133 participants, the average IPs during all the deflation cycles of the AP overlay (with Gel pad) were significantly lower than the average continuous IP recorded for Gel pad throughout the measuring period (p < 0.001). Only three patients (2.26% of study participants) - Gel pad group (n = 2; 2.99%) and AP overlay with Gel pad group (n = 1; 1.52%) developed post-operative pressure ulcer (p = 0.5687). CONCLUSIONS: The lower IP during deflation cycles of the AP overlay (with Gel pad) suggests its potential effectiveness in preventing pressure ulcer formation in patients undergoing prolonged surgery. The prevention and reduction of pressure ulcers will have a considerable impact on the improved quality of life and cost savings for the patient. The study findings may facilitate the formulation of policies for preventing pressure ulcer development in the perioperative setting.

Evaluating simulator sickness and acceptability of virtual reality prototype in pain management in hospitalized patients.

Aim: Acute and chronic noncancer pain is a common healthcare problem locally and globally, and remains under treated and poorly controlled. We created a virtual reality (VR)-based prototype with customization of content to our local population. Materials & methods: This was an open-label, single center, single-arm study to examine the safety, acceptability and tolerability of the use of VR as an adjunctive tool for pain relief in hospitalized patients. The participants rated their baseline and post-VR pain and anxiety scores. Results & conclusion: All 50 patients completed the VR sessions with good tolerability and safety. Preliminary exploration of pain reduction indicated a positive effect (for pain and anxiety visual analog scale scores; p < 0.001). We believe VR is a potentially beneficial tool for use in pain management.

Airway management in patients suffering from morbid obesity.

Obesity is no longer a disease of the affluent. The prevalence of obesity has risen at an exponential rate globally, with an increasing burden on healthcare resources. Perioperative management of patients with morbid obesity is known to be challenging, and this is particularly so in the management of their airway, a crucial procedure that requires meticulous planning and modifications. Anesthesiologists will expect to see more patients with obesity in their practice presenting for both bariatric and non-bariatric surgery, or even for emergency surgery. Hence, any generalist anesthesiologist should be confident in managing such a patient, with the appreciation that these patients often pose a significant challenge to the practice of anesthesia. This article describes different techniques and looks at the evidence for airway management in the morbidly obese. Other aspects of perioperative management of such patients are beyond the scope of this article.

Enhanced Experiential Learning in Airway Management: Surgical Modification of Cadavers.

INTRODUCTION: Failure of airway management remains a significant source of morbidity and mortality. Advanced airway management has been addressed effectively by simulation-based training. However, simulation of difficult airways in manikins is limited by the pre-set conditions provided by the manufacturer. Life-like conditions in the form of the softness of the tissue and true anatomy as seen in cadaver models are needed to create simulated models with a closer resemblance to real patients. The goal of this study was to determine the feasibility of simulating difficult airway from submandibular abscess in cadaver models by surgical modification of the cadaver heads for use in enhanced experiential learning of the management of difficult airways. METHODS: The cadaver heads were modified surgically to simulate a submandibular abscess. The models were used in an airway course where participants provided feedback on the realistic nature of the model and its benefits for difficult airway training. The ease of tracheal intubation of the models with the assistance of video laryngoscopy was assessed. RESULTS: The modified cadavers were acceptable in simulating difficult airway as demonstrated by the feedback from the participants. All participants (100% [95% confidence interval = 89.1%-100%]) found the models to be realistic and beneficial for difficult airway training. A good proportion (56.3%) felt that the intubation technique was made easier with the video laryngoscopy. CONCLUSIONS: Cadavers can be modified to simulate pathologies associated with difficult airways. These models can be used to enhance experiential learning and the management of difficult airways.

Postoperative use of high flow nasal insufflation for obstructive sleep apnea.

BACKGROUND: Continuous positive airway pressure (CPAP) therapy is the gold standard treatment for obstructive sleep apnea (OSA), although, associated with poor patient compliance. Conversely, high flow, humidified, temperature-regulated nasal insufflation of oxygen or air is well tolerated. CASE: We describe our experience of three patients with known or suspected moderate to severe OSA who were poorly compliant to CPAP therapy and received high flow nasal insufflation (HFNI) postoperatively. None had significant episodes of desaturation (SpO2 < 95%) and all patients uniformly reported superior comfort levels than with the CPAP therapy. HFNI generates small amounts of positive end-expiratory pharyngeal pressure, increases inspiratory airflow and decreases dead space ventilation. Due to the open system, less difficulty with the patient-mask interface and improved patient comfort is experienced. These factors help prevent hypopnea and lead to enhanced sleep continuity. CONCLUSIONS: HFNI may be a promising alternative to CPAP therapy in the perioperative setting.