Evaluation of the microbiological efficacy of cleaning agents for tracheostomy inner cannulas.

PURPOSE: Biofilms are a significant cause of morbidity in patients with indwelling medical devices. Biofilms pose a potential risk with reusable inner cannulas by increasing the risk of infections. Effective decontamination is thus vital in decreasing bioburden. The current guidelines for cleaning inner cannulas are varied, with multiple techniques being recommended, which are not supported by strong evidence. This randomized, controlled, cross-over study attempted to enumerate the bacterial count of inner cannulas used in tracheostomy patients (n = 60) pre-and post-decontamination with detergent (A) or sterile water (B). MATERIALS AND METHODS: The patients were randomly allocated to sequence A > B or B > A in 1:1 fashion. The saline flushing of the inner cannulas was plated on trypticase soy agar with 5 % sheep blood to enumerate the bacterial count. RESULTS: The mean ratio [Log (CFU)post/Log (CFU)pre]A/[Log (CFU)post/Log (CFU)pre]B based on 53 samples was 0.918 ± 0.470, two-sided 90 % confidence interval (CI) 0.812, 1.024. The equivalence criterion was met as the mean ratio after cleaning fell within the equivalence region of 0.8 and 1.25. CONCLUSION: This study demonstrated the microbiological efficacy of both detergent and sterile water in the decontamination of inner cannulas, and that sterile water was not less effective than detergent in reducing the bacterial load for safe re-use of inner cannulas. This has the potential to promote cost savings for patients with tracheostomy, both in the hospital and the community. The study findings may also be relevant in formulating tracheostomy care policies.

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.

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.

Effects of tonsillectomy on sleep study parameters in adult patients with obstructive sleep apnea--a prospective study.

OBJECTIVE: The objective of this study is to evaluate the efficacy of tonsillectomy in reduction of respiratory disturbance index (RDI) and other sleep study parameters in patients with obstructive sleep apnea (OSA). METHODS: This study involves 34 adults with OSA and Friedman grade 3 or 4 tonsils. All 34 patients were treated with tonsillectomy, as the only surgical treatment for OSA from 2007 to 2011. Pre- and postoperative polysomnography were performed in all these patients. RESULTS: Prior to tonsillectomy, 21 patients had severe, 9 had moderate, and 4 had mild OSA. Surgical response rate (defined as 50% or more reduction in apnea-hypopnea index (AHI) and a postoperative AHI of less than 20) was 71.4% among patients with severe OSA, 77.7% among patients with moderate, and 75% among patients with mild. Among all the 34 patients, there was a reduction of 24.6 (p = 0.000) in the RDI postoperatively. In our sub-analysis, we arbitrarily divided the patients into three groups: patients with RDI less than 30, patients with RDI between 30 and 60, and patients with RDI above 60. It showed that, in the group with RDI >60, an average reduction of RDI by 57.6 (p = 0.000) was achieved and was the greatest reduction in RDI. CONCLUSIONS: Tonsillectomy alone may be considered as an effective first line surgical procedure in the treatment of OSA in selected patients. Patients with Friedman grade 3 or 4 tonsils may be considered for tonsillectomy as the initial surgical procedure, reserving other upper airway procedures at a later stage if necessary.

Postoperative cardiorespiratory complications and continuous positive airway pressure efficacy in obese patients undergoing noncardiac surgery.

BACKGROUND AND AIMS: One in six Singaporeans has obstructive sleep apnoea (OSA) due to obesity compounded by inherent craniofacial features. We assessed the incidence of cardiopulmonary complications and the effectiveness of continuous positive airway pressure (CPAP) therapy in minimising such complications within an obese population. METHODS: A retrospective study of elective noncardiac surgical patients with a body mass index ≥32 kg/m2 was conducted. Patients at moderate to severe risk of OSA were offered CPAP therapy. CPAP therapy adherence, postoperative complications, length of hospital stay, and type of anaesthesia were analysed. RESULTS: In total, 1400 patients comprising 174 with low risk of OSA (L-OSA) and 1226 with moderate to high risk of OSA were included. Of these, 332 were started on CPAP therapy (C-OSA) while 894 declined CPAP use (R-OSA). There were 10 (0.05%) cardiac events - one (0.6%) in the L-OSA group, six (0.6%) in the R-OSA group and three (0.9%) in the C-OSA group. There were 37 (2.6%) respiratory events - 2 (1.1%) in the L-OSA group, 23 (2.6%) in the R-OSA group, and 12 (3.6%) in the C-OSA group. Multivariate analysis showed no statistical significance in CPAP therapy minimising cardiac (P = 0.147) and respiratory (P = 0.255) complications, when analysed by intention-to-treat. CPAP therapy adherence was 13.6 and 10.2% pre- and postoperatively, respectively. When analysed per protocol, none of the nine patients compliant with both pre- and postoperative CPAP therapy developed cardiopulmonary complications. CONCLUSIONS: Amongst patients with moderate to severe risk of OSA, those who were compliant to perioperative CPAP therapy demonstrated a reduction in cardiopulmonary complications.

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.

Uvulopalatopharyngoplasty outcome assessment with quantitative computer-assisted videoendoscopic airway analysis.

CONCLUSION: Quantitative digital imaging upper airway analysis enables surgeons to assess the pre- and postoperative upper airway morphology quantitatively, objectively and accurately, and to correlate these changes in surgical parameters with improvement of obstructive sleep apnea. OBJECTIVE: This was a prospective study using a new method of quantitative computer-assisted digital-imaging videoendoscopic upper airway analysis to quantify objectively and correlate the changes in surgical parameters with improvement of obstructive sleep apnea following uvulopalatopharyngoplasty. PATIENTS AND METHODS: Nineteen male patients underwent uvulopalatopharyngoplasty for obstructive sleep apnea after continuous positive airway pressure trial. All had undergone pre- and postoperative digital imaging upper airway examination, Epworth scores, and polysomnographic studies. Postoperative static and dynamic changes in upper airway parameters were compared, analyzed and correlated with improvement of the apnea-hypopnea index (AHI) by statistical regression. RESULTS: There were 65.12% and 64.37% improvements in the AHI and Epworth scales, respectively, after uvulopalatopharyngoplasty. Retropalatal areas measured were significantly correlated with improvement of the AHI. A 1 cm2 increase in retropalatal area during Mueller's maneuver in the supine position resulted in an improvement of 32.65 in the AHI; a 1 cm increase in the transverse diameter of the retropalatal area in the erect position resulted in an improvement of 31.83 in the AHI.

Coblation vs electrocautery tonsillectomy: postoperative recovery in adults.

OBJECTIVE: Comparison of coblation and monopolar electrocautery tonsillectomy in terms of postoperative pain and recovery. STUDY DESIGN: Prospective double-blind randomized controlled trial. METHODS: Patients with recurrent tonsillitis requiring tonsillectomy were randomized to 2 groups: coblation or monopolar electrocautery tonsillectomy. Postoperative pain, complications, and days taken to return to work and normal diet were compared and analyzed with the aid of a pain diary, given to the patient. RESULTS: 67 patients were recruited. Patients undergoing coblation tonsillectomy were able to return to normal diet in a shorter space of time following surgery. Patients undergoing coblation tonsillectomy were more likely to recommend the surgery than patients undergoing electrocautery tonsillectomy. No significant differences in the daily visual analog score for pain were seen for both groups of patients. CONCLUSIONS: Our results showed that coblation tonsillectomy has a faster recovery period and may offer advantages when compared to monopolar electrocautery tonsillectomy.

Self-extrusion of a foreign body from the upper digestive tract to the skin.

Migrated ingested foreign bodies from the upper digestive tract have the potential to cause life-threatening complications. Cases of spontaneous expulsion to the skin of the neck are very rare. We present an unusual case of an ingested foreign body that migrated out of the upper digestive tract and self-extruded via the skin of the neck. An approach to the safe management of such seemingly innocuous foreign bodies is discussed. This report highlights the message that non-found ingested foreign bodies should be treated seriously due to the possibility of migration and resulting complications.