Problem in tracheostomy patient care: recognizing the patient with a displaced tracheostomy tube.

There are times when a tracheostomy tube slips out of the trachea. A displaced tracheostomy tube can occur in any patient but is frequently seen in the patient with a full neck. In the overweight patient or patient with a full neck, the tracheostomy tube must pass through a greater amount of soft tissue. Because of this, a smaller portion of the tube is actually within the lumen of the trachea. When the patient coughs excessively or moves the head, the tube can easily slip out of the trachea and into the interstitial tissues of the neck. If the patient has complete obstruction of the upper airway, a displaced tracheostomy tube will result in immediate respiratory distress and can lead to respiratory arrest. If the patient has an intact or at least a partially open upper airway, the displaced tube may not cause an immediate problem. Therefore, displacement of the tracheostomy tube may not be obvious in the patient with a partial airway.

Effects of air-curing environment on alkaloid-derived nitrosamines in burley tobacco.

Levels of nitrite and pyridine alkaloid-derived total tobacco-specific nitrosamines (TSNA) were significantly higher in tobacco leaf (normal or late harvest) air-cured at 32 degrees C/83% relative humidity (RH) than in more moderate environments, i.e., 15 degrees C/50% RH and 24 degrees C/70% RH. These constituents increased appreciably from day 10 to day 21 of the cure. The near-concurrent appearances of maximal total contents of TSNA [sum of N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB) and 4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone) (NNK)] and nitrite supports the concept that nitrite is a limiting and proximal precursor of total TSNA during the curing of tobacco. During a long curing period (50 days) at 32 degrees C/83% RH, nicotine and anatabine contents decreased, but TSNA contents increased in leaves of all harvest dates and stalk positions. These results support the view that nicotine and anatabine are precursors of TSNA. Measurement of nitrite and individual alkaloids during post-harvest processing of tobacco leaf may provide an index of the potential accumulation of alkaloid-derived nitrosamines.