Learning curves of the Airtraq and the Macintosh laryngoscopes for tracheal intubation by novice laryngoscopists: a clinical study.

BACKGROUND: The curved laryngoscope blade described by Macintosh in 1943 remains the most widely used device to facilitate tracheal intubation. The Airtraq laryngoscope is a new, single-use device for tracheal intubation. Several studies compared the use of Airtraq and Macintosh laryngoscopes in simulated intubation scenarios on manikins. We evaluated learning and performance of tracheal intubation by novice laryngoscopists using the Airtraq or Macintosh laryngoscopes in a randomized controlled clinical trial. METHODS: One hundred eight consecutive patients scheduled for surgical procedures requiring tracheal intubation were enrolled. Patients were randomly allocated to undergo tracheal intubation using a Macintosh (n = 54) or an Airtraq (n = 54) laryngoscope. Tracheal intubation was performed by first-year residents who had no prior experience with the use of either laryngoscope. Primary end points were duration of tracheal intubation and intubation difficulty scale score for both devices. RESULTS: Eighteen residents participated in the protocol; 9 were allocated to each study group. Each participant performed at least 6 tracheal intubations with the same device. We observed a more rapid skill acquisition with the Airtraq than with the Macintosh laryngoscope, as demonstrated by the shorter duration of intubation with the Airtraq laryngoscope. Data analysis with the Student t test revealed a significant difference between the groups (P < 0.001). CONCLUSION: The Airtraq laryngoscope facilitates a more rapid learning curve compared with the Macintosh laryngoscope when used in a clinical setting by novice laryngoscopists. The Airtraq laryngoscope was judged easier to use by novice users.

Effects of opioid rotation in chronic pain patients: ORTIBARN study.

BACKGROUND: Opioid rotation is currently the subject of considerable debate for two reasons: firstly as a strategy for pain treatment, and secondly because of the difficulty in determining equianalgesic doses. Switching from one slow-release (SR) opioid analgesic to another raises a number of critical issues, and there are no widespread studies that support a standard protocol. Initiation of opioid therapy must consider gradual dose titration of the drug until the minimum effective and maximum tolerated dosage for each patient is found. OBJECTIVE: This study aimed to evaluate the effects of SR opioid rotation after a stabilization period with normal-release (NR) morphine ('start therapy') in patients with cancer or non-cancer pain not controlled with their current SR opioid. METHODS: This is a multicentre, open-label, prospective study. A total of 326 consecutive patients were enrolled who were affected by chronic cancer or non-cancer pain that was not controlled by an SR opioid administered as either monotherapy or in combination with other analgesic drugs. Following start therapy with oral NR morphine at a dosage of 5 mg or 10 mg every 4 hours, rotation to an SR opioid of a different type from that previously administered was carried out. RESULTS: After about 3 days of start therapy with NR morphine, rotation to an SR opioid allowed a significant decrease of both baseline pain and daily episodes of breakthrough pain. No significant difference was detected between dosages and type of opioid administered, both prior to and after the start therapy period with NR morphine. CONCLUSIONS: Rotation to another opioid preceded by a brief period of opioid receptor resetting by start therapy with NR morphine allows a good level of pain control and avoids rotation to inappropriate opioid dosages or combinations analgesics.

Standard therapy with opioids in chronic pain management : ORTIBER study.

OBJECTIVE: Moderate to severe pain is commonly experienced by cancer and non-cancer patients. Although opioids are generally the most important drugs in chronic pain management, their use in Italy remains low. We designed a prospective open trial to assess the efficacy and safety of a standard therapy clinically available for a large range of patients. METHODS: A total of 172 consecutive patients (89 women and 83 men) with chronic pain (daily mean visual analogue scale (VAS) score > 4) that was not adequately managed by their existing pain regimen were enrolled to receive an immediate release (IR) dose of morphine: 30 mg/day (opioid-naive patients) or 60 mg/day (non-naive patients) for 5 days. After this period (start therapy), all patients were switched to slow release (SR) opioid therapy for 30 days (steady therapy). Each breakthrough pain (BTP) episode was treated with a single dose of IR morphine (20% of the daily dose) during all study periods. RESULTS: Daily VAS score was reduced from 7.4 +/- 1.3 at baseline to 3.8 +/- 1.5 (p < 0.0001) after 30 days of steady therapy in cancer and non-cancer patients. Fewer patients reported BTP events by study end (55% of patients with BTP at basal time had no BTP at last follow up), and the number of daily BTP events experienced by patients was reduced by therapy to 1-2 per day in 75% of patients reporting BTP. Further, the time delay to reach pain relief following administration of a rescue dose of IR morphine was 15 minutes or less in 52.1% of patients at study end. The standard therapy was well tolerated and fewer adverse effects were recorded at the end of the study period compared with baseline, with the exception of constipation, which showed a moderate increase (from 18.2% to 25.0%). CONCLUSION: Start therapy with IR morphine followed by conversion to SR opioid therapy could be implemented as a standard therapy to manage moderate to severe chronic pain in patients with cancer or non-cancer pain. ORamorph in TIBER study (ORTIBER).

Noninvasive ventilation in the treatment of acute respiratory failure induced by all-trans retinoic acid (retinoic acid syndrome) in children with acute promyelocytic leukemia.

PURPOSE: To evaluate the feasibility of noninvasive ventilation through a nasal mask in the treatment of acute respiratory failure induced by all-trans retinoic acid. DESIGN: Observational, nonrandomized report of two cases. SETTING: Intensive care unit in a university hospital. PATIENTS: Two pediatric patients (an 11-yr-old male and a 12-yr-old female) affected by acute promyelocytic leukemia. INTERVENTIONS: Pressure support ventilation was delivered via a nasal mask by means of a bilevel positive pressure ventilator (Respironics, Murrysville, PA). MEASUREMENTS AND MAIN RESULTS: We evaluated the effects of the bilevel positive pressure ventilator on blood gas analysis, respiratory rate, hemodynamics, patient tolerance, complications, and outcome. Patients showed an improvement of blood gas analysis and respiratory rate after 3-6 hrs of noninvasive ventilation. The nasal mask was well tolerated by the two patients. No complications were observed. Patients were discharged from the intensive care unit in stable clinical conditions after 3-4 days. CONCLUSIONS: Noninvasive ventilation by a nasal mask can offer effective ventilatory support and improve gas exchange in the treatment of acute respiratory failure in pediatric hematologic patients. In addition, noninvasive ventilation may decrease the risk of life-threatening complications associated with endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies.