Tracheal cuff pressure change before and after the performance of nursing care / Mudança de pressão do balonete traqueal antes e depois da realização dos cuidados de enfermagem / Cambio de la presión del manguito traqueal antes y después de la realización de los cuidados de enfermeira

ABSTRACT Objective: Verify the changes of endotracheal cuff pressure before and after oral hygiene, head-of-bed elevation at 0º, 30º, and 60º, change in body position, aspiration of the endotracheal tube, and in-bed bathing. Method: The study sample was composed of 88 patients. We performed 3,696 checks from July to September 2014. Results: Pressure values were analyzed in seven nursing care in the morning. Six of them were significantly altered before and after nursing procedure. In the afternoon, five of the health care provided were altered, and in the evening, only two. Most of pressure values were below recommended. Conclusion: There were differences before and after health care provided, showing changes in cuff pressure. In-bed bathing and head-of-bed elevation at 30º were the ones that most altered pressure values in the three working shifts. Therefore, it is necessary to measure cuff pressure at least twice per working shift, preferably after bathing.

RESUMO Objetivo: Verificar As mudanças de pressão do balonete traqueal antes e após higiene oral, elevação da cabeceira do leito a 0 º, 30 º e 60 º, mudança de decúbito, aspiração traqueal e banho no leito. Método: A população foi composta por 88 pacientes, totalizando 3696 verificações de julho a setembro de 2014. Resultados: Os valores de pressão foram analisados em sete procedimentos de cuidados de enfermagem realizados na parte da manhã. Seis apresentaram estavam alterações significativas antes e após a realização dos procedimentos de enfermagem. No período da tarde, cinco dos procedimentos de cuidados de enfermagem realizados apresentaram alterações, e à noite, apenas dois. A maioria dos valores de pressão estava abaixo dos valores recomendados. Conclusão: Houve diferenças antes e após a realização dos cuidados, demonstrando alteração da pressão do balonete. O banho no leito e a elevação da cabeceira do leito a 30 º apresentou valores de pressão mais alterados nos três turnos de trabalho. Portanto, é necessário medir a pressão do balonete pelo menos duas vezes por turno de trabalho, de preferência após o banho.

RESUMEN Objetivo: verificar los câmbios de presión del manguito traqueal antes y después de la higiene oral, elevación de la cabecera del lecho a 0º, 30º y 60º, cambio de decúbito, aspiración traqueal y baño en el lecho. Método: La población fue compuesta por 88 pacientes, totalizando 3696 verificaciones de julio a septiembre de 2014. Resultados: Los valores de presión fueron analisados em siete procedimentos de atención de enfermeira realizados em la parte de la mañana. Seis apresentaron alteraciones significativas antes y después de la realización de los procedimentos de enfermería. En el periodo de la tarde, cinco de los procedimentos de atención de enfermería realizados apresentaron alteraciones, y por la noche, sólo dos. Conclusión: Hubo diferencias antes y después de la realización de la atención de enfermería, demostrando alteración de la presión del manguito. El baño em el lecho y la elevación de la cabecera del lecho a 30º presentó valores de presíonmásalterados em los tres turnos de trabajo, preferentemente después del baño.

Evaluación funcional de la vía aérea / Functional asessment of airway

Airway function study includes a variety of tests involving various sub-specialties of medicine and related professions. We describe the methods that assess: 1) upper airway (nose to larynx): rhinomanometry, acoustic rhinometry and nasopharingolaryngoscopy, 2) central airways (trachea and main bronchi): bronchoscopy, imaging study and Flow / Volume curve, 3) distal or peripheral airway: spirometry, bronchodilator response assessment, airway hyper responsiveness and measurement of airway resistance (plethysmography, interrupted resistence and impulse oscillometry).

El estudio de la función de la vía aérea abarca una gran variedad de exámenes que implican a diversas subespecialidades de la medicina y profesiones relacionadas. Se describen los métodos que evalúan: 1) vía aérea superior (nariz hasta laringe): rinomanometría, rinometría acústica y nasofarigolaringoscopía, 2) vía aérea central (tráquea y bronquios mayores): bronconcoscopia, estudio de imágenes y curva flujo/volumen, 3) vía aérea distalo periférica: espirometría, evaluación de respuesta a broncodilatador y de hiperreactividad bronquial y medición de la resistencia de la vía aérea (pletismografía, resistencia interrumpida y oscilometría de impulso).

Evaluation of the upper airway in obstructive sleep apnoea.

The evaluation of the upper airway (UA) includes the physical examination of pharyngeal structures and a number of imaging techniques that vary from the mostly used lateral cephalometry and computed tomography to more sophisticated methods such as tri-dimensional magnetic resonance image (MRI). Other complex techniques addressing UA collapsibility assessed by measurement of pharyngeal critical pressure and negative expiratory pressure however are not routinely performed. These methods provide information about anatomic abnormalities and the level of pharyngeal narrowing or collapse while the patient is awake or asleep. Data suggest that individual patients have different patterns of UA narrowing. So, the best method for evaluating obstruction during obstructive events remains controversial. In general, in clinical practice physical examination including a systematic evaluation of facial morphology, mouth, nasal cavity and the pharynx as well as simple imaging techniques such as nasopharyngoscopy and cephalometry have been more routinely utilized. Findings associated with obstructive sleep apnoea (OSA) are UA narrowing by the lateral pharyngeal walls and enlargements of tonsils, uvula and tongue. Additionally cephalometry identifies the most significant craniofacial characteristics associated with this disease. MRI studies demonstrated that lateral narrowing of UA in OSA is due to parapharyngeal muscle hypertrophy and/or enlargement of non adipose soft tissues. The upper airway evaluation has indubitably contributed to understand the pathophysiology and the diagnosis of OSA and snoring. Additionally, it also helps to identify the subjects with increased OSA risk as well as to select the more appropriate modality of treatment, especially for surgical procedures.

Quantitative anatomy of the trachea of the giraffe (Giraffa camelopardalis rothschildi) / Anatomía cuantitativa de la tráquea de la jirafa (Giraffa camelopardalis rothschildi)

We described the macroscopic and quantitative anatomy of the trachea of the Giraffe (Giraffa camelopardalis rothschildi). The trachea of one juvenile male giraffe (25 months of age) weighing 754 kg was used in this study. The length of the neck was 125 cm. The trachea had 107 cm in length on its cervical part and 18 cm on its thoracic part. The total number of cartilage was 87.74 at the neck and 13 at the thorax. The general shape of the duct was mostly circular. The separation of the dorsal ends of the tracheal cartilages was pronounced in the first half of the cervical trachea, reducing caudally and overlapping in the thoracic trachea. In the caudal part the trachea had a tracheal bronchus for the cranial lobe of the right lung and the end of the trachea was divided into two main bronchi, where the left was larger in diameter.

Describimos la anatomía macroscópica y cuantitativa de la tráquea de la jirafa (Giraffa camelopardalis rothschildi). La tráquea de una jirafa macho joven (25 meses de edad), con un peso 754 kg fue utilizada en este estudio. La longitud del cuello era de 125 cm. La tráquea tuvo 107 cm de longitud en su parte cervical y 18 cm en su parte torácica. El número total de cartílagos fue de 87,74 en el cuello y 13 en el tórax. La forma general de la vía fue principalmente circular. La separación de los extremos dorsales de los cartílagos traqueales se pronunció en la primera mitad de la tráquea cervical, reduciéndose caudalmente y superponiéndose en la tráquea torácica. En la parte caudal la tráquea tenía un bronquio traqueal para el lobo craneal del pulmón derecho y el final de la tráquea se dividió en dos bronquios principales, donde el izquierdo fue de mayor diámetro.

Umidificador de traqueostoma: influência na secreção e voz de laringectomizados / Tracheostoma humidifier: influence on secretion and voice of patients with total laryngectomy

TEMA: a laringectomia total acarreta sequelas como a perda da voz laríngea e alteração no sistema respiratório. OBJETIVOS: avaliar a influência do uso do umidificador de traqueostoma (heat moisture exchanger - HME) no controle da secreção pulmonar e na qualidade vocal esofágica e traqueoesofágica de pacientes submetidos à laringectomia total. MÉTODO: nove pacientes do sexo masculino, com idades entre 46 a 67 anos, submetidos à laringectomia total. Os pacientes responderam a um protocolo sobre questões subjetivas relacionadas à secreção pulmonar em três momentos, sendo T1 (avaliação pré-uso do HME), T2 (avaliação pré-uso do HME após seis semanas da primeira avaliação) e T3 (avaliação após seis semanas do uso do HME). Conjuntamente foram feitas gravações das vozes dos pacientes nos mesmos três momentos citados acima. As vozes foram avaliadas por três fonoaudiólogas, em estudo cego, de acordo com um protocolo de avaliação perceptivo-auditiva da voz. Para comparar os resultados obtidos em ambos os protocolos aplicados foram utilizados teste não-paramétrico e Wilcoxon. RESULTADOS: não foi observada nenhuma diferença estatisticamente significativa dos parâmetros de qualidade vocal esofágica ou traqueoesofágica entre os tempos T1 (avaliação pré-uso do HME) e T2 (avaliação pré-uso do HME pós seis semanas) e T3 (avaliação após seis semanas do uso do HME). Verificaram-se diferenças estatisticamente significativas para as variáveis de quantidade de tosse e expectoração forçada, durante o dia, após o período de uso do HME. CONCLUSÃO: O uso do HME durante seis semanas diminuiu a tosse e a expectoração em pacientes laringectomizados totais, porém não apresentou influência na qualidade vocal esofágica ou traqueoesofágica.

BACKGROUND: total laryngectomy has several consequences such as loss of the laryngeal voice and alterations in the respiratory system. AIM: to evaluate the influence of a traqcheostoma humidifier (heat moisture exchanger - HME) on the control of lung secretion and esophageal and traqueoesophageal vocal quality in patients with total laryngectomy. METHOD: nine male individuals, aged between 46 to 67 years, submitted to total laryngectomy. The patients answered a protocol containing subjective questions related to lung secretion in three different moments: T1 (pre-use assessment of the HME), T2 (pre-use assessment of the HME six weeks after the first assessment) and T3 (assessment six weeks after the use of the HME). Voice samples were recorded during these 3 different assessments and were evaluated by three speech-language pathologists, in a blind study format, according to a perceptual auditory vocal analysis protocol. The non-parametric test of Wilcoxon was used to compare results of both protocols. RESULTS: no significant differences were observed for traqueoesophageal and esophageal vocal quality in the three different moments of assessment: T1 (pre-use assessment of the HME), T2 (pre-use assessment of the HME six weeks after the first assessment) and T3 (assessment six weeks after the use of the HME). On the other hand, there were significant differences, after the period of the HME use, regarding occurrence of cough and forced expectoration during the day time. CONCLUSION: The use of the HME during the period of six weeks reduced cough and expectoration of patients with total laryngectomy. However, the use of the humidifier did not have any influence on the traqueoesophageal and esophageal vocal quality of these patients.

Alteração da pressão intra-cuff do tubo endotraqueal após mudança da posição em pacientes sob ventilação mecânica / Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation

OBJETIVO: O objetivo deste trabalho foi investigar a alteração da pressão intra-cuff (Pcuff) do tubo endotraqueal em pacientes sob ventilação mecânica, após alteração de sua posição corporal. MÉTODOS: Todos os pacientes selecionados eram inicialmente colocados em posição de semi-Fowler (35º), Pcuff em 20 mmHg, e divididos aleatoriamente em dois grupos. No Grupo A: a Pcuff era medida após mover-se o paciente para decúbito lateral, costas voltadas para o ventilador (denominada Pcuff A1); após retornar o paciente à posição inicial (denominada Pcuff A2); após mover-se o paciente para decúbito lateral, de frente para o ventilador (denominada Pcuff A3); e após retornar o paciente, novamente, à posição inicial (denominada Pcuff A4). No Grupo B: a Pcuff era medida após mover-se o paciente para decúbito lateral, de frente para o ventilador (denominada Pcuff B1); após retornar o paciente à posição inicial (denominada Pcuff B2); após mover-se o paciente para decúbito lateral, costas voltadas para o ventilador (denominada Pcuff B3); e após retornar o paciente, novamente, à posição inicial (denominada Pcuff B4). RESULTADOS: Foram incluídos 70 pacientes no estudo, 31 no grupo A e 39 no grupo B. Valores >22 mmHg foram observados em 142 (50,7 por cento) das 280 medidas de Pcuff realizadas, e valores <18 mmHg, em 14 (5 por cento). Quando movidos da posição de semi-Fowler (35º) para decúbito lateral, costas voltadas para o ventilador, 58 (82,2 por cento) dos pacientes apresentaram valores médios de Pcuff mais altos, >22 mmHg. CONCLUSÕES: Mudanças na posição corporal dos pacientes sob ventilação mecânica podem alterar significativamente a Pcuff.

OBJECTIVE: The purpose of this study was to investigate endotracheal tube cuff pressure (Pcuff) alteration in patients under mechanical ventilation after changes in position. METHODS: All selected patients were initially placed in the 35º semi-Fowler position, with Pcuff adjusted to 20 mmHg, and randomly divided into two groups. Group A, in which patients were moved to the lateral decubitus position, facing away from the ventilator (measurement designated Pcuff A1), returned to the initial position (measurement designated Pcuff A2), moved to a lateral decubitus position, facing the ventilator (measurement designated Pcuff A3) and then returned to the initial position (measurement designated Pcuff A4); and Group B, in which patients were moved to the lateral decubitus position, facing the ventilator (measurement designated Pcuff B1), returned to the initial position (measurement designated Pcuff B2), moved to the lateral decubitus position; facing away from the ventilator (measurement designated Pcuff B3) and then returned to the initial position (measurement designated Pcuff B4). RESULTS: The study comprised 70 patients, 31 allocated to group A and 39 allocated to group B. Values >22 mmHg were observed in 142(50.7 percent) of the 280 Pcuff measurements taken, and values <18 mmHg were observed in 14 (5 percent). When moved from the 35º semi-Fowler position to the lateral decubitus position, facing away from the ventilator, 58 (82.2 percent) of the patients presented mean Pcuff values in the higher range (>22 mmHg). CONCLUSIONS: Changes in body position can cause significant Pcuff variations in patients under mechanical ventilation.

Demonstration of antihistamine properties with AST-1: a bioactive extract from garden slugs (Diplosolenodes occidentalis) / Demostración de las propiedades antihestamínicas con ast-1, un extracto bioactivo de las babosas de jardín (diplosolenodes occidentalis)

Parched and ground whole garden slugs are claimed in rural Jamaican folklore practices to have useful effects in the treatment of bronchial asthma. Since this claim may be associated with respiratory dysfunction due to histamine from allergic sensitization, the authors investigated the effects of a semi-pure alcoholic extract (AST-1) on histamine-induced contraction of the guinea pig in vitro tracheal muscle preparation and cutaneous allergic responses in ovalbumin sensitized guinea pigs. Chemical analysis of AST-1 by column chromatography and thin layer chromatography indicated two compounds in the composition, but the molecular structures were not determined Pharmacological evaluation of AST-1 produced a concentration-dependent inhibition of histamine-induced contraction of the guinea pig tracheal muscle preparation. AST-1 also inhibited contraction of the tracheal muscle produced by selective H1 receptor stimulation with HTMT dimaleate. H2 receptors were not involved, as indicated by the absence of contraction with dimaprit hydrochloride, a selective H2 agonist. Also, in ovalbumin sensitized guinea pigs, AST-1 and diphenhydramine, a selective H1 antagonist, inhibited the cutaneous responses due to intradermal injection of histamine and ovalbumin. These results suggest that AST-1 has H1 anti-histamine properties which can inhibit histamine-induced tracheobronchial muscle contraction and cutaneous responses due to allergy.

En el contexto de las prácticas folclóricas de la Jamaica rural, se afirma que las babosas de jardín tostadas y molidas, tienen efectos útiles en el tratamiento del asma bronquial. Como que esta afirmación puede estar asociada con una disfunción respiratoria debida a la histamina de la sensibilización alérgica, los autores se dieron a la tarea de investigar los efectos de un extracto alcohólico semi-puro (AST-1) sobre la contracción inducida por histamina de un preparado in vitro de músculo de tráquea de cobayo, y las respuestas cutáneas alérgicas en cobayos sensibilizados con ovalbúmina. El análisis químico de AST-1 mediante cromatografía en columna y cromatografía en capa fina, indicaron dos compuestos en la composición, pero no se determinaron las estructuras moleculares. La evaluación farmacológica de AST-1 produjo una inhibición ­ dependiente de la concentración ­ de la contracción, inducida por histamina, del preparado de músculo de tráquea de cobayo. El AST-1 también inhibió la contracción del músculo traqueal producida por la estimulación de receptor selectivo H1 con dimaleato de HTMT. No se involucraron receptores H2, como lo indicó la ausencia de contracción con hidrocloruro de dimaprit ­ un agonista selectivo H2. Asimismo, en cobayos sensibilizados con ovalbúmina, el AST-1 y la difenidramina ­ un antagonista selectivo H1 ­ inhibieron las respuestas cutáneas debido a la inyección intradérmica de histamina y ovalbúmina. Estos resultados sugieren que el AST-1 tiene propiedades antihestamínicas H1, las cuales pueden inhibir la contracción muscular traqueobronquial inducida por la histamina y las reacciones cutáneas debido a la alergia

Comparative anatomy of the syrinx in the tribe arini (Aves psittacidae)

The syrinx is the organ responsible for producing the vast majority of bird sounds. Because its anatomyvaries greatly among bird taxa, prior knowledge of variations is extremely important to studies of functionalanatomy and phylogenetic systematics. With the aim of accessing and describing morphological variationin birds of the tribe Arini, this paper presents the findings of a comparative analysis of the syrinxes of 156specimens belonging to 47 species in 22 genera of the tribe. A number of hitherto unknown variationsare highlighted and confronted with the knowledge produced to date on the morphology of the syrinx inPsittaciformes. Some of the variations detected occurred in structures probably involved in sound productionand this should be taken into consideration in future studies of functional anatomy. Several characterssuggest the presence of a phylogenetic signal, given the congruence between their distribution among taxaand the hypotheses regarding monophyletic groupings proposed in the literature. Some of the variationsfound, including those suggesting a phylogenetic signal, are intraspecifically polymorphic, which reinforcesthe importance of using series of specimens in studies of syrinx anatomy.

Do the length-based (Broselow) Tape, APLS, Argall and Nelson's formulae accurately estimate weight of Indian children?

This study was aimed at validating the usefulness of a length based pediatric emergency tape (Broselow) in an Indian population. The secondary objective was to validate age based weight estimation formulae (Nelson, Argalls, APLS) for emergency needs (doses, sizes). This cross sectional study was done at a tertiary teaching hospital on a sample of 500 children attending outpatient clinic. Inclusion criteria was age between 1 month to 12 years. Children who were unstable, uncooperative or critically ill requiring emergency care and those measuring more than 145 cm in length or weighing more than 35 kg weight were excluded from the study. Measurement of actual weights, calculation of weight, adrenaline dose, fluid bolus and endotracheal tube size was done by all four methods. Results indicated good positive correlation between actual measured weights and weights estimated using Broselow Tape (r = 0.974), APLS (r = 0.902), Argalls modification (r = 0.902), and combined Nelson formulae (0.935). However, specific Nelson formulas for 7-12 yr and 3-12 mo were especially poor in correlation. Bland-Altman Plots comparing actual weight showed least mean bias for Broselow Tape estimations in < 15 kg group (0.080 +/- 0.96 kg) and maximum bias with Nelsons formula for 7 to12 yr (5.204 +/- 4.272 kg). For adrenaline doses and fluid bolus calculations, Broselow estimations were valid estimates. Broselow tape did underestimate endotracheal tube size (mean bias -0.53 +/- 0.18). To conclude, length based pediatric emergency tape (Broselow) correlates well with overall emergency decision making process in our setting. This is especially validated in the age group 0.1 to 6.7 yr weighing less than 15 kg.

Manejo de la vía aérea en trasplante de tráquea / Managing of the airway in transplant of trachea

A pesar de los grandes avances en cirugía de resección traqueal y en dispositivos como las endoprótesis, existen pacientes en quienes dichas técnicas no son viables debido al compromiso tan extenso de su estenosis; por lo tanto, su problema no se ha podido resolver alterando la calidad de vida y muchas veces poniendo en riesgo la vida de los pacientes, secundario a una obstrucción de la vía aérea. A continuación, se describe la experiencia del grupo de la Universidad de Antioquia y el Hospital Universitario San Vicente de Paúl, en el manejo de la vía aérea durante el transplante de tráquea realizado a 5 pacientes en la institución, ya que dicho procedimiento se convierte en un reto para el anestesiólogo por compartir el campo quirúrgico con el cirujano. Gracias al entrenamiento previo en cadáveres y en modelos experimentales animales y al trabajo multidisciplinario llevado a cabo, es que se llega a mostrar buenos resultados.

Activation of guanylate cyclase in the guinea-pig trachea reduces contractile responses of the smooth muscle

Guinea-pig tracheal strips were used to investigate whether activation of guanylate cyclase in the trachea can reduce the contractile response of the smooth muscle. Guanylate cyclase was activated by glyceryl trinitrate and a combination of sodium nitrite and ascorbic acid. These activators inhibited tracheal smooth muscle contractions produced by acetylcholine histamine and electrical field stimulation. However, in the presence of methylene blue, a guanylate cyclase inhibitor, tracheal smooth muscle contractions were not inhibited by the activators. But, in the presence of propranolol, which blocked inhibition mediated by beta-adrenoceptor, both glyceryl trinitrate and the sodium nitrite/ascorbic acid combination were still capable of inhibiting tracheal smooth muscle contractions. Additionally, methylene blue inhibited tracheal smooth muscle relaxation that was electrically induced. These results suggest that the inhibitory action mediated by activated guanylate cyclase may be a mechanism for regulating tracheal smooth muscle contractile reponses

Histologia de Ixodidae: I. Ovário e traquéia de Amblymma tigrinum (Acari) / Histology of Ixodidae: I. Ovary and trachea of Amblyomma tigrinum (Acari)

I was studied the histology of Amblyomma tigrinum (Ixodidae) an ixodid fick. Three A. tigrinum engorged females were dissected, collected ovary and tracheae, and fixed in Bouin's aqueous fixative during 24 hours; the organs were cut at a thickness of 6-7 um and stained by hematoxylin-eosin. Ovary of A. tigrinum (Fig. 1) showed two cellular layers, similar to the ovary of D. andersoni and B. microplus, being one outer (oocyts) and the inner layer (epithelial cells). Trachea (Fig. 2) showed a cellular layer and a chitions spiral, similar to D. andersoni

Reversal of endothelin-1-induced contractions by isoproterenol without myosin dephosphorylation in tracheal smooth muscle.

Effects of isoproterenol on isometric force, and 20,000 Da myosin light chain (LC20) phosphorylation were examined in smooth muscle fibre strips from lamb trachea stimulated with endothelin-1 (ET-1). ET-1 induced a rapidly rising isometric tension which was coupled with a multiple site phosphorylation of LC20. Isoproterenol addition at the time of peak isometric force resulted in a brisk relaxation of the fibre strips. Myosin light chain phosphorylation, however, remained unaffected.