Ultrasonography for airway management

Prognostic value of the early lung ultrasound B-line score for postoperative pulmonary insufficiency in patients undergoing thoracic surgery: an observational study

BACKGROUND

Postoperative pulmonary insufficiency (PPI) is an important contributor to morbidity and mortality after thoracic surgery. Lung ultrasound is a reliable tool for assessing respiratory function. We sought to determine the clinical value of the early lung ultrasound B-line score for predicting changes in pulmonary function after thoracic surgery.

METHODS

Eighty-nine patients undergoing elective lung surgery were included in this study. The B-line score was determined 30 min after removal of the endotracheal tube, and the PaO2/FiO2 ratio was recorded 30 min after extubation and on the third postoperative day. Patients were divided into normal (PaO2/FiO2 ≥ 300) and PPI (PaO2/FiO2 < 300) groups according to their PaO2/FiO2 ratios. A multivariate logistic regression model was used to identify independent predictors of postoperative pulmonary insufficiency. Receiver operating characteristic (ROC) analysis was performed for significantly correlated variables.

RESULTS

Eighty-nine patients undergoing elective lung surgery were included in this study. We evaluated 69 patients in the normal group and 20 in the PPI group. Patients conforming to NYHA class 3 at administration were significantly more represented in the PPI group (5.8 and 55%; p < 0.001). B-line scores were significantly higher in the PPI group than in the normal group (16; IQR 13-21 vs. 7; IQR 5-10; p < 0.001). The B-line score was an independent risk factor (OR = 1.349 95% CI 1.154-1.578; p < 0.001), and its best cutoff value for predicting PPI was 12 (sensitivity: 77.5%; specificity: 66.7%).

CONCLUSIONS

Lung ultrasound B-line scores 30 min after extubation are effective in predicting early PPI in patients undergoing thoracic surgery. Trial registration This study was registered with the Chinese Clinical Trials Registry (ChiCTR2000040374).

Delayed subcutaneous emphysema, mediastinal emphysema and pneumothorax after tracheal intubation in a child: a case report

BACKGROUND

Subcutaneous emphysema and mediastinal emphysema and/or pneumothorax after mechanical ventilation through endotracheal intubation is not uncommon. However, cases of delayed mediastinal emphysema and subcutaneous emphysema after extubation and their further development into pneumothorax have rarely been reported, especially in children. Given this, we provide such a case for the reference of clinicians.

CASE DESCRIPTION

We report a case of a 2-year-old girl with no abnormalities at the preoperative examination, who developed subcutaneous emphysema and mediastinal emphysema 4 hours after recovery from general anesthesia due to ophthalmic arterial infusion chemotherapy for retinoblastoma, and bilateral pneumothorax 12 hours later. The patient recovered and was discharged following aggressive treatment of subcutaneous exhaust and thoracic closed drainage. Due to fiberoptic bronchoscopy was refused by the guardian to determine the cause, we hypothesized tracheal intubation injury occurs, air enter the trachea or bronchial mucosa, extend up to the neck, head and face along the blood vessels, larynx and deep cervical fascia spaces, causing subcutaneous emphysema, and then gradually spread to the mediastinum, resulting in mediastinal emphysema and pneumothorax. However, the etiology and preventive measures warrant further study.

CONCLUSIONS

Strengthen the etiological study of subcutaneous and/or mediastinal emphysema and pneumothorax due to endotracheal intubation, perioperative observation and postoperative follow-up are important measures for the effective prevention, early diagnosis, and timely treatment of subcutaneous and/or mediastinal emphysema and pneumothorax, and are also conducive to ensuring the safety of patients.

Neonatal intensive care unit nurse training in identifying ultrasound landmarks in the neonatal mediastinum. Α training program for nurses in North-Eastern Greece

PURPOSE

To demonstrate methods and landmarks for mediastinum ultrasound as part of ultrasound examination of the lung for nurses. This will be the first step in their education to detect finally the tubes and lines malpositioning in order to distinguish emergency conditions of the lungs in neonates hospitalized in neonatal intensive care units.

DESIGN AND METHODS

Theoretical and practical interventions were developed to create a 3-month training program based on similar medical courses. The study was approved by the hospital's ethics committee.The program was performed in the neonatal intensive care unit of a single academic institution. Participating nurse was supervised by a paediatric surgeon and trained in lung ultrasound (a safe method without radiation) by a paediatric radiologist.

RESULTS

During the practical period (2 months), the neonatal intensive care unit nurse examined 50 neonates (25 + 6-40 + 4 weeks gestational age; 21 males) separated into two subgroups of 25 neonates each for each training month. In the first month under supervision, the nurse was trained to recognise the aortic arch, the right pulmonary artery, the esophagus, the tracheal air, and the 'sliding lung sign' in the anterior, lateral, and posterolateral aspects of the thoracic cage. In the second month, the nurse recorded the ultrasound examinations. The identified structures were then assessed and graded by the supervising radiologist. The overall estimated success rate (5 landmarks × 25 neonates = 125) was 90.4%.

CONCLUSIONS

Although this is the first report of the design of a 'hands-on', lung ultrasound training program for neonatal intensive care unit nurses, our findings demonstrate that it is a safe and useful program for all neonatal intensive care unit nurses because theoverall success rate of the 3-month program was determined by accurate identification of basic anatomical structures (90,4%) by the nurse.

PRACTICE IMPLICATIONS

This study describes the first educational training program for NICU nurses designed to recognise basic structures in the neonatal mediastinum. If the program is effective, NICU nurses will be able to identify respiratory emergencies. NICU nurses can inform doctors about emergencies according to tubes and lines malpositioning in a timely manner to avoid negative consequences.