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Hayes-Bradley C, McCreery M, Delorenzo A, Bendall J, Lewis A, Bowles KA. Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis. Br J Anaesth 2024; 132:918-935. [PMID: 38508943 DOI: 10.1016/j.bja.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/15/2024] [Accepted: 02/01/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022353609).
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Affiliation(s)
- Clare Hayes-Bradley
- Department of Paramedicine, Monash University, Frankston, VIC, Australia; NSW Ambulance Aeromedical Operations, Sydney, NSW, Australia.
| | | | - Ashleigh Delorenzo
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
| | | | | | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Frankston, VIC, Australia
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Hayes-Bradley C, Miller M, Kua BH, Ragavan D, Gospel A, Partyka C, Bliss JM, Ferguson IMC. Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service. Air Med J 2024; 43:157-162. [PMID: 38490780 DOI: 10.1016/j.amj.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/22/2023] [Accepted: 11/29/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Desaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. METHODS This was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. RESULTS Desaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. CONCLUSION Increased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.
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Affiliation(s)
- Clare Hayes-Bradley
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia; Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.
| | - Mathew Miller
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia
| | - Bi Hua Kua
- CareFlight NSW, New South Wales, Australia
| | - Dassen Ragavan
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia
| | - Amy Gospel
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia
| | | | - Jimmy M Bliss
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia
| | - Ian M C Ferguson
- Aeromedical Operations, NSW Ambulance Service, New South Wales, Australia
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Miller M, Storey H, Andrew J, Christian E, Hayes-Bradley C. Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy. Pediatr Emerg Care 2023; 39:666-671. [PMID: 36790879 DOI: 10.1097/pec.0000000000002909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations. METHODS We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes. RESULTS Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient. CONCLUSIONS Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.
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Affiliation(s)
| | - Heather Storey
- Department of Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
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Hayes-Bradley C, Tarrant M. Re: DIDO: Dubious (weight-estimation) data in, dubious (dosing) data out. Emerg Med Australas 2022; 34:1029. [PMID: 36038147 DOI: 10.1111/1742-6723.14067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Clare Hayes-Bradley
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Madelaine Tarrant
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia
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Hayes-Bradley C, Tarrant M. Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study. Emerg Med Australas 2022; 34:892-897. [PMID: 35649634 DOI: 10.1111/1742-6723.14008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/16/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. METHODS Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. RESULTS From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. CONCLUSIONS Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.
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Affiliation(s)
- Clare Hayes-Bradley
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Madelaine Tarrant
- Greater Sydney Area Helicopter Emergency Medical Service, NSW Ambulance, Sydney, New South Wales, Australia
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Miller MR, Gemal H, Ware S, Hayes-Bradley C. The Association of Laryngeal Position on Videolaryngoscopy and Time Taken to Intubate Using Spatial Point Pattern Analysis of Prospectively Collected Quality Assurance Data. Anesth Analg 2022; 134:1288-1296. [PMID: 35020681 DOI: 10.1213/ane.0000000000005868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND During videolaryngoscopy (VL), the larynx appears within the defined area of the video screen, and its location can be measured as a point within this space. Spatial statistics offer methods to explore the relationship between location data and associated variables of interest. The aims of this study were to use spatial point pattern analysis to explore if the position of the larynx on VL is associated with longer times to intubate, increased risk of a needing >1 intubation attempt, or percentage of glottic opening. METHODS Quality assurance data and clinical notes from all prehospital intubations using C-MAC Pocket Monitor with CMAC-4 blade (Karl Storz) from January 1, 2018, to July 31, 2020, were reviewed. We extracted 6 measurements corresponding to the time taken to obtain the initial and then best laryngeal view, time to manipulate a bougie, and time to place the endotracheal tube, as well a percentage of glottic opening and a number of intubation attempts. Larynx location was the middle of the base of glottis, in cm from the left and bottom on the C-MAC screen. Two plots were produced to summarize the base of glottis location and time to perform each time component of intubation. Next, a cross mark function and a maximum absolute deviation hypothesis test were performed to assess the null hypotheses that the spatial distributions were random. The association between glottis location and >1 intubation attempt was assessed by a spatial relative risk plot. RESULTS Of 619 eligible intubations, 385 had a video for analysis. The following time variables had a nonrandom spatial distribution with a tendency for longer times when the larynx was off-center to the top or right of the screen: laryngoscope passing from teeth to glottis, glottis first view to best view of the larynx, time from bougie appearing to being placed in the cords, and overall time from teeth to endotracheal tube passing through cords. There was no increased relative risk for >1 intubation attempt. CONCLUSIONS Spatial point pattern analysis identified a relationship between the position of the larynx during VL and prolonged intubation times. We did not find a relationship between larynx location and >1 attempt. Whether the location of the larynx on the screen is a marker for difficult VL or if optimizing the larynx position to the center of the screen improves intubation times would require further prospective studies.
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Affiliation(s)
- Matthew R Miller
- From the Aeromedical Operations, New South Wales Ambulance, Sydney, New South Wales, Australia.,St George Hospital, Sydney, New South Wales, Australia.,St George and Sutherland Clinical Schools, UNSW, Sydney, New South Wales, Australia
| | - Hugo Gemal
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sandra Ware
- From the Aeromedical Operations, New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Clare Hayes-Bradley
- From the Aeromedical Operations, New South Wales Ambulance, Sydney, New South Wales, Australia
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McQuade D, Miller MR, Hayes-Bradley C. Addition of Nasal Cannula Can Either Impair or Enhance Preoxygenation With a Bag Valve Mask: A Randomized Crossover Design Study Comparing Oxygen Flow Rates. Anesth Analg 2019; 126:1214-1218. [PMID: 28759496 DOI: 10.1213/ane.0000000000002341] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A critical safety component of emergency anesthesia is the avoidance of hypoxemia during the apneic phase of a rapid sequence intubation. Preoxygenation with a bag valve mask (BVM) or anesthetic circuit may be improved with supplemental oxygen by nasal cannula (NC) if there is a mask leak. In addition, NC is recommended for apneic oxygenation after induction and may be placed before preoxygenation. However, the optimum NC flow rate for preoxygenation or whether the presence of NC alone creates a mask leak remains unclear. METHODS We performed a randomized crossover study on healthy volunteers comparing BVM alone and BVM with NC flow rates of 0 (NC-0), 5 (NC-5), 10 (NC-10), and 15 (NC-15) liters per minute (lpm). Our primary outcome was end-tidal oxygen (ETO2) after 3-minute preoxygenation. RESULTS There was no difference in ETO2 between NC-15, NC-10, or BVM-only at 3 minutes. NC-0 and NC-5 recorded significantly lower ETO2 at all times compared with NC-15, NC-10, or BVM-only (least difference NC-5, -7% [95% confidence interval {CI}, -4% to -10%), NC-0, 16% [95% CI, 13%-19%]). There was a difference in ETO2 between NC-15 and BVM-only at 1 minute (7%; 95% CI, 5%-9%), but not at 2 or 3 minutes. There was no difference in ETO2 between NC-10 and NC-15. CONCLUSIONS Our study found that NC at 0 and 5 lpm with a BVM is deleterious to preoxygenation and should be avoided. In addition, a lack of difference between NC-10 and BVM-only demonstrates that NC at flows of at least 10 lpm should not impair the preoxygenation process. While NC-15 may offer a benefit by reaching maximal ETO2 at 1 minute, this would need to be balanced against patient comfort.
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Affiliation(s)
- David McQuade
- From the Wellington Hospital, C&CDHB, Wellington, New Zealand
| | - Matthew R Miller
- Department of Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Clare Hayes-Bradley
- Greater Sydney Area HEMS, NSW Ambulance Aeromedical Service, Rozelle, New South Wales, Australia
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Reid C, Hayes-Bradley C, Burns B. Pre-hospital pre-oxygenation strategies. Anaesthesia 2017; 72:1038-1039. [DOI: 10.1111/anae.13949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- C. Reid
- Greater Sydney Area HEMS; New South Wales Australia
| | | | - B. Burns
- Greater Sydney Area HEMS; New South Wales Australia
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Hayes-Bradley C, McQuade D, Miller M. Preoxygenation via a non-rebreather mask comparing a standard oxygen flowmeter rate of 15 Lpm to maximally open. Emerg Med Australas 2017; 29:372. [DOI: 10.1111/1742-6723.12784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
| | - David McQuade
- Department of Emergency Medicine, Wellington Hospital; Wellington New Zealand
| | - Matthew Miller
- Department of Anaesthesia, Toronto Western Hospital, Toronto; Ontario Canada
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Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med 2016; 68:174-80. [DOI: 10.1016/j.annemergmed.2015.11.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/02/2015] [Accepted: 11/06/2015] [Indexed: 11/24/2022]
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Hayes-Bradley C. CT images of LMA mistaken for oesophageal foreign body. Anaesth Intensive Care 2013; 41:819. [PMID: 24180738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Sherren PB, Hayes-Bradley C, Reid C, Burns B, Habig K. Are physicians required during HEMS winch rescue missions? Crit Care 2013. [PMCID: PMC3642556 DOI: 10.1186/cc12220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Sherren PB, Hayes-Bradley C, Reid C, Burns B, Habig K. Are physicians required during winch rescue missions in an Australian helicopter emergency medical service? Emerg Med J 2013; 31:229-32. [PMID: 23353665 DOI: 10.1136/emermed-2012-201879] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A helicopter emergency medical service (HEMS) capable of winching offers several advantages over standard rescue operations. Little is known about the benefit of physician winching in addition to a highly trained paramedic. OBJECTIVE To analyse the mission profiles and interventions performed during rescues involving the winching of a physician in the Greater Sydney Area HEMS (GSA-HEMS). METHODS All winch missions involving a physician from August 2009 to January 2012 were identified from the prospectively completed GSA-HEMS electronic database. A structured case sheet review for a predetermined list of demographic data and physician-only interventions (POIs) was conducted. RESULTS We identified 130 missions involving the winching of a physician, of which 120 case sheets were available for analysis. The majority of patients were traumatically injured (90%) and male (85%) with a median age of 37 years. Seven patients were pronounced dead at the scene. A total of 63 POIs were performed on 48 patients. Administration of advanced analgesia was the most common POI making up 68.3% of interventions. Patients with abnormal RTSc(2) scores were more likely to receive a POI than those with normal RTSc(2) (84.8% vs 15.2%; p=0.03). The performance of a POI had no effect on median scene times (45 vs 43 min; p=0.51). CONCLUSIONS Our high POI rate of 40% (48/120) coupled with long rescue times and the occasional severe injuries support the argument for winching Physicians. Not doing so would deny a significant proportion of patients time-critical interventions, advanced analgesia and procedural sedation.
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Affiliation(s)
- Peter Brendon Sherren
- Department of Pre-hospital Care, Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS), , Sydney, New South Wales, Australia
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Hayes-Bradley C, Caddel S, Paddle J. Observational cohort of renal replacement therapy patients at a district general hospital ICU: case mix and outcomes. Crit Care 2009. [PMCID: PMC4084158 DOI: 10.1186/cc7436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hayes-Bradley C. Accident and emergency in Jamaica⇓. Assoc Med J 2004. [DOI: 10.1136/bmj.328.7448.s183-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Ventilation in the prone position is used in patients with acute respiratory distress syndrome (ARDS), although data supporting this strategy are limited, and benefit for patients with other conditions is unclear. The patient in this report had severe hypoxaemia from diffuse alveolar haemorrhage caused by vasculitis with positive antineutrophil cytoplasmic antibodies (ANCA). Ventilation in the prone position improved oxygenation dramatically. This improvement was initially maintained when returned supine, accompanied by increased ventilation. Prone ventilation was used on three consecutive days for 10, 14 and 15 h, respectively. Prone ventilation could improve oxygenation by better ventilation-perfusion (V/Q) matching and improved drainage of blood from the dorsal lung. The improved oxygenation in this patient should encourage the use of prone ventilation in other patients with pulmonary haemorrhage and severe hypoxia.
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Affiliation(s)
- C Hayes-Bradley
- Anaesthetics Department, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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