Acute and Critical Care

Original Articles

Trauma
Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit: Nader Markazi Moghaddam, Mohammad Fathi, Sanaz Zargar Balaye Jame, Mohammad Darvishi, Morteza Mortazavi; Acute Crit Care. 2023;38(1):113-121. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.00927

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Abstract PDF: Background
We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI). Methods: From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients’ demographic, clinical, and laboratory features. Results: EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81). Conclusions: A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

Liver
Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study: Saad Saffo, Guadalupe Garcia-Tsao; Acute Crit Care. 2022;37(3):355-362. Published online August 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00528

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Background
Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.
Methods
The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.
Results
Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14–4.20; P<0.001) and in all sensitivity analyses.
Conclusions
Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Citations

Citations to this article as recorded by

Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis
Xiao-Wei Tang, Wen-Sen Ren, Shu Huang, Kang Zou, Huan Xu, Xiao-Min Shi, Wei Zhang, Lei Shi, Mu-Han Lü
World Journal of Hepatology.2024; 16(4): 625. CrossRef
Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy
Zhe Zhang, Jian Wang, Wei Han, Li Zhao
BMC Gastroenterology.2023;[Epub] CrossRef
Experience in Non-invasive Ventilation in Grade 3 Hepatic Encephalopathy
İlhan Ocak, Mustafa Çolak, Erdem Kınacı
Istanbul Medical Journal.2023; 24(3): 295. CrossRef

Nursing
Effect of modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients: Suphannee Triamvisit, Wassana Wongprasert, Chalermwoot Puttima, Matchima Na Chiangmai, Nawaphan Thienjindakul, Laksika Rodkul, Chumpon Jetjumnong; Acute Crit Care. 2021;36(4):294-299. Published online November 23, 2021; DOI: https://doi.org/10.4266/acc.2021.00983

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Abstract PDF: Background
Care bundles for ventilator-associated pneumonia (VAP) have been shown to minimize the rate of VAP in critically ill patients. Standard care bundles may need to be modified in resource-constrained situations. The goal of this study was to see if our modified VAP-care bundles lowered the risk of VAP in neurosurgical patients.
Methods
A prospective cohort study was conducted in mechanically ventilated neurosurgical patients. The VAP bundle was adjusted in the cohort group by increasing the frequency of intermittent endotracheal tube cuff pressure monitoring to six times a day while reducing oral care with 0.12% chlorhexidine to three times a day. The rate of VAP was compared to the historical control group.
Results
A total of 146 and 145 patients were enrolled in control and cohort groups, respectively. The mean age of patients was 52±16 years in both groups (P=0.803). The admission Glasgow coma scores were 7.79±2.67 and 7.80±2.77 in control and cohort group, respectively (P=0.969). VAP was found in nine patients in control group but only one patient in cohort group. The occurrence rate of VAP was significantly reduced in cohort group compared to control group (0.88/1,000 vs. 6.84/1,000 ventilator days, P=0.036).
Conclusions
The modified VAP bundle is effective in lowering the VAP rate in critically ill neurosurgical patients. It requires low budget and manpower and can be employed in resource-constrained settings.

CPR/Resuscitation
Risk factors associated with inpatient cardiac arrest during emergency endotracheal intubation at general wards: Chul Park; Acute Crit Care. 2019;34(3):212-218. Published online August 31, 2019; DOI: https://doi.org/10.4266/acc.2019.00598; Correction in: Acute Crit Care 2020;35(3):228

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Abstract PDF

Background
Peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is a rare, however, potentially preventable type of cardiac arrest. Limited published data have described factors associated with inpatient PICA and patient outcomes. The aim of this study was to identify risk factors associated with PICA among hospitalized patients emergently intubated at a general ward as compared to non-PICA inpatients. In addition, we identified a difference of clinical outcomes in patients between PICA and other types of inpatient cardiac arrest (OTICA).
Methods
We conducted a retrospective observational study of patients at two institutions between January 2016 to December 2017. PICA was defined in patients emergently intubated who experienced cardiac arrest within 20 minutes after ETI. The non-PICA group consisted of inpatients emergently intubated without cardiac arrest. Risk factors for PICA were identified through univariate and multivariate logistic regression analysis. Clinical outcomes were compared between PICA and OTICA.
Results
Fifteen episodes of PICA occurred during the study period, accounting for 3.6% of all inpatient arrests. Intubation-related shock index, number of intubation attempts, pre-ETI vasopressor use, and neuromuscular blocking agent (NMBA) use, especially succinylcholine, were independently associated with PICA. Clinical outcomes of intensive care unit and hospital length of stay, survival to discharge, and neurologic outcome at hospital discharge were not significantly different between PICA and OTICA.
Conclusions
We identified four independent risk factors for PICA, and preintubation hemodynamic stabilization and avoidance of NMBA were possibly correlated with a decreased PICA risk. Clinical outcomes of PICA were similar to those of OTICA.

Citations

Citations to this article as recorded by

Risk factors for peri-intubation cardiac arrest: A systematic review and meta-analysis
Ting-Hao Yang, Shih-Chieh Shao, Yi-Chih Lee, Chien-Han Hsiao, Chieh-Ching Yen
Biomedical Journal.2023; : 100656. CrossRef
Reverse shock index (RSI) as a predictor of post-intubation cardiac arrest (PICA)
Mehdi Torabi, Ghazal Soleimani Mahani, Moghaddameh Mirzaee
International Journal of Emergency Medicine.2023;[Epub] CrossRef
Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial
Cédric Gil-Jardiné, Patricia Jabre, Frederic Adnet, Thomas Nicol, Patrick Ecollan, Bertrand Guihard, Cyril Ferdynus, Valery Bocquet, Xavier Combes
Internal and Emergency Medicine.2022; 17(2): 611. CrossRef
Risk factors associated with peri-intubation cardiac arrest in the emergency department
Ting-Hao Yang, Kuan-Fu Chen, Shi-Ying Gao, Chih-Chuan Lin
The American Journal of Emergency Medicine.2022; 58: 229. CrossRef
Comparison of video-stylet and conventional laryngoscope for endotracheal intubation in adults with cervical spine immobilization: A PRISMA-compliant meta-analysis
I-Wen Chen, Yu-Yu Li, Kuo-Chuan Hung, Ying-Jen Chang, Jen-Yin Chen, Ming-Chung Lin, Kuei-Fen Wang, Chien-Ming Lin, Ping-Wen Huang, Cheuk-Kwan Sun
Medicine.2022; 101(33): e30032. CrossRef
Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review
Rohit S. Loomba, Riddhi Patel, Elizabeth Kunnel, Enrique G. Villarreal, Juan S. Farias, Saul Flores
Journal of Pediatric Intensive Care.2022;[Epub] CrossRef
Comparison of Suction Rates Between a Standard Yankauer, a Commercial Large-Bore Suction Device, and a Makeshift Large-Bore Suction Device
Dhimitri A. Nikolla, Briana King, Andrew Heslin, Jestin N. Carlson
The Journal of Emergency Medicine.2021; 61(3): 265. CrossRef
Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies
Kunal Karamchandani, Jonathan Wheelwright, Ae Lim Yang, Nathaniel D. Westphal, Ashish K. Khanna, Sheila N. Myatra
Anesthesia & Analgesia.2021; 133(3): 648. CrossRef
Further Validation of a Novel Acute Myocardial Infarction Risk Stratification (nARS) System for Patients with Acute Myocardial Infarction
Shinnosuke Sawano, Kenichi Sakakura, Kei Yamamoto, Yousuke Taniguchi, Takunori Tsukui, Masaru Seguchi, Hiroshi Wada, Shin-ichi Momomura, Hideo Fujita
International Heart Journal.2020; 61(3): 463. CrossRef
Corrigendum to: Risk factors associated with inpatient cardiac arrest during emergency endotracheal intubation at general wards
Chul Park
Acute and Critical Care.2020; 35(3): 228. CrossRef

Pulmonary
Clinical Application of Modified Burns Wean Assessment Program Scores at First Spontaneous Breathing Trial in Weaning Patients from Mechanical Ventilation: Eun Suk Jeong, Kwangha Lee; Acute Crit Care. 2018;33(4):260-268. Published online November 30, 2018; DOI: https://doi.org/10.4266/acc.2018.00276

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Abstract PDF

Background
The purpose of this study was to evaluate the clinical application of modified Burns Wean Assessment Program (m-BWAP) scoring at first spontaneous breathing trial (SBT) as a predictor of successful liberation from mechanical ventilation (MV) in patients with endotracheal intubation.
Methods
Patients requiring MV for more than 72 hours and undergoing more than one SBT in a medical intensive care unit (ICU) were prospectively enrolled over a 3-year period. The m-BWAP score at first SBT was obtained by a critical care nursing practitioner.
Results
A total of 103 subjects were included in this study. Their median age was 69 years (range, 22 to 87 years) and 72 subjects (69.9%) were male. The median duration from admission to first SBT was 5 days (range, 3 to 26 days), and the rate of final successful liberation from MV was 84.5% (n=87). In the total group of patients, the successful liberation from MV group at first SBT (n=65) had significantly higher m-BWAP scores than did the unsuccessful group (median, 60; range, 43 to 80 vs. median, 53; range, 33 to 70; P<0.001). Also, the area under the m-BWAP curve for predicting successful liberation of MV was 0.748 (95% confidence interval, 0.650 to 0.847), while the cutoff value based on Youden’s index was 53 (sensitivity, 76%; specificity, 64%).
Conclusions
The present data show that the m-BWAP score represents a good predictor of weaning success in patients with an endotracheal tube in place at first SBT.

Citations

Citations to this article as recorded by

What do we know about experiencing end-of-life in burn intensive care units? A scoping review
André Filipe Ribeiro, Sandra Martins Pereira, Rui Nunes, Pablo Hernández-Marrero
Palliative and Supportive Care.2023; 21(4): 741. CrossRef
Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses
Rika KIMURA, Naoko HAYASHI, Akemi UTSUNOMIYA
Journal of Nursing Research.2023; 31(4): e287. CrossRef
Value of modified Burns Wean Assessment Program scores in the respiratory intensive care unit: An Egyptian study
Nermeen A. Abdelaleem, Sherif A.A. Mohamed, Azza S. Abd ElHafeez, Hassan A. Bayoumi
Multidisciplinary Respiratory Medicine.2020;[Epub] CrossRef
Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review
Minhyeok Lee, Ji Hye Kim, In Beom Jeong, Ji Woong Son, Moon Jun Na, Sun Jung Kwon
Acute and Critical Care.2019; 34(1): 60. CrossRef

Thoracic Surgery
A Closed-Suction Catheter with a Pressure Valve Can Reduce Tracheal Mucosal Injury in Intubated Patients: Jin Heon Jeong, Sung Jin Nam, Young Jae Cho, Yeon Joo Lee, Se Joong Kim, In Ae Song, Sang Heon Park, Young Tae Jeon; Korean J Crit Care Med. 2014;29(1):7-12. Published online February 28, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.1.7

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Abstract PDF

Background
Endotracheal suctioning is associated with complications that include bleeding, infection, hypoxemia, cardiovascular instability, and tracheal mucosal injury. Recently, a closed-suction catheter with a pressure valve (Acetrachcare, AceMedical Co., Republic of Korea) was developed. We hypothesized that this new catheter might reduce tracheal mucosal injury compared to a conventional closed-suction catheter (Trachcare, Kimberly-balla RD, USA).
Methods
This prospective, randomized study enrolled medical and surgical patients who required mechanical ventilation for more than 48 hours. Patients were randomized into two groups: one group was suctioned with the conventional closed-suction catheter (CCC) and the other group was suctioned with the closed-suction catheter with pressure valve (CCPV). Bronchoscopy was performed 48 hours later, and the severity of tracheal mucosal injury was graded on a 5-point scale, as follows: 0 = normal; 1 = erythema or edema; 2 = erosion; 3 = hemorrhage; and 4 = ulceration or necrosis.
Results
A total of 76 patients (37 with CCPV and 39 with CCC) were included. There were no significant differences between the groups regarding demographic characteristics, changes in hemodynamic parameters during suction, incidence of pneumonia, length of intensive care unit (ICU) stay, or ICU mortality. On bronchoscopic evaluation, the use of the CCPV led to a significant decrease in tracheal mucosal injury (median tracheal mucosal injury grade 1 [IQR 0-1] vs. 2 [IQR 1-3], p = 0.001).
Conclusions
We conclude that the novel closed-suction catheter with pressure valve may reduce tracheal mucosal injury compared to conventional catheters.

Citations

Citations to this article as recorded by

“Study on Device System to Reduce Tracheal Mucosal Injury in Intubation Patients” [ASME Journal of Medical Devices, 2022, 16(3), p. 031006; DOI: 10.1115/1.4054334]

Journal of Medical Devices.2022;[Epub] CrossRef
Efficacy of the Closed Suction Applied To Patients In Intensive Care Units with Different Techniques: A Nonrandomized Controlled Trial
Zuhal GÜLSOY, Şerife KARAGÖZOĞLU
Cumhuriyet Medical Journal.2020;[Epub] CrossRef

Comparison of Hemodynamic Changes by the Thoracic Electrical Bioimpedance Device during Endotracheal Intubation or Insertion of Laryngeal Mask Airway in General Anesthesia: Han Mok You, Jin Mo Kim, Jae Kyu Cheun; Korean J Crit Care Med. 1998;13(1):67-72.

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Abstract PDF: Introduction: we measured the hemodynamic changes by the thoracic electrical bioimpedance (TEB) device during induction of anesthesia, endotracheal intubation or insertion of layngeal mask airway (LMA). This TEB device is safe, reliable and estimate continuously and invasively hemodynamic variables.
METHODS
We measured the cardiovascular response of endotracheal intubation or that of LMA insertion in thirty ASA class I patients. General anesthesia was induced with injection of fentany 1 microgram/kg, thiopetal sodium 5 mg/kg and vecuronium 1 mg/kg intravenously. Controlled ventilation was for 3 minutes with inhalation of 50% nitrous oxide and 1.5 vol% of enflurane before tracheal intubation or LMA insertion in all patients. The patient was randomly assinged to either tracheal intubation group (ET group) or laryngeal mask airway group (LMA group). Heart rate (HR), mean arterial pressure (MAP), systemic vascular resistance (SVR), stroke index (SI) and cardic index (CI) were measured to pre-induction, pre-intubation, 1 minute after intubation, 2 minute, 3 minute, 5 minute, 7 minute.
RESULTS
MAP and SVR were decreased effectively LMA group than ET group during 1 minute after intubation, 2 minute, 3 minute, 5 minute, 7 minute (p<0.05). HR was decreased effectively LMA group than ET group between pre-induction and 1 minute after intubation, between 1 minute after intubation and 2 minute after intubation (p<0.05). But, SI and CI were no difference between ET group and LMA group during induction of anesthesia and intubation (p<0.05).
CONCLUSION
The insertion of LMA is beneficial for certain patients than endotracheal tube to avoid harmful cardiovascular response in the management of airway during anesthesia.

Case Reports

Transient Dilation of the Membranous Trachea after Endotracheal Intubation: A Case Report: Seung Choi, Eun Woo Lee, Myung Ho Yun, Jae Young Park, Cheol Hwan Kim, Jae Won Beom, Gun Park; Korean J Crit Care Med. 2012;27(1):55-58.; DOI: https://doi.org/10.4266/kjccm.2012.27.1.55

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Abstract PDF: Endotracheal intubation is a quick, simple and safe procedure for airway management and is used in various medical procedures. Many endotracheal tubes have a cuff system, which prevents aspiration and allows positive pressure ventilation. However excessive inflation of the cuff can cause mucosal ischemia with tracheal dilation which may result in tracheal rupture, or even death. Fortunately, mucosal ischemia of the trachea can be treated successfully with well-timed control of cuff pressure. It is essential for medical practitioners to be aware of these complications and to be able to manage them effectively if they arise. We present a case of diverticular-like dilation of the lower trachea detected by fiberoptic bronchoscopy that eventually improved in the hemoptysis patient after endotracheal intubation.

A Case of Bilateral Vocal Cord Paralysis Due to Subglottic Pressure Injury after Endotracheal Intubation: A Case Report: Gyu Sik Choi, Sang Hoon Kim, Jae Hyung Lee, You Lim Kim, Ji Hyun Lee, Young Woo Jang, Eun Sun Cheong, Jong Kwan Jung, Byoung Hoon Lee; Korean J Crit Care Med. 2011;26(3):191-195.; DOI: https://doi.org/10.4266/kjccm.2011.26.3.191

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Abstract PDF: Bilateral vocal cord paralysis may occur as a result of mechanical injury during neck surgery, nerve compression by endotracheal intubation or mass, trauma, and neuromuscular diseases. However, only a few cases of bilateral vocal cord paralysis have occurred following short-term endotracheal intubation. We report a case of bilateral vocal cord paralysis subsequent to extubation after endotracheal intubation and mechanical ventilation due to severe pneumonia for 2 days.

Original Article

The Consistency and Clinical Significance between Bronchoscopic Samples and Endotracheal or Tracheostomic Aspirates in Severe Pneumonia Under Mechanical Ventilation: Hye Sung Park, Seo Woo Kim, Yun Su Sim, Ji Hye Kim, Yon Ju Ryu, Jin Hwa Lee, Jung Hyun Chang; Korean J Crit Care Med. 2011;26(2):83-88.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.83

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Abstract PDF

BACKGROUND
Distal airway bacterial colonization occurs more frequently in patients with endotracheal tubes or tracheostomy of intensive care units (ICU) care. In general, bronchoscopic samples are considered more accurate than transtracheal aspirates. In this study, we evaluated the consistency and clinical significance between bronchoscopic samples and transtracheal aspirates (TTA) in severe pneumonia under mechanical ventilation.
METHODS
We investigated the consistency between bronchoscopic samples and transtracheal aspirates among patients with endotracheal tubes or tracheostomy, retrospectively. Fiberoptic bronchoscopy was performed in 212 patients with mechanical ventilation via endotracheal tube or tracheostomy between January 1st, 2004 and December 31th, 2008 in ICU at Ewha Womans University Hospital. We evaluated consistency in terms of true pathogen according to the arbitrary ICU days progress.
RESULTS
Among the 212 enrolled patients, 113 (53%) had consistency between bronchoscopic samples and transtracheal aspirates. When evaluated alteration trends in consistency according to ICU stay, the consistency was maintained for 5 to 9 ICU days with statistical significance (p< 0.05) since adjusting for age, sex, and combined risk factors. Consistency in sampling status between the endotracheal tube and tracheostomy was also evaluated, however, there was no statistical significance (OR 1.9 vs. 1, 95% CI = 0.997-3.582, p = 0.051).
CONCLUSIONS
Shorter hospital stay (within 9 days of ICU stay) had higher probability of consistency between bronchoscopic samples and TTA samples. TTA may be as confident as bronchoscopic samples in patients of pneumonia under mechanical ventilation with shorter ICU stays, especially less than 10 days.

Citations

Citations to this article as recorded by

Comparison of the Pattern in Semi-Quantitative Sputum Cultures Based on Different Endotracheal Suction Techniques
Jiwoong Oh, Kum Whang, Hyenho Jung, Jongtaek Park
Korean Journal of Critical Care Medicine.2012; 27(2): 70. CrossRef

Case Reports

Delayed Obstruction of Endotracheal Tube by Previously Aspirated Foreign Body: A Case Report: Sungsik Chon, Jinho Kim, Shin Ok Koh, Jung Goo Cho, In Soon Hwang, In Seon Jin; Korean J Crit Care Med. 2005;20(2):174-177.

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Abstract PDF: Acute airway obstruction during endotracheal intubation status is embarrassing and critical situation which requires early diagnosis and immediate management. Endotracheal tube obstruction with foreign body is rare but a variety of objects have been reported. We present a case of endotracheal tube obstruction as a result of previous aspirated foreign body that moved from the bronchial tree into the endobroncheal tube.

Subcutaneous Emphysema and Pneumothorax Occurred during Patient Transfer to Intensive Care Unit: A Case Report: Yoonki Lee, Won Young Kim; Korean J Crit Care Med. 2004;19(1):52-56.

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Abstract PDF: A 48 years old female patient was scheduled for emergency surgery due to bleeding after intracerebral aneurysmal clipping under general anesthesia. Previously checked chest X-ray taken just a few hours before surgery showed no abnormal finding and she didn't show any sign of pneumothorax or hemothorax including dyspnea, tachypnea or cyanosis. Surgery was uneventful. After the completion of surgery, patient was transferred to the neurosurgical intensive care unit with intubation. During transfer, patient showed bucking and signs of subcutaneous emphysema around chest, shoulder and face. Oxygen saturation was low when she admitted to the neurosurgical intensive care unit, so the ventilator care was started. The patient's oxygenation were getting worse progressively, so we checked chest AP several times and one of the chest X-ray taken at that time revealed no vascular and lung marking on the left lung field suggesting pneumothorax. Emergency chest tube drainage was performed. She recovered dramatically and three days later, ches X-ray showed the complete resorption of the pneumothorax.

Tracheoesophageal Fistula as a Complication after Endotracheal Intubation: A Case Report: Woong Mo Kim, Seong Wook Jeong, Sang Hyun Kwak, Sung Su Chung, Chang Young Jeong; Korean J Crit Care Med. 2003;18(1):39-42.

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Abstract PDF: Placement of endotracheal tube, even for extremely short periods, can result in injury to laryngeal and tracheal tissue. This may be clinically insignificant, but in rare cases, it could be life threatening and results in permanent disability. Especially, tracheoesophageal fistula (TEF) is a serious and challenging problem because it may contaminate the tracheobronchial tree and interfere with nutrition. This uncommon but lethal complication has been reported to be associated with certain risk factors in tracheally intubated patients, and better knowledge of these factors could reduce the incidence of post-intubation TEF. We report a case of 49-year old male patient who has acquired TEF caused by endotracheal intubation and positive pressure ventilation.

Original Articles

Predictors for Reintubation after Unplanned Endotracheal Extubation in Multidisciplinary Intensive Care Unit: Bon Nyeo Koo, Shin Ok Koh, Tae Dong Kwon; Korean J Crit Care Med. 2003;18(1):20-25.

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Abstract PDF: BACKGROUND
Unplanned endotracheal extubation is a potentially serious complication, as some patients may need reintubation while in very critical conditions that may increase the morbidity and mortality rates. We conducted a study to evaluate the predictors for reintubation after unplanned extubation. METHODS: Patients who presented unplanned extubation over a 35-month period in two multidisciplinary intensive care units of university affiliated hospital were included. Any replacement of an endotracheal tube within 48 hours after unplanned extubation was considered as reintubation. RESULTS: There were 62 episodes of unplanned endotracheal extubation in 56 patients (incidence rate 2.8%). Fifty seven episodes (91.9%) were deliberate self-extubation, while 5 episodes (8.1%) were accidental extubation. Reintubation was required in 42 episodes (67.7%). Only 44.4% (12/27) of the patients who presented unplanned extubation required reintubation during weaning period, while reintubation was mandatory in 85.7% (30/35) of the patients who presented unplanned extubation during full ventilatory support (P<0.001). The multiple logistic regression analysis was made to obtain a model to predict the need for reintubation as a dependent variable: ventilatory support mode (odds ratio: 12.0) was significantly associated with the need for reintubation. The model correctly classified the need of reintubation in 72.6% (45/62) of the patients. CONCLUSIONS: Reintubation in unplanned extubation strongly depended on the type of the mechanical ventilatory support. The probability of requiring reintubation after unplanned extubation was higher during full ventilatory support than during weaning period.

Clinical Survey of Appropriate Cuff Volume and Pressure during General Anesthesia in Pediatric Patients: Dong Suk Chung; Korean J Crit Care Med. 2000;15(2):93-97.

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Abstract PDF: BACKGROUND
Uncuffed endotracheal tubes are commonly used in pediatrics even when the risk of gastric aspiration is significant. But cuffed endotracheal tubes effectively protect the risk of pulmonary aspiration and completely seal the airway. This study was designed to determine the appropriate cuff volume and pressure with low risk of ischemic injury to children's airway.
METHODS
We intubated cuffed endotracheal tube (internal diameter 4.5, 5.0, 5.5 mm) in 90 surgical pediatric patient from 16 to 118 months of age. After intubation, initial cuff volume and pressure were measured at the level of complete sealing in each group. Each group was administrated 50% nitrous oxide and 67% nitrous oxide and measured cuff pressure at 20 minutes, 40 minutes.
RESULTS
1) The mean initial cuff volume and pressure of 4.5 ID tube were 0.59 +/- 0.16 ml and 14.5 +/- 0.31 cmH2O (n=30). 2) The mean initial cuff volume and pressure of 5.0 ID tube were 1.00 +/- 0.38 ml and 14.3 +/- 3.55 cmH2O (n=30). 3) The mean initial cuff volume and pressure of 5.5 ID tube were 1.06 +/- 0.26 ml and 14.28 +/- 2.01 cmH2O (n=30). 4) The cuff pressure increased significantly in the course of time, but no pressure in three groups was above 30 cmH2O.
CONCLUSIONS
We could determine the appropriate cuff volume of cuffed endotracheal tube in pediatric patients. Also we concluded that nitrous oxide concentration affect little intracuff pressure in brief operation.

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