Respiratory care
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Fiberoptic intubation (FOI) is an effective technique for establishing airway access in patients with both anticipated and unanticipated difficult airways. First described in the late 1960s, this approach can facilitate airway management in a variety of clinical scenarios given proper patient preparation and technique. ⋯ Evidence is presented comparing FOI to other techniques with regard to difficult airway management. In addition, we have reviewed the literature on training processes and skill development in FOI.
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Tracheal extubation in both the critical care and anesthesia setting is not only an important milestone for patient recovery, but also a procedure that carries a considerable risk of complication or failure. Mechanical ventilation is associated with significant complications that are time-dependent in nature, with a longer duration of intubation resulting in a higher incidence of complications, including ventilator-associated pneumonia, and increased mortality. ⋯ These risks demand that the process of extubation be managed by practitioners with a detailed understanding of the causes of extubation failure and the potential complications. A pre-established extubation plan with considerations made for the possible need for re-intubation is of the utmost importance.
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Management of the artificial airway includes securing the tube to prevent dislodgement or migration as well as removal of secretions. Preventive measures include adequate humidification and appropriate airway suctioning. ⋯ A number of new monitoring techniques have been introduced, and automated cuff pressure control is becoming more common. The respiratory therapist should be adept with all these devices and understand the appropriate application and management.
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Although endotracheal intubation is commonly performed in the hospital setting, it is not without risk. In this article, we review the impact of endotracheal intubation on airway injury by describing the acute and long-term sequelae of each of the most commonly injured anatomic sites along the respiratory tract, including the nasal cavity, oral cavity, oropharynx, larynx, and trachea. ⋯ This article also includes a review of complications of airway management pertaining to video laryngoscopy and supraglottic airway devices. Finally, potential strategies to prevent intubation-associated injuries are outlined.
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Performing emergency endotracheal intubation necessarily means doing so under less than ideal conditions. Rates of first-time success will be lower than endotracheal intubation performed under controlled conditions in the operating room. Some factors associated with improved success are predictable and can be modified to improve outcome. Factors to be discussed include the initial decision to perform endotracheal intubation in out-of-hospital settings, qualifications and training of providers performing intubation, the technique selected for advanced airway management, and the use of sedatives and neuromuscular blocking agents.