Week 11

Reflection

 

Using the Gibb’s Reflective Model I will reflect on the eleventh Lab session we had for this semester

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:  Description: I was given a scenario of a 58 male complaining of cough. Demonstrating a correct management and logical sequence of history taking was required from me. Vital signs was obtained from the patient. Patient has history of smoking and a lot of tissues were around the patient. Wheezing sound was found in the patient chest.

Feelings: I felt very interested to practice this case scenario. I felt my management was not fully right however I tried to treat the patient. Also, I felt happy because I give the medication that help to the patient condition.  

Evaluation: what was good about the case was I felt my management was correct to this patient. Also, I gave the combination of metoclopramide and salbutamol which helped the patient. In addition, oxygen therapy was given early. Moreover, what want bad in the case was, I didn’t initiate transport early. Also, I continued giving high flow oxygen to the patient although, I realized the patient may has COPD. Moreover, the right sequences of following of OSCE sheet was not present.   

Analysis: In this patient high flow oxygen is not recommended because it may worse the case and cause hypoxic drive. Nasal cannula or sample face mask may be recommended with low flow oxygen.

Conclusion: In next time, I will make sure that I have read the paper carefully to avoid mistakes. Also, I will make sure that I am providing the correct amount oxygen to COPD patient.

Action plan: I plan to go through the OSCE sheet for medical case and make sure I know the steps in correct sequence .Furthermore, I will refer to JRCALC to read the management of COPD especially, the oxygen therapy and make sure that I am following the correct management.

Domain knowledge

Enquiry and Research

In this week, in order to understand more, I have read about croup condition. I find that most children who present with acute onset of barky cough, stridor, and chest-wall in drawing have croup. Also, I found a careful history and physical examination is the best method to confirm the diagnosis and to rule out potentially serious alternative disorders such as bacterial tracheitis and other rare causes of upper-airway obstruction. Epinephrine delivered via a nebuliser is effective for temporary relief of symptoms of airway obstruction. Corticosteroids are the mainstay of treatment, and benefit is seen in children with all levels of severity of croup, including mild cases) Bjornson & Johnson, 2008)

 :References

Bjornson, C., & Johnson, D. (2008).Croup. Lancet, 371(9609):329-39. doi: 10.1016/S0140-6736(08)60170-1.

 

Week 10

Reflection

Using the Gibb’s reflective I will reflect on the tenth lab session we had for this semester.

Description: In this week, we have practiced advance airway management using endotracheal intubation. First I prepared the equipment for each skill. For the intubation, first I preoxygante the patient for 2 to 3 minutes with a bag valve mask device 100% oxygen. Then, I left the patient tongue and mandible anteriorly. I inserted the ET tube into the midline of the patient’s mouth and slowly advance toward the larynx, but stop before passing through the vocal cords. I observed for a tightly circumscribed light at the midline of the neck and advance the ET tube 2 to 4 cm farther. I inflated the distal cuff of ET tube with 5 to 10 ml of air and detach the syringe. I attached the bag mask device, ventilate and auscultate over the apices and epigastrium.

Feelings: I felt this was the biggest has impression in my whole lab sessions. Because all the skills which advanced have been covered in this lab. Also, I felt confident while practicing those skills since I was following the instructions.

Evaluation: What was good about the case was I learned a lot from this lab session. I was able to intubate the patient in 30 seconds which is really good. I felt I am confident to apply this advanced producer if needed. Moreover, nothing was done bad.

Analysis: I have to consider the intubation as a last solution, if I am not able to provide an adequate ventilation because it’s an invasive procedure and it may cause more damage.  

Conclusion: In next time, I make sure that I am following the OSCE sheet of advanced airway.

Action plan: I plan to go through the OSCE sheet for advanced airway and make sure I know the steps in correct sequence .Furthermore, I will keep practice those advanced skills until it becomes easy. Also, I will refer to the core textbook to read further about advanced airway.  

 preparing the ET tube

Preparing the combitube and king LT

Domain knowledge

Enquiry and Research

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Also,In this week, I have further read the condition that was in lecture. I have read about acute laryngitis, laryngeal Oedema and laryngopharyngeal reflux disease (LPRD) .

Acute laryngitis

Acute laryngitis is a clinical syndrome characterized by a hoarse voice with decreased phonation and voice projection, usually occurring after an upper respiratory tract infection with cough. Approximately 1% of medical care claims are due to dysphonia, with 42 of these classified as acute laryngitis. Two percent of individuals with acute respiratory symptoms are diagnosed with acute laryngitis.

Acute laryngitis is diagnosed more frequently in women than men. More cases are diagnosed in the colder months of the year.

A viral upper respiratory tract infection is often associated with acute laryngitis. Bacterial infections of the upper respiratory tract have also been implicated.

Clinical diagnosis is based on the appropriate history and changes of the voice. Visualization of the larynx reveals edema and vascular engorgement of the mucous membranes with hyperemic and erythematous vocal folds. 

Treatment of acute laryngitis is based on the underlying cause of the laryngeal pathologic process. Often, symptomatic therapy with voice rest, analgesic and humidification is sufficient.

 (Anniko, 2010)

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Laryngeal Oedema

Laryngeal edema is a common cause of airway obstruction after extubation and is thought to arise from direct mechanical trauma to the larynx by the endotracheal tube. The severity of airway obstruction due to laryngeal edema varies. In severe cases, the edema can lead to acute respiratory compromise needing emergency reintubation. Reintubation itself is associated with more effects such as, increased mechanical ventilation days and length of stay in the intensive care unit, morbidity and mortality. These associations, however, don’t all apply to reintubation due to laryngeal oedema. Endotracheal intubation can cause damage to the oropharynx, larynx and trachea. Laryngeal edema and mucosal ulcerations occur in almost all patients intubated for 4 days or more. Ulceration in vocal cord and granulation tissue are also found in most cases, usually located posterior to the level of the vocal cords, where the tube exerts the highest pressure. These injuries are usually reversible, with most of the lesions resolving within 1 month.  Ischemia and pressure are thought to contribute to mucosal edema, which may subsequently progress and present as inspiratory stridor within hours of extubation (Figure 1) (Wittekamp, van Mook, Tjan, Zwaveling, & Bergmans, 2009).

Laryngeal Oedema (Figure.1)

Laryngopharyngeal reflux disease

Laryngopharyngeal reflux (LPR) is defined as the reflux of gastric content into the larynx and pharynx (Vakil, van Zanten, Kahrilas, Dent, & Jones, 2006). According to the Montreal Consensus Conference, the manifestations of gastroesophageal reflux disease (GERD) have been classified into either esophageal or extraesophageal syndromes (Martinucci et al., 2013).

(Table.1)

 

The positive effects of lifestyle modifications compared with those of uncertain efficacy in the treatment of laryngopharyngeal reflux disease (LPRD).

After, I did the research I found useful information in terms of Laryngeal Oedema, Acute laryngitis and Laryngopharyngeal reflux. Also, now I am very happy to acquire the information.  

References: 

 Anniko, M. (2010). Otorhinolaryngology, head and neck surgery. Berlin: Springer.

Courtesy of L. Baijens. (2009). Laryngeal edema. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811912/

Martinucci, I., de Bortoli, N., Savarino, E., Nacci, A., Romeo, S., & Bellini, M. et al. (2013). Optimal treatment of laryngopharyngeal reflux disease. Therapeutic Advances in Chronic Disease, 4(6), 287-301. doi:10.1177/2040622313503485
Vakil, N., van Zanten, S., Kahrilas, P., Dent, J., & Jones, R. (2006). The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus. The American Journal of Gastroenterology, 101(8), 1900-1920. doi: 10.1111/j.1572-0241.2006.00630.x

Wittekamp, B., van Mook, W., Tjan, D., Zwaveling, J., & Bergmans, D. (2009). Clinical review: Post-extubation laryngeal edema and extubation failure in critically ill adult patients. Critical Care, 13(6), 233. doi: 10.1186/cc8142