《氣道管理新進(jìn)展》

SealingOutDoubtAdvancesinAirwayManagement氣道管理新進(jìn)展Disclosure

MarkProcyshyn,RRTistheSeniorRegionalMarketingManagerforCovidien’sRespiratoryDivisioninAsia.Whatarepostoperativepulmonarycomplications?何為術(shù)后肺部并發(fā)癥Whatistheirsignificanceintermsof:Incidence?發(fā)生率？Clinicaloutcomes?臨床結(jié)果？Outline:PostoperativePulmonaryComplications

術(shù)后肺部并發(fā)癥Thesecomplicationsrangefromminor,self-limitedconditionstomajordiseasestateswithsignificantmorbidityandmortality.

這些并發(fā)癥小至自限性疾病，大至具有較高發(fā)病率和死亡率的疾病。Themostcommonlycitedexamplesintheclinicalliteratureare:1

在醫(yī)學(xué)文獻(xiàn)中最常見(jiàn)引用的并發(fā)癥是：Pneumonia肺炎R(shí)espiratoryfailure呼吸衰竭Atelectasis肺不張Acuteexacerbationofchroniclungdisease慢性肺部疾病的急性加重OtherprominentexamplesincludeARDS,bronchospasm,tracheobronchitisandperioperativehypoxia.

其他突出的并發(fā)癥包括：ARDS，支氣管痙攣，支氣管炎，術(shù)中低氧血癥1.Arozullahetal.AnnSurg.2000;232(2):242-253.Whatarepostoperativepulmonarycomplications?何為術(shù)后肺部并發(fā)癥Whatistheirsignificanceintermsof:Incidence?發(fā)生率？Clinicaloutcomes?Outline:PostoperativePulmonaryComplicationsAreSurprisinglyCommon

術(shù)后肺部并發(fā)癥十分常見(jiàn)SurgicalsiteReportedcomplicationrateStudies,nAAArepair腹主動(dòng)脈瘤切除術(shù)25.5%16Esophagectomy食道切除術(shù)18.9%11Abdominalsurgery腹部手術(shù)14.2%43Headandnecksurgery頭頸部手術(shù)10.3%6Hipsurgery髖部手術(shù)5.1%5Gynecologic/Urologicprocedures

婦科/泌尿科操作1.8%21.Smetanaetal.AnnInternMed.2006;144:581-95.Summaryofstudiesinvestigatingincidenceofpostoperativepulmonarycomplicationsbysurgicalsite,aspersystematicliteraturereviewin200612006年不同部位外科手術(shù)后術(shù)后肺部并發(fā)癥發(fā)生率研究的概要Multiplestudiesshowthehighincidenceofpostoperativepulmonarycomplications.多項(xiàng)研究先提示術(shù)后肺部并發(fā)癥的發(fā)生率較高。PostoperativePulmonaryComplicationsDeserveEqualAttentionwithPerioperativeCardiacComplications

術(shù)后肺部并發(fā)癥應(yīng)與術(shù)中心臟并發(fā)癥一樣引起重視Retrospectivemulticentercohortstudyof8,930patients60yearsorolderforhipsurgery1針對(duì)8930例60歲以上髖部手術(shù)患者的多中心回顧性隊(duì)列研究，1.Lawrenceetal.ArchInternMed.2002.ComplicationIncidence30-daymortality1-yearmortalitySeriouscardiac*嚴(yán)重的心血管疾病2.0%22%36%Seriouspulmonary?嚴(yán)重的肺部疾病2.6%17%44%p-value:->0.05>0.05*DefiniteorprobableMI,emergencycardioversion,pacemakerinsertion,ventricularfibrillation,ventriculartachycardia,hypotensionrequiringvasopressors,sicksinussyndromeorotherconductiondefect,orCPR.?Respiratoryfailureorpneumonia.Nostatisticaldifferencefoundforincidenceormortalityat30daysand1year.30天或1年的發(fā)病率或死亡率無(wú)顯著性差異。InAggregate,PostoperativePulmonaryComplicationsOccurMoreOftenThanCardiac

總體上，術(shù)后肺部并發(fā)癥多于心臟并發(fā)癥Casecontrolfrom2,291patientsundergoingelectiveabdominalsurgery,excludingatelectasis12291例進(jìn)行擇期腹部手術(shù)患者的病例對(duì)照研究，除外肺不張ComplicationEstimatedincidence(95%CI)LOS(±SD),p=0.001Pulmonary肺部9.6%(7.2-12.0)22.5(±17)daysCardiac心臟5.7%(3.8-7.7)10.4(±4.5)days1.Lawrenceetal.JGenInternMed.1995;10:671-678.Totalpulmonarycomplicationsoccurrednearlytwiceasoftenandresultedinhospitallengthsofstayovertwiceaslong.總的肺部并發(fā)癥發(fā)生率高一倍，住院天數(shù)延長(zhǎng)一倍多Pneumonia,inParticular,IsVeryCommoninSurgicalPatients

肺炎，外科患者尤為常見(jiàn)Mostcommonpost-surgicalcomplicationinnoncardiacsurgicalpatients1

非心臟手術(shù)患者最常見(jiàn)術(shù)后并發(fā)癥Mostcommoncomplicationintraumapatients2、

外傷患者最常見(jiàn)術(shù)后并發(fā)癥1.Khanetal.JGenInternMed.2006;21:177-180.2.Hemmilaetal.Surgery.2008;144:307-316.Whatarepostoperativepulmonarycomplications?術(shù)后并發(fā)癥Whatistheirsignificanceintermsof:Incidence?Clinicaloutcomes?臨床結(jié)果？Outline:PostoperativePneumoniaConfersSignificantMortality

術(shù)后肺炎導(dǎo)致死亡率增加Aprospectivestudyin155,266surgicalpatientsdemonstrated30-daymortalityratetobe21percentinpatientswithpostoperativepneumoniavs.only2percentwithout(p<0.001).1

一項(xiàng)155,266例外科患者的前瞻性研究證明，術(shù)后肺炎患者的30天死亡率為21%，而無(wú)術(shù)后肺炎患者的死亡率僅為2%(p<0.001)。1Patients>70yearsofagewithpostoperativepneumoniawhosurvivedtheirprimaryadmissionhadatwofoldincreasedriskofdeathatthreeyears.2大于70歲合并術(shù)后肺炎的患者出院后三年的死亡率增加一倍。1.Arozullahetal.AnnofInternMed.2001;135:847-857.2.Mankuetal.AnesthAnalg.2003;96:590-594.PostoperativePneumoniaIsAssociatedwithaTenfoldIncreaseinMortalityAfterAbdominalSurgery

術(shù)后肺炎導(dǎo)致腹部手術(shù)患者死亡率增加十倍OutcomePatientswithHAPPatientswithoutHAPOddsratio95%CIMortality,n1,421(10.7%)7,217(1.2%)9.91(9.34-10.52Impactofhosp-acquiredpneumonia(HAP)duringoriginaladmissionafterabdominalsurgery,n=618,495patients1腹部手術(shù)術(shù)后醫(yī)院獲得性肺炎的影響1.Thompsonetal.AnnSurg.2006;243:547-552.Summary總結(jié):Readmissionofsurgicalpatientswithpneumoniaisasignificantsourceofincreasedhealthcarecosts.外科患者因肺炎再入院治療顯著增加了醫(yī)療費(fèi)用。Postoperativepulmonarycomplicationsarecommon,expensiveandassociatedwithincreasedmortality.

術(shù)后肺部并發(fā)癥是常見(jiàn)的，昂貴的，增加了死亡率。TheRoleofMicroaspirationinDownstreamComplications

隱性誤吸對(duì)后續(xù)并發(fā)癥的影響Microaspiration隱性誤吸:Microaspirationreferstothemigrationofforeign,supraglotticmaterialpasttheairwaydevice(e.g.ETTcuff)intotherespiratorytract.隱性誤吸是指外源性的聲門(mén)上物質(zhì)通過(guò)導(dǎo)氣管裝置（如氣管插管套囊）進(jìn)入呼吸道。Pictured:inadvertentmicroaspirationofcontrastmediaafterabariumswallowexaminationinanintubatedpatient圖示：一個(gè)氣管插管患者進(jìn)行吞鋇實(shí)驗(yàn)后不慎誤吸造影劑ReproducedfromMacraeetal.BrMedJ.1981(ClinResEd);283:1220withpermissionfromBMJPublishingGroupLtd.CuffRedesigninthe1970s

重新設(shè)計(jì)氣管套囊Traditional“redrubber”ETTsrequiredhighpressures(>60cmH2O)toachieveaseal,andwerefrequentlyassociatedwithseveretrachealinjury.1,2

傳統(tǒng)氣管插管需要高壓套囊，且常導(dǎo)致嚴(yán)重氣道損傷ThenewETTswithhigh-volume,low-pressure(HVLP)cuffswereintroducedintheearly1970stospecificallyaddressthisissue,achievingclinicalsealsatsaferpressures(<30cmH2O).

新的氣管插管具有低壓高容量套囊(HVLP)1.KnowelsonGTC,BassetHFM.BrJAnesth.1970;42:834-837.2.SeegobinRD,VanHesseltGL.BMJ.1984;288:965-968.CuffRedesigninthe1970s

上世紀(jì)70年代改進(jìn)套囊Bydesign,HVLPcuff?diametermustbegreaterthanthediameterofthetracheatoensurecontactbetweenthetwo.

新套囊直徑大于氣管直徑Whenproperlysizedcuffsareappropriatelyinflated,theexcesscuffmaterialfoldsontoitself,whichcancreatechannelsthatallowaccumulatedsecretionstopassintothetracheobronchialtree.1-5

當(dāng)氣囊達(dá)到合適的體積，多余的套囊折疊，形成通道，使得積蓄在氣囊上物質(zhì)便于進(jìn)入氣道。1.Seegobinetal.CanAnaesthSocJ.1986;33:27327-9. 4.Seegobinetal.BritishMedicalJournal.1984;288:965-968.2.Youngetal.Anaesthesia.1999;54:559-563. 5.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.3.Pavlinetal.Anesthesiology.1975;42:216-219.?Pictured:amodernhigh-volume,low-pressure(HVLP)ETTcuff,firstintroducedinthe1970s圖示：高容低壓氣管套管(HVLP)在上世紀(jì)70年代問(wèn)世ExcessCuffMaterialFormingFoldsandChannels

多余的套囊材料形成折疊和通道1.Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.CTimageofaninflatedETTcuffinatracheamodel1LEFT:FullcrosssectionofintubatedmodeltracheaRIGHT:EnlargementofregiondemonstratingacufffoldandchannelMicroaspirationIsSurprisinglyCommonintheOperatingRoomwithConventionalHVLPETTs

手術(shù)室HVLP氣管插管的隱性誤吸十分常見(jiàn)“Extensivefoldingofcuffmaterial”containingsecretionsisseenatallcuffpressures(25–100cmH2O).

在任何壓力下均可見(jiàn)多余套囊折疊處的含有分泌物Seegobinetal.BrMedJ.1984;288:965-968.“…h(huán)igh-volume,low-pressure(HVLP)cuffswereintroduced....thesehavefailedtodemonstrateeffectivepreventionofleakageinvitroandinvivo.”體內(nèi)體外實(shí)驗(yàn)均不能證實(shí)HVLP氣管插管能夠有效預(yù)防滲漏Dullenkopfetal.IntensiveCareMed.2003;29:1849-1853.Microaspirationfoundin100percentofgeneralendotrachealanesthetics.

全身麻醉100%存在隱性誤吸Seegobinetal.CanAnaesthSocJ.1986;33:273-279.CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential20|MinimizingAspiration避免誤吸.

PulmonaryComplications肺部并發(fā)癥Atelectasis肺不張ARDSCOPDTrachealbronchitis支氣管炎VAP呼吸機(jī)相關(guān)性肺炎TheCausalRelationshipBetweenMicroaspirationandVAPHasBeenWellEstablished1-5

隱性誤吸和VAP的因果關(guān)系已被證實(shí)1.Mahuletal.IntensiveCareMed.1992;18:20-25. 2.Estesetal.IntensiveCareMed.1995;21:365-383. 3.Chastreetal.AmJRespirCritCareMed.2002;165:867-903.4.Sadfaretal.RespiratoryCare.2005;50:725-741.5.Kollefetal.Chest.1999;116:1339-1346.MallinckrodtTM

Hi-LoTMcuffAspiration誤吸Tachypnea呼吸急促Severepneumonitis

重癥肺炎AcuteRespiratoryDistressSyndrome(ARDS)InfiltrateonCXR滲出Pulmonary1Systemic1Bronchialirritation

支氣管刺激Bronchospasm

支氣管痙攣Atelectasis肺不張Tracheobronchial1Inflammatory1,21.JandaM,etal.BestPractResClinAnaesthesiol.2006;20:409–427.2.KalinowskiCP,etal.BestPractResClinAnaesthesiol.2004;18:719–737.22

Particle-associatedaspiration微粒性誤吸Bacterialinfection細(xì)菌感染Acid-associatedaspirationpneumonitis酸性吸入性肺炎Fluidshifts液體重新分布Hemodynamicchanges

血流動(dòng)力學(xué)變化Hypovolemia血容量不足Fever發(fā)熱Hypoxia缺氧Activationofneutrophils中性粒細(xì)胞升高Cytokinerelease

細(xì)胞因子釋放Increasedthromboxaneandoxygenradicalrelease促凝氧自由基釋放AspirationCanCauseLocalandSystemicInjury

誤吸可能導(dǎo)致局部和系統(tǒng)損傷MicroaspirationCausingVAPMayBeJusttheTipoftheIceberg

隱性誤吸導(dǎo)致的VAP可能只是冰山一角Post-intubationpulmonarycomplications插管后肺部并發(fā)癥:Pulmonarycomplicationsfollowingintubation插管后肺部并發(fā)癥VAPUnplannedrespiratoryReadmissions計(jì)劃外的因肺部疾病而再入院PostoperativePneumonia術(shù)后肺炎R(shí)espiratoryfailure,

COPDexacerbations,etc.呼吸衰竭，COPD加重CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential24|Thesepulmonarycomplicationsleadto:

這些并發(fā)癥導(dǎo)致：Daysofmechanicalventilation

機(jī)械通氣時(shí)間延長(zhǎng)ICUlengthofstayICU住院天數(shù)延長(zhǎng)Hospitallengthofstay

總住院天數(shù)延長(zhǎng)Costofcare

費(fèi)用增加CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential25|WhatdomostVAPbundlecomponentshaveincommon?大多數(shù)VAP治療的共同點(diǎn)Headofbed(HOB)elevation床頭抬高Reducestheincidenceofaspiratinggastriccontents減少胃內(nèi)容物的誤吸Oralcareandchlorhexadinerinse口腔護(hù)理Reducebacterialloadoforalsecretions.減少口腔分泌物的細(xì)菌量Oralandin-linesuction口腔吸引Reducesthevolumeofaspirates.減少誤吸量TheyprimarilyreducetheincidenceofVAPbyaddressingaspiration通過(guò)避免誤吸減少VAP的發(fā)生率CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential26|ReducingPulmonaryComplicationsintheICU減少I(mǎi)CU肺部并發(fā)癥的發(fā)生: Isabout

MinimizingAspiration,andreducingthe

accumulationof

aspirationovertime.避免誤吸，減少蓄積CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential27|CurrentSuctionTechnique

目前的吸引技術(shù)SubglotticSpaceSubglotticSpace聲門(mén)下CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential28|CurrentSuctionProtocols目前的吸引流程O(píng)ralandin-linesuctioningQ2-Q4

每2-4小時(shí)口腔吸引PRN需要時(shí)What’shappeninginbetween?那么在這期間發(fā)生什么了呢？CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential29|DemonstrationCovidienRespiratory&MonitoringSolutions|April2,2023|Confidential30|Mallinckrodt?EvacProvidessubglotticsecretiondrainagetominimizetheoccurrenceofmicroaspiration

聲門(mén)下分泌物引流以減少隱性誤吸Separatesuctionlumeninwalloftube.CrossSectionSuctionportabovecuffCovidienRespiratory&MonitoringSolutions|April2,2023|Confidential31|SuctionregulatorSuctioncanisterSuctiontubinMallinckrodtEvac?CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential32|SubglotticSecretionDrainage(SSD)

聲門(mén)下分泌物引流ReductionintheincidenceofVAP減少VAP發(fā)生率Delaystheon-setofVAP

延后了VAP的發(fā)生時(shí)間ReducesICUlengthofstay(LOS)

縮短了ICU住院天數(shù)Reducesdurationofmechanicalventilation

縮短了機(jī)械通氣時(shí)間Reducestheuseofantibiotics

減少了抗生素的應(yīng)用VAPClaimsImprovedOutcomesCovidienRespiratory&MonitoringSolutions|April2,2023|Confidential33|Uniquetaper-shapedcuffGraduallyTapersSoatsomepointMatchesthediameterofthetrachea.在某一點(diǎn)與氣管直徑吻合Taper-ShapedCuff

梯形套囊CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential34|MinimizingAspiration避免誤吸

Summary總結(jié)AllVentprotocolsattempttominimizeaspiration

所有的呼吸機(jī)流程目的在于避免誤吸TheSubglotticspaceremainsunaddressed.聲門(mén)下空間問(wèn)題尚未解決TwoETTtechnologiesaddressAspirationSubglotticSecretionDrainage聲門(mén)下分泌物引流Taperedcufftechnology.梯形套囊CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential35|ClinicalEvidence臨床依據(jù)7independentclinicalstudies.7個(gè)獨(dú)立臨床研究Patientsexpectedtobeintubated>48hrs.

患者插管大于48小時(shí)ComparedstandardETTvs.MallinckrodtEvac.

常規(guī)氣管套管vs.MallinckrodtEvac（聲門(mén)下分泌物引流）Commonventbundleprecautionsinplace.HOB抬高床頭Oralcare口腔護(hù)理CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential36|Bouzaetal3943%reductioninVAP呼吸機(jī)相關(guān)性肺炎發(fā)生率降低43%

ICULOSby9.5daysICU住院天數(shù)縮短9.5天 MVby4days機(jī)械通氣時(shí)間縮短4天 Reductioninantibioticsby30%抗生素應(yīng)用減少30%ReductioninABacquisitioncosts$30,000(ITT)CostofEVAC$4,300(ITT)NewClinicalEvidenceForEvac

關(guān)于Evac新的臨床證據(jù)CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential37|SSDclinicallyprovento:ReduceVAP75%呼吸機(jī)相關(guān)性肺炎發(fā)生率降低75%ReduceICUlengthofstayby9.5daysICU住院天數(shù)縮短9.5天Shortenthedurationofmechanicalventilationby4days

機(jī)械通氣時(shí)間減縮短4天DelaytheonsetofVAPby6.8daysVAP發(fā)生延遲6.8天ReducetheuseofAntibiotics抗生素應(yīng)用減少30%SSDisagloballyrecognizedintervention,recommendedbytheCDC,ATS,AACN,SHEA,IDSAandtheAHRQ.聲門(mén)下分泌物引流被全球認(rèn)可。ClinicalEvidenceSummary臨床證據(jù)總結(jié)

VAPreductionandImprovedpatientoutcomes.

VAP發(fā)生率降低，改善患者預(yù)后CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential38|EconomicImpact經(jīng)濟(jì)影響CurrentstudiesequatethecostofVAP目前相關(guān)的研究經(jīng)費(fèi)與VAP的治療費(fèi)用相當(dāng)$40,000-$60,000MallinckrodtEvacassociatedwitha75%VAPreduction.MallinckrodtEvac降低VAP發(fā)生率75%ReducingevenoneVAPmayresultinsignificantsavings.

減少一個(gè)VAP患者也能帶來(lái)顯著的節(jié)約

SubglotticSecretionDrainageUsingMallinckrodt?EvacTechnologyImprovesOutcomes

應(yīng)用MallinckrodtEvac進(jìn)行聲門(mén)下分泌物引流能夠改善預(yù)后ClinicaloutcomeinpatientsreceivingMVfor>48hTheadditionofsubglotticsecretiondrainageimprovedmultipleoutcomes.Bouzaetal.Chest.2008;134:938-946.CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential精選ppt40|BouzaetalReduceICUlengthofstayby9.5days減少I(mǎi)CU住院天數(shù)Reducetheuseofantibioticsby30%減少抗生素應(yīng)用Shortendurationofmechanicalventilationby4days縮短機(jī)械通氣時(shí)間ImprovedOutcome改善預(yù)后Cost花費(fèi)ICUday$2-3KCostsavingsinBouzaetal$30KMVday$1,5009.5X2,000=$19,000Costsavings=$30,0004X1,500=$6,000Potentialcostsavings潛在的費(fèi)用的節(jié)省Totalpotentialcostsavings=$55,000CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential41|EffectiveImplementationisSimple

有效實(shí)施是簡(jiǎn)單的UsethetubeforallNon-Elective(non-OR)intubations.

在所有非選擇性插管患者使用該套管StockICUandFloorcrashcarts在ICU、救護(hù)車(chē)上常備StockED在急癥室常備UseselectivelyinOR

Typically10%ofoverallETTusage.

MicroaspirationMayBeginasSoonas5MinutesAfterCuffInflation

隱性誤吸可能在氣囊充氣后五分鐘內(nèi)發(fā)生Resultsandimagefrominternaltesting.CovidienRespiratory&MonitoringSolutions|April2,2023|Confidential43|Reducesmicroaspirationbyatleast90%減少至少90%的隱性誤吸ComparedtotheMallinckrodt?Hi-Lo?cuff.

Providesabetterfluidseal

更好地密閉CombinedwithlatestgenerationMallinckrodtEvac?technologyTheNEWTaperGuard?Evaccufftechnology

新的TaperGuard?Evac套囊技術(shù)BetterPerformingEndotrachealTubeCuffsMayReduceRisk

更好的氣管內(nèi)導(dǎo)管套囊可以減少風(fēng)險(xiǎn)Hi-LoTMCuffTaperGuardTMCuffThisisthenewTaperGuardTMcuffcomparedtotheHi-LoTMcuff.OikkonenetalreferredtotheHi-LoTMcuffasthebestsealingoftheninetubeshetestedinhisstudy.1TheTaperGuardTMcuffhasbeenshowntoreducemicroaspirationbyanaverageof90percentcomparedtotheHi-LoTMcuff.2

Internalbenchtopcomparison1.Oikkonenetal.Anaesthesia.1997;52:567-569.2.FDA510(k)clearedclaim.TaperGuard?EvacTubeHasan80PercentImprovementinMicroaspirationReductionUnderSuctionvs.Hi-Lo?EvacTube

與Hi-Lo?Evac氣管套管比較，TaperGuard?Evac氣管套管能夠減少80%的隱性誤吸InternaltestingofHi-Lo?andTaperGuard?cufftested(90unitseach)inbenchtopsetting.Suctionrateswereequalbetweenthetwotestarms.UseofTaperGuard?EvactuberesultedinlessmicroaspirationcomparedtotheHi-Lo?Evactube.1.Internaltesting,2009.Taper-shapedCuffsAirSealComparedtoCylindrical-shapedCuffs

梯形套囊空氣密閉與圓柱形套囊的比較1.Madjdpouretal.EuropeanJournalofAnaesthesiology.2009;26(Supplement45):19AP7-10.Intubatedlungmodel,ventilatedat20and25cmH2Opeakinspiratorypressure(PIP),anesthetizedwith1%sevorane.Leakmeasuredaboveendotrachealcuff.1Taper-shapedcuffwasfoundtoreduceleak.梯形套囊減少滲漏OpinionsVaryRegardingCuffSealingPerformance

對(duì)于套囊密閉性能的不同意見(jiàn)ThoughmicroaspirationiswellrecognizedintheICU,itisusuallynotbelievedtoexistoutsidetheICU.隱性誤吸也存在于ICU之外“You’regoingofftheassumptionthatmicroaspirationisbad.Noone’sproventhatmicroaspirationisbad.”

Anesthesiologist,Boston

“Intheliteratureyoureadalotmoreabouttheaspirationproblemsthanyouactuallyseeinpractice.”

CRNA,Houston

“Idon’t