BACKGROUND: The importance of building ventilation to protect health has been more widely recognized since the COVID-19 pandemic. Outdoor air ventilation in buildings dilutes indoor-generated air pollutants (including bioaerosols) and reduces resulting occupant exposures. Many countries and organizations have advisory guidelines or mandatory standards for minimum ventilation rates (VRs) to maintain indoor air quality (IAQ). Because directly measuring VRs is often difficult, many IAQ guidelines instead specify indoor concentration limits for carbon dioxide (CO2), using CO2 exhaled by building occupants as an indicator of VR. Although indoor CO2 guidelines are common, the evidence basis for the various CO2 limits has not been clear.
OBJECTIVE: To review current indoor CO2 guidelines worldwide and the supportive evidence provided.
METHODS: We identified worldwide CO2-based guidelines for IAQ or ventilation, along with any supportive evidence provided. We excluded occupational guidelines for CO2 levels ≥5000 ppm.
RESULTS: Among 43 guidelines identified, 35 set single CO2 concentration limits and eight set multi-tiered limits; 16 mentioned no specific human effect to be controlled, 19 specified only odor dissatisfaction, five specified non-infectious health effects, and three specified airborne infectious disease transmission. The most common indoor CO2 limit was 1000 ppm. Thirteen guidelines specified maximum CO2 limits as extended time-weighted averages, none with evidence linking averaged limits to occupant effects. Of only 18 guidelines citing evidence to support limits set, we found this evidence persuasive for eight. Among these eight guidelines, seven set limits to control odor perception. One provided 17 scientifically-based CO2 limits, for specific example space uses and occupancies, to control long-range COVID-19 transmission indoors.
CONCLUSIONS: Many current indoor carbon dioxide (CO2) guidelines for indoor air quality specified no adverse effects intended for control. Odor dissatisfaction was the effect mentioned most frequently, few mentioned health, and three mentioned control of infectious disease. Only one CO2 guideline was developed from scientific models to control airborne transmission of COVID-19. Most guidelines provided no supportive evidence for specified limits; few provided persuasive evidence. No scientific basis is apparent for setting one CO2 limit for IAQ across all buildings, setting a CO2 limit for IAQ as an extended time-weighted average, or using any arbitrary one-time CO2 measurement to verify a desired VR.

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This study aimed to compare the environmental impacts and diet qualities of popular diet models with the recommendations of the Turkish national dietary guidelines.
Seven-day isocaloric (8368 kJ) diet models were created taking into account the Mediterranean, Atkins (20/40/100), Ornish, Zone diets, and Turkey Dietary Guidelines-2015 recommendations with different food and nutrient contents. Water footprints were evaluated using the global water footprint standards. Greenhouse gas emissions were evaluated using carbon footprint factors compiled as a result of meta-analyses of life cycle analysis studies in the literature. In addition, the quality of diets was evaluated with the Diet Quality Index-International.
Atkins20 diet model had the most harmful environmental impact (greenhouse gas emissions 8.74 kg CO2 -eq/per/day and total water footprint 7731 L/per/day), whereas Ornish and Mediterranean diet models (greenhouse gas emissions 2.2/3.07 kg CO2 -eq/per/day and total water footprints 3184/3675 L/per/day, respectively) had less harmful environmental impact. The highest Diet Quality Index-International score was in the Ornish diet model while the lowest Diet Quality Index-International was in the Atkins20 diet model.
Ornish and Mediterranean diet models had less harmful environmental impacts, which contributed to sustainable nutrition. The importance of diet quality and environmental impacts should be kept in mind when evaluating diet models to ensure sustainable nutrition.

Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of \'sustained exhaled carbon dioxide\' using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.

BACKGROUND: Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.
METHODS: A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.
RESULTS: Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.
CONCLUSIONS: Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

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OBJECTIVE: To provide expert opinion and consensus on salvage carbon dioxide transoral laser microsurgery (CO2 TOLMS) for recurrent laryngeal squamous cell carcinoma (LSCC) after (chemo)radiotherapy [(C)RT].
METHODS: Expert members of the European Laryngological Society (ELS) Cancer and Dysplasia Committee were selected to create a dedicated panel on salvage CO2 TOLMS for LSCC. A series of statements regarding the critical aspects of decision-making were drafted, circulated, and modified or excluded in accordance with the Delphi process.
RESULTS: The expert panel reached full consensus on 19 statements through a total of three sequential evaluation rounds. These statements were focused on different aspects of salvage CO2 TOLMS, with particular attention on preoperative diagnostic work-up, treatment indications, postoperative management, complications, functional outcomes, and follow-up.
CONCLUSIONS: Management of recurrent LSCC after (C)RT is challenging and is based on the need to find a balance between oncologic and functional outcomes. Salvage CO2 TOLMS is a minimally invasive approach that can be applied to selected patients with strict and careful indications. Herein, a series of statements based on an ELS expert consensus aimed at guiding the main aspects of CO2 TOLMS for LSCC in the salvage setting is presented.

BACKGROUND: Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery.
METHODS: This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation.
RESULTS: Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient\'s tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence.
CONCLUSIONS: Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.

These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.

Malignant hyperthermia is defined in the International Classification of Diseases as a progressive life-threatening hyperthermic reaction occurring during general anaesthesia. Malignant hyperthermia has an underlying genetic basis, and genetically susceptible individuals are at risk of developing malignant hyperthermia if they are exposed to any of the potent inhalational anaesthetics or suxamethonium. It can also be described as a malignant hypermetabolic syndrome. There are no specific clinical features of malignant hyperthermia and the condition may prove fatal unless it is recognised in its early stages and treatment is promptly and aggressively implemented. The Association of Anaesthetists has previously produced crisis management guidelines intended to be displayed in all anaesthetic rooms as an aide memoire should a malignant hyperthermia reaction occur. The last iteration was produced in 2011 and since then there have been some developments requiring an update. In these guidelines we will provide background information that has been used in updating the crisis management recommendations but will also provide more detailed guidance on the clinical diagnosis of malignant hyperthermia. The scope of these guidelines is extended to include practical guidance for anaesthetists dealing with a case of suspected malignant hyperthermia once the acute reaction has been reversed. This includes information on care and monitoring during and after the event; appropriate equipment and resuscitative measures within the operating theatre and ICU; the importance of communication and teamwork; guidance on counselling of the patient and their family; and how to make a referral of the patient for confirmation of the diagnosis. We also review which patients presenting for surgery may be at increased risk of developing malignant hyperthermia under anaesthesia and what precautions should be taken during the peri-operative management of the patients.