Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan.

PubMed

Nakao, Shunichiro; Kimura, Akio; Hagiwara, Yusuke; Hasegawa, Kohei

2015-02-04

Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan. Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry. 13 academic and community EDs from different geographic regions across Japan. 723 trauma patients who underwent emergency intubation from March 2010 through August 2012. ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events. A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs. In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Use of a Flexible Intubating Scope in Combination with a Channeled Video Laryngoscope for Managing a Difficult Airway in the Emergency Department.

PubMed

Sowers, Nicholas; Kovacs, George

2016-02-01

Difficulty with intubation is not uncommon in the emergency setting. Video laryngoscopes (VLs) are commonly used to manage the difficult airway in the emergency department (ED). Intubation using a flexible bronchoscope, while considered the gold standard for managing the anticipated difficult airway in the operating room, is not commonly used in the ED. We present a case describing VL-assisted flexible scope intubation performed in the ED as a novel feasible approach to managing the difficult airway. A 65-year-old male, post cardiac arrest, with multiple unsuccessful attempts at prehospital intubation had rapid sequence intubation (RSI) performed and, despite obtaining a view with a King Vision™ VL, the skilled operator was unable to advance the endotracheal tube (ETT). An Ambu™ aScope3 flexible intubating scope (FIS) was placed through the ETT loaded in the channel of the King Vision and advanced through the cords to a position proximal to the carina. The ETT was then advanced easily over the FIS and down the trachea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although video laryngoscopy is commonly used in the ED, intubation can prove difficult, despite having an adequate view of the glottis. Use of an FIS, however, through a channeled VL makes navigation of the ETT easier and facilitates tube advancement, which can be difficult with VL. Channeled VL-assisted use of an FIS is a viable option for managing the difficult airway. Copyright © 2016 Elsevier Inc. All rights reserved.

Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs.

PubMed

James, Dorsha N; Voskresensky, Igor V; Jack, Meg; Cotton, Bryan A

2009-06-01

Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs. The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail. 89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times. The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.

Simulation Based Training Improves Airway Management for Helicopter EMS Teams

NASA Technical Reports Server (NTRS)

Dhindsa, Harinder S.; Reid, Renee; Murray, David; Lovelady, James; Powell, Katie; Sayles, Jeff; Stevenson, Christopher; Baker, Kathy; Solada, Brian; Carroll, Scott;

An update on out-of-hospital airway management practices in the United States.

PubMed

Diggs, Leigh Ann; Yusuf, Juita-Elena Wie; De Leo, Gianluca

2014-07-01

We characterized out-of-hospital airway management interventions, outcomes, and complications using the 2012 NEMSIS Public-Release Research Data Set containing almost 20 million Emergency Medical Services activations from 40 states and two territories. We compared the outcomes with a previous study that used 2008 NEMSIS data containing 16 states with 4 million EMS activations. Patients who received airway management interventions including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and surgical) were identified. Using descriptive statistics, airway management success and complications were examined in the full cohort and key subsets including cardiac arrest, non-arrest medical, non-arrest injury, children<10 years, children 10-19 years, rapid sequence intubation (RSI), population setting, U.S. census region, and U.S. census division. Among 19,831,189 EMS activations, there were 74,993 ETIs, 21,990 alternate airways, and 1332 cricothyroidotomies. ETI success rates were: overall 63,956/74,993 (85.3%; 95% CI: 85.0-85.5), cardiac arrest 33,558/39,270 (85.5%), non-arrest medical 12,215/13,611 (89.7%), non-arrest injury (90.1%), children <10 years 2069/2468 (83.8%), children 10-19 years 1647/1900 (86.7%), adults >19 years 58,965/69,144 (85.3%), and rapid sequence intubation 5265/5658 (93.1%). Major complications included bleeding 677 (4.4 per 1000 interventions), vomiting 1221 (8 per 1000 interventions), esophageal intubation immediately detected 874 (5.7 per 1000 interventions), and esophageal intubations other 219 (1.4 per 1000 interventions). Low out-of-hospital ETI and alternate airway success rates were observed. These data may guide national efforts to improve out-of-hospital airway management quality leading efforts to better educate providers on ETI. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Prospective Comparison of Live Evaluation and Video Review in the Evaluation of Operator Performance in a Pediatric Emergency Airway Simulation

PubMed Central

House, Joseph B.; Dooley-Hash, Suzanne; Kowalenko, Terry; Sikavitsas, Athina; Seeyave, Desiree M.; Younger, John G.; Hamstra, Stanley J.; Nypaver, Michele M.

2012-01-01

Introduction Real-time assessment of operator performance during procedural simulation is a common practice that requires undivided attention by 1 or more reviewers, potentially over many repetitions of the same case. Objective To determine whether reviewers display better interrater agreement of procedural competency when observing recorded, rather than live, performance; and to develop an assessment tool for pediatric rapid sequence intubation (pRSI). Methods A framework of a previously established Objective Structured Assessment of Technical Skills (OSATS) tool was modified for pRSI. Emergency medicine residents (postgraduate year 1–4) were prospectively enrolled in a pRSI simulation scenario and evaluated by 2 live raters using the modified tool. Sessions were videotaped and reviewed by the same raters at least 4 months later. Raters were blinded to their initial rating. Interrater agreement was determined by using the Krippendorff generalized concordance method. Results Overall interrater agreement for live review was 0.75 (95% confidence interval [CI], 0.72–0.78) and for video was 0.79 (95% CI, 0.73–0.82). Live review was significantly superior to video review in only 1 of the OSATS domains (Preparation) and was equivalent in the other domains. Intrarater agreement between the live and video evaluation was very good, greater than 0.75 for all raters, with a mean of 0.81 (95% CI, 0.76–0.85). Conclusion The modified OSATS assessment tool demonstrated some evidence of validity in discriminating among levels of resident experience and high interreviewer reliability. With this tool, intrareviewer reliability was high between live and 4-months' delayed video review of the simulated procedure, which supports feasibility of delayed video review in resident assessment. PMID:23997874

Developing an e-learning resource for nurse airway assistants in the emergency department.

PubMed

Hersey, Peter; McAleer, Sean

2017-02-23

The aims of this project were to determine the required competencies for a nurse in the emergency department assisting with a rapid sequence induction of anaesthesia (RSI), and to produce a relevant e-learning resource. A three-round multidisciplinary Delphi process produced the following competencies: ability to describe the steps and sequence of events of an RSI, familiarity with the equipment used during an RSI, ability to recognise and help manage problems occurring during an RSI, ability to prepare for an RSI, ability to apply cricoid pressure, and understanding the modification of an RSI in special circumstances. An interactive e-learning package was produced and made available online. Twelve emergency department nurses took part in an evaluation of the e-learning package. All either agreed or strongly agreed that they had increased their knowledge and found the learning useful, and 11 out of 12 nurses reported being somewhat or very confident in the role of airway assistant following completion of the learning.

Ultra-modified rapid sequence induction with transnasal humidified rapid insufflation ventilatory exchange: Challenging convention.

PubMed

Kulkarni, Ketan Sakharam; Dave, Nandini; Saran, Shriyam; Garasia, Madhu; Parelkar, Sandesh

2018-04-01

During positive pressure ventilation, gastric inflation and subsequent pulmonary aspiration can occur. Rapid sequence induction (RSI) technique is an age-old formula to prevent this. We adopted a novel approach of RSI for patients with high risk of aspiration and evaluated it further in patients undergoing laparoscopic surgeries. We believe that, in patients with risk of gastric insufflation and pulmonary aspiration, transnasal humidified rapid-insufflation ventilatory exchange can be useful in facilitating pre- and apnoeic oxygenation till tracheal isolation is achieved.

The effect of the apneic period on the respiratory physiology of patients undergoing intubation in the ED.

PubMed

West, Jason R; Scoccimarro, Anthony; Kramer, Cody; Caputo, Nicholas D

2017-09-01

We sought to examine the physiological impact the apneic period has on the respiratory physiology of patients undergoing intubation in the emergency department and whether DAO, the delivery of 15L oxygen by nasal cannula during apnea, can affect the development of respiratory acidosis. This was a prospective observational cohort study conducted at an urban academic level 1 trauma center. A convenience sample of 100 patients was taken. Timed data collection forms were completed during the periintubation period. We report the mean ABG and end-tidal CO2 (EtCO2) values between those with normal and prolonged apnea times (>60s) and between those who received DAO and those who did not. 100 patients met our inclusion criteria. There were no significant differences in the pre-RSI ABG values between those who received DAO and those who did not and between those with apnea times less than or >60s. Only in the group of patients with apnea times >60s did significant changes in respiratory physiology occur. DAO did not alter the trend in respiratory acidosis during the periintubation period. EtCO2 increased as apnea times were prolonged, and DAO altered this trend. Post-RSI EtCO2 increased as apnea times were prolonged. DAO may alter this trend. Statistically significant changes in pH and PaCO2 (mean differences of 0.15 and 12.5, respectively) occurred in the group of patients who had mean apnea times of >60s but not in those with apnea times <60s. Copyright © 2017 Elsevier Inc. All rights reserved.

Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.

PubMed

Bernard, Stephen A; Nguyen, Vina; Cameron, Peter; Masci, Kevin; Fitzgerald, Mark; Cooper, David J; Walker, Tony; Std, B Paramed; Myles, Paul; Murray, Lynne; David; Taylor; Smith, Karen; Patrick, Ian; Edington, John; Bacon, Andrew; Rosenfeld, Jeffrey V; Judson, Rodney

2010-12-01

To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital. Severe TBI is associated with a high rate of mortality and long-term morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics perform intubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes. In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1-6) in patients intubated by paramedics compared with 3 (interquartile range, 1-6) in the patients intubated at hospital (P = 0.28).The proportion of patients with favorable outcome (GOSe, 5-8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00-1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge. In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.

Effects of strategy sequences and response-stimulus intervals on children's strategy selection and strategy execution: a study in computational estimation.

PubMed

Lemaire, Patrick; Brun, Fleur

2014-07-01

The present study investigates how children's better strategy selection and strategy execution on a given problem are influenced by which strategy was used on the immediately preceding problem and by the duration between their answer to the previous problem and current problem display. These goals are pursued in the context of an arithmetic problem solving task. Third and fifth graders were asked to select the better strategy to find estimates to two-digit addition problems like 36 + 78. On each problem, children could choose rounding-down (i.e., rounding both operands down to the closest smaller decades, like doing 40 + 60 to solve 42 + 67) or rounding-up strategies (i.e., rounding both operands up to the closest larger decades, like doing 50 + 70 to solve 42 + 67). Children were tested under a short RSI condition (i.e., the next problem was displayed 900 ms after participants' answer) or under a long RSI condition (i.e., the next problem was displayed 1,900 ms after participants' answer). Results showed that both strategy selection (e.g., children selected the better strategy more often under long RSI condition and after selecting the poorer strategy on the immediately preceding problem) and strategy execution (e.g., children executed strategy more efficiently under long RSI condition and were slower when switching strategy over two consecutive problems) were influenced by RSI and which strategy was used on the immediately preceding problem. Moreover, data showed age-related changes in effects of RSI and strategy sequence on mean percent better strategy selection and on strategy performance. The present findings have important theoretical and empirical implications for our understanding of general and specific processes involved in strategy selection, strategy execution, and strategic development.

Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study.

PubMed

April, Michael D; Arana, Allyson; Pallin, Daniel J; Schauer, Steven G; Fantegrossi, Andrea; Fernandez, Jessie; Maddry, Joseph K; Summers, Shane M; Antonacci, Mark A; Brown, Calvin A

2018-05-07

Although both succinylcholine and rocuronium are used to facilitate emergency department (ED) rapid sequence intubation, the difference in intubation success rate between them is unknown. We compare first-pass intubation success between ED rapid sequence intubation facilitated by succinylcholine versus rocuronium. We analyzed prospectively collected data from the National Emergency Airway Registry, a multicenter registry collecting data on all intubations performed in 22 EDs. We included intubations of patients older than 14 years who received succinylcholine or rocuronium during 2016. We compared the first-pass intubation success between patients receiving succinylcholine and those receiving rocuronium. We also compared the incidence of adverse events (cardiac arrest, dental trauma, direct airway injury, dysrhythmias, epistaxis, esophageal intubation, hypotension, hypoxia, iatrogenic bleeding, laryngoscope failure, laryngospasm, lip laceration, main-stem bronchus intubation, malignant hyperthermia, medication error, pharyngeal laceration, pneumothorax, endotracheal tube cuff failure, and vomiting). We conducted subgroup analyses stratified by paralytic weight-based dose. There were 2,275 rapid sequence intubations facilitated by succinylcholine and 1,800 by rocuronium. Patients receiving succinylcholine were younger and more likely to undergo intubation with video laryngoscopy and by more experienced providers. First-pass intubation success rate was 87.0% with succinylcholine versus 87.5% with rocuronium (adjusted odds ratio 0.9; 95% confidence interval 0.6 to 1.3). The incidence of any adverse event was also comparable between these agents: 14.7% for succinylcholine versus 14.8% for rocuronium (adjusted odds ratio 1.1; 95% confidence interval 0.9 to 1.3). We observed similar results when they were stratified by paralytic weight-based dose. In this large observational series, we did not detect an association between paralytic choice and first-pass rapid sequence intubation success or peri-intubation adverse events. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Prophylaxis against the systemic hypotension induced by propofol during rapid-sequence intubation.

PubMed

el-Beheiry, H; Kim, J; Milne, B; Seegobin, R

1995-10-01

The objective of this study was to determine the effectiveness of two prophylactic approaches against the anticipated hypotension induced by propofol during rapid-sequence intubation. Thirty-six male or female nonpremedicated ASA class I-II patients aged 21-60 yr undergoing elective outpatient surgery were included in the study. Patients were randomly allocated to receive pre-induction ephedrine sulphate (70 micrograms x kg(-1)iv), pre-induction volume loading (12 ml x kg(-1) Ringer's lactate) or no treatment. Rapid-sequence intubation with cricoid pressure was then performed with propofol (2.5 mg. x kg(-1)) and succinylcholine (1.5 mg x kg(-1). The lungs were subsequently ventilated with 0.25-0.5% isoflurane in a 2:1 N2O/O2 mixture. Vecuronium was given once neuromuscular function had recovered from the succinylcholine. Heart rate and systemic arterial blood pressure were measured non-invasively before induction, after propofol administration and every minute for ten minutes after intubation. Pre-induction volume loading prevented the hypotension observed before surgical stimulation in control and ephedrine groups. Moreover, pre-induction volume loading was not associated with increases in heart rate after intubation as was ephedrine administration. The intubating conditions were excellent to satisfactory in most patients and the overall incidence of adverse events during intubation was mainly due to pain during injection of propofol. The present study showed that preoperative volume loading is more efficacious than pre-induction administration of ephedrine sulphate in maintaining haemodynamic stability during rapid-sequence induction with propofol and succinylcholine. In addition, propofol in combination with succinylcholine provides excellent conditions for rapid-sequence intubation.

The Process of Prehospital Airway Management: Challenges and Solutions During Paramedic Endotracheal Intubation

PubMed Central

Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D.

2016-01-01

Objective Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Design Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services (EMS) administrative database. Setting EMS system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e. rapid sequence intubation). Patients A total of 7,523 patients >12 years old in whom paramedics attempted prehospital endotracheal intubation. Interventions None Measurements and Main Results An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (N=1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, N=27) and bag-valve-mask ventilation (0.8%, N=60) were rarely performed by paramedics as final rescue airway strategies. Conclusions Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion. PMID:24589641

The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation.

PubMed

Prekker, Matthew E; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D

2014-06-01

Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. None. An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.

Do rhesus monkeys (Macaca mulatta) perceive illusory motion?

PubMed

Agrillo, Christian; Gori, Simone; Beran, Michael J

2015-07-01

During the last decade, visual illusions have been used repeatedly to understand similarities and differences in visual perception of human and non-human animals. However, nearly all studies have focused only on illusions not related to motion perception, and to date, it is unknown whether non-human primates perceive any kind of motion illusion. In the present study, we investigated whether rhesus monkeys (Macaca mulatta) perceived one of the most popular motion illusions in humans, the Rotating Snake illusion (RSI). To this purpose, we set up four experiments. In Experiment 1, subjects initially were trained to discriminate static versus dynamic arrays. Once reaching the learning criterion, they underwent probe trials in which we presented the RSI and a control stimulus identical in overall configuration with the exception that the order of the luminance sequence was changed in a way that no apparent motion is perceived by humans. The overall performance of monkeys indicated that they spontaneously classified RSI as a dynamic array. Subsequently, we tested adult humans in the same task with the aim of directly comparing the performance of human and non-human primates (Experiment 2). In Experiment 3, we found that monkeys can be successfully trained to discriminate between the RSI and a control stimulus. Experiment 4 showed that a simple change in luminance sequence in the two arrays could not explain the performance reported in Experiment 3. These results suggest that some rhesus monkeys display a human-like perception of this motion illusion, raising the possibility that the neurocognitive systems underlying motion perception may be similar between human and non-human primates.

Prevalence and associations of symptoms of upper extremities, repetitive strain injuries (RSI) and 'RSI-like condition'. A cross sectional study of bank workers in Northeast Brazil.

PubMed

Lacerda, Eliana M; Nácul, Luis C; Augusto, Lia G da S; Olinto, Maria Teresa A; Rocha, Dyhanne C; Wanderley, Danielle C

2005-10-11

The repetitive strain injury syndrome (RSI) is a worldwide occupational health problem affecting all types of economic activities. We investigated the prevalence and some risk factors for RSI and related conditions, namely 'symptoms of upper limbs' and 'RSI-like condition'. We conducted a cross-sectional study with 395 bank workers in Recife, Northeast Brazil. Symptoms of upper limbs and 'RSI-like condition' were assessed by a simple questionnaire, which was used to screen probable cases of RSI. The diagnosis of RSI was confirmed by clinical examination. The associations of potential risk factors and the outcomes were assessed by multiple logistic regression analysis. We found prevalence rates of 56% for symptoms of the upper limbs and 30% for 'RSI-like condition'. The estimated prevalence of clinically confirmed cases of RSI was 22%. Female sex and occupation (as cashier or clerk) increased the risk of all conditions, but the associations were stronger for cases of RSI than for less specific diagnoses of 'RSI-like condition' and symptoms of upper limbs. Age was inversely related to the risk of symptoms of upper limbs but not to 'RSI-like' or RSI. The variation in the magnitude of risk according to the outcome assessed suggests that previous studies using different definitions may not be immediately comparable. We propose the use of a simple instrument to screen cases of RSI in population based studies, which still needs to be validated in other populations. The high prevalence of RSI and related conditions in this population suggests the need for urgent interventions to tackle the problem, which could be directed to individuals at higher risk and to changes in the work organization and environment of the general population.

Prevalence and associations of symptoms of upper extremities, repetitive strain injuries (RSI) and 'RSI-like condition'. A cross sectional study of bank workers in Northeast Brazil

PubMed Central

Lacerda, Eliana M; Nácul, Luis C; da S Augusto, Lia G; Olinto, Maria Teresa A; Rocha, Dyhanne C; Wanderley, Danielle C

2005-01-01

Background The repetitive strain injury syndrome (RSI) is a worldwide occupational health problem affecting all types of economic activities. We investigated the prevalence and some risk factors for RSI and related conditions, namely 'symptoms of upper limbs' and 'RSI-like condition'. Methods We conducted a cross-sectional study with 395 bank workers in Recife, Northeast Brazil. Symptoms of upper limbs and 'RSI-like condition' were assessed by a simple questionnaire, which was used to screen probable cases of RSI. The diagnosis of RSI was confirmed by clinical examination. The associations of potential risk factors and the outcomes were assessed by multiple logistic regression analysis. Results We found prevalence rates of 56% for symptoms of the upper limbs and 30% for 'RSI-like condition'. The estimated prevalence of clinically confirmed cases of RSI was 22%. Female sex and occupation (as cashier or clerk) increased the risk of all conditions, but the associations were stronger for cases of RSI than for less specific diagnoses of 'RSI-like condition' and symptoms of upper limbs. Age was inversely related to the risk of symptoms of upper limbs but not to 'RSI-like' or RSI. Conclusion The variation in the magnitude of risk according to the outcome assessed suggests that previous studies using different definitions may not be immediately comparable. We propose the use of a simple instrument to screen cases of RSI in population based studies, which still needs to be validated in other populations. The high prevalence of RSI and related conditions in this population suggests the need for urgent interventions to tackle the problem, which could be directed to individuals at higher risk and to changes in the work organization and environment of the general population. PMID:16219095

Dose of rocuronium for rapid tracheal intubation following remifentanil 2 μg kg-1 and propofol 2 mg kg-1.

PubMed

Oh, Ah-Young; Cho, Suk-Ju; Seo, Kwang-Suk; Ryu, Jung-Hee; Han, Sung-Hee; Hwang, Jung-Won

2013-09-01

Full relaxation is not mandatory for successful tracheal intubation. We tried to find the dose of rocuronium that gave acceptable intubation conditions in a rapid sequence intubation with remifentanil and propofol. A dose-finding study of rocuronium using a modified Dixon's up-and-down method. A single tertiary care teaching hospital. Patients undergoing elective surgery under general anaesthesia. After premedication with midazolam and glycopyrrolate, anaesthesia was induced using remifentanil 2 μg kg and propofol 2 mg kg, and a predetermined dose of rocuronium was administered. The dose of rocuronium was determined by a modified Dixon's up-and-down method starting from 0.8 mg kg with an interval of 0.1 or 0.05 mg kg. Intubation was performed 60 s after the start of the rocuronium injection. Intubation conditions were graded as excellent, good or poor. Excellent or good were regarded as clinically acceptable. A dose of rocuronium needed for acceptable intubation condition in 50% of patients (ED50) during rapid tracheal intubation after induction of anaesthesia with remifentanil and propofol. Twenty-eight patients were enrolled to obtain six crossovers. The ED50 of rocuronium was 0.20 mg kg (95% confidence interval, CI 0.17 to 0.23 mg kg) by a modified Dixon's up-and-down method. After induction of anaesthesia with remifentanil 2 μg kg and propofol 2 mg kg, the ED50 of rocuronium for acceptable intubation condition was 0.20 mg kg (95% CI, 0.17 to 0.23 mg kg) for rapid sequence intubation. Thus, we recommend that the intubation dose should be 0.8 mg kg. Clinical trial registration KCT0000094.

Comparison of rocuronium at two different doses and succinylcholine for endotracheal intubation in adult patients for elective surgeries.

PubMed

Chavan, S G; Gangadharan, S; Gopakumar, A K

2016-01-01

The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia. Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared. To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t -test were used. The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg. Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated.

Comparison of single-use and reusable metal laryngoscope blades for orotracheal intubation during rapid sequence induction of anesthesia: a multicenter cluster randomized study.

PubMed

Amour, Julien; Le Manach, Yannick Le; Borel, Marie; Lenfant, François; Nicolas-Robin, Armelle; Carillion, Aude; Ripart, Jacques; Riou, Bruno; Langeron, Olivier

2010-02-01

Single-use metal laryngoscope blades are cheaper and carry a lower risk of infection than reusable metal blades. The authors compared single-use and reusable metal blades during rapid sequence induction of anesthesia in a multicenter cluster randomized trial. One thousand seventy-two adult patients undergoing general anesthesia under emergency conditions and requiring rapid sequence induction were randomly assigned on a weekly basis to either single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using the opposite type of blade. The primary endpoint was the rate of failed intubation, and the secondary endpoints were the incidence of complications (oxygen desaturation, lung aspiration, and/or oropharynx trauma) and the Cormack and Lehane score. Both groups were similar in their main characteristics, including the risk factors for difficult intubation. The rate of failed intubation was significantly decreased with single-use metal blades at the first attempt compared with reusable blades (2.8 vs. 5.4%, P < 0.05). In addition, the proportion of grades III and IV in Cormack and Lehane score were also significantly decreased with single-use metal blades (6 vs. 10%, P < 0.05). The global complication rate did not reach statistical significance, although the same trend was noted (6.8% vs. 11.5%, P = not significant). An investigator survey and a measure of illumination pointed that illumination might have been responsible for this result. The single-use metal blade was more efficient than a reusable metal blade in rapid sequence induction of anesthesia.

Bilateral changes in forearm oxygen consumption at rest and after exercise in patients with unilateral repetitive strain injury: a case-control study.

PubMed

Brunnekreef, Jaap J J; Thijssen, Dick H J; Oosterhof, Jan; Hopman, Maria T E

2012-04-01

Case-control study. To investigate whether oxygen consumption and blood flow at rest and after exercise are lower in the affected arm of patients with repetitive strain injury (RSI) compared to controls, and lower in the healthy nonaffected forearm within patients with unilateral RSI. RSI is considered an upper extremity overuse injury. Despite the local presentation of complaints, RSI may be represented by systemic adaptations. Insight into the pathophysiology of RSI is important to better understand the development of RSI complaints and to develop effective treatment and prevention strategies. Twenty patients with unilateral RSI and 20 gender-matched control subjects participated in this study. Forearm muscle blood flow and oxygen consumption were measured using near-infrared spectroscopy at baseline and immediately after isometric handgrip exercises at 10%, 20%, and 40% of the individual maximal voluntary contraction. Unilateral RSI resulted in a lower oxygen consumption and blood flow in the affected forearm at baseline and lower oxygen consumption after incremental handgrip exercises compared to controls (P<.05). In addition, exercise-induced blood flow and oxygen consumption in the nonaffected forearm in patients with RSI were similarly reduced. Blood flow and oxygen consumption after exercise are similarly attenuated in the affected and nonaffected arms of patients with unilateral RSI. Our findings suggest that, despite the unilateral character in clinical symptoms, RSI demonstrates systemic adaptations in forearm blood flow and oxygen consumption at rest and after exercise.

A study of RSI under combined stresses

NASA Technical Reports Server (NTRS)

Kibler, J. J.; Rosen, B. W.

1974-01-01

The behavior of typical rigidized surface insulation material (RSI) under combined loading states was investigated. In particular, the thermal stress states induced during reentry of the space shuttle were of prime concern. A typical RSI tile was analyzed for reentry thermal stresses under computed thermal gradients for a model of the RSI material. The results of the thermal stress analyses were then used to aid in defining typical combined stress states for the failure analysis of RSI.

The Dutch language anterior cruciate ligament return to sport after injury scale (ACL-RSI) - validity and reliability.

PubMed

Slagers, Anton J; Reininga, Inge H F; van den Akker-Scheek, Inge

2017-02-01

The ACL-Return to Sport after Injury scale (ACL-RSI) measures athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport after ACL reconstruction. Aim of this study was to study the validity and reliability of the Dutch version of the ACL-RSI (ACL-RSI (NL)). Total 150 patients, who were 3-16 months postoperative, completed the ACL-RSI(NL) and 5 other questionnaires regarding psychological readiness to return to sports, knee-specific physical functioning, kinesiophobia, and health-specific locus of control. Construct validity of the ACL-RSI(NL) was determined with factor analysis and by exploring 10 hypotheses regarding correlations between ACL-RSI(NL) and the other questionnaires. For test-retest reliability, 107 patients (5-16 months postoperative) completed the ACL-RSI(NL) again 2 weeks after the first administration. Cronbach's alpha, Intraclass Correlation Coefficient (ICC), SEM, and SDC, were calculated. Bland-Altman analysis was conducted to assess bias between test and retest. Nine hypotheses (90%) were confirmed, indicating good construct validity. The ACL-RSI(NL) showed good internal consistency (Cronbach's alpha 0.94) and test-retest reliability (ICC 0.93). SEM was 5.5 and SDC was 15. A significant bias of 3.2 points between test and retest was found. Therefore, the ACL-RSI(NL) can be used to investigate psychological factors relevant to returning to sport after ACL reconstruction.

Validation of a Radiosensitivity Molecular Signature in Breast Cancer

PubMed Central

Eschrich, Steven A.; Fulp, William J.; Pawitan, Yudi; Foekens, John A.; Smid, Marcel; Martens, John W. M.; Echevarria, Michelle; Kamath, Vidya; Lee, Ji-Hyun; Harris, Eleanor E.; Bergh, Jonas; Torres-Roca, Javier F.

2014-01-01

Purpose Previously, we developed a radiosensitivity molecular signature (RSI) that was clinically-validated in three independent datasets (rectal, esophageal, head and neck) in 118 patients. Here, we test RSI in radiotherapy (RT) treated breast cancer patients. Experimental Design RSI was tested in two previously published breast cancer datasets. Patients were treated at the Karolinska University Hospital (n=159) and Erasmus Medical Center (n=344). RSI was applied as previously described. Results We tested RSI in RT-treated patients (Karolinska). Patients predicted to be radiosensitive (RS) had an improved 5 yr relapse-free survival when compared with radioresistant (RR) patients (95% vs. 75%, p=0.0212) but there was no difference between RS/RR patients treated without RT (71% vs. 77%, p=0.6744), consistent with RSI being RT-specific (interaction term RSIxRT, p=0.05). Similarly, in the Erasmus dataset RT-treated RS patients had an improved 5-year distant-metastasis-free survival over RR patients (77% vs. 64%, p=0.0409) but no difference was observed in patients treated without RT (RS vs. RR, 80% vs. 81%, p=0.9425). Multivariable analysis showed RSI is the strongest variable in RT-treated patients (Karolinska, HR=5.53, p=0.0987, Erasmus, HR=1.64, p=0.0758) and in backward selection (removal alpha of 0.10) RSI was the only variable remaining in the final model. Finally, RSI is an independent predictor of outcome in RT-treated ER+ patients (Erasmus, multivariable analysis, HR=2.64, p=0.0085). Conclusions RSI is validated in two independent breast cancer datasets totaling 503 patients. Including prior data, RSI is validated in five independent cohorts (621 patients) and represents, to our knowledge, the most extensively validated molecular signature in radiation oncology. PMID:22832933

Effect of hydrocolloids on the physico-chemical and rheological properties of reconstituted sweetened yoghurt powder.

PubMed

Seth, Dibyakanta; Mishra, Hari Niwas; Deka, Sankar Chandra

2018-03-01

The consistency of sweetened yoghurt (misti dahi) is a desired characteristic which is attributed to the casein protein network formation during fermentation. Unfortunately, this property is lost in reconstituted sweetened yoghurt (RSY) due to the irreversible nature of protein denaturation during spray drying. Therefore, this study aimed to increase the consistency of RSY using different hydrocolloids. The effects addition of guar gum, pectin, κ-carrageenan and gelatin (0.1%w/v each) on the physico-chemical, microbial, rheological and sensory properties of RSY were investigated. RSY with 40% total solids demonstrated the rheological properties which are very similar to those of fresh sweetened yoghurt. RSY containing different hydrocolloids further increased the rheological properties. The dynamic rheological study revealed that the magnitude of storage modulus (G'), loss modulus (G″), and loss tangent (tan δ) were significantly influenced by the addition of hydrocolloids and gelatin exhibited highest dynamic moduli in RSY. However, κ-carrageenan added RSY was preferred sensorially as the rheological properties were very close to gelatin added RSY. Addition of hydrocolloids significantly increased the starter bacteria count and pH and reduced water expulsion rate (P < 0.05). Addition of hydrocolloids can improve the rheological properties of reconstituted yoghurt. The study concluded that the addition of κ-carrageenan showed better results in terms of rheological and sensory properties of RSY. © 2017 Society of Chemical Industry. © 2017 Society of Chemical Industry.

Assessing Advanced Airway Management Performance in a National Cohort of Emergency Medical Services Agencies.

PubMed

Wang, Henry E; Donnelly, John P; Barton, Dustin; Jarvis, Jeffrey L

2018-05-01

Although often the focus of quality improvement efforts, emergency medical services (EMS) advanced airway management performance has few national comparisons, nor are there many assessments with benchmarks accounting for differences in agency volume or patient mix. We seek to assess variations in advanced airway management and conventional intubation performance in a national cohort of EMS agencies. We used EMS data from ESO Solutions, a national EMS electronic health record system. We identified EMS emergency responses with attempted advanced airway management (conventional intubation, rapid sequence intubation, sedation-assisted intubation, supraglottic airway insertion, and cricothyroidotomy). We also separately examined cases with initial conventional intubation. We determined EMS agency risk-standardized advanced airway management and initial conventional intubation success rates by using mixed-effects regression models, fitting agency as a random intercept, adjusting for patient age, sex, race, cardiac arrest, or trauma status, and use of rapid sequence or sedation-assisted intubation, and accounting for reliability variations from EMS agency airway volume. We assessed changes in agency advanced airway management and initial conventional intubation performance rank after risk and reliability adjustment. We also identified high and low performers (reliability-adjusted and risk-standardized success confidence intervals falling outside the mean). During 2011 to 2015, 550 EMS agencies performed 57,209 advanced airway management procedures. Among 401 EMS agencies with greater than or equal to 10 advanced airway management procedures, there were a total of 56,636 procedures. Median reliability-adjusted and risk-standardized EMS agency advanced airway management success was 92.9% (interquartile range 90.1% to 94.8%; minimum 58.2%; maximum 99.0%). There were 56 advanced airway management low-performing and 38 high-performing EMS agencies. Among 342 agencies with greater than or equal to 10 initial conventional intubations, there were a total of 37,360 initial conventional intubations. Median reliability-adjusted and risk-standardized EMS agency initial conventional intubation success was 77.3% (interquartile range 70.9% to 83.6%; minimum 47.1%; maximum 95.8%). There were 64 initial conventional intubation low-performing and 45 high-performing EMS agencies. In this national series, EMS advanced airway management and initial conventional intubation performance varied widely. Reliability adjustment and risk standardization may influence EMS airway management performance assessments. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Improvement of reusable surface insulation material

NASA Technical Reports Server (NTRS)

1972-01-01

The results are presented of a program to improve the reusable surface insulation (RSI) system through the improvement of the LI-1500 material properties and the simplification of the RSI system. The improvements made include: 2500 F-capability RSI systems, water-impervious surface coatings, establishment of a high-emittance coating constituent, development of a secondary water-reduction system, and achievement of a lower density (9 pcf) RSI material.

Transatlantic Collaboration: Government Policies, Industry Perspectives

DTIC Science & Technology

1993-01-01

nations would be better able to rationalize, standardize, and increase the interoperability (RSI) of their forces. RSI was seen as a positive outcome for...peacetime, it was hoped that collaboration would also increase NATO burden-sharing. Concern over burden-sharing and RSI led Congress to pass three...to increase RSI and burden-sharing. Protective trade barriers and Buy America provisions make collaborative programs less, rather than more, feasible

RSI: oxygen consumption, blood flow, and reoxygenation in patients suffering RSI measured by noninvasive optical spectroscopy

NASA Astrophysics Data System (ADS)

Thijssen, Dick H. J.; van Uden, Caro J. T.; Krijgsman, Hans; Colier, Willy N. J. M.

2003-07-01

Background: Repetitive Strain Injury (RSI) is a major problem in nowadays health care and creates high financial costs and personal distress. Average prevalence rates in the Netherlands vary from 20-40% of the working population. Insight into the patho-physiological mechanism of RSI is important in order to establish adequate treatment and prevention programs. Objective: The aim of this study was to gain insight in muscle oxygen consumption (mVO2), blood flow (BF), and reoxygenation (ReOx) in the forearm of computer workers with stage III Repetitive Strain Injury (RSI). Method: We have used continuous wave infrared spectroscopy (NIRS) to measure these variables. Measurements were conducted on the extensor and flexor muscle in both arms as well in RSI-patients (n=10) as in control subjects (n=21). A protocol of increased isometric repetitive contraction in a handgrip ergonometer was used with increasing levels of strength. Results: mVO2 in the extensor muscle in RSI-subjects (dominant side) was increased compared to control subjects and compared to the non-dominant side (p<0.05). ReOx was not increased in RSI (dominant side-extensor muscle). However, there was a tendency towards statistical significance (p=0.065). BF in rest was equal in both groups, however after exercise it tended to be increased. Half-time recovery (T ») was measured during only one part of the protocol and it was significantly increased (p<0.05). Conclusion: mVO2 in RSI is impaired. BF and ReOx did not show difference between both groups. Future research should aim at a microvascular dysfunction in RSI.

Predictive value of T2 relative signal intensity for response to somatostatin analogs in newly diagnosed acromegaly.

PubMed

Shen, Ming; Zhang, Qilin; Liu, Wenjuan; Wang, Meng; Zhu, Jingjing; Ma, Zengyi; He, Wenqiang; Li, Shiqi; Shou, Xuefei; Li, Yiming; Zhang, Zhaoyun; Ye, Hongying; He, Min; Lu, Bin; Yao, Zhenwei; Lu, Yun; Qiao, Nidan; Ye, Zhao; Zhang, Yichao; Yang, Yeping; Zhao, Yao; Wang, Yongfei

2016-11-01

The difficulty of predicting the efficacy of somatostatin analogs (SSA) is not fully resolved. Here, we quantitatively evaluated the predictive value of relative signal intensity (rSI) on T1- and T2-weighted magnetic resonance imaging (MRI) for the short-term efficacy (3 months) of SSA therapy in patients with active acromegaly and assessed the correlation between MRI rSI and expression of somatostatin receptors (SSTR). This was a retrospective review of prospectively recorded data. Ninety-two newly diagnosed patients (37 males and 55 females) with active acromegaly were recruited. All patients were treated with pre-surgical SSA, followed by reassessment and transspenoidal surgery. rSI values were generated by calculating the ratio of SI in the tumor to the SI of normal frontal white matter. The Youden indices were calculated to determine the optimal cutoff of rSI to determine the efficacy of SSA. The correlation between rSI and expression of SSTR2/5 was analyzed by the Spearman rank correlation coefficient. T2 rSI was strongly correlated with biochemical sensitivity to SSA. The cutoff value of T2 rSI to distinguish biochemical sensitivity was 1.205, with a positive predictive value (PPV) of 81.5 % and a negative predictive value (NPV) of 77.3 %. No correlation was found between MRI and tumor size sensitivity. Moreover, T2 rSI was negatively correlated with the expression of SSTR5. T2 rSI correlates with the expression of SSTR5 and quantitatively predicts the biochemical efficacy of SSA in acromegaly.

Data correlation and analysis of arc tunnel and wind tunnel tests of RSI joints and gaps. Volume 2: Data base

NASA Technical Reports Server (NTRS)

Christensen, H. E.; Kipp, H. W.

1974-01-01

Wind tunnel tests were conducted to determine the aerodynamic heating created by gaps in the reusable surface insulation (RSI) thermal protection system (TPS) for the space shuttle. The effects of various parameters of the RSI on convective heating characteristics are described. The wind tunnel tests provided a data base for accurate assessment of gap heating. Analysis and correlation of the data provide methods for predicting heating in the RSI gaps on the space shuttle.

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital.

PubMed

Phillips, Luke; Orford, Neil; Ragg, Michael

2014-08-01

The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of a preclinical cardiopulmonary resuscitation.

PubMed

Jaeger, K; Ruschulte, H; Osthaus, A; Scheinichen, D; Heine, J

2000-01-01

Management of the difficult airway requires an appropriate approach based on personal clinical experiences. For every physician involved in rescue and emergency medicine, it is important to know the difficult airway algorithm and be familiar with alternative techniques of managing the difficult airway. We report a case of tracheal injury caused by multiple attempts at intubating the trachea. Based on current knowledge, apart from surgical equipment for cricothyroidotomy the laryngeal mask airway (LMA) and the Combitube (ETC) should be available on any ambulance vehicle staffed by an emergency physician. In future, blind intubation through the intubating laryngeal mask airway (ILMA) could offer a new opportunity.

A systematic review and meta-regression analysis of mivacurium for tracheal intubation.

PubMed

Vanlinthout, L E H; Mesfin, S H; Hens, N; Vanacker, B F; Robertson, E N; Booij, L H D J

2014-12-01

We systematically reviewed factors associated with intubation conditions in randomised controlled trials of mivacurium, using random-effects meta-regression analysis. We included 29 studies of 1050 healthy participants. Four factors explained 72.9% of the variation in the probability of excellent intubation conditions: mivacurium dose, 24.4%; opioid use, 29.9%; time to intubation and age together, 18.6%. The odds ratio (95% CI) for excellent intubation was 3.14 (1.65-5.73) for doubling the mivacurium dose, 5.99 (2.14-15.18) for adding opioids to the intubation sequence, and 6.55 (6.01-7.74) for increasing the delay between mivacurium injection and airway insertion from 1 to 2 min in subjects aged 25 years and 2.17 (2.01-2.69) for subjects aged 70 years, p < 0.001 for all. We conclude that good conditions for tracheal intubation are more likely by delaying laryngoscopy after injecting a higher dose of mivacurium with an opioid, particularly in older people. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

A comparative study of effect of sevoflurane on intubating conditions with rocuronium in neurosurgical patients.

PubMed

Mitra, Saikat; Purohit, Shobha; Bhatia, Sonali; Kalra, Poonam; Sharma, Satya Prakash

2015-12-01

Rocuronium may not always be the preferred relaxant for rapid sequence intubation. When 2% sevoflurane is used in conjunction with rocuronium, it may reduce the time required for achieving complete skeletal muscle relaxation with the intubating dose of rocuronium. This study was prospective, randomised, double-blind in nature and compared the effect of sevoflurane on intubation time and intubating conditions when used along with rocuronium. Thirty adult patients belonging to American Society of Anesthesiologists physical status Grades 1 and 2, of either gender aged between 30 and 65 years undergoing neurosurgical operations were randomly allocated into two equal groups: Group R received 0.8 mg/kg rocuronium, and Group RS received 0.8 mg/kg of rocuronium with 2% sevoflurane. Onset time of intubation was assessed using train-of-four stimuli. The intubating conditions were compared using the Cooper scoring system and the haemodynamic responses were compared between the two groups. The onset time of intubation was 101.73 ± 10.28 s in Group R and 60.4 ± 4.1 s in Group RS (P < 0.001), with excellent intubating conditions in both groups and without any adverse effects. Significant differences in heart rate and mean arterial pressure were seen immediately after intubation, at 1 and 3 min (P < 0.05) between the two groups. Rocuronium 0.8 mg/kg along with 2% sevoflurane provides excellent intubating conditions within 60-66 s from its administration.

Airway management of patients with traumatic brain injury/C-spine injury

PubMed Central

2015-01-01

Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury. PMID:26045922

Reaching Success through Involvement--Implementation Strategy for Creating and Maintaining Effective Schools.

ERIC Educational Resources Information Center

Furtwengler, Willis J.

The educational change strategy termed "reaching success through involvement" (RSI) has yielded promising results in creating school effectiveness. This paper analyzes the theoretical bases and practical applications of RSI strategy among 14 schools over an 8-year period. RSI theory assumes that educational organizations are dynamic social systems…

Comparison of the effect of rocuronium dosing based on corrected or lean body weight on rapid sequence induction and neuromuscular blockade duration in obese female patients

PubMed Central

Sakızcı-Uyar, Bahar; Çelik, Şeref; Postacı, Aysun; Bayraktar, Yeşim; Dikmen, Bayazit; Özkoçak-Turan, Işıl; Saçan, Özlem

2016-01-01

Objectives: To compare onset time, duration of action, and tracheal intubation conditions in obese patients when the intubation dose of rocuronium was based on corrected body weight (CBW) versus lean body weight (LBW) for rapid sequence induction. Methods: This prospective study was carried out at Numune Education and Research Hospital, Ankara, Turkey between August 2013 and May 2014. Forty female obese patients scheduled for laparoscopic surgery under general anesthesia were randomized into 2 groups. Group CBW (n=20) received 1.2 mg/kg rocuronium based on CBW, and group LBW (n=20) received 1.2 mg/kg rocuronium based on LBW. Endotracheal intubation was performed 60 seconds after injection of muscle relaxant, and intubating conditions were evaluated. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis. Onset time, defined as time to depression of the twitch tension to 95% of its control value, and duration of action, defined as time to achieve one response to train-of-four stimulation (T1) were recorded. Results: No significant differences were observed between the groups in intubation conditions or onset time (50-60 seconds median, 30-30 interquartile range [IQR]). Duration of action was significantly longer in the CBW group (60 minutes median, 12 IQR) than the LBW group (35 minutes median, 16 IQR; p<0.01). Conclusion: In obese patients, dosing of 1.2 mg/kg rocuronium based on LBW provides excellent or good tracheal intubating conditions within 60 seconds after administration and does not lead to prolonged duration of action. PMID:26739976

Clinical expression profiles of complex regional pain syndrome, fibromyalgia and a-specific repetitive strain injury: more common denominators than pain?

PubMed

Marinus, Johan; Van Hilten, Jacobus J

2006-03-30

To systematically evaluate and compare the clinical manifestations, disease course, risk factors and demographic characteristics of Complex Regional Pain Syndrome type 1 (CRPS), fibromyalgia (FM) and a-specific Repetitive Strain Injury (RSI). A literature search was performed using terms related to the aforementioned topics and diseases. Only original clinical studies that included at least 20 subjects were eligible. Fifty-nine studies on CRPS, 73 on FM and 7 on a-specific RSI were identified. The diseases show similarities in age distribution, male-female ratio, pain characteristics and sensory signs and symptoms. Motor, autonomic and trophic changes are frequently reported in CRPS, but only occasionally in FM and RSI. Systemic symptoms are found in patients with CRPS and FM, and in a subgroup of patients with RSI. In all three disorders, symptoms usually start locally, but may spread to other body regions later, which, in the case of FM, is a prerequisite for diagnosis. Disease onset is always, usually, or occasionally of traumatic origin in RSI, CRPS and FM, respectively. Anxiety and depression are more frequent in patients compared to controls, but probably not very different from patients with other pain conditions or chronic diseases. Apart from some obvious differences between CRPS, FM and RSI, the similarities are conspicuous. The common features of CRPS, FM and a-specific RSI may suggest that a common pathway is involved, but until patients with these type of symptoms are assessed with a uniform assessment procedure, a thorough comparison cannot be made. A systematic evaluation of patients with a suspected diagnosis of CRPS, FM or RSI, may lead to a better appreciation of the differences and similarities in these diseases and help to unravel the underlying mechanisms.

Independent prognostic importance of respiratory instability and sympathetic nerve activity in patients with chronic heart failure.

PubMed

Asanoi, Hidetsugu; Harada, Daisuke; Oda, Yoshitaka; Ueno, Hiroshi; Takagawa, Junya; Ishise, Hisanari; Goso, Yukiko; Joho, Shuji; Inoue, Hiroshi

2017-11-01

Respiratory instability in chronic heart failure (CHF) is characterized by irregularly rapid respiration or non-periodic breathing rather than by Cheyne-Stokes respiration. We developed a new quantitative measure of respiratory instability (RSI) and examined its independent prognostic impact upon CHF. In 87 patients with stable CHF, respiratory flow and muscle sympathetic nerve activity (MSNA) were simultaneously recorded. RSI was calculated from the frequency distribution of respiratory spectral components and very low frequency components. During a mean follow-up of 85±38 months, 24 patients died. Sixteen patients who died of cardiac causes had a lower RSI (16±6 vs. 30±21, p<0.01), a lower specific activity scale (4.3±1.4 Mets vs. 5.7±1.4 Mets, p<0.005), a higher MSNA burst area (16±5% vs. 11±4%, p<0.001), and a higher brain natriuretic peptide (BNP) level (514±559pg/ml vs. 234±311pg/ml, p<0.05) than 71 patients who did not die of cardiac causes. Multivariate analysis revealed that RSI (p=0.015), followed by MSNA burst area (p=0.033), was an independent predictor of subsequent all-cause deaths and that RSI (p=0.026), MSNA burst area (p=0.001), and BNP (p=0.048) were independent predictors of cardiac deaths. Patients at very high risk of fatal outcome could be identified by an RSI<20. The daytime respiratory instability quantified by a new measure of RSI has prognostic importance independent of sympathetic nerve activation in patients with clinically stable CHF. An RSI of <20 identifies patients at very high risk for subsequent all-cause and cardiovascular death. Copyright © 2017. Published by Elsevier Ltd.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway

PubMed Central

Vivek, Bangaru; Sripriya, R.; Mishra, Gayatri; Ravishankar, M.; Parthasarathy, S.

2017-01-01

Background and Aims: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. Material and Methods: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. Results: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26–80) s and 49 (range 28–83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. Conclusion: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt. PMID:28413282

Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study.

PubMed

Van Oeveren, Lucas; Donner, Julie; Fantegrossi, Andrea; Mohr, Nicholas M; Brown, Calvin A

2017-04-01

Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.

Comparison of Orbiter STS-2 development flight instrumentation data with thermal math model predictions

NASA Technical Reports Server (NTRS)

Norman, I.; Rochelle, W. C.; Kimbrough, B. S.; Ritrivi, C. A.; Ting, P. C.; Dotts, R. L.

1982-01-01

Thermal performance verification of Reusable Surface Insulation (RSI) has been accomplished by comparisons of STS-2 Orbiter Flight Test (OFT) data with Thermal Math Model (TMM) predictions. The OFT data was obtained from Development Flight Instrumentation RSI plug and gap thermocouples. Quartertile RSI TMMs were developed using measured flight data for surface temperature and pressure environments. Reference surface heating rates, derived from surface temperature data, were multiplied by gap heating ratios to obtain tile sidewall heating rates. This TMM analysis resulted in good agreement of predicted temperatures with flight data for thermocouples located in the RSI, Strain Isolation Pad, filler bar and structure.

Arc Jet Screening Tests Of Phase 1 Orbiter Tile Repair Materials and Uncoated RSI High Temperature Emittance Measurements

NASA Technical Reports Server (NTRS)

DelPapa, Steven V.

2005-01-01

Arc jet tests of candidate tile repair materials and baseline Orbiter uncoated reusable surface insulation (RSI) were performed in the Johnson Space Center's (JSC) Atmospheric Reentry Materials and Structures Evaluation Facility (ARMSEF) from June 23, 2003, through August 19, 2003. These tests were performed to screen candidate tile repair materials by verifying the high temperature performance and determining the thermal stability. In addition, tests to determine the surface emissivity at high temperatures and the geometric shrinkage of bare RSI were performed. In addition, tests were performed to determine the surface emissivity at high temperatures and the geometric shrinkage of uncoated RSI.

The demographic and contextual correlates of work-related repetitive strain injuries among Canadian men and women.

PubMed

Breslin, F Curtis; Ibrahim, S; Smith, P; Mustard, C; Amick, B; Shankardass, K

2013-10-01

The study sought to identify gender differences in work-related repetitive strain injuries (RSI), as well as examine the degree to which non-work factors such as family roles interact with gender to modify RSI risk. Another aim is to examine whether there are potential provincial differences in work-related RSI risk. The 2003/2005 Canadian Community Health Survey included over 89,000 respondents who reported working in the past 12 months. Separate multi-level models for men and women were used to identify the correlates of work-related RSIs. Women reported sustaining more work-related RSIs than men. Also, having one or more children in the household was associated with lower work-related RSI risk for females. Both men and women in British Columbia reported higher work-related RSI rates than in Ontario. Gender contributes to RSI risk in multiple and diverse ways based on labor market segregation, non-work exposures, and possibly biological vulnerability, which suggests more tailored interventions. Also, the provincial differences indicate that monitoring and surveillance of work injury across jurisdictions can assist in province-wide prevention and occupational health and safety evaluation. Copyright © 2013 Wiley Periodicals, Inc.

Reactive Strength Index: A Poor Indicator of Reactive Strength?

PubMed

Healy, Robin; Kenny, Ian; Harrison, Drew

2017-11-28

The primary aim was to assess the relationships between reactive strength measures and associated kinematic and kinetic performance variables achieved during drop jumps. A secondary aim was to highlight issues with the use of reactive strength measures as performance indicators. Twenty eight national and international level sprinters, consisting of fourteen men and women, participated in this cross-sectional analysis. Athletes performed drop jumps from a 0.3 m box onto a force platform with dependent variables contact time (CT), landing time (TLand), push-off time (TPush), flight time (FT), jump height (JH), reactive strength index (RSI, calculated as JH / CT), reactive strength ratio (RSR, calculated as FT / CT) and vertical leg spring stiffness (Kvert) recorded. Pearson's correlation test found very high to near perfect relationships between RSI and RSR (r = 0.91 to 0.97), with mixed relationships found between RSI, RSR and the key performance variables, (Men: r = -0.86 to -0.71 between RSI/RSR and CT, r = 0.80 to 0.92 between RSI/RSR and JH; Women: r = -0.85 to -0.56 between RSR and CT, r = 0.71 between RSI and JH). This study demonstrates that the method of assessing reactive strength (RSI versus RSR) may be influenced by the performance strategies adopted i.e. whether an athlete achieves their best reactive strength scores via low CTs, high JHs or a combination. Coaches are advised to limit the variability in performance strategies by implementing upper and / or lower CT thresholds to accurately compare performances between individuals.

Evaluating the Impact of Radio Frequency Identification Retained Surgical Instruments Tracking on Patient Safety: Literature Review.

PubMed

Schnock, Kumiko O; Biggs, Bonnie; Fladger, Anne; Bates, David W; Rozenblum, Ronen

2017-02-22

Retained surgical instruments (RSI) are one of the most serious preventable complications in operating room settings, potentially leading to profound adverse effects for patients, as well as costly legal and financial consequences for hospitals. Safety measures to eliminate RSIs have been widely adopted in the United States and abroad, but despite widespread efforts, medical errors with RSI have not been eliminated. Through a systematic review of recent studies, we aimed to identify the impact of radio frequency identification (RFID) technology on reducing RSI errors and improving patient safety. A literature search on the effects of RFID technology on RSI error reduction was conducted in PubMed and CINAHL (2000-2016). Relevant articles were selected and reviewed by 4 researchers. After the literature search, 385 articles were identified and the full texts of the 88 articles were assessed for eligibility. Of these, 5 articles were included to evaluate the benefits and drawbacks of using RFID for preventing RSI-related errors. The use of RFID resulted in rapid detection of RSI through body tissue with high accuracy rates, reducing risk of counting errors and improving workflow. Based on the existing literature, RFID technology seems to have the potential to substantially improve patient safety by reducing RSI errors, although the body of evidence is currently limited. Better designed research studies are needed to get a clear understanding of this domain and to find new opportunities to use this technology and improve patient safety.

Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study.

PubMed

Ferguson, Ian; Alkhouri, Hatem; Fogg, Toby; Aneman, Anders

2018-06-11

This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Integration of a Radiosensitivity Molecular Signature Into the Assessment of Local Recurrence Risk in Breast Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Torres-Roca, Javier F., E-mail: javier.torresroca@moffitt.org; Department of Chemical Biology and Molecular Medicine, Moffitt Cancer Center, Tampa, Florida; Fulp, William J.

Purpose: Recently, we developed radiosensitivity (RSI), a clinically validated molecular signature that estimates tumor radiosensitivity. In the present study, we tested whether integrating RSI with the molecular subtype refines the classification of local recurrence (LR) risk in breast cancer. Methods and Materials: RSI and molecular subtype were evaluated in 343 patients treated with breast-conserving therapy that included whole-breast radiation therapy with or without a tumor bed boost (dose range 45-72 Gy). The follow-up period for patients without recurrence was 10 years. The clinical endpoint was LR-free survival. Results: Although RSI did not uniformly predict for LR across the entire cohort, combining RSImore » and the molecular subtype identified a subpopulation with an increased risk of LR: triple negative (TN) and radioresistant (reference TN-radioresistant, hazard ratio [HR] 0.37, 95% confidence interval [CI] 0.15-0.92, P=.02). TN patients who were RSI-sensitive/intermediate had LR rates similar to those of luminal (LUM) patients (HR 0.86, 95% CI 0.47-1.57, P=.63). On multivariate analysis, combined RSI and molecular subtype (P=.004) and age (P=.001) were the most significant predictors of LR. In contrast, integrating RSI into the LUM subtype did not identify additional risk groups. We hypothesized that radiation dose escalation was affecting radioresistance in the LUM subtype and serving as a confounder. An increased radiation dose decreased LR only in the luminal-resistant (LUM-R) subset (HR 0.23, 95% CI 0.05-0.98, P=.03). On multivariate analysis, the radiation dose was an independent variable only in the LUMA/B-RR subset (HR 0.025, 95% CI 0.001-0.946, P=.046), along with age (P=.008), T stage (P=.004), and chemotherapy (P=.008). Conclusions: The combined molecular subtype–RSI identified a novel molecular subpopulation (TN and radioresistant) with an increased risk of LR after breast-conserving therapy. We propose that the combination of RSI and molecular subtype could be useful in guiding radiation therapy–based decisions in breast cancer.« less

Translation and cross-cultural adaptation of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish.

PubMed

Harput, Gulcan; Tok, Damla; Ulusoy, Burak; Eraslan, Leyla; Yildiz, Taha Ibrahim; Turgut, Elif; Demirci, Serdar; Duzgun, Irem; Tunay, Volga Bayrakci; Baltaci, Gul; Ergun, Nevin

2017-01-01

To translate and culturally adapt the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish (ACL-RSI-Tr) and examine and evaluate the psychometric properties of the Turkish version in individuals who have undergone anterior cruciate ligament (ACL) reconstruction. The ACL-RSI was forward- and back-translated, culturally adapted and validated on ninety-three Turkish individuals who had undergone ACL reconstruction (5 females, 88 males; age 28.7 ± 8.6 years; body mass 80.1 ± 13.9 kg; height 178.8 ± 6.9 cm; body mass index 25.0 ± 3.7 kg/m 2 ). All patients completed the translated ACL-RSI, Tampa Scale of Kinesiophobia (TSK), Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentary Committee (IKDC) and Lysholm questionnaires. We then analysed the internal consistency, reliability and validity of the newly formed ACL-RSI-Tr scale. The ACL-RSI-Tr showed good internal consistency (Cronbach's alpha 0.86) and test-retest reliability (ICC 0.92) and was significantly correlated with the KOOS 'quality of life' (r = 0.58, p < 0.002), 'symptoms and stiffness' (r = 0.35, p = 0.001), 'pain' (r = 0.49, p < 0.001), 'sports' (r = 0.44, p < 0.001) and 'daily life' (r = 0.42, p < 0.001) subscales. The ACL-RSI-Tr also correlated significantly with the TSK (r = - 0.45, p < 0.001), Lysholm (r = 0.45, p < 0.001) and IKDC (r = 0.44, p < 0.001) scores. The Turkish version of the ACL-RSI scale was valid, discriminant, consistent and reliable in patients who had undergone ACL reconstruction. This score could be useful to evaluate the effect of psychological factors on return to sport following ACL surgery. Diagnostic study, Level I.

A design assessment of multiwall, metallic stand-off, and RSI reusable thermal protection systems including space shuttle application

NASA Technical Reports Server (NTRS)

Jackson, L. R.; Dixon, S. C.

1980-01-01

The design and assessment of reusable surface insulation (RSI), metallic stand off and multiwall thermal protection systems (TPS) is discussed. Multiwall TPS is described in some detail, and analyses useful for design of multiwall are included. Results indicate that multiwall has the potential to satisfy the TPS design goals better than the other systems. The total mass of the stand-off TPS and of the metallic systems require less primary structure mass than the RSI system, since the nonbuckling skin criteria required for RSI may be removed. Continued development of multiwall TPS is required to verify its potential and to provide the necessary data base for design.

The Neural Correlates of Shoulder Apprehension: A Functional MRI Study

PubMed Central

Shitara, Hitoshi; Shimoyama, Daisuke; Sasaki, Tsuyoshi; Hamano, Noritaka; Ichinose, Tsuyoshi; Yamamoto, Atsushi; Kobayashi, Tsutomu; Osawa, Toshihisa; Iizuka, Haku; Hanakawa, Takashi; Tsushima, Yoshito; Takagishi, Kenji

2015-01-01

Although shoulder apprehension is an established clinical finding and is important for the prevention of shoulder dislocation, how this subjective perception is evoked remains unclear. We elucidated the functional neuroplasticity associated with apprehension in patients with recurrent anterior shoulder instability (RSI) using functional magnetic resonance imaging (fMRI). Twelve healthy volunteers and 14 patients with right-sided RSI performed a motor imagery task and a passive shoulder motion task. Brain activity was compared between healthy participants and those with RSI and was correlated with the apprehension intensity reported by participants after each task. Compared to healthy volunteers, participants with RSI exhibited decreased brain activity in the motor network, but increased activity in the hippocampus and amygdala. During the passive motion task, participants with RSI exhibited decreased activity in the left premotor and primary motor/somatosensory areas. Furthermore, brain activity was correlated with apprehension intensity in the left amygdala and left thalamus during the motor imagery task (memory-induced), while a correlation between apprehension intensity and brain activity was found in the left prefrontal cortex during the passive motion task (instability-induced). Our findings provide insight into the pathophysiology of RSI by identifying its associated neural alterations. We elucidated that shoulder apprehension was induced by two different factors, namely instability and memory. PMID:26351854

The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea.

PubMed

Brain, A I; Verghese, C; Addy, E V; Kapila, A; Brimacombe, J

1997-12-01

We have assessed the efficacy of a new laryngeal mask prototype, the intubating laryngeal mask airway (ILMA), as a ventilatory device and blind intubation guide. The ILMA consists of an anatomically curved, short, wide bore, stainless steel tube sheathed in silicone which is bonded to a laryngeal mask and a guiding handle. It has a single moveable aperture bar, a guiding ramp and can accommodate an 8 mm tracheal tube (TT). After induction of anaesthesia with propofol 2.5 mg kg-1 and fentanyl 2.5 micrograms kg-1, the device was inserted successfully at the first attempt in all 150 (100%) patients and adequate ventilation achieved in all, with minor adjustments required in four patients. Placement did not require movement of the head and neck or insertion of the fingers in the patient's mouth. Blind tracheal intubation using a straight silicone cuffed TT was attempted after administration of atracurium 0.5 mg kg-1. If resistance was felt during intubation, a sequence of adjusting manoeuvres was used based on the depth at which resistance occurred. Tracheal intubation was possible in 149 of 150 (99.3%) patients. In 75 (50%) patients no resistance was encountered and the trachea was intubated at the first attempt, 28 (19%) patients required one adjusting manoeuvre and 46 (31%) patients required 2-4 adjusting manoeuvres before intubation was successful. There were 13 patients with potential or known airway problems. The lungs of all of these patients were ventilated easily and the trachea intubated using the ILMA. In 10 of 13 (77%) of these patients, no resistance was encountered and the trachea was intubated at the first attempt; three of 13 (23%) patients required one adjusting manoeuvre. Tracheal intubation required significantly fewer adjusting manoeuvres in patients with a predicted or known difficult airway (P < 0.05). We conclude that the ILMA appeared on initial assessment to be an effective ventilatory device and intubation guide for routine and difficult airway patients not at risk of gastric aspiration.

Relationships Between Countermovement Jump Ground Reaction Forces and Jump Height, Reactive Strength Index, and Jump Time.

PubMed

Barker, Leland A; Harry, John R; Mercer, John A

2018-01-01

Barker, LA, Harry, JR, and Mercer, JA. Relationships between countermovement jump ground reaction forces and jump height, reactive strength index, and jump time. J Strength Cond Res 32(1): 248-254, 2018-The purpose of this study was to determine the relationship between ground reaction force (GRF) variables to jump height, jump time, and the reactive strength index (RSI). Twenty-six, Division-I, male, soccer players performed 3 maximum effort countermovement jumps (CMJs) on a dual-force platform system that measured 3-dimensional kinetic data. The trial producing peak jump height was used for analysis. Vertical GRF (Fz) variables were divided into unloading, eccentric, amortization, and concentric phases and correlated with jump height, RSI (RSI = jump height/jump time), and jump time (from start to takeoff). Significant correlations were observed between jump height and RSI, concentric kinetic energy, peak power, concentric work, and concentric displacement. Significant correlations were observed between RSI and jump time, peak power, unload Fz, eccentric work, eccentric rate of force development (RFD), amortization Fz, amortization time, second Fz peak, average concentric Fz, and concentric displacement. Significant correlations were observed between jump time and unload Fz, eccentric work, eccentric RFD, amortization Fz, amortization time, average concentric Fz, and concentric work. In conclusion, jump height correlated with variables derived from the concentric phase only (work, power, and displacement), whereas Fz variables from the unloading, eccentric, amortization, and concentric phases correlated highly with RSI and jump time. These observations demonstrate the importance of countermovement Fz characteristics for time-sensitive CMJ performance measures. Researchers and practitioners should include RSI and jump time with jump height to improve their assessment of jump performance.

Refurbishment cost study of the thermal protection system of a space shuttle vehicle. Phase 2: Supplement

NASA Technical Reports Server (NTRS)

Haas, D. W.; Gerler, V. M.

1972-01-01

The labor costs and techniques associated with the maintenance of a bonded-on ablator thermal protection system (TPS) concept, suitable for Space Shuttle application are examined. The baseline approach to TPS attachment involves bonding reusable surface insulation (RSI) and/or ablators to the structural skin of the vehicle. The RSI and/or ablators in the form of either flat or contoured panels can be bonded to the skin of the primary structure directly or by way of an intermediate silicone foam rubber pad. The use of foam rubber pads permits the use of buckling skins and protruding heat rivets on the primary structure, minimizing structural weight and fabrication costs. In the case of the RSI, the foam rubber pad serves as a required strain isolator. For purpose of comparison, test data were obtained for an installation with and without the use of a strain isolator. The refurbishment aspects of a bonded-on RSI concept (without a strain isolator) were examined experimentally along with several externally removable panel concepts employing both ablator and RSI TPS. The various concepts are compared.

Sugammadex rescue following prolonged rocuronium neuromuscular blockade with ‘recurarisation’ in a patient with severe renal failure

PubMed Central

Lobaz, Steven; Sammut, Mario; Damodaran, Anand

2013-01-01

We describe our experience of a 71-year-old patient with severe renal failure, who exhibited an unusually prolonged rocuronium-induced neuromuscular blockade (>4 h) and apparent recurarisation, following emergency rapid sequence induction (RSI). At the end of operation, 45 min post induction, train-of-four (TOF) testing had been 4/4 prior to wake up. No respiratory effort was seen 150 min postinduction, despite further neostigmine/glycopyrrolate and repeat TOF 4/4. The patient was resedated and transferred to the intensive care unit (ICU). At 180 min postinduction, fade was evident on TOF, suggestive of rocuronium reblockade. At 285 min, the patient was extubated safely following sugammadex administration and discharged uneventfully from the ICU. An important lesson to recognise is the potential for extremely prolonged neuromuscular blockade following rocuronium in patients with severe renal failure, particularly when using the higher doses (1.2 mg/kg) required for RSI, and that TOF in such cases may not be reliable in detecting residual blockade. PMID:23396837

Effect of drop jump technique on the reactive strength index.

PubMed

Struzik, Artur; Juras, Grzegorz; Pietraszewski, Bogdan; Rokita, Andrzej

2016-09-01

The basic drill of plyometric training aimed at improving lower limb power and jump height is a drop jump. This exercise can be performed using different techniques, which substantially affects jump variables. Therefore, the aim of this study was to compare the values of the reactive strength index (RSI) for countermovement drop jumps (CDJs) and bounce drop jumps (BDJs). The study was carried out in a group of 8 male youth basketball players. The tests were conducted using the AMTI BP600900 force plate to measure ground reaction forces and the Noraxon MyoMotion system to record kinematic data. Each player performed two CDJs and two BDJs from the height of 15, 30, 45 and 60 cm. The RSI was calculated as a ratio of jump height and contact time. Moreover, the RSI was determined for the amortization and take-off phases separately. Significant differences (p < 0.05) between RSI values for CDJs and BDJs were recorded for jumps from 30, 45 and 60 cm. Differences in RSI values for jumps from 15 cm were not significant. Furthermore, CDJ height values were significantly higher (p < 0.05) than the values recorded for BDJs. Times of contact, amortization and take-off during BDJs were significantly shorter (p < 0.05) than the respective values obtained for CDJs. Therefore, the use of the RSI to monitor plyometric training should be based on the drop jump technique that is commonly performed by basketball players.

Remote sensing imagery classification using multi-objective gravitational search algorithm

NASA Astrophysics Data System (ADS)

Zhang, Aizhu; Sun, Genyun; Wang, Zhenjie

2016-10-01

Simultaneous optimization of different validity measures can capture different data characteristics of remote sensing imagery (RSI) and thereby achieving high quality classification results. In this paper, two conflicting cluster validity indices, the Xie-Beni (XB) index and the fuzzy C-means (FCM) (Jm) measure, are integrated with a diversity-enhanced and memory-based multi-objective gravitational search algorithm (DMMOGSA) to present a novel multi-objective optimization based RSI classification method. In this method, the Gabor filter method is firstly implemented to extract texture features of RSI. Then, the texture features are syncretized with the spectral features to construct the spatial-spectral feature space/set of the RSI. Afterwards, cluster of the spectral-spatial feature set is carried out on the basis of the proposed method. To be specific, cluster centers are randomly generated initially. After that, the cluster centers are updated and optimized adaptively by employing the DMMOGSA. Accordingly, a set of non-dominated cluster centers are obtained. Therefore, numbers of image classification results of RSI are produced and users can pick up the most promising one according to their problem requirements. To quantitatively and qualitatively validate the effectiveness of the proposed method, the proposed classification method was applied to classifier two aerial high-resolution remote sensing imageries. The obtained classification results are compared with that produced by two single cluster validity index based and two state-of-the-art multi-objective optimization algorithms based classification results. Comparison results show that the proposed method can achieve more accurate RSI classification.

Effect of drop jump technique on the reactive strength index

PubMed Central

Juras, Grzegorz; Pietraszewski, Bogdan; Rokita, Andrzej

2016-01-01

Abstract The basic drill of plyometric training aimed at improving lower limb power and jump height is a drop jump. This exercise can be performed using different techniques, which substantially affects jump variables. Therefore, the aim of this study was to compare the values of the reactive strength index (RSI) for countermovement drop jumps (CDJs) and bounce drop jumps (BDJs). The study was carried out in a group of 8 male youth basketball players. The tests were conducted using the AMTI BP600900 force plate to measure ground reaction forces and the Noraxon MyoMotion system to record kinematic data. Each player performed two CDJs and two BDJs from the height of 15, 30, 45 and 60 cm. The RSI was calculated as a ratio of jump height and contact time. Moreover, the RSI was determined for the amortization and take-off phases separately. Significant differences (p < 0.05) between RSI values for CDJs and BDJs were recorded for jumps from 30, 45 and 60 cm. Differences in RSI values for jumps from 15 cm were not significant. Furthermore, CDJ height values were significantly higher (p < 0.05) than the values recorded for BDJs. Times of contact, amortization and take-off during BDJs were significantly shorter (p < 0.05) than the respective values obtained for CDJs. Therefore, the use of the RSI to monitor plyometric training should be based on the drop jump technique that is commonly performed by basketball players. PMID:28149403

The atypical two-subunit σ factor from Bacillus subtilis is regulated by an integral membrane protein and acid stress.

PubMed

Davis, Maria C; Smith, Logan K; MacLellan, Shawn R

2016-02-01

Extracytoplasmic function (ECF) σ factors constitute a major component of the physicochemical sensory apparatus in bacteria. Most ECF σ factors are co-expressed with a negative regulator called an anti-σ factor that binds to its cognate σ factor and sequesters it from productive association with core RNA polymerase (RNAP). Anti-σ factors constitute an important element of signal transduction pathways that mediate an appropriate transcriptional response to changing environmental conditions. The Bacillus subtilis genome encodes seven canonical ECF σ factors and six of these are co-expressed with experimentally verified anti-σ factors. B. subtilis also expresses an ECF-like atypical two-subunit σ factor composed of subunits SigO and RsoA that becomes active after exposure to certain cell-wall-acting antibiotics and to growth under acidic conditions. This work describes the identification and preliminary characterization of a protein (RsiO, formerly YvrL) that constitutes the anti-σ factor cognate to SigO-RsoA. Synthesis of RsiO represses SigO-RsoA-dependent transcription initiation by binding the N-terminus of SigO under neutral (pH 7) conditions. Reconstitution of the SigO-RsoA-RsiO regulatory system into a heterologous host reveals that the imposition of acid stress (pH 5.4) abolishes the ability of RsiO to repress SigO-RsoA-dependent transcription and this correlates with loss of RsiO binding affinity for SigO. A current model for RsiO function indicates that RsiO responds, either directly or indirectly, to increased extracytoplasmic hydrogen ion concentration and becomes inactivated. This results in the release of SigO into the cytoplasm, where it productively associates with RsoA and core RNAP to initiate transcription from target promoters in the cell.

Timing of intubation and ventilator-associated pneumonia following injury.

PubMed

Evans, Heather L; Zonies, David H; Warner, Keir J; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2010-11-01

In an emergency medical system with established rapid-sequence intubation protocols, prehospital (PH) intubation of patients with trauma is not associated with a higher rate of ventilator-associated pneumonia (VAP) than emergency department (ED) intubation. Retrospective observational cohort. Level I trauma center. Adult patients with trauma intubated in a PH or an ED setting from July 1, 2007, through July 31, 2008. Diagnosis of VAP by means of bronchoscopic alveolar lavage or clinical assessment when bronchoscopic alveolar lavage was impossible. Secondary outcomes included time to VAP, length of hospitalization, and in-hospital mortality. Of 572 patients, 412 (72.0%) underwent PH intubation. The ED group was older than the PH group (mean ages, 46.4 vs 39.1 years; P < .001) and had a higher incidence of blunt injury (142 [88.8%] vs 322 [78.2%]; P = .002). The mean (SD) lowest recorded ED systolic blood pressure was lower in the ED group (102.8 [1.9] vs 111.4 [1.2] mm Hg; P < .001), despite similar mean injury severity scores in both groups (27.2 [0.7] vs 27.0 [1.1]; P = .94). There was no difference in the mean rate of VAP (30 [18.8%] vs 71 [17.2%]; P = .66) or mean time to diagnosis (8.1 [1.2] vs 7.8 [1.0] days; P = .89). Logistic regression analysis identified history of drug abuse, lowest recorded ED systolic blood pressure, and injury severity score as 3 independent factors predictive of VAP. Prehospital intubation of patients with trauma is not associated with higher risk of VAP. Further investigation of intubation factors and the incidence and timing of aspiration is required to identify potentially modifiable factors to prevent VAP.

[Exploring novel hyperspectral band and key index for leaf nitrogen accumulation in wheat].

PubMed

Yao, Xia; Zhu, Yan; Feng, Wei; Tian, Yong-Chao; Cao, Wei-Xing

2009-08-01

The objectives of the present study were to explore new sensitive spectral bands and ratio spectral indices based on precise analysis of ground-based hyperspectral information, and then develop regression model for estimating leaf N accumulation per unit soil area (LNA) in winter wheat (Triticum aestivum L.). Three field experiments were conducted with different N rates and cultivar types in three consecutive growing seasons, and time-course measurements were taken on canopy hyperspectral reflectance and LNA tinder the various treatments. By adopting the method of reduced precise sampling, the detailed ratio spectral indices (RSI) within the range of 350-2 500 nm were constructed, and the quantitative relationships between LNA (gN m(-2)) and RSI (i, j) were analyzed. It was found that several key spectral bands and spectral indices were suitable for estimating LNA in wheat, and the spectral parameter RSI (990, 720) was the most reliable indicator for LNA in wheat. The regression model based on the best RSI was formulated as y = 5.095x - 6.040, with R2 of 0.814. From testing of the derived equations with independent experiment data, the model on RSI (990, 720) had R2 of 0.847 and RRMSE of 24.7%. Thus, it is concluded that the present hyperspectral parameter of RSI (990, 720) and derived regression model can be reliably used for estimating LNA in winter wheat. These results provide the feasible key bands and technical basis for developing the portable instrument of monitoring wheat nitrogen status and for extracting useful spectral information from remote sensing images.

Application and Validation of Remaining Service Interval Framework for Pavements

DOT National Transportation Integrated Search

2016-10-01

The pavement remaining service interval (RSI) terminology was developed to remove confusion caused by the multitude of meanings assigned to the various forms of pavement remaining service life (RSL). The RSI concept considers the complete maintenance...

Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

PubMed Central

Webster, Kate E.; Feller, Julian A.

2018-01-01

Background: The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale was developed to measure an athlete’s psychological readiness to return to sport after anterior cruciate ligament (ACL) injury and reconstruction surgery. The scale is being used with increasing frequency in both research and clinical settings. Purpose: To generate and validate a short version of the ACL-RSI scale. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The ACL-RSI scale was administered to 535 patients who had undergone ACL reconstruction surgery. Reliability (Cronbach alpha) was determined and factor analysis of the full scale was undertaken along with a process of item selection and elimination. A second group of 250 patients participated in a predictive validation analysis. This group completed the ACL-RSI scale at 6 months and reported return-to-sport outcomes 12 months following ACL reconstruction surgery. The predictive validity of both scales (full and short versions) was assessed by use of receiver operating characteristic (ROC) curve statistics. Results: The scale was found to have high internal consistency (Cronbach alpha, 0.96), which suggested that item redundancy was present. After an item selection process, the scale was reduced to a 6-item format. Cronbach alpha for the short version was 0.92, and factor analysis confirmed the presence of 1 factor accounting for 71% of the total variance. Scores for the short version were significantly different between patients who had and those who had not returned to sport. Six-month ACL-RSI scores for both the full and short versions had fair to good predictive ability for 12-month return-to-sport outcomes (full version: area under ROC curve, 0.77 [95% CI, 0.7-0.8]; short version: area under ROC curve, 0.75 [95% CI, 0.7-0.8]). Conclusion: A 6-item short version of the ACL-RSI scale was developed from a large cohort of patients undergoing ACL reconstruction. The short version appears to be as robust as the full version for discriminating between and predicting return-to-sport outcomes. The short version of the ACL-RSI may be of use in busy clinical settings to help identify athletes who may find return to sport challenging. PMID:29662909

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults†

PubMed Central

Frerk, C.; Mitchell, V. S.; McNarry, A. F.; Mendonca, C.; Bhagrath, R.; Patel, A.; O'Sullivan, E. P.; Woodall, N. M.; Ahmad, I.

2015-01-01

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. PMID:26556848

Ablative heat shield design for space shuttle

NASA Technical Reports Server (NTRS)

Seiferth, R. W.

1973-01-01

Ablator heat shield configuration optimization studies were conducted for the orbiter. Ablator and reusable surface insulation (RSI) trajectories for design studies were shaped to take advantage of the low conductance of ceramic RSI and high temperature capability of ablators. Comparative weights were established for the RSI system and for direct bond and mechanically attached ablator systems. Ablator system costs were determined for fabrication, installation and refurbishment. Cost penalties were assigned for payload weight penalties, if any. The direct bond ablator is lowest in weight and cost. A mechanically attached ablator using a magnesium subpanel is highly competitive for both weight and cost.

Estimates Of The Orbiter RSI Thermal Protection System Thermal Reliability

NASA Technical Reports Server (NTRS)

Kolodziej, P.; Rasky, D. J.

2002-01-01

In support of the Space Shuttle Orbiter post-flight inspection, structure temperatures are recorded at selected positions on the windward, leeward, starboard and port surfaces. Statistical analysis of this flight data and a non-dimensional load interference (NDLI) method are used to estimate the thermal reliability at positions were reusable surface insulation (RSI) is installed. In this analysis, structure temperatures that exceed the design limit define the critical failure mode. At thirty-three positions the RSI thermal reliability is greater than 0.999999 for the missions studied. This is not the overall system level reliability of the thermal protection system installed on an Orbiter. The results from two Orbiters, OV-102 and OV-105, are in good agreement. The original RSI designs on the OV-102 Orbital Maneuvering System pods, which had low reliability, were significantly improved on OV-105. The NDLI method was also used to estimate thermal reliability from an assessment of TPS uncertainties that was completed shortly before the first Orbiter flight. Results fiom the flight data analysis and the pre-flight assessment agree at several positions near each other. The NDLI method is also effective for optimizing RSI designs to provide uniform thermal reliability on the acreage surface of reusable launch vehicles.

The effect of amphipilic lignin derivatives addition on enzymatic hydrolysis performance of kraft pulp from sorghum bagasse

NASA Astrophysics Data System (ADS)

Fatriasari, Widya; Nugroho Adi, D. T.; Laksana, R. P. B.; Fajriutami, T.; Raniya, R.; Ghozali, M.; Hermiati, E.

2018-03-01

Previously, the chemical characteristics of isolated lignin from Acacia mangium black liquor of kraft pulping was characterized. This lignin was blended with natural rubber latex (NR-L) as adhesive in laminated wood. In addition, lignin has potency for biosurfactant materials by modification of the hydrophobic into hydrophilic properties. Therefore, this study was intended to develop lignin as material for amphipilic lignin derivatives (A-LD) biosurfactant by reacting lignin with epoxilated polyethylene glicol (PEG). A-LD addition in slurries was used to improve the enzymatic hydrolysis (EH) of kraft pulp sweet bagasse sorghum (SSB). The main observation in EH performance was to investigate the effect of lignin isolation method (one and two step) in A-LD and A-LD loading addition on reducing sugar yield (RSY) of SSB kraft pulp. The pulp was hydrolyzed at 50°C and 150 rpm for 72 h with 10 FPU cellulase loading in the shaking incubator. A-LD from one (L1S) and two step (L2S) lignin was added with A-LD loading of 0, 1, 2, 5, and 10% (b/v). The RSY of hydrolyzate has been observed after EH. A-LDs addition in EH of SSB kraft pulp enhanced RSY. L1S worked better in reaction performance with PEDGE compared to L2S and LS. A better performance was showed by PEDGE 500 than that of PEDGE 6000. Generally, the higher A-LDs loading resulted higher RSY. The highest RSY (81.33%) was resulted in addition of 10% A-LD L1S using PEDGE 500. A 5% A-LD loading was more considered to be added in EH because the RSY was comparable with 10% A-LD loading.

Clinical significance of laryngopharyngeal reflux in patients with chronic obstructive pulmonary disease.

PubMed

Jung, Young Ho; Lee, Doh Young; Kim, Dong Wook; Park, Sung Soo; Heo, Eun Young; Chung, Hee Soon; Kim, Deog Kyeom

2015-01-01

Although chronic obstructive pulmonary disease (COPD) is closely associated with gastroesophageal reflux disease (GERD), the clinical significance of laryngopharyngeal reflux (LPR) is not fully understood in COPD. Prospective cohorts were established among 118 patients with COPD from March 2013 to July 2014. Thirty-two age-matched and sex-matched normal controls, who had routine health check-ups during the study period, were included. Laryngopharyngeal reflux finding scores (RFS) and reflux symptom index (RSI) for LPR were subjected to association analysis with severity and acute exacerbation of COPD during the 1-year follow-up. The mean age of patients enrolled in the study was 69.2±8.8 years, with 93.2% being male. Positive RFS (>7) and RSI (>13) were observed in 51 (42.5%) and six patients (5.0%), respectively. RFS and RSI were significantly higher in patients with COPD than in normal, healthy patients (P<0.001). RFS was significantly correlated with residual volume/total lung capacity (%, P=0.048). Scores for diffuse laryngeal edema, erythema, and hyperemia were significantly higher in the high-risk group (Global Initiative for Chronic Obstructive Lung Disease classification C and D; P=0.025 and P=0.049, respectively), while RSI was significantly higher in the more symptomatic group (Global Initiative for Chronic Obstructive Lung Disease classification B and D; P=0.047). RSI and RFS were significant predictors for severe acute exacerbation of COPD (P=0.03 and P=0.047, respectively), while only RSI was associated with severity of dyspnea. Laryngeal examination and evaluation of laryngeal reflux symptom could be a surrogate clinical indicator related to severe acute exacerbation of COPD. Further studies of LPR in COPD patients should be considered.

Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate?

PubMed

Cemalovic, Nail; Scoccimarro, Anthony; Arslan, Albert; Fraser, Robert; Kanter, Marc; Caputo, Nicholas

2016-06-01

The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physician's perception of desaturation events. A timed, observation prospective cohort study was conducted. A post-intubation survey was administered to the intubating physician. Each step of the procedure was timed by an observer in order to determine actual TTI. The number of desaturation events was also recorded. One hundred individual intubations were included. The provider perceived TTI was significantly different and underestimated when compared with the actual TTI (23 s, 95% confidence interval (CI) 20.4-25.49 vs 45.5 s, 95% CI 40.2-50.7, P < 0.001, respectively). Pearson correlation coefficient of perceived TTI to actual TTI was r(2)  = 0.39 (95% CI 0.21-0.54, P < 0.001). The provider perceived desaturation rate was also significantly different from actual desaturation rate (13, 95% CI 3-12 vs 23, 95% CI 13-29, P = 0.05, respectively). The overall time to desaturation was 65.1 s. Our findings have shown that provider's perception of TTI occurs sooner than actually observed. Also, the providers were less aware of desaturation during the procedure. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Research-Supported Intervention and Discretion among Frontline Workers Implementing Home Visitation Services

ERIC Educational Resources Information Center

Willging, Cathleen E.; Trott, Elise M.; Fettes, Danielle; Gunderson, Lara; Green, Amy E.; Hurlburt, Michael S.; Aarons, Gregory A.

2017-01-01

Objective: We examine how frontline workers and supervisors delivering a research-supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients. Methods: We conducted semi-structured interviews, small group…

Teachers! Parents! Beware of RSI.

ERIC Educational Resources Information Center

Ubelacker, Sandra

Musculo-skeleton injuries, which include tendinitis, carpal tunnel syndrome, chronic neck and back pain, and other Repetitive Strain Injuries (RSI), are the leading causes of disability in working-age people in North America. This paper highlights studies indicating that computer users are especially susceptible to these injuries; therefore, the…

SU-F-T-615: Comparison of Plan Quality for Linac-Based Stereotactic Radiosurgery (SRS) Using Single- and Multi-Isocenter Techniques

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chang, J; Dept of Radiation Oncology, NewYork Hospital/Weill Cornell Medical College, New York, NY; Wernicke, A

2016-06-15

Purpose: To compare the plan quality of linear accelerator (linac)-based stereotactic radiosurgery (SRS) using single-isocenter volumetric arc therapy (SI-VMAT), restricted single-isocenter dynamic-arc (RSI-DARC), and multi-isocenter DARC (MI-DARC) techniques. Methods: Fifteen SRS cases were randomly selected and re-planned using the SI-VMAT (Pinnacle), RSI-DARC (iPlanNet) and MI-DARC (iPlanNet). The number of planning target volumes (PTVs) for each plan ranged from 1 to 6. For SI-VMAT, a single isocenter and 3-4 VMAT beams are used for all PTVs, while for MI-DARC, each PTV has its own isocetner with 3 DARC beams. RSI-DARC uses one isocnter with 3-6 DARC beams to irradiate all PTVsmore » within 2.5-cm radius. Both SI-DARC and RSI-DARC plans were optimized manually. The prescription dose was 20 Gy to each PTV. The maximal dose was 25 Gy for RSI-DARC and MI-DARC, but could not be controlled for SI-VMAT due to the nature of VMAT planning. Plan quality indexes including PTV coverage, mean dose of PTV (PTVmean) and tissue (Tmean), V12Gy, conformity index (CI), and V10Gy/VPTV were calculated and compared. Results: Full PTV coverage was achieved for all three techniques. Using the MI-DARC plans as the gold standard, the PTVmean of the SI-VMAT plans was 12.5%±8.3% (mean±standard deviation) higher, in comparison to 0.7%±1.4% for the RSI-DARC plans. Similar trend was observed for other indexes including V12Gy (39.4%±27.3% vs. 9.3%±7.8%), Tmean (35.0%±26.8% vs. 2.8%±3.4%), and V10Gy/VPTV (42.2%±31.5% vs. 9.9%±8.2%). CI is comparable (6.2%±14.2% vs. 6.3%±7.2%). Assuming the treatment time is proportional to the number of isocenters, the reduction of the treatment time in comparison to MI-DARC was 70% for SI-VMAT and 42% for RSI-DARC. Conclusion: Although the SI-VMAT can save a considerable amount of treatment time, the plan indexes also significantly deviates from the gold standard, MI-DARC. RSI-DARC, on the other hand, provides a good compromise between the treatment time and plan quality.« less

Improvement in Simulation of Eurasian Winter Climate Variability with a Realistic Arctic Sea Ice Condition in an Atmospheric GCM

NASA Technical Reports Server (NTRS)

Lim, Young-Kwon; Ham, Yoo-Geun; Jeong, Jee-Hoon; Kug, Jong-Seong

2012-01-01

The present study investigates how much a realistic Arctic sea ice condition can contribute to improve simulation of the winter climate variation over the Eurasia region. Model experiments are set up using different sea ice boundary conditions over the past 24 years (i.e., 1988-2011). One is an atmospheric model inter-comparison (AMIP) type of run forced with observed sea-surface temperature (SST), sea ice, and greenhouse gases (referred to as Exp RSI), and the other is the same as Exp RSI except for the sea ice forcing, which is a repeating climatological annual cycle (referred to as Exp CSI). Results show that Exp RSI produces the observed dominant pattern of Eurasian winter temperatures and their interannual variation better than Exp CSI (correlation difference up to approx. 0.3). Exp RSI captures the observed strong relationship between the sea ice concentration near the Barents and Kara seas and the temperature anomaly across Eurasia, including northeastern Asia, which is not well captured in Exp CSI. Lagged atmospheric responses to sea ice retreat are examined using observations to understand atmospheric processes for the Eurasian cooling response including the Arctic temperature increase, sea-level pressure increase, upper-level jet weakening and cold air outbreak toward the mid-latitude. The reproducibility of these lagged responses by Exp RSI is also evaluated.

Prevalence of patients with respiratory symptoms through active case finding and diagnosis of pulmonary tuberculosis among prisoners and related predictors in a jail in the city of Carapicuíba, Brazil

PubMed Central

Vieira, Amadeu A.; Ribeiro, Sandra A.; de Siqueira, Ana M.; Galesi, Vera M. N.; dos Santos, Laedi A. R.; Golub, Jonathan E.

2013-01-01

Background Prisons offer a fertile setting for the transmission of tuberculosis due to the presence of many classic risk factors for both infection and disease: overcrowding, poor ventilation, and little sunlight. Prisoners are often malnourished and have poor hygiene and are more likely to have a background of alcohol and drug abuse. Objectives To determine the prevalence of prisoners with respiratory symptoms and pulmonary tuberculosis (PTB) through active case finding in a prisoner population of the county jail of Carapicuíba, and to study possible related variables. Methods This was a cross-sectional study, and respiratory symptomatic individuals (RSI) were detected through active case finding. Socio-demographic data were collected from inmates’ judicial history using a specific questionnaire. The RSI provided sputum specimens for detection of acid fast bacilli and culture for mycobacterium identification. Results Among the 397 prisoners studied, 154 reported respiratory symptoms for more than three weeks, and were considered RSI; the variables associated with RSI were: having already been tried and incarcerated for more than six months and seven were diagnosed as PTB (1,763 cases/100,000 inhabitants). Conclusions The prevalence of RSI and PTB cases were respectively 39 and 35 times greater than the general population. PMID:21180853

Assessing the Sustainable Development of Coastal Reclamation: A Case of Makassar Using GIS Application

NASA Astrophysics Data System (ADS)

Yurnita, A.; Trisutomo, S.; Ali, M.

2017-07-01

Reclamation has been made in many areas in Indonesia including Makassar, as a response to the present needs of land as the impact of human activity in urban area. This research aims to assess the sustainable development of coastal reclamation and focus on environmental dimension of sustainable urban development. Assessment will be done by reclamation sustainability index (RSI) and analysis by GIS as the tools. RSI was built from previous research that has simplified from many researches and analysis by Structure of Analytic Hierarchy Process (AHP) and expert choice. RSI uses 9 indices from three indicators of environment factor which are coastal resources, building and infrastructure.

Application of wide-field optical coherence tomography to monitoring of viability of rat brain in vivo

NASA Astrophysics Data System (ADS)

Sato, Manabu; Nishidate, Izumi

2014-05-01

We investigated the feasibility of OCT in monitoring the viability of the brain. It was confirmed that after an overdose of pentobarbital sodium salt for an euthanasia, the OCT signal intensity increased before cardiac arrest and finally became 2.7 times, and by periodically changing the tissue temperature from 20 to 32 °C in vivo, average correlation coefficients between the ratio of signal intensity (RSI) and temperature were determined to be -0:42 to -0:50. RSI reversibly changed with subsequent variations of temperatures and finally increased rapidly just before cardiac arrest. These results indicate that RSI could correspond to decreases in viability.

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

PubMed

Stourac, Petr; Adamus, Milan; Seidlova, Dagmar; Pavlik, Tomas; Janku, Petr; Krikava, Ivo; Mrozek, Zdenek; Prochazka, Martin; Klucka, Jozef; Stoudek, Roman; Bartikova, Ivana; Kosinova, Martina; Harazim, Hana; Robotkova, Hana; Hejduk, Karel; Hodicka, Zuzana; Kirchnerova, Martina; Francakova, Jana; Obare Pyszkova, Lenka; Hlozkova, Jarmila; Sevcik, Pavel

2016-05-01

Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

A Validity Estimate of the Religious Status Interview.

ERIC Educational Resources Information Center

Montes, Bob; Rosenkoetter, Linda; Newman, Isadore; Zarski, John

Drawing on the work of Pruyser (1976) and Malony (1985, 1987), the Religious Status Interview (RSI), a measure of theological functioning, was created. The RSI was designed to help counselors judge the health of a parishioner's religious beliefs as they relate to the problem that brings the person to pastoral counseling. This study investigated…

An Analysis of the Mode of Gene Action Affecting Pupa Weight in TRIBOLIUM CASTANEUM

PubMed Central

Goodwill, R.

1975-01-01

Triple-testcross experiments (Kearsey and Jinks 1968) were employed to investigate the mode of gene action affecting pupa weight in Tribolium castaneum. Their experimental design involves two inbred lines, the F1 progeny and a segregating population derived from the cross of the inbred lines. In the present experiments, four segregating populations were used. These populations included the F2 generation, a select line (SEL) and two relaxed select lines (RSI and RSII). In addition, all possible reciprocal crosses were made among the RSI, RSII, and SEL populations. It was observed that: (1) additive, dominant and epistatic gene effects all made significant contributions to the pupa weight of the progeny from all four segregating populations; (2) there was no evidence of either accumulation of epistasis as a result of selection in the SEL population or decline in epistasis as a result of removing selection pressure from the RSI and RSII populations; and (3) significant negative heterosis and maternal effects contributed to the pupa weight of the crossbred progeny of the RSI, RSII and SEL populations. PMID:1132679

Telepresent intubation supervision is as effective as in-person supervision of procedurally naive operators.

PubMed

Prescher, Hannes; Grover, Emily; Mosier, Jarrod; Stolz, Uwe; Biffar, David E; Hamilton, Allan J; Sakles, John C

2015-03-01

Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

Chitosan nanoparticles for the linear release of model cationic Peptide.

PubMed

Piras, Anna Maria; Sandreschi, Stefania; Maisetta, Giuseppantonio; Esin, Semih; Batoni, Giovanna; Chiellini, Federica

2015-07-01

The present study is focused on the development of a model drug delivery system (DDS) based on Chitosan (CS) nanoparticles using Renin substrate I (RSI) as model agent. RSI shares the main chemical-physical features of several biologically active antimicrobial peptides (AMPs). AMPs have a great therapeutic potential that is hampered by their lability in the biological fluids and as such they are perfect candidates for DDS. The development studies of quality DDS loaded with AMPs would require highly sensitive and specific quantification assays. The use of RSI allowed for the fine-tuning and optimization of the formulation parameters to promote the hydrophobic interactions between CS and the cationic peptide, favour the loading of the active ingredient and enhance the release properties of the carrier. RSI was encapsulated in chitosan NPs by mean of ionic gelation and a chromogenic enzymatic essay was carried out for the release kinetics evaluation. The developed formulations displayed almost 100% of encapsulation efficacy, low burst percentages, and a linear release of the model peptide. A release model was created showing a direct dependence on both the amount of RSI and NPs radius. Although CS has always been formulated with negatively charged active agents (e.g. oligonucleotides or anionic proteins), the use of ionotropic gelation in presence of a small cationic active agent promoted the formation of "core-shell" NPs. The described model, with tuneable linear release rates, appears eligible for further exploitation such as the loading of therapeutically active AMPs.

Restriction spectrum imaging reveals decreased neurite density in patients with temporal lobe epilepsy.

PubMed

Loi, Richard Q; Leyden, Kelly M; Balachandra, Akshara; Uttarwar, Vedang; Hagler, Donald J; Paul, Brianna M; Dale, Anders M; White, Nathan S; McDonald, Carrie R

2016-11-01

Diffusion tensor imaging (DTI) has become a popular tool for delineating the location and extent of white matter injury in temporal lobe epilepsy (TLE). However, DTI yields nonspecific measures that are confounded by changes occurring within both the intracellular and extracellular environments. This study investigated whether an advanced diffusion method, restriction spectrum imaging (RSI) could provide a more robust measure of white matter injury in TLE relative to DTI due to RSI's ability to separate intraaxonal diffusion (i.e., neurite density; ND) from diffusion associated with extraaxonal factors (e.g., inflammation; crossing fibers). RSI and DTI scans were obtained on 21 patients with TLE and 11 age-matched controls. RSI-derived maps of ND, isotropic-hindered (IH) and isotropic-free (IF) water, and crossing fibers (CFs) were compared to DTI-derived fractional anisotropy (FA) maps. Voxelwise and tract-based analyses were performed comparing patients with TLE to controls on each diffusion metric. Reductions in FA were seen primarily in frontotemporal white matter in TLE, and they were most pronounced proximal to the seizure focus. Reductions in ND corresponded to those seen in the FA maps; however, ND reductions were greater in magnitude, more lateralized to the epileptogenic hemisphere, and showed a broader pattern. Increases in IF/IH and effects from CFs also contributed to reduced FA in the ipsilateral parahippocampal cingulum and fornix, with decreases in IH extending into extratemporal regions. Reduced ND of the uncinate fasciculus was associated with longer disease duration, whereas FA was not associated with any clinical variables. RSI may provide a more specific measure of white matter pathology in TLE, distinguishing regions primarily affected by axonal/myelin loss from those where CFs and increases in extracellular water also play a role. By providing a more specific measure of axonal/myelin loss, RSI-derived ND may better reflect overall white matter burden in epilepsy. Wiley Periodicals, Inc. © 2016 International League Against Epilepsy.

[The role of laryngopharyngeal reflux in the pathogenesis of Reinke's edema].

PubMed

Wang, J S; Li, J R

2016-12-01

Objective: To determine the significance of laryngopharyngeal reflux(LPR) in Reinke's edema. Method: Sixteen patients who have been diagnosed as Reinke's edema between February 2014 to June 2016 were included in this study. The control group included fifty vocal cord leukoplakia and early glottic cancer patients for the corresponding period. RSI,RFS,numbers of laryngopharyngeal acid reflux events,and time of laryngopharyngeal acid exposure were evaluated between two groups. Result: The mean RSI of the Reinke's edema was 11.2±3.8,the mean RFS was 8.2±1.5,the median numbers of laryngopharyngeal acid reflux events was 4.0［0.0；9.0］,the time of laryngopharyngeal acid exposure was 5.6［0.0；16.7］min.The rate of LPR positive in Reinke's edema patients was 100.0%（16/16）by RSI and RFS,56.2%（9/16）by 24 hour MII-pH monitoring.The mean RSI of the control group was 8.6±3.2,the mean RFS was 6.8±2.1,the median numbers of laryngopharyngeal acid reflux events was 0.0［0.0；3.0］,the time of laryngopharyngeal acid exposure was 0.0［0.0；4.3］min.The rate of LPR positive in control group was 58.0%（29/50）by RSI and RFS,28.0%（14/50）by 24 hour MII-pH monitoring.There were statistically significance in RSI,RFS,numbers of laryngopharyngeal acid reflux events,and time of laryngopharyngeal acid exposure between two groups( P <0.01 or P <0.05). Conclusion: Laryngopharyngeal reflux might play a role as an etiologic factor in Reinke's edema,awareness should increase about acid suppression therapy in Reinke's edema. Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale.

PubMed

Bohu, Y; Klouche, S; Lefevre, N; Webster, K; Herman, S

2015-04-01

The aim of this study was to translate, adapt and validate in French the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction. The ACL-RSI scale was forward and back translated, cross-culturally adapted and validated using international guidelines. The study population included all patients who were active in sports and underwent primary arthroscopic ACL reconstruction. The control group included subjects with no history of knee trauma. At the 6-month follow-up, the study population completed the ACL-RSI scale twice within 3-4 days, Knee injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) scores. Statistical tests assessed the construct validity, discriminant validity, internal consistency, reliability and feasibility of the ACL-RSI scale. Ninety-one patients with ACL tears and 98 control subjects were included: mean age 31.7 ± 8.1 and 21.8 ± 2, respectively. The ACL-RSI scores were correlated with all KOOS sub-categories (r = 0.22-0.64, p < 0.05) as well as the subjective IKDC score (r = 0.42, p < 0.00001). The mean scores of the study and control groups were significantly different (62.8 ± 19.4 vs. 89.6 ± 11.5, p < 0.00001), and scores were significantly better in patients who returned to the same sport (72.1 ± 21.4 vs. 60.3 ± 18.1, p = 0.008). Internal consistency was high (α = 0.96). Test-retest reproducibility was excellent: ρ = 0.90 (0.86-0.94), p < 0.00001. Administration time was 1.32 ± 0.7 mn, and all items were answered. This study showed that the cross-cultural adaptation of the English version of the ACL-RSI was successful and validated in a French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was confirmed. II.

Bacillus subtilis Intramembrane Protease RasP Activity in Escherichia coli and In Vitro.

PubMed

Parrell, Daniel; Zhang, Yang; Olenic, Sandra; Kroos, Lee

2017-10-01

RasP is a predicted intramembrane metalloprotease of Bacillus subtilis that has been proposed to cleave the stress response anti-sigma factors RsiW and RsiV, the cell division protein FtsL, and remnant signal peptides within their transmembrane segments. To provide evidence for direct effects of RasP on putative substrates, we developed a heterologous coexpression system. Since expression of catalytically inactive RasP E21A inhibited expression of other membrane proteins in Escherichia coli , we added extra transmembrane segments to RasP E21A, which allowed accumulation of most other membrane proteins. A corresponding active version of RasP appeared to promiscuously cleave coexpressed membrane proteins, except those with a large periplasmic domain. However, stable cleavage products were not observed, even in clpP mutant E. coli Fusions of transmembrane segment-containing parts of FtsL and RsiW to E. coli maltose-binding protein (MBP) also resulted in proteins that appeared to be RasP substrates upon coexpression in E. coli , including FtsL with a full-length C-terminal domain (suggesting that prior cleavage by a site 1 protease is unnecessary) and RsiW designed to mimic the PrsW site 1 cleavage product (suggesting that further trimming by extracytoplasmic protease is unnecessary). Purified RasP cleaved His 6 -MBP-RsiW(73-118) in vitro within the RsiW transmembrane segment based on mass spectrometry analysis, demonstrating that RasP is an intramembrane protease. Surprisingly, purified RasP failed to cleave His 6 -MBP-FtsL(23-117). We propose that the lack of α-helix-breaking residues in the FtsL transmembrane segment creates a requirement for the membrane environment and/or an additional protein(s) in order for RasP to cleave FtsL. IMPORTANCE Intramembrane proteases govern important signaling pathways in nearly all organisms. In bacteria, they function in stress responses, cell division, pathogenesis, and other processes. Their membrane-associated substrates are typically inferred from genetic studies in the native bacterium. Evidence for direct effects has come sometimes from coexpression of the enzyme and potential substrate in a heterologous host and rarely from biochemical reconstitution of cleavage in vitro We applied these two approaches to the B. subtilis enzyme RasP and its proposed substrates RsiW and FtsL. We discovered potential pitfalls and solutions in heterologous coexpression experiments in E. coli , providing evidence that both substrates are cleaved by RasP in vivo but, surprisingly, that only RsiW was cleaved in vitro , suggesting that FtsL has an additional requirement. Copyright © 2017 American Society for Microbiology.

Reading Strategy Instruction and Teacher Change: Implications for Teacher Training

ERIC Educational Resources Information Center

Klapwijk, Nanda M.

2012-01-01

I report on teacher change in the context of a reading strategy instruction intervention. Reading Strategy Instruction (RSI) was implemented by three teachers, new to the concept, over a period of 15 weeks. Observations of these teachers showed that a multitude of factors affect the uptake of RSI as part of everyday teaching practice, and that…

Official Guard and Reserve Manpower Strengths and Statistics. FY 2000 Summary

DTIC Science & Technology

2000-01-01

t- 0- at UJ UJ 1/1 oo X LULO > < o Z r- u. or O O Z O. < a: oe S»5 < r- O corvi mo -q-m HHfnSin^ Is-. r** rococo m...1- r^ •=!•-ŗ-•<!• rH rHCTirH to »T O rsi Tfrgr^rH ino rH *j- I— iH m m rsirHinm ro rsi rH rsi COCO Lnoo -1 <r m LnoOf\\IC7l rococo r-^ 1- TJ...i a. t i 1 cn > lOolOIN^ioooooolcoHHrrnj-ttiALOLDiflfnOcoOHHONNO rococo in inmioi£)CT1n-i^-inco CTCOOOCOCOOOCOOOCOCOC71CTlCTlCTlC71C71CT

The ASPRS Remote Sensing Industry Forecast: Phase II & III - Digital Sensor Compilation

NASA Technical Reports Server (NTRS)

Mondello, Charles

2007-01-01

In August 1999, ASPRS and NASA's (then) Commercial Remote Sensing Program (CRSP) entered into a 5-year Space Act Agreement (SAA), combining resources and expertise to: (a) Baseline the Remote Sensing Industry (RSI) based on GEIA Model; (b) Develop a 10-Year RSI market forecast and attendant processes; and (c) Provide improved information for decision makers.

The Influence of Two Different Doses of Magnesium Sulfate on Intraocular Pressure Variations after Injection of Succinylcholine and Endotracheal Intubation: A Prospective, Randomized, Parallel Three-Arm, Double-blind, Placebo-controlled Clinical Trial.

PubMed

Yassin, Hany Mahmoud; Abdel Moneim, Ahmed Tohamy; Mostafa Bayoumy, Ahmed Sherin; Bayoumy, Hasan Metwally; Taher, Sameh Galal

2017-01-01

The use of succinylcholine for rapid sequence induction in patients with open globe injuries may be detrimental to the eye. The aim of this study is to determine if the premedication with magnesium sulfate (MgSO 4 ) could attenuate the increase in intraocular pressure (IOP) associated with succinylcholine injection and intubation. Operation theaters in a tertiary care University Hospital between December 2014 and July 215. This was a prospective, randomized, parallel three-arm, double-blind, placebo-controlled clinical trial. One hundred and thirteen patients' physical status ASA Classes I and II underwent elective cataract surgery under general anesthesia. These patients allocated into three groups: Group C (control group) received 100 ml normal saline, Group M1 received 30 mg/kg MgSO 4 in 100 ml normal saline, and Group M2 received 50 mg/kg MgSO 4 in 100 ml normal saline. IOP, mean arterial pressure (MAP), and heart rate (HR) reported at 5-time points related to study drug administration. In addition, any adverse effects related to MgSO 4 were recorded. Intragroup and between-groups differences were examined by analysis of variance test. We noticed a significant decrease in IOP in M1 ( n = 38) and M2 ( n = 37) groups as compared with C group ( n = 38) after study drugs infusion, 2 and 5 min after intubation, P < 0.001. While the difference between M1 and M2 groups was insignificant, P = 0.296 and P = 0.647, respectively. There was a significant decrease in MAP and HR in M1 and M2 groups as compared with C group 2 and 5 min after intubation, P = 0.01. While the difference between M1 and M2 groups was insignificant, P = 1. MgSO 4 30 mg/kg as well as 50 mg/kg effectively prevented the rise in IOP, MAP, and HR associated with rapid sequence induction by succinylcholine and endotracheal intubation.

Interior, Environment, and Related Agencies: FY2007 Appropriations

DTIC Science & Technology

2007-03-07

reported bill for FY2007, from the FY2006 level, were the following: ! $-209.5 million (9%) for the National Park Service (NPS); ! $-153.5 million (10%) for...Humphries RSI 7-7264 mhumphries@crs.loc.gov National Park Service David Whiteman RSI 7-7786 dwhiteman@crs.loc.gov Payments in Lieu of Taxes Program (PILT) M...11 National Wildlife Refuge System and Law Enforcement . . . . . . . . . . 12 Avian Flu

A Legacy of Leadership and Lessons Learned: Results from the Rural Systemic Initiatives for Improving Mathematics and Science Education

ERIC Educational Resources Information Center

Harmon, Hobart L.; Smith, Keith

2007-01-01

This report pays tribute to the National Science Foundation's (NSF) Rural Systemic Initiatives (RSIs), an investment of more than $140 million to improve mathematics and science education in some of rural America's most impoverished communities. The report illustrates the impact of NSF's RSI program on a national scale. Each RSI planned a project…

[Study on the correlation between adenoid hypertrophy and laryngopharyngeal reflux in children].

PubMed

Huang, Y D; Tan, J J; Han, X Y; Zeng, F F; Li, Y F; Wang, L; Li, X P

2018-06-01

Objective: To discuss the correlation between adenoid hypertrophy and laryngopharyngeal reflux in children, and to determine the accuracy of reflux symptom index(RSI) and reflux finding score(RFS) in predicting adenoid hypertrophy and laryngopharyngeal reflux(LPR). Method: Assessment of RSI and RFS was performed in 71 children with adenoid hypertrophy who underwent surgery.The adenoid biopsy specimens were examined by pepsin immunohistochemical staining. According to the positive results of pepsin staining to evaluate the sensitivity and specificity of RSI and RFS to predict LPR. Result: Among the 71 children with adenoid hypertrophy, RSI was greater than 13 points in 4 cases (5.63%), RFS was greater than 7 points in 26 cases (36.62%), and 1(1.41%) was positive in both scores. Pepsin expression was detected in 52 cases of adenoid hypertrophy tissues, with a total positive rate of 73.24% (52/71),most were strong positive（15/71,21.13%）and positive（23/71,32.39%）. The higher the adenoid hypertrophy grade, the higher the expression level of pepsin ( r =0.476, P <0.01).Define the positive rate of pepsin as the gold standard for the diagnosis of LPR, the sensitivity and specificity of RSI and RFS were 5.77%,34.62% and 94.74%,57.89% respectively. Pepsin staining intensity was positively correlated with troublesome or annoying cough（ r =0.356, P =0.002）and was negatively correlated with ventricular obliteration（ r =－0.212， P =0.038）. Conclusion: There is a correlation between adenoid hypertrophy and LPR in children，LPR plays an important role in the development of adenoid and the role and mechanism of pepsin in adenoid hypertrophy needs further studyAs the low sensitivity of RSI and RFS, it is not suitable for the screening of adenoid hypertrophy in children with LPR. Children with adenoid hypertrophy cough for a long time and the laryngoscopy shows the ventricular obliteration, the presence of LPR should be warned. Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.

[RSI/WRMSD in the third decade after restructuring of banking: new associated factors?].

PubMed

Scopel, Juliana; Oliveira, Paulo Antonio Barros; Wehrmeister, Fernando César

2012-10-01

To estimate the prevalence of cases suggestive of repetitive strain injury/work-related musculoskeletal disorders (RSI/WRMSD), three decades after restructuring of banking. This was a cross-sectional study on 356 employees in 27 bank branches of public and private banks in Porto Alegre, Southern Brazil, between April and August 2009. After crude statistical analysis, adjustments were made using a Poisson regression model with robust variance and a three-level hierarchy that incorporated the design structure and adjustments for the clusters. The results were stratified according to the size of the bank branch and were dichotomized (> 25; ≤ 25 employees). The prevalence of cases suggestive of RSI/WRMSD was lower among the men (PR = 0.62; 95%CI: 0.47-0.81). Workers aged 26 to 45 years (PR = 2.51; 95%CI 1.02;6.14) presented greater prevalence of this outcome. Individuals with postgraduate qualifications (PR = 0.45; 95%CI 0.22;0.90) and length of time in the job between 5.1 and 15 years (PR = 0.62; 95%CI 0.47;0.81) presented protection against RSI/WRMSD. On stratifying the analyses according to size, it was found that age, income and length of time in the job remained associated in branches with 25 employees or fewer, while in branches with more than 25 employees, sex and schooling level were associated with the outcome. The characteristics of importance in relation to bank employees who become ill due to rsi/wrmsd seem to be different today from those that were known historically. greater attention to organizing work and management strategies should be taken into consideration in drawing up illness prevention programs for banking work.

Design and development of the 2m resolution camera for ROCSAT-2

NASA Astrophysics Data System (ADS)

Uguen, Gilbert; Luquet, Philippe; Chassat, François

2017-11-01

EADS-Astrium has recently completed the development of a 2m-resolution camera, so-called RSI (Remote Sensing Instrument), for the small-satellite ROCSAT-2, which is the second component of the long-term space program of the Republic of China. The National Space Program Office of Taïwan selected EADS-Astrium as the Prime Contractor for the development of the spacecraft, including the bus and the main instrument RSI. The main challenges for the RSI development were: - to introduce innovative technologies in order to meet the high performance requirements while achieving the design simplicity necessary for the mission (low mass, low power) - to have a development approach and verification compatible with the very tight development schedule This paper describes the instrument design together with the development and verification logic that were implemented to successfully meet these objectives.

Switching between univalent task-sets in schizophrenia: ERP evidence of an anticipatory task-set reconfiguration deficit.

PubMed

Karayanidis, Frini; Nicholson, Rebecca; Schall, Ulrich; Meem, Lydia; Fulham, Ross; Michie, Patricia T

2006-10-01

The present study used behavioral and event-related potential (ERP) indices of task-switching to examine whether schizophrenia patients have a specific deficit in anticipatory task-set reconfiguration. Participants switched between univalent tasks in an alternating runs paradigms with blocked response-stimulus interval (RSI) manipulation (150, 300, 600, and 1200ms). Nineteen high functioning people with schizophrenia were compared to controls that were matched for age, gender, education and premorbid IQ estimate. Schizophrenia patients had overall increased RT, but no increase in corrected RT switch cost. In the schizophrenia group, ERPs showed reduced activation of the differential positivity in anticipation of switch trial at the optimal 600ms RSI and reduced activation of the frontal post-stimulus switch negativity at both 600 and 1200ms RSI compared to the control group. Despite no behavioral differences in task switching performance, anticipatory and stimulus-triggered ERP indices of task-switching suggest group differences in processing of switch and repeat trials, especially at longer RSI conditions that for control participants provide opportunity for anticipatory activation of task-set reconfiguration processes. These results are compatible with impaired implementation of endogenously driven processes in schizophrenia and greater reliance on external task cues, especially at long preparation intervals.

The effect of itopride combined with lansoprazole in patients with laryngopharyngeal reflux disease.

PubMed

Chun, Byung-Joon; Lee, Dong-Soo

2013-03-01

The objective of this study is to determine the efficacy of adding a prokinetic agent to proton pump inhibitors (PPI) for the treatment of laryngopharyngeal reflux (LPR) disease. A prospective, randomized open trial comparing lansoprazole plus itopride to lansoprazole single therapy was performed for 12 weeks. Sixty-four patients with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were enrolled and received either lansoprazole 30 mg once daily with itopride 50 mg three times daily or lansoprazole 30 mg once daily for 12 weeks. RSI and RFS were completed at baseline, after 6 weeks, and after 12 weeks. During the treatment period, RSI and RFS were significantly improved compared with the pretreatment scores in both study groups. Reductions of total RSI and globus symptom were significantly higher in the lansoprazole plus itopride group compared to the lansoprazole group. In the RFS, however, there were no significant differences between the two groups. In conclusion, itopride in addition to PPI did not show any superior RFS improvement compared to PPI single therapy, but was helpful in speeding up relief of reflux symptoms in LPR patients. Thus, itopride may be considered as the secondary additive agent in the PPI treatment of LPR patients.

Attitude Control Optimization for ROCSAT-2 Operation

NASA Astrophysics Data System (ADS)

Chern, Jeng-Shing; Wu, A.-M.

The second satellite of the Republic of China is named ROCSAT-2. It is a small satellite with total mass of 750 kg for remote sensing and scientific purposes. The Remote Sensing Instrument (RSI) has resolutions of 2 m for panchromatic and 8 m for multi-spectral bands, respectively. It is mainly designed for disaster monitoring and rescue, environment and pollution monitoring, forest and agriculture planning, city and country planning, etc. for Taiwan and its surrounding islands and oceans. In order to monitor Taiwan area constantly for a long time, the orbit is designed to be sun-synchronous with 14 revolutions per day. As to the scientific payload, it is an Imager of Sprite, the Upper Atmospheric Lightening (ISUAL). Since it is a small satellite, the RSI, ISUAL, and solar panel are all body-fixed. Consequently, the satellite has to maneuver as a whole body so that either RSI or ISUAL or solar panel can be pointing to the desired direction. When ROCSAT-2 rises from the horizon and catches the sunlight, it has to maneuver to face the sun for the battery to be charged. As soon as it flies to Taiwan area, several maneuvers must be made to cover the whole area for remote sensing mission. Since the swath of ROCSAT-2 is 24 km, it needs four stripes to form the mosaic of Taiwan area. Usually, four maneuvers are required to fulfill the mission in one flight path. The sequence is very important from the point of view of saving energy. However, in some cases, we may need to sacrifice energy in order to obtain good remote sensing data at a particularly specified ground region. After that mission, its solar panel has to face the sun again. Then when ROCSAT-2 sets the horizon, it has to maneuver to point the ISUAL in the specified direction for sprite imaging mission. It is the direction where scientists predict the sprite is most probable to exist. Further maneuver may be required for the down loading of onboard data. When ROCSAT-2 rises from the horizon again, it completes one revolution. The purpose of this paper is to present the attitude control design optimization such that the maximum solar energy is ingested while minimum maneuvering energy is dissipated. The strategy includes the maneuvering sequence design, the minimization of angular path, the sizing of three magnetic torquers, and the trade-off of the size, number and orientations arrangement of momentum wheels.

Airway Management in a Patient With Tracheal Disruption due to Penetrating Neck Trauma With Hollow Point Ammunition: A Case Report.

PubMed

Johnson, Angela M; Hill, James L; Zagorski, Dave J; McClain, Joseph M; Maronian, Nicole C

2017-11-27

Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.

Airway Management in a Patient With Tracheal Disruption due to Penetrating Neck Trauma With Hollow Point Ammunition: A Case Report.

PubMed

Johnson, Angela M; Hill, James L; Zagorski, Dave J; McClain, Joseph M; Maronian, Nicole C

2018-05-01

Rapid sequence induction and intubation was performed for a patient in respiratory distress after a gunshot wound to the neck. Resistance was noted distal to vocal cords. With a bronchoscope unavailable, the endotracheal tube was advanced with a corkscrew maneuver. Subcutaneous emphysema had developed. The endotracheal tube was advanced into the right mainstem with adequate ventilation. Imaging illustrated tracheoesophageal injury. The patient was emergently explored. An intraluminal bullet was removed, lateral wall tracheal defect was repaired, and a tracheostomy was placed. The intubating provider should secure the airway by the method they are most comfortable, have high suspicion of airway injury, and prepare to manage airway disruption.

Fabrication and Improvement of Lmsc's All-silica RSI

NASA Technical Reports Server (NTRS)

Beasley, R. M.; Izu, Y. D.; Nakano, H. N.; Ozolin, A. A.; Peachman, A.

1973-01-01

The LI-1500 and LI-900 all silica RSI materials have made the transition from laboratory to manufacturing operation. Improvements in both quality and reproducibility have been achieved. The LI-1500 material has displayed superior reliability in evaluations conducted at various facilities. The dependable performance of the material is attributed to the adherence to the stringent requirements of the numerous material, process, and product control evaluations and inspection points performed during manufacture.

MRI-Derived Cellularity Index as a Potential Noninvasive Imaging Biomarker of Prostate Cancer

DTIC Science & Technology

2016-12-01

whole mount pathology sections. Analysis of these UCLA data resulted in four published manuscripts (White et al, Cancer Research 2014; Rakow-Penner...Yamin et al., Clinical Cancer Research , 2016) RSI-MRI mean z-score grouped by pathologic Gleason grade. Mean RSI-MRI cellularity index represented as...Figure 2). A quantitative validation of this approach is now provided in this study. Specifically, in a group of patients with known PCa, ROC

[Construction and deconstruction of masculine identities among metalworkers with RSI/WRMD].

PubMed

Saldanha, Jorge Henrique Santos; Lima, Mônica Angelim Gomes de; Neves, Robson da Fonseca; Iriart, Jorge Alberto Bernstein

2018-05-10

This study aimed to reveal how metalworkers experience prolonged incapacity for work due to repetitive strain injury/work-related musculoskeletal disorder (RSI/WRMD) and the impact of chronic illness on the construction/deconstruction of masculinity. A qualitative study was performed, based on narrative interviews with male metalworkers in an automotive factory in the State of Bahia, Brazil. The results showed how the conflict in the experience of illness, the maintenance of male identity, and expectations of meeting the rules dictated by hegemonic masculinity are experienced and signified in daily life. Metalworkers' experience of illness with RSI/WRMD is expressed in their incapacity for work, deconstruction of self-esteem, loss of collective identity, and interruption of future prospects. In conclusion, hegemonic masculinity exposes men to more health risks, plays a mediating role in work-related illness, alters trajectories of care, and explains men's unwillingness to seek help.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux.

PubMed

Zalvan, Craig H; Hu, Shirley; Greenberg, Barbara; Geliebter, Jan

2017-10-01

Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions. To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions. This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI). Recorded change in the RSI after 6 weeks of treatment. Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68). Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Intubation after rapid sequence induction performed by non-medical personnel during space exploration missions: a simulation pilot study in a Mars analogue environment.

PubMed

Komorowski, Matthieu; Fleming, Sarah

2015-01-01

The question of the safety of anaesthetic procedures performed by non anaesthetists or even by non physicians has long been debated. We explore here this question in the hypothetical context of an exploration mission to Mars. During future interplanetary space missions, the risk of medical conditions requiring surgery and anaesthetic techniques will be significant. On Earth, anaesthesia is generally performed by well accustomed personnel. During exploration missions, onboard medical expertise might be lacking, or the crew doctor could become ill or injured. Telemedical assistance will not be available. In these conditions and as a last resort, personnel with limited medical training may have to perform lifesaving procedures, which could include anaesthesia and surgery. The objective of this pilot study was to test the ability for unassisted personnel with no medical training to perform oro-tracheal intubation after a rapid sequence induction on a simulated deconditioned astronaut in a Mars analogue environment. The experiment made use of a hybrid simulation model, in which the injured astronaut was represented by a torso manikin, whose vital signs and hemodynamic status were emulated using a patient simulator software. Only assisted by an interactive computer tool (PowerPoint(®) presentation), five participants with no previous medical training completed a simplified induction of general anaesthesia with intubation. No major complication occurred during the simulated trials, namely no cardiac arrest, no hypoxia, no cardiovascular collapse and no failure to intubate. The study design was able to reproduce many of the constraints of a space exploration mission. Unassisted personnel with minimal medical training and familiarization with the equipment may be able to perform advanced medical care in a safe and efficient manner. Further studies integrating this protocol into a complete anaesthetic and surgical scenario will provide valuable input in designing health support systems for space exploration missions.

Pepper CabZIP63 acts as a positive regulator during Ralstonia solanacearum or high temperature-high humidity challenge in a positive feedback loop with CaWRKY40.

PubMed

Shen, Lei; Liu, Zhiqin; Yang, Sheng; Yang, Tong; Liang, Jiaqi; Wen, Jiayu; Liu, Yanyan; Li, Jiazhi; Shi, Lanping; Tang, Qian; Shi, Wei; Hu, Jiong; Liu, Cailing; Zhang, Yangwen; Lin, Wei; Wang, Rongzhang; Yu, Huanxin; Mou, Shaoliang; Hussain, Ansar; Cheng, Wei; Cai, Hanyang; He, Li; Guan, Deyi; Wu, Yang; He, Shuilin

2016-04-01

CaWRKY40 is known to act as a positive regulator in the response of pepper (Capsicum annuum) to Ralstonia solanacearum inoculation (RSI) or high temperature-high humidity (HTHH), but the underlying mechanism remains elusive. Herein, we report that CabZIP63, a pepper bZIP family member, participates in this process by regulating the expression of CaWRKY40. CabZIP63 was found to localize in the nuclei, be up-regulated by RSI or HTHH, bind to promoters of both CabZIP63(pCabZIP63) and CaWRKY40(pCaWRKY40), and activate pCabZIP63- and pCaWRKY40-driven β-glucuronidase expression in a C- or G-box-dependent manner. Silencing of CabZIP63 by virus-induced gene silencing (VIGS) in pepper plants significantly attenuated their resistance to RSI and tolerance to HTHH, accompanied by down-regulation of immunity- or thermotolerance-associated CaPR1, CaNPR1, CaDEF1, and CaHSP24. Hypersensitive response-mediated cell death and expression of the tested immunity- and thermotolerance-associated marker genes were induced by transient overexpression (TOE) of CabZIP63, but decreased by that of CabZIP63-SRDX. Additionally, binding of CabZIP63 to pCaWRKY40 was up-regulated by RSI or HTHH, and the transcript level of CaWRKY40 and binding of CaWRKY40 to the promoters of CaPR1, CaNPR1, CaDEF1 and CaHSP24 were up-regulated by TOE of CabZIP63. On the other hand, CabZIP63 was also up-regulated transcriptionally by TOE of CaWRKY40. The data suggest collectively that CabZIP63 directly or indirectly regulates the expression of CaWRKY40 at both the transcriptional and post-transcriptional level, forming a positive feedback loop with CaWRKY40 during pepper's response to RSI or HTHH. Altogether, our data will help to elucidate the underlying mechanism of crosstalk between pepper's response to RSI and HTHH. © The Author 2016. Published by Oxford University Press on behalf of the Society for Experimental Biology.

Relative performance of three stream bed stability indices as indicators of stream health.

PubMed

Kusnierz, Paul C; Holbrook, Christopher M

2017-10-16

Bed stability is an important stream habitat attribute because it affects geomorphology and biotic communities. Natural resource managers desire indices of bed stability that can be used under a wide range of geomorphic conditions, are biologically meaningful, and are easily incorporated into sampling protocols. To eliminate potential bias due to presence of instream wood and increase precision of stability values, we modified a stream bed instability index (ISI) to include measurements of bankfull depth (d bf ) and median particle diameter (D 50 ) only in riffles and increased the pebble count to decrease variability (i.e., increase precision) in D 50 . The new riffle-based instability index (RISI) was compared to two established indices: ISI and the riffle stability index (RSI). RISI and ISI were strongly associated with each other but neither was closely associated with RSI. RISI and ISI were closely associated with both a diatom- and two macrovertebrate-based stream health indices, but RSI was only weakly associated with the macroinvertebrate indices. Unexpectedly, precision of D 50 did not differ between RISI and ISI. Results suggest that RISI is a viable alternative to both ISI and RSI for evaluating bed stability in multiple stream types. With few data requirements and a simple protocol, RISI may also better conform to riffle-based sampling methods used by some water quality practitioners.

Relative performance of three stream bed stability indices as indicators of stream health

USGS Publications Warehouse

Kusnierz, Paul C; Holbrook, Christopher

2017-01-01

Bed stability is an important stream habitat attribute because it affects geomorphology and biotic communities. Natural resource managers desire indices of bed stability that can be used under a wide range of geomorphic conditions, are biologically meaningful, and are easily incorporated into sampling protocols. To eliminate potential bias due to presence of instream wood and increase precision of stability values, we modified a stream bed instability index (ISI) to include measurements of bankfull depth (dbf) and median particle diameter (D50) only in riffles and increased the pebble count to decrease variability (i.e., increase precision) in D50.The new riffle-based instability index (RISI) was compared to two established indices: ISI and the riffle stability index (RSI). RISI and ISI were strongly associated with each other but neither was closely associated with RSI. RISI and ISI were closely associated with both a diatom- and two macrovertebrate-based stream health indices, but RSI was only weakly associated with the macroinvertebrate indices. Unexpectedly, precision of D50 did not differ between RISI and ISI. Results suggest that RISI is a viable alternative to both ISI and RSI for evaluating bed stability in multiple stream types. With few data requirements and a simple protocol, RISI may also better conform to riffle-based sampling methods used by some water quality practitioners.

A repeated short educational intervention improves asthma control and quality of life.

PubMed

Plaza, Vicente; Peiró, Meritxell; Torrejón, Montserrat; Fletcher, Monica; López-Viña, Antolín; Ignacio, José María; Quintano, José Antonio; Bardagí, Santiago; Gich, Ignasi

2015-11-01

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life. A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group. A significant improvement in the Asthma Control Test score was observed in all three groups (p<0.001), but improvements were higher in the intervention and gold standard groups than in the usual clinical practice group (p=0.042), which also showed fewer exacerbations (mean±sd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively). The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life. Copyright ©ERS 2015.

Restriction spectrum imaging reveals decreased neurite density in patients with temporal lobe epilepsy

PubMed Central

Loi, Richard Q.; Leyden, Kelly M.; Balachandra, Akshara; Uttarwar, Vedang; Hagler, Donald J.; Paul, Brianna M.; Dale, Anders M.; White, Nathan S.; McDonald, Carrie R.

2016-01-01

Objective Diffusion tensor imaging (DTI) has become a popular tool for delineating the location and extent of white matter injury in temporal lobe epilepsy (TLE). However, DTI yields nonspecific measures that are confounded by changes occurring within both the intracellular and extracellular environments. This study investigated whether an advanced diffusion method, restriction spectrum imaging (RSI) could provide a more robust measure of white matter injury in TLE relative to DTI due to RSI’s ability to separate intra-axonal diffusion (i.e., neurite density; ND) from diffusion associated with extra-axonal factors (e.g., inflammation; crossing fibers). Methods RSI and DTI scans were obtained on 21 patients with TLE and 11 age-matched controls. RSI-derived maps of ND, isotropic hindered (IH) and free (IF) water, and crossing fibers (CF) were compared to DTI-derived fractional anisotropy (FA) maps. Voxelwise and tract-based analyses were performed comparing patients with TLE to controls on each diffusion metric. Results Reductions in FA were seen primarily in frontotemporal white matter in TLE and were most pronounced proximal to the seizure focus. Reductions in ND corresponded to those seen in the FA maps; however, ND reductions were greater in magnitude, more lateralized to the epileptogenic hemisphere, and showed a broader pattern. Increases in IF/IH and effects from CFs also contributed to reduced FA in the ipsilateral parahippocampal cingulum and fornix, with decreases in IH extending into extratemporal regions. Reduced ND of the uncinate fasciculus was associated with longer disease duration, whereas FA was not associated with any clinical variables. Significance RSI may provide a more specific measure of white matter pathology in TLE, distinguishing regions primarily affected by axonal/myelin loss from those where CFs and increases in extracellular water also play a role. By providing a more specific measure of axonal/myelin loss, RSI-derived ND may better reflect overall white matter burden in epilepsy. PMID:27735051

Differences Between Colon Cancer Primaries and Metastases Using a Molecular Assay for Tumor Radiation Sensitivity Suggest Implications for Potential Oligometastatic SBRT Patient Selection

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ahmed, Kamran A.; Fulp, William J.; Berglund, Anders E.

2015-07-15

Purpose: We previously developed a multigene expression model of tumor radiation sensitivity index (RSI) with clinical validation in multiple independent cohorts (breast, rectal, esophageal, and head and neck patients). The purpose of this study was to assess differences between RSI scores in primary colon cancer and metastases. Methods and Materials: Patients were identified from our institutional review board–approved prospective observational protocol. A total of 704 metastatic and 1362 primary lesions were obtained from a de-identified metadata pool. RSI was calculated using the previously published rank-based algorithm. An independent cohort of 29 lung or liver colon metastases treated with 60 Gy in 5more » fractions stereotactic body radiation therapy (SBRT) was used for validation. Results: The most common sites of metastases included liver (n=374; 53%), lung (n=116; 17%), and lymph nodes (n=40; 6%). Sixty percent of metastatic tumors, compared with 54% of primaries, were in the RSI radiation-resistant peak, suggesting metastatic tumors may be slightly more radiation resistant than primaries (P=.01). In contrast, when we analyzed metastases based on anatomical site, we uncovered large differences in RSI. The median RSIs for metastases in descending order of radiation resistance were ovary (0.48), abdomen (0.47), liver (0.43), brain (0.42), lung (0.32), and lymph nodes (0.31) (P<.0001). These findings were confirmed when the analysis was restricted to lesions from the same patient (n=139). In our independent cohort of treated lung and liver metastases, lung metastases had an improved local control rate compared to that in patients with liver metastases (2-year local control rate of 100% vs 73.0%, respectively; P=.026). Conclusions: Assessment of radiation sensitivity between primary and metastatic tissues of colon cancer histology revealed significant differences based on anatomical location of metastases. These initial results warrant validation in a larger clinical cohort.« less

[Ryan index for detection of laryngopharyngeal reflux diseases].

PubMed

Wu, W; Wang, G; Wang, L; Liu, H D; Wang, Q; Xu, X H; Ding, R Y; Xu, B X; Han, H L; Zhou, Y; Gong, J; Wang, H N; Li, B W; Sun, Z Z

2017-12-07

Objective: To explore the utility of pharyngeal pH monitoring which positive standard is Ryan index in diagnosis of laryngopharyngeal reflux disease. Methods: In a retrospective study, clinical data of 590 patients who had symptoms laryngopharyngeal reflux disease from February 2016 to March 2017 were analyzed. All patients were received electronic laryngoscopy, assessment of reflux symptom index(RSI) and reflux finding score(RFS), and pharyngeal pH monitoring. SPSS 19.0 software was used to analyze the date. Results: There were 94 patients whose Ryan index were positive(15.93%). Among the 94 patients, 70 were positive during upright, 12 during supine and 12 during both upright and supine. There were 40 patients(6.78%)with pH decline events related to symptoms, while those Ryan index were normal. There were 536(90.85%), 417(70.68%), 233(39.49%) and 117(19.83%) patients with pH<6.5, pH<6.0, pH<5.5 and pH<5.0 events respectively. The positive rate of RSI, RFS, RSI and RFS, RSI or RFS were 44.24%, 16.78%, 7.12%, 53.90% respectively. The RFS score in Ryan index positive group was higher than that in Ryan index negative group[(8.2±2.4) vs (4.0±2.9), u =5.424, P <0.05], while the RSI score in Ryan index positive group was not statistically different from that in Ryan index negative group[(11.3±6.2) vs (12.7±5.8), t =1.247, P =0.167]. Conclusions: Pharyngeal pH monitoring is an objective and non-invasive method which can reflect laryngopharyngeal reflux directly. However, with the Ryan index as a criterion for the diagnosis of laryngopharyngeal reflux disease, partial patients may be missed. Further studies are needed to obtain more accurate and objective laryngopharyngeal pH statistical index for diagnosis of laryngopharyngeal reflux disease.

Management of critical illness with non-invasive ventilation by an Australian HEMS

PubMed Central

Coggins, Andrew R; Cummins, Erin N; Burns, Brian

2016-01-01

Background Non-invasive ventilation (NIV) therapy is widely used for the management of acute respiratory failure. The objective of this study was to investigate the current use of NIV during interhospital retrievals in an Australian physician-led aeromedical service. Methods We reviewed patients receiving NIV during interhospital retrieval at the Greater Sydney Area Helicopter Medical Services (GSA-HEMS) over a 14-month period. The main objectives were to describe the number of retrievals using NIV, the need for intubation in NIV patients and the effect of the therapy on mission duration. Results Over the study period, 3018 missions were reported; 106 cases (3.51%) involved administration of NIV therapy during the retrieval. The most common indication for NIV was pneumonia (34.0%). 86/106 patients received a successful trial of NIV therapy prior to interhospital transfer. 58 patients were transferred on NIV, while 28 patients had NIV removed during transport. None of these 86 patients required intubation or died, although 17/86 ultimately required intubation within 24 hours at the receiving centre. 20/106 patients required intubation at the referring hospital after a failed trial of NIV therapy. NIV was successfully used in all available transport platforms including rotary wing. Patients receiving NIV were found to have prolonged mission durations compared with other GSA-HEMS patients (222.5 vs 193 min). This increase in mission duration was largely attributable to NIV failure, resulting in a need for Rapid Sequence Intubation at the referring hospital. Conclusions With careful patient selection, the use of interhospital NIV is feasible and appears to be safe in a retrieval system with care provided by a critical care physician. PMID:27371641

Aerodynamic heat transfer to RSI tile surfaces and gap intersections. [Reusable Surface Insulation

NASA Technical Reports Server (NTRS)

Dunavant, J. C.; Throckmorton, D. A.

1974-01-01

Review of the results of aerothermal heating tests of a simulated reusable surface insulation (RSI) tile array, performed on the sidewall of a Mach-10 hypersonic tunnel. In particular, the heating characteristics of the tile array, such as they result from heating inside the tile-expansion-space providing gaps between individual tiles, are investigated. The results include the finding that heating on the upstream face of a tile is strongly affected by the interacting longitudinal gap flow.

Performance of LI-1542 reusable surface insulation system in a hypersonic stream

NASA Technical Reports Server (NTRS)

Hunt, L. R.; Shideler, J. L.; Weinstein, I.

1976-01-01

The thermal and structural performance LI-1542 reusable surface insulation (RSI) tiles was investigated. The test panel was designed to represent part of the surface structure on a space shuttle orbiter fuselage along a 1250 K isotherm. Aerothermal tests were conducted at a free-stream Mach number of 6.6, a total temperature of 1820 K, Reynolds numbers of 2 millon and 5 million per meter, and dynamic pressures of 26 and 65 kPa. The RSI tiles demonstrated good thermal protection and structural integrity. High temperatures were caused by misalinement in tile height, offset the tile longitudinal alinement, and leakage around thermal seals when differential pressure existed across the panel. The damage tolerance of LI-1542 RSI appeared high. The tile coating crazed early in the test program, but this did not effect the tile integrity. Erosion of the tile edges occurred at forward-facing steps and at the ends of longitudinal gaps because of particle impacts and flow shear.

[The construction of the "sick-subject" in RSI].

PubMed

Verthein, M A; Minayo-Gomez, C

2000-01-01

There is a running debate over the relationship between work and disease, namely the disease known as repetitive strain injury (RSI), or else work-related osteomuscular disturbances (in Portuguese DORT), as it was renamed in 1997 by the Instituto Nacional de Seguridade Social (INSS) in accordance with the Disability Assessment Norms. Standing out among the signs brought about by this new infirmity process is its restricted focus on the subjective aspects in the analysis of the disease. Underlying the INSS stance is the view of a sickness-prone subject and the notion of health as capacity for work. This paper analyzes the historical context which characterizes these health/work and body/disease notions. It also discusses the construction of the 'sick-subject' and the way in which such a subjectivizing process entraps the subject itself. Finally, we show the way in which the INSS in Rio de Janeiro has managed to stop this disease of its work-related characteristics, fighting and reducing the occurrences of RSI as well as the costs with work compensation claims.

Knowing what to respond in the future does not cancel the influence of past events.

PubMed

Tubau, Elisabet; López-Moliner, Joan

2009-05-29

Everyday tasks seldom involve isolate actions but sequences of them. We can see whether previous actions influence the current one by exploring the response time to controlled sequences of stimuli. Specifically, depending on the response-stimulus temporal interval (RSI), different mechanisms have been proposed to explain sequential effects in two-choice serial response tasks. Whereas an automatic facilitation mechanism is thought to produce a benefit for response repetitions at short RSIs, subjective expectancies are considered to replace the automatic facilitation at longer RSIs, producing a cost-benefit pattern: repetitions are faster after other repetitions but they are slower after alternations. However, there is not direct evidence showing the impact of subjective expectancies on sequential effects. By using a fixed sequence, the results of the reported experiment showed that the repetition effect was enhanced in participants who acquired complete knowledge of the order. Nevertheless, a similar cost-benefit pattern was observed in all participants and in all learning blocks. Therefore, results of the experiment suggest that sequential effects, including the cost-benefit pattern, are the consequence of automatic mechanisms which operate independently of (and simultaneously with) explicit knowledge of the sequence or other subjective expectancies.

Cost-effectiveness analysis of flexible optical scopes for tracheal intubation: a descriptive comparative study of reusable and single-use scopes.

PubMed

Gupta, Deepak; Wang, Hong

2011-12-01

To calculate the costs per intubation of reusable fiberoptic scopes versus single-use intubation scopes. Open-label retrospective study. University-affiliated hospital. The one-year intubation records of intubations performed with reusable intubation scopes, the one-year maintenance costs of these scopes, and their three-year repair cost records were analyzed. A total of 166 intubations were performed with reusable fiberoptic scopes in 2009. Calculations to assess the costs per intubation based on the documented records at our institution were made. The total cost of an intubation, the repair-to-intubation ratio, and the repair cost per intubation were determined. The total cost of an intubation at our institution in 2009, using reusable scopes, was $119.75 [US dollars (USD)], which included $20.15 (purchasing), $53.48 (repair), $33.16 (maintenance), and $12.96 (labor). The repair-to-intubation ratio was 1:55. Repair costs were $53.48 per intubation and $2,959.44 per instance of repair. The Ambu aScope, a single-use intubation scope, is a new addition to video laryngoscopy. The price should range within 10% of our intubation cost ($120.00 to $132.00 per single-use intubation scope). Copyright © 2011 Elsevier Inc. All rights reserved.

A Unified Theoretical Framework for Cognitive Sequencing.

PubMed

Savalia, Tejas; Shukla, Anuj; Bapi, Raju S

2016-01-01

The capacity to sequence information is central to human performance. Sequencing ability forms the foundation stone for higher order cognition related to language and goal-directed planning. Information related to the order of items, their timing, chunking and hierarchical organization are important aspects in sequencing. Past research on sequencing has emphasized two distinct and independent dichotomies: implicit vs. explicit and goal-directed vs. habits. We propose a theoretical framework unifying these two streams. Our proposal relies on brain's ability to implicitly extract statistical regularities from the stream of stimuli and with attentional engagement organizing sequences explicitly and hierarchically. Similarly, sequences that need to be assembled purposively to accomplish a goal require engagement of attentional processes. With repetition, these goal-directed plans become habits with concomitant disengagement of attention. Thus, attention and awareness play a crucial role in the implicit-to-explicit transition as well as in how goal-directed plans become automatic habits. Cortico-subcortical loops basal ganglia-frontal cortex and hippocampus-frontal cortex loops mediate the transition process. We show how the computational principles of model-free and model-based learning paradigms, along with a pivotal role for attention and awareness, offer a unifying framework for these two dichotomies. Based on this framework, we make testable predictions related to the potential influence of response-to-stimulus interval (RSI) on developing awareness in implicit learning tasks.

A Unified Theoretical Framework for Cognitive Sequencing

PubMed Central

Savalia, Tejas; Shukla, Anuj; Bapi, Raju S.

2016-01-01

The capacity to sequence information is central to human performance. Sequencing ability forms the foundation stone for higher order cognition related to language and goal-directed planning. Information related to the order of items, their timing, chunking and hierarchical organization are important aspects in sequencing. Past research on sequencing has emphasized two distinct and independent dichotomies: implicit vs. explicit and goal-directed vs. habits. We propose a theoretical framework unifying these two streams. Our proposal relies on brain's ability to implicitly extract statistical regularities from the stream of stimuli and with attentional engagement organizing sequences explicitly and hierarchically. Similarly, sequences that need to be assembled purposively to accomplish a goal require engagement of attentional processes. With repetition, these goal-directed plans become habits with concomitant disengagement of attention. Thus, attention and awareness play a crucial role in the implicit-to-explicit transition as well as in how goal-directed plans become automatic habits. Cortico-subcortical loops basal ganglia-frontal cortex and hippocampus-frontal cortex loops mediate the transition process. We show how the computational principles of model-free and model-based learning paradigms, along with a pivotal role for attention and awareness, offer a unifying framework for these two dichotomies. Based on this framework, we make testable predictions related to the potential influence of response-to-stimulus interval (RSI) on developing awareness in implicit learning tasks. PMID:27917146

Difficult airway simulator intubation success rates using Commission on Accreditation of Medical Transport systems training standards.

PubMed

Thomas, Frank; Rhoades, Carol; Carpenter, Judi; Holleran, Renee; Handrahan, Diana

2011-01-01

This study was undertaken to evaluate difficult airway simulator intubation success rates using Commission on Accreditation of Medical Transport Systems (CAMTS) initial and maintenance intubation training standards on transport-RN novice intubators over a 1-year period. Twelve transport nurses were blinded to and randomly assigned five or six of 64 different difficult airway simulator scenarios. Intubation success rates were measured 1 month before training, 1 month after training, and 1 year later, following CAMTS initial and maintenance intubation standards. Outcome measurements included first attempt intubation rate, overall intubation success rate, number of attempts to intubation, time per attempt, time to intubation, and time between attempts. During the study, participants received no additional training or opportunities to intubate. First-attempt intubation rates significantly improved (P 5 .022) from 19% 1 month before training to 36% 1 month after training, but did not significantly change (P > .999) 1 year later following CAMTS maintenance standards (34%). Mean cumulative success rates did not significantly improve after four attempts or after 3.5 minutes. The overall mean time per attempt and time between attempts declined with subsequent intubation attempts. Using initial and maintenance CAMTS standards, simulator difficult airway intubation success rates are low in novice intubators. Our results suggest that one intubation/quarter may be enough to maintain difficult airway intubation success rates. Training significantly improves intubation rates. Little advantage occurs in intubation rates after four attempts or 3.5 minutes. Copyright © 2011 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Reference Book on NATO Rationalization, Standardization and Interoperability (RSI). Volume 2. Department of Defense Official Directives and Statements of Secretary of Defense, Under Secretary of Defense (R&E), Concerning RSI.

DTIC Science & Technology

1979-11-01

operated as an integrated whole in meeting a mission need . h. Major system means that combination of elements that will function together to produce...developed and in production, it is by no means sure that it will fill a military need of another country. We intend to harmonize requirements... means to review national armaments plans and identify opportunities for armaments cooperation. It is expected that NAPR will eventually fold into PAPS

Changes of individual perception in psychosocial stressors related to German reunification in 1989/1990 and cardiovascular risk factors and cardiovascular diseases in a population-based study in East Germany

PubMed Central

Kluttig, Alexander; Werdan, Karl; Nuding, Sebastian; Greiser, Karin Halina; Kuss, Oliver; Markus, Marcello Ricardo Paulista; Schmidt, Carsten Oliver; Völzke, Henry; Krabbe, Christine; Haerting, Johannes

2016-01-01

Objectives Aim was to examine the relationship between individually perceived changes in psychosocial stressors associated with German reunification and cardiovascular effects. We hypothesised that higher levels of psychosocial stress related to German reunification were associated with an increase in cardiovascular risk factors and cardiovascular diseases (CVDs). Design Cross-sectional data from 2 cohort studies in East Germany were used: Cardiovascular Disease, Living and Ageing in Halle Study (CARLA), and Study of Health in Pomerania (SHIP). Setting 2 populations in East Germany. Participants CARLA study: 1779 participants, aged 45–83 years at baseline (812 women), SHIP study: 4308 participants, aged 20–79 years at baseline (2193 women). Primary and secondary outcome measures Psychosocial stressors related to reunification were operationalised by the Reunification Stress Index (RSI; scale from 0 to 10). This index was composed of questions that were related to individually perceived changes in psychosocial stressors (occupational, financial and personal) after reunification. To examine the associations between the RSI and each stressor separately with cardiovascular risk factors and CVD, regression models were used. Results RSI was associated with CVD in women (RR=1.15, 95% CI 1.00 to 1.33). Cardiovascular risk factors were associated with RSI for both men and women, with strongest associations between RSI and diabetes in women (RR=1.10, 95% CI 1.01 to 1.20) and depressive disorders in men (RR=1.15, 95% CI 1.07 to 2.77). The change in occupational situation related to reunification was the major contributing psychosocial stressor. We observed a strong association with CVD in women who experienced occupational deterioration after reunification (RR=4.04, 95% CI 1.21 to 13.43). Conclusions Individually perceived deterioration of psychosocial stressors (occupational, financial and personal) related to German reunification was associated with cardiovascular risk factors and CVD. The associations were stronger for women than for men. An explanation for these findings could be that women were more often affected by unemployment after reunification. Morbidity and mortality follow-up of both cohorts could enhance the results. PMID:26729378

The Reactive Species Interactome: Evolutionary Emergence, Biological Significance, and Opportunities for Redox Metabolomics and Personalized Medicine.

PubMed

Cortese-Krott, Miriam M; Koning, Anne; Kuhnle, Gunter G C; Nagy, Peter; Bianco, Christopher L; Pasch, Andreas; Wink, David A; Fukuto, Jon M; Jackson, Alan A; van Goor, Harry; Olson, Kenneth R; Feelisch, Martin

2017-10-01

Oxidative stress is thought to account for aberrant redox homeostasis and contribute to aging and disease. However, more often than not, administration of antioxidants is ineffective, suggesting that our current understanding of the underlying regulatory processes is incomplete. Recent Advances: Similar to reactive oxygen species and reactive nitrogen species, reactive sulfur species are now emerging as important signaling molecules, targeting regulatory cysteine redox switches in proteins, affecting gene regulation, ion transport, intermediary metabolism, and mitochondrial function. To rationalize the complexity of chemical interactions of reactive species with themselves and their targets and help define their role in systemic metabolic control, we here introduce a novel integrative concept defined as the reactive species interactome (RSI). The RSI is a primeval multilevel redox regulatory system whose architecture, together with the physicochemical characteristics of its constituents, allows efficient sensing and rapid adaptation to environmental changes and various other stressors to enhance fitness and resilience at the local and whole-organism level. To better characterize the RSI-related processes that determine fluxes through specific pathways and enable integration, it is necessary to disentangle the chemical biology and activity of reactive species (including precursors and reaction products), their targets, communication systems, and effects on cellular, organ, and whole-organism bioenergetics using system-level/network analyses. Understanding the mechanisms through which the RSI operates will enable a better appreciation of the possibilities to modulate the entire biological system; moreover, unveiling molecular signatures that characterize specific environmental challenges or other forms of stress will provide new prevention/intervention opportunities for personalized medicine. Antioxid. Redox Signal. 00, 000-000.

The validity and reliability of the my jump 2 app for measuring the reactive strength index and drop jump performance.

PubMed

Haynes, Tom; Bishop, Chris; Antrobus, Mark; Brazier, Jon

2018-03-27

This is the first study to independently assess the concurrent validity and reliability of the My Jump 2 app for measuring drop jump performance. It is also the first to evaluate the app's ability to measure the reactive strength index (RSI). Fourteen male sport science students (age: 29.5 ± 9.9 years) performed three drop jumps from 20 cm and 40 cm (totalling 84 jumps), assessed via a force platform and the My Jump 2 app. Reported metrics included reactive strength index, jump height, ground contact time, and mean power. Measurements from both devices were compared using the intraclass correlation coefficient (ICC), Pearson product moment correlation coefficient (r), Cronbach's alpha (α), coefficient of variation (CV) and BlandAltman plots. Near perfect agreement was seen between devices at 20 cm for RSI (ICC = 0.95) and contact time (ICC = 0.99) and at 40 cm for RSI (ICC = 0.98), jump height (ICC = 0.96) and contact time (ICC = 0.92); with very strong agreement seen at 20 cm for jump height (ICC = 0.80). In comparison with the force plate the app showed good validity for RSI (20 cm: r = 0.94; 40 cm; r = 0.97), jump height (20 cm: r = 0.80; 40 cm; r = 0.96) and contact time (20 cm = 0.96; 40 cm; r = 0.98). The results of the present study show that the My Jump 2 app is a valid and reliable tool for assessing drop jump performance.

Diagnosis of psychosocial risk factors in prevention of low back pain in athletes (MiSpEx).

PubMed

Wippert, Pia-Maria; Puschmann, Anne-Katrin; Arampatzis, Adamantios; Schiltenwolf, Marcus; Mayer, Frank

2017-01-01

Low back pain (LBP) is a common pain syndrome in athletes, responsible for 28% of missed training days/year. Psychosocial factors contribute to chronic pain development. This study aims to investigate the transferability of psychosocial screening tools developed in the general population to athletes and to define athlete-specific thresholds. Data from a prospective multicentre study on LBP were collected at baseline and 1-year follow-up (n=52 athletes, n=289 recreational athletes and n=246 non-athletes). Pain was assessed using the Chronic Pain Grade questionnaire. The psychosocial Risk Stratification Index (RSI) was used to obtain prognostic information regarding the risk of chronic LBP (CLBP). Individual psychosocial risk profile was gained with the Risk Prevention Index - Social (RPI-S). Differences between groups were calculated using general linear models and planned contrasts. Discrimination thresholds for athletes were defined with receiver operating characteristics (ROC) curves. Athletes and recreational athletes showed significantly lower psychosocial risk profiles and prognostic risk for CLBP than non-athletes. ROC curves suggested discrimination thresholds for athletes were different compared with non-athletes. Both screenings demonstrated very good sensitivity (RSI=100%; RPI-S: 75%-100%) and specificity (RSI: 76%-93%; RPI-S: 71%-93%). RSI revealed two risk classes for pain intensity (area under the curve (AUC) 0.92(95% CI 0.85 to 1.0)) and pain disability (AUC 0.88(95% CI 0.71 to 1.0)). Both screening tools can be used for athletes. Athlete-specific thresholds will improve physicians' decision making and allow stratified treatment and prevention.

High temperature glass thermal control structure and coating. [for application to spacecraft reusable heat shielding

NASA Technical Reports Server (NTRS)

Stewart, D. A.; Goldstein, H. E.; Leiser, D. B. (Inventor)

1983-01-01

A high temperature stable and solar radiation stable thermal control coating is described which is useful either as such, applied directly to a member to be protected, or applied as a coating on a re-usable surface insulation (RSI). It has a base coat layer and an overlay glass layer. The base coat layer has a high emittance, and the overlay layer is formed from discrete, but sintered together glass particles to give the overlay layer a high scattering coefficient. The resulting two-layer space and thermal control coating has an absorptivity-to-emissivity ratio of less than or equal to 0.4 at room temperature, with an emittance of 0.8 at 1200 F. It is capable of exposure to either solar radiation or temperatures as high as 2000 F without significant degradation. When used as a coating on a silica substrate to give an RSI structure, the coatings of this invention show significantly less reduction in emittance after long term convective heating and less residual strain than prior art coatings for RSI structures.

Feasibility and process scale-up low cost alumina fibers for advanced Re-usable Surface Insulation (RSI)

NASA Technical Reports Server (NTRS)

Pearson, A.

1975-01-01

The objective of this program was to establish feasibility of a process to produce low cost aluminum oxide fibers having sufficient strength, flexibility, and thermal stability for multiple re-use at temperatures to 1480 C in advanced RSI type heat shields for reentry vehicles. Using bench-scale processing apparatus, the Alcoa 'Saphiber' process was successfully modified to produce nominally 8 microns diameter polycrystalline alpha-alumina fiber. Thermal stability was demonstrated in vacuum reheating tests to 1371 C and in atmospheric reheating to 1483 C. Individual fiber properties of strength, modulus, and flexibility were not determined because of friability and short length of the fiber. Rigidized tile produced from fiber of nominally 8, 20 and 40 micron diameter had thermal conductivities significantly higher than those of RSI SiO2 or mullite at relatively low temperature but became comparable above about 1000 C. Tile densities were high due to short fiber length, especially in the coarser diameter fiber. No significant effect of fiber diameter on thermal properties could be determined form the data. Mechanical properties of tiles deteriorated as fiber diameter increased.

Does CPAP Affect Patient-Reported Voice Outcomes?

PubMed

Hartke, Vance; Gillespie, Amanda; Smith, Libby J; Soose, Ryan J

2018-04-01

Upper aerodigestive tract symptoms are common in patients with obstructive sleep apnea (OSA). It remains unclear whether continuous positive airway pressure (CPAP) improves or worsens these otolaryngology symptoms. As therapy-related side effects limit CPAP adherence, this study aimed to determine if CPAP negatively affects voice, sinonasal, and reflux symptoms of the upper airway. Case series with planned data collection was performed at an academic otolaryngology sleep center. Newly diagnosed patients with OSA were evaluated before and 6 months after initiating CPAP therapy. Data collected included CPAP data download, Reflux Symptom Index (RSI), Epworth Sleepiness Scale (ESS), Voice Handicap Index 10 (VHI-10), Sino-Nasal Questionnaire (SNQ), and oral dryness visual analog scale (VAS). For the 11 CPAP-adherent participants, the RSI significantly improved with CPAP (mean RSI, 22.0-9.5; P = .002); however, the VAS, VHI-10, and SNQ did not change after 6 months of CPAP therapy. In a small sample size, patient-reported voice outcomes (VHI-10) and other upper aerodigestive tract symptoms did not worsen with CPAP; rather, CPAP therapy was associated with a reduction in reflux symptoms.

Importance of Muscle Power Variables in Repeated and Single Sprint Performance in Soccer Players

PubMed Central

López-Segovia, Manuel; Dellal, Alexandre; Chamari, Karim; González-Badillo, Juan José

2014-01-01

This study examined the relationship between lower body power and repeated as well as single sprint performance in soccer players. The performance of nineteen male soccer players was examined. The first testing session included the countermovement jump (CMJL) and the progressive full squat (FSL), both with external loads. Power in the CMJL and FSL was measured with each load that was lifted. The second session included a protocol of 40-m repeated sprints with a long recovery period (2 min). The number of sprints executed until there was a 3% decrease in performance for the best 40-m sprint time was recorded as a repeated sprint index (RSI). The RSI was moderately associated with power output relative to body mass in the CMJL and FSL (r = 0.53/0.54, p ≤ 0.05). The most and least powerful players (determined by FSL) showed significant differences in the RSI (9.1 ± 4.2 vs. 6.5 ± 1.6) and 10 m sprint time (p ± 0.01). Repeated and single sprints are associated with relatively lower body power in soccer players. PMID:25031688

Fiberoptic intubation in 327 neurosurgical patients with lesions of the cervical spine.

PubMed

Fuchs, G; Schwarz, G; Baumgartner, A; Kaltenböck, F; Voit-Augustin, H; Planinz, W

1999-01-01

In patients with lesions of the cervical spine, direct laryngoscopy for endotracheal intubation entails the risk of injuring the spinal cord. In an attempt to avoid this complication, the authors used flexible fiberoptic nasal intubation in a series of 327 patients with cervical lesions undergoing elective neurosurgical procedures. The nasal route was preferred for laryngeal intubation because it is easier than the oral route and a restraining collar or halo device does not impair the intubating maneuver. Bronchoscopic intubation was possible in all patients. In 12 patients (3.6%), anatomic abnormalities prevented transnasal insertion of the endotracheal tube, and transoral fiberoptic intubation was necessary. Endotracheal intubation was graded as slightly difficult in 85 patients (26%). The minimal peripheral oxygen saturation during intubation exceeded 90% in 289 patients (88%). In the other 38 patients, the mean O2 saturation was 84.2+/-4.3% (range, 72-89%). Intubation was well tolerated by all patients and none had recall of the procedure. Cervical stabilizers did not have to be removed for intubation in any patient. None of the patients had postoperative neurologic deficits attributable to the intubation procedure. The authors consider fiberoptic transnasal intubation to be a useful alternative to direct laryngoscopic tracheal intubation in patients undergoing elective surgical procedures on the cervical spine to avoid potential injury to the cervical spinal cord.

Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants

PubMed Central

Hatch, L. Dupree; Grubb, Peter H.; Lea, Amanda S.; Walsh, William F.; Markham, Melinda H.; Whitney, Gina M.; Slaughter, James C.; Stark, Ann R.; Ely, E. Wesley

2015-01-01

Objective To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events. Study design We conducted a prospective, observational study in a 100-bed, academic, level IV Neonatal Intensive Care Unit (NICU) from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as non-severe or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent or emergent). We used logistic regression models to estimate the association of these variables with adverse events. Results During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with non-severe and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (odds ratio [OR] 2.1, 95% confidence intervals [CI], 1.6–2.6) and emergent intubations (OR 4.7, 95% CI, 1.7– 13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%). Conclusion Adverse events are common in the NICU, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety. PMID:26541424

Incidence and predictors of difficult nasotracheal intubation with airway scope.

PubMed

Ono, Koyu; Goto, Tomoko; Nakai, Daishi; Ueki, Shuhei; Takenaka, Seiichiro; Moriya, Tomomi

2014-10-01

The airway scope (AWS) improves views of the larynx during orotracheal intubation. However, the role of the AWS in routine nasotracheal intubation has not been studied adequately. One hundred and three patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. The study was approved by our Institution Review Board, and written informed consent was obtained from all patients. We evaluated the success rate of AWS intubation and the incidence of difficult nasotracheal intubation using a modified intubation difficulty scale (IDS) to examine preoperative characteristics and intubation profiles. Categories were difficult intubation (IDS ≥5), mildly difficult (IDS = 1-4), and intubation without difficulty (IDS = 0). We also assessed the incidence of the use of Magill forceps or cuff inflation (the cuff of endotracheal tube is inflated with 10-15 ml air) to guide the endotracheal tube into the glottis. AWS nasotracheal intubation was 100% successful. The cuff inflation technique was used in 37 patients. Neither Magill forceps nor other devices were needed for any patient during AWS use. The incidence of difficult nasotracheal intubation was 10% (n = 10). Of the patients, 61% (n = 63) had mildly difficult intubation and 29% (n = 30) had no difficulty. Patients with difficult intubation were more likely to be male and to have a larger tongue and a higher Cormack grade than in the other two groups. Complications, involving minor soft tissue injury, were observed in only 1 patient (1%). The AWS achieves a high success rate for nasotracheal intubation with cuff inflation in patients undergoing dental and maxillofacial surgery.

A pilot study of the effect of pressure-driven lidocaine spray on airway topical anesthesia for conscious sedation intubation.

PubMed

Jiang, Hai; Miao, Hai-Sheng; Jin, San-Qing; Chen, Li-Hong; Tian, Jing-Ling

2011-12-01

Difficult airway remains not only a challenge to the anesthesiologists, but also a life-threatening event to the patients. Awake intubation is the principal choice to deal with difficult airway, and a key point for awake intubation is airway topical anesthesia. Yet, so far there is no ideal topical anesthesia approach for awake intubation. This study aimed at evaluating the effect of pressure-driven (by 10 L/min oxygen flow) lidocaine spray on airway topical anesthesia in order to find a powerful and convenient method for airway topical anesthesia for conscious sedation intubation. Thirty adult patients referred for elective surgery under general anesthesia, aged 18 - C60 years and Mallampati class I or II, were recruited for the study. Before topical anesthesia, the observer's assessment of alert and sedation (OAA/S) scale was controlled between 3 and 4 by intravenous midazolam (0.03 mg/kg), propofol (2 mg×kg(-1)×h(-1)) and remifentanil (0.05 µg×kg(-1)×min(-1)). Ten minutes after sedation, topical anesthesia was performed with the pressure-driven lidocaine spray; the driving pressure was achieved by an oxygen flow of 10 L/min. After topical anesthesia, tracheal intubation was performed and the intubation condition was assessed with modified the Erhan's intubation condition score by an experienced anesthesiologist, and a score of less than 10 was considered to be satisfactory. Attempts to intubate the patient were recorded, and the complications such as local anesthetic toxicity, mucosa injury, and respiration depression were also recorded. The mean arterial blood pressure (MAP), heart rate (HR) and pulse oxygen saturation (SpO2) were recorded at different time points before and after intubation. Patients were asked 24 hours after the operation whether they could recall the events during intubation. All patients were intubated at the first attempt, the average intubation condition score was 7.0 ± 1.1, from 6 to 10, satisfied intubation condition. MAP and HR increased significantly but mildly immediately after the tracheal intubation (P < 0.05), and decreased to the pre-intubation level soon after intubation. There were no related complications and patients had no recall of the intubation procedures. Topical anesthesia with pressure driven 2% lidocaine spray, where pressure is achieved by 10 L/min oxygen flow, can offer satisfactory intubation conditions for conscious sedation intubation.

Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes.

PubMed

Prekker, Matthew E; Delgado, Fernanda; Shin, Jenny; Kwok, Heemun; Johnson, Nicholas J; Carlbom, David; Grabinsky, Andreas; Brogan, Thomas V; King, Mary A; Rea, Thomas D

2016-01-01

Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The Intubating Laryngeal Mask Airway Facilitates Tracheal Intubation in the Lateral Position

PubMed Central

Komatsu, Ryu; Nagata, Osamu; Sessler, Daniel I.; Ozaki, Makoto

2005-01-01

Although the difficulty of tracheal intubation in the lateral position has not been systematically evaluated, airway loss during surgery in a laterally positioned patient may have hazardous consequences. We explored whether the intubating laryngeal mask airway (ILMA) facilitates tracheal intubation in patients with normal airway anatomy, i.e., Mallampati grade ≤ 3 and thyromental distance ≥ 5 cm, positioned in the lateral position. And we evaluated whether this technique can be used as a rescue when the airway is lost mid-case in laterally positioned patients with respect to success rate and intubation time. Anesthesia was induced with propofol, fentanyl, and vecuronium in 50 patients undergoing spine surgery for lumbar disk herniation (Lateral) and 50 undergoing other surgical procedures (Supine). Patients having disk surgery (Lateral) were positioned on their right or left sides before induction of general anesthesia, and intubation was performed in that position. Patients in control group (Supine) were anesthetized in supine position, and intubation was performed in that position. Intubation was performed blindly via an ILMA in both groups. The time required for intubation and number and types of adjusting maneuvers employed were recorded. Data were compared by Mann-Whitney U, Fisher’s exact, chi-square, or unpaired t-tests, as appropriate. Data presented as mean (SD). Demographic and airway measures were similar in the two groups, except for mouth opening which was slightly wider in patients in the lateral position: 5.1 (0.9) vs. 4.6 (0.7) cm. The time required for intubation was similar in each group (≈25 s), as was intubation success (96%). We conclude that blind intubation via an ILMA offers a frequent success rate and a clinically acceptable intubation time (< one min) even in the lateral position. Summary Blind intubation via the intubating laryngeal mask airway (ILMA) offers a high success rate and a clinically acceptable intubation time even in patients in the lateral position. PMID:14980953

The Reactive Species Interactome: Evolutionary Emergence, Biological Significance, and Opportunities for Redox Metabolomics and Personalized Medicine

PubMed Central

Koning, Anne; Kuhnle, Gunter G.C.; Nagy, Peter; Bianco, Christopher L.; Pasch, Andreas; Wink, David A.; Fukuto, Jon M.; Jackson, Alan A.; van Goor, Harry; Olson, Kenneth R.

2017-01-01

Abstract Significance: Oxidative stress is thought to account for aberrant redox homeostasis and contribute to aging and disease. However, more often than not, administration of antioxidants is ineffective, suggesting that our current understanding of the underlying regulatory processes is incomplete. Recent Advances: Similar to reactive oxygen species and reactive nitrogen species, reactive sulfur species are now emerging as important signaling molecules, targeting regulatory cysteine redox switches in proteins, affecting gene regulation, ion transport, intermediary metabolism, and mitochondrial function. To rationalize the complexity of chemical interactions of reactive species with themselves and their targets and help define their role in systemic metabolic control, we here introduce a novel integrative concept defined as the reactive species interactome (RSI). The RSI is a primeval multilevel redox regulatory system whose architecture, together with the physicochemical characteristics of its constituents, allows efficient sensing and rapid adaptation to environmental changes and various other stressors to enhance fitness and resilience at the local and whole-organism level. Critical Issues: To better characterize the RSI-related processes that determine fluxes through specific pathways and enable integration, it is necessary to disentangle the chemical biology and activity of reactive species (including precursors and reaction products), their targets, communication systems, and effects on cellular, organ, and whole-organism bioenergetics using system-level/network analyses. Future Directions: Understanding the mechanisms through which the RSI operates will enable a better appreciation of the possibilities to modulate the entire biological system; moreover, unveiling molecular signatures that characterize specific environmental challenges or other forms of stress will provide new prevention/intervention opportunities for personalized medicine. Antioxid. Redox Signal. 27, 684–712. PMID:28398072

Comparison between the Reflux Finding Score and the Reflux Symptom Index in the Practice of Otorhinolaryngology.

PubMed

Nunes, Heloisa Sobreira; Pinto, José Antonio; Zavanela, Adma Roberta; Cavallini, André Freitas; Freitas, Gabriel Santos; Garcia, Fabiola Esteves

2016-07-01

The Gastroesophageal Reflux Disease has a prevalence of ∼12% of the urban population in Brazil. Koufman proposed the term to designate Laryngeal Pharyngeal Reflux (LPR) symptoms, signs or tissue damage resulting from aggression of the gastrointestinal contents in the upper aerodigestive tract. Belafsky et al proposed a score that points to inflammatory laryngeal signs through videolaryngoscopic findings, the Reflux Finding Score (RFS). Moreover, in 2002, they published the Reflux Symptom Index (RSI). The objective of this study is to provide a comparison between the Reflux Finding Score and the Reflux Symptom Index in the practice of Otorhinolaryngology. Our study involved a total of 135 patients who visited the Ear, Nose, and Throat (ENT) clinic Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo between April 2014 and May 2015 with suspected LPR. We excluded nine patients and the study group was 126 patients. All patients were ranked by their RSI and RFS scores. The study group consisted of 126 patients (88 women and 38 men). Their main complaints were cough (40.4%), globus (21.4%), dysphonia (19.8%), throat clearing (15.8%), postnasal drip (3.17%), snoring (1.5%), dysphagia (1.5%), cacosmia (0.7%), and regurgitation (1.5%). The RSI ranges from 13 to 42 with a mean of 20.7 (SD = 6.67). The RFS ranged from 3 to 19 with a mean of 9.53 (SD = 2.64). The RSI and RFS can easily be included in ENT routines as objective parameters, with low cost and high practicality. Based on the clinical index, the specialist can evaluate the need for further tests.

Comparison between the Reflux Finding Score and the Reflux Symptom Index in the Practice of Otorhinolaryngology

PubMed Central

Nunes, Heloisa Sobreira; Pinto, José Antonio; Zavanela, Adma Roberta; Cavallini, André Freitas; Freitas, Gabriel Santos; Garcia, Fabiola Esteves

2016-01-01

Introduction  The Gastroesophageal Reflux Disease has a prevalence of ∼12% of the urban population in Brazil. Koufman proposed the term to designate Laryngeal Pharyngeal Reflux (LPR) symptoms, signs or tissue damage resulting from aggression of the gastrointestinal contents in the upper aerodigestive tract. Belafsky et al proposed a score that points to inflammatory laryngeal signs through videolaryngoscopic findings, the Reflux Finding Score (RFS). Moreover, in 2002, they published the Reflux Symptom Index (RSI). Objective  The objective of this study is to provide a comparison between the Reflux Finding Score and the Reflux Symptom Index in the practice of Otorhinolaryngology. Methods  Our study involved a total of 135 patients who visited the Ear, Nose, and Throat (ENT) clinic Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo between April 2014 and May 2015 with suspected LPR. We excluded nine patients and the study group was 126 patients. All patients were ranked by their RSI and RFS scores. Results  The study group consisted of 126 patients (88 women and 38 men). Their main complaints were cough (40.4%), globus (21.4%), dysphonia (19.8%), throat clearing (15.8%), postnasal drip (3.17%), snoring (1.5%), dysphagia (1.5%), cacosmia (0.7%), and regurgitation (1.5%). The RSI ranges from 13 to 42 with a mean of 20.7 (SD = 6.67). The RFS ranged from 3 to 19 with a mean of 9.53 (SD = 2.64). Conclusion  The RSI and RFS can easily be included in ENT routines as objective parameters, with low cost and high practicality. Based on the clinical index, the specialist can evaluate the need for further tests. PMID:27413402

Effect of hand hygiene and glove use on cleanliness of reusable surgical instruments.

PubMed

Costa, D M; Lopes, L K O; Tipple, A F V; Castillo, R B; Hu, H; Deva, A K; Vickery, K

2017-12-01

During functionality testing and packaging of reusable surgical instruments (RSI) for sterilization, instruments are frequently touched. There is a lack of standards relating to hand hygiene frequency and use of gloves in the sterilizing service unit packing area. To determine the effect of hand hygiene and glove use on maintenance of RSI cleanliness. Following manual and automated cleaning, Halsted-mosquito forceps were assessed for adenosine triphosphate (ATP), protein and microbial contamination after handling with gloved and ungloved but washed hands using an ATP surface swab test, bicinchoninic acid assay, and standard culture plate/broth, respectively. Gram's stain was used to classify the isolates. RSI contamination was assessed immediately following and 1, 2, and 4 h after washing hands. Packing instruments with hands that had been unwashed for 2 or 4 h resulted in a significant increase in contaminating ATP when compared with all other treatment groups (P < 0.05). There was a significant correlation between the time since washing hands, the amount of ATP (r = 0.93; P ≤ 0.001), and the microbial load (r = 0.83; P ≤ 0.001) contaminating the forceps, where the longer the time the hands remained unwashed the higher the contamination. Significantly more contaminating protein was found on forceps handled with ungloved hands that had not been washed for 2 or 4 h (P < 0.001). Critical RSI inspection, assembling, lubricating and packing should be performed using either gloves or within 1 h of washing hands. Copyright © 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Radiosensitivity Differences Between Liver Metastases Based on Primary Histology Suggest Implications for Clinical Outcomes After Stereotactic Body Radiation Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ahmed, Kamran A.; Caudell, Jimmy J.; El-Haddad, Ghassan

Purpose/Objectives: Evidence from the management of oligometastases with stereotactic body radiation therapy (SBRT) reveals differences in outcomes based on primary histology. We have previously identified a multigene expression index for tumor radiosensitivity (RSI) with validation in multiple independent cohorts. In this study, we assessed RSI in liver metastases and assessed our clinical outcomes after SBRT based on primary histology. Methods and Materials: Patients were identified from our prospective, observational protocol. The previously tested RSI 10 gene assay was run on samples and calculated using the published algorithm. An independent cohort of 33 patients with 38 liver metastases treated with SBRTmore » was used for clinical correlation. Results: A total of 372 unique metastatic liver lesions were identified for inclusion from our prospective, institutional metadata pool. The most common primary histologies for liver metastases were colorectal adenocarcinoma (n=314, 84.4%), breast adenocarcinoma (n=12, 3.2%), and pancreas neuroendocrine (n=11, 3%). There were significant differences in RSI of liver metastases based on histology. The median RSIs for liver metastases in descending order of radioresistance were gastrointestinal stromal tumor (0.57), melanoma (0.53), colorectal neuroendocrine (0.46), pancreas neuroendocrine (0.44), colorectal adenocarcinoma (0.43), breast adenocarcinoma (0.35), lung adenocarcinoma (0.31), pancreas adenocarcinoma (0.27), anal squamous cell cancer (0.22), and small intestine neuroendocrine (0.21) (P<.0001). The 12-month and 24-month Kaplan-Meier rates of local control (LC) for colorectal lesions from the independent clinical cohort were 79% and 59%, compared with 100% for noncolorectal lesions (P=.019), respectively. Conclusions: In this analysis, we found significant differences based on primary histology. This study suggests that primary histology may be an important factor to consider in SBRT radiation dose selection.« less

Effects of in-season low-volume high-intensity plyometric training on explosive actions and endurance of young soccer players.

PubMed

Ramírez-Campillo, Rodrigo; Meylan, César; Alvarez, Cristian; Henríquez-Olguín, Carlos; Martínez, Cristian; Cañas-Jamett, Rodrigo; Andrade, David C; Izquierdo, Mikel

2014-05-01

Integrating specific training methods to improve explosive actions and endurance in youth soccer is an essential part of players' development. This study investigated the efficiency of short-term vertical plyometric training program within soccer practice to improve both explosive actions and endurance in young soccer players. Seventy-six players were recruited and assigned either to a training group (TG; n = 38; 13.2 ± 1.8 years) or a control group (CG; n = 38; 13.2 ± 1.8 years) group. All players trained twice per week, but the TG followed a 7-week plyometric program implemented within soccer practice, whereas the CG followed regular practice. Twenty-meter sprint time (20-m), Illinois agility test time, countermovement jump (CMJ) height, 20- (RSI20) and 40- (RSI40) cm drop jump reactive strength index, multiple 5 bounds distance (MB5), maximal kicking test for distance (MKD), and 2.4-km time trial were measured before and after the 7-week period. Plyometric training induced significant (p ≤ 0.05) and small to moderate standardized effect (SE) improvement in the CMJ (4.3%; SE = 0.20), RSI20 (22%; SE = 0.57), RSI40 (16%; SE = 0.37), MB5 (4.1%; SE = 0.28), Illinois agility test time (-3.5%, SE = -0.26), MKD (14%; SE = 0.53), 2.4-km time trial (-1.9%; SE = -0.27) performances but had a trivial and nonsignificant effect on 20-m sprint time (-0.4%; SE = -0.03). No significant improvements were found in the CG. An integrated vertical plyometric program within the regular soccer practice can substitute soccer drills to improve most explosive actions and endurance, but horizontal exercises should also be included to enhance sprinting performance.

Predictive parameters for return to pre-injury level of sport 6 months following anterior cruciate ligament reconstruction surgery.

PubMed

Müller, Ulrike; Krüger-Franke, Michael; Schmidt, Michael; Rosemeyer, Bernd

2015-12-01

The aim of the study was to find predictive parameters for a successful resumption of pre-injury level of sport 6 months post anterior cruciate ligament (ACL) reconstruction. In a prospective study, 40 patients with a ruptured ACL were surgically treated with semitendinosus tendon autograft. Six months after surgery, strength of knee extensors and flexors, four single-leg hop tests, Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI), subjective International Knee Documentation Committee (IKDC) 2000 and the Tampa Scale of Kinesiophobia-11 (TSK-11) were assessed. Seven months post-operatively, a standardized interview was conducted to identify "return to sport" (RS) and "non-return to sport" (nRS) patients. Logistic regression and "Receiver Operating Characteristic" (ROC) analyses were used to determine predictive parameters. No significant differences could be detected between RS and nRS patients concerning socio-demographic data, muscle tests, square hop and TSK-11. In nRS patients, the Limb Symmetry Index (LSI) of single hop for distance (p = 0.005), crossover hop (p = 0.008) and triple hop (p = 0.001) were significantly lower, in addition to the ACL-RSI (p = 0.013) and IKDC 2000 (p = 0.037). The cut-off points for LSI single hop for distance were 75.4 % (sensitivity 0.74; specificity 0.88), and for ACL-RSI 51.3 points (sensitivity 0.97; specificity 0.63). Logistic regression distinguished between RS and nRS subjects (sensitivity 0.97; specificity 0.63). The single hop for distance and ACL-RSI were found to be the strongest predictive parameters, assessing both the objective functional and the subjective psychological aspects of returning to sport. Both tests may help to identify patients at risk of not returning to pre-injury sport. II.

Intubation learning curve: comparison between video and direct laryngoscopy by inexperienced students.

PubMed

Aghamohammadi, H; Massoudi, N; Fathi, M; Jaffari, A; Gharaei, B; Moshki, A

2015-01-01

Background: Direct laryngoscopy (DL) is considered the most common method of tracheal intubation. On the other hand, evidence shows the growing role of video laryngoscopy in danger airway administration. Objectives: Due to the importance of a proper training to accomplish an accurate and fast intubation by the student of anesthesia, this research was conducted to assess the effects of DL and video laryngoscopy (Glidescope VL) training on the success rate of tracheal intubation by low-skill students. Materials/Patients and styles: 50 undergraduate students of anesthesiology took part in this randomized control educational intervention. Having no considerable experience in intubation, they were selected and divided randomly into two equal groups (n = 25); video-laryngoscopy via GlideScope VL and direct laryngoscopy (DL) via a Macintosh blade were prepared by the same experienced anesthesiologist. All the participants practiced intubation six times on the same mannequin within a routine airway situation. The maximum acceptable time for each intubation was 3 minutes and three times of successful intubation was considered as an appropriate intubation skill. The required time for laryngoscopy and intubation at each stage, the grade of glottis view, the reasons for an unsuccessful intubation and the amount of successful intubations were recorded and compared between groups. Results: There was a clear variation between the 2 teams, in all the steps, based on the required time for laryngoscopy and intubation (p = 0.0001). Data analysis was performed by using repeated measures data which demonstrated that the necessary time for laryngoscopy and intubation during the study was clearly lower in the GlideScope VL team (p = .0001). In first five rounds of training, the glottis view in the DL group was significantly better than in the VL group (p < 0.05). Conclusion: Based on the result of today' study, routine airway intubation by using GlideScope VL is significantly faster than direct laryngoscopy. It seems that further studies are needed to investigate the effect of the educational program on different laryngoscopy and intubation situations.

Avoiding endotracheal intubation of neonates undergoing laser surgery for retinopathy of prematurity.

PubMed

Woodhead, D D; Lambert, D K; Molloy, D A; Schmutz, N; Righter, E; Baer, V L; Christensen, R D

2007-04-01

Respiratory support of neonates during and following laser surgery for retinopathy of prematurity (ROP) is commonly accomplished using endotracheal intubation and mechanical ventilation. However, most patients undergoing ROP surgery have been weaned off mechanical ventilation days or weeks before the surgery. When they are electively re-intubated for ROP surgery, it can be difficult to extubate them postoperatively. One of the three level III neonatal intensive care units (NICUs) in the Intermountain Healthcare system initiated a program of using nasopharyngeal prongs, rather than endotracheal intubation, for respiratory support during ROP surgery. We performed an historic cohort analysis of all neonates undergoing ROP surgery during their NICU stay at the three level III NICU's between 1 January 2002 and 31 March 2006. Data collected included birth weight, gestational age at delivery and corrected gestational age at ROP surgery, whether or not they were intubated in the days immediately preceding the ROP surgery, whether or not they were electively intubated for the ROP surgery, the respiratory modality used during and the 3 days following ROP surgery, and all blood gas determinations and respiratory charges during this period. Fifty-four patients underwent ROP surgery during this period. All 23 from NICUs 'A' and 'B' had endotracheal intubation for surgery, while in NICU 'C' 24 were managed using nasopharyngeal prongs. The birth weights of those intubated for surgery (661+/-180 g, mean+/-s.d.) were similar to those not intubated (732+/-180 g). Similarly, the gestational age at birth did not differ between those intubated for surgery (25.2+/-1.3 week) and those not (25.6+/-2.1 week). The day following surgery, 77% (23/30) of those who had been intubated for surgery remained intubated and on mechanical ventilation, whereas only one (4%) of those not intubated for surgery was intubated in the postoperative period (P<0.001). On day 3 following surgery, 50% (15/30) of those intubated for surgery remained intubated and on mechanical ventilation, whereas none of those not intubated for surgery were intubated (P<0.001). Management with nasopharyngeal prongs did not result in higher PCO(2)s, or lower pH values, during or after surgery. Respiratory charges for the 3 days following surgery were 1762+/-678 dollars (mean+/-s.d.)/patient among those intubated versus 357+/-352 dollars/patient for those managed with nasopharyngeal prongs (P<0.001). Neonates undergoing laser surgery for ROP can often be supported intraoperatively and postoperatively using nasopharyngeal prongs, thus avoiding the need for endotracheal intubation.

Characterization of Detonation Products of RSI-007 Explosive

NASA Astrophysics Data System (ADS)

Ager, Timothy; Neel, Christopher; Chhabildas, Lalit

2011-06-01

PDV and VISAR have been employed to characterize the detonation products of a production quality RSI-007 explosive. The explosive was part of an exploding foil initiator (EFI) detonator assembly in which the explosive was contained within a Kovar (Fe-Ni-Co alloy) cup. The free surface of the Kovar serves as the witness plate for the interferometry measurements. Detailed shock reverberations are recorded on the witness plate and the isentropic release path of the explosive is inferred though the velocity history. Two separate window materials are bonded to the Kovar cup in subsequent experiments and are used to further determine the release state in different pressure regimes. Presenter

Upper limb musculoskeletal complaints among technicians working in a diagnostic tuberculosis laboratory: two case reports.

PubMed

Wong, Joyce Y P; Chin, David; Fung, Henry; Li, Ann; Wong, Marcus M S; Kwok, Henry K H

2014-01-01

Upper limb musculoskeletal complaints are common among certain health professionals. We report two cases, both involving technicians working in a diagnostic tuberculosis laboratory in Hong Kong. A work process evaluation suggest that the need to repeatedly open and close small bottles, as well as to work for prolonged periods of time in confined areas, could be related to the workers' clinical presentation. The cases are also compatible with the diagnosis of repetitive strain injury (RSI) of the upper limb, but this term is not commonly used nowadays because of various definitional issues. A review of the various diagnostic issues in RSI is presented.

Evaluation of low cost/high temperature insulation, July 1974 - June 1975

NASA Technical Reports Server (NTRS)

Strauss, E. L.

1975-01-01

Six fiber products and six insulation blankets comprising silica, alumina, zirconia, mullite, and mixed ceramic systems were subjected to furnace exposures up to 500 hours at temperatures of 1000 to 1600 C and evaluated for chemical and dimensional stability and for changes in thermal conductivity. Alumina, zirconia, and mullite fibers were fabricated into reusable surface insulation (RSI) tile by water-felting and reimpregnation with ethyl silicate. Specimens were exposed to 25 thermal cycles at 1200 C and 1400 C and a pressure of 10 and 32 torr, respectively. Production costs for 930 sq m (10,000 sq ft) of blanket insulation and of alumina RSI tile were developed.

Structural active cooling applications for the Space Shuttle.

NASA Technical Reports Server (NTRS)

Masek, R. V.; Niblock, G. A.; Huneidi, F.

1972-01-01

Analytic and experimental studies have been conducted to evaluate a number of active cooling approaches to structural thermal protection for the Space Shuttle. The primary emphasis was directed toward the thermal protection system. Trade study results are presented for various heat shield material and TPS arrangements. Both metallic and reusable surface insulation (RSI) concepts were considered. Active systems heat sinks consisted of hydrogen, phase change materials, and expendable water. If consideration is given only to controlling the surface temperature, passive TPS was found to provide the most efficient system. Use of active cooling which incorporates some interior temperature control made the thermally less efficient RSI system more attractive.

Transonic stability and control characteristics of a 0.015 scale model 69-0 of the space shuttle orbiter with forebody RSI modification in the NASA/LaRC 8 foot TPT (LA72)

NASA Technical Reports Server (NTRS)

Ball, J. W.; Edwards, C. R.

1976-01-01

Tests were conducted in the NASA/LaRC 8 foot transonic wind tunnel from March 26 through 31, 1976. The model was a 0.015 scale SSV Orbiter with forebody modifications to simulate slight reductions in the reusable surface insulation (RSI) thickness. Six component aerodynamic force and moment data were obtained at Mach numbers from 0.35 to 1.20 over an angle of attack range from -2 deg to 20 deg at sideslip angles of 0 deg and 5 deg.

Range side lobe inversion for chirp-encoded dual-band tissue harmonic imaging.

PubMed

Shen, Che-Chou; Peng, Jun-Kai; Wu, Chi

2014-02-01

Dual-band (DB) harmonic imaging is performed by transmitting and receiving at both fundamental band (f0) and second-harmonic band (2f0). In our previous work, particular chirp excitation has been developed to increase the signal- to-noise ratio in DB harmonic imaging. However, spectral overlap between the second-order DB harmonic signals results in range side lobes in the pulse compression. In this study, a novel range side lobe inversion (RSI) method is developed to alleviate the level of range side lobes from spectral overlap. The method is implemented by firing an auxiliary chirp to change the polarity of the range side lobes so that the range side lobes can be suppressed in the combination of the original chirp and the auxiliary chirp. Hydrophone measurements show that the RSI method reduces the range side lobe level (RSLL) and thus increases the quality of pulse compression in DB harmonic imaging. With the signal bandwidth of 60%, the RSLL decreases from -23 dB to -36 dB and the corresponding compression quality improves from 78% to 94%. B-mode images also indicate that the magnitude of range side lobe is suppressed by 7 dB when the RSI method is applied.

Randomized Trial of Group Music Therapy With Chinese Prisoners: Impact on Anxiety, Depression, and Self-Esteem.

PubMed

Chen, Xi-Jing; Hannibal, Niels; Gold, Christian

2016-07-01

This study investigated the effects of group music therapy on improving anxiety, depression, and self-esteem in Chinese prisoners. Two-hundred male prisoners were randomly assigned to music therapy (n = 100) or standard care (n = 100). The music therapy had 20 sessions of group therapy compared with standard care. Anxiety (State and Trait Anxiety Inventory [STAI]), depression (Beck Depression Inventory [BDI]), and self-esteem (Texas Social Behavior Inventory [TSBI], Rosenberg Self-Esteem Inventory [RSI]) were measured by standardized scales at baseline, mid-program, and post-program. Data were analyzed based on the intention to treat principle. Compared with standard care, anxiety and depression in the music therapy condition decreased significantly at mid-test and post-test; self-esteem improved significantly at mid-test (TSBI) and at post-test (TSBI, RSI). Improvements were greater in younger participants (STAI-Trait, RSI) and/or in those with a lower level of education (STAI-State, STAI-Trait). Group music therapy seems to be effective in improving anxiety, depression, and self-esteem and was shown to be most beneficial for prisoners of younger age or with lower education level. © The Author(s) 2015.

Changes of individual perception in psychosocial stressors related to German reunification in 1989/1990 and cardiovascular risk factors and cardiovascular diseases in a population-based study in East Germany.

PubMed

Bohley, Stefanie; Kluttig, Alexander; Werdan, Karl; Nuding, Sebastian; Greiser, Karin Halina; Kuss, Oliver; Markus, Marcello Ricardo Paulista; Schmidt, Carsten Oliver; Völzke, Henry; Krabbe, Christine; Haerting, Johannes

2016-01-04

Aim was to examine the relationship between individually perceived changes in psychosocial stressors associated with German reunification and cardiovascular effects. We hypothesised that higher levels of psychosocial stress related to German reunification were associated with an increase in cardiovascular risk factors and cardiovascular diseases (CVDs). Cross-sectional data from 2 cohort studies in East Germany were used: Cardiovascular Disease, Living and Ageing in Halle Study (CARLA), and Study of Health in Pomerania (SHIP). 2 populations in East Germany. CARLA study: 1779 participants, aged 45-83 years at baseline (812 women), SHIP study: 4308 participants, aged 20-79 years at baseline (2193 women). Psychosocial stressors related to reunification were operationalised by the Reunification Stress Index (RSI; scale from 0 to 10). This index was composed of questions that were related to individually perceived changes in psychosocial stressors (occupational, financial and personal) after reunification. To examine the associations between the RSI and each stressor separately with cardiovascular risk factors and CVD, regression models were used. RSI was associated with CVD in women (RR=1.15, 95% CI 1.00 to 1.33). Cardiovascular risk factors were associated with RSI for both men and women, with strongest associations between RSI and diabetes in women (RR=1.10, 95% CI 1.01 to 1.20) and depressive disorders in men (RR=1.15, 95% CI 1.07 to 2.77). The change in occupational situation related to reunification was the major contributing psychosocial stressor. We observed a strong association with CVD in women who experienced occupational deterioration after reunification (RR=4.04, 95% CI 1.21 to 13.43). Individually perceived deterioration of psychosocial stressors (occupational, financial and personal) related to German reunification was associated with cardiovascular risk factors and CVD. The associations were stronger for women than for men. An explanation for these findings could be that women were more often affected by unemployment after reunification. Morbidity and mortality follow-up of both cohorts could enhance the results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

The cost-effectiveness of the RSI QuickScan intervention programme for computer workers: Results of an economic evaluation alongside a randomised controlled trial.

PubMed

Speklé, Erwin M; Heinrich, Judith; Hoozemans, Marco J M; Blatter, Birgitte M; van der Beek, Allard J; van Dieën, Jaap H; van Tulder, Maurits W

2010-11-11

The costs of arm, shoulder and neck symptoms are high. In order to decrease these costs employers implement interventions aimed at reducing these symptoms. One frequently used intervention is the RSI QuickScan intervention programme. It establishes a risk profile of the target population and subsequently advises interventions following a decision tree based on that risk profile. The purpose of this study was to perform an economic evaluation, from both the societal and companies' perspective, of the RSI QuickScan intervention programme for computer workers. In this study, effectiveness was defined at three levels: exposure to risk factors, prevalence of arm, shoulder and neck symptoms, and days of sick leave. The economic evaluation was conducted alongside a randomised controlled trial (RCT). Participating computer workers from 7 companies (N = 638) were assigned to either the intervention group (N = 320) or the usual care group (N = 318) by means of cluster randomisation (N = 50). The intervention consisted of a tailor-made programme, based on a previously established risk profile. At baseline, 6 and 12 month follow-up, the participants completed the RSI QuickScan questionnaire. Analyses to estimate the effect of the intervention were done according to the intention-to-treat principle. To compare costs between groups, confidence intervals for cost differences were computed by bias-corrected and accelerated bootstrapping. The mean intervention costs, paid by the employer, were 59 euro per participant in the intervention and 28 euro in the usual care group. Mean total health care and non-health care costs per participant were 108 euro in both groups. As to the cost-effectiveness, improvement in received information on healthy computer use as well as in their work posture and movement was observed at higher costs. With regard to the other risk factors, symptoms and sick leave, only small and non-significant effects were found. In this study, the RSI QuickScan intervention programme did not prove to be cost-effective from the both the societal and companies' perspective and, therefore, this study does not provide a financial reason for implementing this intervention. However, with a relatively small investment, the programme did increase the number of workers who received information on healthy computer use and improved their work posture and movement. NTR1117.

Retrograde light-guided laryngoscopy for tracheal intubation: clinical practice and comparison with conventional direct laryngoscopy.

PubMed

Yang, Tao; Hou, Jiong; Li, Jinbao; Zhang, Xu; Zhu, Xiaoyan; Ni, Wen; Mao, Yanfei; Deng, Xiaoming

2013-05-01

Tracheal intubation with conventional laryngoscopy requires many trials until beginners are sufficiently skilled in intubating patients safely. To facilitate intubation, the authors used retrograde light-guided laryngoscopy (RLGL) and compared its feasibility with conventional direct laryngoscopy (DL). Twenty operators participated in a prospective, randomized, open-label, parallel-arm study. These operators intubated 205 patients randomly according to a computer-generated procedure by using either DL or RLGL (five intubations with each technique). The primary outcome was the success rate of tracheal intubation. The authors evaluated the success rate of tracheal intubation, the time to glottic exposure and tracheal intubation, and the Cormack and Lehane grades. Compared with DL, the success rate was greater in the RLGL group for all five intubations (72% vs. 47%; rate difference, 25%; 95% CI [11.84-38.16%], P < 0.001). This was associated with a shorter time to glottic exposure (median [25th and 75th percentile]; 27 [15; 42] vs. 45 [30; 73] s, P < 0.001), shorter intubation time (66 [44; 120] vs. 120 [69; 120] s, P < 0.001), and decreased throat soreness (mean ± SD; visual analog scale, 2.1 ± 0.9 vs. 3.7 ± 1.0 cm, P = 0.001) in the RLGL group compared to the DL group. RLGL is an alternative intubation technique. In our study, it enables beginners to intubate patients more successfully and quickly than conventional DL.

The 30-second rule: the effects of prolonged intubation attempts on oxygen saturation and heart rate in preterm infants in the delivery room.

PubMed

Wozniak, Madeline; Arnell, Kathy; Brown, Melissa; Gonzales, Sarah; Lazarus, Danielle; Rich, Wade; Katheria, Anup

2018-04-01

A duration of 30 seconds has been shown to improve the success rate of intubation attempts without any decompensation. There is limited data regarding the detrimental effects of prolonged intubation attempts in preterm infants. The aim was to determine the effect of prolonged intubation attempts on heart rate and oxygen saturation in preterm infants. We retrospectively reviewed videos and physiologic data collected during delivery room (DR) resuscitations. Infants who had a functioning pulse oximeter at the time of intubation in the delivery room were analyzed using video and analog recordings. The duration of the intubation attempt was defined as the time the laryngoscope blade was in the infant's mouth. Prolonged intubations were defined as intubations over 30 seconds. Baseline heart rate and saturations were defined as the heart rate and saturation immediately prior to the intubation attempt. Video recording was used to determine time laryngoscope was in the mouth, what other procedures were performed, and whether there was recovery between attempts. Analog data including heart rate, airway pressure and saturation was also recorded. There were 52 intubation attempts in 28 infants. The median (IQR) birth weight and gestational age were 795 (705, 972) grams and 25 (25, 27) weeks. The duration of an intubation attempt was 35 (27, 46) seconds with number of attempts 2 (1, 2). There were 34 intubation attempts greater than 30 seconds (prolonged group) and 18 attempts less than or equal to 30 seconds (short group). Longer attempts did not affect intubation success (successful 34 [25,37] seconds vs. unsuccessful 41[29, 53] seconds; P=0.05). Infants in the prolonged group had a greater decrease in oxygen saturation percentage from baseline (5±8 percent, short intubation group and 13±27 prolonged intubation group; P=0.004). There was also a significant decrease in heart rate beats per minute between the two groups (6±9 in the short intubation group and 23±29 prolonged group; P=0.004). The currently recommended guideline by the Neonatal Resuscitation Program limiting intubation attempts to less than 30 seconds is supported by stable oxygen saturations and heart rate. Prolonging the intubation more than 30 seconds leads to greater hypoxia and may contribute to increased neonatal morbidity, with no effect on success rate.

Compression force on the upper jaw during neonatal intubation: mannequin study.

PubMed

Doreswamy, Srinivasa Murthy; Almannaei, Khaled; Fusch, Chris; Shivananda, Sandesh

2015-03-01

Neonatal intubation is a technically challenging procedure, and pressure-related injuries to surrounding structures have been reported. The primary objective of this study was to determine the pressure exerted on the upper jaw during tracheal intubation using a neonatal mannequin. Multidisciplinary care providers working at a neonatal intensive care unit were requested to intubate a neonatal mannequin using the standard laryngoscope and 3.0-mm (internal diameter) endotracheal tube. Compression force exerted was measured by using pressure-sensitive film taped on the upper jaw before every intubation attempt. Pressure, area under pressure and time taken to intubate were compared between the different types of health-care professionals. Thirty care providers intubated the mannequin three times each. Pressure impressions were observed on the developer film after every intubation attempt (n = 90). The mean pressure exerted during intubation across all health-care providers was 568 kPa (SD 78). The mean area placed under pressure was 142 mm(2) (SD 45), and the mean time taken for intubation was 14.7 s (SD 4.3). There was no difference in pressure exerted on the upper jaw between frequent and less frequent intubators. It was found that pressure greater than 400 kPa was inadvertently applied on the upper jaw during neonatal intubation, far exceeding the 250 kPa shown to cause tissue injury in animal models. The upper jaw is exposed to a significant compression force during intubation. Although such exposure is brief, it has the potential to cause tissue injury. Contact of the laryngoscope blade with the upper jaw occurred in all intubation attempts with the currently used design of laryngoscope. © 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

A cost analysis of reusable and disposable flexible optical scopes for intubation.

PubMed

Tvede, M F; Kristensen, M S; Nyhus-Andreasen, M

2012-05-01

Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities. The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied. During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes. At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.

The Effects of Pediatric Advanced Life Support Guidelines on Pediatric Trauma Airway Management.

PubMed

Sperka, Jana; Hanson, Sheila J; Hoffmann, Raymond G; Dasgupta, Mahua; Meyer, Michael T

2016-08-01

Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update. This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations. There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity. There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.

Intubation of the morbidly obese patient: GlideScope(®) vs. Fastrach™.

PubMed

Ydemann, M; Rovsing, L; Lindekaer, A L; Olsen, K S

2012-07-01

Several potential problems can arise from airway management in morbidly obese patients, including difficult mask ventilation and difficult intubation. We hypothesised that endotracheal intubation of morbidly obese patients would be more rapid using the GlideScope(®) (GS) (Verathon Inc Corporate Headquarters, Bothell, WA, USA) than with the Fastrach™ (FT) (The Laryngeal Mask Company Ltd, Le Rocher, Victoria, Mahe, Seychelles). One hundred patients who were scheduled for bariatric surgery were randomised to tracheal intubation using either a GS or an FT. The inclusion criteria were age 18-60 years and a body mass index of ≥ 35 kg/m(2) . The primary end point was intubation time, and if intubation was not achieved after two attempts, the other method was used for the third attempt. The mean intubation time was 49 s using the GS and 61 s using the FT (P = 0.86). A total of 92% and 84% of the patients were intubated on the first attempt using the GS and the FT, respectively. One tracheal intubation failed on the second attempt when the GS was used, and five failed on the second attempt when the FT was used. There were no incidents of desaturation and no differences between the groups in terms of mucosal damage or intubation difficulty. We experienced one oesophageal intubation using GS and six oesophageal intubations in five patients using FT. There was no difference between the pain scores or incidence of post-operative hoarseness associated with the two intubation techniques. No significant difference between the two methods was found. The GS and the FT may therefore be considered to be equally good when intubating morbidly obese patients. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.

A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: a manikin study.

PubMed

Michalek, P; Donaldson, W; Graham, C; Hinds, J D

2010-01-01

Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach laryngeal mask and the I-gel supraglottic airway. A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins. Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts (P<0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel (P>0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel (P<0.0001 for bougie, Aintree catheter and tracheal tube, respectively). The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted. Copyright 2009 Elsevier Ireland Ltd. All rights reserved.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates.

PubMed

Lingappan, Krithika; Arnold, Jennifer L; Fernandes, Caraciolo J; Pammi, Mohan

2018-06-04

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates. We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies. RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy. Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence. The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy. Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.

Recovery of Psychological Readiness May Differ Between Genders Following ACL Reconstruction in Adolescent Athletes

PubMed Central

Milewski, Matthew David; Kostyun, Regina; Iannicelli, Julie P.; Kostyun, Kyle J.; Solomito, Matthew; Nissen, Carl W.

2016-01-01

Objectives: Injury to the anterior cruciate ligament (ACL) is a traumatic and emotional event for adolescent athletes. Preparation to return to play (RTP) and the potential risk of re-injury are often equally as emotional as the injury, and have been identified as possible limiting factors to a successful rehabilitation and RTP. In order to create a comprehensive rehabilitation model, further understanding of psychological readiness following surgical intervention is needed. The purpose of this study was to determine if clinical outcomes of subjective knee function and psychological readiness differ between genders following ACL reconstruction surgery in adolescent athletes, and if higher knee function and physiological readiness was associated with an earlier to RTP. Methods: Athletes who underwent ACL reconstruction surgery and were successfully returned back to unrestricted sport were included in the analysis. At approximately six months post surgery, knee function was assessed using the validated International Knee Documentation Committee (IKDC) Subjective Form, and psychological readiness was assessed using the validated ACL-Return to Sport after Injury (ACL-RSI) scale. Formal clearance to resume unrestricted sport was obtained from clinic notes. A T-test was used to determine if demographics, IKDC and ACL-RSI scores between genders. A mixed effects random intercept regression model was used to determine the association of time to RTP with IKDC and ACL-RSI scores. Results: A total of 45 adolescent athletes (23 females) were included in this analysis. No significant differences were found between males and females for age (16.2±1.5 years, 16.3±2.2 years) and average time to RTP (7.3±2.0 months, 7.3±1.8 months). No significant differences in IKDC scores were found between males and females (88±10%, 87±10%). A trend was identified that males demonstrated higher ACL-RSI scores at six month post surgery than females (81±14%, 72±17%, p = 0.063). In females, higher IKDC scores (p=0.013, Ɓ =-0.09) and higher ACL-RSI scores (p = 0.002, Ɓ = -0.06) were associated with an earlier time to RTP. This association was not found in male athletes. Conclusion: Although both genders felt their knee would function well during sport at approximately six months following ACL reconstruction, male athletes seem to demonstrate an overall stronger psychological readiness to RTP. However, better scores on the ACL-RSI and IKDC were associated with an earlier RTP only in female athletes. The results of this study suggest a difference in the psychological readiness to RTP between male and female adolescent athletes approximately six months following ACL reconstruction. Further investigations are warranted to investigate the psychological hurdles that face each gender when trying to RTP following an ACL injury. A better understanding of these emotional limitations could help to clinically identify patients that may benefit from counseling.

Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications.

PubMed

Wilcox, Susan R; Bittner, Edward A; Elmer, Jonathan; Seigel, Todd A; Nguyen, Nicole Thuy P; Dhillon, Anahat; Eikermann, Matthias; Schmidt, Ulrich

2012-06-01

Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07). The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

PubMed Central

Mutlak, Haitham; Rolle, Udo; Rosskopf, Willi; Schalk, Richard; Zacharowski, Kai; Meininger, Dirk; Byhahn, Christian

2014-01-01

OBJECTIVE: Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation. METHODS: In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis. RESULTS: A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation. CONCLUSION: All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients. PMID:24473556

Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: A prospective, comparative study in the ICU

PubMed Central

2012-01-01

Introduction Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy. Methods In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC®). Results A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001). Conclusion Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur. PMID:22695007

The Intubating Laryngeal Mask Airway Allows Tracheal Intubation When the Cervical Spine Is Immobilized by a Rigid Collar

PubMed Central

Komatsu, Ryu; Nagata, Osamu; Kamata, Kotoe; Yamagata, Katsuyuki; Sessler, Daniel I.; Ozaki, Makoto

2005-01-01

Summary An intubating laryngeal mask airway (ILMA) facilitates tracheal intubation with the neck in neutral position, which is similar to the neck position maintained by a rigid cervical collar. However, a cervical collar virtually obliterates neck movement, even the small movements that normally facilitate airway insertion. We therefore tested the hypothesis that the ILMA facilitates tracheal intubation even in patients wearing a rigid cervical collar. In 50 cervical spine surgery patients with a rigid Philadelphia collar in place and 50 general surgery patients under general anaesthesia, we performed blind tracheal intubation via an ILMA. The time required for intubation, intubation success rate, and numbers and type of adjusting manoeuvres employed were recorded. Inter-incisor distance was significantly smaller (4.1 [0.8] cm vs. 4.6 [0.7] cm, mean [SD], P<0.01) and Mallampati scores were significantly greater (P<0.001) in the collared patients. ILMA insertion took longer (30 [25] vs. 22 [6] seconds), more patients required 2 insertion attempts (15 vs. 3; P<0.005), and ventilation adequacy with ILMA was worse (P<0.05) in collared patients. However, there were no significant differences between the collared and control patients in terms of total time required for intubation (60 [41] vs. 50 [30] seconds), number of intubation attempts, overall intubation success rate (96 vs. 98%), or the incidence of intubation complications. Blind intubation through an ILMA is thus a reasonable strategy for controlling the airway in patients who are immobilized with a rigid cervical collar, especially when urgency precludes a fiberoptic approach. PMID:15321932

Encountering unexpected difficult airway: relationship with the intubation difficulty scale

PubMed Central

Koh, Wonuk; Kim, Hajung; Kim, Kyongsun; Ro, Young-Jin

2016-01-01

Background An unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS. Methods We retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed. Results For the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure. Conclusions Unexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation. PMID:27274369

Comparison of the Laryngeal View during Tracheal Intubation Using Airtraq and Macintosh Laryngoscopes by Unskillful Anesthesiology Residents: A Clinical Study

PubMed Central

Ferrando, Carlos; Aguilar, Gerardo; Belda, F. Javier

2011-01-01

Background and Objective. The Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) is a novel tracheal intubation device. Studies, performed until now, have compared the Airtraq with the Macintosh laryngoscope, concluding that it reduces the intubation times and increase the success rate at first intubation attempt, decreasing the Cormack-Lehane score. The aim of the study was to evaluate if, in unskillful anesthesiology residents during the laryngoscopy, the Airtraq compared with the Macintosh laryngoscope improves the laryngeal view, decreasing the Cormack-Lehane score. Methods. A prospective, randomized, crossed-over trial was carried out on 60 patients. Each one of the patients were intubated using both devices by unskillful (less than two hundred intubations with the Macintosh laryngoscope and 10 intubations using the Airtraq) anesthesiology residents. The Cormack-Lehane score, the success rate at first intubation attempt, and the laryngoscopy and intubation times were compared. Results. The Airtraq significantly decreased the Cormack-Lehane score (P = 0.04). On the other hand, there were no differences in times of laryngoscopy (P = 0.645; IC 95% 3.1, +4.8) and intubation (P = 0.62; C95%  −6.1, +10.0) between the two devices. No relevant complications were found during the maneuvers of intubation using both devices. Conclusions. The Airtraq is a useful laryngoscope in unskillful anesthesiology residents improving the laryngeal view and, therefore, facilitating the tracheal intubation. PMID:22162683

The effects of succinylcholine or low-dose rocuronium to aid endotracheal intubation of adult sows

PubMed Central

Duke-Novakovski, Tanya; Ambros, Barbara; Auckland, Crissie D.; Harding, John C.S.

2012-01-01

This randomized, prospective, blinded study compared the use of succinylcholine or rocuronium to aid endotracheal intubation of 27 adult sows [mean body weight 261 ± 28 (standard deviation) kg]. Preliminary trials allowed development of the intubation technique and skills. The sows were premedicated with azaperone, atropine, and morphine, and anesthesia was induced with thiopental [6 mg/kg body weight (BW)]. Nine sows each received succinylcholine (1.0 mg/kg BW), rocuronium (0.5 mg/kg BW), or saline (15 mL) after induction. Increments of thiopental (1 mg/kg BW) were used if swallowing impaired intubation. Intubation was performed 45 s after injection of the test drug and was timed and scored. The intubation scores were analyzed with Kruskal-Wallis analysis of variance (ANOVA). Time taken for intubation, body weight, and total dose of thiopental were analyzed with ANOVA and Bonferroni’s multiple-comparisons test. No significant differences (at P < 0.05) were found between the groups with regard to intubation score, time taken for intubation, or total thiopental dose. Thus, neuromuscular blocking agents did not aid endotracheal intubation of adult sows anesthetized with thiopental. PMID:22754096

Conventional tracheal tubes for intubation through the intubating laryngeal mask airway.

PubMed

Kundra, Pankaj; Sujata, N; Ravishankar, M

2005-01-01

The laryngeal mask airway (LMA)-Fastrach silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n=50), prewarmed PVCT (n=50), and LAT (n=50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P <0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P <0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P <0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.

Hands-Off Time for Endotracheal Intubation during CPR Is Not Altered by the Use of the C-MAC Video-Laryngoscope Compared to Conventional Direct Laryngoscopy. A Randomized Crossover Manikin Study.

PubMed

Schuerner, Philipp; Grande, Bastian; Piegeler, Tobias; Schlaepfer, Martin; Saager, Leif; Hutcherson, Matthew T; Spahn, Donat R; Ruetzler, Kurt

2016-01-01

Sufficient ventilation and oxygenation through proper airway management is essential in patients undergoing cardio-pulmonary resuscitation (CPR). Although widely discussed, securing the airway using an endotracheal tube is considered the standard of care. Endotracheal intubation may be challenging and causes prolonged interruption of chest compressions. Videolaryngoscopes have been introduced to better visualize the vocal cords and accelerate intubation, which makes endotracheal intubation much safer and may contribute to intubation success. Therefore, we aimed to compare hands-off time and intubation success of direct laryngoscopy with videolaryngoscopy (C-MAC, Karl Storz, Tuttlingen, Germany) in a randomized, cross-over manikin study. Twenty-six anesthesia residents and twelve anesthesia consultants of the University Hospital Zurich were recruited through a voluntary enrolment. All participants performed endotracheal intubation using direct laryngoscopy and C-MAC in a random order during ongoing chest compressions. Participants were strictly advised to stop chest compression only if necessary. The median hands-off time was 1.9 seconds in direct laryngoscopy, compared to 3 seconds in the C-MAC group. In direct laryngoscopy 39 intubation attempts were recorded, resulting in an overall first intubation attempt success rate of 97%, compared to 38 intubation attempts and 100% overall first intubation attempt success rate in the C-MAC group. As a conclusion, the results of our manikin-study demonstrate that video laryngoscopes might not be beneficial compared to conventional, direct laryngoscopy in easily accessible airways under CPR conditions and in experienced hands. The benefits of video laryngoscopes are of course more distinct in overcoming difficult airways, as it converts a potential "blind intubation" into an intubation under visual control.

Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers—Cadavers vs. Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion

PubMed Central

Hindman, Bradley J.; From, Robert P.; Fontes, Ricardo B.; Traynelis, Vincent C.; Todd, Michael M.; Zimmerman, M. Bridget; Puttlitz, Christian M.; Santoni, Brandon G.

2015-01-01

Introduction The aims of this study were to characterize: 1) cadaver intubation biomechanics, including the effect of repeated intubations; and 2) the relationship between intubation force and the motion of an injured cervical segment. Methods Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (Type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations. Results Cadaver intubation biomechanics were comparable to those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (Set 2/Set1 force ratio = 0.61 [95% CI: 0.46, 0.81]; P=0.002) and Oc-C5 extension (Set 2 –Set 1 difference = −6.1 degrees [95% CI: −11.4, −0.9]; P=0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ: 1) between intact and injured states; or 2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm [95% CI: 0.7, 4.9 mm]; P=0.004). Discussion With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a Type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression. PMID:26288267

Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway.

PubMed

Trevisan, P

2002-10-01

Anaesthetic management of a parturient with predicted difficult airway presenting for caesarean section (CS) is not a straightforward decision: general anaesthesia should be avoided because intubation can be impossible and a "cannot intubate, cannot ventilate" scenario might ensue, on the other hand regional techniques can be unsuccessful or, though rarely, have complications that require emergency intubation. The case is presented of a primigravida admitted to hospital at 37 weeks' gestation with hypertension, intrauterine growth retardation and oligohydramnios. After a few days' observation, it was decided to proceed with an elective CS. The preoperative airway examination revealed a poor mouth opening with an interdental distance of 20 mm and a Mallampati class IV. The patient was classified as a case of difficult intubation and the following anaesthetic options were considered: epidural anaesthesia, spinal anaesthesia and awake fibreoptic intubation followed by general anaesthesia. The pros and the cons of these techniques were explained to the patient and it was suggested that awake fibreoptic intubation was the safest option. The patient gave her consent, so an uneventful nasal awake fibreoptic intubation was carried out under local anaesthesia. This case report offers the opportunity to underline the risk to perform a central blockade in a parturient with predicted difficult intubation, arguing that the safest course of action is an awake fibrescopic intubation, besides some controversial points to safely perform awake fibreoptic intubation in obstetric patients are discussed.

Cost-effectiveness analysis of the use of high-flow oxygen through nasal cannula in intensive care units in NHS England.

PubMed

Eaton Turner, Emily; Jenks, Michelle

2018-06-01

To estimate the cost-effectiveness of Nasal High Flow (NHF) in the intensive care unit (ICU) compared with standard oxygen or non-invasive ventilation (NIV) from a UK NHS perspective. Three cost-effectiveness models were developed to reflect scenarios of NHF use: first-line therapy (pre-intubation model); post-extubation in low-risk, and high-risk patients. All models used randomized control trial data on the incidence of intubation/re-intubation, events leading to intubation/re-intubation, mortality and complications. NHS reference costs were primarily used. Sensitivity analyses were conducted. When used as first-line therapy, Optiflow™ NHF gives an estimated cost-saving of £469 per patient compared with standard oxygen and £611 versus NIV. NHF cost-savings for high severity sub-group were £727 versus standard oxygen, and £1,011 versus NIV. For low-risk post-intubation patients, NHF generates estimated cost-saving of £156 versus standard oxygen. NHF decreases the number of re-intubations required in these scenarios. Results were robust in most sensitivity analyses. For high-risk post-intubation patients, NHF cost-savings were £104 versus NIV. NHF results in a non-significant increase in re-intubations required. However, reduction in respiratory failure offsets this. For patients in ICU who are at risk of intubation or re-intubation, NHF cannula is likely to be cost-saving.

Fundamental studies on the nature and properties of ceramic fiber insulation

NASA Technical Reports Server (NTRS)

Mueller, J. I.; Whittemore, O. J., Jr.; Scott, W. D.; Miller, A. D.; Smiser, L. W.; Leiser, D. B.

1975-01-01

Silica and mullite fibers used to fabricate reusable surface insulation (RSI) for the space shuttle orbiter may devitrify/recrystallize within the temperature range anticipated upon reentry. This is shown to be dependent upon impurity level, temperature, and time at temperature. It is determined that the effects of the material improvement and optimization program are positive. The degree of crystallinity is shown to have a predominant effect upon the strength of fabricated RSI tile, and limits are determined. Models are developed to predict tensile strengths and shrinkage rates of silica tile based upon readily measurable parameters. Thermal cycling which simulates reentry results in an increase in the crystallinity and in the porosity of tile coatings.

Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit.

PubMed

Khandelwal, Nita; Khorsand, Sarah; Mitchell, Steven H; Joffe, Aaron M

2016-04-01

Based on the data from elective surgical patients, positioning patients in a back-up head-elevated position for preoxygenation and tracheal intubation can improve patient safety. However, data specific to the emergent setting are lacking. We hypothesized that back-up head-elevated positioning would be associated with a decrease in complications related to tracheal intubation in the emergency room environment. This retrospective study was approved by the University of Washington Human Subjects Division (Seattle, WA). Eligible patients included all adults undergoing emergent tracheal intubation outside of the operating room by the anesthesiology-based airway service at 2 university-affiliated teaching hospitals. All intubations were through direct laryngoscopy for an indication other than full cardiopulmonary arrest. Patient characteristics and details of the intubation procedure were derived from the medical record. The primary study endpoint was the occurrence of a composite of any intubation-related complication: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. Multivariable logistic regression was used to estimate the odds of the primary endpoint in the supine versus back-up head-elevated positions with adjustment for a priori-defined potential confounders (body mass index and a difficult intubation prediction score [Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score]). Five hundred twenty-eight patients were analyzed. Overall, at least 1 intubation-related complication occurred in 76 of 336 (22.6%) patients managed in the supine position compared with 18 of 192 (9.3%) patients managed in the back-up head-elevated position. After adjusting for body mass index and the Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score, the odds of encountering the primary endpoint during an emergency tracheal intubation in a back-up head-elevated position was 0.47 (95% confidence interval, 0.26-0.83; P = 0.01). Placing patients in a back-up head-elevated position, compared with supine position, during emergency tracheal intubation was associated with a reduced odds of airway-related complications.

Tracheal intubation by novice staff: the direct vision laryngoscope or the lighted stylet (Trachlight)?

PubMed Central

Soh, C; Kong, C; Kong, C; Ip-Yam, P; Chin, E; Goh, M

2002-01-01

Objective: To compare the ease of use of the direct vision laryngoscope and the lighted stylet (Trachlight) by novice staff. Methods: Ten novice medical officers (MOs) performed orotracheal intubations using either the conventional direct vision laryngoscope (DL) or a lighted stylet device (Trachlight). They performed their DL intubations during the first phase of the study, followed by the Trachlight intubations in the subsequent phase. Results: 51 of 54 (94%) of the DL intubation attempts were successful compared with 36 of 54 (67%) of the Trachlight intubations (p<0.001). The mean (SEM) time for intubation was 44 (7) seconds in the DL group and 66 (13) seconds in the Trachlight group (p=0.004). In addition 45 of 54 (83%) of the DL intubations were successful at the first attempt versus 15 of 54 (28%) in the Trachlight group (p<0.001). Conclusion: The results show that the use of the conventional direct vision laryngoscope in novices is associated with significantly shorter mean intubation times and higher success rates on the first attempt compared with the Trachlight. PMID:12101133

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

PubMed

Driver, Brian E; Prekker, Matthew E; Klein, Lauren R; Reardon, Robert F; Miner, James R; Fagerstrom, Erik T; Cleghorn, Mitchell R; McGill, John W; Cole, Jon B

2018-05-16

The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. clinicaltrials.gov Identifier: NCT02902146.

A decadal observation of vegetation dynamics using multi-resolution satellite images

NASA Astrophysics Data System (ADS)

Chiang, Yang-Sheng; Chen, Kun-Shan; Chu, Chang-Jen

2012-10-01

Vegetation cover not just affects the habitability of the earth, but also provides potential terrestrial mechanism for mitigation of greenhouse gases. This study aims at quantifying such green resources by incorporating multi-resolution satellite images from different platforms, including Formosat-2(RSI), SPOT(HRV/HRG), and Terra(MODIS), to investigate vegetation fractional cover (VFC) and its inter-/intra-annual variation in Taiwan. Given different sensor capabilities in terms of their spatial coverage and resolution, infusion of NDVIs at different scales was used to determine fraction of vegetation cover based on NDVI. Field campaign has been constantly conducted on a monthly basis for 6 years to calibrate the critical NDVI threshold for the presence of vegetation cover, with test sites covering IPCC-defined land cover types of Taiwan. Based on the proposed method, we analyzed spatio- temporal changes of VFC for the entire Taiwan Island. A bimodal sequence of VFC was observed for intra-annual variation based on MODIS data, with level around 5% and two peaks in spring and autumn marking the principal dual-cropping agriculture pattern in southwestern Taiwan. Compared to anthropogenic-prone variation, the inter-annual VFC (Aug.-Oct.) derived from HRV/HRG/RSI reveals that the moderate variations (3%) and the oscillations were strongly linked with regional climate pattern and major disturbances resulting from extreme weather events. Two distinct cycles (2002-2005 and 2005-2009) were identified in the decadal observations, with VFC peaks at 87.60% and 88.12% in 2003 and 2006, respectively. This time-series mapping of VFC can be used to examine vegetation dynamics and its response associated with short-term and long-term anthropogenic/natural events.

Gradations of awareness in a modified sequence learning task.

PubMed

Norman, Elisabeth; Price, Mark C; Duff, Simon C; Mentzoni, Rune A

2007-12-01

We argue performance in the serial reaction time (SRT) task is associated with gradations of awareness that provide examples of fringe consciousness [Mangan, B. (1993b). Taking phenomenology seriously: the "fringe" and its implications for cognitive research. Consciousness and Cognition, 2, 89-108, Mangan, B. (2003). The conscious "fringe": Bringing William James up to date. In B. J. Baars, W. P. Banks & J. B. Newman (Eds.), Essential sources in the scientific study of consciousness (pp. 741-759). Cambridge, MA: The MIT Press.], and address limitations of the traditional SRT procedure, including criticism of exclusion generation tasks. Two experiments are conducted with a modified SRT procedure where irrelevant stimulus attributes obscure the sequence rule. Our modified paradigm, which includes a novel exclusion task, makes it easier to demonstrate a previously controversial influence of response stimulus interval (RSI) on awareness. It also allows identification of participants showing fringe consciousness rather than explicit sequence knowledge, as reflected by dissociations between different awareness measures. The NEO-PI-R variable Openness to Feelings influenced the diversity of subjective feelings reported during two awareness measures, but not the degree of learning and awareness as previously found with traditional SRT tasks [Norman, E., Price, M. C., & Duff, S. C. (2006). Fringe consciousness in sequence learning: the influence of individual differences. Consciousness and Cognition, 15(4), 723-760.]. This suggests possible distinctions between two components of fringe consciousness.

Automated identification of retained surgical items in radiological images

NASA Astrophysics Data System (ADS)

Agam, Gady; Gan, Lin; Moric, Mario; Gluncic, Vicko

2015-03-01

Retained surgical items (RSIs) in patients is a major operating room (OR) patient safety concern. An RSI is any surgical tool, sponge, needle or other item inadvertently left in a patients body during the course of surgery. If left undetected, RSIs may lead to serious negative health consequences such as sepsis, internal bleeding, and even death. To help physicians efficiently and effectively detect RSIs, we are developing computer-aided detection (CADe) software for X-ray (XR) image analysis, utilizing large amounts of currently available image data to produce a clinically effective RSI detection system. Physician analysis of XRs for the purpose of RSI detection is a relatively lengthy process that may take up to 45 minutes to complete. It is also error prone due to the relatively low acuity of the human eye for RSIs in XR images. The system we are developing is based on computer vision and machine learning algorithms. We address the problem of low incidence by proposing synthesis algorithms. The CADe software we are developing may be integrated into a picture archiving and communication system (PACS), be implemented as a stand-alone software application, or be integrated into portable XR machine software through application programming interfaces. Preliminary experimental results on actual XR images demonstrate the effectiveness of the proposed approach.

Pressure gradient effects on heat transfer to reusable surface insulation tile-array gaps

NASA Technical Reports Server (NTRS)

Throckmorton, D. A.

1975-01-01

An experimental investigation was performed to determine the effect of pressure gradient on the heat transfer within space shuttle reusable surface insulation (RSI) tile-array gaps under thick, turbulent boundary-layer conditions. Heat-transfer and pressure measurements were obtained on a curved array of full-scale simulated RSI tiles in a tunnel-wall boundary layer at a nominal free-stream Mach number and free-stream Reynolds numbers. Transverse pressure gradients of varying degree were induced over the model surface by rotating the curved array with respect to the flow. Definition of the tunnel-wall boundary-layer flow was obtained by measurement of boundary-layer pitot pressure profiles, wall pressure, and heat transfer. Flat-plate heat-transfer data were correlated and a method was derived for prediction of heat transfer to a smooth curved surface in the highly three-dimensional tunnel-wall boundary-layer flow. Pressure on the floor of the RSI tile-array gap followed the trends of the external surface pressure. Heat transfer to the surface immediately downstream of a transverse gap is higher than that for a smooth surface at the same location. Heating to the wall of a transverse gap, and immediately downstream of it, at its intersection with a longitudinal gap is significantly greater than that for the simple transverse gap.

Symptom overlap between laryngopharyngeal reflux and glottic insufficiency in vocal fold atrophy patients.

PubMed

Patel, Anju K; Mildenhall, Nicholas R; Kim, William; Carroll, Thomas L

2014-04-01

To determine in true vocal fold (TVF) atrophy patients if symptoms of throat clearing and mucus sensation, attributed to laryngopharyngeal reflux (LPR), are due to glottic insufficiency. Is the TVF atrophy population being prescribed proton pump inhibitors unnecessarily? A retrospective review of patients with TVF atrophy but no other underlying laryngeal pathology seen at a tertiary voice center from July 2009 to May 2012 was conducted. Patient demographics, symptoms, LPR diagnosis, interventions, and pre-intervention and post-intervention Voice Handicap Index-10 (VHI) and Reflux Symptom Index (RSI) scores were recorded. Twenty-six patients met inclusion criteria, and 85% were treated for LPR. Throat clearing and mucus sensation (85%), dysphonia (54%), and globus sensation (46%) were recorded. Interventions included LPR medical management (65%), vocal fold augmentation (23%), and voice therapy (12%). Reflux Symptom Index scores improved in all groups. Voice Handicap Index-10 and RSI scores normalized in patients treated with augmentation. Globus was never present in patients who received augmentation. Throat clearing and mucus sensation may be due to underlying glottic insufficiency and changes of the aging larynx rather than LPR. High VHI and RSI scores normalized with TVF augmentation. Further work is needed to evaluate symptom presentation and risk versus benefit of treatment options, especially if it avoids unnecessary proton pump inhibitor trials.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Plessis, F.C.P. du; Willemse, C.A.

In this paper the radiological properties of a compensator material consisting of wax and gypsum is presented. Effective attenuation coefficients (EACs) have been determined from transmission measurements with an ion chamber in a Perspex phantom. Measurements were made at 80 and 100 cm source-to-skin distance (SSD) for beam energies of 6, 8, and 15 MV, for field sizes ranging from narrow beam geometries up to 40x40 cm{sup 2}, and at measurement depths of maximum dose build-up, 5 and 10 cm. A parametrization equation could be constructed to predict the EAC values within 4% uncertainty as a function of field sizemore » and depth of measurement. The EAC dependence on off-axis position was also quantified at each beam energy and SSD. It was found that the compensator material reduced the required thickness for compensation by 26% at 8 MV when compared to pure paraffin wax for a 10x10 cm{sup 2} field. Relative surface ionization (RSI) measurements have been made to quantify the effect of scattered electrons from the wax-gypsum compensator. Results indicated that for 80 cm SSD the RSI would exceed 50% for fields larger than 15x15 cm{sup 2}. At 100 cm SSD the RSI values were below 50% for all field sizes used.« less

Management of hypertrophic pylorus stenosis with ultrasound guided single shot epidural anaesthesia--a retrospective analysis of 20 cases.

PubMed

Willschke, Harald; Machata, Anette-Marie; Rebhandl, Winfried; Benkoe, Thomas; Kettner, Stephan C; Brenner, Lydia; Marhofer, Peter

2011-02-01

To retrospectively describe the performance of ultrasound guided thoracic epidural anaesthesia under sedation for anaesthesia management of open pyloromyotomy. Anaesthesia management for hypertrophic pylorus stenosis (HPS) is usually performed under general anaesthesia with tracheal intubation. Only a few publications describe avoidance of tracheal intubation in infants by using spinal or caudal anaesthesia. The present retrospective analysis describes the performance of ultrasound guided thoracic epidural anaesthesia under sedation for anaesthetic management of open pyloromyotomy. Twenty consecutive infants scheduled for pyloromyotomy according to the Weber-Ramstedt technique were retrospectively analysed. After sedation with nalbuphine and propofol, an ultrasound guided single shot thoracic epidural anaesthesia was performed with 0.75 ml·kg(-1) ropivacaine 0.475%. Insufficient blockade was defined as increase of HR > 15% from initial value and/or any movements at skin incision. In those cases we were prepared for rapid sequence intubation according to the departmental standard. All pyloromyotomies could be performed under single shot thoracic epidural anaesthesia and sedation. One case of moderate oxygen desaturation was treated with intermittent ventilation via face mask. Thoracic epidural anaesthesia under sedation for pyloromyotomy has been a useful technique in this retrospective series of infants suffering from HPS. In 1/20 infants short term assisted ventilation via face mask was required. Undisturbed surgery was possible in all cases. © 2010 Blackwell Publishing Ltd.

A Mixed-Methods Study of Patient Views on Reflux Symptoms and Medication Routines.

PubMed

Pisegna, Jessica M; Yang, Sky; Purcell, Audrey; Rubio, Alix

2017-05-01

Gastroesophageal reflux disease is a chronic disorder often accompanied by laryngopharyngeal reflux. Speech-language pathologists are tasked with treating these patients with voice, dysphagia, and/or reflux therapy. This study investigated patient-reported reasons for reduced compliance with recommended reflux treatment and the top symptoms in patients with reflux, dysphagia, and voice symptoms. This study used a cross-sectional qualitative and quantitative mixed-methods design to identify and describe patients' reflux symptoms and reflux medication routines. Fifty-one patients completed a face-to-face, semistructured interview, a questionnaire, and the Reflux Symptom Index (RSI). Interview transcripts were coded by authors for concepts in two cycles. During the 51 interviews, the top four reported symptoms were heartburn (n = 17), mucous (n = 11), dysphagia, and globus (n = 10). Further, 62.7% (n = 32/51) described an incorrect routine in taking their proton pump inhibitor (PPI): taking it with other pills, taking it with food/drink, and uncertainty about which pill is for reflux. RSI scores were moderately correlated with patient-reported reflux severity (r = 0.62, P < 0.0001, r 2  = 0.34). Correct compliance with PPI timing was not enough to significantly lower RSI scores more than those who did not comply (an average RSI of 20.0 vs. 25.9, P = 0.1252). Literature has not described the most relevant reflux-related symptoms and why PPI compliance is notoriously poor, from the patients' perspective. The results of this study confirm that PPI compliance is poor, and the reasons for poor compliance could have been prevented with patient education. Even when PPI compliance was adequate, symptoms like globus, mucous, voice dysfunction, and dysphagia persisted. Other interventions such as evidence-based diet and behavioral changes should be a part of voice/dysphagia/reflux therapy. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Numerical Study of a High Head Francis Turbine with Measurements from the Francis-99 Project

NASA Astrophysics Data System (ADS)

Wallimann, H.; Neubauer, R.

2015-01-01

For the Francis-99 project initiated by the Norwegian University of Science and Technology (NTNU, Norway) and the Luleå University of Technology (LTU, Sweden) numerical flow simulation has been performed and the results compared to experimentally obtained data. The full machine including spiral casing, stay vanes, guide vanes, runner and draft tube was simulated transient for three operating points defined by the Francis-99 organisers. Two sets of results were created with differing time steps. Additionally, a reduced domain was simulated in a stationary manner to create a complete cut along constant prototype head and constant prototype discharge. The efficiency values and shape of the curves have been investigated and compared to the experimental data. Special attention has been given to rotor stator interaction (RSI). Signals from several probes and their counterpart in the simulation have been processed to evaluate the pressure fluctuations occurring due to the RSI. The direct comparison of the hydraulic efficiency obtained by the full machine simulation compared to the experimental data showed no improvement when using a 1° time step compared to a coarser 2° time step. At the BEP the 2° time step even showed a slightly better result with an absolute deviation 1.08% compared with 1.24% for the 1° time step. At the other two operating points the simulation results were practically identical but fell short of predicting the measured values. The RSI evaluation was done using the results of the 2° time step simulation, which proved to be an adequate setting to reproduce pressure signals with peaks at the correct frequencies. The simulation results showed the highest amplitudes in the vaneless space at the BEP operating point at a location different from the probe measurements available. This implies that not only the radial distance, but the shape of the vaneless space influences the RSI.

A randomized controlled study to evaluate and compare Truview blade with Macintosh blade for laryngoscopy and intubation under general anesthesia.

PubMed

Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev

2011-04-01

The Truview EVO2™ laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade. In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20-50 years), presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated. Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05). The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds) was more with Truview than with Macintosh blade (P < 0.01). The Percentage of Glottic Opening (POGO) score was significantly higher (97.26±8) in Truview as that observed with Macintosh blade (83.70±21.5). Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05) in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted. Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview.

A Comparison Between the Conventional and the Laryngoscope-Assisted Lightwand Intubation Techniques in Patients With Cervical Immobilization: A Prospective Randomized Study.

PubMed

Kim, Eugene; Kim, Byung-Gun; Lim, Young-Jin; Jeon, Young-Tae; Hwang, Jung-Won; Lee, Seo-Yun; Park, Hee-Pyoung

2017-09-01

Positioning of a lightwand in the midline of the oral cavity can be challenging in patients with cervical immobilization. Direct laryngoscopy may permit the lightwand tip to more easily access the glottic opening. We tested our hypothesis that a laryngoscope-assisted lightwand technique allows more successful endotracheal intubation than does a conventional lightwand approach. A total of 162 patients requiring cervical immobilization during intubation for cervical spine surgery were allocated randomly to 2 groups. The conventional lightwand technique (group C, n = 80) or the laryngoscope-assisted lightwand technique (group L, n = 82) was used for endotracheal intubation. In the group L, a Macintosh laryngoscope was inserted into the oral cavity, advanced until the epiglottis tip was visible, but not used to lift the epiglottis tip. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip. The primary outcome (the initial intubation success rate) and secondary outcomes (intubation time, hemodynamic changes, and postoperative airway complications) were evaluated. The initial intubation success rate was significantly lower (75% vs 89%; relative risk [95% confidence interval]: 1.2 [1.0-1.4]; P = .034) in group C than group L. The intubation time (22 ± 13 vs 24 ± 12 seconds; mean difference [98.33% confidence interval]: 2.4 [-2.3 to 7.2]; P = .217) did not differ between groups. Postoperative sore throat score, incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness also did not differ between groups. Laryngoscope-assisted lightwand intubation did not increase intubation time, and it increased first attempt intubation rates compared with traditional lightwand intubation in patients requiring cervical immobilization for cervical spine surgery.

Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

PubMed

Burjek, Nicholas E; Nishisaki, Akira; Fiadjoe, John E; Adams, H Daniel; Peeples, Kenneth N; Raman, Vidya T; Olomu, Patrick N; Kovatsis, Pete G; Jagannathan, Narasimhan; Hunyady, Agnes; Bosenberg, Adrian; Tham, See; Low, Daniel; Hopkins, Paul; Glover, Chris; Olutoye, Olutoyin; Szmuk, Peter; McCloskey, John; Dalesio, Nicholas; Koka, Rahul; Greenberg, Robert; Watkins, Scott; Patel, Vikram; Reynolds, Paul; Matuszczak, Maria; Jain, Ranu; Khalil, Samia; Polaner, David; Zieg, Jennifer; Szolnoki, Judit; Sathyamoorthy, Kumar; Taicher, Brad; Riveros Perez, N Ricardo; Bhattacharya, Solmaletha; Bhalla, Tarun; Stricker, Paul; Lockman, Justin; Galvez, Jorge; Rehman, Mohamed; Von Ungern-Sternberg, Britta; Sommerfield, David; Soneru, Codruta; Chiao, Franklin; Richtsfeld, Martina; Belani, Kumar; Sarmiento, Lina; Mireles, Sam; Bilen Rosas, Guelay; Park, Raymond; Peyton, James

2017-09-01

The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

Atraumatic intubation: experience using a 5.0 endotracheal tube without a stylet for laryngeal surgery.

PubMed

Moore, Jaime E; Hu, Amanda; Rutt, Amy; Green, Parmis; Hawkshaw, Mary; Sataloff, Robert T

2015-02-01

Vocal fold injury is a well-know complication of intubation, with rates reported as high as 69%. Laryngology textbooks recommend the use of a small endotracheal tube (ETT) to help avoid these complications and optimize visualization. Case reports have suggested that the rigid stylet can lead to laryngeal injury. Given the additional risks, intubation without the stylet is our preferred practice. There is limited documentation in the literature regarding this viewpoint. Our study investigated the feasibility of and potential barriers to intubation using 5.0 ETT without a stylet. Prospective study. Consecutive adult patients undergoing laryngeal surgery were recruited for intubation with a 5.0 ETT without a stylet. Demographic data, specialty and training level of the intubator, and factors that would predict a difficult intubation were recorded. Descriptive statistical analysis was performed. Findings of the participants (n = 67) included average American Society of Anesthesiologists (ASA) physical status classification (2.2), average Mallampati score (1.7), average Cormack-Lehane grade (1.5), and average body mass index (28.0). Five patients (7.4%) required intubation using a stylet, and one of these five participants was intubated initially with a stylet. Of these five participants, 80% required use of a GlideScope (P < .001), and they had significantly higher ASA classification (P = .047) and number of intubation attempts (P = .042). One patient sustained an oropharyngeal injury during intubation with a stylet. No participants had laryngeal injury. Most patients can be intubated successfully using a 5.0 ETT without a stylet. There were no cases of laryngeal trauma with this technique. 2b. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

A randomized controlled study to evaluate and compare Truview blade with Macintosh blade for laryngoscopy and intubation under general anesthesia

PubMed Central

Timanaykar, Ramesh T; Anand, Lakesh K; Palta, Sanjeev

2011-01-01

Background: The Truview EVO2™ laryngoscope is a recently introduced device with a unique blade that provides a magnified laryngeal view at 42° anterior reflected view. It facilitates visualization of the glottis without alignment of oral, pharyngeal, and tracheal axes. We compared the view obtained at laryngoscopy, intubating conditions and hemodynamic parameters of Truview with Macintosh blade. Materials and Methods: In prospective, randomized and controlled manner, 200 patients of ASA I and II of either sex (20–50 years), presenting for surgery requiring tracheal intubation, were assigned to undergo intubation using a Truview or Macintosh laryngoscope. Visualization of the vocal cord, ease of intubation, time taken for intubation, number of attempts, and hemodynamic parameters were evaluated. Results: Truview provided better results for the laryngeal view using Cormack and Lehane grading, particularly in patients with higher airway Mallampati grading (P < 0.05). The time taken for intubation (33.06±5.6 vs. 23.11±57 seconds) was more with Truview than with Macintosh blade (P < 0.01). The Percentage of Glottic Opening (POGO) score was significantly higher (97.26±8) in Truview as that observed with Macintosh blade (83.70±21.5). Hemodynamic parameters increased after tracheal intubation from pre-intubation value (P < 0.05) in both the groups, but they were comparable amongst the groups. No postoperative adverse events were noted. Conclusion: Tracheal intubation using Truview blade provided consistently improved laryngeal view as compared to Macintosh blade without the need to align the oral, pharyngeal and tracheal axes, with equal attempts for successful intubation and similar changes in hemodynamics. However, the time taken for intubation was more with Truview. PMID:21772680

NewB for newbies: a randomized control trial training housestaff to perform neonatal intubation with direct and videolaryngoscopy.

PubMed

Koele-Schmidt, Lindsey; Vasquez, Margarita M

2016-04-01

Competency rates in neonatal intubation among pediatric residents are low and currently not meeting ACGME/AAP standards. The aim of this study was to compare standard bedside teaching of neonatal endotracheal intubation to a computer module, as well as introduce residents to the emerging technology of videolaryngoscopy. The study population consisted of The University of Texas Health Science Center at San Antonio Pediatric interns/residents and PGY-1 Anesthesia interns rotating through the NICU. Prior to participating in the study, the residents completed a survey addressing past experiences with intubation, comfort level, and prior use of direct and videolaryngoscopy. Participants then performed timed trials of both direct and videolaryngoscopy on the SimNewB(®). They had up to three attempts to successfully intubate, with up to 30 s on each attempt. After randomization, participants received one of the following teaching interventions: standard, computer module, or both. This was followed by a second intubation trial and survey completion. Thirty residents were enrolled in the study. There was significant improvement in time to successful intubation in both methods after any teaching intervention (direct 22.0 ± 13.4 s vs 14.7 ± 5.9 s, P = 0.002 and videolaryngoscopy 42.2 ± 29.3 s vs 26.8 ± 18.6 s, P = 0.003). No differences were found between the types of teaching. Residents were faster at intubating with direct laryngoscopy compared to videolaryngoscopy before and after teaching. By the end of the study, only 33% of residents preferred using videolaryngoscopy over direct laryngoscopy, but 76% felt videolaryngoscopy was better to teach intubation. Both standard teaching and computer module teaching of neonatal intubation on a mannequin model results in improved time to successful intubation and overall improved resident confidence with intubation equipment and technique. Although intubation times were lower with direct laryngoscopy compared to videolaryngoscopy, the participating residents felt that videolaryngoscopy is an important educational tool. © 2015 John Wiley & Sons Ltd.

Out-of-hospital tracheal intubation with single-use versus reusable metal laryngoscope blades: a multicenter randomized controlled trial.

PubMed

Jabre, Patricia; Galinski, Michel; Ricard-Hibon, Agnes; Devaud, Marie Laure; Ruscev, Mirko; Kulstad, Erik; Vicaut, Eric; Adnet, Fréderic; Margenet, Alain; Marty, Jean; Combes, Xavier

2011-03-01

Emergency tracheal intubation is reported to be more difficult with single-use plastic than with reusable metal laryngoscope blades in both inhospital and out-of-hospital settings. Single-use metal blades have been developed but have not been compared with conventional metal blades. This controlled trial compares the efficacy and safety of single-use metal blades with reusable metal blades in out-of-hospital emergency tracheal intubation. This randomized controlled trial was carried out in France with out-of-hospital emergency medical units (Services de Médecine d'Urgence et de Réanimation). This was a multicenter prospective noninferiority randomized controlled trial in adult out-of-hospital patients requiring emergency tracheal intubation. Patients were randomly assigned to either single-use or reusable metal laryngoscope blades and intubated by a senior physician or a nurse anesthetist. The primary outcome was first-pass intubation success. Secondary outcomes were incidence of difficult intubation, need for alternate airway devices, and early intubation-related complications (esophageal intubation, mainstem intubation, vomiting, pulmonary aspiration, dental trauma, bronchospasm or laryngospasm, ventricular tachycardia, arterial desaturation, hypotension, or cardiac arrest). The study included 817 patients, including 409 intubated with single-use blades and 408 with a reusable blade. First-pass intubation success was similar in both groups: 292 (71.4%) for single-use blades, 290 (71.1%) for reusable blades. The 95% confidence interval (CI) for the difference in treatments (0.3%; 95% CI -5.9% to 6.5%) did not include the prespecified inferiority margin of -7%. There was no difference in rate of difficult intubation (difference 3%; 95% CI -7% to 2%), need for alternate airway (difference 4%; 95% CI -8% to 1%), or early complication rate (difference 3%; 95% CI -3% to 8%). First-pass out-of-hospital tracheal intubation success with single-use metal laryngoscopy blades was noninferior to first-pass success with reusable metal laryngoscope blades. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage.

PubMed

Lioutas, Vasileios-Arsenios; Marchina, Sarah; Caplan, Louis R; Selim, Magdy; Tarsia, Joseph; Catanese, Luciana; Edlow, Jonathan; Kumar, Sandeep

2018-06-13

Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for "airway protection" with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated. We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders. Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48-7.22; p < 0.0001) and 4.32 (95% CI 2.5-7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively. In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies. © 2018 S. Karger AG, Basel.

A Randomized Crossover Study Comparing Cervical Spine Motion During Intubation Between Two Lightwand Intubation Techniques in Patients With Simulated Cervical Immobilization: Laryngoscope-Assisted Versus Conventional Lightwand Intubation.

PubMed

Kim, Tae Kyong; Son, Je-Do; Seo, Hyungseok; Lee, Yun-Seok; Bae, Jinyoung; Park, Hee-Pyoung

2017-08-01

In patients with cervical immobilization, jaw thrust can cause cervical spine movement. Concurrent use of a laryngoscope may facilitate lightwand intubation, allowing midline placement and free movement of the lightwand in the oral cavity without jaw thrust. We compared the effects of laryngoscope-assisted lightwand intubation (LALI) versus conventional lightwand intubation (CLI) on cervical spine motion during intubation in patients with simulated cervical immobilization. In this randomized crossover study, the cervical spine angle was measured before and during intubation at the occiput-C1, C1-C2, and C2-C5 segments in 20 patients with simulated cervical immobilization who underwent intubation using both the LALI and CLI techniques. Cervical spine motion was defined as the change from baseline in angle measured at each cervical segment during intubation. Cervical spine motion at the occiput-C1 segment was 5.6° (4.3) and 9.3° (4.5) when we used the LALI and CLI techniques, respectively (mean difference [98.33% CI]; -3.8° [-7.2 to -0.3]; P = .007). At other cervical segments, it was not significantly different between the 2 techniques (-0.1° [-2.6 to 2.5]; P = .911 in the C1-C2 segment and -0.2° [-2.8 to 2.5]; P = .795 in the C2-C5 segment). The LALI technique produces less upper cervical spine motion during intubation than the CLI technique in patients with simulated cervical immobilization.

A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient.

PubMed

Dronen, S C; Merigian, K S; Hedges, J R; Hoekstra, J W; Borron, S W

1987-06-01

In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.

Influence of clinical experience of the Macintosh laryngoscope on performance with the Pentax-AWS Airway Scope(®), a rigid video-laryngoscope, by paramedics in Japan.

PubMed

Ota, Kohei; Sadamori, Takuma; Kusunoki, Shinji; Otani, Tadatsugu; Tamura, Tomoko; Une, Kazunobu; Kida, Yoshiko; Itai, Junji; Iwasaki, Yasumasa; Hirohashi, Nobuyuki; Nakao, Masakazu; Tanigawa, Koichi

2015-10-01

We sought to establish the clinical utility of the Pentax-AWS Airway Scope(®) (AWS) when used by paramedics to intubate the trachea, and to evaluate whether their performance was influenced by previous clinical experience with the Macintosh laryngoscope (ML). Twenty paramedics attempted tracheal intubation using the AWS in five patients each in the operating room. We recorded the success rate, the number of intubation attempts, and the time for intubation and adverse events, and compared these based on the paramedics' previous clinical experience with the ML. Ten paramedics had no prior clinical experience of the ML (group A) and 10 had used it on more than 30 occasions (group B). The intubation success rate was 99 % (99/100). Notably, 96 % (47/49) of intubations were achieved on the first attempt by the inexperienced paramedics in group A, compared with 64 % (32/50) by the experienced paramedics in group B (p = 0.0001). The time to intubation (mean ± SD) was significantly shorter in group A than in group B (37 ± 24 vs. 48 ± 21 s, p = 0.002). There were marked variations in the times taken to intubate, but no apparent improvement as the intubators gained experience between their first and fifth cases. No complications were encountered in either group. We found that paramedics could achieve a high tracheal intubation success rate using the AWS independent of previous airway management experience. Better intubation performance with the AWS was observed in paramedics without clinical experience with the ML.

[Work, exclusion, pain, suffering, and gender relations: a survey of female workers treated for repetitive strain injury at a public health clinic].

PubMed

Neves, Ilidio Roda

2006-06-01

This article presents the results of a qualitative study based on patient records from a public health clinic and focusing on four therapeutic groups from 1995 to 1997. The study aimed to reconstruct the life and work history of women with repetitive strain injury (RSI) in relation to family, friends, company, workmates, health services, and impacts on daily life. The results corroborate the data in the scientific literature pointing to greater frequency of RSI among women, and allow us to list the needs related to the resulting biopsychosocial distress, suggesting the need for new research and intervention aimed at producing preventive and therapeutic technologies for such injuries.

[Tracheal Intubation by Paramedics in a Local Community: Current Situation and Future Challenges].

PubMed

Takinami, Yoshikazu

2016-03-01

As of April 2013, 164 paramedics are certified to perform tracheal intubation in Fukui Prefecture. This study investigated the current situation surrounding tracheal intubation performed by paramedics in prehospital care. Subjects were 58 paramedics who completed practical training at our hospital. Post-training duration, number of tracheal intubation cases, number of attempts before successful tracheal intubation, disease involved, rate of return of spontaneous circulation, and prognosis were examined. Tracheal intubation was successful on the first attempt in 92% of cases. Rate of return of spontaneous circulation was high in paramedics whose post-training duration was short. No return of spontaneous circulation occurred after a second attempt. Four patients survived asphyxia or aspiration. It is important to perform successful tracheal intubation on the first attempt, to recognize the probability of successful resuscitation in patients with exogenous disease, and to strengthen the medical control system.

Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students.

PubMed

Herbstreit, Frank; Fassbender, Philipp; Haberl, Helge; Kehren, Clemens; Peters, Jürgen

2011-09-01

Teaching endotracheal intubation to medical students is a task provided by many academic anesthesia departments. We tested the hypothesis that teaching with a novel videolaryngoscope improves students' intubation skills. We prospectively assessed in medical students (2nd clinical year) intubation skills acquired by intubation attempts in adult anesthetized patients during a 60-hour clinical course using, in a randomized fashion, either a conventional Macintosh blade laryngoscope or a videolaryngoscope (C-MAC®). The latter permits direct laryngoscopy with a Macintosh blade and provides a color image on a video screen. Skills were measured before and after the course in a standardized fashion (METI Emergency Care Simulator) using a conventional laryngoscope. All 1-semester medical students (n = 93) were enrolled. The students' performance did not significantly differ between groups before the course. After the course, students trained with the videolaryngoscope had an intubation success rate on a manikin 19% higher (95% CI 1.1%-35.3%; P < 0.001) and intubated 11 seconds faster (95% CI 4-18) when compared with those trained using a conventional laryngoscope. The incidence of "difficult (manikin) laryngoscopy" was less frequent in the group trained with the videolaryngoscope (8% vs 34%; P = 0.005). Education using a video system mounted into a traditional Macintosh blade improves intubation skills in medical students.

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

PubMed Central

Xue, Fu-Shan; Li, Hui-Xian; Liu, Ya-Yang; Yang, Gui-Zhen

2017-01-01

The C-MAC videolaryngoscope is the first Macintosh-typed videolaryngoscope. Since the advent of its original version video Macintosh system in 1999, this device has been modified several times. A unique feature of C-MAC device is its ability to provide the 2 options of direct and video laryngoscopy with the same device. The available evidence shows that in patients with normal airways, C-MAC videolaryngoscope compared with direct laryngoscopy can provide comparable or better laryngeal views and exerts less force on maxillary incisors, but does not offer conclusive benefits with regard to intubation time, intubation success, number of intubation attempts, the use of adjuncts, and hemodynamic responses to intubation. In patients with predicted or known difficult airways, C-MAC videolaryngoscope can achieve a better laryngeal view, a higher intubation success rate and a shorter intubation time than direct laryngoscopy. Furthermore, the option to perform direct and video laryngoscopy with the same device makes C-MAC videolaryngoscope exceptionally useful for emergency intubation. In addition, the C-MAC videolaryngoscope is a very good tool for tracheal intubation teaching. However, tracheal intubation with C-MAC videolaryngoscope may occasionally fail and introduction of C-MAC videolaryngoscope in clinical practice must be accompanied by formal training programs in normal and difficult airway managements. PMID:28740393

Intubation methods by novice intubators in a manikin model.

PubMed

O'Carroll, Darragh C; Barnes, Robert L; Aratani, Ashley K; Lee, Dane C; Lau, Christopher A; Morton, Paul N; Yamamoto, Loren G; Berg, Benjamin W

2013-10-01

Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1 ± 27.4 sec vs 45.9 ± 39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2 ± 1.0 95%CI [2.9-3.5] vs 2.4 ± 0.9 95%CI [2.1-2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5 ± 0.6 95%CI [3.3-3.7]) and ease of use (1.5 ± 0.7 95%CI [1.3-1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods.

Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation.

PubMed

Koh, Jae-Chul; Lee, Jong Seok; Lee, Youn-Woo; Chang, Chul Ho

2010-11-01

For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar. Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation. The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 ± 20%) than in Group L (6 ± 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups. The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injury.

Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults: A Retrospective Comparative Analysis from the Multicenter Perioperative Outcomes Group.

PubMed

Aziz, Michael F; Brambrink, Ansgar M; Healy, David W; Willett, Amy Wen; Shanks, Amy; Tremper, Tyler; Jameson, Leslie; Ragheb, Jacqueline; Biggs, Daniel A; Paganelli, William C; Rao, Janavi; Epps, Jerry L; Colquhoun, Douglas A; Bakke, Patrick; Kheterpal, Sachin

2016-10-01

Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques. Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet. A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period. Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

An evaluation of out-of-hospital advanced airway management in an urban setting.

PubMed

Colwell, Christopher B; McVaney, Kevin E; Haukoos, Jason S; Wiebe, David P; Gravitz, Craig S; Dunn, Will W; Bryan, Tamara

2005-05-01

To determine the success and complication rates associated with endotracheal intubation in an urban emergency medical services (EMS) system. This study evaluated consecutive airway interventions between March 2001 and May 2001 performed by paramedics from the Denver Health Paramedic Division in Denver, Colorado. Patients were identified and enrolled prospectively with the identification of all patients for whom intubation was attempted. A retrospective chart review of the emergency department (ED), intensive care unit, other hospital records, and the coroner's records was then conducted with the intent of identifying all complications related to attempted intubation, including the placement of each endotracheal tube. A total of 278 patients were included in this study. Of these, 154 (55%) had an initial nasal intubation attempt, and 124 (45%) had an initial oral intubation attempt. Of the 278 patients for whom an intubation was attempted, 234 (84%, 95% CI = 77% to 88%) were reported by paramedics to be successfully intubated. Of 114 nasal intubations reported as successful by paramedics, two (2%; 95% CI = 0.2% to 6%) were found to be misplaced. Of the 120 oral intubations reported as successful by paramedics, one (1%; 95% CI = 0.02% to 5%) was found to be misplaced. Of the 278 patients, 22 (8%; 95% CI = 5% to 12%) had complications; three (1%; 95% CI = 0.2% to 3%) endotracheal tubes were incorrectly positioned, two (0.7%; 95% CI = 0.08% to 3%) of which were undetected esophageal intubations and one (0.4%; 95% CI = 0 to 2%) of which was in the posterior pharynx. Reasonable success and complication rates of endotracheal intubation in the out-of-hospital setting can be achieved in a busy, urban EMS system without the assistance of medications.

A 12-month descriptive analysis of emergency intubations at Brooke Army Medical Center: a National Emergency Airway Registry study.

PubMed

April, Michael D; Schauer, Steven G; Brown Rd, Calvin A; Ng, Patrick C; Fernandez, Jessie; Fantegrossi, Andrea E; Maddry, Joseph K; Summers, Shane; Sessions, Daniel J; Barnwell, Robert M; Antonacci, Mark

2017-01-01

Emergency airway management is a critical skill for military healthcare providers. Our goal was to describe the Emergency Department (ED) intubations at Brooke Army Medical Center (BAMC) over a 12-month period. Physicians performing endotracheal intubations in the BAMC ED complete data collection forms for each intubation event as part of the National Emergency Airway Registry, including patient demographics, intubation techniques, success and failure rates, adverse events, and patient disposition. We cross-referenced these forms against the numbers of intubation events reported in the ED nursing daily reports to ensure capture of all intubations. Providers completed forms for every intubation within 6 weeks of the procedure. We analyzed data from March 28, 2016, to March 27, 2017. During the study period, providers performed 259 intubations in the BAMC ED. Reasons for intubation were related to trauma for 184 patients (71.0%) and medical conditions for 75 patients (29.0%). Overall, first-attempt success was 83.0%. Emergency medicine residents performed a majority of first attempts (95.0%). Most common devices chosen on first attempt were a video laryngoscope for 143 patients (55.2%) and a direct laryngoscope for 115 patients (44.4%). One patient underwent cricothyrotomy. The 2 most common induction agents were ketamine (59.8%; 95% CI, 55.2%-67.4%) and etomidate (19.3%; 95% CI, 14.7%-24.7%). The most common neuromuscular blocking agents were rocuronium (62.9%; 95% CI, 56.7%-68.8%) and succinylcholine (18.9%; 95% CI, 14.3%-24.2%). In the BAMC ED, emergency intubation most commonly occurred for trauma indications using video laryngoscopy with a high first-pass success.

High levels of IGF-1 predict difficult intubation of patients with acromegaly.

PubMed

Zhang, Yu; Guo, Xiaopeng; Pei, Lijian; Zhang, Zhuhua; Tan, Gang; Xing, Bing

2017-08-01

To investigate the characteristics of difficult intubation and identify novel efficient predictors in patients with acromegaly. Patients with either untreated acromegaly or non-functional pituitary adenomas were enrolled. Patients with acromegaly underwent hormone assays, upper airway computed tomography and magnetic resonance imaging examinations and preoperative overnight polysomnography. The modified Mallampati classification, mouth opening, neck circumference, and neck extension were assessed, and the Cormack-Lehane grades and the time of tracheal intubation were recorded. Patients with acromegaly had a higher incidence of difficult intubation (62.5%). The time of tracheal intubation was prolonged, the neck circumference was enlarged, and the neck extension was confined. In patients with acromegaly and difficult intubation, the insulin-like growth factor 1 levels and apnea/hypoxia index were significantly higher compared to patients without difficult intubation (1115.40 ± 253.73 vs. 791.67 ± 206.62 ng/ml, P = 0.020; 22.17 ± 23.25 vs. 2.47 ± 2.84, P = 0.026, respectively). The bilateral regression analysis revealed that high levels of insulin-like growth factor 1 were an independent risk factor for developing difficult intubation (p = 0.042, Exp B = 1.006). The modified Mallampati classification was positively correlated with apnea/hypoxia index and could be calculated using the following logarithmic equation: MMC = 0.2982 * ln (AHI) + 2.1836. In patients with acromegaly, neck movement is confined, the time of tracheal intubation is prolonged, and the neck circumference is enlarged, and these patients suffer from an increased incidence of difficult intubation (62.5%) during anesthesia induction. The apnea/hypoxia index and insulin-like growth factor 1 levels are both increased in acromegalic patients with difficult intubation, and elevated insulin-like growth factor 1 levels are an independent risk factor of difficult intubation in acromegalic patients.

Ventilator-associated pneumonia, like real estate: location really matters.

PubMed

Eckert, Matthew J; Davis, Kimberly A; Reed, R Lawrence; Esposito, Thomas J; Santaniello, John M; Poulakidas, Stathis; Gamelli, Richard L; Luchette, Fred A

2006-01-01

Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

Acromegaly and papillomatosis: difficult intubation and use of the airway exchange catheter.

PubMed

Hulme, G J; Blues, C M

1999-08-01

We describe the anaesthetic management of a patient with acromegaly scheduled for transsphenoidal resection of a pituitary tumour who was found at intubation to have coexisting laryngeal papillomatosis. Oral intubation was impossible using both direct and fibreoptic techniques. Nasal fibreoptic intubation was successful but precluded the transsphenoidal approach to surgery. A Cook Airway Exchange Catheter [Cook (UK) Ltd, Monroe House, Letchworth SG6 1LN] was used with a Negus bronchoscope to convert to oral intubation and allow completion of surgery without resort to tracheostomy.

Hydrodynamic damping and stiffness prediction in Francis turbine runners using CFD

NASA Astrophysics Data System (ADS)

Nennemann, Bernd; Monette, Christine; Chamberland-Lauzon, Joël

2016-11-01

Fluid-structure interaction (FSI) has a major impact on the dynamic response of the structural components of hydroelectric turbines. On mid- to high-head Francis runners, the rotor-stator interaction (RSI) phenomenon has to be considered carefully during the design phase to avoid operational issues on the prototype machine. The RSI dynamic response amplitudes of the runner are driven by three main factors: (1) pressure forcing amplitudes, (2) excitation frequencies in relation to natural frequencies and (3) damping. All three of the above factors are significantly influenced by both mechanical and hydraulic parameters. The prediction of the first two factors has been largely documented in the literature. However, the prediction of hydro-dynamic damping has only recently and only partially been treated. Two mode-based approaches (modal work and coupled single degree of freedom) for the prediction of flow-added dynamic parameters using separate finite element analyses (FEA) in still water and unsteady computational fluid dynamic (CFD) analyses are presented. The modal motion is connected to the time resolved CFD calculation by means of dynamic mesh deformation. This approach has partially been presented in a previous paper applied to a simplified hydrofoil. The present work extends the approach to Francis runners under RSI loading. In particular the travelling wave mode shapes of turbine runners are considered. Reasonable agreement with experimental results is obtained in parts of the operating range.

Three novel proteins co-localise with polyhydroxybutyrate (PHB) granules in Rhodospirillum rubrum S1.

PubMed

Narancic, Tanja; Scollica, Elisa; Cagney, Gerard; O'Connor, Kevin E

2018-04-01

Polyhydroxybutyrate (PHB), a biodegradable polymer accumulated by bacteria is deposited intracellularly in the form of inclusion bodies often called granules. The granules are supramolecular complexes harbouring a varied number of proteins on their surface, which have specific but incompletely characterised functions. By comparison with other organisms that produce biodegradable polymers, only two phasins have been described to date for Rhodosprillum rubrum, raising the possibility that more await discovery. Using a comparative proteomics strategy to compare the granules of wild-type R. rubrum with a PHB-negative mutant housing artificial PHB granules, we identified four potential PHB granules' associated proteins. These were: Q2RSI4, an uncharacterised protein; Q2RWU9, annotated as an extracellular solute-binding protein; Q2RQL4, annotated as basic membrane lipoprotein; and Q2RQ51, annotated as glucose-6-phosphate isomerase. In silico analysis revealed that Q2RSI4 harbours a Phasin_2 family domain and shares low identity with a single-strand DNA-binding protein from Sphaerochaeta coccoides. Fluorescence microscopy found that three proteins Q2RSI4, Q2EWU9 and Q2RQL4 co-localised with PHB granules. This work adds three potential new granule associated proteins to the repertoire of factors involved in bacterial storage granule formation, and confirms that proteomics screens are an effective strategy for discovery of novel granule associated proteins.

Rapid sequence induction has no use in pediatric anesthesia.

PubMed

Engelhardt, Thomas

2015-01-01

(Classic) rapid sequence induction and intubation (RSII) has been considered fundamental to the provision of safe anesthesia. This technique consists of a combination of drugs and techniques and is intended to prevent pulmonary aspiration of gastric content with catastrophic outcomes to the patient. This review investigates aspects of this technique and highlights dangers and frauds if this technique is transferred directly into pediatric anesthesia practice. The author recommends a controlled anesthesia induction by trained pediatric anesthesiologist with suitable equipment for the children considered at risk of pulmonary aspiration. RSSI is a dangerous technique if adopted without modification into pediatric anesthesia and has in its 'classic' form no use. © 2014 John Wiley & Sons Ltd.

Intubation conditions in young infants after propofol and remifentanil induction with and without low-dose rocuronium.

PubMed

Gelberg, J; Kongstad, L; Werner, O

2014-08-01

Bolus injections of intravenous propofol and remifentanil can be used in the tracheal intubation of infants and children, but relatively large doses are needed. We hypothesised that addition of a small bolus of rocuronium would ensure good intubation conditions when modest propofol and remifentanil doses were used. Seventy infants between 3 weeks and 4 months of age were randomised to receive either placebo or rocuronium. Anaesthesia was induced with IV propofol, 3 (3-5) mg/kg [median (range)]. Rocuronium (0.2 mg/kg) or placebo was then injected, followed 15 s later by 2 μg/kg remifentanil. One anaesthetist attempted tracheal intubation 1 min after the rocuronium/placebo injection and used the 'Copenhagen scoring system' to assess intubation conditions. The neuromuscular effect of 0.2 mg/kg rocuronium was recorded in another eight, already intubated, infants using thumb accelerometry during train-of-four stimulation of the ulnar nerve. Intubation conditions were classified as 'poor' in 14 of 34 (41%) patients given placebo and in 10 of 36 (28%) patients given rocuronium (P = 0.32). There were four failed first attempts at intubation in the placebo group and none in the rocuronium group (P = 0.051). Maximum neuromuscular depression occurred 4 (3-8) after injection of 0.2 mg/kg rocuronium. Intubation conditions were poor in almost one third of the patients receiving propofol-remifentanil. Adding a low-dose rocuronium did not significantly improve intubation conditions. © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit

PubMed Central

Grubb, Peter H.; Lea, Amanda S.; Walsh, William F.; Markham, Melinda H.; Maynord, Patrick O.; Whitney, Gina M.; Stark, Ann R.; Ely, E. Wesley

2016-01-01

OBJECTIVE: To improve patient safety in our NICU by decreasing the incidence of intubation-associated adverse events (AEs). METHODS: We sequentially implemented and tested 3 interventions: standardized checklist for intubation, premedication algorithm, and computerized provider order entry set for intubation. We compared baseline data collected over 10 months (period 1) with data collected over a 10-month intervention and sustainment period (period 2). Outcomes were the percentage of intubations containing any prospectively defined AE and intubations with bradycardia or hypoxemia. We followed process measures for each intervention. We used risk ratios (RRs) and statistical process control methods in a times series design to assess differences between the 2 periods. RESULTS: AEs occurred in 126/273 (46%) intubations during period 1 and 85/236 (36%) intubations during period 2 (RR = 0.78; 95% confidence interval [CI], 0.63–0.97). Significantly fewer intubations with bradycardia (24.2% vs 9.3%, RR = 0.39; 95% CI, 0.25–0.61) and hypoxemia (44.3% vs 33.1%, RR = 0.75, 95% CI 0.6–0.93) occurred during period 2. Using statistical process control methods, we identified 2 cases of special cause variation with a sustained decrease in AEs and bradycardia after implementation of our checklist. All process measures increased reflecting sustained improvement throughout data collection. CONCLUSIONS: Our interventions resulted in a 10% absolute reduction in AEs that was sustained. Implementation of a standardized checklist for intubation made the greatest impact, with reductions in both AEs and bradycardia. PMID:27694281

Intubation Methods by Novice Intubators in a Manikin Model

PubMed Central

O'Carroll, Darragh C; Aratani, Ashley K; Lee, Dane C; Lau, Christopher A; Morton, Paul N; Yamamoto, Loren G; Berg, Benjamin W

2013-01-01

Tracheal Intubation is an important yet difficult skill to learn with many possible methods and techniques. Direct laryngoscopy is the standard method of tracheal intubation, but several instruments have been shown to be less difficult and have better performance characteristics than the traditional direct method. We compared 4 different intubation methods performed by novice intubators on manikins: conventional direct laryngoscopy, video laryngoscopy, Airtraq® laryngoscopy, and fiberoptic laryngoscopy. In addition, we attempted to find a correlation between playing videogames and intubation times in novice intubators. Video laryngoscopy had the best results for both our normal and difficult airway (cervical spine immobilization) manikin scenarios. When video was compared to direct in the normal airway scenario, it had a significantly higher success rate (100% vs 83% P=.02) and shorter intubation times (29.1±27.4 sec vs 45.9±39.5 sec, P=.03). In the difficult airway scenario video laryngoscopy maintained a significantly higher success rate (91% vs 71% P=0.04) and likelihood of success (3.2±1.0 95%CI [2.9–3.5] vs 2.4±0.9 95%CI [2.1–2.7]) when compared to direct laryngoscopy. Participants also reported significantly higher rates of self-confidence (3.5±0.6 95%CI [3.3–3.7]) and ease of use (1.5±0.7 95%CI [1.3–1.8]) with video laryngoscopy compared to all other methods. We found no correlation between videogame playing and intubation methods. PMID:24167768

Evaluation of chest compression effect on airway management with air-Q, aura-i, i-gel, and Fastrack intubating supraglottic devices by novice physicians: a randomized crossover simulation study.

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Kaminoh, Yoshiroh; Nishi, Shin-Ichi

2014-10-01

In the 2010 American Heart Association guidelines, supraglottic devices (SGDs) such as the laryngeal mask are proposed as alternatives to tracheal intubation for cardiopulmonary resuscitation. Some SGDs can also serve as a means for tracheal intubation after successful ventilation. The purpose of this study was to evaluate the effect of chest compression on airway management with four intubating SGDs, aura-i (aura-i), air-Q (air-Q), i-gel (i-gel), and Fastrack (Fastrack), during cardiopulmonary resuscitation using a manikin. Twenty novice physicians inserted the four intubating SGDs into a manikin with or without chest compression. Insertion time and successful ventilation rate were measured. For cases of successful ventilation, blind tracheal intubation via the intubating SGD was performed with chest compression and success or failure within 30 s was recorded. Chest compression did not decrease the ventilation success rate of the four intubating SGDs (without chest compression (success/total): air-Q, 19/20; aura-i, 19/20; i-gel, 18/20; Fastrack, 19/20; with chest compression: air-Q, 19/20; aura-i, 19/20; i-gel, 16/20; Fastrack, 18/20). Insertion time was significantly lengthened by chest compression in the i-gel trial (P < 0.05), but not with the other three devices. The blind intubation success rate with chest compression was the highest in the air-Q trial (air-Q, 15/19; aura-i, 14/19; i-gel, 12/16; Fastrack, 10/18). This simulation study revealed the utility of intubating SGDs for airway management during chest compression.

Practice of Intubation of the Critically Ill at Mayo Clinic.

PubMed

Smischney, Nathan J; Seisa, Mohamed O; Heise, Katherine J; Busack, Kyle D; Loftsgard, Theodore O; Schroeder, Darrell R; Diedrich, Daniel A

2017-01-01

To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic's campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. Critically ill adult (≥18 years) patients admitted to a medical-surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.

[Inductions and intubating conditions with sevoflurane and different doses of remifentanil without muscle relaxant in children].

PubMed

Wei, Ling-Xin; Deng, Xiao-Ming; Liu, Ju-Hui; Luo, Mao-Ping; Tong, Shi-Yi; Zhang, Yan-Ming; Liao, Xu; Xu, Kun-Lin

2008-12-01

To observe the clinical effectiveness of inductions and tracheal intubating conditions with 3% sevoflurane and different doses of remifentanil without muscle relaxant in children. Totally 120 peadiatric patients (aged 4-10 years, American Society of Anesthesiologists grade I for inhalational induction) were randomly allocated into group I (remifentanil 1 microg/kg), group II (remifentanil 2 microg/kg), group III (remifentanil 3 microg/kg), and control group (vecuronium bromide 0.1 mg/kg). After inhalational induction with 3% sevoflurane and 60% nitrous oxide in 40% oxygen for 2 minutes, remifentanil 1 microg/kg, 2 microg/ kg, and 3 microg/kg were intravenously injected over 1 minute into patients in group I , group II, and group III, respectively. After remifentanil administration and manual ventilation for 1 minute, the trachea was intubated. In the control group, 2 minutes after intravenous administration of vecuronium bromide 0.1 mg/kg, tracheal intubation was attempted. Agitation, intubating satisfactoriness, and the circulation changes after tracheal intubation and anesthesia induction were observed. In these four groups, agitation occurred in 37.5% of patients during sevoflurane induction. Satisfactory intubation rate was 70.0% in group I, 86.7% in group II, 90.0% in group III, and 93.3% in the control group. Compared with the control group, the impact of tracheal intubation on the circulatory system was smaller in group I , II , and III. Induction with 3% sevoflurane combined with remifentanil can be smoothly performed, followed by the successful tracheal intubation. The intubating conditions are more satisfactory with 3% sevoflurane combined with remifentanil 2 microg/kg or 3 microg/kg.

Failed Endotracheal Intubation and Adverse Outcomes Among Extremely Low Birth Weight Infants

PubMed Central

Wallenstein, Matthew B.; Birnie, Krista L.; Arain, Yassar H.; Yang, Wei; Yamada, Nicole K.; Huffman, Lynne C.; Palma, Jonathan P.; Chock, Valerie Y.; Shaw, Gary M.; Stevenson, David K.

2015-01-01

OBJECTIVE To quantify the importance of successful endotracheal intubation on the first attempt among extremely low birth weight (ELBW) infants who require resuscitation after delivery. STUDY DESIGN A retrospective chart review was conducted for all ELBW infants ≤1000 g born between January 2007 and May 2014 at a level IV neonatal intensive care unit. Infants were included if intubation was attempted during the first five minutes of life, or if intubation was attempted during the first 10 minutes of life with heart rate < 100. The primary outcome was death or neurodevelopmental impairment. The association between successful intubation on the first attempt and the primary outcome was assessed using multivariable logistic regression with adjustment for birth weight, gestational age, gender, and antenatal steroids. RESULTS The study sample included 88 ELBW infants. Forty-percent were intubated on the first attempt and 60% required multiple intubation attempts. Death or neurodevelopmental impairment occurred in 29% of infants intubated on the first attempt, compared to 53% of infants that required multiple attempts, adjusted odds ratio 0.4 (95% confidence interval 0.1 - 1.0), p < 0.05. CONCLUSION Successful intubation on the first attempt is associated with improved neurodevelopmental outcomes among ELBW infants. This study confirms the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation after birth and has implications for personnel selection and role assignment in the delivery room. PMID:26540244

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

PubMed

Kim, Hyun-Jung; Kim, Jin-Tae; Kim, Hee-Soo; Kim, Chong-Sung; Kim, Seong-Deok

2011-04-01

The relative effectiveness of GlideScope(®) videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients. Our patient cohort consisted of 80 children <10 years of age who required nasotracheal intubation for elective dental or facial surgery. The patients were randomly allocated to GV (n = 40) or DL (n = 40) group. The time to intubation (TTI), glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation were evaluated. The median TTI was similar between the groups. The TTI of the former 20 patients was faster in the DL group (53.3 s, interquartile range: 42.0-64.3) than GV group (65.9 s, interquartile range: 56.0-93.9) (P = 0.007), whereas the TTI of the latter 20 patients was comparable between the groups. There were no significant differences in glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation between the two groups. GV can provide similar intubation performance characteristics compared with DL when used for nasotracheal intubation in pediatric patients. However, experience is needed to be skillful in the GV to acquire comparable TTI with DL. © 2011 Blackwell Publishing Ltd.

Evaluation of alternative airway management strategies in surgical repair of severe cranio-maxillofacial trauma.

PubMed

Zhang, Xinpei; Wang, Xing; Gu, Qianping; Zhang, Jie; Wu, Ruihan; Zhuang, Qianwei; Na, Li; Meng, Jian

2016-12-01

Severe cranio-maxillofacial trauma requires the utilization of alternative airway management techniques when oral and nasal routes of tracheal intubation are either not possible or contraindicated. This retrospective study evaluated the techniques of submental intubation, retromolar intubation and tracheostomy in terms of their frequency of use, time required, costs involved and associated complications in a total of 200 patients. Frequency of utilization of alternative airway management techniques was 3.63%. Tracheostomy was associated with the most severe complications, took the most time to establish and was the most expensive technique. Although retromolar intubation was not associated with any complications, it was not suitable in adults with erupted third molars and interfered with the surgical field. Submental intubation was associated with minor complications, was suitable in all cases and did not interfere with surgical access. Retromolar intubation must be considered as a first choice alternative in patients with unerupted third molars provided the surgeon is adept at working in the presence of an oral tube. Submental intubation is a good second choice when retromolar intubation is not possible or is not acceptable to the surgeon. Tracheostomy is only indicated in patients who require long term control of the airway.

[Usefullness of bronchofiberscopy for difficult intubation in patients with severe motor and intellectual disabilities].

PubMed

Mizuno, Yuji; Ukaji, Koutarou

2005-11-01

In 21 patients with severe motor and intellectual disabilities, bronchofiberoptic intubation was performed because of difficulty in tracheal intubation by direct laryngoscopy. The patients ranged from 3 to 35 years old (mean age: 20.2 years). Twenty patients (95.2%) were bedridden. Among the 21 patients, 15 had cerebral palsy and 20 had hypertonia. The reason for intubation were acute respiratory failure due to pneumonia in 17 cases, suffocation after aspiration of food in 2 cases, hypovolemic shock in 1 case, and laryngotracheomalacia in 1 case. Intubation was done pernasally in 15 patients and perorally in 10. It was successful in 20 cases without any significant complications. The Cormack score ranged from 3rd degree in 4 cases to 4th in 17 cases. The 20 cases of successful fiberoptic intubation were divided into 7 patients with and 13 without tracheostomy. The mortality rate was 14.3% in patients with tracheostomy and 30.8% in those without tracheostomy. When more than 4 intubation trials were needed, there was a significantly higher mortality rate. In neurologically handicapped patients with deformity or hypertonia of the oral, cervical, or airway structures, a bronchofiberoptic procedure may be recommended when there is difficulty with intubation.

A nationwide postal questionnaire survey: the presence of airway guidelines in anaesthesia department in Sweden.

PubMed

Knudsen, Kati; Pöder, Ulrika; Högman, Marieann; Larsson, Anders; Nilsson, Ulrica

2014-01-01

In Sweden, airway guidelines aimed toward improving patient safety have been recommended by the Swedish Society of Anaesthesia and Intensive Care Medicine. Adherence to evidence-based airway guidelines is known to be generally poor in Sweden. The aim of this study was to determine whether airway guidelines are present in Swedish anaesthesia departments. A nationwide postal questionnaire inquiring about the presence of airway guidelines was sent out to directors of Swedish anaesthesia departments (n = 74). The structured questionnaire was based on a review of the Swedish Society of Anaesthesia and Intensive Care voluntary recommendations of guidelines for airway management. Mean, standard deviation, minimum/maximum, percentage (%) and number of general anaesthesia performed per year as frequency (n), were used to describe, each hospital type (university, county, private). For comparison between hospitals type and available written airway guidelines were cross tabulation used and analysed using Pearson's Chi-Square tests. A p- value of less than 0 .05 was judged significant. In total 68 directors who were responsible for the anaesthesia departments returned the questionnaire, which give a response rate of 92% (n 68 of 74). The presence of guidelines showing an airway algorithm was reported by 68% of the departments; 52% reported having a written patient information card in case of a difficult airway and guidelines for difficult airways, respectively; 43% reported the presence of guidelines for preoperative assessment; 31% had guidelines for Rapid Sequence Intubation; 26% reported criteria for performing an awake intubation; and 21% reported guidelines for awake fibre-optic intubation. A prescription for the registered nurse anaesthetist for performing tracheal intubation was reported by 24%. The most frequently pre-printed preoperative elements in the anaesthesia record form were dental status and head and neck mobility. Despite recommendations from the national anaesthesia society, the presence of airway guidelines in Swedish anaesthesia departments is low. From the perspective of safety for both patients and the anaesthesia staff, airway management guidelines should be considered a higher priority.

Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit.

PubMed

Decelle, Lydie; Thys, Frédéric; Zech, Francis; Verschuren, Franck

2013-02-01

The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients. This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among 75 patients, 15 patients developed VAP (20%; 95% CI 12-31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P=0.001), out-of-hospital as the location of intubation (P=0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P=0.024). Death rate was 17% and was not significantly higher for patients with VAP (P=0.9; 95% CI 0.32-4.95%). Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.

Adhesives for bonding RSI tile to GrPI structure for advanced space transportation systems

NASA Technical Reports Server (NTRS)

Smith, K. E.; Hamermesh, C. L.; Hogenson, P. A.

1979-01-01

A system was developed for bonding RSI tiles to a graphite/polymide composite substrate which would withstand the full range of environmental conditions. The bonding system, designated RA59, consists of a mixture of glass (sesquisiloxane) resin in RTV 560 silicone. A significant number of data points for the RA59 are in the 65-psi failure range both when tested, and after exposure to 700 F. This is over two times the best shear and tensile values obtained with RV60 at this temperature. It is concluded that with a thorough understanding of the critical parameters involved, the higher values should be obtained consistently with the RA59. This is of particular significance if higher strength tiles were to be used in a hard-bonded configuration.

Comparison of Macintosh and Intubrite laryngoscopes for intubation performed by novice physicians in a difficult airway scenario.

PubMed

Szarpak, Lukasz; Smereka, Jacek; Ladny, Jerzy R

2017-05-01

In the difficult airway, the intubation skills are critically important. In selected cases, particularly in airway edema, laryngeal or tongue edema, endotracheal intubation can turn out very difficult, and repeated attempts may even worsen the airway edema, causing trauma and bleeding, and finally leading to complete airway obstruction and inability to ventilate the patient. The aim of the study was to compare the efficacy of endotracheal intubation performed by novice physicians using a standard Macintosh laryngoscope and an Intubrite videolaryngoscope. The study was designed as a prospective, randomized, crossover, simulation study and continues our research assessing the effectiveness of selected endotracheal intubation techniques in prehospital settings. All participants were experienced with the Macintosh direct laryngoscope but remained novice to videolaryngoscopy. Instructions on the correct use of the Macintosh and Intubrite laryngoscopes were given before the procedure, and all the 30 novice physicians were allowed to practice at least 10 times before the study on manikin with normal airways. We employed an airway manikin (Trucorp Airsim Bronchi; Trucorp Ltd., Belfast, Northern Ireland) to simulate difficult airway, with was obtained by inflating the tongue with 50mL of air. The participants were asked to perform tracheal intubation using an endotracheal tube with 7.5mm of internal diameter (Portex; Smiths Medical, Hythe, UK) through the vocal cords, applying either a conventional Macintosh laryngoscope with a size 3 blade (MAC; Mercury Medical, Clearwater, FL, USA) or the Intubrite videolaryngoscope, also with a Macintosh No. 3 blade (INT; Intubrite Llc, Vista, CA, USA). In both intubation techniques, a guide stylet (Rusch Inc., Duluth, GA, USA) was introduced into the endotracheal tube in order to obtain a C-shape curve to facilitate tracheal intubation. Each participating physician was randomly assigned to three attempts of tracheal intubation with each device. The effectiveness of the first intubation attempt using MAC and INT was 63.6% and 53.4%, respectively (p=0.023), and the total percentage of intubation was 100% for both methods. The median time to intubation was 29.5 (interquartile range [IQR], 27-35.5) s with MAC, and 229 (IQR, 25.5-37) s with INT. The total of 24 physicians out of all study participants would choose MAC as a device to intubate with in real terms, while only 6 physicians would choose INT. During the simulation study, the novice physicians were able to perform endotracheal intubation at the same time using both the Macintosh and Intubrite videolaryngoscope. However, the efficacy of the first intubation attempt was higher for MAC. Further studies are needed to confirm the results. Copyright © 2017 Elsevier Inc. All rights reserved.

Critical Analyses and Development of Training Mechanisms: Cholinergic Crisis and Pediatric/Neonatal Intubation

DTIC Science & Technology

2015-02-01

Anaesthesia, 1989. 36(2): p. 141-144. 8. Hall, R., et al., Human Patient Simulation Is Effective for Teaching Paramedic Students Endotracheal Intubation...duration and # of attempts, checklist and GRS scores [5]Calderwood -Medical students -Anesthetized cats -Success -PM [6]Falck -449 intubation...optic intubation – realism and effectiveness -Pig -Mannequin -Secretions -Anatomy -Appearance Technique - [8]Hall -36 paramedic students

Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation.

PubMed

Hilton, Michael T; Wayne, Max; Martin-Gill, Christian

2016-01-01

Orotracheal intubation is a key component of prehospital airway management and success rates are dependent on procedural experience. Supraglottic airway devices are increasingly being used in the prehospital setting. As a result, paramedics may have fewer opportunities for performing intubation, limiting their proficiency in the procedure. We aimed to determine the trends in intubation versus supraglottic airway use over an 8 year period. We also aimed to determine the association between system-wide introduction of King LT guidelines and ETI success rates. We performed a retrospective observational study of 37 Emergency Medical Services (EMS) agencies in a 10 county region of Southwestern Pennsylvania. Cases between January 1, 2005 and December 31, 2012 were included if an advanced airway procedure was performed. We determined trends in advanced airway placement and compared the proportion of cases with first pass intubation success before and after the King LT was introduced and promoted by statewide protocol starting in 2007. Use of airway devices before and after King LT implementation were presented using descriptive statistics and compared using Pearson's Chi-square or Fishers Exact test as appropriate. We compared first pass success rate of orotracheal intubation between study periods using multivariable logistic regression, controlling for other factors that may impact success of orotracheal intubation (year, EMS agency, age category, traumatic injury, and cardiac arrest). There were 712 cases of orotracheal intubation before and 2,835 cases after introduction of the King LT. The proportion of cases ultimately managed with orotracheal intubation before and after 2007 decreased from 72.3% (95% CI 68.9-75.6%) to 67.1% (95% CI 65.3-68.8%) (p = 0.007). In the multivariable analysis, success of orotracheal intubation was not associated with implementation of the King LT airway (OR 1.02, 95% CI 0.74-1.41). Fewer patients with advanced airway management received orotracheal intubation since introduction of the King LT. In spite of this modest change in airway management, there has not been a change in orotracheal intubation success rate since introduction of this supraglottic device as a primary or rescue airway in this regional EMS setting.

Effects of nicardipine on the onset time and intubation conditions of rocuronium-induced neuromuscular blockade.

PubMed

Lee, Sun-Yeul; Kim, Yoon-Hee; Ko, Young-Kwon; Park, Sang-Il; Lee, Jung-Un; Chung, Woo-Suk; Lim, Chae-Seong

2016-08-01

The objective of this study was to identify the effects of nicardipine on neuromuscular blockade of rocuronium, such as the onset time and intubation conditions, using a nicardipine dose that attenuates cardiovascular responses during endotracheal intubation. Randomized, double-blinded, placebo-controlled clinical comparison was used as the design of this study The study was conducted at the operating room of a university hospital. Participants of this study comprise 78 American Society of Anesthesiologists physical status 1 and 2 patients, aged 18 to 60 years who were undergoing elective surgery under general anesthesia. The nicardipine group was given an intravenous bolus of 20 μg/kg nicardipine before tracheal intubation: the control group was given an intravenous bolus of a comparable volume of normal saline before tracheal intubation. Using a TOF-Watch SX monitor, the time from the end of the injection of rocuronium to maximum depression of T1 (onset time) was measured. Intubation was performed 1 minute after rocuronium administration, and the status of the intubation conditions was assessed. The mean blood pressure and heart rate were each measured after endotracheal intubation. Rate pressure product values were also calculated. Intubation conditions were clinically acceptable in 37 (94.9%) of 39 patients in group N compared with 29 (74.4%) of 39 in group C (P < .05). The onset time of rocuronium was significantly faster in group N than in group C (P < .05). The mean blood pressure was significantly lower in group N than in group C (P < .05). The heart rate was significantly higher in group N than in group C (P < .05). Rate pressure product values showed no significant difference between the two groups (P > .05). Pretreatment with 20 μg/kg nicardipine improves intubation conditions, shortens the onset time of rocuronium, and attenuates cardiovascular responses to tracheal intubation. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of the Pentax AirwayScope and McGrath MAC videolaryngoscope for endotracheal intubation in patients with a normal airway

PubMed Central

Lee, Jiyoung; Kwak, Hyun Jeong; Lee, Ji Yeon; Chang, Min Young; Lee, Sook Young; Kim, Jong Yeop

2017-01-01

Abstract Various videolaryngoscopes (VLs) have been developed to provide a better laryngeal view and facilitate difficult intubations. The goal of this study was to compare 2 VLs, the Pentax AWS and the McGrath VL, with respect to intubation time and ease of intubation. One hundred forty patients aged 19 to 65 years (American Society of Anesthesiologists classification I or II), who required tracheal intubation for elective surgery, were randomly assigned to 1 of the 2 groups: the Pentax AWS (n = 70) or the McGrath VL (n = 70). The primary outcome was time to intubation (TTI) measured by a blind observer. The intubation difficulty scale (IDS), percentage of glottic opening (POGO) scale, glottic grade, use of optimal external laryngeal manipulation (OELM), and ease of intubation were also recorded. The Pentax AWS provided a better laryngeal view than the McGrath VL with respect to the Cormack-Lehane (CL) glottic grade (1/2a/2b) (63/7/0 vs 43/24/3, P < .001) and the POGO scale (median [interquartile range, IQR]) (100 [100–100] vs 100 [80–100], P < .001). The IDS was significantly lower in the Pentax AWS group compared with the McGrath VL group (median [IQR]) (0 [0–0] vs 0 [0–1], P < .001). However, the TTI was similar in both the Pentax AWS and McGrath VL groups (median [IQR]) (30 [27–34] vs 32 [27–35] seconds, P = .440). OELM and ease of intubation were also similar between the 2 groups. The Pentax AWS offered a superior laryngeal view compared with the McGrath VL. There was no significant difference in either the intubation time or ease of intubation using these 2 devices in patients with normal airways. PMID:29145308

A comparison of direct versus indirect laryngoscopic visualization during endotracheal intubation of lightly embalmed cadavers utilizing the GlideScope®, Storz Medi Pack Mobile Imaging System™ and the New Storz CMAC™ videolaryngoscope.

PubMed

Boedeker, Ben H; Nicholsal, Thomas A; Carpenter, Jennifer; Singh, Leighton; Bernhagen, Mary A; Murray, W Bosseau; Wadman, Michael C

2011-01-01

Studies indicate that the skills needed to use video laryngoscope systems are easily learned by healthcare providers. This study compared several video laryngoscopic (VL) systems and a direct laryngoscope (DL) view when used by medical residents practicing intubation on cadavers. The video devices used included the Storz Medi Pack Mobile Imaging System™, the Storz CMAC® VL System and the GlideScope®. After Institutional Review Board (IRB) approval, University of Nebraska Medical Center, Department of Emergency Medicine (UNMC EM) residents were recruited and given a brief pre-study informational period. The cadavers were lightly embalmed. The study subjects were asked to perform intubations on two cadavers using both DL and VL while using the three different VL systems. Procedural data was recorded for each attempt and pre and post experience perceptions were collected. N=14. All subjects reported their varied previous intubation experience. The average airway score using DL: for the Storz VL was 1.54 (SD = 0.576) and for the C-MAC was 1.46 (SD = 0.637). Success in intubation of the standard airway using DL was 93% versus a 100% success rate when intubating with indirect VL visualization. Based on our data, we believe that the incorporation of VL into cadaver airway management training provided an improved learning environment for the study residents. In our study, the resident subjects were 93% successful with DL intubation even though 50% had less than 30 intubations. As well, there was a 100% success rate when intubating with indirect VL visualization. In conclusion, the researchers believe this cadaver model incorporated with VL is a powerful tool which may help improve the overall learning curve for orotracheal intubation. 2011.

Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.

PubMed

Sakles, John C; Mosier, Jarrod M; Chiu, Stephen; Keim, Samuel M

2012-04-01

Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy. To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations. This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure. There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005. The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management. Published by Elsevier Inc.

Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium.

PubMed

Anandan, Krishnadas; Suseela, Indu; Purayil, Harish Valiya

2017-01-01

Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO 4 pretreatment is good options. To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18-60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40-70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Chi-square test and independent t -test were done with PASW statistics 18 to analyze data. The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s ( P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups ( P = 0.791). Hemodynamic parameters were comparable between groups at all time frames ( P > 0.05). Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation.

Estimating 'lost heart beats' rather than reductions in heart rate during the intubation of critically-ill children.

PubMed

Jones, Peter; Ovenden, Nick; Dauger, Stéphane; Peters, Mark J

2014-01-01

Reductions in heart rate occur frequently in children during critical care intubation and are currently considered the gold standard for haemodynamic instability. Our objective was to estimate loss of heart beats during intubation and compare this to reduction in heart rate alone whilst testing the impact of atropine pre-medication. Data were extracted from a prospective 2-year cohort study of intubation ECGs from critically ill children in PICU/Paediatric Transport. A three step algorithm was established to exclude variation in pre-intubation heart rate (using a 95%CI limit derived from pre-intubation heart rate variation of the children included), measure the heart rate over time and finally the estimate the numbers of lost beats. 333 intubations in children were eligible for inclusion of which 245 were available for analysis (74%). Intubations where the fall in heart rate was less than 50 bpm were accompanied almost exclusively by less than 25 lost beats (n = 175, median 0 [0-1]). When there was a reduction of >50 bpm there was a poor correlation with numbers of lost beats (n = 70, median 42 [15-83]). During intubation the median number of lost beats was 8 [1]-[32] when atropine was not used compared to 0 [0-0] when atropine was used (p<0.001). A reduction in heart rate during intubation of <50 bpm reliably predicted a minimal loss of beats. When the reduction in heart rate was >50 bpm the heart rate was poorly predictive of lost beats. A study looking at the relationship between lost beats and cardiac output needs to be performed. Atropine reduces both fall in heart rate and loss of beats. Similar area-under-the-curve methodology may be useful for estimating risk when biological parameters deviate outside normal range.

A Randomized Study Comparing the Sniffing Position with Simple Head Extension for Glottis Visualization and Difficulty in Intubation during Direct Laryngoscopy.

PubMed

Akhtar, Mehmooda; Ali, Zulfiqar; Hassan, Nelofar; Mehdi, Saqib; Wani, Gh Mohammad; Mir, Aabid Hussain

2017-01-01

Proper positioning of the head and neck is important for an optimal laryngeal visualization. Traditionally, sniffing position (SP) is recommended to provide a superior glottic visualization, during direct laryngoscopy, enhancing the ease of intubation. Various studies in the last decade of this belief have challenged the need for sniffing position during intubation. We conducted a prospective study comparing the sniffing head position with simple head extension to study the laryngoscopic view and intubation difficulty during direct laryngoscopy. Five-hundred patients were included in this study and randomly distributed to SP or simple head extension. In the sniffing group, an incompressible head ring was placed under the head to raise its height by 7 cm from the neutral plane followed by maximal extension of the head. In the simple extension group, no headrest was placed under the head; however, maximal head extension was given at the time of laryngoscopy. Various factors as ability to mask ventilate, laryngoscopic visualization, intubation difficulty, and posture of the anesthesiologist during laryngoscopy and tracheal intubation were noted. In the incidence of difficult laryngoscopy (Cormack Grade III and IV), Intubation Difficulty Scale (IDS score) was compared between the two groups. There was no significant difference between two groups in Cormack grades. The IDS score differed significantly between sniffing group and simple extension group ( P = 0.000) with an increased difficulty during intubation in the simple head extension. Patients with simple head extension needed more lifting force, increased use of external laryngeal manipulation, and an increased use of alternate techniques during intubation when compared to SP. We conclude that compared to the simple head extension position, the SP should be used as a standard head position for intubation attempts under general anesthesia.

High flow nasal cannula oxygen versus noninvasive ventilation in adult acute respiratory failure: a systematic review of randomized-controlled trials.

PubMed

Beng Leong, Lim; Wei Ming, Ng; Wei Feng, Lee

2018-06-19

We reviewed the use of noninvasive ventilation (NIV) versus high flow nasal cannula (HFNC) oxygen in adult acute respiratory failure (ARF). We searched major databases and included randomized trials comparing at least NIV with HFNC or NIV+HFNC with NIV in ARF. Primary outcomes included intubation/re-intubation rates. Secondary outcomes were ICU mortality and morbidities. Five trials were included; three compared HFNC with NIV, one compared HFNC, NIV and oxygen whereas one compared HFNC+NIV with NIV. Patients had hypoxaemic ARF (PaO2/FiO2≤300 mmHg). Heterogeneity prevented result pooling. Three and two studies had superiority and noninferiority design, respectively. Patients were postcardiothoracic surgery, mixed medical/surgical patients and those with pneumonia. Two trials were conducted after extubation, two before intubation and one during intubation. Three trials reported intubation/re-intubation rates as the primary outcomes. The other two trials reported the lowest peripheral capillary oxygen saturation readings during bronchoscopy or intubation. In the former three trials, the odds ratio for intubation/re-intubation rates between HFNC versus the NIV group ranged from 0.80 (95% confidence interval: 0.54-1.19) to 1.65 (95% confidence interval: 0.96-2.84). In the latter two trials, only one reported a difference in the lowest peripheral capillary oxygen saturation between NIV+HFNC versus the NIV group during intubation [100% (interquartile range: 95-100) vs. 96% (interquartile range: 92-99); P=0.029]. The secondary outcomes included differences in ICU mortality and patient tolerability, favouring HFNC, were conflicting, but highlighted future research directions. These include patients with hypercapneic ARF, more severe hypoxaemia (PaO2/FiO2≤200 mmHg), a superiority design, an oxygen arm and patient-centred outcomes.

Magnesium sulphate: an adjuvant to tracheal intubation without muscle relaxation--a randomised study.

PubMed

Aissaoui, Younes; Qamous, Youssef; Serghini, Issam; Zoubir, Mohammed; Salim, Jaafar Lalaoui; Boughalem, Mohammed

2012-08-01

Tracheal intubation without administration of a neuromuscular blocking drug is used frequently in anaesthesia. Several techniques and adjuvants have been tried to improve intubating conditions. Magnesium sulphate is an agent with analgesic, anaesthetic and muscle relaxant effects. To assess the effect of magnesium sulphate on intubating conditions after induction of anaesthesia without a neuromuscular blocking drug. Double-blinded randomised study. Sixty patients with American Society of Anesthesiologists physical status 1/2 scheduled for elective surgery under general anaesthesia were included. Avicenna Military Hospital between June 2010 and March 2011. Before induction of general anaesthesia, patients were assigned to receive either a 10-min infusion of magnesium sulphate 45 mg kg(-1) in 100 ml of isotonic saline (magnesium group, n = 30) or the same volume of saline (control group, n = 30). Anaesthesia was induced with fentanyl 3 μg kg(-1) followed 3 min later by propofol 2.5 mg kg(-1). Intubating conditions were evaluated by a blinded anaesthesiologist using the criteria of the Copenhagen consensus conference: ease of laryngoscopy, vocal cord position and/or movement and response to intubation or cuff inflation (cough or diaphragmatic movement). Intubating conditions were considered as acceptable (excellent or good) or unacceptable (poor). Mean arterial pressure and heart rate were also recorded during the study period. The two groups were comparable in their demographic profiles. Clinically acceptable intubating conditions were observed more frequently in the magnesium group than in the control group: 25 (83%) vs. 18 patients (60%) (P = 0.042). There was no failed intubation. There were no differences between the groups with regard to haemodynamic variables. Addition of magnesium sulphate to propofol and fentanyl at induction of anaesthesia significantly improved intubating conditions without administration of a neuromuscular blocking drug.

Intubation Biomechanics: Laryngoscope force and cervical spine motion during intubation with Macintosh and Airtraq laryngoscopes

PubMed Central

Hindman, Bradley J.; Santoni, Brandon G.; Puttlitz, Christian M.; From, Robert P.; Todd, Michael M.

2014-01-01

Introduction Laryngoscopy and endotracheal intubation in the presence of cervical spine instability may put patients at risk of cervical cord injury. Nevertheless, the biomechanics of intubation (cervical spine motion as a function of applied force) have not been characterized. This study characterized and compared the relationship between laryngoscope force and cervical spine motion using two laryngoscopes hypothesized to differ in force. Methods Fourteen adults undergoing elective surgery were intubated twice (Macintosh, Airtraq). During each intubation, laryngoscope force, cervical spine motion, and glottic view were recorded. Force and motion were referenced to a pre-intubation baseline (stage 1) and were characterized at three stages: stage 2 (laryngoscope introduction); stage 3 (best glottic view); stage 4 (endotracheal tube in trachea). Results Maximal force and motion occurred at stage 3, and differed between the Macintosh and Airtraq: 1) Force: 48.8±15.8 vs. 10.4±2.8 N, respectively; P=0.0001; 2) occiput-C5 extension: 29.5±8.5 vs. 19.1±8.7 degrees, respectively; P=0.0023. Between stages -2 and -3, the motion/force ratio differed between Macintosh and Airtraq: 0.5±0.2 vs. 2.0±1.4 degrees/N, respectively; P=0.0006. Discussion The relationship between laryngoscope force and cervical spine motion is: 1) non-linear and 2) differs between laryngoscopes. Differences between laryngoscopes in motion/force relationships are likely due to: 1) laryngoscope-specific cervical extension needed for intubation, 2) laryngoscope-specific airway displacement/deformation needed for intubation, and 3) cervical spine and airway tissue viscoelastic properties. Cervical spine motion during endotracheal intubation is not directly proportional to force. Low force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion. PMID:24739996

Air-Q intubating laryngeal airway: A study of the second generation supraglottic airway device.

PubMed

Attarde, Viren Bhaskar; Kotekar, Nalini; Shetty, Sarika M

2016-05-01

Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity. Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed. Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma. Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway.

Intravenous rocuronium 0.3 mg/kg improves the conditions for tracheal intubation in cats: a randomized, placebo-controlled trial.

PubMed

Sakai, Daniel M; Zornow, Kailee Anne; Campoy, Luis; Cable, Christina; Appel, Leslie D; Putnam, Holly J; Martin-Flores, Manuel

2018-01-01

Objectives We evaluated the use of rocuronium 0.3 mg/kg intravenously (IV) to facilitate tracheal intubation in cats anesthetized for elective ovariohysterectomy. Methods Thirty female cats were randomly allocated to receive rocuronium 0.3 mg/kg IV or an equal volume of normal saline, following induction of anesthesia with ketamine and midazolam. Thirty seconds after induction, a single investigator, unaware of treatment allocation, attempted tracheal intubation. The number of attempts and the time to complete intubation were measured. Intubating conditions were assessed as acceptable or unacceptable based on a composite score consisting of five different components. Duration of apnea after induction was measured and cases of hemoglobin desaturation (SpO 2 <90%) were identified. Results Intubation was completed faster (rocuronium 12 s [range 8-75 s]; saline 60 s [range 9-120 s]) and with fewer attempts (rocuronium 1 [range 1-2]; saline 2 [range 1-3], both P = 0.006) in cats receiving rocuronium. Unacceptable intubating conditions on the first attempt occurred in 3/15 cats with rocuronium and in 10/15 with saline ( P = 0.01). Apnea lasted 4 ± 1.6 mins with rocuronium and 2.3 ± 0.5 mins with saline ( P = 0.0007). No cases of desaturation were observed. Conclusions and relevance Rocuronium 0.3 mg/kg IV improves intubating conditions compared with saline and reduces the time and number of attempts to intubate with only a short period of apnea in cats.

The usefulness of design of experimentation in defining the effect difficult airway factors and training have on simulator oral-tracheal intubation success rates in novice intubators.

PubMed

Thomas, Frank; Carpenter, Judi; Rhoades, Carol; Holleran, Renee; Snow, Gregory

2010-04-01

This exploratory study examined novice intubators and the effect difficult airway factors have on pre- and posttraining oral-tracheal simulation intubation success rates. Using a two-level, full-factorial design of experimentation (DOE) involving a combination of six airway factors (curved vs. straight laryngoscope blade, trismus, tongue edema, laryngeal spasm, pharyngeal obstruction, or cervical immobilization), 64 airway scenarios were prospectively randomized to 12 critical care nurses to evaluate pre- and posttraining first-pass intubation success rates on a simulator. Scenario variables and intubation outcomes were analyzed using a generalized linear mixed-effects model to determine two-way main and interactive effects. Interactive effects between the six study factors were nonsignificant (p = 0.69). For both pre- and posttraining, main effects showed the straight blade (p = 0.006), tongue edema (p = 0.0001), and laryngeal spasm (p = 0.004) significantly reduced success rates, while trismus (p = 0.358), pharyngeal obstruction (p = 0.078), and cervical immobilization did not significantly change the success rate. First-pass intubation success rate on the simulator significantly improved (p = 0.005) from pre- (19%) to posttraining (36%). Design of experimentation is useful in analyzing the effect difficult airway factors and training have on simulator intubation success rates. Future quality improvement DOE simulator research studies should be performed to help clarify the relationship between simulator factors and patient intubation rates.

Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting.

PubMed

Levitan, R M; Goldman, T S; Bryan, D A; Shofer, F; Herlich, A

2001-01-01

Video imaging of intubation as seen by the laryngoscopist has not been a part of traditional instruction methods, and its potential impact on novice intubation success rates has not been evaluated. We prospectively tracked the success rates of novice intubators in paramedic classes who were required to watch a 26-minute instructional videotape made with a direct laryngoscopy imaging system (video group). We compared the prospectively obtained intubation success rate of the video group against retrospectively collected data from prior classes of paramedic students (traditional group) in the same training program. All classes received the same didactic airway instruction, same mannequin practice time, same paramedic textbook, and were trained in the same operating room with the same teaching staff. The traditional group (n=113, total attempts 783) had a mean individual intubation success rate of 46.7% (95% confidence interval 42.2% to 51.3%). The video group (n=36, total attempts 102) had a mean individual intubation success rate of 88.1% (95% confidence interval 79.6% to 96.5%). The difference in mean intubation success rates between the 2 groups was 41.4% (95% confidence interval 31.1% to 50.7%, P <.0001). The 2 groups did not differ in respect to age, male sex, or level of education. An instructional videotape made with the direct laryngoscopy video system significantly improved the initial success rates of novice intubators in an operating room setting.

Comparison between the Trachway video intubating stylet and Macintosh laryngoscope in four simulated difficult tracheal intubations: A manikin study

PubMed Central

Ong, Jimmy; Lee, Chia-Ling; Huang, Shen-Jer; Shyr, Ming-Hwang

2016-01-01

Objectives: It remains to be determined whether the TVI-4000 Trachway video intubating (TVI) stylet (Markstein Sichtec Medical Corp, Taichung, Taiwan), an airway device for novices, improves airway management practice by experienced anesthesiologists. The aim of this study was to evaluate the feasibility of using the TVI stylet in difficult tracheal intubation situations compared with that of using the Macintosh laryngoscope on an airway manikin. Materials and Methods: Ten anesthesiologists (with 3–21 years’ experience), including three senior residents, participated. We compared tracheal intubation in four airway scenarios: normal airway, tongue edema, cervical spine immobilization, and tongue edema combined with cervical spine immobilization. The time of tracheal intubation (TTI), success rate, and perceived difficulty of intubation for each scenario were compared and analyzed. Results: The TTI was significantly shorter in both the tongue edema and combined scenarios with the TVI stylet compared with the Macintosh laryngoscope (21.60 ± 1.45 seconds vs. 24.07 ± 1.58 seconds and 23.73 ± 2.05 seconds vs. 26.6 ± 2.77 seconds, respectively). Success rates for both devices were 100%. Concomitantly, participants rated using the TVI stylet in these two scenarios as being less difficult. Conclusion: The learning time for tracheal intubation using the TVI stylet in difficult airway scenarios was short. Use of the TVI stylet was easier and required a shorter TTI for tracheal intubation in the tongue edema and combined scenarios. PMID:28757736

Regional Radiation Therapy Impacts Outcome for Node-Positive Cutaneous Melanoma.

PubMed

Strom, Tobin; Torres-Roca, Javier F; Parekh, Akash; Naghavi, Arash O; Caudell, Jimmy J; Oliver, Daniel E; Messina, Jane L; Khushalani, Nikhil I; Zager, Jonathan S; Sarnaik, Amod; Mulé, James J; Trotti, Andy M; Eschrich, Steven A; Sondak, Vernon K; Harrison, Louis B

2017-04-01

Background: Regional radiation therapy (RT) has been shown to reduce the risk of regional recurrence with node-positive cutaneous melanoma. However, risk factors for regional recurrence, especially in the era of sentinel lymph node biopsy (SLNB), are less clear. Our goals were to identify risk factors associated with regional recurrence and to determine whether a radiosensitivity index (RSI) gene expression signature (GES) could identify patients who experience a survival benefit with regional RT. Methods: A single-institution, Institutional Review Board-approved study was performed including 410 patients treated with either SLNB with or without completion lymph node dissection (LND; n=270) or therapeutic LND (n=91). Postoperative regional RT was delivered to the involved nodal basin in 83 cases (20.2%), to a median dose of 54 Gy (range, 30-60 Gy) in 27 fractions (range, 5-30). Primary outcomes were regional control and overall survival by RSI GES status. Results: Median follow-up was 69 months (range, 13-180). Postoperative regional RT was associated with a reduced risk of regional recurrence among all patients on univariate (5-year estimate: 95.0% vs 83.3%; P =.036) and multivariate analysis (hazard ratio[HR], 0.15; 95% CI, 0.05-0.43; P <.001). Among higher-risk subgroups, regional RT was associated with a lower risk of regional recurrence among patients with clinically detected lymph nodes (n=175; 5-year regional control: 94.1% vs 69.5%; P =.003) and extracapsular extension (ECE) present (n=138; 5-year regional control: 96.7% vs 62.2%; P <.001). Among a subset of radiated patients with gene expression data available, a low RSI GES (radiosensitive) tumor status was associated with improved survival compared with a high RSI GES (5-year: 75% vs 0%; HR, 10.68; 95% CI, 1.24-92.14). Conclusions: Regional RT was associated with a reduced risk of regional recurrence among patients with ECE and clinically detected nodal disease. Gene expression data show promise for better predicting radiocurable patients in the future. In the era of increasingly effective systemic therapies, the value of improved regional control potentially takes on greater significance. Copyright © 2017 by the National Comprehensive Cancer Network.

Clinical-Radiological Parameters Improve the Prediction of the Thrombolysis Time Window by Both MRI Signal Intensities and DWI-FLAIR Mismatch.

PubMed

Madai, Vince Istvan; Wood, Carla N; Galinovic, Ivana; Grittner, Ulrike; Piper, Sophie K; Revankar, Gajanan S; Martin, Steve Z; Zaro-Weber, Olivier; Moeller-Hartmann, Walter; von Samson-Himmelstjerna, Federico C; Heiss, Wolf-Dieter; Ebinger, Martin; Fiebach, Jochen B; Sobesky, Jan

2016-01-01

With regard to acute stroke, patients with unknown time from stroke onset are not eligible for thrombolysis. Quantitative diffusion weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR) MRI relative signal intensity (rSI) biomarkers have been introduced to predict eligibility for thrombolysis, but have shown heterogeneous results in the past. In the present work, we investigated whether the inclusion of easily obtainable clinical-radiological parameters would improve the prediction of the thrombolysis time window by rSIs and compared their performance to the visual DWI-FLAIR mismatch. In a retrospective study, patients from 2 centers with proven stroke with onset <12 h were included. The DWI lesion was segmented and overlaid on ADC and FLAIR images. rSI mean and SD, were calculated as follows: (mean ROI value/mean value of the unaffected hemisphere). Additionally, the visual DWI-FLAIR mismatch was evaluated. Prediction of the thrombolysis time window was evaluated by the area-under-the-curve (AUC) derived from receiver operating characteristic (ROC) curve analysis. Factors such as the association of age, National Institutes of Health Stroke Scale, MRI field strength, lesion size, vessel occlusion and Wahlund-Score with rSI were investigated and the models were adjusted and stratified accordingly. In 82 patients, the unadjusted rSI measures DWI-mean and -SD showed the highest AUCs (AUC 0.86-0.87). Adjustment for clinical-radiological covariates significantly improved the performance of FLAIR-mean (0.91) and DWI-SD (0.91). The best prediction results based on the AUC were found for the final stratified and adjusted models of DWI-SD (0.94) and FLAIR-mean (0.96) and a multivariable DWI-FLAIR model (0.95). The adjusted visual DWI-FLAIR mismatch did not perform in a significantly worse manner (0.89). ADC-rSIs showed fair performance in all models. Quantitative DWI and FLAIR MRI biomarkers as well as the visual DWI-FLAIR mismatch provide excellent prediction of eligibility for thrombolysis in acute stroke, when easily obtainable clinical-radiological parameters are included in the prediction models. © 2016 S. Karger AG, Basel.

Discovery of unexpected pain in intubated and sedated patients.

PubMed

Clukey, Lory; Weyant, Ruth A; Roberts, Melanie; Henderson, Ann

2014-05-01

The perceptions of patients who are restrained and sedated while being treated with mechanical ventilation in the intensive care unit are not well understood. The effectiveness of sedation used to aid in recovery and enhance comfort during intubation is unknown. To explore the perceptions of patients who were intubated and receiving pain medication while sedated and restrained in the intensive care unit, in particular, their experience and their memories of the experience. In a phenomenological study, 14 patients who were intubated and receiving pain medication while sedated and restrained were interviewed at the bedside. A semistructured interview guide was used. Data were analyzed by using an inductive method consistent with qualitative research. Three major themes were identified from the data: lack of memory of being restrained; a perception of being intubated as horrific; nursing behaviors that were helpful and comforting. An unexpected discovery was that sedation may be interfering with pain assessment and management. Being intubated can be painful and traumatic despite administration of sedatives and analgesics. Sedation may mask uncontrolled pain for intubated patients and prevent them from communicating this condition to a nurse. Nurses may need to evaluate current interventions in order to provide maximum comfort and promote optimal positive outcomes for intensive care patients who are intubated.

Effects of tung oil on salivary viscosity and extent and incidence of dental caries in rats.

PubMed

Biesbrock, A R; Dirksen, T; Schuster, G

1992-01-01

Increased salivary viscosity may be associated with an increase in dental caries. In order to examine this relationship, the caries level in rats was monitored following gastric intubation with tung oil which has been shown to significantly increase salivary viscosity. Tung oil intubation over an 8-week period significantly increased the salivary viscosity in rats as compared with deoinized water and corn oil intubation. The total number of carious lesions was significantly increased (p less than 0.05) in the tung oil intubated rats as compared with the two other groups. This increase in carious lesions was primarily associated with the smooth surfaces of the teeth. There was also a significant increase (p less than 0.05) in the extent of enamel and dentin involvement of the tung oil intubated rats as compared with the other two groups. Histologic examination of the submandibular glands revealed an increase in the amount of glycoprotein material in the convoluted granular tubules of the tung oil intubated rats as compared with the deionized water and corn oil intubated animals. Collectively, these results suggest that tung oil intubation is correlated with both increased salivary viscosity and increased smooth-surface dental caries, suggesting that the viscosity may be related to dental caries progression.

A Comparison of the C-MAC Video Laryngoscope to the Macintosh Direct Laryngoscope for Intubation in the Emergency Department

PubMed Central

Sakles, John C.; Mosier, Jarrod; Chiu, Stephen; Cosentino, Mari; Kalin, Leah

2015-01-01

Study objective We determine the proportion of successful intubations with the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in emergency department (ED) intubations. Methods This was a retrospective analysis of prospectively collected data entered into a continuous quality improvement database during a 28-month period in an academic ED. After each intubation, the operator completed a standardized data form evaluating multiple aspects of the intubation, including patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. Intubation was considered ultimately successful if the endotracheal tube was correctly inserted into the trachea with the initial device. An attempt was defined as insertion of the device into the mouth regardless of whether there was an attempt to pass the tube. The primary outcome measure was ultimate success. Secondary outcome measures were first-attempt success, Cormack-Lehane view, and esophageal intubation. Multivariate logistic regression analyses, with the inclusion of a propensity score, were performed for the outcome variables ultimate success and first-attempt success. Results During the 28-month study period, 750 intubations were performed with either the C-MAC with a size 3 or 4 blade or a direct laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed with the C-MAC as the initial device and 495 with a Macintosh direct laryngoscope as the initial device. The C-MAC resulted in successful intubation in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95% CI 81.0% to 87.5%). In the multivariate regression model, with a propensity score included, the C-MAC was positively predictive of ultimate success (odds ratio 12.7; 95% CI 4.1 to 38.8) and first-attempt success (odds ratio 2.2; 95% CI 1.2 to 3.8). When the C-MAC was used as a video laryngoscope, a Cormack-Lehane grade I or II view (video) was obtained in 117 of 125 cases (93.6%; 95% CI 87.8% to 97.2%), whereas when a direct laryngoscope was used, a grade I or II view was obtained in 410 of 495 cases (82.8%; 95% CI 79.2% to 86.1%). The C-MAC was associated with immediately recognized esophageal intubation in 4 of 255 cases (1.6%; 95% CI 0.4% to 4.0%), whereas a direct laryngoscope was associated with immediately recognized esophageal intubation in 24 of 495 cases (4.8%; 95% CI 3.1% to 7.1%). Conclusion When used for emergency intubations in the ED, the C-MAC was associated with a greater proportion of successful intubations and a greater proportion of Cormack-Lehane grade I or II views compared with a direct laryngoscope. PMID:22560464

Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway.

PubMed

Monclus, Enric; Garcés, Antonio; Artés, David; Mabrock, Maged

2008-07-01

For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.

Snake scope camera assisted endotracheal intubation: a procedural skills training in cadaver to prepare preclinical students for their clerkships.

PubMed

Tansatit, Tanvaa; Apinuntrum, Prawit; Phetudom, Thavorn

2012-02-01

Preparing students to perform specific procedures on patients presents a challenge of student confidence in performing these tasks. This descriptive study determined the ability of the medical students to perform a basic clinical task after a short hands-on training workshop in cadavers. This basic procedural skills training was an attempt for developing conceptual understanding and increasing procedural skills in endotracheal intubation of the medical students. The students were trained to perform two different endotracheal intubations, uncomplicated intubation, and a traumatic difficult airway scenario. The training session consisted of two methods of endotracheal intubation, oral intubations using direct laryngoscopy (DL) in two cadavers with uncomplicated airway and the Flexible Snake Scope camera (FSSC) assisted nasal intubation procedures in two cadavers simulated trauma victims with difficult airway. In the assessment session, the students performed one timed trial with each device. All four cadavers were changed but the scenarios were the same. The groups of the medical students were randomly assigned to perform the tasks in one of two cadavers of the two scenarios. Thirty-two medical students participated in this training and assessment. The training session and the assessment lasted five hours and three hours respectively. No student was asked to perform the second trial. The average time for successful intubation with DL was 32.7 seconds (SD, 13.8 seconds) and for FSSC was 127.0 seconds (SD, 32.6 seconds). The intubation failure rate was 0% for the entire study. The medical students have the ability to accomplish a basic clinical task after a short hands-on training workshop.

Middle finger length-based tracheal intubation depth improves the rate of appropriate tube placement in children.

PubMed

Zhou, Qing-he; Xiao, Wang-pin; Zhou, Hong-mei

2015-11-01

It is challenging for anesthetists to determine the optimal tracheal intubation depth in children. We hypothesize that a measure three times the length of the middle finger can be used for predicting tracheal tube depth in children. Eighty-six children (4-14 years of age) were included in this study. After the children were anesthetized, a fiberoptic bronchoscope (FOB) was inserted into the trachea, the lengths from the upper incisor teeth to carina and vocal cords were measured, and a suitably sized cuffed tracheal tube was inserted into the trachea. Age-based and middle finger length-based formulas were used to determine the tracheal intubation depth. All 86 children enrolled were included in this study. Compared with the age-based intubation, the rate of appropriate tube placement was higher for middle finger length-based intubation (88.37% vs 66.28%, P = 0.001). The proximal intubation rate was lower in middle finger length-based intubation (4.65% vs 32.56%, P < 0.001). There was only weak evidence for a difference in the distal intubation rate between the two methods (6.97% vs 1.16%, P = 0.054). The correlation coefficient between middle finger length and optimal tracheal tube depth was larger than that between age and optimal tracheal tube depth (0.883 vs 0.845). Our data indicate that the appropriate tube placement rate can be improved by using three times the middle finger length as the tracheal intubation depth in children. © 2015 John Wiley & Sons Ltd.

BMI as a Predictor for Potential Difficult Tracheal Intubation in Males.

PubMed

Uribe, Alberto A; Zvara, David A; Puente, Erika G; Otey, Andrew J; Zhang, Jianying; Bergese, Sergio D

2015-01-01

Difficult tracheal intubation is a common source of mortality and morbidity in surgical and critical care settings. The incidence reported of difficult tracheal intubation is 0.1%-13% and reaches 14% in the obese population. The objective of our retrospective study was to investigate and compare the utility of body mass index (BMI) as indicator of difficult tracheal intubation in males and females. We performed a retrospective chart review of patients who underwent abdominal surgeries with American Society of Anesthesiologists I to V under general anesthesia requiring endotracheal intubation. The following information was obtained from medical records for analysis: gender, age, height, weight, BMI, length of patient stay in the Post Anesthesia Care Unit, past medical history of sleep apnea, Mallampati score, and the American Society of Anesthesiologists classification assigned by the anesthesia care provider performing the endotracheal intubation. Of 4303 adult patients, 1970 (45.8%) men and 2333 (54.2%) women were enrolled in the study. Within this group, a total of 1673 (38.9%) patients were morbidly obese. The average age of the study group was 51.4 ± 15.8 and the average BMI was 29.7 ± 8.2 kg/m(2). The overall incidence of the encountered difficult intubations was 5.23% or 225 subjects. Thus, our results indicate that BMI is a reliable predictor of difficult tracheal intubation predominantly in the male population; another strong predictor, with a positive linear correlation, being the Mallampati score. In conclusion, our data shows that BMI is a reliable indicator of potential difficult tracheal intubation only in male surgical patients.

Comparing GlideScope Video Laryngoscope and Macintosh Laryngoscope Regarding Hemodynamic Responses During Orotracheal Intubation: A Randomized Controlled Trial

PubMed Central

Pournajafian, Ali Reza; Ghodraty, Mohammad Reza; Faiz, Seyed Hamid Reza; Rahimzadeh, Poupak; Goodarzynejad, Hamidreza; Dogmehchi, Enseyeh

2014-01-01

Background: To determine if the GlideScope® videolaryngoscope (GVL) could attenuate the hemodynamic responses to orotracheal intubation compared with conventional Macintosh laryngoscope. Objectives: The aim of this relatively large randomized trial was to compare the hemodynamic stress responses during laryngoscopy and tracheal intubation using GVL versus MCL amongst healthy adult individuals receiving general anesthesia for elective surgeries. Patients and Methods: Ninety five healthy adult patients with American Society of Anesthesiologists physical status class I or II that were scheduled for elective surgery under general anesthesia were randomly allocated to either Macintosh or GlideScope arms. All patients received a standardized protocol of general anesthesia. Hemodynamic changes associated with intubation were recorded before and at 1, 3 and 5 minutes after the intubation. The time taken to perform endotracheal intubation was also noted in both groups. Results: Immediately before laryngoscopy (pre-laryngoscopy), the values of all hemodynamic variables did not differ significantly between the two groups (All P values > 0.05). Blood pressures and HR values changed significantly over time within the groups. Time to intubation was significantly longer in the GlideScope (15.9 ± 6.7 seconds) than in the Macintosh group (7.8 ± 3.7 sec) (P< 0.001). However, there were no significant differences between the two groups in hemodynamic responses at all time points. Conclusions: The longer intubation time using GVL suggests that the benefit of GVL could become apparent if the time taken for orotracheal intubation could be decreased in GlideScope group. PMID:24910788

Understanding decision-making towards housework among women with upper limb repetitive strain injury.

PubMed

Cheung, Therma W C; Clemson, Lindy; O'Loughlin, Kate; Shuttleworth, Russell

2016-02-01

Among women with upper limb repetitive strain injury (RSI), occupational therapy interventions include education to facilitate ergonomic practices in housework. From a client-centred perspective, an understanding of women's decision-making about housework is needed to design effective occupational therapy programmes. This study addresses a gap in research in this area by exploring women's views about changing housework habits. The aim was to construct a conceptual representation to explain decision-making in housework by drawing on experiences of a sample of Singapore Chinese women with upper limb RSI from one hand therapy clinic. Based on a constructivist grounded theory methodology, data were collected through in-depth interviewing with 15 women. Interviews were audiotaped and transcribed. Data were analysed with line by line coding, focussed coding and axial coding with constant comparison throughout data collection. Decision-making in housework among these women involved three main themes: (i) emotional attachment to housework; (ii) cognitively informed decision; and (iii) emotionally influenced decision. Women with upper limb RSI had to make cognitive decisions for or against a change in housework to manage their condition. However, the women's cognitively informed decisions were shaped by their emotional attachment to housework. As such, they experienced strong emotional barriers to changing their housework practices even when they had cognitively accepted the necessity and possibility of making a change. Therapists need to be aware that counselling to address the emotional barriers experienced by women is important during ergonomic education. © 2016 Occupational Therapy Australia.

The effect of varying plyometric volume on stretch-shortening cycle capability in collegiate male rugby players.

PubMed

Jeffreys, Mark; De Ste Croix, Mark; Lloyd, Rhodri S; Oliver, Jon L; Hughes, Jonathan

2017-03-25

The purpose of this study was to identify the effectiveness of low and high volume plyometric loads on developing stretch shortening cycle capability in collegiate rugby players. A between- group repeated measures design was used. Thirty six subjects (age 20.3 ±1.6 yrs, mass 91.63 ±10.36kg, stature 182.03 ±5.24cm) were randomly assigned to one of three groups, a control group (CG), a low volume plyometric group (LPG) or a high volume plyometric group (HPG). Data were collected from a force plate, and measures of reactive strength index (RSI) and leg stiffness were calculated from jump height, contact time and flight time. A significant between group × time (F = 4.01, P <0.05) interaction effect for RSI was observed. Bonferroni post hoc analysis indicated that both the LPG training group (P = 0.002) and HPG training group (P = 0.009) were significantly higher than the control group. No significant interaction effect between time × group were observed for leg stiffness (F = 1.39, P = 0.25). The current study has demonstrated that it is possible to improve reactive strength capabilities via the use of a low volume plyometric program. The low volume program elicited the same performance improvement in RSI as a high volume program whilst undertaking a lower dose. This suggests that strength and conditioning coaches may be able to benefit from the ability to develop more time efficient and effective plyometric programs.

[Rapid sequence induction in a patient with Steinert myotonic dystrophy: Interest of the association of high doses of rocuronium and sugammadex].

PubMed

Pellegrini, L; Mercier, M-F; Cornese, A; Blasco, V; Albanèse, J

2012-02-01

We report in this clinical case the successful use of a combination of rocuronium and sugammadex in a patient with Steinert myotonic dystrophy to perform a rapid sequence induction of anaesthesia. The patient had both contraindication to succinylcholine and a risk of prolonged neuromuscular blockade with non-depolarizing neuromuscular blocking agents. The use of high dose rocuronium (1mg/kg) allowed a quick and easy orotracheal intubation but induced a prolonged neuromuscular block, reversed with success by sugammadex (8 mg/kg). Copyright © 2011 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Antisense protein kinase A RIalpha inhibits 7,12-dimethylbenz(a)anthracene-induction of mammary cancer: blockade at the initial phase of carcinogenesis.

PubMed

Nesterova, Maria V; Cho-Chung, Yoon S

2004-07-01

There are two types of cyclic AMP (cAMP)-dependent protein kinase (PKA), type I (PKA-I) and type II (PKA-II), which share a common catalytic (C) subunit but contain distinct regulatory (R) subunits, RI versus RII, respectively. Evidence suggests that increased expression of PKA-I and its regulatory subunit (RIalpha) correlates with tumorigenesis and tumor growth. We investigated the effect of sequence-specific inhibition of RIalpha gene expression at the initial phase of 7,12-dimethylbenz(alphaa)anthracene (DMBA)-induced mammary carcinogenesis. Antisense RIalpha oligodeoxynucleotide (ODN) targeted against PKA RIalpha was administered (0.1 mg/day/rat, i.p.) 1 day before DMBA intubation and during the first 9 days post-DMBA intubation to determine the anticarcinogenic effects. Antisense RIalpha, in a sequence-specific manner, inhibited the tumor production. At 90 days after DMBA intubation, untreated controls and RIalpha-antisense-treated rats exhibited an average mean number of tumors per rat of 4.2 and 1.8, respectively, and 90% of control and 45% of antisense-treated animals had tumors. The antisense also delayed the first tumor appearance. An increase in RIalpha and PKA-I levels in the mammary gland and liver preceded DMBA-induced tumor production, and antisense down-regulation of RIalpha restored normal levels of PKA-I and PKA-II in these tissues. Antisense RIalpha in the liver induced the phase II enzymes, glutathione S-transferase and quinone oxidoreductase, c-fos protein, and activator protein 1 (AP-1)- and cAMP response element (CRE)-directed transcription. In the mammary glands, antisense RIalpha promoted DNA repair processes. In contrast, the CRE transcription-factor decoy could not mimic these effects of antisense RIalpha. The results demonstrate that RIalpha antisense produces dual anticarcinogenic effects: (a) increasing DMBA detoxification in the liver by increasing phase II enzyme activities, increasing CRE-binding-protein phosphorylation and enhancing CRE- and Ap-1-directed transcription; and (b) activating DNA repair processes in the mammary gland by down-regulating PKA-I.

Comparison of glottic visualisation and ease of intubation with different laryngoscope blades.

PubMed

Kulkarni, Atul P; Tirmanwar, Amar S

2013-03-01

Literature suggests glottic view is better with straight blades while tracheal intubation is easier with curved blades. To compare glottic view and ease of intubation with Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope. This prospective randomised study was undertaken in operation theatres of a 550 bedded tertiary referral cancer centre after approval from the Institutional Review Board. We compared the Macintosh, Miller, McCoy blades and the Trueview(®) laryngoscope for glottic visualisation and ease of tracheal intubation; in 120 patients undergoing elective cancer surgery; randomly divided into four groups. After induction of anaesthesia laryngoscopy was performed and trachea intubated. We recorded: Visualisation of glottis (Cormack Lehane grade), ease of intubation, number of attempts; need to change the blade and need for external laryngeal manipulation. Demographic data, Mallampati classification were compared using the Chi-square test. A P<0.05 was considered significant. Grade 1 view was obtained most often (87% patients) with Trueview(®) laryngoscope. Intubation was easier (Grade 1) with Trueview(®) and McCoy blades (93% each). Seven patients needed two attempts; one patient in Miller group needed three attempts. No patient in McCoy and Trueview(®) Groups required external laryngeal manipulation. We found that in patients with normal airway glottis was best visualised with Miller blade and Trueview(®) laryngoscope however, the trachea was more easily intubated with McCoy and Macintosh blades and Trueview(®) laryngoscope.

Randomised controlled trial of thiopental for intubation in neonates

PubMed Central

Bhutada, A; Sahni, R; Rastogi, S; Wung, J

2000-01-01

AIMS—To determine the effects of premedication with thiopental on heart rate, blood pressure, and oxygen saturation during semi-elective nasotracheal intubation in neonates.
METHODS—A randomised, placebo controlled, non-blinded study design was used to study 30 neonates (mean birthweight 3.27 kg) requiring semi-elective nasotracheal intubation. The babies were randomly allocated to receive either 6 mg/kg of thiopental (study group) or an equivalent volume of physiological saline (control group) one minute before the start of the procedure. Six infants were intubated primarily and 24 were changed from orotracheal to a nasotracheal tube. The electrocardiogram, arterial pressure wave, and transcutaneous oxygen saturation were recorded continuously 10 minutes before, during, and 20 minutes after intubation. Minute by minute measurements of heart rate, heart rate variability, mean blood pressure (MBP) and transcutaneous oxygen saturation (SpO2) were computed. The differences for all of these between the baseline measurements and those made during and after intubation were determined. Differences in the measurements made in the study and the control groups were compared using Student's t test.
RESULTS—During intubation, heart rate increased to a greater degree (12.0 vs−0.5 beats per minute, p < 0.03) and MBP increased to a lesser degree (−2.9 vs 4.4 mm Hg; p < 0.002) in the infants who were premedicated with thiopental. After intubation only the changes in MBP differed significantly between the two groups (−3.8 vs 4.6 mm Hg; p < 0.001). There were no significant changes in the oxygen saturation between the two groups during or after intubation. The time taken for intubation was significantly shorter in the study group (p < 0.04).
CONCLUSIONS—The heart rate and blood pressure of infants who are premedicated with thiopental are maintained nearer to baseline values than those of similar infants who receive no premedication. Whether this lessening of the acute drop in the heart rate and increase in blood pressure typically seen during intubation of unmedicated infants is associated with long term advantages to the infants remains to be determined.

 PMID:10634839

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged.

PubMed

Harbrecht, Brian G; Franklin, Glen A; Smith, Jason W; Benns, Matthew V; Miller, Keith R; Nash, Nicholas A; Bozeman, Matthew C; Coleman, Royce; O'Brien, Dan; Richardson, J David

2016-04-01

Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

A mannequin study of intubation with the AP advance and GlideScope Ranger videolaryngoscopes and the Macintosh laryngoscope.

PubMed

Hodd, Jack A R; Doyle, D John; Gupta, Shipra; Dalton, Jarrod E; Cata, Juan P; Brewer, Edward J; James, Monyulona; Sessler, Daniel I

2011-10-01

The AP Advance (APA) is a videolaryngoscope with interchangeable blades: intubators can choose standard Macintosh blades or a difficult-airway blade with increased curvature and a channel to guide the tube to the larynx. The APA may therefore be comparably effective in both normal and difficult airways. We tested the hypotheses that intubation with the APA is no slower than Macintosh laryngoscopy for normal mannequin airways, and that it is no slower than videolaryngoscopy using a GlideScope Ranger in difficult mannequin airways. Medical professionals whose roles potentially include tracheal intubation were trained with each device. Participants intubated simulated (Laerdal SimMan) normal and difficult airways with the APA, GlideScope, and a conventional Macintosh blade. Speed of intubation was compared using Cox proportional hazards regression, with a hazard ratio >0.8 considered noninferior. We also compared laryngeal visualization, failures, and participant preferences. Unadjusted intubation times in the normal airway with the APA and Macintosh were virtually identical (median, 22 vs 23 seconds); after adjustment for effects of experience, order, and period, the hazard ratio (95% confidence interval) comparing APA with Macintosh laryngoscopy was 0.87 (0.65, 1.17), which was not significantly more than our predefined noninferiority boundary of 0.8 (P = 0.26). Intubation with the APA was faster than with the GlideScope in difficult airways (hazard ratio = 7.6 [5.0, 11.3], P < 0.001; median, 20 vs 59 seconds). All participants intubated the difficult airway mannequin with the APA, whereas 33% and 37% failed with the GlideScope and Macintosh, respectively. In the difficult airway, 99% of participants achieved a Cormack and Lehane grade I to II view with the APA, versus 85% and 33% with the GlideScope and Macintosh, respectively. When asked to choose 1 device overall, 82% chose the APA. Intubation times were similar with the APA and Macintosh laryngoscopes in mannequins with normal airways. However, intubation with the APA was significantly faster than with the GlideScope in the difficult mannequin simulation.

A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients.

PubMed

El-Jawahri, Areej; Mitchell, Susan L; Paasche-Orlow, Michael K; Temel, Jennifer S; Jackson, Vicki A; Rutledge, Renee R; Parikh, Mihir; Davis, Aretha D; Gillick, Muriel R; Barry, Michael J; Lopez, Lenny; Walker-Corkery, Elizabeth S; Chang, Yuchiao; Finn, Kathleen; Coley, Christopher; Volandes, Angelo E

2015-08-01

Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.

Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial

PubMed Central

2014-01-01

Background Tracheal intubation without muscle relaxants is usually performed with remifentanil and propofol or sevoflurane. Remifentanil 1.0 to 4.0 μg·kg-1 and propofol 2.0-3.0 mg·kg-1 or sevoflurane up to 8.0 Vol% provide acceptable, i.e. excellent or good intubating conditions. We hypothesized that sevoflurane 1.0 MAC would provide acceptable intubating conditions when combined with propofol and remifentanil. Methods Eighty-three patients to be intubated were randomised to two groups. The SEVO group received propofol 1.5 mg kg-1, remifentanil 0.30 μg kg min-1 and sevoflurane 1.0 MAC; the MR group received the same doses of propofol and remifentanil plus rocuronium 0.45 mg kg-1. We evaluated intubation and extubation conditions, mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS). The vocal cords were examined for injury by videolaryngoscopy before and 24 hours after surgery. Results Acceptable intubating conditions were seen more frequently with rocuronium than with sevoflurane: 97% versus 82%; p = 0.03; the subscore for vocal cords was comparable: 100% versus 98%. MAP before intubation decreased significantly compared with the MAP at baseline to the same extent in both groups; ephedrine IV was given in 15 (SEVO) versus 16 (MR) patients; p = 0.93. BIS at tracheal intubation was 27 (13-65) in the SEVO group, 29 (14-62) in the MR group; p = 0.07. Vocal cord injuries (oedema, haematoma) were similar: 4 patients in each group. Conclusions Overall intubating conditions were better when rocuronium was used; the subscore for vocal cords was comparable. The incidence of side effects was the same in the two groups. Trial registration ClinicalTrials.Gov: NCT 01591031. PMID:24860256

Endotracheal Intubation with the King Laryngeal Tube™ In Situ Using Video Laryngoscopy and a Bougie: A Retrospective Case Series and Cadaveric Crossover Study.

PubMed

Dodd, Kenneth W; Kornas, Rebecca L; Prekker, Matthew E; Klein, Lauren R; Reardon, Robert F; Driver, Brian E

2017-04-01

Removal of a functioning King laryngeal tube (LT) prior to establishing a definitive airway increases the risk of a "can't intubate, can't oxygenate" scenario. We previously described a technique utilizing video laryngoscopy (VL) and a bougie to intubate around a well-seated King LT with the balloons deflated; if necessary, the balloons can be rapidly re-inflated and ventilation resumed. Our objective is to provide preliminary validation of this technique. Emergency physicians performed all orotracheal intubations in this two-part study. Part 1 consisted of a historical analysis of VL recordings from emergency department (ED) patients intubated with the King LT in place over a two-year period at our institution. In Part 2, we analyzed VL recordings from paired attempts at intubating a cadaver, first with a King LT in place and then with the device removed, with each physician serving as his or her own control. The primary outcome for all analyses was first-pass success. There were 11 VL recordings of ED patients intubated with the King LT in place (Part 1) and 11 pairs of cadaveric VL recordings (Part 2). The first-pass success rate was 100% in both parts. In Part 1, the median time to intubation was 43 s (interquartile range [IQR] 36-60 s). In Part 2, the median time to intubation was 23 s (IQR 18-35 s) with the King LT in place and 17 s (IQR 14-18 s) with the King LT removed. Emergency physicians successfully intubated on the first attempt with the King LT in situ. The technique described in this proof-of-concept study seems promising and merits further validation. Copyright © 2016 Elsevier Inc. All rights reserved.

Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials.

PubMed

Cabrini, Luca; Landoni, Giovanni; Baiardo Radaelli, Martina; Saleh, Omar; Votta, Carmine D; Fominskiy, Evgeny; Putzu, Alessandro; Snak de Souza, Cézar Daniel; Antonelli, Massimo; Bellomo, Rinaldo; Pelosi, Paolo; Zangrillo, Alberto

2018-01-20

We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool. We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation , while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials. The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.

Comparison of Effect of Ephedrine and Priming on the Onset Time of Vecuronium

PubMed Central

Anandan, Krishnadas; Suseela, Indu; Purayil, Harish Valiya

2017-01-01

Background: Succinylcholine has been the neuromuscular blocking drug of choice for laryngoscopy and intubation, but it has several adverse effects. Nondepolarizing neuromuscular blocking drugs are good alternative provided their onset of action is hastened. Priming technique and use of ephedrine or MgSO4 pretreatment is good options. Aims: To compare the effects of priming and ephedrine pretreatment on the onset time of intubating dose of vecuronium. Settings and Design: A prospective, randomized comparative study was done at a state-owned tertiary care teaching hospital. Materials and Methods: After obtaining the Institutional Ethical Committee approval and written informed consent, sixty patients of either gender aged 18–60 years, the American Society of Anesthesiologists physical status Class I/II, weighing 40–70 kg, were randomly divided into two groups of thirty each. Group E received 70 μg/kg ephedrine, and Group P received 0.01 mg/kg of vecuronium 3 min before intubating dose of vecuronium. Intubation was done after getting a train of four zero. Intubation time, clinical intubation grade using Cooper's scale, and hemodynamic parameters were noted. Statistical Analysis Used: Chi-square test and independent t-test were done with PASW statistics 18 to analyze data. Results: The mean time for intubation in ephedrine group (E) was 104 ± 23.282 s and in the priming group (P), it was 142 ± 55.671 s (P = 0.001). All patients had clinically acceptable intubating conditions, and the grades were comparable among groups (P = 0.791). Hemodynamic parameters were comparable between groups at all time frames (P > 0.05). Conclusion: Pretreatment with ephedrine 70 μg/kg shortens the onset time of vecuronium for intubation and is superior to the priming technique. Low-dose ephedrine, when used along with propofol induction, provides hemodynamic stability during induction and intubation. PMID:28663634

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

PubMed

Gonzalez-Rivas, Diego; Bonome, Cesar; Fieira, Eva; Aymerich, Humberto; Fernandez, Ricardo; Delgado, Maria; Mendez, Lucia; de la Torre, Mercedes

2016-03-01

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol

PubMed Central

Kriege, Marc; Alflen, Christian; Tzanova, Irene; Schmidtmann, Irene; Piepho, Tim; Noppens, Ruediger R

2017-01-01

Introduction The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. Methods and analysis The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. Ethics and dissemination The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. Trial registration number ClinicalTrials.gov NCT 02611986; pre-results. PMID:28827261

Role of the Truview EVO2 laryngoscope in the airway management of elective surgical patients: A comparison with the Macintosh laryngoscope

PubMed Central

Saxena, Arpita; Madan, Manish; Shrivastava, Uma; Mittal, Apurva; Dwivedi, Yogita; Agrawal, Archna; Puri, Rajeev

2013-01-01

Background: The Truview EVO2(C) laryngoscope (TL) is a recently introduced optical device designed to provide an unmagnified anterior image of the glottic opening and allow indirect laryngoscopy. Aim: This study is designed to determine whether the TL is a better alternative to the Macintosh laryngoscope (ML) for routine endotracheal intubations in patients with usual airway characteristics. Methods: We compared the Truview EVO2(C) and MLs in 140 elective surgical patients requiring general anaesthesia and intubation in a prospective crossover fashion. The two blades were compared in terms of Cormack and Lehane grades, time required for intubation, anaesthetists’ assessment of ease of intubation, intubation difficulty score, attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. The Student t test and Chi-square test were used to determine the statistical significance of parametric data and categorical data, respectively. Results: The Truview EVO2(C) blade provided a better laryngoscopic view than the Macintosh blade as suggested by improved Cormack and Lehane grades (in 48 patients), but required a longer time for intubation than the Macintosh blade (34.1 vs. 22.4 s), i.e., an improved view at the cost of longer mean intubation time. In spite of lower intubation difficulty scores, Truview EVO2(C) was considered as difficult to use on subjective assessment by the anaesthesiologist when compared with Macintosh. There was no difference observed between the two groups in attempts at intubation, success rate, soft tissue damage and arterial oxygen saturation during laryngoscopy. Conclusion: We opine that although Truview provides a better laryngoscopic view than Macintosh in difficult cases, it does not have an extra benefit over Macintosh otherwise, further indicating the need for more experience with the use of a Truview laryngoscope. PMID:23983287

Changing patterns in endotracheal intubation for anaesthesia trainees: a retrospective analysis of 80,000 cases over 10 years.

PubMed

Smith, N A; Tandel, A; Morris, R W

2011-07-01

Several overseas studies have suggested that opportunities for anaesthesia trainees to learn and practise endotracheal intubation have decreased over time. We analysed the operating theatre data collection system at a large Australian metropolitan teaching hospital from 1998 to 2008 to determine if numbers for trainees' caseloads in general, and endotracheal intubation in particular had changed. The total caseload per trainee of approximately 800 cases per year was stable throughout the study period. The number of gastrointestinal endoscopies per trainee increased significantly with a corresponding decrease in the number of other cases. The mean number of endotracheal intubations per trainee per year fell by 10% and of supraglottic devices by 16%, neither of which was statistically significant. Endotracheal intubation for caesarean sections did however fall significantly from an average of nine to an average of six cases per trainee per year. Our findings contrast with other reports of much larger decreases in the number of endotracheal intubations performed by trainees over the last decade, but suggest that our local practice is similar to the international experience of decreasing opportunities for endotracheal intubation in obstetric anaesthesia.

Ease of intubation: A randomized, double-blind study to compare two doses of rocuronium bromide for endotracheal intubation.

PubMed

Shukla, Aparna; Misra, Shilpi

2016-01-01

Clinical need for a nondepolarizing agent with a rapid onset time and a brief duration of action has led to the development of rocuronium bromide. The aim of this study was to evaluate optimal dose of rocuronium bromide for intubation and to compare the onset time, duration of action, intubating conditions, and hemodynamic effects of two doses of rocuronium bromide. A prospective, randomized, double-blind study. All the patients were divided in a randomized, double-blind fashion into two groups of twenty patients each. Group I patients received rocuronium bromide 0.6 mg/kg intravenously and intubated at 60 s, Group II patients received rocuronium bromide 0.9 mg/kg and intubated at 60 s. The neuromuscular block was assessed using single twitch stimulation of 0.1 Hz at adductor pollicis muscle of hand at every 10 s. The results were compiled and analyzed statistically using Chi-square test for qualitative data and Student's t -test for quantitative data. Time of onset was significantly shorter ( P < 0.01) and duration of action was prolonged ( P < 0.001) for Group II as compared to Group I. The intubating conditions were (excellent + good) in 100% patients of Group II and (excellent + good) in 80% of Group I. There was no significant change in pulse rate and mean arterial pressure from the baseline value after the administration of muscle relaxants in either of the two groups. Rocuronium bromide 0.9 mg/kg is a safer alternative to rocuronium bromide 0.6 mg/kg for endotracheal intubation with shorter time of onset and better intubating conditions.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators.

PubMed

Kim, Jong Won; Park, Sang O; Lee, Kyeong Ryong; Hong, Dae Young; Baek, Kwang Je; Lee, Young Hwan; Lee, Jeong Hun; Choi, Pil Cho

2016-08-01

This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs). This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices. Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL). The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions. Clinical Research Information Service (CRIS) in South Korea KCT0000849. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Predictive value of preoperative tests in estimating difficult intubation in patients who underwent direct laryngoscopy in ear, nose, and throat surgery].

PubMed

Karakus, Osman; Kaya, Cengiz; Ustun, Faik Emre; Koksal, Ersin; Ustun, Yasemin Burcu

2015-01-01

Predictive value of preoperative tests in estimating difficult intubation may differ in the laryngeal pathologies. Patients who had undergone direct laryngoscopy (DL) were reviewed, and predictive value of preoperative tests in estimating difficult intubation was investigated. Preoperative, and intraoperative anesthesia record forms, and computerized system of the hospital were screened. A total of 2611 patients were assessed. In 7.4% of the patients, difficult intubations were detected. Difficult intubations were encountered in some of the patients with Mallampati scoring (MS) system Class 4 (50%), Cormack-Lehane classification (CLS) Grade 4 (95.7%), previous knowledge of difficult airway (86.2%), restricted neck movements (cervical ROM) (75.8%), short thyromental distance (TMD) (81.6%), vocal cord mass (49.5%) as indicated in parentheses (p<0.0001). MS had a low sensitivity, while restricted cervical ROM, presence of a vocal cord mass, short thyromental distance, and MS each had a relatively higher positive predictive value. Incidence of difficult intubations increased 6.159 and 1.736-fold with each level of increase in CLS grade and MS class, respectively. When all tests were considered in combination difficult intubation could be classified accurately in 96.3% of the cases. Test results predicting difficult intubations in cases with DL had observedly overlapped with the results provided in the literature for the patient populations in general. Differences in some test results when compared with those of the general population might stem from the concomitant underlying laryngeal pathological conditions in patient populations with difficult intubation. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

A simple method for accurate endotracheal placement of an intubation tube in Guinea pigs to assess lung injury following chemical exposure.

PubMed

Nambiar, M P; Gordon, R K; Moran, T S; Richards, S M; Sciuto, A M

2007-01-01

ABSTRACT Guinea pigs are considered as the animal model of choice for toxicology and medical countermeasure studies against chemical warfare agents (CWAs) and toxic organophosphate pesticides because of the low levels of carboxylesterase compared to rats and mice. However, it is difficult to intubate guinea pigs without damaging the larynx to perform CWA inhalation experiments. We describe an easy technique of intubation of guinea pigs for accurate endotracheal placement of the intubation tube. The technique involves a speculum made by cutting the medium-size ear speculum in the midline leaving behind the intact circular connector to the otoscope. Guinea pigs were anesthetized with Telazol/meditomidine, the tongue was pulled using blunt forceps, and an otoscope attached with the specially prepared speculum was inserted gently. Insertion of the speculum raises the epiglottis and restrains the movements of vocal cord, which allows smooth insertion of the metal stylet-reinforced intubation tube. Accurate endotracheal placement of the intubation tube was achieved by measuring the length from the tracheal bifurcation to vocal cord and vocal cord to the upper front teeth. The average length of the trachea in guinea pigs (275 +/- 25 g) was 5.5 +/- 0.2 cm and the distance from the vocal cord to the front teeth was typically 3 cm. Coinciding an intubation tube marked at 6 cm with the upper front teeth accurately places the intubation tube 2.5 cm above the tracheal bifurcation. This simple method of intubation does not disturb the natural flora of the mouth and causes minimum laryngeal damage. It is rapid and reliable, and will be very valuable in inhalation exposure to chemical/biological warfare agents or toxic chemicals to assess respiratory toxicity and develop medical countermeasures.

Effect of prophylactic bronchodilator treatment with intravenous colforsin daropate, a water-soluble forskolin derivative, on airway resistance after tracheal intubation.

PubMed

Wajima, Zen'ichiro; Shiga, Toshiya; Yoshikawa, Tatsusuke; Ogura, Akira; Imanaga, Kazuyuki; Inoue, Tetsuo; Ogawa, Ryo

2003-07-01

After induction of anesthesia, lung resistance increases. The authors hypothesized that prophylactic bronchodilator treatment with intravenous colforsin daropate, a water-soluble forskolin derivative, before tracheal intubation would result in decreased lung resistance and increased lung compliance after tracheal intubation when compared with placebo medication. Forty-six adult patients were randomized to placebo or colforsin daropate treatment. Patients in the control group received normal saline; patients in the colforsin group received 0.75 microg. kg-1 x min-1 colforsin daropate intravenously until the study ended. Thirty minutes after the study began, the authors administered 5 mg/kg thiamylal and 5 microg/kg fentanyl for induction of general anesthesia and 0.3 mg/kg vecuronium for muscle relaxation. A 15-mg. kg-1. h-1 continuous infusion of thiamylal followed anesthetic induction. Four, 8, 12, and 16 min after tracheal intubation, mean airway resistance (R(awm)), expiratory airway resistance (R(awe)), and dynamic lung compliance (C(dyn)) were measured. Patients in the colforsin group had significantly lower R(awm) and R(awe) and higher C(dyn) after intubation than those in the control group. Differences in R(awm), R(awe), and C(dyn) between the two groups persisted through the final measurement at 16 min. At 4 min after intubation, smokers had a higher R(awm) and a lower C(dyn) than nonsmokers in the control group. After treatment by intravenous colforsin daropate, R(awm), R(awe), and C(dyn) values were similar for smokers and nonsmokers after tracheal intubation. Prophylactic treatment with colforsin daropate produced lower R(awm) and R(awe) and higher C(dyn) after tracheal intubation when compared with placebo medication. Pretreatment before intubation may be beneficial and advantageous for middle-aged smokers.

Intubation biomechanics: laryngoscope force and cervical spine motion during intubation with Macintosh and Airtraq laryngoscopes.

PubMed

Hindman, Bradley J; Santoni, Brandon G; Puttlitz, Christian M; From, Robert P; Todd, Michael M

2014-08-01

Laryngoscopy and endotracheal intubation in the presence of cervical spine instability may put patients at risk of cervical cord injury. Nevertheless, the biomechanics of intubation (cervical spine motion as a function of applied force) have not been characterized. This study characterized and compared the relationship between laryngoscope force and cervical spine motion using two laryngoscopes hypothesized to differ in force. Fourteen adults undergoing elective surgery were intubated twice (Macintosh, Airtraq). During each intubation, laryngoscope force, cervical spine motion, and glottic view were recorded. Force and motion were referenced to a preintubation baseline (stage 1) and were characterized at three stages: stage 2 (laryngoscope introduction); stage 3 (best glottic view); and stage 4 (endotracheal tube in trachea). Maximal force and motion occurred at stage 3 and differed between the Macintosh and Airtraq: (1) force: 48.8 ± 15.8 versus 10.4 ± 2.8 N, respectively, P = 0.0001; (2) occiput-C5 extension: 29.5 ± 8.5 versus 19.1 ± 8.7 degrees, respectively, P = 0.0023. Between stages 2 and 3, the motion/force ratio differed between Macintosh and Airtraq: 0.5 ± 0.2 versus 2.0 ± 1.4 degrees/N, respectively; P = 0.0006. The relationship between laryngoscope force and cervical spine motion is: (1) nonlinear and (2) differs between laryngoscopes. Differences between laryngoscopes in motion/force relationships are likely due to: (1) laryngoscope-specific cervical extension needed for intubation, (2) laryngoscope-specific airway displacement/deformation needed for intubation, and (3) cervical spine and airway tissue viscoelastic properties. Cervical spine motion during endotracheal intubation is not directly proportional to force. Low-force laryngoscopes cannot be assumed to result in proportionally low cervical spine motion.

The effects of water lubrication of tracheal tubes on post-intubation airway complications: study protocol for a randomized controlled trial.

PubMed

Kim, Eugene; Yang, Seong Mi; Yoon, So Jeong; Bahk, Jae-Hyon; Seo, Jeong-Hwa

2016-11-25

Water is known to have lubricating properties, thus it is used for lubrication of tracheal tubes to reduce airway injuries caused by intubation. However, there is no definite evidence to substantiate the beneficial effects of lubricating tracheal tubes using water for attenuating airway injuries. Moreover, the lubrication pretreatment may cause contamination of the tube, leading to respiratory infections. Therefore, this trial aims to assess whether no pretreatment of tracheal tubes does not increase post-intubation airway complications as compared with water lubrication of tubes. This is a prospective, double-blind, single-center, parallel-arm, noninferiority, randomized controlled trial to be conducted in participants aged 20-80 years who are undergoing elective surgery under general anesthesia with orotracheal intubation. Participants are randomly assigned into one of two groups depending on whether intubation is performed using a tracheal tube lubricated with water (n = 150) or without any pretreatment (n = 150). The primary outcome is the incidence of sore throat at 0, 2, 4, and 24 h after surgery, which is analyzed with a noninferiority test. The secondary outcomes are the incidence and severity of postoperative hoarseness, oropharyngeal injuries, and respiratory infections. Because we hypothesized that lubricating tracheal tubes using water has no advantage in reducing airway injuries associated with intubation, we will compare the incidence of sore throat, which is the most common complaint after intubation, in a noninferiority manner. This is the first randomized controlled trial to investigate the possibly beneficial or harmful effects of lubricating tracheal tubes using water before intubation. We expect that this trial will provide useful evidence to formulate a protocol for preparing tracheal tubes before intubation. This trial is registered at ClinicalTrials.gov on 1 July 2015 ( NCT02492646 ).

[Comparison between VAMA(®) and Berman(®) cannulas for fibroscopic orotracheal intubation in anaesthetised patients].

PubMed

Castañeda Pascual, M; Batllori Gastón, M; Unzué Rico, P; Murillo Jaso, E; Dorronsoro Auzmendi, M; Martín Vizcaíno, M P

2013-03-01

In fibroscopic intubation, the fact of achieving a direct view in real time does not guarantee the correct advance of the endotracheal tube (ET) to its intratracheal position. The use of oral cannulas helps in achieving a free airway in order to pass the fibroscope and the ET. This study compares the VAMA(®) (V) and Berman(®) (B) cannulas as regards the time required for the intubation, fibroscopic view, and the ease in positioning the ET. 90 patients with no signs of difficult airway were randomised into 2 groups, Berman(®) (B) and VAMA(®) (V), depending on the type of cannula employed. After inducing general anaesthesia, they were intubated using a flexible fibroscope. The fibroscope and intubation times were recorded, as well as the quality of the fibroscopic view, and the level of difficulty in positioning the ET. No statistically significant differences were observed between the cannulas, although the intubation time (P=.292) and the difficulty found in positioning the ET were slightly less (P=.447) in the VAMA(®) group compared to the Berman(®) group. The vision quality was good with both devices, with only some degree of obstruction being encountered in only 22% of the patients. In no case was there complete obstruction, thus all the patients could be intubated correctly. The VAMA(®) cannula is an effective alternative to the classic cannulas for fibreoptic assisted intubation. Furthermore, the novel design provides advantages for the correct orientation of the fiberscope and the withdrawal of the cannula after intubation. Copyright © 2011 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Cost of Chronic Obstructive Pulmonary Disease in the Emergency Department and Hospital: An Analysis of Administrative Data from 218 US Hospitals.

PubMed

Stanford, Richard H; Shen, Yingjia; McLaughlin, Trent

2006-01-01

Treatment of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) or hospital accounts for a significant portion of COPD costs. This study estimates the cost of a COPD ED or hospitalization visit in the US. This observational study utilized administrative data from 218 acute care hospitals. ED/hospital discharges for COPD (International Classification of Diseases - Ninth Revision - Clinical Modification codes 491.xx. 492.xx, 496.xx) during 2001 were identified. Costs were determined for three groups: (i) ED only; (ii) standard admission; and (iii) severe admissions (intensive care unit [ICU] or intubation). Severe admissions were stratified into: (i) ICU/no intubation; (ii) intubation/no ICU; and (iii) ICU + intubation. Mean total costs and length of stay (LOS) were calculated for each group. A total of 59 735 ED/hospital encounters were identified: 20 431 ED only, 33 210 standard admissions, and 6094 severe admissions (4456 ICU/no intubation, 496 intubation/no ICU, and 1142 ICU/intubation). ED visits had a mean cost of $US571 +/- 507 (year 2001 value). Inpatient costs ranged from $US5997 (+/- 5752) for a standard admission to $US36 743 (+/- 62 886) for ICU plus intubation admissions, while LOS ranged from 5.1 days (+/- 4.5) to 14.8 days (+/- 16.7), respectively. In addition, only 10% of encounters required an intubation/ICU admission, but these accounted for 34% of the cost. Cost of a COPD hospitalization is substantial in the US, with one-third of those costs being associated with severe admissions, which make up only 10% of all COPD admissions. Treatments aimed at reducing hospitalizations and length of stay could result in substantial cost savings.

Evaluation of Optimum Dietary Threonine Requirement by Plasma Free Threonine and Ammonia Concentrations in Surgically Modified Rainbow Trout, Oncorhynchus mykiss

PubMed Central

Yun, Hyeonho; Park, Gunjun; Ok, Imho; Katya, Kumar; Heung, Silas; Bai, Sungchul C.

2015-01-01

This study was carried out to evaluate the dietary threonine requirement by measuring the plasma free threonine and ammonia concentrations in rainbow trout, Oncorhynchus mykiss after dorsal aorta cannulation. A total of 70 fish (average initial weight 506±8.2 g) were randomly distributed into each of the 14 net cages (5 fish/cage). After 48 hours (h) of feed deprivation, each group was intubated at 1% body weight with one of the seven L-amino acid based diets containing graded levels of threonine (0.42%, 0.72%, 0.92%, 1.12%, 1.32%, 1.52%, or 1.82% of diet, dry matter basis). Blood samples were taken at 0, 5, and 24 h after intubation. Post-prandial plasma free threonine concentrations (PPthr) of fish 5 h after intubation with diets containing 1.32% or more threonine were significantly higher than those of fish intubated with diets containing 1.12% or less threonine (p<0.05). Post-absorptive free threonine concentrations (PAthr) after 24 h of intubation of the fish with diets containing 0.92% or more threonine were significantly higher than those of fish intubated with diets containing 0.72% or less threonine. Post-prandial plasma ammonia concentrations (PPA, 5 h after intubation) were not significantly different among fish intubated with diets containing 1.12% or less threonine, except the PPA of fish intubated with diet containing 0.42% threonine. Broken-line model analyses of PPthr, PAthr, and PPA indicated that the dietary threonine requirement of rainbow trout should be between 0.95% (2.71) and 1.07% (3.06) of diet (% of dietary protein on a dry matter basis). PMID:25656187

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial.

PubMed

Smereka, Jacek; Ladny, Jerzy R; Naylor, Amanda; Ruetzler, Kurt; Szarpak, Lukasz

2017-08-01

The aim of this study was to compare C-MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with <5years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Scenario A: Nearly all participants performed successful intubations with both MAC and C-MAC on the first attempt (95.7% MAC vs. 100% C-MAC), with similar intubation times (16.5s MAC vs. 18s C-MAC). Scenario B: The results with C-MAC were significantly better than those with MAC (p<0.05) for the time of intubation (23 s MAC vs. 19 s C-MAC), success of the first intubation attempt (88.6% MAC vs. 100% C-MAC), Cormack-Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C-MAC were significantly better than those with MAC (p<0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C-MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C-MAC), Cormack-Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. The C-MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization. Copyright © 2017 Elsevier Inc. All rights reserved.

The Pentax airway scope versus the Macintosh laryngoscope: Comparison of hemodynamic responses and concentrations of plasma norepinephrine to tracheal intubation

PubMed Central

2013-01-01

Background The Pentax Airway Scope (AWS) is a video laryngoscope designed to facilitate tracheal intubation with a high-resolution image. The Pentax AWS has been reported to cause less hemodynamic stress than the Macintosh laryngoscope. The aims of this study are to investigate the differences in hemodynamic responses and norepinephrine concentrations to tracheal intubation between procedures using he Pentax AWS and the Macintosh laryngoscope. Methods Forty patients (American Society of Anesthesiologists class I-II, age range: 18-60 years) were randomly assigned to be intubated with either the Pentax AWS or the Macintosh laryngoscope while under general anesthesia. Routine monitoring, including invasive arterial blood pressure and bispectral index, were applied. Thiopental (4 mg/kg), fentanyl (1 µg/kg), midazolam (0.05 mg/kg), and rocuronium (0.6 mg/kg) were administered for anesthetic induction. Systolic, diastolic, and mean blood pressures and heart rates were recorded pre-intubation, immediately post-intubation (T0), and over the following 10 minutes at one minute intervals (T1, T2, T3, T4, T5…T10). Patient blood was sampled for norepinephrine concentrations pre-intubation (baseline) and post-intubation (T1). Evidence of sore throat was evaluated 30 min and 24 hr after extubation. Data were transformed to % basal and expressed as mean ± SD. Results The systolic, diastolic, and mean blood pressure, and heart rate at T0 and T4 were significantly different between the two groups. There was no significant difference in plasma norepinephrine between the two groups. The difference in incidence of sore throat was not significant between the two groups. Conclusions Pentax-AWS for tracheal intubation has greater hemodynamic stability than the Macintosh blade laryngoscope. PMID:23646240

Sugammadex for reversal of neuromuscular block after rapid sequence intubation: a systematic review and economic assessment†

PubMed Central

Chambers, D.; Paulden, M.; Paton, F.; Heirs, M.; Duffy, S.; Hunter, J. M.; Sculpher, M.; Woolacott, N.

2010-01-01

Summary Sugammadex 16 mg kg−1 can be used for the immediate reversal of neuromuscular block 3 min after administration of rocuronium and could be used in place of succinylcholine for emergency intubation. We have systematically reviewed the efficacy and cost-effectiveness and made an economic assessment of sugammadex for immediate reversal. The economic assessment investigated whether sugammadex appears cost-effective under various assumptions about the value of any reduction in recovery time with sugammadex, the likelihood of a ‘can't intubate, can't ventilate’ (CICV) event, the age of the patient, and the length of the procedure. Three trials were included in the efficacy review. Sugammadex administered 3 or 5 min after rocuronium produced markedly faster recovery than placebo or spontaneous recovery from succinylcholine-induced block. No published economic evaluations were found. Our economic analyses showed that sugammadex appears more cost-effective, where the value of any reduction in recovery time is greater, where the reduction in mortality compared with succinylcholine is greater, and where the patient is younger, for lower probabilities of a CICV event and for long procedures which do not require profound block throughout. Because of the lack of evidence, the value of some parameters remains unknown, which makes it difficult to provide a definitive assessment of the cost-effectiveness of sugammadex in practice. The use of sugammadex in combination with high-dose rocuronium is efficacious. Further research is needed to clarify key parameters in the analysis and to allow a fuller economic assessment. PMID:20937718

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates).

PubMed

Abdelgadir, Ibtihal S; Phillips, Robert S; Singh, Davinder; Moncreiff, Michael P; Lumsden, Joanne L

2017-05-24

Direct laryngoscopy is the method currently used for tracheal intubation in children. It occasionally offers unexpectedly poor laryngeal views. Indirect laryngoscopy involves visualizing the vocal cords by means other than obtaining a direct sight, with the potential to improve outcomes. We reviewed the current available literature and performed a meta-analysis to compare direct versus indirect laryngoscopy, or videolaryngoscopy, with regards to efficacy and adverse effects. To assess the efficacy of indirect laryngoscopy, or videolaryngoscopy, versus direct laryngoscopy for intubation of children with regards to intubation time, number of attempts at intubation, and adverse haemodynamic responses to endotracheal intubation. We also assessed other adverse responses to intubation, such as trauma to oral, pharyngeal, and laryngeal structures, and we assessed vocal cord view scores. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and trial registers (www.clinicaltrials.gov and www.controlledtrials) in November 2015. We reran the search in January 2017. We added new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. We performed reference checking and citation searching and contacted the authors of unpublished data to ask for more information. We applied no language restrictions. We included only randomized controlled trials. Participants were children aged 28 days to 18 years. Investigators performed intubations using any type of indirect laryngoscopes, or videolaryngoscopes, versus direct laryngoscopes. We used Cochrane standard methodological procedures. Two review authors independently reviewed titles, extracted data, and assessed risk of bias. We included 12 studies (803 children) in this review and meta-analysis. We identified three studies that are awaiting classification and two ongoing studies.Trial results show that a longer intubation time was required when indirect laryngoscopy, or videolaryngoscopy, was used instead of direct laryngoscopy (12 trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence interval (CI) 1.37 to 9.60; I 2 = 90%; very low-quality evidence). Researchers found no significant differences between direct and indirect laryngoscopy on assessment of success of the first attempt at intubation (11 trials; n = 749; risk ratio (RR) 0.96, 95% CI 0.91 to 1.02; I 2 = 67%; low-quality evidence) and observed that unsuccessful intubation (five trials; n = 263) was significantly increased in the indirect laryngoscopy, or videolaryngoscopy, group (RR 4.93, 95% CI 1.33 to 18.31; I 2 = 0%; low-quality evidence). Five studies reported the effect of intubation on oxygen saturation (n = 272; very low-quality evidence). Five children had desaturation during intubation: one from the direct laryngoscopy group and four from the indirect laryngoscopy, or videolaryngoscopy, group.Two studies (n = 100) reported other haemodynamic responses to intubation (very low-quality evidence). One study reported a significant increase in heart rate five minutes after intubation in the indirect laryngoscopy group (P = 0.007); the other study found that the heart rate change in the direct laryngoscopy group was significantly less than the heart rate change in the indirect laryngoscopy, or videolaryngoscopy, group (P < 0.001). A total of five studies (n = 244; very low-quality evidence) looked at evidence of trauma resulting from intubation. Investigators reported that only two children from the direct laryngoscopy group had trauma compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group.Use of indirect laryngoscopy, or videolaryngoscopy, improved the percentage of glottic opening (five trials; n = 256). Studies noted no significant difference in Cormack and Lehane score (C&L) grade 1 (three trials; n = 190; RR 1.06, 95% CI 0.93 to 1.21; I 2 = 59%). Evidence suggests that indirect laryngoscopy, or videolaryngoscopy, leads to prolonged intubation time with an increased rate of intubation failure when compared with direct laryngoscopy (very low-quality evidence due to imprecision, inconsistency, and study limitations). Review authors had difficulty reaching conclusions on adverse haemodynamic responses and other adverse effects of intubation, as only a few children were reported to have these outcomes. Use of indirect laryngoscopy, or videolaryngoscopy, might lead to improved vocal cord view, but marked heterogeneity between studies made it difficult for review authors to reach conclusions on this outcome.

[Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

PubMed

Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

2016-04-01

We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.

Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation.

PubMed

Blaivas, Michael; Tsung, James W

2008-05-01

Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases. We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed. Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction. Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

PubMed

MacNab, A J; MacPhail, I; MacNab, M K; Noble, R; O'Flaherty, D

1998-01-01

We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.

Improving the safety of remote site emergency airway management.

PubMed

Wijesuriya, Julian; Brand, Jonathan

2014-01-01

Airway management, particularly in non-theatre settings, is an area of anaesthesia and critical care associated with significant risk of morbidity & mortality, as highlighted during the 4th National Audit Project of the Royal College of Anaesthetists (NAP4). A survey of junior anaesthetists at our hospital highlighted a lack of confidence and perceived lack of safety in emergency airway management, especially in non-theatre settings. We developed and implemented a multifaceted airway package designed to improve the safety of remote site airway management. A Rapid Sequence Induction (RSI) checklist was developed; this was combined with new advanced airway equipment and drugs bags. Additionally, new carbon dioxide detector filters were procured in order to comply with NAP4 monitoring recommendations. The RSI checklists were placed in key locations throughout the hospital and the drugs and advanced airway equipment bags were centralised in the Intensive Care Unit (ICU). It was agreed with the senior nursing staff that an appropriately trained ICU nurse would attend all emergency situations with new airway resources upon request. Departmental guidelines were updated to include details of the new resources and the on-call anaesthetist's responsibilities regarding checks and maintenance. Following our intervention trainees reported higher confidence levels regarding remote site emergency airway management. Nine trusts within the Northern Region were surveyed and we found large variations in the provision of remote site airway management resources. Complications in remote site airway management due lack of available appropriate drugs, equipment or trained staff are potentially life threatening and completely avoidable. Utilising the intervention package an anaesthetist would be able to safely plan and prepare for airway management in any setting. They would subsequently have the drugs, equipment, and trained assistance required to manage any difficulties or complications. We suggest that this should be the gold standard of airway resource provision and is in line with NAP4 recommendations.

Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status.

PubMed

Snipelisky, David; Dumitrascu, Adrian; Ray, Jordan; Roy, Archana; Matcha, Gautam; Harris, Dana; Vadeboncoeur, Tyler; Kusumoto, Fred; Burton, M Caroline

2017-12-06

Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. A total of 239 patients were included. Almost all (n = 218, 91.2%) required intubation during the hospitalization. Over half (n = 117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n = 10, 47.6% versus n = 55, 25.2%; p = 0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n = 8, 38.1% versus n = 50, 22.9%; p = 0.37). No differences in 24-hour and posthospital survivals were present. Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.

Neurological deterioration during intubation in cervical spine disorders

PubMed Central

Durga, Padmaja; Sahu, Barada Prasad

2014-01-01

Anaesthesiologists are often involved in the management of patients with cervical spine disorders. Airway management is often implicated in the deterioration of spinal cord function. Most evidence on neurological deterioration resulting from intubation is from case reports which suggest only association, but not causation. Most anaesthesiologists and surgeons probably believe that the risk of spinal cord injury (SCI) during intubation is largely due to mechanical compression produced by movement of the cervical spine. But it is questionable that the small and brief deformations produced during intubation can produce SCI. Difficult intubation, more frequently encountered in patients with cervical spine disorders, is likely to produce greater movement of spine. Several alternative intubation techniques are shown to improve ease and success, and reduce cervical spine movement but their role in limiting SCI is not studied. The current opinion is that most neurological injuries during anaesthesia are the result of prolonged deformation, impaired perfusion of the cord, or both. To prevent further neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and positioning for surgery are essential. The features that diagnose laryngoscopy induced SCI are myelopathy present on recovery, short period of unconsciousness, autonomic disturbances following laryngoscopy, cranio-cervical junction disease or gross instability below C3. It is difficult to accept or refute the claim that neurological deterioration was induced by intubation. Hence, a record of adequate care at laryngoscopy and also perioperative period are important in the event of later medico-legal proceedings. PMID:25624530

Does Video Laryngoscopy Offer Advantages over Direct Laryngoscopy during Cardiopulmonary Resuscitation?

PubMed

Saraçoğlu, Ayten; Bezen, Olgaç; Şengül, Türker; Uğur, Egin Hüsnü; Şener, Sibel; Yüzer, Fisun

2015-08-01

Interruption of chest compressions should be minimized because of its negative effects on survival. This randomized, controlled, cross-over study aimed to analyze the effectiveness of Macintosh, Miller, McCoy and McGrath laryngoscopes during with or without chest compressions in the scope of a simulated cardiopulmonary resuscitation scenario. The time required for successful tracheal intubation, number of attempts, dental trauma severity and the need for optimization manoeuvres were recorded during cardiopulmonary resuscitation with and without chest compressions. The experience with computer games during the last 10 years were asked to the participants and recorded. McCoy laryngoscope yielded the shortest time for successful tracheal intubation both in the presence of and without chest compressions. During the use of McCoy laryngoscopes, fewer tracheal intubation attempts, lower incidence of dental trauma and lower visual analogue scale scores on the ease of intubation were recorded. Participants who are experienced computer game players using Macintosh, McCoy and McGrath achieved successful tracheal intubation in a significantly shorter time during resuscitation without chest compressions. Dental trauma incidence and number of tracheal intubation attempts did not show any significant difference between the four laryngoscopes being related to the rate of playing computer games. McGrath video laryngoscopes do not appear to have advantages over direct laryngoscopes for securing a smooth and successful tracheal intubation during rhythmic chest compressions. We believe that as McCoy laryngoscope provided tracheal intubation in a shorter time and with fewer attempts, this laryngoscope may increase the success rate of resuscitation.

An autonomous organic reaction search engine for chemical reactivity.

PubMed

Dragone, Vincenza; Sans, Victor; Henson, Alon B; Granda, Jaroslaw M; Cronin, Leroy

2017-06-09

The exploration of chemical space for new reactivity, reactions and molecules is limited by the need for separate work-up-separation steps searching for molecules rather than reactivity. Herein we present a system that can autonomously evaluate chemical reactivity within a network of 64 possible reaction combinations and aims for new reactivity, rather than a predefined set of targets. The robotic system combines chemical handling, in-line spectroscopy and real-time feedback and analysis with an algorithm that is able to distinguish and select the most reactive pathways, generating a reaction selection index (RSI) without need for separate work-up or purification steps. This allows the automatic navigation of a chemical network, leading to previously unreported molecules while needing only to do a fraction of the total possible reactions without any prior knowledge of the chemistry. We show the RSI correlates with reactivity and is able to search chemical space using the most reactive pathways.

An autonomous organic reaction search engine for chemical reactivity

NASA Astrophysics Data System (ADS)

Dragone, Vincenza; Sans, Victor; Henson, Alon B.; Granda, Jaroslaw M.; Cronin, Leroy

2017-06-01

The exploration of chemical space for new reactivity, reactions and molecules is limited by the need for separate work-up-separation steps searching for molecules rather than reactivity. Herein we present a system that can autonomously evaluate chemical reactivity within a network of 64 possible reaction combinations and aims for new reactivity, rather than a predefined set of targets. The robotic system combines chemical handling, in-line spectroscopy and real-time feedback and analysis with an algorithm that is able to distinguish and select the most reactive pathways, generating a reaction selection index (RSI) without need for separate work-up or purification steps. This allows the automatic navigation of a chemical network, leading to previously unreported molecules while needing only to do a fraction of the total possible reactions without any prior knowledge of the chemistry. We show the RSI correlates with reactivity and is able to search chemical space using the most reactive pathways.

An autonomous organic reaction search engine for chemical reactivity

PubMed Central

Dragone, Vincenza; Sans, Victor; Henson, Alon B.; Granda, Jaroslaw M.; Cronin, Leroy

2017-01-01

The exploration of chemical space for new reactivity, reactions and molecules is limited by the need for separate work-up-separation steps searching for molecules rather than reactivity. Herein we present a system that can autonomously evaluate chemical reactivity within a network of 64 possible reaction combinations and aims for new reactivity, rather than a predefined set of targets. The robotic system combines chemical handling, in-line spectroscopy and real-time feedback and analysis with an algorithm that is able to distinguish and select the most reactive pathways, generating a reaction selection index (RSI) without need for separate work-up or purification steps. This allows the automatic navigation of a chemical network, leading to previously unreported molecules while needing only to do a fraction of the total possible reactions without any prior knowledge of the chemistry. We show the RSI correlates with reactivity and is able to search chemical space using the most reactive pathways. PMID:28598440

Optimization study on the primary mirror lightweighting of a remote sensing instrument

NASA Astrophysics Data System (ADS)

Chan, Chia-Yen; Huang, Bo-Kai; You, Zhen-Ting; Chen, Yi-Cheng; Huang, Ting-Ming

2015-07-01

Remote sensing instrument (RSI) is used to take images for ground surface observation, which will be exposed to high vacuum, high temperature difference, gravity, 15 g-force and random vibration conditions and other harsh environments during operation. While designing a RSI optical system, not only the optical quality but also the strength of mechanical structure we should be considered. As a result, an optimization method is adopted to solve this engineering problem. In the study, a ZERODUR® mirror with a diameter of 466 mm has been chosen as the model and the optimization has been executed by combining the computer-aided design, finite element analysis, and parameter optimization software. The optimization is aimed to obtain the most lightweight mirror with maintaining structural rigidity and good optical quality. Finally, the optimum optical mirror with a lightweight ratio of 0.55 is attained successfully.

Comparisons of the Pentax-AWS, Glidescope, and Macintosh Laryngoscopes for Intubation Performance during Mechanical Chest Compressions in Left Lateral Tilt: A Randomized Simulation Study of Maternal Cardiopulmonary Resuscitation

PubMed Central

Lee, Sanghyun; Kim, Wonhee; Kang, Hyunggoo; Oh, Jaehoon; Lim, Tae Ho; Lee, Yoonjae; Kim, Changsun; Cho, Jun Hwi

2015-01-01

Purpose. Rapid advanced airway management is important in maternal cardiopulmonary resuscitation (CPR). This study aimed to compare intubation performances among Pentax-AWS (AWS), Glidescope (GVL), and Macintosh laryngoscope (MCL) during mechanical chest compression in 15° and 30° left lateral tilt. Methods. In 19 emergency physicians, a prospective randomized crossover study was conducted to examine the three laryngoscopes. Primary outcomes were the intubation time and the success rate for intubation. Results. The median intubation time using AWS was shorter than that of GVL and MCL in both tilt degrees. The time to visualize the glottic view in GVL and AWS was significantly lower than that of MCL (all P < 0.05), whereas there was no significant difference between the two video laryngoscopes (in 15° tilt, P = 1; in 30° tilt, P = 0.71). The progression of tracheal tube using AWS was faster than that of MCL and GVL in both degrees (all P < 0.001). Intubations using AWS and GVL showed higher success rate than that of Macintosh laryngoscopes. Conclusions. The AWS could be an appropriate laryngoscope for airway management of pregnant women in tilt CPR considering intubation time and success rate. PMID:26161426

Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study.

PubMed

Longari, F; Dehgani Mobaraki, P; Ricci, A L; Lapenna, R; Cagini, C; Ricci, G

2016-08-01

The objective of this study is to assess different outcomes between endoscopic dacryocystorhinostomy (En-DCR) with and without silicone intubation. We retrospectively analyzed 84 patients (89 procedures), suffering from chronic epiphora for primary acquired nasolacrimal duct obstruction, treated with En-DCR and divided into two groups depending on silicone stent intubation. The surgical outcomes were evaluated at 7 post-operative controls using Munk's score criteria. Functional success was defined as absence of epiphora, no further episodes of dacryocystitis, and a patent ostium after fluorescein irrigation. 45 En-DCR with stent and 44 En-DCR without stent were performed. Success rate after 18 months follow-up were, respectively, 82.2 % in the stent group and 88.6 % in the non-stent group (OR 0.59) with no statistical differences. The ostial size reduction has been reported in higher percentage in the stent group, mainly due to peristomal granuloma (OR 3.64), scar tissue formation (OR 2.25), and turbinoseptal synaechia (OR 1.76). The benefits of non-intubation are less patient discomfort, reduced surgical time and costs, simpler follow-up regimen and less intubation-associated complications. En-DCR without silicone stent intubation should be the first choice of procedure, stent intubation should be reserved in selected cases with poor local conditions pre and intra-operatively assessed.

Dynamic Contrast-Enhanced MRI of Cervical Cancers: Temporal Percentile Screening of Contrast Enhancement Identifies Parameters for Prediction of Chemoradioresistance

DOE Office of Scientific and Technical Information (OSTI.GOV)

Andersen, Erlend K.F.; Hole, Knut Hakon; Lund, Kjersti V.

Purpose: To systematically screen the tumor contrast enhancement of locally advanced cervical cancers to assess the prognostic value of two descriptive parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods and Materials: This study included a prospectively collected cohort of 81 patients who underwent DCE-MRI with gadopentetate dimeglumine before chemoradiotherapy. The following descriptive DCE-MRI parameters were extracted voxel by voxel and presented as histograms for each time point in the dynamic series: normalized relative signal increase (nRSI) and normalized area under the curve (nAUC). The first to 100th percentiles of the histograms were included in a log-rank survival test,more » resulting in p value and relative risk maps of all percentile-time intervals for each DCE-MRI parameter. The maps were used to evaluate the robustness of the individual percentile-time pairs and to construct prognostic parameters. Clinical endpoints were locoregional control and progression-free survival. The study was approved by the institutional ethics committee. Results: The p value maps of nRSI and nAUC showed a large continuous region of percentile-time pairs that were significantly associated with locoregional control (p < 0.05). These parameters had prognostic impact independent of tumor stage, volume, and lymph node status on multivariate analysis. Only a small percentile-time interval of nRSI was associated with progression-free survival. Conclusions: The percentile-time screening identified DCE-MRI parameters that predict long-term locoregional control after chemoradiotherapy of cervical cancer.« less

Eight weeks of omeprazole 20 mg significantly reduces both laryngopharyngeal reflux and comorbid chronic rhinosinusitis signs and symptoms: Randomised, double-blind, placebo-controlled trial.

PubMed

Anzić, S A; Turkalj, M; Župan, A; Labor, M; Plavec, D; Baudoin, T

2018-04-01

Gastroesophageal reflux recommended treatment (dose and duration) with proton-pump inhibitor (PPI) compared to placebo significantly reduces the signs and symptoms of laryngopharyngeal reflux (LPR) and comorbid chronic rhinosinusitis (CRS). Double-blind randomised placebo-controlled trial. Eight weeks of treatment with omeprazole 20 mg once daily (OD). Sixty patients (28 women, aged 19-87 years) with diagnosed LPR and comorbid CRS. Significant reduction in signs and symptoms (reflux symptom index (RSI) score as subjective, and reflux finding score (RFS) as objective measure) of LPR after 8 weeks of treatment with omeprazole 20 mg OD when compared to placebo. Secondary objectives were significant reduction in signs and symptoms of comorbid CRS after 8 weeks of treatment with omeprazole 20 mg OD when compared to placebo and the association of the severity of signs and symptoms of LPR with the ones of CRS. RSI and RFS decreased significantly more in the active treatment group after 8 weeks compared to placebo (P < .001 for both). CRS and endoscopy scoring decreased both significantly more in the active group after 8 weeks compared to placebo (P < .001 for both). CRS scoring significantly correlated with RSI (R = 0.312, P = .015) but not with RFS (R = 0.199, P = .127). The results of our trial suggest that omeprazole 20 mg OD for 8 weeks was effective in reducing signs and symptoms of both LPR and CRS, although in most patients still present at the end of the trial. © 2017 John Wiley & Sons Ltd.

Using the reactive strength index modified to evaluate plyometric performance.

PubMed

Ebben, William P; Petushek, Erich J

2010-08-01

The ability to develop force quickly is a requisite ability in most sports. The reactive strength index (RSI) has been developed as a measure of explosive strength and is derived by evaluating jump height divided by ground contact time during the depth jump (DJ). At present, the RSI is typically used to evaluate DJ performance, because it is the only plyometric exercise with an identifiable ground contact time. The purpose of this study was to introduce a modification of the RSI (RSImod) that can be used to evaluate the explosive power of any vertical plyometric exercise. This study will also assess the reliability of the RSImod, evaluate the RSImod of a variety of plyometric exercises, and examine gender differences. Twenty-six men and 23 women served as subjects. Subjects performed 3 repetitions for each of 5 plyometric exercises including the countermovement jump (CMJ), tuck jump, single-leg jump, squat jump, and dumbbell CMJ. Data were analyzed using a 2-way analysis of variance to evaluate differences in RSImod between the plyometric exercise and the interaction between plyometric exercise RSImod and gender. The analysis of RSImod revealed significant main effects for plyometric exercise type (p 0.05). Results of pairwise comparisons indicate that the RSImod is statistically different between all plyometric exercises studied. Intraclass correlation coefficients indicate that RSImod is highly reliable for all of the exercises studied. The RSImod offers a highly reliable method of assessing the explosiveness developed during a variety of plyometric exercises.

[Analysis of the characteristic of pharyngeal paraesthesia patients by high resolution manometry].

PubMed

Gu, Yun; Qian, Wei

2015-09-01

To discuss the pressure changing characteristics of upper esophageal sphincter (UES), lower esophageal sphincter (LES) and the esophagus kinetic characteristics of pharyngeal paraesthesia patients. To take high resolution manometry in 44 cases of pharyngeal paraesthesia patients and 23 normal subjects separately. According to the RSI score,the 44 patients were divided into group A (the group without reflux, RSI < 13, n = 25) and group B (the group with reflux, RSI ≥ 13, n = 19). The UES average resting pressure and average residual pressure of patients group were higher than the control group (P < 0.05); The UES average resting pressure and average residual pressure of group B were higher than group A (P < 0.05); The LES average resting pressure and average residual pressure of group B were lower than group A and the control group (P < 0.05); The comparison of LES average resting pressure and average residual pressure between group A and the control group was not statistically significant (P > 0.05). The esophagus DCI of group B was lower than that of group A and control group (P < 0.05). The esophagus DCI comparison between group A and control group was not statistically significant (P > 0.05). The pharyngeal paresthesia symptoms of'patients was associated with the increasing of UES pressure. The pharyngeal paresthesia symptoms of group with reflux was related to low pressure of LES and high pressure of UES. The last part of esophagus of group with reflux had obstacles in powers, which weaken the peristalsis and declined the ability to clear the bolus and gastric reflux material.

Assessment of the storz video Macintosh laryngoscope for use in difficult airways: A human simulator study.

PubMed

Bair, Aaron E; Olmsted, Kalani; Brown, Calvin A; Barker, Tobias; Pallin, Daniel; Walls, Ron M

2010-10-01

Video laryngoscopy has been shown to improve glottic exposure when compared to direct laryngoscopy in operating room studies. However, its utility in the hands of emergency physicians (EPs) remains undefined. A simulated difficult airway was used to determine if intubation by EPs using a video Macintosh system resulted in an improved glottic view, was easier, was faster, or was more successful than conventional direct laryngoscopy. Emergency medicine (EM) residents and attending physicians at two academic institutions performed endotracheal intubation in one normal and two identical difficult airway scenarios. With the difficult scenarios, the participants used video laryngoscopy during the second case. Intubations were performed on a medium-fidelity human simulator. The difficult scenario was created by limiting cervical spine mobility and inducing trismus. The primary outcome was the proportion of direct versus video intubations with a grade I or II Cormack-Lehane glottic view. Ease of intubation (self-reported via 10-cm visual analog scale [VAS]), time to intubation, and success rate were also recorded. Descriptive statistics as well as medians with interquartile ranges (IQRs) are reported where appropriate. The Wilcoxon matched pairs signed-rank test was used for comparison testing of nonparametric data. Participants (n = 39) were residents (59%) and faculty. All had human intubation experience; 51% reported more than 100 prior intubations. On difficult laryngoscopy, a Cormack-Lehane grade I or II view was obtained in 20 (51%) direct laryngoscopies versus 38 (97%) of the video-assisted laryngoscopies (p < 0.01). The median VAS score for difficult airways was 50 mm (IQR = 28–73 mm) for direct versus 18 mm (IQR = 9–50 mm) for video (p < 0.01). The median time to intubation in difficult airways was 25 seconds (IQR = 16–44 seconds) for direct versus 20 seconds (IQR = 12–35 seconds) for video laryngoscopy (p < 0.01). All intubations were successful without need for an invasive airway. In this simulation, video laryngoscopy was associated with improved glottic exposure, was perceived as easier, and was slightly faster than conventional direct laryngoscopy in a simulated difficult airway. Absence of secretions and blood limits the generalizability of our findings; human studies are needed.

A nationwide postal questionnaire survey: the presence of airway guidelines in anaesthesia department in Sweden

PubMed Central

2014-01-01

Background In Sweden, airway guidelines aimed toward improving patient safety have been recommended by the Swedish Society of Anaesthesia and Intensive Care Medicine. Adherence to evidence-based airway guidelines is known to be generally poor in Sweden. The aim of this study was to determine whether airway guidelines are present in Swedish anaesthesia departments. Methods A nationwide postal questionnaire inquiring about the presence of airway guidelines was sent out to directors of Swedish anaesthesia departments (n = 74). The structured questionnaire was based on a review of the Swedish Society of Anaesthesia and Intensive Care voluntary recommendations of guidelines for airway management. Mean, standard deviation, minimum/maximum, percentage (%) and number of general anaesthesia performed per year as frequency (n), were used to describe, each hospital type (university, county, private). For comparison between hospitals type and available written airway guidelines were cross tabulation used and analysed using Pearson’s Chi-Square tests. A p- value of less than 0 .05 was judged significant. Results In total 68 directors who were responsible for the anaesthesia departments returned the questionnaire, which give a response rate of 92% (n 68 of 74). The presence of guidelines showing an airway algorithm was reported by 68% of the departments; 52% reported having a written patient information card in case of a difficult airway and guidelines for difficult airways, respectively; 43% reported the presence of guidelines for preoperative assessment; 31% had guidelines for Rapid Sequence Intubation; 26% reported criteria for performing an awake intubation; and 21% reported guidelines for awake fibre-optic intubation. A prescription for the registered nurse anaesthetist for performing tracheal intubation was reported by 24%. The most frequently pre-printed preoperative elements in the anaesthesia record form were dental status and head and neck mobility. Conclusions Despite recommendations from the national anaesthesia society, the presence of airway guidelines in Swedish anaesthesia departments is low. From the perspective of safety for both patients and the anaesthesia staff, airway management guidelines should be considered a higher priority. PMID:24708670

Disposable stainless steel vs plastic laryngoscope blades among paramedics.

PubMed

Dos Santos, Frank D; Schnakofsky, Roberto; Cascio, Anthony; Liu, Junfeng; Merlin, Mark A

2011-07-01

Several studies have been published in the literature about intubation methods, but little is available on intubation equipment used in this setting. This is the first prehospital comparison of disposable plastic vs disposable stainless steel laryngoscope blades used by paramedics. The objective of this study was to compare prehospital intubation success rates on first attempt and overall number of attempts to obtain intubations using disposable plastic laryngoscopes blades vs disposable stainless steel laryngoscope blades. A retrospective prehospital cohort study was conducted during two 3-year periods. Two-way contingency table and χ(2) test were conducted to determine if there was a difference between the 2 types of blades. A proportional odds model with calculated 95% confidence interval (CI) and odd ratios were then calculated. A total of 2472 paramedic intubations were recorded over the 6-year period. The stainless steel single-use blades had a first attempt success rate of 88.9% vs 78.5% with plastic blades (P = .01; odds ratio, 1.94; 95% CI, 1.17-3.41). The stainless steel single-use laryngoscope blade had a lower number of attempts to successful intubation than the plastic blade (88.8% vs 74.3%, respectively) (P < .01; odds ratio, 1.64; 95% CI, 1.34-2.00). In the prehospital setting, stainless steel disposable blades were superior to plastic disposable blades in first attempt and overall number of attempts to intubation. Until further research is done, we recommend use of stainless steel blades for intubations in the prehospital setting by paramedics. Copyright © 2011 Elsevier Inc. All rights reserved.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

PubMed

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS ( P =0.001), respiratory rate ( P =0.001), and higher frequency of head ( P =0.02) and chest injuries ( P =0.04). The rate of VAP in PHI group was comparable to the TRI group ( P =0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Efficacy of video-guided laryngoscope in airway management skills of medical students.

PubMed

Peirovifar, Ali; Mahmoodpoor, Ata; Golzari, Samad Ej; Soleimanpour, Hassan; Eslampour, Yashar; Fattahi, Vahid

2014-10-01

Video-guided laryngoscopy, though unproven in achieving better success rates of laryngoscopy outcome and intubation, seems to provide better glottic visualization compared with direct laryngoscopy. The objective of this study was to compare the efficacy of video-guided laryngoscope (VGL) in the airway management skills of medical students. Medical students throughout their anesthesiology rotations were enrolled in this study. All students received standard training in the airway management during their course and were randomly allocated into two 20 person groups. In Group D, airway management was performed by direct laryngoscopy via Macintosh blade and in Group G intubation was performed via VGL. Time to intubation, number of laryngoscopy attempts and success rate were noted. Successful intubation was considered as the primary outcome. All data were analyzed using SPSS 16 software. Chi-square and Fisher's exact test were used for analysis of categorical variables. For analyzing continuous variables independent t-test was used. P < 0.05 was considered as statistically significant. Number of laryngoscopy attempts was less in Group G in comparison to Group D; this, however, was statistically insignificant (P: 0.18). Time to intubation was significantly less in Group G as compared to Group D (P: 0.02). Successful intubation in Group G was less frequently when compared to Group D (P: 0.66). Need for attending intervention, esophageal intubation and hypoxemic events during laryngoscopy were less in Group G; this, however, was statistically insignificant. The use of video-guided laryngoscopy improved the first attempt success rate, time to intubation, laryngoscopy attempts and airway management ability of medical students compared to direct laryngoscopy.

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults.

PubMed

Myatra, Sheila Nainan; Shah, Amit; Kundra, Pankaj; Patwa, Apeksh; Ramkumar, Venkateswaran; Divatia, Jigeeshu Vasishtha; Raveendra, Ubaradka S; Shetty, Sumalatha Radhakrishna; Ahmed, Syed Moied; Doctor, Jeson Rajan; Pawar, Dilip K; Ramesh, Singaravelu; Das, Sabyasachi; Garg, Rakesh

2016-12-01

The All India Difficult Airway Association (AIDAA) guidelines for management of the unanticipated difficult airway in adults provide a structured, stepwise approach to manage unanticipated difficulty during tracheal intubation in adults. They have been developed based on the available evidence; wherever robust evidence was lacking, or to suit the needs and situation in India, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. We recommend optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful. Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available. We recommend no more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95%. Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended. If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation. Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes 'complete ventilation failure', and emergency cricothyroidotomy should be performed. Patient counselling, documentation and standard reporting of the airway difficulty using a 'difficult airway alert form' must be done. In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.

Implementation of remaining service interval concept.

DOT National Transportation Integrated Search

2016-10-01

This document is a technical summary of the Federal Highway Administration (FHWA) report, "Application and Validation of RSI Framework to Pavements" (FHWA-HRT-16-053). The goal of this project was to demonstrate and to validate the application of the...

75 FR 80563 - Agency Information Collection Activities: Proposed Request and Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-22

.... The respondents are a statistically valid sample of all RSI/DI beneficiaries in current pay status or... SSN. We send this form to the employer to identify the employees involved, to resolve the discrepancy...

Influence of the rotor-stator interaction on the dynamic stresses of Francis runners

NASA Astrophysics Data System (ADS)

Guillaume, R.; Deniau, J. L.; Scolaro, D.; Colombet, C.

2012-11-01

Thanks to advances in computing capabilities and Computational Fluid Dynamics (CFD) techniques, it is now possible to calculate realistic unsteady pressure fields in Francis turbines. This paper will explain methods to calculate the structural loads and the dynamic behaviour in order to optimize the turbine design and maximize its reliability and lifetime. Depending on the operating conditions of a Francis turbine, different hydraulic phenomena may impact the mechanical behaviour of the structure. According to their nature, these highly variable phenomena should be treated differently and specifically in order to estimate the potential risks arising on submerged structures, in particular the runner. The operating condition studied thereafter is the point at maximum power with the maximum head. Under this condition, the runner is excited by only one dynamic phenomenon named the Rotor-Stator Interaction (RSI). The origin of the phenomenon is located on the radial gap of the turbine and is the source of pressure fluctuations. A fluid-structure analysis is performed to observe the influence of that dynamic pressure field on the runner behaviour. The first part of the paper deals with the unsteady fluid computation. The RSI phenomenon is totally unsteady so the fluid simulation must take into account the entire machine and its rotation movement, in order to obtain a dynamic pressure field. In the second part of the paper, a method suitable for the RSI study is developed. It is known that the fluctuating pressure in this gap can be described as a sum of spatial components. By evaluating these components in the CFD results and on the scale model, it is possible to assess the relevance of the numerical results on the whole runner. After this step, the numerical pressure field can be used as the dynamic load of the structure. The final part of the paper presentsthe mechanical finite element calculations. A modal analysis of the runner in water and a harmonic analysis of its dynamic behaviour using the CFD results are carried out. These calculations will show that the RSI on the medium head Francis runner does not create damage on the runner even if the natural frequencies are closed to the wicket gates passing frequency. The numerical results are reinforced by experimental observations done on runner prototypes showing that the wicket gates passing frequency does not have significant influence on low and medium head Francis runner behaviour.

Comparison of Macintosh and Airtraq™ laryngoscopes in obese patients placed in the ramped position.

PubMed

Ranieri, D; Filho, S M; Batista, S; do Nascimento, P

2012-09-01

This study compared intubation conditions produced by the Macintosh and Airtraq™ laryngoscopes when used in obese patients in the ramped position. One hundred and thirty-two patients having bariatric surgery were placed in the ramped position and randomly assigned to have their tracheas intubated using either the Macintosh (n=64) or an Airtraq (n=68) laryngoscope. Mean (SD) intubation times were 37 (23) s and 14 (3) s for Macintosh and Airtraq, respectively (p<0.0001). Compared with the Macintosh laryngoscope, the Airtraq laryngoscope provided an improved vocal cord view as assessed by the Cormack and Lehane score (number of patients with Cormack-Lehane scores of 1/2/3/4/37/20/4/3 for the Macintosh, and 65/3/0/0 for the Airtraq laryngoscopes, p<0.0001). One patient in the Macintosh group had a failed intubation and intubation was achieved with the Airtraq. For obese patients in ramped position, Airtraq affords faster tracheal intubation than the Macintosh laryngoscope. Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland.

[Comparison of airway scope and videolaryngoscope portable VLP-100 in the presence of a neck collar--a manikin study].

PubMed

Saito, Tomoyuki; Asai, Takashi; Arai, Takerou; Tsuchida, Misa; Ogawa, Katsumi; Okuda, Yasuhisa

2010-12-01

Tracheal intubation should be performed with great care in the multiple injury patient, particularly when damage to the cervical spine is suspected. The patient with unstable cervical spine requires a neck collar in prehospital area, and medical personnel may be required to perform tracheal intubation. We compared Macintosh laryngoscope with the Airway Scope (AWS), and Coopdeck videolaryngoscope portable VLP-100 (VLP-100) in a manikin model with the presence of a neck collar. We conducted a prospective study in 20 medical residents with little prior airway management experience. They inserted the AWS, VLP-100 and Macintosh laryngoscope, in turn, and the view of the glottis at laryngoscopy was graded, using a classification reported by Cormack and Lehane. Tracheal intubation time and the success rate of tracheal intubation (within 120 sec) were also recorded. The AWS provided a best view of the glottis, a shorter tracheal intubation time and a higher success rate of tracheal intubation, compared with VLP- 100 and Macintosh laryngoscope. The AWS may possess advantages over conventional direct laryngoscopes in patients with restricted neck movement.

Comparison of blind intubation through the I-gel and ILMA Fastrach by nurses during cardiopulmonary resuscitation: a manikin study.

PubMed

Melissopoulou, Theodora; Stroumpoulis, Konstantinos; Sampanis, Michail A; Vrachnis, Nikolaos; Papadopoulos, Georgios; Chalkias, Athanasios; Xanthos, Theodoros

2014-01-01

To investigate whether nursing staff can successfully use the I-gel and the intubating laryngeal mask Fastrach (ILMA) during cardiopulmonary resuscitation. Although tracheal intubation is considered to be the optimal method for securing the airway during cardiopulmonary resuscitation, laryngoscopy requires a high level of skill. Forty five nurses inserted the I-gel and the ILMA in a manikin, with continuous and without chest compressions. Mean intubation times for the ILMA and I-gel without chest compressions were 20.60 ± 3.27 and 18.40 ± 3.26 s, respectively (p < 0.0005). ILMA proved more successful than the I-gel regardless of compressions. Continuation of compressions caused a prolongation in intubation times for both the I-gel (p < 0.0005) and the ILMA (p < 0.0005). In this mannequin study, nursing staff can successfully intubate using the I-gel and the ILMA as conduits with comparable success rates, regardless of whether chest compressions are interrupted or not. Copyright © 2014 Elsevier Inc. All rights reserved.

Topical airway anesthesia for awake fiberoptic intubation: Comparison between airway nerve blocks and nebulized lignocaine by ultrasonic nebulizer

PubMed Central

Gupta, Babita; Kohli, Santvana; Farooque, Kamran; Jalwal, Gopal; Gupta, Deepak; Sinha, Sumit; Chandralekha

2014-01-01

Overview: Awake fiberoptic bronchoscope (FOB) guided intubation is the gold standard of airway management in patients with cervical spine injury. It is essential to sufficiently anesthetize the upper airway before the performance of awake FOB guided intubation in order to ensure patient comfort and cooperation. This randomized controlled study was performed to compare two methods of airway anesthesia, namely ultrasonic nebulization of local anesthetic and performance of airway blocks. Materials and Methods: A total of 50 adult patients with cervical spine injury were randomly allocated into two groups. Group L received airway anesthesia through ultrasonic nebulization of 10 ml of 4% lignocaine and Group NB received airway blocks (bilateral superior laryngeal and transtracheal recurrent laryngeal) each with 2 ml of 2% lignocaine and viscous lignocaine gargles. FOB guided orotracheal intubation was then performed. Hemodynamic variables at baseline and during the procedure, patient recall, vocal cord visibility, ease of intubation, coughing/gagging episodes, and signs of lignocaine toxicity were noted. Results: The observations did not reveal any significant differences in demographics or hemodynamic parameters at any time during the study. However, the time taken for intubation was significantly lower in Group NB as compared with the Group L. Group L had an increased number of coughing/gagging episodes as compared with Group NB. Vocal cord visibility and ease of intubation were better in patients who received airway blocks and hence the amount of supplemental lignocaine used was less in this group. Overall patient comfort was better in Group NB with fewer incidences of unpleasant recalls as compared with Group L. Conclusion: Upper airway blocks provide better quality of anesthesia than lignocaine nebulization as assessed by patient recall of procedure, coughing/gagging episodes, ease of intubation, vocal cord visibility, and time taken to intubate. PMID:25538514

Airway Management of Near-Complete Tracheal Transection by Through-the-Wound Intubation: A Case Report.

PubMed

Jean, Yuel-Kai; Potnuru, Paul; Diez, Christian

2018-06-11

We present an approach to airway management in a patient with machete injuries culminating in near-complete cricotracheal transection, in addition to a gunshot wound to the neck. Initial airway was established by direct intubation through the cricotracheal wound. Once the airway was secured, a bronchoscopy-guided orotracheal intubation was performed with simultaneous retraction of the cricotracheal airway to optimize the surgical field. This case offers insight into a rarely performed approach to airway management. Furthermore, our case report demonstrates that, in select airway injuries, performing through-the-wound intubation engenders a multitude of benefits.

Analysis of Decadal Vegetation Dynamics Using Multi-Scale Satellite Images

NASA Astrophysics Data System (ADS)

Chiang, Y.; Chen, K.

2013-12-01

This study aims at quantifying vegetation fractional cover (VFC) by incorporating multi-resolution satellite images, including Formosat-2(RSI), SPOT(HRV/HRG), Landsat (MSS/TM) and Terra/Aqua(MODIS), to investigate long-term and seasonal vegetation dynamics in Taiwan. We used 40-year NDVI records for derivation of VFC, with field campaigns routinely conducted to calibrate the critical NDVI threshold. Given different sensor capabilities in terms of their spatial and spectral properties, translation and infusion of NDVIs was used to assure NDVI coherence and to determine the fraction of vegetation cover at different spatio-temporal scales. Based on the proposed method, a bimodal sequence of intra-annual VFC which corresponds to the dual-cropping agriculture pattern was observed. Compared to seasonal VFC variation (78~90%), decadal VFC reveals moderate oscillations (81~86%), which were strongly linked with landuse changes and several major disturbances. This time-series mapping of VFC can be used to examine vegetation dynamics and its response associated with short-term and long-term anthropogenic/natural events.

Usefulness and diagnostic value of the NEMA parameter combined with other selected bedside tests for prediction of difficult intubation.

PubMed

Torres, Kamil; Błoński, Marcin; Pietrzyk, Łukasz; Piasecka-Twaróg, Małgorzata; Maciejewski, Ryszard; Torres, Anna

2017-02-01

To assess the usefulness of the new NEMA (Neck Circumference Minus Acromion-Acromion Distance) parameter, in preoperative identification of patients' difficult intubation and compare it with other commonly used scales and tests. Prospective study. District Specialist Hospital of Lublin, Poland. Six hundreds twenty-nine patients underwent nonemergency surgical interventions. The NEMA parameter was confronted with: Modified Mallampati classification, TMD, RHTMD, NC, MPND, SMD, I-I D, A-AD, and medical history of difficult intubation and diagnosed obstructive sleep apnea syndrome or snoring. Higher medians of NEMA and Mallampati parameters were reported in patients with difficult intubation. AUC for Mallampati parameter was 0.733 while the NEMA parameter's AUC was 0.625. Sensitivity and specificity for Mallampati and NEMA parameter were respectively 0.79; 0.55 and 0.42; 0.75. Significantly higher MPN, RHTMD, Mallampati, and NEMA parameter were observed in patients in whom the BURP was used. Easy intubation occurs more frequently in patients with a history of OSAS or snoring than in those with difficult intubation. It seems that none of the known bedside tests for predicting difficult intubation have a discriminating power sufficient for clinicians. Our study draws attention to a novel parameter, called NEMA, which appears to be a strong predictor of DEI, especially in combination with the Mallampati scale. Copyright © 2016 Elsevier Inc. All rights reserved.

Submental Orotracheal Intubation in Maxillofacial Fracture Surgery: Report of Two Cases

PubMed Central

Tekelioğlu, Ümit Yaşar; Karabekmez, Furkan Erol; Demirhan, Abdullah; Akkaya, Akcan; Bayır, Hakan; Koçoğlu, Hasan

2013-01-01

Two patients, aged 18 and 28 years, with maxillofacial trauma due to motor vehicle accident, were operated upon by a team of plastic surgeons. In this report we aimed to present our experience with submental intubation procedure in these cases, in which orotracheal or nasotracheal intubation was impossible due to panfacial fracture. PMID:27366379

Difficult intubation: are you prepared for it?

PubMed

Balcom, C

1994-01-01

The endotracheal intubation of a patient for surgery requires an anaesthetist who is aided by a skilled and experienced helper. This paper explores reasons why some patients are difficult to intubate. Some are predictable on pre-operative assessment and others are not. Suggestions are given on how the helper is useful to the anaesthetist in this potentially critical situation.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

PubMed

Freno, Daniel; Sahawneh, James; Harrison, Sarah; Sahawneh, Tim; Patterson, Scott; Kahn, Steven A

2018-05-01

Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy. Copyright © 2017. Published by Elsevier Ltd.

[Comparison of two shaping methods for double-lumen endotracheal tube intubation by Shikani optical stylet laryngoscope].

PubMed

Xu, T; Li, M; Xu, M; Guo, X Y

2016-12-18

To compare the efficacy and safety of two different shaping methods for double-lumen endotracheal tube (DLT).DLT was shaped with the rod of a Shikani optical stylet (SOS) with the tracheal orifice aligned with the convex aspect of the distal curvature or the concave aspect of the distal curvature. Patients scheduled for elective thoracic surgery and required intubation with a left-sided DLT were enrolled in this study. They were randomized into two groups. They were intubated with a DLT, which was shaped with the rod of a SOS with its tracheal orifice aligned with the convex aspect of the distal curvature (group T) or the concave aspect of the distal curvature (group U). Time for SOS manipulation, intubation attempts, intubation resistance score, malposition of bronchial intubation, time for fiberoptic bronchoscope (FOB) identification of bronchial placement, total intubation time and oral mucosal or dental injury were recorded. Hoarseness and throat sore of the patients were evaluated 1 hour and 24 hours after surgery. A total of 136 patients completed the study, with 68 in each group. Time for SOS manipulation was significantly shorter in group U [(35.1±6.1) s vs. 39.6±11.8) s, P=0.007]. First attempt success rate did not differ between the groups (92.6% vs.88.2%, P=0.561). Intubation resistance score was significantly lower in group U. Group T had fewer patients who suffered malposition of bronchial intubation than group U (4 vs.13, P=0.020) and cost less time for FOB identification of bronchial placement [(44.1±20.9) s vs.(53.6±29.2) s, P=0.032]. Total intubation time and the incidence of oral mucosal or dental injury did not differ between the groups. The severity and incidence of hoarseness were lower in group U than in group T 1 hour after surgery. The severity and incidence of sore throat were lower in group U than in group T 1 hour and 24 hours postoperatively. When lacing a left-sided DLT using a SOS, shaping the DLT with the tracheal orifice aligned with the concave aspect of the distal curvature saves SOS manipulation time, decreases the severity and incidence of postoperative hoarseness and sore throat. However, this modified shaping method increases the incidence of malposition of bronchial intubation and time for FOB identification of bronchial placement.

A survey of Canadian anesthesiologists' preferences in difficult intubation and "cannot intubate, cannot ventilate" situations.

PubMed

Wong, David T; Mehta, Arpan; Tam, Amanda D; Yau, Brian; Wong, Jean

2014-08-01

The purpose of this survey was to determine the equipment that anesthesiologists prefer in difficult tracheal intubation and "cannot intubate, cannot ventilate" (CICV) situations. A questionnaire was e-mailed to members of the Canadian Anesthesiologists' Society to ascertain their preferences, experience, and comfort level with regard to their use of airway equipment in difficult intubation and CICV situations in adult patients. A Chi square test was used to analyse the data. All reported P values are two-sided. Nine hundred ninety-seven of 2,532 questionnaires (39%) were returned. In an unanticipated difficult direct laryngoscopic intubation situation, 893 of 997 (90%) respondents chose a video laryngoscope as the first-choice rescue technique, while 41 (4%) and 21 (2%) of respondents chose a flexible bronchoscope and an intubating laryngeal mask airway device, respectively. The majority of anesthesiologists had experience and were comfortable with using a flexible bronchoscope or a video laryngoscope. Regarding CICV, 294 of 955 (31%) respondents stated that they had never encountered it. Wire-guided cricothyroidotomy was chosen as the first-choice surgical airway by 375 of 955 (39%) respondents, while intravenous catheter cricothyroidotomy and "defer to tracheostomy by surgeon" were selected by 266 (28%) and 215 (23%) respondents, respectively. Seven hundred eighty-five of 997 (78%) respondents were familiar with the exact steps of the American Society of Anesthesiologists' difficult airway algorithm, while 448 (47%) had attended an airway workshop within the past five years. In a difficult intubation situation, the most frequently selected first-choice airway device was a video laryngoscope, followed by a flexible bronchoscope. In a CICV situation, the most frequently selected first-choice surgical airway technique was a wire-guided cricothyroidotomy, followed by an intravenous catheter cricothyroidotomy.

Endotracheal tube placement by EMT-Basics in a rural EMS system.

PubMed

Pratt, Jeffrey C; Hirshberg, Alan J

2005-01-01

To evaluate the effectiveness of an intubation-training module and special-waiver project in which Emergency Medical Technician (EMT)-Basics were trained to perform endotracheal intubations in a rural community. This was a prospective observational study over a four-year period (July 1998 through May 2002) of all intubation attempts by EMT-Basics in the field. The authors observed intubation data, training methods, and quality-assurance methods of a special-waiver project agreed to by the State Department of Public Health to train and allow EMT-Basics to intubate patients. Data were from documentation unique to the project. Project documentation evaluated the placement and complication(s) of endotracheal tube (ETT) placement after arrival to the emergency department. An intubation attempt was defined as direct laryngoscopy. A successful attempt was defined as an appropriately sized ETT placed and secured in the trachea below the vocal cords and above the carina. Confirmation of placement in the field included accepted clinical methods and the use of qualitative colorimetric end-tidal carbon dioxide detectors. The EMT-Basics were trained using a paramedic curriculum, including operating room intubations on live adult patients. All patients were in either cardiopulmonary or respiratory arrest. Thirty-two intubations were performed by EMT-Basics. Thirty attempts were successful and two were unsuccessful (94%; 95% confidence interval [CI] 80-98%). Unsuccessful ETT placements were managed with accepted basic life support airway standards. There were no unrecognized esophageal ETT placements (0%; 95% CI 0-11%). This study demonstrated that with an intensive training program using selected highly motivated providers and close monitoring, a program of EMT-Basic ETT placement in a rural setting can achieve acceptable success rates in patients in cardiac or respiratory arrest.

Does systemic lidocaine reduce ketamine requirements for endotracheal intubation in calves?

PubMed

Lauper, Josiane; Marolf, Vincent; Levionnois, Olivier; Schelling, Esther; Meylan, Mireille; Spadavecchia, Claudia

2017-03-01

To investigate whether an intravenous (IV) lidocaine bolus in calves premedicated with xylazine-butorphanol reduces the amount of ketamine required to allow endotracheal intubation. Randomized, prospective clinical study. In total, 41 calves scheduled for elective umbilical surgery. Calves were randomly assigned to one of two groups (L: lidocaine or S: saline). The calves were administered xylazine (0.07 mg kg -1 ) and butorphanol (0.1 mg kg -1 ) intramuscularly and 10 minutes later lidocaine (2 mg kg -1 ; group L) or saline (group S) IV over 1 minute. After 2 minutes, ketamine (2.5 mg kg -1 ) was injected IV. If the depth of anaesthesia was insufficient for intubation, additional ketamine (1 mg kg -1 ) was administered every minute until intubation was successful. The amount of ketamine required for intubation, respiratory rate, pulse rate, arterial pressures, the depth of sedation and conditions of endotracheal intubation after induction of anaesthesia were compared between the two groups. The calves in group L were sedated more deeply than those in group S; however, neither the median (range) amount of ketamine required for intubation, 3.5 (2.5-4.5) mg kg -1 and 3.5 (2.5-3.5) mg kg -1 , respectively, nor the induction quality differed significantly between the groups. A bolus of lidocaine (2 mg kg -1 ) administered 10 minutes after xylazine-butorphanol in calves deepened the degree of sedation but did not decrease the requirement of ketamine for endotracheal intubation. No adverse effects were recorded in the physiological variables measured. Copyright © 2017. Published by Elsevier Ltd.

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis

PubMed Central

Arumugam, Suresh Kumar; Mudali, Insolvisagan; Strandvik, Gustav; El-Menyar, Ayman; Al-Hassani, Ammar; Al-Thani, Hassan

2018-01-01

BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients. METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP. RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models. CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role. PMID:29796145

Determination of the diagnostic value of the Modified Mallampati Score, Upper Lip Bite Test and Facial Angle in predicting difficult intubation: A prospective descriptive study.

PubMed

Mahmoodpoor, Ata; Soleimanpour, Hassan; Golzari, Samad Ej; Nejabatian, Arezoo; Pourlak, Tannaz; Amani, Masoumeh; Hajmohammadi, Saeed; Hosseinzadeh, Hamzeh; Esfanjani, Robab Mehdizadeh

2017-02-01

Difficult intubation is a significant cause of mortality and morbidity related to anesthesia. We decided to evaluate the value of Modified Mallampati Score, Upper Lip Bite Test and Facial Angle in the prediction of difficult intubation. In a prospective descriptive study, data from 132 patients who were candidates for elective maxillofacial surgeries under general anesthesia were gathered. Facial Angles were measured by a maxillofacial surgeon according to cephalometry. The Modified Mallampati Score and Upper Lip Bite Test were first measured by an anesthesiologist and then another anesthesiologist was assigned to record the Cormack and Lehane score during the intubation. Grades 3 and 4 were considered as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were calculated for all tests. Difficult intubation was reported in 12% of the patients. Facial Angle≤82.5° can predict difficult intubation with 87.5% sensitivity and 88.8% specificity. Among the three tests, a high Modified Mallampati Score had the highest specificity (94.5%) and a high Modified Mallampati Score and Facial Angle (FA≤82.5°) had the highest sensitivity (87.5%). The highest NPV, sensitivity and Youden index were observed when using Facial Angle with the Modified Mallampati Score or with Upper Lip Bite Test. Facial Angle has a high sensitivity, NPV and Youden index for the prediction of difficult intubation, but the best result is achieved when Facial Angle is used in combination with either the Modified Mallampati Score or Upper Lip Bit Test. Copyright © 2017 Elsevier Inc. All rights reserved.

Just-in-Time Video Laryngoscopy Versus Direct Laryngoscopy for Neonatal Intubation.

PubMed

Grgurich, Erin; Arnemann, Cynthia; Amon, Kim; Horton, Rose; Carlson, Jestin N

As neonatal endotracheal intubation (ETI) is a low-frequency, high-consequence event, it is essential that providers have access to resources to aid in ETI. We sought to determine the impact of video laryngoscopy (VL) with just-in-time training on intubation outcomes over direct laryngoscopy (DL) when performed by neonatal nurses. We conducted a prospective, randomized, crossover study with neonatal nurses employed at a level 2 neonatal intensive care unit (NICU). Nurses performed both DL and VL on a neonatal mannequin using a CMAC (Karl Storz Corp, Tuttlingen, Germany) either with the assistance of the screen (VL) or without (DL). Before performing the intubation, providers were given a just-in-time, brief education presentation and allowed to practice with the device. Each ETI attempt was reviewed to obtain the percentage of glottic opening (POGO) score, time to intubation (TTI, time from insertion of the blade into the mouth until the first breath was delivered), and time from blade insertion until the best POGO score. We enrolled 19 participants, with a median (interquartile range) of 20 (9-26) years of experience and having a median of 2 (1-3) intubations within the past year. None had used VL in the NICU previously. Median TTI did not differ between DL and VL: 19.9 (15.3-41.5) vs 20.3 (17.9-24.4) (P = 1). POGO scores and the number of attempts also did not differ between DL and VL. In our simulated setting, just-in-time VL training provided similar intubation outcomes compared with DL in ETI performed by neonatal nurses. Just-in-time VL education may be an alternative to traditional DL for neonatal intubations.

Tracheal intubation in patients with cervical spine immobilization: A comparison of McGrath(®) video laryngoscope and Truview EVO2(®) laryngoscope.

PubMed

Bhola, Ruchi; Bhalla, Swaran; Gupta, Radha; Singh, Ishwar; Kumar, Sunil

2014-05-01

Literature suggests that glottic view is better when using McGrath(®) Video laryngoscope and Truview(®) in comparison with McIntosh blade. The purpose of this study was to evaluate the effectiveness of McGrath Video laryngoscope in comparison with Truview laryngoscope for tracheal intubation in patients with simulated cervical spine injury using manual in-line stabilisation. This prospective randomised study was undertaken in operation theatre of a tertiary referral centre after approval from the Institutional Review Board. A total of 100 consenting patients presenting for elective surgery requiring tracheal intubation were randomly assigned to undergo intubation using McGrath(®) Video laryngoscope (n = 50) or Truview(®) (n = 50) laryngoscope. In all patients, we applied manual-in-line stabilisation of the cervical spine throughout the airway management. Statistical testing was conducted with the statistical package for the social science system version SPSS 17.0. Demographic data, airway assessment and haemodynamics were compared using the Chi-square test. A P < 0.05 was considered significant. The time to successful intubation was less with McGrath video laryngoscope when compared to Truview (30.02 s vs. 38.72 s). However, there was no significant difference between laryngoscopic views obtained in both groups. The number of second intubation attempts required and incidence of complications were negligible with both devices. Success rate of intubation with both devices was 100%. Intubation with McGrath Video laryngoscope caused lesser alterations in haemodynamics. Both laryngoscopes are reliable in case of simulated cervical spine injury using manual-in-line stabilisation with 100% success rate and good glottic view.

Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study.

PubMed

Knudsen, Kati; Nilsson, Ulrica; Högman, Marieann; Pöder, Ulrika

2016-08-30

Awake fiberoptic intubation is an alternative procedure for securing the airway and is a recommended option when a difficult airway is expected. The aim of the present study was to describe patient experiences with this procedure. A qualitative, descriptive design was used and patients were recruited from three county hospitals and one university hospital in Sweden. Data was collected by semi-structured interviews with 13 patients who underwent awake fiberoptic intubation. A qualitative content analysis extracted theme, categories, and subcategories. From the patient statements, one main theme emerged, feelings of being in a vulnerable situation but cared for in safe hands, which were described in five categories with 15 subcategories. The categories were: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation. The patients felt they lacked information about what to expect and relied on the professionals' expertise. Some patients felt overwhelmed by the information they were given and wanted less specific information about the equipment used but more information about how they would be cared for in the operating room. Undergoing awake intubation was an acceptable experience for most patients, whereas others experienced it as being painful and terrifying because they felt they could not breathe or communicate during the procedure itself. Tailored information about what to expect, ensuring eye contact and breathing instruction during the procedure seems to reduce patient distress when undergoing awake fiberoptic intubation. Most of the patients would not hesitate to undergo awake intubation again in the future if needed.

Patients with difficult intubation may need referral to sleep clinics.

PubMed

Chung, Frances; Yegneswaran, Balaji; Herrera, Francisco; Shenderey, Alex; Shapiro, Colin M

2008-09-01

Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG). Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI >5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and chi(2) test. Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI >5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5-15), 6 (18%) had moderate OSA (AHI >15/h), and 6 (18%) had severe OSA (AHI >30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index. Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG.

Comparison of rocuronium and succinylcholine on postintubation sedative and analgesic dosing in the emergency department.

PubMed

Korinek, Justin D; Thomas, Rachel M; Goddard, Luke A; St John, Alexander E; Sakles, John C; Patanwala, Asad E

2014-06-01

Rocuronium and succinylcholine are both commonly used neuromuscular blockers for rapid sequence intubation in the emergency department (ED). The objective of this study was to determine if patients who receive rocuronium are more likely to receive lower doses of postintubation sedatives and analgesics compared with patients who receive succinylcholine. This was a retrospective cohort study carried out in a tertiary, academic ED. Consecutive adult patients, who were intubated using etomidate for induction of sedation, were included. Patients were categorized on the basis of whether they received (a) rocuronium or (b) succinylcholine for paralysis. The dosing of postintubation sedative and analgesic infusions were compared 30 min after initiation between the two groups. A total of 254 patients were included in the final analysis (rocuronium=127 and succinylcholine=127). In the overall cohort, 90.2% (n=229) of patients were administered a sedative postintubation in the ED. Most of these patients were initiated on propofol infusions. The mean propofol infusion rate at 30 min was 30±23 mcg/kg/min in the rocuronium group and 42±24 mcg/kg/min in the succinylcholine group (P=0.002). A total of 42.5% of patients (n=108) received an analgesic infusion (all patients received fentanyl). The mean fentanyl infusion rate at 30 min was 0.65±0.55 and 0.86±0.49 mcg/kg/h in the rocuronium and succinylcholine groups, respectively (P=0.041). Patients who receive rocuronium are more likely to receive lower doses of sedative and analgesic infusions after intubation. This may place them at risk of being awake under paralysis.

Endotracheal intubation: application of virtual reality to emergency medical services education.

PubMed

Mayrose, James; Myers, Jeffrey W

2007-01-01

Virtual reality simulation has been identified as an emerging educational tool with significant potential to enhance teaching of residents and students in emergency clinical encounters and procedures. Endotracheal intubation represents a critical procedure for emergency care providers. Current methods of training include working with cadavers and mannequins, which have limitations in their representation of reality, ethical concerns, and overall availability with access, cost, and location of models. This paper will present a human airway simulation model designed for tracheal intubation and discuss the aspects that lend itself to use as an educational tool. This realistic and dynamic model is used to teach routine intubations, while future models will include more difficult airway management scenarios. This work provides a solid foundation for future versions of the intubation simulator, which will incorporate two haptic devices to allow for simultaneous control of the laryngoscope blade and endotracheal tube.

Monitoring the onset of neuromuscular blockade with double burst stimulation (DBS).

PubMed

Gorgias, N; Maidatsi, P; Zaralidou, A; Ourailoglou, V; Fakidou, A; Giala, M

1998-11-01

The present study was undertaken to evaluate the suitability of the DBS mode in the determination of the proper time to perform tracheal intubation following cisatracurium muscle relaxation. The DBS3.3 pattern was administered to the ulnar nerve at the wrist in 45 patients paralyzed with cisatracurium 0.15 mg.kg-1 and tracheal intubation was attempted immediately after the disappearance of both palpable contractions of the adductor pollicis. Intubation conditions were assessed with a standard four-graded scoring system and the onset time of the relaxant was determined. Forty-two patients (93%) exhibited acceptable intubation conditions as soon as both responses to DBS were absent and the estimated apparent onset time, according to the stimulation mode applied, was 114.68 +/- 13.2 sec. Our data suggest that disappearance of both palpable responses to DBS3.3 may be used as an accurate predictor of acceptable intubation conditions, following nondepolarizing relaxants such as cisatracurium.

Modeling populations of rotationally mixed massive stars

NASA Astrophysics Data System (ADS)

Brott, I.

2011-02-01

Massive stars can be considered as cosmic engines. With their high luminosities, strong stellar winds and violent deaths they drive the evolution of galaxies through-out the history of the universe. Despite the importance of massive stars, their evolution is still poorly understood. Two major issues have plagued evolutionary models of massive stars until today: mixing and mass loss On the main sequence, the effects of mass loss remain limited in the considered mass and metallicity range, this thesis concentrates on the role of mixing in massive stars. This thesis approaches this problem just on the cross road between observations and simulations. The main question: Do evolutionary models of single stars, accounting for the effects of rotation, reproduce the observed properties of real stars. In particular we are interested if the evolutionary models can reproduce the surface abundance changes during the main-sequence phase. To constrain our models we build a population synthesis model for the sample of the VLT-FLAMES Survey of Massive stars, for which star-formation history and rotational velocity distribution are well constrained. We consider the four main regions of the Hunter diagram. Nitrogen un-enriched slow rotators and nitrogen enriched fast rotators that are predicted by theory. Nitrogen enriched slow rotators and nitrogen unenriched fast rotators that are not predicted by our model. We conclude that currently these comparisons are not sufficient to verify the theory of rotational mixing. Physical processes in addition to rotational mixing appear necessary to explain the stars in the later two regions. The chapters of this Thesis have been published in the following Journals: Ch. 2: ``Rotating Massive Main-Sequence Stars I: Grids of Evolutionary Models and Isochrones'', I. Brott, S. E. de Mink, M. Cantiello, N. Langer, A. de Koter, C. J. Evans, I. Hunter, C. Trundle, J.S. Vink submitted to Astronomy & Astrop hysics Ch. 3: ``The VLT-FLAMES Survey of Massive Stars: Rotation and Nitrogen Enrichment as the Key to Understanding Massive Star Evolution'', I.Hunter, I.Brott, D.J. Lennon, N. Langer, C. Trundle, A. de Koter, C.J. Evans and R.S.I. Ryans The Astrophysical Journal, 2008, 676, L29-L32 Ch. 4: ``The VLT-FLAMES Survey of Massive Stars: Constraints on Stellar Evolution from the Chemical Compositions of Rapidly Rotating Galactic and Magellanic Cloud B-type Stars '', I. Hunter, I. Brott, N. Langer, D.J. Lennon, P.L. Dufton, I.D. Howarth R.S.I. Ryan, C. Trundle, C. Evans, A. de Koter and S.J. Smartt Published in Astronomy & Astropysics, 2009, 496, 841- 853 Ch. 5: ``Rotating Massive Main-Sequence Stars II: Simulating a Population of LMC early B-type Stars as a Test of Rotational Mixing '', I. Brott, C. J. Evans, I. Hunter, A. de Koter, N. Langer, P. L. Dufton, M. Cantiello, C. Trundle, D. J. Lennon, S.E. de Mink, S.-C. Yoon, P. Anders submitted to Astronomy & Astrophysics Ch 6: ``The Nature of B Supergiants: Clues From a Steep Drop in Rotation Rates at 22 000 K - The possibility of Bi-stability braking'', Jorick S. Vink, I. Brott, G. Graefener, N. Langer, A. de Koter, D.J. Lennon Astronomy & Astrophysics, 2010, 512, L7

Effects of fenoterol and ipratropium on respiratory resistance of asthmatics after tracheal intubation.

PubMed

Wu, R S; Wu, K C; Wong, T K; Tsai, Y H; Cheng, R K; Bishop, M J; Tan, P P

2000-03-01

We have studied the effects of a beta-agonist, fenoterol, and a cholinergic antagonist, ipratropium, on post-intubation total respiratory system resistance (Rrs) in asthmatics who developed increased Rrs after tracheal intubation. Sixteen stable asthmatics in whom Rrs increased after intubation were allocated randomly to receive either 10 puffs of fenoterol (group F) or 10 puffs of ipratropium (group IB) via a metered dose inhaler 5 min after intubation. Anaesthesia was induced and maintained with propofol i.v. Rrs was recorded before treatment and again 5, 15 and 30 min after treatment. Rrs decreased significantly from pretreatment values by mean 53 (SD 8)%, 53 (7)% and 58 (6)% at 5, 15 and 30 min, respectively, in group F, but declined by only 12 (6)%, 15 (4)% and 17 (5)% in group IB. At all times after treatment, patients in the fenoterol group had significantly lower Rrs values than those in the ipratropium group. We conclude that increased Rrs after tracheal intubation in asthmatics can be reduced effectively by treatment with fenoterol. A secondary finding of our study was that even after induction of anaesthesia with propofol, patients with a history of asthma may develop high Rrs.

Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing.

PubMed

Repka, Michael X; Chandler, Danielle L; Holmes, Jonathan M; Hoover, Darren L; Morse, Christine L; Schloff, Susan; Silbert, David I; Tien, D Robbins

2009-05-01

To compare the outcomes of balloon catheter dilation and nasolacrimal intubation as treatment for congenital nasolacrimal duct obstruction after failed probing in children younger than 4 years. We conducted a prospective, nonrandomized, multicenter study that enrolled 159 children aged 6 months to younger than 48 months who had a history of a single failed nasolacrimal duct probing and at least 1 of the following clinical signs of nasolacrimal duct obstruction: epiphora, mucous discharge, or increased tear lake. One hundred ninety-nine eyes underwent either balloon catheter nasolacrimal duct dilation or nasolacrimal duct intubation. Treatment success was defined as absence of epiphora, mucous discharge, or increased tear lake at the outcome visit 6 months after surgery. Treatment success was reported in 65 of 84 eyes (77%; 95% confidence interval, 65%-85%) in the balloon catheter dilation group compared with 72 of 88 eyes (84% after adjustment for intereye correlation; 74%-91%) in the nasolacrimal intubation group (risk ratio for success for intubation vs balloon dilation, 1.08; 0.95-1.22). Both balloon catheter dilation and nasolacrimal duct intubation alleviate the clinical signs of persistent nasolacrimal duct obstruction in a similar percentage of patients.

A Prospective Observational Study of Technical Difficulty With GlideScope-Guided Tracheal Intubation in Children.

PubMed

Zhang, Bin; Gurnaney, Harshad G; Stricker, Paul A; Galvez, Jorge A; Isserman, Rebecca S; Fiadjoe, John E

2018-05-09

The GlideScope Cobalt is one of the most commonly used videolaryngoscopes in pediatric anesthesia. Although visualization of the airway may be superior to direct laryngoscopy, users need to learn a new indirect way to insert the tracheal tube. Learning this indirect approach requires focused practice and instruction. Identifying the specific points during tube placement, during which clinicians struggle, would help with targeted education. We conducted this prospective observational study to determine the incidence and location of technical difficulties using the GlideScope, the success rates of various corrective maneuvers used, and the impact of technical difficulty on success rate. We conducted this observational study at our quaternary pediatric hospital between February 2014 and August 2014. We observed 200 GlideScope-guided intubations and documented key intubation-related outcomes. Inclusion criteria for patients were <6 years of age and elective surgery requiring endotracheal intubation. We documented the number of advancement maneuvers required to intubate the trachea, the location where technical difficulty occurred, the types of maneuvers used to address difficulties, and the tracheal intubation success rate. We used a bias-corrected bootstrapping method with 300 replicates to determine the 95% confidence interval (CI) around the rate of difficulty with an intubation attempt. After excluding attempts by inexperienced clinicians, there were 225 attempts in 187 patients, 58% (131 of 225; bootstrap CI, 51.6%-64.6%]) of the attempts had technical difficulties. Technical difficulty was most likely to occur when inserting the tracheal tube between the plane of the arytenoid cartilages to just beyond the vocal cords: "zone 3." Clockwise rotation of the tube was the most common successful corrective maneuver in zone 3. The overall tracheal intubation success rate was 98% (CI, 95%-99%); however, the first attempt success rate was only 80% (CI, 74%-86%). Patients with technical difficulty had more attempts (median [interquartile range], 2 [1-3] than those without technical difficulty median (interquartile range, 1 [1-1; P value <.01]). A variety of clinicians experience technical difficulties with the GlideScope Cobalt videolaryngoscope in children. These difficulties result in more tracheal intubation attempts, an important risk factor for intubation-associated complications. Targeted education of clinicians may reduce the incidence of technical difficulties.

Assistive and Autonomous Breast Ultrasound Screening: Improving PPV and Reducing RSI

DTIC Science & Technology

imaging with quantitative elastography. Major objectives achieved in this period included development of a research platform including a compliant...This report details our first year of research activity on technologies that support sonographer-supervised robotic systems for breast ultrasound

Basic needs and their predictors for intubated patients in surgical intensive care units.

PubMed

Liu, Jin-Jen; Chou, Fan-Hao; Yeh, Shu-Hui

2009-01-01

This study was conducted to investigate the basic needs and communication difficulties of intubated patients in surgical intensive care units (ICUs) and to identify predictors of the basic needs from the patient characteristics and communication difficulties. In this descriptive correlational study, 80 surgical ICU patients were recruited and interviewed using 3 structured questionnaires: demographic information, scale of basic needs, and scale of communication difficulties. The intubated patients were found to have moderate communication difficulties. The sense of being loved and belonging was the most common need in the intubated patients studied (56.00 standardized scores). A significantly positive correlation was found between communication difficulties and general level of basic needs (r = .53, P < .01), and another positive correlation was found between the length of stay in ICUs and the need for love and belonging (r = .25, P < .05). The basic needs of intubated patients could be significantly predicted by communication difficulties (P = .002), use of physical restraints (P = .010), lack of intubation history (P = .005), and lower educational level (P = .005). These 4 predictors accounted for 47% of the total variance in basic needs. The intubated patients in surgical ICUs had moderate basic needs and communication difficulties. The fact that the basic needs could be predicted by communication difficulties, physical restraints, and educational level suggests that nurses in surgical ICUs need to improve skills of communication and limit the use of physical restraints, especially in patients with a lower educational level.

Management of the difficult airway.

PubMed

Schwartz, D E; Wiener-Kronish, J P

1991-09-01

For clinicians involved in airway management, a plan of action for dealing with the difficult airway or a failed intubation should be developed well in advance of encountering a patient in whom intubation is not routine. When difficulty is anticipated, the equipment necessary for performing a difficult intubation should be immediately available. It also is prudent to have a surgeon skilled in performing a tracheotomy and a criothyroidotomy stand by. The intubation should be attempted in the awake state, preferably using the fiberoptic bronchoscope. The more challenging situation is when the difficult airway is confronted unexpectedly. After the first failed attempt at laryngoscopy, head position should be checked and the patient ventilated with oxygen by mask. A smaller styletted tube and possibly a different laryngoscope blade should be selected for a second attempt at intubation. The fiberoptic bronchoscope and other equipment for difficult intubation should be obtained. A second attempt should then be made. If this is unsuccessful, the patient should be reoxygenated, and assistance including a skilled anesthesiologist and surgeon should be summoned. On a third attempt, traction to the tongue can be applied by an assistant, a tube changer could be used to enter the larynx, or one of the other special techniques previously described can be used. If this third attempt fails, it may be helpful to have a physician more experienced in airway management attempt intubation after oxygen has been administered to the patient. If all attempts are unsuccessful, then invasive techniques to secure the airway will have to be performed.

Comparison of the Airtraq® and Truview® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation in manikins

PubMed Central

Nasim, Sajid; Maharaj, Chrisen H; Butt, Ihsan; Malik, Muhammad A; O' Donnell, John; Higgins, Brendan D; Harte, Brian H; Laffey, John G

2009-01-01

Background Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq® and Truview® laryngoscopes may reduce this risk. Methods We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq® and Truview® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin. Results The Airtraq® reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview® increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq® devices. Conclusion The Airtraq® laryngoscope performed more favourably than the Macintosh and Truview® devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting. PMID:19216776

Comparison of the Glidescope® and Pentax AWS® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation

PubMed Central

Nasim, Sajid; Maharaj, Chrisen H; Malik, Muhammad A; O' Donnell, John; Higgins, Brendan D; Laffey, John G

2009-01-01

Background Intubation of the trachea in the pre-hospital setting may be lifesaving in severely ill and injured patients. However, tracheal intubation is frequently difficult to perform in this challenging environment, is associated with a lower success rate, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Glidescope® and the AWS® laryngoscopes may reduce this risk. Methods We compared the efficacy of these devices to the Macintosh laryngoscope when used by 25 Advanced Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Glidescope® and the AWS® laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan® manikin. Results Both the Glidescope® and the AWS® performed better than the Macintosh, and demonstrate considerable promise in this context. The AWS® had the least number of dental compressions in all three scenarios, and in the cervical spine immobilization scenario it required fewer maneuvers to optimize the view of the glottis. Conclusion The Glidescope® and AWS® devices possess advantages over the conventional Macintosh laryngoscope when used by Advanced Paramedics in normal and simulated difficult intubation scenarios in this manikin study. Further studies are required to extend these findings to the clinical setting. PMID:19445719

Cluster analysis of dynamic contrast enhanced MRI reveals tumor subregions related to locoregional relapse for cervical cancer patients.

PubMed

Torheim, Turid; Groendahl, Aurora R; Andersen, Erlend K F; Lyng, Heidi; Malinen, Eirik; Kvaal, Knut; Futsaether, Cecilia M

2016-11-01

Solid tumors are known to be spatially heterogeneous. Detection of treatment-resistant tumor regions can improve clinical outcome, by enabling implementation of strategies targeting such regions. In this study, K-means clustering was used to group voxels in dynamic contrast enhanced magnetic resonance images (DCE-MRI) of cervical cancers. The aim was to identify clusters reflecting treatment resistance that could be used for targeted radiotherapy with a dose-painting approach. Eighty-one patients with locally advanced cervical cancer underwent DCE-MRI prior to chemoradiotherapy. The resulting image time series were fitted to two pharmacokinetic models, the Tofts model (yielding parameters K trans and ν e ) and the Brix model (A Brix , k ep and k el ). K-means clustering was used to group similar voxels based on either the pharmacokinetic parameter maps or the relative signal increase (RSI) time series. The associations between voxel clusters and treatment outcome (measured as locoregional control) were evaluated using the volume fraction or the spatial distribution of each cluster. One voxel cluster based on the RSI time series was significantly related to locoregional control (adjusted p-value 0.048). This cluster consisted of low-enhancing voxels. We found that tumors with poor prognosis had this RSI-based cluster gathered into few patches, making this cluster a potential candidate for targeted radiotherapy. None of the voxels clusters based on Tofts or Brix parameter maps were significantly related to treatment outcome. We identified one group of tumor voxels significantly associated with locoregional relapse that could potentially be used for dose painting. This tumor voxel cluster was identified using the raw MRI time series rather than the pharmacokinetic maps.

Pepsin and bile acids in saliva in patients with laryngopharyngeal reflux - a prospective comparative study.

PubMed

Sereg-Bahar, M; Jerin, A; Jansa, R; Stabuc, B; Hocevar-Boltezar, I

2015-06-01

Laryngopharyngeal reflux (LPR) and biliary duodenogastric reflux can cause damage to the laryngeal mucosa and voice disorders. The aim of this study was to find out whether levels of pepsin and bile acids in the saliva can serve as diagnostic markers of LPR. A prospective comparative study. Twenty-eight patients with LPR proven via high-resolution manometry and combined multichannel intraluminal impedance and 24-h pH monitoring and 48 healthy controls without symptoms of LPR were included in the study. In the patients with LPR symptoms, oesophagogastroscopy with oesophageal biopsy was performed. The levels of total pepsin, active pepsin, bile acids and the pH of the saliva were determined in all participants and compared between the groups. Reflux symptom index (RSI) and reflux finding score (RFS) were also obtained and compared. The groups differed significantly in RSI (P = 0.00), RFS (P = 0.00), the levels of bile acids (P = 0.005) and total pepsin in saliva (P = 0.023). The levels of total pepsin and bile acids were about three times higher in the patients with LPR than in the healthy controls. There was a significant correlation between the RSI and RFS score and the level of total pepsin and bile acids in the saliva. Histopathological examination of the oesophageal biopsy taken 5 cm above the lower oesophageal sphincter confirmed reflux in almost 93% of patients with symptoms. The study results show that the levels of total pepsin and bile acids in saliva are significantly higher in patients with LPR than in the controls, thus suggesting this as a useful tool in the diagnosis of LPR and particularly biliary LPR. © 2014 John Wiley & Sons Ltd.

Neural Mechanisms Underlying the Cost of Task Switching: An ERP Study

PubMed Central

Li, Ling; Wang, Meng; Zhao, Qian-Jing; Fogelson, Noa

2012-01-01

Background When switching from one task to a new one, reaction times are prolonged. This phenomenon is called switch cost (SC). Researchers have recently used several kinds of task-switching paradigms to uncover neural mechanisms underlying the SC. Task-set reconfiguration and passive dissipation of a previously relevant task-set have been reported to contribute to the cost of task switching. Methodology/Principal Findings An unpredictable cued task-switching paradigm was used, during which subjects were instructed to switch between a color and an orientation discrimination task. Electroencephalography (EEG) and behavioral measures were recorded in 14 subjects. Response-stimulus interval (RSI) and cue-stimulus interval (CSI) were manipulated with short and long intervals, respectively. Switch trials delayed reaction times (RTs) and increased error rates compared with repeat trials. The SC of RTs was smaller in the long CSI condition. For cue-locked waveforms, switch trials generated a larger parietal positive event-related potential (ERP), and a larger slow parietal positivity compared with repeat trials in the short and long CSI condition. Neural SC of cue-related ERP positivity was smaller in the long RSI condition. For stimulus-locked waveforms, a larger switch-related central negative ERP component was observed, and the neural SC of the ERP negativity was smaller in the long CSI. Results of standardized low resolution electromagnetic tomography (sLORETA) for both ERP positivity and negativity showed that switch trials evoked larger activation than repeat trials in dorsolateral prefrontal cortex (DLPFC) and posterior parietal cortex (PPC). Conclusions/Significance The results provide evidence that both RSI and CSI modulate the neural activities in the process of task-switching, but that these have a differential role during task-set reconfiguration and passive dissipation of a previously relevant task-set. PMID:22860090

Double-blind, placebo-controlled study with alginate suspension for laryngopharyngeal reflux disease.

PubMed

Tseng, Wen-Hsuan; Tseng, Ping-Huei; Wu, Jia-Feng; Hsu, Ya-Chin; Lee, Ting-Yi; Ni, Yen-Hsuan; Wang, Hsiu-Po; Hsiao, Tzu-Yu; Hsu, Wei-Chung

2018-02-05

Treatment for laryngopharyngeal reflux disease (LPRD) is challenging because of delays in recognition and poor responsiveness to proton-pump inhibitor therapy. The aim of this study was to determine the efficacy and safety of liquid alginate suspension for treating LPRD. A double-blind, placebo-controlled, prospective study comparing 8 weeks of treatment with Alginos Oral Suspension (TTY Biopharm Co. Ltd., Taipei, Taiwan) (sodium alginate 1,000 mg three times daily) with a placebo was conducted on patients who fulfilled the criteria of at least one symptom consistent with LPRD, a total reflux symptom index (RSI) score of > 10, and a total reflux finding score (RFS) of > 5. Those with erosive gastroesophageal reflux disease, as evidenced through screened transnasal upper gastrointestinal endoscopy, were excluded. Efficacy was assessed by RSI, RFS, and ambulatory multichannel intraluminal impedance and pH (MII-pH) monitoring. A total of 80 patients aged 22 to 72 years were enrolled. Compared with baseline, both Alginos (TTY Biopharm Co. Ltd.) and the placebo significantly reduced the total RSI (P < 0.001) and the total number of reflux episodes shown by MII-pH monitoring (P < 0.05) after 8 weeks of treatment. However, liquid alginate suspension was unable to show superiority over the placebo. The incidence of various adverse events from Alginos (TTY Biopharm Co. Ltd.) was relatively low (7.7%) and mild. This study showed that liquid alginate suspension was well tolerated by LPRD patients. It effectively improved symptoms and reflux numbers but was unable to show superiority over placebo. As observed in previous studies, a great placebo effect was present. The importance of lifestyle modification could not be overlooked. 2. Laryngoscope, 00:000-000, 2018. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.

Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications.

PubMed

Yang, Jin; Dehom, Salem; Sanders, Stephanie; Murry, Thomas; Krishna, Priya; Crawley, Brianna K

To determine if an anti-reflux induction program relieves laryngopharyngeal reflux (LPR) symptoms more effectively than medication and behavioral changes alone. Retrospective study. Tertiary care academic center. A database was populated with patients treated for LPR. Patients were included in the study group if they completed a two-week anti-reflux program (diet, alkaline water, medications, behavioral modifications). Patients were included in the control group if they completed anti-reflux medications and behavioral modifications only. Patients completed the voice handicap index (VHI), reflux symptom index (RSI), cough severity index (CSI), dyspnea index (DI) and eating assessment tool (EAT-10) surveys and underwent laryngoscopy for examination and reflux finding score (RFS) quantification. Of 105 study group patients, 96 (91%) reported subjective improvement in their LPR symptoms after an average 32-day first follow-up and their RSI and CSI scores improved significantly. No significant differences were found in VHI, DI, or EAT-10 scores. Fifteen study patients who had previously failed adequate high-dose medication trials reported improvement and their CSI and EAT-10 scores improved significantly. Ninety-five percent of patients with a chief complaint of cough reported improvement and their CSI scores improved significantly from 12.3 to 8.2. Among 81 controls, only 39 (48%) patients reported improvement after an average 62-day first follow-up. Their RSI scores did not significantly change. The anti-reflux program yielded rapid and substantial results for a large cohort of patients with LPR. It compared favorably with medication and behavioral modification alone. It was effective in improving cough and treating patients who had previously failed medications alone. Copyright © 2017 Elsevier Inc. All rights reserved.

Role of Pepsin and Oropharyngeal pH-Monitoring to Assess the Postoperative Outcome of Patients with Laryngopharyngeal Reflux: Results of a Pilot Trial.

PubMed

Weitzendorfer, Michael; Pfandner, Richard; Antoniou, Stavros A; Langsteger, Werner; Witzel, Kai; Emmanuel, Klaus; Koch, Oliver O

2017-09-01

The aim of this study was to evaluate the value of salivary pepsin and oropharyngeal pH-monitoring to assess the surgical outcome of patients with laryngopharyngeal reflux (LPR). Twenty consecutive patients with LPR despite proton pump inhibitor treatment received laparoscopic antireflux surgery. Twenty-four hour esophageal pH-monitoring (multichannel intraluminal impedance monitoring [MII]-pH) and esophageal manometry (high-resolution manometry) data were documented preoperatively and at 3-month follow-up. An ears, nose and throat (ENT) examination was performed, including assessment of Belafsky Reflux Finding Score (RFS). Clinical symptoms were evaluated with the Belafsky Reflux Symptom Index (RSI) and the Gastrointestinal Quality of Life Index (GIQLI). Simultaneous to the MII-pH and collection of saliva samples, detection of oropharyngeal reflux events was performed. Treatment failure was defined as postoperative pathologic RFS or RSI score and improvement of GIQLI of <10 points, despite showing a normal DeMeester score. At baseline, all patients had a pathological ENT examination, RSI score, and MII-pH data. All patients showed postoperatively a normal DeMeester score (mean 6.39 ± 4.87). Five patients were defined as treatment failures with a change of pepsin concentration from median 157.0 (95% confidence interval [CI]: 0-422) to 180.7 (95% CI: 0-500). In patients defined as treatment success, median pepsin value decreased from 206.3 (95% CI: 89-278) to 76.0 (95% CI: 55-205); (P = .093). Oropharyngeal pH-monitoring data showed no significant change in both groups. Salivary pepsin could be a marker for treatment success, while oropharyngeal pH-monitoring seems to be inadequate in these terms. However, larger studies are required to reach firm conclusions.

[Significance of pharyngeal biochemical indexes in the diagnosis of laryngopharyngeal reflux disease].

PubMed

Wang, L; Wu, W; Wang, G

2018-02-27

Objective: To investigate the significance of the detection of pepsin in saliva and the pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux disease(LPRD). Methods: A total of 176 patients (140 patients with simple pharyngitis and 36 patients with space-occupying lesions of larynx) who were suspected to have laryngopharyngeal reflux between February and December 2016 were retrospectively reviewed. All the patients were evaluated with reflux symptom index (RSI), reflux finding score (RFS) and 24-hour pharyngeal pH monitoring(Dx-pH). Saliva of patients was collected and the pepsin in the saliva was measured by enzyme-linked immunosorbent assay (ELISA). Results: The positive rate of RSI (RSI>13) and/or RFS (RFS>7) was 56.8% (100/176). The positive rate of pepsin in saliva was 40.9% (72/176) and pepsin in saliva collected at the time of onset of symptom was much higher than that at other time points ( P <0.001). The positive rate of pepsin in saliva, Ryan score and the pH<6.0 laryngopharyngeal reflux in space-occupying lesions group [55.6%(20/36), 27.8% (10/36), 69.4%(25/36), respectively] were all higher than simple pharyngitis group [37.1% (52/140), 5.0% (7/140), 50% (70/140), respectively] ( P =0.045, P <0.001, P =0.037, respectively). Conclusions: The detection of pepsin in saliva and the pharyngeal pH monitoring reflected different reflux agents, and there was great significance for the diagnosis of LPRD by using two methods together. We found that the weak acid state and consequent pepsin damage played an important role in the occurrence and development of space-occupying lesions of larynx.

Diffusion-weighted imaging in cancer: Physical foundations and applications of Restriction Spectrum Imaging

PubMed Central

White, Nathan S.; McDonald, Carrie; Farid, Niky; Kuperman, Josh; Karow, David; Schenker-Ahmed, Natalie M.; Bartsch, Hauke; Rakow-Penner, Rebecca; Holland, Dominic; Shabaik, Ahmed; Bjørnerud, Atle; Hope, Tuva; Hattangadi-Gluth, Jona; Liss, Michael; Parsons, J. Kellogg; Chen, Clark C.; Raman, Steve; Margolis, Daniel; Reiter, Robert E.; Marks, Leonard; Kesari, Santosh; Mundt, Arno J.; Kane, Chris J.; Carter, Bob S.; Bradley, William G.; Dale, Anders M.

2014-01-01

Diffusion weighted imaging (DWI) has been at the forefront of cancer imaging since the early 2000’s. Prior to its application in clinical oncology, this powerful technique had already achieved widespread recognition due to its utility in the diagnosis of cerebral infarction. Following this initial success, the ability of DWI to detect inherent tissue contrast began to be exploited in the field of oncology. Although the initial oncologic applications for tumor detection and characterization, assessing treatment response, and predicting survival were primarily in the field of neuro-oncology, the scope of DWI has since broadened to include oncologic imaging of the prostate gland, breast, and liver. Despite its growing success and application, misconceptions as to the underlying physical basis of the DWI signal exist among researchers and clinicians alike. In this review, we provide a detailed explanation of the biophysical basis of diffusion contrast, emphasizing the difference between hindered and restricted diffusion, and elucidating how diffusion parameters in tissue are derived from the measurements via the diffusion model. We describe one advanced DWI modeling technique, called Restriction Spectrum Imaging (RSI). This technique offers a more direct in vivo measure of tumor cells, due to its ability to distinguish separable pools of water within tissue based on their intrinsic diffusion characteristics. Using RSI as an example, we then highlight the ability of advanced DWI techniques to address key clinical challenges in neuro-oncology, including improved tumor conspicuity, distinguishing actual response to therapy from pseudoresponse, and delineation of white matter tracts in regions of peritumoral edema. We also discuss how RSI, combined with new methods for correction of spatial distortions inherent diffusion MRI scans, may enable more precise spatial targeting of lesions, with implications for radiation oncology, and surgical planning. PMID:25183788

Contemporary ventilator management in patients with and at risk of ALI/ARDS.

PubMed

Chang, Steven Y; Dabbagh, Ousama; Gajic, Ognen; Patrawalla, Amee; Elie, Marie-Carmelle; Talmor, Daniel S; Malhotra, Atul; Adesanya, Adebola; Anderson, Harry L; Blum, James M; Park, Pauline K; Gong, Michelle Ng

2013-04-01

Ventilator practices in patients at risk for acute lung injury (ALI) and ARDS are unclear. We examined factors associated with choice of set tidal volumes (VT), and whether VT < 8 mL/kg predicted body weight (PBW) relates to the development of ALI/ARDS. We performed a secondary analysis of a multicenter cohort of adult subjects at risk of lung injury with and without ALI/ARDS at onset of invasive ventilation. Descriptive statistics were used to describe ventilator practices in specific settings and ALI/ARDS risk groups. Logistic regression analysis was used to determine the factors associated with the use of VT < 8 mL/kg PBW and the relationship of VT to ALI/ARDS development and outcome. Of 829 mechanically ventilated patients, 107 met the criteria for ALI/ARDS at time of intubation, and 161 developed ALI/ARDS after intubation (post-intubation ALI/ARDS). There was significant intercenter variability in initial ventilator settings, and in the incidence of ALI/ARDS and post-intubation ALI/ARDS. The median VT was 7.96 (IQR 7.14-8.94) mL/kg PBW in ALI/ARDS subjects, and 8.45 (IQR 7.50-9.55) mL/kg PBW in subjects without ALI/ARDS (P = .004). VT decreased from 8.40 (IQR 7.38-9.37) mL/kg PBW to 7.97 (IQR 6.90-9.23) mL/kg PBW (P < .001) in those developing post-intubation ALI/ARDS. Among subjects without ALI/ARDS, VT ≥ 8 mL/kg PBW was associated with shorter height and higher body mass index, while subjects with pneumonia were less likely to get ≥ 8 mL/kg PBW. Initial VT ≥ 8 mL/kg PBW was not associated with the post-intubation ALI/ARDS (adjusted odds ratio 1.30, 95% CI 0.74-2.29) or worse outcomes. Post-intubation ALI/ARDS subjects had mortality similar to subjects intubated with ALI/ARDS. Clinicians seem to respond to ALI/ARDS with lower initial VT. Initial VT, however, was not associated with the development of post-intubation ALI/ARDS or other outcomes.

Comparison of five video-assisted intubation devices by novice and expert laryngoscopists for use in the aeromedical evacuation environment.

PubMed

Wallace, Matthew C; Britton, SSgt Tyler; Meek, Robbie; Walsh-Hart, Sharon; Carter, Col Todd E; Lisco, Steven J

2017-01-01

The critically ill or injured patient undergoing military medical evacuation may require emergent intubation. Intubation may be life-saving, but it carries risks. The novice or infrequent laryngoscopist has a distinct disadvantage because experience is critical for the rapid and safe establishment of a secured airway. This challenge is compounded by the austere environment of the back of an aircraft under blackout conditions. This study determined which of five different video-assisted intubation devices (VAIDs) was best suited for in-flight use by U.S. Air Force Critical Care Air Transport Teams by comparing time to successful intubation between novice and expert laryngoscopists under three conditions, Normal Airway Lights on (NAL), Difficult Airway Lights on (DAL) and Difficult Airway Blackout (DAB), using manikins on a standard military transport stanchion and the floor with a minimal amount of setup time and extraneous light emission. A convenience sample size of 40 participants (24 novices and 16 experts) attempted intubation with each of the 5 different video laryngoscopic devices on high-fidelity airway manikins. Time to tracheal intubation and number of optimization maneuvers used were recorded. Kruskal-Wallis testing determined significant differences between the VAIDs in time to intubation for each particular scenario. Devices with significant differences underwent pair-wise comparison testing using rank-sum analysis to further clarify the difference. Device assembly times, startup times and the amount of light emitted were recorded. Perceived ease of use was surveyed. Novices were fastest with the Pentax AWS in all difficult airway scenarios. Experts recorded the shortest median times consistently using 3 of the 5 devices. The AWS was superior overall in 4 of the 6 scenarios tested. Experts and novices subjectively judged the GlideScope Ranger as easiest to use. The light emitted by all the devices was less than the USAF-issued headlamp. Novices intubated fastest with the Pentax AWS in all difficult airway scenarios. The GlideScope required the shortest setup time, and participants judged this device as the easiest to use. The GlideScope and AWS exhibited the two fastest total setup times. Both devices are suitable for in-flight use by infrequent and seasoned laryngoscopists.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

PubMed

Birnbach, David J; Rosen, Lisa F; Fitzpatrick, Maureen; Carling, Philip; Arheart, Kristopher L; Munoz-Price, L Silvia

2015-04-01

Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

Development and Design Application of Rigidized Surface Insulation Thermal Protection Systems, Volume 1. [for the space shuttle

NASA Technical Reports Server (NTRS)

1972-01-01

Materials and design technology of the all-silica LI-900 rigid surface insulation (RSI) thermal protection system (TPS) concept for the shuttle spacecraft is presented. All results of contract development efforts are documented. Engineering design and analysis of RSI strain arrestor plate material selections, sizing, and weight studies are reported. A shuttle prototype test panel was designed, analyzed, fabricated, and delivered. Thermophysical and mechanical properties of LI-900 were experimentally established and reported. Environmental tests, including simulations of shuttle loads represented by thermal response, turbulent duct, convective cycling, and chemical tolerance tests are described and results reported. Descriptions of material test samples and panels fabricated for testing are included. Descriptions of analytical sizing and design procedures are presented in a manner formulated to allow competent engineering organizations to perform rational design studies. Results of parametric studies involving material and system variables are reported. Material performance and design data are also delineated.

Who Comes Out with Their Mental Illness and How Does it Help?

PubMed Central

Corrigan, Patrick W.; Michaels, Patrick J.; Powell, Karina; Bink, Andrea; Sheehan, Lindsay; Schmidt, Annie; Apa, Bethany; Al-Khouja, Maya

2015-01-01

Coming out with mental illness may be an effective strategy for reducing self-stigma. This study examined predictors and consequences of coming out. Participants (N=106) with severe mental illness who reported being out (n=79) or not out (n=27) endorsed benefits of being out (BBO) and reasons for staying in (RSI). Predictors from baseline measures were self-stigma, insight, and psychiatric diagnosis. Three outcome measures -- basic psychological needs, care engagement, and depression – were also completed at baseline and one-month follow-up. Among participants already out, BBO and RSI were significantly and independently associated with self-stigma, insight, and lifetime affective diagnoses. In terms of consequences, BBO was associated with cross-sectional and one-month measures of engagement for those already out, but not for closeted participants. Among closeted participants, BBO was associated with baseline and one-month measures of basic psychological needs. Implications for strategies meant to promote disclosure in order to decrease self-stigma are considered. PMID:26785058

GIPAW (gauge including projected augmented wave) and local dynamics in 13C and 29Si solid state NMR: the study case of silsesquioxanes (RSiO1.5)8.

PubMed

Gervais, Christel; Bonhomme-Coury, Laure; Mauri, Francesco; Babonneau, Florence; Bonhomme, Christian

2009-08-28

Octameric silsesquioxanes (RSiO(1.5))(8) are versatile and interesting nano building blocks, suitable for the synthesis of nanocomposites with controlled porosity. In this paper, we revisit the (29)Si and (13)C solid state NMR spectroscopy for this class of materials, by using GIPAW (gauge including projected augmented wave) first principles calculations [Pickard & Mauri, Phys. Rev. B, 2001, 63, 245101]. Full tensorial data, including the chemical shift anisotropies (CSA) and the absolute orientation of the corresponding principal axes systems (PAS), were calculated. Subsequent averaging of the calculated tensors (due to fast reorientation of the R groups around the Si-C bonds) allowed for the interpretation of the strong reduction of CSA and dipolar couplings for these derivatives. Good agreement was observed between the averaged calculated data and the experimental parameters. Interesting questions related to the interplay between X-ray crystallography and solid state NMR are raised and will be emphasized.

Application of the ex-Gaussian function to the effect of the word blindness suggestion on Stroop task performance suggests no word blindness

PubMed Central

Parris, Benjamin A.; Dienes, Zoltan; Hodgson, Timothy L.

2013-01-01

The aim of the present paper was to apply the ex-Gaussian function to data reported by Parris et al. (2012) given its utility in studies involving the Stroop task. Parris et al. showed an effect of the word blindness suggestion when Response-Stimulus Interval (RSI) was 500 ms but not when it was 3500 ms. Analysis revealed that: (1) The effect of the suggestion on interference is observed in μ, supporting converging evidence indicating the suggestion operates over response competition mechanisms; and, (2) Contrary to Parris et al. an effect of the suggestion was observed in μ when RSI was 3500 ms. The reanalysis of the data from Parris et al. (2012) supports the utility of ex-Gaussian analysis in revealing effects that might otherwise be thought of as absent. We suggest that word reading itself is not suppressed by the suggestion but instead that response conflict is dealt with more effectively. PMID:24065947

Application of the ex-Gaussian function to the effect of the word blindness suggestion on Stroop task performance suggests no word blindness.

PubMed

Parris, Benjamin A; Dienes, Zoltan; Hodgson, Timothy L

2013-01-01

The aim of the present paper was to apply the ex-Gaussian function to data reported by Parris et al. (2012) given its utility in studies involving the Stroop task. Parris et al. showed an effect of the word blindness suggestion when Response-Stimulus Interval (RSI) was 500 ms but not when it was 3500 ms. Analysis revealed that: (1) The effect of the suggestion on interference is observed in μ, supporting converging evidence indicating the suggestion operates over response competition mechanisms; and, (2) Contrary to Parris et al. an effect of the suggestion was observed in μ when RSI was 3500 ms. The reanalysis of the data from Parris et al. (2012) supports the utility of ex-Gaussian analysis in revealing effects that might otherwise be thought of as absent. We suggest that word reading itself is not suppressed by the suggestion but instead that response conflict is dealt with more effectively.

Use of video-assisted intubation devices in the management of patients with trauma.

PubMed

Aziz, Michael

2013-03-01

Patients with trauma may have airways that are difficult to manage. Patients with blunt trauma are at increased risk of unrecognized cervical spine injury, especially patients with head trauma. Manual in-line stabilization reduces cervical motion and should be applied whenever a cervical collar is removed. All airway interventions cause some degree of cervical spine motion. Flexible fiberoptic intubation causes the least cervical motion of all intubation approaches, and rigid video laryngoscopy provides a good laryngeal view and eases intubation difficulty. In emergency medicine departments, video laryngoscopy use is growing and observational data suggest an improved success rate compared with direct laryngoscopy. Copyright © 2013 Elsevier Inc. All rights reserved.

[Case of awake intubation in semi-sitting position for a patient with myasthenia gravis combined with cervical disc hernia utilizing Pentax-AWS Airwayscope].

PubMed

Komasawa, Nobuyasu; Ueki, Ryusuke; Tomita, Yukihiko; Kaminoh, Yoshiroh; Tashiro, Chikara

2011-01-01

We report a case of awake intubation utilizing Pentax-AWS Airwayscope in semi-sitting position. A 74-year-old man with myasthenia gravis and cervical disc hernia was scheduled for distal gastrectomy under general anesthesia. He could not move his head due to severe cervical disc hernia and also could not sufficiently breathe due to the fatigue of respiratory muscles by myasthenia gravis in supine position. With fentanyl bolus administration and lidocaine spray for laryngotracheal anesthesia, we performed awake intubation in semi-sitting position with AWS from cranial side. The patient did not buck during intubation and no hemodynamic change was observed.

Utilization of virtual reality for endotracheal intubation training.

PubMed

Mayrose, James; Kesavadas, T; Chugh, Kevin; Joshi, Dhananjay; Ellis, David G

2003-10-01

Tracheal intubation is performed for urgent airway control in injured patients. Current methods of training include working on cadavers and manikins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time, the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The haptic device along with the real-time performance of the simulator give it both visual and physical realism. The three-dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many endotracheal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

Rescue ventilation: resolving a "cannot mask ventilate, cannot intubate" situation during exchange of a Combitube for a definitive airway.

PubMed

Rich, James M; Mason, Andrew M; Tillmann, H A; Foreman, Michael

2009-10-01

Our anesthesia care team was called to care for a patient who was admitted to the emergency department with the esophageal-tracheal double-lumen airway device (Combitube, Tyco Healthcare, Nellcor, Pleasanton, California) in place, which needed to be exchanged for a definitive airway because the patient required an extended period of mechanical ventilation. Several techniques were attempted to exchange the esophageal-tracheal Combitube (ETC) without success. First, we attempted direct laryngoscopy with the ETC in place after deflation of the No. 1 proximal cuff and sweeping the ETC to the left. We were prepared to use bougie-assisted intubation but could not identify any airway anatomy. After removal of the ETC, we unsuccessfully attempted ventilation/intubation with a laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, California). Our third attempt was insertion of another laryngeal mask airway (LMA Unique, LMA North America) with marginal ventilation, but we again experienced unsuccessful intubation using a fiberscope. The ETC was reinserted after each intubation attempt because mask ventilation was impossible. Before proceeding with cricothyrotomy, we repeated direct laryngoscopy but without the ETC in place. We identified the tip of the epiglottis, which allowed for bougie-assisted intubation. This obviated the need for emergency cricothyrotomy.

[Selective left mainstem bronchial intubation in the neonatal intensive care unit].

PubMed

Ho, Anthony M H; Flavin, Michael P; Fleming, Melinda L; Mizubuti, Glenio Bitencourt

Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Laryngeal complications by orotracheal intubation: Literature review.

PubMed

Mota, Luiz Alberto Alves; de Cavalho, Glauber Barbosa; Brito, Valeska Almeida

2012-04-01

 The injuries caused for the orotracheal intubation are common in our way and widely told by literature. Generally the pipe rank of or consequence of its permanence in the aerial ways of the patient is caused by accidents in. It has diverse types of larynx injuries, caused for multiple mechanisms.  To verify, in literature, the main causes of laryngeal complications after- orotracheal intubation and its mechanisms of injury. Revision of Literature: The searched databases had been LILACS, BIREME and SCIELO. Were updated, books and theses had been used, delimiting itself the period enters 1953 the 2009. The keywords used for the search of articles had been: complications, injuries, larynx, intubation, endotracheal, orotracheal, granulomas, stenosis. 59 references had been selected. The used criteria of inclusion for the choice of articles had been the ones that had shown to the diverse types of injuries caused for the orotracheal intubation and its pathophysiology.  This revision of literature was motivated by the comment in the practical clinic of a great number of laryngeal sequels in patients submitted to the orotracheal intubation. Of that is ahead important the knowledge, for the professionals of the area of health, the types of complications and its causes, with intention to prevent them, adopting measured of prevention of these injuries.

A canine model of tracheal stenosis induced by cuffed endotracheal intubation

PubMed Central

Su, Zhuquan; Li, Shiyue; Zhou, Ziqing; Chen, Xiaobo; Gu, Yingying; Chen, Yu; Zhong, Changhao; Zhong, Minglu; Zhong, Nanshan

2017-01-01

Postintubation tracheal stenosis is a complication of endotracheal intubation. The pathological mechanism and risk factors for endotracheal intubation-induced tracheal stenosis remain not fully understood. We aimed to establish an animal model and to investigate risk factors for postintubation tracheal stenosis. Beagles were intubated with 4 sized tubes (internal diameter 6.5 to 8.0 mm) and cuff pressures of 100 to 200 mmHg for 24 hr. The status of tracheal wall was evaluated by bronchoscopic and histological examinations. The model was successfully established by cuffed endotracheal intubation using an 8.0 mm tube and an intra-cuff pressure of 200 mmHg for 24 hr. When the intra-cuff pressures were kept constant, a larger sized tube would induce a larger tracheal wall pressure and more severe injury to the tracheal wall. The degree of tracheal stenosis ranged from 78% to 91% at 2 weeks postextubation. Histological examination demonstrated submucosal infiltration of inflammatory cells, hyperplasia of granulation tissue and collapse of tracheal cartilage. In summary, a novel animal model of tracheal stenosis was established by cuffed endotracheal intubation, whose histopathological feathers are similar to those of clinical cases of postintubation tracheal stenosis. Excessive cuff pressure and over-sized tube are the risk factors for postintubation tracheal stenosis. PMID:28349955

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome].

PubMed

Fuentes, Ricardo; De la Cuadra, Juan Carlos; Lacassie, Hector; González, Alejandro

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al. An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube. The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

PubMed

Paolini, Jean-Baptiste; Donati, François; Drolet, Pierre

2013-02-01

An adequate airway management plan is essential for patient safety. Recently, new tools have been developed as alternatives to direct laryngoscopy and intubation. Among these, video-laryngoscopy has enjoyed a rapid increase in popularity and is now considered by many as the first-line technique in airway management. This paradigm shift may have an impact on patient safety. Studies show that video-laryngoscopes are associated with better glottic visualization, a higher success rate for difficult airways, and a faster learning curve, resulting in a higher success rate for intubations by novice physicians. Thus, unanticipated difficult intubations may be less frequent if video-laryngoscopy is used as the first-line approach. In addition, on-screen viewing by the operator creates a new dynamic interaction during airway management. The entire operating room team can assess progress in real time, which enhances communication and improves teaching. However, if video-laryngoscopes become standard tools for tracheal intubation, these more costly devices will need to be widely available in all locations where airway management is conducted. Furthermore, algorithms for difficult intubation will require modification, and the question of selecting alternate devices will arise. If the incidence of difficult intubation decreases, the lack of motivation to teach and learn the use of alternative devices might adversely impact patient safety. The greater effectiveness of video-laryngoscopes associated with multi-person visualization could enhance overall patient safety during airway management. However, the routine use of video-laryngoscopy also introduces some issues that need to be addressed to avoid potentially dangerous pitfalls.

Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade.

PubMed

Alter, Scott M; Haim, Eithan D; Sullivan, Alex H; Clayton, Lisa M

2018-02-17

Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades. Design: retrospective chart review. hospital-based suburban ALS service with 20,000 annual calls. prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated. 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7). Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success. Copyright © 2018 Elsevier Inc. All rights reserved.

Quality control in QuantiFERON-TB gold in-tube for screening latent tuberculosis infection in health care workers.

PubMed

Igari, Hidetoshi; Watanabe, Akira; Ichimura, Yasunori; Sakurai, Takayuki; Taniguchi, Toshibumi; Ishiwada, Naruhiko

2017-04-01

QuantiFERON-TB gold in-tube has been used for screening latent tuberculosis infection in newly employed health care workers in Japan. There have been a few studies concerning quality control. We retrospectively analysed QuantiFERON-TB gold in-tube results in a hospital in Japan. Interferon-γ values in three blood collection tubes for QuantiFERON-TB gold in-tube were analysed in association with the positivity rate. The data set consisted of health care workers aged 20-29 years during the 7 years between 2010 and 2016. The yearly QuantiFERON-TB gold in-tube positivity rate was 0.9%, 16.4%, 3.0%, 39.3%, 2.8%, 0.9% and 1.5%, and was extremely high in 2011 and 2013. The interferon-γ values in the tuberculosis antigen tube were elevated in these two years, as indicated by higher median and wider interquartile range. The interferon-γ value in the negative control tube was also higher in 2011. The higher interferon-γ values in collection tubes (tuberculosis antigen tube and/or negative control tube) resulted in higher QuantiFERON-TB gold in-tube positivity rate. The distribution of interferon-γ in tuberculosis antigen tube and negative control tube, as evaluated by median and interquartile range, proved to be an effective index for the quality control of QuantiFERON-TB gold in-tube. Copyright © 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Effects of premedication with oral gabapentin on intraocular pressure changes following tracheal intubation in clinically normal dogs.

PubMed

Trbolova, Alexandra; Ghaffari, Masoud Selk; Capik, Igor

2017-09-19

Gabapentin is an antiepileptic drug widely approved as an add-on therapy for epilepsy treatment in human and dogs. There is a clinical impression that gabapentin is a suitable drug which attenuates the IOP elevation associated with tracheal intubation in humans. The present study performed to determine the effects of oral gabapentin on intraocular pressure (IOP) changes following tracheal intubation in dogs. Twenty adult healthy dogs were randomly assigned to treatment (n = 10) and control (n = 10) groups. Dogs in the treatment group received oral gabapentin (50 mg/kg) 2 h before induction of anesthesia and dogs in the control group received oral gelatin capsule placebo at the same time. The dogs were anesthetized with propofol 6 mg/kg, and anesthesia was maintained with a constant infusion of 0.2 mg/kg/min of propofol for 20 min. IOP were measured immediately before induction and then repeated immediately after induction, as well as 5 min, 10 min and 15 min following tracheal intubation in both groups. IOP was significantly higher immediately after induction, and 5 min after tracheal intubation when compared with IOP reading before induction in the control group. There was no statistically significant change in IOPs immediately after induction, and 5 min after tracheal intubation in comparison to the values before induction in the treatment group. Based on the findings of this study, preanesthetic oral administration of gabapentin significantly prevents an increase in the IOP associated with tracheal intubation in dogs anesthetized with propofol.

Comparison of Coopdech®, CoPilot®, Intubrite®, and Macintosh laryngoscopes for tracheal intubation during pediatric cardiopulmonary resuscitation: a randomized, controlled crossover simulation trial.

PubMed

Szarpak, Łukasz; Czyżewski, Łukasz; Truszewski, Zenon; Kurowski, Andrzej; Gaszyński, Tomasz

2015-11-01

The aim of the study was to compare the intubation times and success rates of various laryngoscopes during resuscitation in pediatric emergency intubation with uninterrupted chest compression on a standardized pediatric manikin model. This was a randomized crossover study with 107 paramedic participants. We compared times to successful intubation, intubation success rates, and glottic visibility using a Cormack-Lehane grade for Macintosh, Intubrite®, Coopdech®, and Copilot® laryngoscopes. One hundred seven paramedics (mean age 31.2 ± 7.5 years) routinely involved in the management of prehospital care participated in this study. Intubation success rates (overall effectiveness), which was the primary study endpoint, were highest for the Coopdech® and CoPilot® devices (100 %) and were lowest for Intubrite® (89.7 %, p < 0.001) and Macintosh (80.4 %, p < 0.001). The secondary study endpoint, time to first effective ventilation, was achieved fastest when using the Coopdech® laryngoscope (21.6 ± 6.2 s) and was significantly slower with all other devices (Intubrite® 25.4 ± 10.5 s, p = 0.006; CoPilot® 25.6 ± 7.4 s, p = 0.007; Macintosh 29.4 ± 8.2 s, p < 0.001). We conclude that in child simulations managed by paramedics, the Coopdech® and Copilot® video laryngoscopes performed better than the standard Macintosh or Intubrite® laryngoscopes for endotracheal intubation during child chest compression.

Predictors of Silicone Tube Intubation Success in Patients with Lacrimal Drainage System Stenosis.

PubMed

Baek, Ji Sun; Lee, Saem; Lee, Jung Hye; Choi, Hye Sun; Jang, Jae Woo; Kim, Sung Joo

2016-06-01

To evaluate prognostic factors affecting silicone tube intubation outcomes in Asian patients with lacrimal drainage system stenosis. A retrospective review was conducted on the medical records of 822 patients (1,118 eyes) who had undergone silicone tube intubation to treat lacrimal drainage system stenosis between January 2011 and December 2012. Patients were divided into two groups: a success group and a failure group. Success was defined as the disappearance of epiphora symptoms, normalization of tear meniscus height, and the easy passage of fluid without resistance on the postoperative syringing test. Patient and ocular parameters were compared between the success and failure groups. A total of 994 eyes of 727 patients were included in analyses. Patients had a mean follow-up period of 34.11 ± 18.70 weeks. Silicone tube intubation was successful in 67.2% of participants. Significant differences between the success and failure groups were found for age (p < 0.001), history of ipsilateral facial palsy (p = 0.028), follow-up period (p < 0.001), and degree of passage on the preoperative syringing test (p = 0.001). Only age (p < 0.001) and degree of passage on the preoperative syringing test (p = 0.002) remained significantly associated with silicone tube intubation success in multivariate analysis. Age was negatively associated with silicone tube intubation success in patients with lacrimal drainage system stenosis. The success rate was higher in patients who showed easy passage of fluid without resistance on the preoperative syringing test. These factors should be considered by surgeons planning silicone tube intubation in patients with lacrimal drainage system stenosis.

Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics

PubMed Central

2011-01-01

Background Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics. Methods Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated. Results Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade. Conclusions The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics. PMID:21241469

Ability of paramedics to perform endotracheal intubation during continuous chest compressions: a randomized cadaver study comparing Pentax AWS and Macintosh laryngoscopes.

PubMed

Truszewski, Zenon; Czyzewski, Lukasz; Smereka, Jacek; Krajewski, Paweł; Fudalej, Marcin; Madziala, Marcin; Szarpak, Lukasz

2016-09-01

The aim of the trial was to compare the time parameters for intubation with the use of the Macintosh (MAC) laryngoscope and Pentax AWS-S100 videolaryngoscope (AWS; Pentax Corporation, Tokyo, Japan) with and without chest compression (CC) by paramedics during simulated cardiopulmonary resuscitation in a cadaver model. This was a randomized crossover cadaver trial. Thirty-five paramedics with no experience in videolaryngoscopy participated in the study. They performed intubation in two emergency scenarios: scenario A, normal airway without CC; scenario B, normal airway with continuous CC. The median time to first ventilation with the use of the AWS and the MAC was similar in scenario A: 25 (IQR, 22-27) seconds vs. 24 (IQR, 22.5-26) seconds (P=.072). A statistically significant difference in TTFV between AWS and MAC was noticed in scenario B (P=.011). In scenario A, the first endotracheal intubation (ETI) attempt success rate was achieved in 97.1% with AWS compared with 94.3% with MAC (P=.43). In scenario B, the success rate after the first ETI attempt with the use of the different intubation methods varied and amounted to 88.6% vs. 77.1% for AWS and MAC, respectively (P=.002). The Pentax AWS offered a superior glottic view as compared with the MAC laryngoscope, which was associated with a higher intubation rate and a shorter intubation time during an uninterrupted CC scenario. However, in the scenario without CC, the results for AWS and MAC were comparable. Copyright © 2016 Elsevier Inc. All rights reserved.

[A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation].

PubMed

Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel

Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anaesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical assisted intubation compared to other devices. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation.

PubMed

Metterlein, Thomas; Dintenfelder, Anna; Plank, Christoph; Graf, Bernhard; Roth, Gabriel

Fiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. With approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). Demographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. None of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical assisted intubation compared to other devices. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.

PubMed

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-11-01

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. © 2015 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.

Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics*

PubMed Central

Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

2015-01-01

The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the ‘can't intubate, can't oxygenate’ situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. PMID:26449292

Technical realization of a sensorized neonatal intubation skill trainer for operators' retraining and a pilot study for its validation.

PubMed

Panizza, Davide; Scaramuzzo, Rosa T; Moscuzza, Francesca; Vannozzi, Ilaria; Ciantelli, Massimiliano; Gentile, Marzia; Baldoli, Ilaria; Tognarelli, Selene; Boldrini, Antonio; Cuttano, Armando

2018-01-04

In neonatal endotracheal intubation, excessive pressure on soft tissues during laryngoscopy can determine permanent injury. Low-fidelity skill trainers do not give valid feedback about this issue. This study describes the technical realization and validation of an active neonatal intubation skill trainer providing objective feedback. We studied expert health professionals' performances in neonatal intubation, underlining chance for procedure retraining. We identified the most critical points in epiglottis and dental arches and fixed commercial force sensors on chosen points on a ©Laerdal Neonatal Intubation Trainer. Our skill trainer was set up as a grade 3 on Cormack and Lehane's scale, i.e. a model of difficult intubation. An associated software provided real time sound feedback if pressure during laryngoscopy exceeded an established threshold. Pressure data were recorded in a database, for subsequent analysis with non-parametric statistical tests. We organized our study in two intubation sessions (5 attempts each one) for everyone of our participants, held 24 h apart. Between the two sessions, a debriefing phase took place. In addition, we gave our participants two interview, one at the beginning and one at the end of the study, to get information about our subjects and to have feedback about our design. We obtained statistical significant differences between consecutive attempts, with evidence of learning trends. Pressure on critical points was significantly lower during the second session (p < 0.0001). Epiglottis' sensor was the most stressed (p < 0.000001). We found a significant correlation between time spent for each attempt and pressures applied to the airways in the two sessions, more significant in the second one (shorter attempts with less pressure, r s  = 0.603). Our skill trainer represents a reliable model of difficult intubation. Our results show its potential to optimize procedures related to the control of trauma risk and to improve personnel retraining.

Comparison of Preloaded Bougie versus Standard Bougie Technique for Endotracheal Intubation in a Cadaveric Model.

PubMed

Baker, Jay B; Maskell, Kevin F; Matlock, Aaron G; Walsh, Ryan M; Skinner, Carl G

2015-07-01

We compared intubating with a preloaded bougie (PB) against standard bougie technique in terms of success rates, time to successful intubation and provider preference on a cadaveric airway model. In this prospective, crossover study, healthcare providers intubated a cadaver using the PB technique and the standard bougie technique. Participants were randomly assigned to start with either technique. Following standardized training and practice, procedural success and time for each technique was recorded for each participant. Subsequently, participants were asked to rate their perceived ease of intubation on a visual analogue scale of 1 to 10 (1=difficult and 10=easy) and to select which technique they preferred. 47 participants with variable experience intubating were enrolled at an emergency medicine intern airway course. The success rate of all groups for both techniques was equal (95.7%). The range of times to completion for the standard bougie technique was 16.0-70.2 seconds, with a mean time of 29.7 seconds. The range of times to completion for the PB technique was 15.7-110.9 seconds, with a mean time of 29.4 seconds. There was a non-significant difference of 0.3 seconds (95% confidence interval -2.8 to 3.4 seconds) between the two techniques. Participants rated the relative ease of intubation as 7.3/10 for the standard technique and 7.6/10 for the preloaded technique (p=0.53, 95% confidence interval of the difference -0.97 to 0.50). Thirty of 47 participants subjectively preferred the PB technique (p=0.039). There was no significant difference in success or time to intubation between standard bougie and PB techniques. The majority of participants in this study preferred the PB technique. Until a clear and clinically significant difference is found between these techniques, emergency airway operators should feel confident in using the technique with which they are most comfortable.

Effect of just-in-time simulation training on tracheal intubation procedure safety in the pediatric intensive care unit.

PubMed

Nishisaki, Akira; Donoghue, Aaron J; Colborn, Shawn; Watson, Christine; Meyer, Andrew; Brown, Calvin A; Helfaer, Mark A; Walls, Ron M; Nadkarni, Vinay M

2010-07-01

Tracheal intubation-associated events (TIAEs) are common (20%) and life threatening (4%) in pediatric intensive care units. Physician trainees are required to learn tracheal intubation during intensive care unit rotations. The authors hypothesized that "just-in-time" simulation-based intubation refresher training would improve resident participation, success, and decrease TIAEs. For 14 months, one of two on-call residents, nurses, and respiratory therapists received 20-min multidisciplinary simulation-based tracheal intubation training and 10-min resident skill refresher training at the beginning of their on-call period in addition to routine residency education. The rate of first attempt and overall success between refresher-trained and concurrent non-refresher-trained residents (controls) during the intervention phase was compared. The incidence of TIAEs between preintervention and intervention phase was also compared. Four hundred one consecutive primary orotracheal intubations were evaluated: 220 preintervention and 181 intervention. During intervention phase, neither first-attempt success nor overall success rate differed between refresher-trained residents versus concurrent non-refresher-trained residents: 20 of 40 (50%) versus 15 of 24 (62.5%), P = 0.44 and 23 of 40 (57.5%) versus 18 of 24 (75.0%), P = 0.19, respectively. The resident's first attempt and overall success rate did not differ between preintervention and intervention phases. The incidence of TIAE during preintervention and intervention phases was similar: 22.0% preintervention versus 19.9% intervention, P = 0.62, whereas resident participation increased from 20.9% preintervention to 35.4% intervention, P = 0.002. Resident participation continued to be associated with TIAE even after adjusting for the phase and difficult airway condition: odds ratio 2.22 (95% CI 1.28-3.87, P = 0.005). Brief just-in-time multidisciplinary simulation-based intubation refresher training did not improve the resident's first attempt or overall tracheal intubation success.

Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients.

PubMed

Hsiao, Chen-Hao; Chen, Ke-Cheng; Chen, Jin-Shing

2017-04-01

Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated. We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared. Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.

A prospective randomized controlled study to evaluate and compare GlideScope with Macintosh laryngoscope for ease of endotracheal intubation in adult patients undergoing elective surgery under general anesthesia

PubMed Central

Jafra, Anudeep; Gombar, Satinder; Kapoor, Dheeraj; Sandhu, Harpreet Singh; Kumari, Kamlesh

2018-01-01

Background: The aim of the study was to compare the ease the intubation using GlideScope video laryngoscope and Macintosh laryngoscope in adult patients undergoing elective surgery under general anesthesia. Materials and Methods: A total of 200 American Society of Anesthesiologists I–II patients of either sex, in the age group of 18–60 years were included in the study. Patients were randomly allocated to two groups. We assessed ease of intubation depending on time to tracheal intubation, number of attempts, glottic view (Cormack–Lehane grade [CL grade] and percentage of glottis opening [POGO]) and intubation difficulty score (IDS), hemodynamic variables and any intra- and post-operative adverse events. Results: The rate of successful endotracheal intubation (ETI) in both groups was 100% in the first attempt. The time required for successful ETI was 24.89 ± 5.574 in Group G and 20.68 ± 3.637 in Group M (P < 0.001) found to be statistically significant. There was significant improvement in glottic view with GlideScope (as assessed by POGO score 66.71 ± 29.929 and 94.40 ± 10.476 in group G and 75.85 ± 26.969 and 74.20 ± 29.514 Group M and CL grading [P < 0.001]). A comparison of mean IDS between two groups revealed intubation was easier with the use of GlideScope. The hemodynamic response to intubation was significantly lesser with the use of GlideScope when compared with Macintosh laryngoscope. The incidence of adverse events, though minor like superficial lip or tongue bleed, was similar in two groups. Conclusions: GlideScope offers superiority over Macintosh laryngoscope in terms of laryngeal views and the difficulty encountered at ETI in an unselected population. PMID:29628839

Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients.

PubMed

Sunde, Geir Arne; Heltne, Jon-Kenneth; Lockey, David; Burns, Brian; Sandberg, Mårten; Fredriksen, Knut; Hufthammer, Karl Ove; Soti, Akos; Lyon, Richard; Jäntti, Helena; Kämäräinen, Antti; Reid, Bjørn Ole; Silfvast, Tom; Harm, Falko; Sollid, Stephen J M

2015-08-07

Despite numerous studies on prehospital airway management, results are difficult to compare due to inconsistent or heterogeneous data. The objective of this study was to assess advanced airway management from international physician-staffed helicopter emergency medical services. We collected airway data from 21 helicopter emergency medical services in Australia, England, Finland, Hungary, Norway and Switzerland over a 12-month period. A uniform Utstein-style airway template was used for collecting data. The participating services attended 14,703 patients on primary missions during the study period, and 2,327 (16 %) required advanced prehospital airway interventions. Of these, tracheal intubation was attempted in 92 % of the cases. The rest were managed with supraglottic airway devices (5 %), bag-valve-mask ventilation (2 %) or continuous positive airway pressure (0.2 %). Intubation failure rates were 14.5 % (first-attempt) and 1.2 % (overall). Cardiac arrest patients showed significantly higher first-attempt intubation failure rates (odds ratio: 2.0; 95 % CI: 1.5-2.6; p < 0.001) compared to non-cardiac arrest patients. Complications were recorded in 13 %, with recognised oesophageal intubation being the most frequent (25 % of all patients with complications). For non-cardiac arrest patients, important risk predictors for first-attempt failure were patient age (a non-linear association) and administration of sedatives (reduced failure risk). The patient's sex, provider's intubation experience, trauma type (patient category), indication for airway intervention and use of neuromuscular blocking agents were not risk factors for first-attempt intubation failure. Advanced airway management in physician-staffed prehospital services was performed frequently, with high intubation success rates and low complication rates overall. However, cardiac arrest patients showed significantly higher first-attempt failure rates compared to non-cardiac arrest patients. All failed intubations were handled successfully with a rescue device or surgical airway. www.clinicaltrials.gov NCT01502111 . Registered 22 December 2011.

Preoperative airway assessment - experience gained from a multicentre cluster randomised trial and the Danish Anaesthesia Database.

PubMed

Nørskov, Anders Kehlet

2016-05-01

Difficulties with airway management in relation to general anaesthesia have been a challenge for the anaesthesiologist since the birth of anaesthesia. Massive landmark improvements have been made and general anaesthesia is now regarded as a safe procedure. However, rare, difficult airway management still occurs and it prompts increased risk of morbidity and mortality - especially when not anticipated. Several preoperative risk factors for airway difficulties have been identified, yet none have convincing diagnostic accuracy as stand alone tests. Combining several risk factors increase the predictive value of the test and multivariable risk models have been developed. The Simplified Airway Risk Index (SARI) is a predictive model developed for anticipation of a difficult direct laryngoscopy. However, neither the diagnostic accuracy of the SARI nor of any other model has been tested prospectively and compared with existing practice for airway assessment in a randomised trial setting. The first objective of this thesis was to quantify the proportion of unanticipated difficult intubation and difficult mask ventilation in Denmark. The second objective was to design a cluster randomised trial, using state of the art methodology, in order to test the clinical impact of using the SARI for preoperative airway assessment compared with a clinical judgement based on usual practice for airway assessment. Finally, to test if implementation of the SARI would reduce the proportion of unanticipated difficult intubation compared with usual care for airway assessment. This thesis is based on data from the Danish Anaesthesia Database (DAD). Paper 1 presents an observational cohort study on 188,064 patients who underwent tracheal intubation from 2008 to 2011. Data on the anaesthesiologists' preoperative anticipations of airway difficulties was compared with actual airway management conditions, thus enabling an estimation of the proportion of unanticipated difficulties with intubation and mask ventilation. Papers 2 and 3 outline the methodology and the pre-trial calculations and considerations leading to the DIFFICAIR trial described in Paper 4. The trial was designed to randomise anaesthesia department to either thorough education in, and subsequent use of the SARI for preoperative airway assessment or to continue usual care. Registration of the SARI in DAD was made mandatory in SARI departments and impossible in usual care departments. Conditions regarding anticipation of difficulties and actual airway managements were recorded as for Paper 1. DAD data made it possible to estimate an appropriate sample size, considering the between cluster variation, and to construct a stratification variable based on 2011 baseline values of the primary outcome used in the DIFFICAIR trial. Paper 1 revealed that 1.86% of all patients who were intubated, but not planned for advanced intubation techniques (e.g. video laryngoscopy), were unanticipated difficult to intubate. However, 75 to 93% of all difficult intubations were unanticipated. Furthermore, 94% of all difficult mask ventilations were unanticipated. In Paper 4, 59,514 patients were included in the primary analyses. The proportion of unanticipated difficult intubations was 2.38% (696/29,209) in SARI departments and 2.39% (723/30,305) in usual care departments. The adjusted odds ratio was 1.03 (95% CI: 0.77-1.38), p = 0.84. No significant differences were detected in other adjusted outcome measures and neither a 58% increase in patients anticipated to have intubation difficulties nor an 84% increase in patients scheduled for advanced intubation techniques in SARI departments reached statistical significance, p = 0.29 and p = 0.06 respectively. The papers constituting this thesis demonstrate that at high proportion of airway management difficulties are unanticipated. In a cluster randomised trial it was not possible to reduce the proportion of unanticipated difficult intubation in daily clinical practice by implementing a systematic approach for airway assessment compared with usual care. However, implementation of the SARI may increase the anticipation of intubation difficulties and it may change practice towards advanced intubation techniques. This thesis underlines the continued challenge anaesthesiologists face in predicting airway management related difficulties.

The combined use of Skype and the STORZ CMAC video laryngoscope in field intubation training with the Nebraska National Air Guard.

PubMed

Boedeker, Ben H; Bernhagen, Mary; Miller, David J; Miljkovic, Nikola; Kuper, Gail M; Murray, W Bosseau

2011-01-01

This study examined the feasibility of using Skype technology in basic manikin intubation instruction of Nebraska National Air Guard personnel at a Casualty Training Exercise. Results show that the Skype monitor provided clear sound and visualization of the airway view to the trainees and the combination of VoIP technology and videolaryngoscopy for intubation training was highly valued by study participants.

Asymptomatic vallecular cyst: case report.

PubMed

Yuce, Yucel; Uzun, Sennur; Aypar, Ulku

2013-01-01

A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200 mg propofol, 50 μg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2x2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.

Neurological Development of Children With Isolated Robin Sequence Treated With Nasopharyngeal Intubation in Early Infancy.

PubMed

Alencar, Tatiane Romanini Rodrigues; Marques, Ilza Lazarini; Bertucci, Alvaro; Prado-Oliveira, Rosana

2017-05-01

The study assessed the neurodevelopment of children with isolated Robin sequence (IRS) and evaluated if children treated exclusively with nasopharyngeal intubation (NPI) present delay in neurological development. The prospective and cross-sectional study was conducted at the Hospital for Rehabilitation of Craniofacial Anomalies, Brazil. Children with IRS were divided into two groups according to the type of treatment in early infancy: 38 were treated with NPI (more severe cases) and 24 with postural treatment (less severe cases). Regarding interventions, children were assessed at 2 to 6 years of age using the Denver II Developmental Screening Test (Denver II) and Neurological Evolutionary Examination (NEE). According to Denver II, 73.7% in the NPI group and 79.2% in the postural group presented normal development. This result was similar to the results of different studies in the literature with typical population. Considering all areas of development, there were no significant differences in Denver II between the NPI and postural groups (P = .854). In the NPI group, 89.5% of children and 87.5% in the postural group presented normal development in NEE. Language was the most affected area, as 18.4% and 20.8% of children in NPI and postural group, respectively, presented risk for delay in the Denver II. The increased risk for delay in language area was probably due to anatomical conditions of the muscles involved in speech, and to hearing oscillations, as 47.4% in NPI group and 58.3% in postural group underwent myringotomy. IRS treated with NPI had neurological development similar to those in less severe cases. Children treated exclusively with NPI did not present delay in neurological development.

Remote Services, Inc.

ERIC Educational Resources Information Center

Morris, Steven A.

2008-01-01

The Remote Services, Inc. (RSI) case is designed as an extensible, database design and implementation project. The case is designed in two primary components: design and implementation. The design component of the case allows students to evaluate a scenario that is similar to a real-world business situation and create an appropriate design…

DIRECT DOSING OF PRE-WEANING RODENTS IN TOXICITY TESTING AND RESEARCH: DELIBERATIONS OF AN ILSI RSI EXPERT WORKING GROUP.

EPA Science Inventory

Laboratory animal studies that are designed to assess the effects of exposure of a test substance during postnatal development are commonly utilized in basic research and to evaluate potential hazard to children for chemical and pharmaceutical regulation. Direct dosing, defined ...

Protection afforded by respirators when performing endotracheal intubation using a direct laryngoscope, GlideScope®, and i-gel® device: A randomized trial

PubMed Central

Lim, Tae Ho; Oh, Jaehoon; Lee, Juncheol; Shin, Hyungoo

2018-01-01

Emergency physicians are at risk of infection during invasive procedures, and wearing a respirator can reduce this risk. The aim of this study was to determine whether the protection afforded by a respirator during intubation is affected by the type of airway device used. In this randomized crossover study, 26 emergency physicians underwent quantitative fit tests for a N95 respirator (cup-type or fold-type) before and during intubation with a direct laryngoscope, GlideScope®, or i-gel® airway device. The primary outcome was the fit factor value of the respirator and the secondary outcome was the level of acceptable protection provided (percentage of fit factor scores above 100). Compared with the GlideScope and i-gel device, the fit factor values and level of acceptable protection provided were lower when physicians wore the cup-type respirator while intubating using the direct laryngoscope (200 fit factor [152–200] and 200 fit factor [121.25–200] versus 166 fit factor [70–200], 100% and 100% versus 75%, respectively; all P < 0.001). There were no significant differences in the fit factor value or level of acceptable protection provided when the physicians wore the fold-type respirator while intubating using any of the three airway devices (all P > 0.05). The type of airway device used for endotracheal intubation may influence the protective performance of some types of respirators. Emergency physicians should consider the effects of airway device types on fit factor of N95 respirators, when they perform intubation at risk of infection. PMID:29672533

Proper size of endotracheal tube for cleft lip and palate patients and intubation outcomes.

PubMed

Abdollahifakhim, Shahin; Sheikhzadeh, Dariush; Shahidi, Nikzad; Nojavan, Gholamreza; Bayazian, Gholamreza; Aleshi, Hamideh

2013-05-01

The aim of the current study was to identify the proper size of endotracheal tube for intubation of cleft lip and palate patients and intubation outcomes in these patients. In this analytic cross-sectional study, 60 nonsyndromic cleft lip and palate patients were selected who had surgery between April 2010 and April 2012 at Pediatrics Hospital, Tabriz University of Medical Sciences, Iran. Demographic findings, previous admissions, and surgical history were registered. The proper tube size was measured by normal children formulas. Then tube size was confirmed by patients' minimum resistance to intubation, proper ventilation reported by anesthesiologist, and appropriate air leakage at an airway pressure of 15-20 cm H₂O. If intubation was unsuccessful then smaller size of endotracheal tube would be tried. Frequency of intubation trials and the biggest endotracheal tube size were recorded. Their average age, weight and height were 21.39 ± 4.95 months, 9.97 ± 1.18 kg and 74.30 ± 26.61 cm, respectively. The average tracheal tube size and frequency of intubation trials were 4.34 ± 0.78 and 1.63 ± 0.80, respectively. Seven cases required an endotracheal tube size smaller than the recommended size for that age including one case in unilateral cleft palate, three cases in unilateral cleft lip, one case in unilateral cleft lip and palate, and two cases in bilateral cleft lip and palate. Findings proved that considering subglottic stenosis incidence in these children, it is reasonable to determine the tube size for nonsyndromic cleft lip and palate patients by applying the currently available standards for normal children. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration

PubMed Central

Cha, Dong Guk; Jeong, Ji Seon; Kwon, Hye Mee

2014-01-01

Background The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration. Methods A total of 140 adult patients were randomized into 4 groups to receive either 30 µg/kg ephedrine (Group 30, n = 35), 70 µg/kg ephedrine (Group 70, n = 35), 110 µg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration. Results An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 ± 44.7 s, Group 70: 152.6 ± 40.3 s, Group 110: 151.2 ± 51.6 s) compared to Group C (224.6 ± 56.9 s) after 0.15 mg/kg of cisatracurium (P < 0.001). Ephedrine doses of either 70 or 110 µg/kg for pretreatment significantly improved intubating conditions (P < 0.05). Systolic and diastolic blood pressure and heart rate at 1 min after tracheal intubation were significantly increased than other times in all groups (P < 0.001), with no differences among the groups. However, 5 patients in Group 110 experienced marked hypertension (systolic/diastolic blood pressure: > 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups. Conclusions We conclude that pre-treatment with ephedrine 70 µg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects. PMID:25097735

A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI).

PubMed

Valori, Roland M; Damery, Sarah; Gavin, Daniel R; Anderson, John T; Donnelly, Mark T; Williams, J Graham; Swarbrick, Edwin T

2018-01-01

 Cecal intubation rate (CIR) is an established performance indicator of colonoscopy. In some patients, cecal intubation with acceptable tolerance is only achieved with additional sedation. This study proposes a composite Performance Indicator of Colonic Intubation (PICI), which combines CIR, comfort, and sedation. METHODS : Data from 20 085 colonoscopies reported in the 2011 UK national audit were analyzed. PICI was defined as the percentage of procedures achieving cecal intubation with median dose (2 mg) of midazolam or less, and nurse-assessed comfort score of 1 - 3/5. Multivariate logistic regression analysis evaluated possible associations between PICI and patient, unit, colonoscopist, and diagnostic factors. RESULTS : PICI was achieved in 54.1 % of procedures. PICI identified factors affecting performance more frequently than single measures such as CIR and polyp detection, or CIR + comfort alone. Older age, male sex, adequate bowel preparation, and a positive fecal occult blood test as indication were associated with a higher PICI. Unit accreditation, the presence of magnetic imagers in the unit, greater annual volume, fewer years' experience, and higher training/trainer status were associated with higher PICI rates. Procedures in which PICI was achieved were associated with significantly higher polyp detection rates than when PICI was not achieved. CONCLUSIONS : PICI provides a simpler picture of performance of colonoscopic intubation than separate measures of CIR, comfort, and sedation. It is associated with more factors that are amenable to change that might improve performance and with higher likelihood of polyp detection. It is proposed that PICI becomes the key performance indicator for intubation of the colon in colonoscopy quality improvement initiatives. © Georg Thieme Verlag KG Stuttgart · New York.

Association of cumulative dose of haloperidol with next-day delirium in older medical ICU patients.

PubMed

Pisani, Margaret A; Araujo, Katy L B; Murphy, Terrence E

2015-05-01

To evaluate the association between cumulative dose of haloperidol and next-day diagnosis of delirium in a cohort of older medical ICU patients, with adjustment for its time-dependent confounding with fentanyl and intubation. Prospective, observational study. Medical ICU at an urban, academic medical center. Age 60 years and older admitted to the medical ICU who received at least one dose of haloperidol (n = 93). Of these, 72 patients were intubated at some point in their medical ICU stay, whereas 21 were never intubated. None. Detailed data were collected concerning time, dosage, route of administration of all medications, as well as for important clinical covariates, and daily status of intubation and delirium using the confusion assessment method for the ICU and a chart-based algorithm. Among nonintubated patients, and after adjustment for time-dependent confounding and important covariates, each additional cumulative milligram of haloperidol was associated with 5% higher odds of next-day delirium with odds ratio of 1.05 (credible interval [CI], 1.02-1.09). After adjustment for time-dependent confounding and covariates, intubation was associated with a five-fold increase in odds of next-day delirium with odds ratio of 5.66 (CI, 2.70-12.02). Cumulative dose of haloperidol among intubated patients did not change their already high likelihood of next-day delirium. After adjustment for time-dependent confounding, the positive associations between indicators of intubation and of cognitive impairment and next-day delirium became stronger. These results emphasize the need for more studies regarding the efficacy of haloperidol for treatment of delirium among older medical ICU patients and demonstrate the value of assessing nonintubated patients.

A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, crossover, manikin study.

PubMed

Szarpak, Lukasz; Truszewski, Zenon; Czyzewski, Lukasz; Gaszynski, Tomasz; Rodríguez-Núñez, Antonio

2016-08-01

Prehospital tracheal intubation by paramedics during cardiopulmonary resuscitation (CPR) in children is challenging. The potential role of new intubation devices during CPR is unclear. Our objective was to assess the impact of CPR (with and without chest compressions [CCs]) on the success and time to intubation (TTI) with the Macintosh laryngoscope vs the McGrath video laryngoscope on a pediatric manikin. This was an open, prospective, randomized, crossover, manikin trial involving 95 paramedics who performed intubations in a PediaSIM pediatric high-fidelity manikin with Macintosh and McGrath laryngoscopes, with and without concomitant mechanical CCs. Primary outcome was the TTI, and secondary outcome was success of the attempt. Participants rated their best glottic view, the severity of the potential dental trauma, and subjective opinion about the difficulty of the procedure. The median TTI with the Macintosh in the scenario with uninterrupted CC was 33 (interquartile range [IQR], 24-36) seconds, which is significantly longer than TTI in the scenario with interrupted CC (23 [IQR, 20-29] seconds, P < .001). Time to intubation using the McGrath was similar in both scenarios: 20 (IQR, 17-23) seconds vs 19.5 (IQR, 17-22) seconds (P = .083). A statistically significant difference between McGrath and Macintosh was noticed in TTI both in scenario with (P < .001) and without CC (P = .017). McGrath video laryngoscope helps paramedics to intubate a pediatric manikin in a CPR scenario in less time and with fewer attempts than with the classical Macintosh, both in case of ongoing or stopped CC. McGrath use in actual patients could improve CPR quality by paramedics. Copyright © 2015 Elsevier Inc. All rights reserved.

Crisis management during anaesthesia: difficult intubation.

PubMed

Paix, A D; Williamson, J A; Runciman, W B

2005-06-01

Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. To examine the role of a specific sub-algorithm for the management of difficult intubation. The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

PubMed

von Elm, E; Schoettker, P; Henzi, I; Osterwalder, J; Walder, B

2009-09-01

We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

Nasal high-flow oxygen therapy improves arterial oxygenation during one-lung ventilation in non-intubated thoracoscopic surgery.

PubMed

Wang, Man-Ling; Hung, Ming-Hui; Chen, Jin-Shing; Hsu, Hsao-Hsun; Cheng, Ya-Jung

2018-05-01

Intraoperative hypoxaemia during one-lung ventilation (OLV) remains a major concern in thoracic surgery. Non-intubated video-assisted thoracic surgery (VATS) involves a greater risk of consequent emergent conversion to endotracheal intubation. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has recently been reported to be beneficial for higher oxygen reserves during difficult intubations and for enhancing postoperative recovery after thoracic surgery. However, the effects of THRIVE on oxygenation and carbon dioxide elimination before and during OLV in non-intubated VATS have not been investigated. Between September 2016 and October 2016, 30 patients underwent non-intubated VATS for lung tumour and were maintained with THRIVE at a flow of 20 l/min. These patients were compared with a historical control group comprising 30 patients who were maintained with oxygen masks at an oxygen flow of 10 l/min using a propensity score matching algorithm between September 2015 and July 2016. The preoperative arterial oxygen tension was significantly higher in patients maintained with THRIVE than it was in patients maintained with oxygen masks (mean 416.0 vs 265.9 mmHg, P < 0.01). During OLV, arterial oxygen tension remained significantly higher in the THRIVE group than in the oxygen mask group (mean 207.0 vs 127.8 mmHg, P = 0.01). The arterial carbon dioxide tension was comparable before and during OLV. The results indicated that THRIVE effectively increases the oxygen reserve both during OLV and after anaesthesia. Furthermore, non-intubated VATS is safer if THRIVE with flow adjustment is incorporated into a minimally invasive surgical approach, although carbon dioxide elimination is not facilitated.

Advances in Laryngoscopy.

PubMed

Aziz, Michael

2015-01-01

Recent technological advances have made airway management safer. Because difficult intubation remains challenging to predict, having tools readily available that can be used to manage a difficult airway in any setting is critical. Fortunately, video technology has resulted in improvements for intubation performance while using laryngoscopy by various means. These technologies have been applied to rigid optical stylets, flexible intubation scopes, and, most notably, rigid laryngoscopes. These tools have proven effective for the anticipated difficult airway as well as the unanticipated difficult airway.

An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.

PubMed

Arora, Suman; Rattan, Vidya; Bhardwaj, Neerja

2006-11-01

The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. Children 3-15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.

Awake Fibreoptic Intubation for Forearm Injury in a Patient with Occipito-Cervical Fixator

PubMed Central

Akkaya, Akcan; Yıldız, İsa; Demirhan, Abdullah; Tekelioğlu, Ümit Yaşar; Koçoğlu, Hasan

2013-01-01

A 23-year-old male patient with occipitocervical fixator was scheduled for surgery due to injury to the right forearm. The patient’s thyromental distance was 5 cm, mouth opening grade II, sternomental distance 10 cm and Mallampati score 4. Loss of extension and rotation movements of the head was assessed as difficult intubation criteria. Anaesthetic procedures are almost always difficult in patients with occipitocervical fixation; the limited cervical extension complicated both intubation and ventilation. In this report, application of general anaesthesia using awake fibreoptic bronchoscopic intubation (FOB) is described. After routine monitoring of vital signs and premedication, hypopharyngeal topical anaesthesia was accomplished by instilling 10% lidocaine spray twice via the appropriate nostril. Superior laryngeal nerve block was performed with local anaesthetic infiltration of tissues 1 cm below the greater horns of the hyoid bone. Lingual and pharyngeal branches of the glossopharyngeal nerve were blocked. Transtracheal block was performed. Following completion of local anaesthesia, the patient was intubated using the awake FOB technique, on 5 L min−1 of 100% O2. After muscle relaxation, the patient underwent a microsurgical operation to repair eight tendons, one artery, and one nerve. Surgery lasted for 5 hours. When the extubation criteria were met, the patient was extubated. In cases of occipitocervical fixation, which causes severe limitation of neck movements, the use of awake fibreoptic intubation should be considered. PMID:27366367

Betel quid, chewing habits and difficult intubation: A case report and critical appraisal of evidence for practice.

PubMed

Narendra, P L; Hegde, Harihar V; Vijaykumar, T K; Nallamilli, Samson

2015-01-01

Betel quid is used by 10-20% of world of population. Oral submucus fibrosis (OSF) is a chronic premalignant disease common in South Asian countries where betel quid is chewed. It is characterized by juxtaepithelial fibrosis of oral cavity and limited mouth opening, which can cause difficult intubation. A recent study in Taiwan has revealed long-term betel nut chewing is not predictor of difficult intubation. We describe two cases of OSF and critically analyze this study and its implications for clinical practice. OSF is now seen in Saudi Arabia and western countries with use of commercial betel quid substitutes. Although betel quid without tobacco is used in Taiwan, available evidence suggests rapid and early development of OSF where commercial chewing products like Pan Masala are used in India. Effects of betel quid may vary depending on the composition of quid and chewing habits. Studies where personal habits are involved must be analyzed carefully for external validity. Even though, Taiwan study is controlled, its validity outside Taiwan is highly questionable. Since OSF can cause unanticipated difficult intubation, thus during preanesthetic assessment, history of betel quid chewing, more importantly use of commercial chewing products is more likely to give clues to severity of OSF and possible difficult intubation. Further controlled trails in populations where commercial chewing products are used is necessary to detect association of chewing habits and difficult intubation.

Preventing pressure sores of the nasal ala after nasotracheal tube intubation: from animal model to clinical application.

PubMed

Huang, Tze-Ta; Tseng, Chih-En; Lee, Tsan-Mu; Yeh, Jen-Ying; Lai, Yu-Yung

2009-03-01

Nasal-ala pressure sores induced by nasotracheal intubation are common complications of oral and maxillofacial surgery, but are easily ignored. To determine whether such sores could be prevented, we studied the effects of a combination of cushioning material in an animal model, and then analyzed the efficacy of this combination clinically. Four pigs received nasotracheal intubation. Each pig received intubation for 4, 8, 12, or 16 hours. Outcomes from pigs undergoing 500-gram-weight compression on each nostril were compared: one nostril received an application of cushioning materials, and the contralateral nostril did not. After the required study period, clinical assessment and further evaluation were performed by measuring pressure-sore dimensions and performing incisional biopsies. Clinical applications of this protective technique were then undertaken. Eight patients who underwent intubation without Soft Liner (GC Co, Tokyo, Japan) and DuoDERM CGF (ConvaTec, Inc, Princeton, NJ) protection, and 10 patients with Soft Liner and DuoDERM protection, were evaluated. The protective efficacy of the cushioning materials was significant in the animal model as well as in clinical practice. Pressure sores were avoided on the protected side, with severe tissue necrosis documented on the control side. We found that the combined use of Soft Liner and DuoDERM reduced the size and severity of nasal-ala pressure sores attributable to nasotracheal intubation during oral and maxillofacial surgery.

Laryngoscope plastic blades in scheduled general anesthesia patients: a comparative randomized study.

PubMed

Galinski, Michel; Catineau, Jean; Rayeh, Fatima; Muret, Jane; Ciebiera, Jean-Pierre; Plantevin, Frédéric; Foucrier, Arnaud; Tual, Loic; Combes, Xavier; Adnet, Frédéric

2011-03-01

To compare two brands of disposable plastic laryngoscope blades, Vital View plastic blades and Heine XP plastic blades, with the reusable Heine Classic+ Macintosh metal blades. Prospective randomized, controlled, single-blinded study. Operating room of a university-affiliated hospital. 519 patients without criteria for predicted difficult intubation, undergoing scheduled surgery during general anesthesia. Patients were randomized to three groups according to laryngoscope blade brand. Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS) (IDS > 5 = procedure involving moderate to major difficulty). The percentage of intubations with an IDS > 5 was 3.1% in Group M (metal blade group), 5.1% in Group V (Vital View plastic blade group), and 10.0% in Group H (Heine plastic blade group). A significant difference was noted between Groups M and H (P = 0.02) but not between Groups M and V. Intubation may be more challenging when using Heine XP plastic blades but no significant difference exists between Vital-View plastic blades and Heine Classic+ metal blades. Copyright © 2011 Elsevier Inc. All rights reserved.

Comparison of 4 supraglotttic devices used by paramedics during simulated CPR : a randomized controlled crossover trial.

PubMed

Szarpak, Łukasz; Kurowski, Andrzej; Truszewski, Zenon; Robak, Oliver; Frass, Michael

2015-08-01

Ensuring an open airway during cardiopulmonary resuscitation is fundamental. The aim of this study was to determine the success rate of blind intubation during simulated cardiopulmonary resuscitation by untrained personnel. Four devices were compared in a simulated resuscitation scenario: ILMA (Intavent Direct Ltd, Buckinghamshire, United Kingdom), Cobra PLA (Engineered Medical Systems Inc, Indianapolis, IN), Supraglottic Airway Laryngopharyngeal Tube (SALT) (ECOLAB, St. Paul, MN), and Air-Q (Mercury Medical, Clearwater, FL). A group of 210 paramedics intubated a manikin with continuous chest compressions. The mean times to intubation were 40.46 ± 4.64, 33.96 ± 6.23, 17.2 ± 4.63, and 49.23 ± 13.19 seconds (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The success ratios of blind intubation for the devices were 86.7%, 85.7%, 100%, and 71.4% (SALT vs ILMA, Cobra PLA, and Air-Q; P < .05). The study showed that the most efficient device with the shortest blind intubation time was the SALT device. Copyright © 2015 Elsevier Inc. All rights reserved.

Comparison of the Pentax, Truview, GlideScope, and the Miller laryngoscope for child intubation during resuscitation.

PubMed

Szarpak, Łukasz; Czyżewski, Łukasz; Kurowski, Andrzej

2015-03-01

The study was designed to compare the effectiveness of 3 video laryngoscopes with the Miller laryngoscope during pediatric resuscitation. This was a randomized crossover study involving 87 paramedics and 54 nurses. The primary end point of the study was the success rate of blind tracheal intubation, whereas the secondary end point was defined as the time from insertion of a device to the first manual ventilation of the manikin's lungs. The median time to intubation using the Pentax, Truview, GlideScope, and Miller varied with the times being 20.6 (interquartile range [IQR], 18-27) vs 20.1 (IQR, 18-23.3) vs 30.2 (IQR, 29.6-35) vs 41.3 (IQR, 33-45.2) seconds, respectively. The overall success ratios of intubation for the devices were 100% vs 100% vs 100% vs 79.4%. We concluded that, in a pediatric manikin scenario, the video laryngoscopes are safe devices and can be used for pediatric intubation during uninterrupted chest compressions. Further clinical studies are necessary to confirm these initial positive findings. Copyright © 2015 Elsevier Inc. All rights reserved.

Tracheal intubation using Macintosh and 2 video laryngoscopes with and without chest compressions.

PubMed

Kim, Young-Min; Kim, Ji-Hoon; Kang, Hyung-Goo; Chung, Hyun Soo; Yim, Hyeon-Woo; Jeong, Seung-Hee

2011-07-01

The aim of the study was to compare the time taken for intubation (TTI) using the Macintosh and 2 video laryngoscopes (VLs) (GlideScope [GVL]; Saturn Biomedical System, Burnaby, British Columbia, Canada, and Airway Scope [AWS]; Pentax, Tokyo, Japan) with and without chest compressions by experienced intubators in a mannequin model. This was a randomized crossover study. Twenty-two experienced physicians who have limited experience in the VLs participated in the study. The TTI using 3 laryngoscopes with and without compressions were compared. Median TTI difference between 2 conditions was only significant in the AWS (1.64 seconds; P = .01). There were no significant differences in the TTI between the Macintosh and the GVL or the AWS during compressions. In a mannequin model, the Macintosh or the GVL was not affected by chest compressions. The TTI using the AWS was delayed by compressions but not clinically significant. Considering the lack of experience, 2 VLs may be useful adjuncts for intubation by experienced intubators during chest compressions. Copyright © 2011 Elsevier Inc. All rights reserved.

Routine antibiotic cover for newborns intubated for aspirating meconium: is it necessary?

PubMed

Krishnan, L; Nasruddin; Prabhakar, P; Bhaskaranand, N

1995-05-01

A retrospective analysis was performed on 215 babies to evaluate the incidence of septicemia in babies intubated at birth for aspirating meconium from the trachea. Only term, appropriate for gestational age babies were included. Babies with any known perinatal risk factor for infection were excluded from the study and none of the babies had been put on "prophylactic antibiotics." There were 88 babies in the intubated group in a one year period from January 1991 to December 1991. One hundred and twenty seven babies were taken as controls. There was no significant difference in the incidence of early septicemia in the two groups. There were no deaths in either group. It is concluded that well term babies who are intubated for aspirating meconium need not be put on routine antibiotic cover.

A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age.

PubMed

Szmuk, Peter; Ezri, Tiberiu; Evron, Shmuel; Roth, Yehudah; Katz, Jeffrey

2008-02-01

To present a concise history of tracheostomy and tracheal intubation for the approximately forty centuries from their earliest description around 2000 BC until the middle of the twentieth century, at which time a proliferation of advances marked the beginning of the modern era of anesthesiology. Review of the literature. The colorful and checkered past of tracheostomy and tracheal intubation informs contemporary understanding of these procedures. Often, the decision whether to perform a life-saving tracheostomy or tracheal intubation has been as important as the technical ability to perform it. The dawn of modern airway management owes its existence to the historical development of increasingly effective airway devices and to regular contributions of research into the pathophysiology of the upper airway.

A retrospective study of the performance of video laryngoscopy in an obstetric unit.

PubMed

Aziz, Michael F; Kim, Diana; Mako, Jeffrey; Hand, Karen; Brambrink, Ansgar M

2012-10-01

We evaluated the performance of tracheal intubation using video laryngoscopy in an obstetric unit. We analyzed airway management details during a 3-year period, and observed 180 intubations. All cases were managed with direct or video laryngoscopy. Direct laryngoscopy resulted in 157 out of 163 (95% confidence interval [CI], 92%-99%) first attempt successful intubations and failed once. Video laryngoscopy resulted in 18 of 18 (95% CI, 81%-100%) successful intubations on first attempt. The failed direct laryngoscopy was rescued with video laryngoscopy. The patients managed with video laryngoscopy frequently required urgent or emergency surgery and had predictors of difficult direct laryngoscopy in 16 of 18 cases. Video laryngoscopy may be a useful adjunct for obstetric airway management, and its role in this difficult airway scenario should be further studied.

The study protocol for the Head Injury Retrieval Trial (HIRT): a single centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics.

PubMed

Garner, Alan A; Fearnside, Michael; Gebski, Val

2013-09-14

The utility of advanced prehospital interventions for severe blunt traumatic brain injury (BTI) remains controversial. Of all trauma patient subgroups it has been anticipated that this patient group would most benefit from advanced prehospital interventions as hypoxia and hypotension have been demonstrated to be associated with poor outcomes and these factors may be amenable to prehospital intervention. Supporting evidence is largely lacking however. In particular the efficacy of early anaesthesia/muscle relaxant assisted intubation has proved difficult to substantiate. This article describes the design and protocol of the Head Injury Retrieval Trial (HIRT) which is a randomised controlled single centre trial of physician prehospital care (delivering advanced interventions such as rapid sequence intubation and blood transfusion) in addition to paramedic care for severe blunt TBI compared with paramedic care alone. Primary endpoint is Glasgow Outcome Scale score at six months post injury. Issues with trial integrity resulting from drop ins from standard care to the treatment arm as the result of policy changes by the local ambulance system are discussed. This randomised controlled trial will contribute to the evaluation of the efficacy of advance prehospital interventions in severe blunt TBI. ClinicalTrials.gov: NCT00112398.

Anaesthetic management in Gorlin-Goltz syndrome.

PubMed

Gosavi, Kundan S; Mundada, Surbhi D

2012-07-01

Gorlin-Goltz syndrome is a rare autosomal-dominant syndrome related to mutation in "Patched" tumour suppressor gene on chromosome 9. Basocellular carcinomas, odontogenic keratocysts, palmar and/or plantar pits and ectopic calcifications of the falx cerebri are its major features, along with more than 100 minor features. Odontogenic cysts, notorious for recurrence, can make endotracheal intubation difficult, requiring modification of the standard intubation technique. We report such a case managed successfully by awake fibreoptic intubation. Direct laryngoscopy under anaesthesia later confirmed that it was a good decision.

Critical Analyses and Development of Training Mechanisms: Cholinergic Crisis and Pediatric/Neonatal Intubation

DTIC Science & Technology

2013-12-01

194-195. 9. Akierman A, Daya K , McPhail K , Singhal N, Steinke C, Thomson B . A comparison of three neonatal intubation training programs in calgary...1995;10(4):251-258. 226. Ruetzler K , Roessler B , Potura L, et al. Performance and skill retention of intubation by paramedics using seven different...LIMITATION OF ABSTRACT 18. NUMBER OF PAGES 19a. NAME OF RESPONSIBLE PERSON USAMRMC a. REPORT U b . ABSTRACT U c. THIS PAGE U UU

Intubation simulation with a cross-sectional visual guidance.

PubMed

Rhee, Chi-Hyoung; Kang, Chul Won; Lee, Chang Ha

2013-01-01

We present an intubation simulation with deformable objects and a cross-sectional visual guidance using a general haptic device. Our method deforms the tube model when it collides with the human model. Mass-Spring model with the Euler integration is used for the tube deformation. For the trainee's more effective understanding of the intubation process, we provide a cross-sectional view of the oral cavity and the tube. Our system also applies a stereoscopic rendering to improve the depth perception and the reality of the simulation.

Comparison of Airway Management Methods in Entrapped Patients: A Manikin Study.

PubMed

Martin, Andrew B; Lingg, Jim; Lubin, Jeffrey S

2016-01-01

Endotracheal intubation remains one of the most challenging skills in prehospital care. There is a minimal amount of data on the optimal technique to use when managing the airway of an entrapped patient. We hypothesized that use of a blindly placed device would result in both the shortest time to airway management and highest success rate. A difficult airway manikin was placed in a cervical collar and secured upside down in an overturned vehicle. Experienced paramedics and prehospital registered nurses used four different methods to secure the airway: direct laryngoscopy, digital intubation, King LT-D, and CMAC video laryngoscopy. Each participant was given three opportunities to secure the airway using each technique in random order. A study investigator timed each attempt and confirmed successful placement, which was determined upon inflation of the manikin's lungs. Intubation success rates were analyzed using a general estimating equations model to account for repeated measures and a linear mixed effects model for average time. Twenty-two prehospital providers participated in the study. The one-pass success rate for the King LT-D was significantly higher than direct laryngoscopy (OR 0.048, CI 0.006-0.351, p < 0.01) and digital intubation (OR 0.040, CI 0.005-0.297, p < 0.01). However, there was no statistical difference between the one-pass success rate of the King LT-D and CMAC video laryngoscopy (OR 0.302, 95% CI 0.026-3.44, p = 0.33). The one-pass median placement time of the King LT-D (22 seconds, IQR 17-26) was significantly lower (p < 0.001) than direct laryngoscopy (60 seconds, IQR 42-75), digital intubation (38 seconds, IQR 26-74), and the CMAC (51 seconds, IQR 43-76). In this study, while the King LT-D offered the quickest airway placement, success rates were not significantly greater than intubation using the CMAC video laryngoscope. Intubation using direct laryngoscopy and digital intubation were less successful and took more time. Use of a blindly placed device or a video laryngoscope may provide the best avenues for airway management of entrapped patients.

Tracheal intubation in the ice-pick position with video laryngoscopes: a randomised controlled trial in a manikin.

PubMed

Wetsch, Wolfgang A; Hellmich, Martin; Spelten, Oliver; Schier, Robert; Böttiger, Bernd W; Hinkelbein, Jochen

2013-09-01

Tracheal intubation in nonstandardised positions is associated with a higher risk of tube misplacement and may have deleterious consequences for patients. Video laryngoscopes for tracheal intubation facilitate both glottic view and success rates. However, their use in the ice-pick position has not been evaluated. To evaluate the role of video laryngoscopes for tracheal intubation in the ice-pick position. A randomised, controlled manikin trial. A standardised airway manikin was placed in the corner of a room. Tracheal intubation was only possible from the lower right side of the manikin. In randomised order, participants used a standard Macintosh laryngoscope and GlideScope Ranger, Storz C-MAC, Pentax AWS, Airtraq and McGrath Series5 video laryngoscopes. Statistical analysis was performed using the Wilcoxon signed-rank and McNemar's tests; A P value of less than 0.05 was deemed statistically significant. Twenty anaesthesiologists, all emergency medicine board-certified. Time to first ventilation (primary); time to glottic view and confirmation of tube position (secondary). Successful ventilation was achieved most rapidly with the Macintosh laryngoscope (36.1 ± 13.4 s; reference method), followed by the Airtraq (38.4 ± 36.3 s; P = n.s.), Pentax AWS (51.6 ± 43.3 s; P = n.s.) and Storz C-Mac (62.7 ± 49.7 s; P = n.s.). The use of the GlideScope Ranger (79.8 ± 61.9 s, P = 0.01) and McGrath series5 (79.8 ± 58.5 s, P = 0.023) resulted in significantly longer times. When comparing overall intubation success, the rate of successful tracheal intubation was higher with the Airtraq than with the McGrath Series5 (P = 0.031; all others n.s.). The use of video laryngoscopes did not result in higher success rates or faster tracheal intubation in the ice-pick position when compared with conventional laryngoscopy in this manikin study. www.clinicaltrials.gov, NCT01210105.

Pre-Hospital Intubation Factors and Pneumonia in Trauma Patients

PubMed Central

Warner, Keir; Bulger, Eileen M.; Sharar, Sam R.; Maier, Ronald V.; Cuschieri, Joseph

2011-01-01

Abstract Background We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. Methods The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007–July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥104 colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Results Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Conclusion Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration. PMID:21933010

Pre-hospital intubation factors and pneumonia in trauma patients.

PubMed

Evans, Heather L; Warner, Keir; Bulger, Eileen M; Sharar, Sam R; Maier, Ronald V; Cuschieri, Joseph

2011-10-01

We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.

Pre-hospital aspiration is associated with increased pulmonary complications.

PubMed

Fawcett, Vanessa J; Warner, Keir J; Cuschieri, Joseph; Copass, Michael; Grabinsky, Andreas; Kwok, Heemun; Rea, Thomas; Evans, Heather L

2015-04-01

Rates of ventilator-associated pneumonia (VAP) are highest among patients intubated on an emergency basis following trauma. We reported previously a retrospective analysis demonstrating an association between subjective aspiration and VAP after pre-hospital intubation. We hypothesize that by directing paramedics to note features of aspiration at intubation, we will confirm prospectively the association between pre-hospital aspiration and subsequent pneumonia in trauma patients. Paramedics collected data regarding aspiration at the time of intubation. All intubated patients admitted to a level 1 trauma center intensive care unit (ICU) were included. Data comprised a clinical impression of pre-hospital aspiration, as well as the presence and timing of blood and emesis in the airway. Injury severity, co-morbidities, and outcomes were collected from the trauma registry. Healthcare-associated pneumonia (HAP) was identified by medical record review of both bronchoalveolar lavage culture results and discharge diagnosis. Descriptive statistics and univariate analysis of outcomes by aspiration status, as well as covariable adjustment using propensity scores, were performed. Of the 228 patients, 89 (39%) were determined by paramedics to have aspirated. The majority of those who aspirated (84 [94%]) did so prior to intubation. Patients who aspirated had higher Injury Severity Scores than those who did not aspirate (25.0 ± 1.7 vs. 21.9 ± 1.5 points; p=0.04) and lower preintubation Glasgow Coma Scale scores (8.2 ± 0.50 vs. 9.6 ± 0.40; p=0.02). Of the 89 patients who aspirated around the time of intubation, 14 (16%) developed HAP vs. five (3.6%) of those who did not aspirate (p<0.01). We observed non-significant increases in mortality rate, ICU length of stay (LOS) and duration of mechanical ventilation after aspiration (deaths: 21 [23.6%] vs. 23 [16.6%]; p=0.19; ICU LOS: 5.3 ± 0.9 vs. 4.1 ± 0.5 days; p=0.13; duration of mechanical ventilation: 5.3 ± 1.2 vs. 3.2 ± 0.5 days; p=0.10). Aspiration prior to intubation was reported commonly by paramedics and was associated with a higher risk of HAP.

[The effect of esmolol on corrected-QT interval, corrected-QT interval dispersion changes seen during anesthesia induction in hypertensive patients taking an angiotensin-converting enzyme inhibitor].

PubMed

Ceker, Zahit; Takmaz, Suna Akın; Baltaci, Bülent; Başar, Hülya

2015-01-01

The importance of minimizing the exaggerated sympatho-adrenergic responses and QT interval and QT interval dispersion changes that may develop due to laryngoscopy and tracheal intubation during anesthesia induction in the hypertensive patients is clear. Esmolol decreases the hemodynamic response to laryngoscopy and intubation. However, the effect of esmolol in decreasing the prolonged QT interval and QT interval dispersion as induced by laryngoscopy and intubation is controversial. We investigated the effect of esmolol on the hemodynamic, and corrected-QT interval and corrected-QT interval dispersion changes seen during anesthesia induction in hypertensive patients using angiotensin converting enzyme inhibitors. 60 ASA I-II patients, with essential hypertension using angiotensin converting enzyme inhibitors were included in the study. The esmolol group received esmolol at a bolus dose of 500mcg/kg followed by a 100mcg/kg/min infusion which continued until the 4th min after intubation. The control group received 0.9% saline similar to the esmolol group. The mean blood pressure, heart rate values and the electrocardiogram records were obtained as baseline values before the anesthesia, 5min after esmolol and saline administration, 3min after the induction and 30s, 2min and 4min after intubation. The corrected-QT interval was shorter in the esmolol group (p=0.012), the corrected-QT interval dispersion interval was longer in the control group (p=0.034) and the mean heart rate was higher in the control group (p=0.022) 30s after intubation. The risk of arrhythmia frequency was higher in the control group in the 4-min period following intubation (p=0.038). Endotracheal intubation was found to prolong corrected-QT interval and corrected-QT interval dispersion, and increase the heart rate during anesthesia induction with propofol in hypertensive patients using angiotensin converting enzyme inhibitors. These effects were prevented with esmolol (500mcg/kg bolus, followed by 100mcg/kg/min infusion). During induction, the blood pressure tends to decrease with esmolol where care is needed. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab.

PubMed

Vortia, Eugene; Uko, Victor E; Yen-Lieberman, Belinda; Frawley, Jill; Worley, Sarah E; Danziger-Isakov, Lara; Kaplan, Barbara; Mahajan, Lori

2018-03-19

Tumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen. A single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected. Ninety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004). Pediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.

Influence of the method of fluoride administration on toxicity and fluoride concentrations in Japanese quail

USGS Publications Warehouse

Fleming, W.J.; Schuler, C.A.

1988-01-01

Young Japanese quail (Coturnix japonica) were administered NaF for 16 d either in their diet or by esophageal intubation. Based on the total fluoride ion (Emg F-) intake over the l6-d experimental period, fluoride administered by intubation was at least six times more toxic than that fed in the diet. Dietary concentrations of 1,000 ppm F- (Emg F- for 16 d = approx. 144) produced no mortality, whereas intubated doses produced 73% or greater mortality in all groups administered 54 mg F- /kg/d or more (Emg F- for 16 d _ approx. 23 mg). GraphIc companson of the regression of log F- ppm in femurs/mg F- intake showed that fluoride levels in the femurs of quail administered fluoride by intubation were higher than in those administered fluoride in the diet.

Retrograde intubation: an alternative way for the management of difficult airway.

PubMed

Lama, P; Shrestha, B R

2008-01-01

Inserting a retrograde wire into the pharynx through a cricothyroid puncture can facilitate tracheal intubation in difficult situations where either a flexible fiber-optic bronchoscope or an expert user of such a device is not available. Even in cases when fibropric can not be negotiated for the purpose, this method has been claimed to be useful to manage the airway. Some mouth opening is essential for the oral or nasal retrieval of the wire from the pharynx. Here, a case of post mandibular reconstructed wound infection required surgical debridement and plate removal from reconstructed lower mandible under general anesthesia. We retrieved the guide wire passed through a cricothyroid puncture and subsequently accomplished wire-guided oro-tracheal intubation. In the absence of a flexible fiber-optic bronchoscope, this technique is a very useful aid to intubate patients with limited mouth opening.

Endotracheal intubation - A life saving procedure, still potential hazardous to upper airway: A case report.

PubMed

Afreen, Mahrukh; Ansari, Murtaza Ahsan

2015-12-01

Endotracheal intubation plays a key role in the management of upper airway obstruction in emergency situations. It is non-invasive and easily learned technique by medical professionals as compared to other more skilled, surgical procedures, e.g., tracheostomy and cricothyrotomies etc. But prolonged intubation may result in numerous complications, most notorious being tracheoesophageal fistula and narrowing of subglottic area. We report a profile of a patient who had been diagnosed as case of Guillian-Barre Syndrome, had difficulty in breathing due to paralysis of respiratory muscles. The patient was admitted in Medical Intensive Care Unit (MICU) for 40 days and was kept on artificial breathing through endotracheal intubation, which remained in place for 19 days. Later tracheostomy was performed. Patient ultimately developed severe subglottic stenosis and became dependent on tracheostomy tube.

Front teeth-to-carina distance in children undergoing cardiac catheterization.

PubMed

Hunyady, Agnes I; Pieters, Benjamin; Johnston, Troy A; Jonmarker, Christer

2008-06-01

Knowledge of normal front teeth-to-carina distance (FT-C) might prevent accidental bronchial intubation. The aim of the current study was to measure FT-C and to examine whether the Morgan formula for oral intubation depth, i.e., endotracheal tube (ETT) position at front teeth (cm) = 0.10 x height (cm) + 5, gives appropriate guidance when intubating children of different ages. FT-C was measured in 170 infants and children, aged 1 day to 19 yr, undergoing cardiac catheterization. FT-C was obtained as the sum of the ETT length at the upper front teeth/dental ridge and the distance from the ETT tip to the carina. The latter measure was taken from an anterior-posterior chest x-ray. There was close linear correlation between FT-C and height: FT-C (cm) = 0.12 x height (cm) + 5.2, R = 0.98. The linear correlation coefficients (R) for FT-C versus weight and age were 0.78 and 0.91, respectively. If the Morgan formula had been used for intubation, the ETT tip would have been at 90 +/- 4% of FT-C. No patient would have been bronchially intubated, but the ETT tip would have been less than 0.5 cm from the carina in 13 infants. FT-C can be well predicted from the height/length of the child. The Morgan formula provides good guidance for intubation in children but can result in a distal ETT tip position in small infants. Careful auscultation is necessary to ensure correct tube position.

Endotracheal Intubation With and Without Night Vision Goggles in a Helicopter and Emergency Room Setting: A Manikin Study.

PubMed

Gellerfors, Mikael; Svensén, Christer; Linde, Joacim; Lossius, Hans Morten; Gryth, Dan

2015-09-01

Securing the airway by endotracheal intubation (ETI) is a key issue in prehospital critical care. Night vision goggles (NVG) are used by personnel operating in low-light environments. We examined the feasibility of an anesthesiologist performed ETI using NVG in a helicopter setting. Twelve anesthesiologists performed ETI on a manikin in an emergency room (ER) setting and two helicopter settings, with randomization to either rotary wing daylight (RW-D) or rotary wing in total darkness using binocular NVG (RW-NVG). Primary endpoint was intubation time. Secondary endpoints included success rate, Cormack-Lehane (CL) score, and subjective difficulty according to the Visual Analoge Scale (VAS). The median intubation time was shorter for the RW-D compared to the RW-NVG setting (16.5 seconds vs. 30.0 seconds; p = 0,03). We found no difference in median intubation time for the ER and RW-D settings (16.8 seconds vs. 16.5 seconds; p = 0.91). For all scenarios, success rate was 100%. CL and VAS varied between the ER setting (CL 1.8, VAS 2.8), RW-D setting (CL 2.0, VAS 3.0), and RW-NVG setting (CL 3.0, VAS 6.5). This study suggests that anesthesiologists successfully and quickly can perform ETI in a helicopter setting both in daylight and in darkness using binocular NVG, but with shorter intubation times in daylight. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Optimization of Ultrasound Transducer Positioning for Endotracheal Tube Placement Confirmation in Cadaveric Model.

PubMed

Lonchena, Tiffany; So, Sokpoleak; Ibinson, James; Roolf, Peter; Orebaugh, Steven L

2017-02-01

Sonography has been suggested as a possible means of endotracheal tube (ETT) placement confirmation. However, optimum ultrasound transducer placement has not been established. Using a cadaveric model, ETT placement by the sonographic appearance at the thyroid cartilage, cricoid cartilage, and suprasternal notch in the upper airway was assessed to determine which ultrasound transducer placement offered the most optimal images for ETT confirmation in the airway. One provider intubated 5 cadavers, with the ultrasound transducer at each of the 3 levels, for a total of 30 intubations per specimen, while 2 providers assigned a visual score of 1 (subtle), 2 (clear), or 3 (pronounced) to each sonogram of the ETT in the airway. At the level of the thyroid cartilage, tracheal intubation was detected at a rate of 40%, with a median visualization scale of 1 (subtle movement). At the level of the cricoid cartilage, the visualization scale improved to a median of 2 (clear movement), with a 70% intubation detection rate. At the level of the suprasternal notch, 100% of the tracheal intubations were visualized on sonography, with a median score of 3 (pronounced movement). In comparing sonographic detection of ETT placement at 3 levels of the upper airway in a cadaveric model, our results clearly indicate that visualization was superior at the level of the suprasternal notch, with 100% of intubations detected with the best visualization scores. © 2017 by the American Institute of Ultrasound in Medicine.

Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation.

PubMed

Qureshi, Mosarrat J; Kumar, Manoj

2018-03-15

Providing effective positive pressure ventilation is considered to be the single most important component of successful neonatal resuscitation. Ventilation is frequently initiated manually with bag and face mask (BMV) followed by endotracheal intubation if respiratory depression continues. These techniques may be difficult to perform successfully resulting in prolonged resuscitation or neonatal asphyxia. The laryngeal mask airway (LMA) may achieve initial ventilation and successful resuscitation faster than a bag-mask device or endotracheal intubation. Among newborns requiring positive pressure ventilation for cardio-pulmonary resuscitation, is LMA more effective than BMV or endotracheal intubation for successful resuscitation? When BMV is either insufficient or ineffective, is effective positive pressure ventilation and successful resuscitation achieved faster with the LMA compared to endotracheal intubation? We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 15 February 2017), Embase (1980 to 15 February 2017), and CINAHL (1982 to 15 February 2017). We also searched clinical trials registers, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We included randomised and quasi-randomised controlled trials that compared LMA for neonatal resuscitation with either BMV or endotracheal intubation and reported on any outcomes related to neonatal resuscitation specified in this review. Two review authors independently evaluated studies for risk of bias assessments, and extracted data using Cochrane Neonatal criteria. Categorical treatment effects were described as relative risks and continuous treatment effects were described as the mean difference, with 95% confidence intervals (95% CI) of estimates. We included seven trials that involved a total of 794 infants. Five studies compared LMA with BMV and three studies compared LMA with endotracheal intubation. We added six new studies for this update (754 infants).LMA was associated with less need for endotracheal intubation than BMV (typical risk ratio (RR) 0.24, 95% CI 0.12 to 0.47 and typical risk difference (RD) -0.14, 95% CI -0.14 to -0.06; 5 studies, 661 infants; moderate-quality evidence) and shorter ventilation time (mean difference (MD) -18.90 seconds, 95% CI -24.35 to -13.44; 4 studies, 610 infants). Babies resuscitated with LMA were less likely to require admission to neonatal intensive care unit (NICU) (typical RR 0.60, 95% CI 0.40 to 0.90 and typical RD -0.18, 95% CI -0.31 to -0.04; 2 studies,191 infants; moderate-quality evidence). There was no difference in deaths or hypoxic ischaemic encephalopathy (HIE) events.Compared to endotracheal intubation, there were no clinically significant differences in insertion time or failure to correctly insert the device (typical RR 0.95, 95% CI 0.17 to 5.42; 3 studies, 158 infants; very low-quality evidence). There was no difference in deaths or HIE events. LMA can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current neonatal resuscitation guidelines. Compared to BMV, LMA is more effective in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation (low- to moderate-quality evidence). However, in trials comparing LMA with BMV, over 80% of infants in both trial arms responded to the allocated intervention. In studies that allowed LMA rescue of infants failing with BMV, it was possible to avoid intubation in the majority. It is important that the clinical community resorts to the use of LMA more proactively to provide effective ventilation when newborn is not responding to BMV before attempting intubation or initiating chest compressions.LMA was found to offer comparable efficacy to endotracheal intubation (very low- to low-quality evidence). It therefore offers an alternate airway device when attempts at inserting endotracheal intubation are unsuccessful during resuscitation.Most studies enrolled infants with birth weight over 1500 g or 34 or more weeks' gestation. As such, there is lack of evidence to support LMA use in more premature infants.

Higher Education in Rural Communities: System Reform in Indigenous Schools.

ERIC Educational Resources Information Center

Warner, Linda Sue; Deaton, Brady J.; Briscoe, G. S.

This paper addresses the role of Rural Systemic Initiatives (RSIs) in linking tribally controlled colleges to systemic reform efforts in rural communities. RSI is a program implemented in 1994 by the National Science Foundation to improve science and mathematics education in rural areas. RSIs were established in regions with low population density…

40 CFR 63.705 - Performance test methods and procedures to determine initial compliance.

Code of Federal Regulations, 2014 CFR

2014-07-01

... per gram-mole. Pi = Barometric pressure at the time of sample analysis, millimeters mercury absolute. 760 = Reference or standard pressure, millimeters mercury absolute. 293 = Reference or standard...: ER15DE94.005 (i) The value of RSi is zero unless the owner or operator submits the following information to...

40 CFR 63.705 - Performance test methods and procedures to determine initial compliance.

Code of Federal Regulations, 2012 CFR

2012-07-01

... per gram-mole. Pi = Barometric pressure at the time of sample analysis, millimeters mercury absolute. 760 = Reference or standard pressure, millimeters mercury absolute. 293 = Reference or standard...: ER15DE94.005 (i) The value of RSi is zero unless the owner or operator submits the following information to...

40 CFR 63.705 - Performance test methods and procedures to determine initial compliance.

Code of Federal Regulations, 2010 CFR

2010-07-01

... per gram-mole. Pi = Barometric pressure at the time of sample analysis, millimeters mercury absolute. 760 = Reference or standard pressure, millimeters mercury absolute. 293 = Reference or standard...: ER15DE94.005 (i) The value of RSi is zero unless the owner or operator submits the following information to...

40 CFR 63.705 - Performance test methods and procedures to determine initial compliance.

Code of Federal Regulations, 2013 CFR

2013-07-01

... per gram-mole. Pi = Barometric pressure at the time of sample analysis, millimeters mercury absolute. 760 = Reference or standard pressure, millimeters mercury absolute. 293 = Reference or standard...: ER15DE94.005 (i) The value of RSi is zero unless the owner or operator submits the following information to...

40 CFR 63.705 - Performance test methods and procedures to determine initial compliance.

Code of Federal Regulations, 2011 CFR

2011-07-01

... per gram-mole. Pi = Barometric pressure at the time of sample analysis, millimeters mercury absolute. 760 = Reference or standard pressure, millimeters mercury absolute. 293 = Reference or standard...: ER15DE94.005 (i) The value of RSi is zero unless the owner or operator submits the following information to...

Protecting and Leaving Functions of Trimethylsilyl Groups in Trimethylsilylated Silicates for the Synthesis of Alkoxysiloxane Oligomers.

PubMed

Yoshikawa, Masashi; Tamura, Yasuhiro; Wakabayashi, Ryutaro; Tamai, Misa; Shimojima, Atsushi; Kuroda, Kazuyuki

2017-11-06

The concept of protecting groups and leaving groups in organic synthesis was applied to the synthesis of siloxane-based molecules. Alkoxy-functionalized siloxane oligomers composed of SiO 4 , RSiO 3 , or R 2 SiO 2 units were chosen as targets (R: functional groups, such as Me and Ph). Herein we describe a novel synthesis of alkoxysiloxane oligomers based on the substitution reaction of trimethylsilyl (TMS) groups with alkoxysilyl groups. Oligosiloxanes possessing TMS groups were reacted with alkoxychlorosilane in the presence of BiCl 3 as a catalyst. TMS groups were substituted with alkoxysilyl groups, leading to the synthesis of alkoxysiloxane oligomers. Siloxane oligomers composed of RSiO 3 and R 2 SiO 2 units were synthesized more efficiently than those composed of SiO 4 units, suggesting that the steric hindrance around the TMS groups of the oligosiloxanes makes a difference in the degree of substitution. This reaction uses TMS groups as both protecting and leaving groups for SiOH/SiO - groups. © 2017 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

Research on image evidence in land supervision and GIS management

NASA Astrophysics Data System (ADS)

Li, Qiu; Wu, Lixin

2006-10-01

Land resource development and utilization brings many problems. The numbers, the scale and volume of illegal land use cases are on the increasing. Since the territory is vast, and the land violations are concealment, it is difficulty for an effective land supervision and management. In this paper, the concepts of evidence, and preservation of evidence were described first. The concepts of image evidence (IE), natural evidence (NE), natural preservation of evidence (NPE), general preservation of evidence (GPE) were proposed based on the characteristics of remote sensing image (RSI) which has a characteristic of objectiveness, truthfulness, high spatial resolution, more information included. Using MapObjects and Visual Basic 6.0, under the Access management to implement the conjunction of spatial vector database and attribute data table; taking RSI as the data sources and background layer; combining the powerful management of geographic information system (GIS) for spatial data, and visual analysis, a land supervision and GIS management system was design and implemented based on NPE. The practical use in Beijing shows that the system is running well, and solved some problems in land supervision and management.

An experimental investigation of heat transfer to reusable surface insulation tile array gaps in a turbulent boundary layer with pressure gradient. M.S. Thesis

NASA Technical Reports Server (NTRS)

Throckmorton, D. A.

1975-01-01

An experimental investigation was performed to determine the effect of pressure gradient on the heat transfer to space shuttle reusable surface insulation (RSI) tile array gaps under thick, turbulent boundary layer conditions. Heat transfer and pressure measurements were obtained on a curved array of full-scale simulated RSI tiles in a tunnel wall boundary layer at a nominal freestream Mach number of 10.3 and freestream unit Reynolds numbers of 1.6, 3.3, and and 6.1 million per meter. Transverse pressure gradients were induced over the model surface by rotating the curved array with respect to the flow. Definition of the tunnel wall boundary layer flow was obtained by measurement of boundary layer pitot pressure profiles, and flat plate wall pressure and heat transfer. Flat plate wall heat transfer data were correlated and a method was derived for prediction of smooth, curved array heat transfer in the highly three-dimensional tunnel wall boundary layer flow and simulation of full-scale space shuttle vehicle pressure gradient levels was assessed.

Potential biodegradation of crude petroleum oil by newly isolated halotolerant microbial strains from polluted Red Sea area.

PubMed

Shetaia, Yousseria M H; El Khalik, Wafaa A A; Mohamed, Tarek M; Farahat, Laila A; ElMekawy, Ahmed

2016-10-15

Two microbial isolates from oil polluted Red Sea water in Egypt, designated as RS-Y1 and RS-F3, were found capable of degrading Belayim mix (BX) crude oil. Strains RS-Y1 and RS-F3 were assigned to the genera Lipomyces tetrasporus and Paecilomyces variotii based on their morphological and physiological characteristics. Both isolates were compared for the biodegradation of crude petroleum-oil hydrocarbons in basal salt medium supplemented with 5% (w/v) of BX-crude oil. Gas chromatography profile showed that the biodegradation of total petroleum hydrocarbons (TPHs) inoculated with L. tetrasporus (68.3%) and P. variotii (58.15%) along with their consortium (66%) significantly reduced TPHs levels as compared to the control after 30days. L. tetrasporus (44.5%) was more effective than P. variotii strain (32.89%) in reducing the unresolved complex mixtures (UCM) content from the medium. Both isolates exhibited a strong growth over a wide range of salinity (5-45g/L NaCl). Copyright © 2016 Elsevier Ltd. All rights reserved.

Proactive Semantic Interference is Associated with Total and Regional Abnormal Amyloid Load in Non-Demented Community-Dwelling Elders: A Preliminary Study.

PubMed

Loewenstein, David A; Greig, Maria T; Curiel, Rosie; Rodriguez, Rosemarie; Wicklund, Meredith; Barker, Warren W; Hidalgo, Jacqueline; Rosado, Marian; Duara, Ranjan

2015-12-01

To evaluate the relationship between susceptibility to proactive semantic interference (PSI) and retroactive semantic interference (RSI) and brain amyloid load in non-demented elders. 27 participants (11 cognitively normal [CN] with subjective memory complaints, 8 CN without memory complaints, and 8 with mild cognitive impairment [MCI]) underwent complete neurological and neuropsychological evaluations. Participants also received the Semantic Interference Test (SIT) and AV-45 amyloid PET imaging. High levels of association were present between total amyloid load, regional amyloid levels, and the PSI measure (in the entire sample and a subsample excluding MCI subjects). RSI and other memory measures showed much weaker associations or no associations with total and regional amyloid load. No associations between amyloid levels and non-memory performance were observed. In non-demented individuals, vulnerability to PSI was highly associated with total and regional beta-amyloid load and may be an early cognitive marker of brain pathology. Copyright © 2015 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.

The effects of associative and semantic priming in the lexical decision task.

PubMed

Perea, Manuel; Rosa, Eva

2002-08-01

Four lexical decision experiments were conducted to examine under which conditions automatic semantic priming effects can be obtained. Experiments 1 and 2 analyzed associative/semantic effects at several very short stimulus-onset asynchronies (SOAs), whereas Experiments 3 and 4 used a single-presentation paradigm at two response-stimulus intervals (RSIs). Experiment 1 tested associatively related pairs from three semantic categories (synonyms, antonyms, and category coordinates). The results showed reliable associative priming effects at all SOAs. In addition, the correlation between associative strength and magnitude of priming was significant only at the shortest SOA (66 ms). When prime-target pairs were semantically but not associatively related (Experiment 2), reliable priming effects were obtained at SOAs of 83 ms and longer. Using the single-presentation paradigm with a short RSI (200 ms, Experiment 3), the priming effect was equal in size for associative + semantic and for semantic-only pairs (a 21-ms effect). When the RSI was set much longer (1,750 ms, Experiment 4), only the associative + semantic pairs showed a reliable priming effect (23 ms). The results are interpreted in the context of models of semantic memory.

Ivacaftor and symptoms of extra-oesophageal reflux in patients with cystic fibrosis and G551D mutation.

PubMed

Zeybel, Gemma L; Pearson, Jeffrey P; Krishnan, Amaran; Bourke, Stephen J; Doe, Simon; Anderson, Alan; Faruqi, Shoaib; Morice, Alyn H; Jones, Rhys; McDonnell, Melissa; Zeybel, Mujdat; Dettmar, Peter W; Brodlie, Malcolm; Ward, Chris

2017-01-01

Extra-oesophageal reflux (EOR) may lead to microaspiration in patients with cystic fibrosis (CF), a probable cause of deteriorating lung function. Successful clinical trials of ivacaftor highlight opportunities to understand EOR in a real world study. Data from 12 patients with CF and the G551D mutation prescribed ivacaftor (150mg bd) was collected at baseline, 6, 26 and 52weeks. The changes in symptoms of EOR were assessed by questionnaire (reflux symptom index (RSI) and Hull airway reflux questionnaire (HARQ)). Six patients presented EOR at baseline (RSI >13; median 13; range 2-29) and 5 presented airway reflux (HARQ >13; median 12; range 3 to 33). Treatment with ivacaftor was associated with a significant reduction of EOR symptoms (P<0∙04 versus baseline) denoted by the reflux symptom index and Hull airway reflux questionnaire. Ivacaftor treatment was beneficial for patients with symptoms of EOR, thought to be a precursor to microaspiration. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

Bilateral vocal cord paralysis secondary to head and neck surgery.

PubMed

Tekin, Muhammet; Acar, Gul Ozbilen; Kaytaz, Asim; Savrun, Feray Karaali; Çelik, Melek; Cam, Osman Halit

2012-01-01

Even endotracheal intubation could be considered safe in operations under general anesthesia; rarely, it could cause recurrent laryngeal nerve paralysis as a complication. As mentioned in the literature, as a possible reason for this, anterior branches of the recurrent laryngeal nerve in the larynx could suffer from compression between the posteromedial part of the thyroid cartilage and the cuff of the tube. In the literature, unilateral vocal cord paralysis due to endotracheal intubation occurs more frequently in comparison to bilateral vocal cord paralysis. These types of palsies usually totally improve in approximately 6 months. A patient who experienced bilateral vocal cord paralysis in the early postoperative period after undergoing an endotracheal intubation process for general anesthesia and primary partial lip resection and supraomohyoid neck dissection due to lower lip carcinoma is presented in our article. Although vocal cord paralysis occurring after head and neck surgery is first thought as a complication of the surgery, endotracheal intubation should be considered as a possible cause of this paralysis. In relation with this patient, causes, clinical symptoms, and treatment procedures of vocal cord paralysis due to endotracheal intubation are discussed under guidance of the literature.

Thirty years of submental intubation: a review.

PubMed

Lim, D; Ma, B C; Parumo, R; Shanmuhasuntharam, P

2018-05-03

Submental intubation has been used as an alternative to conventional intubation in the field of oral and maxillofacial surgery since its introduction by Francisco Hernández Altemir in 1986. A review of submental intubation was performed using data from all case reports, case-series, and prospective and retrospective studies published between 1986 and 2016. The indications, variations in incision length, incision sites, types of endotracheal tube used, methods of exteriorization, and complications were recorded and analyzed. A total of 70 articles reporting 1021 patients were included. The main indication was maxillofacial trauma (86.9%, n=887), followed by orthognathic surgery (5.8%, n=59), skull base surgery (2.8%, n=29), and rhinoplasty and rhytidectomy (1.5%, n=15). The complication rate was relatively low: 91.0% of patients (n=929) were complication-free. The most common complication was infection, occurring in 3.5% (n=36) of the total number of patients, followed by scarring (1.2%, n=12) and formation of an orocutaneous or salivary fistula (1.1%, n=11). In summary, submental intubation is a good alternative airway with minimal complications. Copyright © 2018 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

The dynamics of the pulmonary microbiome during mechanical ventilation in the intensive care unit and the association with occurrence of pneumonia.

PubMed

Zakharkina, Tetyana; Martin-Loeches, Ignacio; Matamoros, Sébastien; Povoa, Pedro; Torres, Antoni; Kastelijn, Janine B; Hofstra, Jorrit J; de Wever, B; de Jong, Menno; Schultz, Marcus J; Sterk, Peter J; Artigas, Antonio; Bos, Lieuwe D J

2017-09-01

Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation. We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP. Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis. 111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): -0.03 (95% CI -0.05 to -0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI -0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity. Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Anaesthetic management in Gorlin-Goltz syndrome

PubMed Central

Gosavi, Kundan S; Mundada, Surbhi D

2012-01-01

Gorlin-Goltz syndrome is a rare autosomal-dominant syndrome related to mutation in “Patched” tumour suppressor gene on chromosome 9. Basocellular carcinomas, odontogenic keratocysts, palmar and/or plantar pits and ectopic calcifications of the falx cerebri are its major features, along with more than 100 minor features. Odontogenic cysts, notorious for recurrence, can make endotracheal intubation difficult, requiring modification of the standard intubation technique. We report such a case managed successfully by awake fibreoptic intubation. Direct laryngoscopy under anaesthesia later confirmed that it was a good decision. PMID:23087465

Securing a Difficult Airway: Tracheal Intubation Achieved after Deliberate Placement of an Endotracheal Tube in Esophagus: A New Approach

PubMed Central

Chopra, Vanilla; Mehta, Nandita; Dar, Mohd Reidwan

2017-01-01

Enlarged thyroid gland with retrosternal extension has an increased incidence of difficult intubation, and it poses real airway challenge for the anesthesiologists. Here, we present a case of successful management of a difficult airway in a female patient of enlarged thyroid gland, planned for open reduction and internal fixation of the upper end of humerus. Endotracheal intubation was achieved after deliberate insertion of an endotracheal tube in esophagus. The patient was extubated over a ventilating bougie, with uneventful postoperative course. PMID:29284880

Analysis of the Association Between Motor and Anthropometric Variables with Change of Direction Speed and Reactive Agility Performance

PubMed Central

Sattler, Tine; Sekulić, Damir; Spasić, Miodrag; Perić, Mia; Krolo, Ante; Uljević, Ognjen; Kondrič, Miran

2015-01-01

There is an evident lack of studies examining the factors associated with reactive agility performances. The aim of this study was to evaluate the association between anthropometrics, body composition, jumping capacity, reactive strength, and balance with a stop-and-go change of direction speed (CODS) and reactive agility. The total sample comprised 39 male (body height: 182.95 ± 5.19 cm; body mass: 80.66 ± 7.69 kg) and 34 female (body height: 171.45 ± 6.81 cm; body mass: 61.95 ± 6.70 kg) college-level athletes (21.9 ± 1.9 years of age). The variables included body height, body mass, the percentage of body fat (BF%), balance as measured by an overall-stability index, the countermovement jump (CMJ), a reactive-strength index (RSI), stop-and-go reactive agility, and stop-and-go CODS. To define the associations between motor and anthropometric variables with CODS and reactive agility, the participants were clustered into three achievement groups based on their CODS and reactive agility performances. The ANOVA showed a significant difference between the CODS-based achievement groups for the CMJ (F test = 3.45 and 3.60 for males and females, respectively; p < 0.05), the RSI (F test = 6.94 and 5.29 for males and females, respectively; p < 0.05), and balance (F test = 3.47; p < 0.05 for males). In females, the reactive agility achievement groups differed significantly in the RSI (F test = 6.46; p < 0.05), the CMJ (F test = 4.35; p < 0.05) and BF% (F test = 4.07; p < 0.05), which is further confirmed by discriminant canonical analysis (Can R = 0.74; p < 0.05). The results confirm the need for independent evaluation and training for both CODS and reactive agility performance in sports. PMID:26557198

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial.

PubMed

Sitzwohl, Christian; Langheinrich, Angelika; Schober, Andreas; Krafft, Peter; Sessler, Daniel I; Herkner, Harald; Gonano, Christopher; Weinstabl, Christian; Kettner, Stephan C

2010-11-09

To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity. Prospective randomised blinded study. Department of anaesthesia in tertiary academic hospital. 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery. Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three). Correct and incorrect judgments of endotracheal tube position. 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men. Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. NCT01232166.

Manikin Laryngoscopy Motion as a Predictor of Patient Intubation Outcomes: A Prospective Observational Study

PubMed Central

Kedarisetty, Suraj; Johnson, Jennifer Moitoza; Glaser, Dale; Delson, Nathan

2018-01-01

Background: The goal of this study was to determine whether motion parameters during laryngoscopy in a manikin differed with experienced operators versus novice trainees and whether motion measurements would predict trainee outcomes when intubating patients. Methods: Motion, force, and duration of laryngoscopy on a manikin were compared in two separate experiments between beginning anesthesiology residents (CA1) and anesthesiologists with more than 24 months of anesthesiology training (CA3 or attendings). In one experiment, CA1 residents were also evaluated for the percentage of their laryngoscope path that followed the route used by attending anesthesiologists. The residents were then observed for patient intubation outcomes for 4 weeks after manikin testing. The relationship between manikin test metrics and patient intubation outcomes was analyzed by multilevel modeling. Results: CA1 residents positioned the laryngoscope blade farther right and with less lift than did experienced anesthesiologists. Endpoint position was 0.6 ± 0.3 cm left of midline for residents (n = 10) versus 2.7 ± 0.3 cm for advanced anesthesiologists (n = 8; P = .0003), and 15.6 ± 0.8 versus 17.7 ± 0.2 cm above the table surface, respectively (P = .033). On average, only 74 ± 6% of the CA1 laryngoscopy trajectory coincided with the Attending Route (P < .001 versus 100%). For each percentage point increase in Attending Route match, residents' odds of intubating a patient's trachea improved by a factor of 1.033 (95% confidence interval [CI] 1.007–1.059, P = .040), and their rate of failed laryngoscopy attempts decreased by a factor of 0.982 (0.969–0.996, P = .045). Discussion: Laryngoscopy motion in manikins may predict which trainees can complete a patient intubation successfully in a few attempts. The assessment could help determine readiness for intubating patients with indirect supervision.

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis.

PubMed

Caruana, Emmanuel; Chevret, Sylvie; Pirracchio, Romain

2017-03-01

The benefit of cricoid pressure during tracheal intubation is still debated and, due to its potential negative impact on laryngeal views, its routine use is questioned. The goal of this study was to estimate its impact on laryngeal view. All patients intubated in the prehospital setting were included. Three different propensity score (PS) models were used and compared in terms of the balance achieved between those patients who received cricoid pressure and those who did not. The PS model that optimised the balance was retained in order to estimate the relationship between cricoid pressure and the following outcomes: difficult laryngoscopy, intubation-related complications and difficult intubation. Among the 1195 patients included, 499 (41.7%) received cricoid pressure. The optimal PS included seven variables (cardiac arrest, altered neurological status, shock, respiratory distress, gender, obesity, patient's position). After PS matching, no significant risk difference (RD) in the rate of difficult laryngoscopy was found between the patients who received cricoid pressure and those who did not (RD=0.001, 95% CI -0.07 to 0.08, p=0.50). No significant difference was found in terms of difficult intubation (RD=0.06, 95% CI -0.13 to 0.25, p=0.28) and in terms of prevalence of complications, except for airway trauma that were more frequent in cricoid pressure group (RD=0.03, 95% CI 0.002 to 0.05, p=0.01). No significant relationship was found between the use of cricoid pressure for prehospital intubation and difficult laryngoscopy. Cricoid pressure was found to be associated with more airway trauma. This finding could question its routine use. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Incidence of Connected Consciousness after Tracheal Intubation: A Prospective, International, Multicenter Cohort Study of the Isolated Forearm Technique.

PubMed

Sanders, Robert D; Gaskell, Amy; Raz, Aeyal; Winders, Joel; Stevanovic, Ana; Rossaint, Rolf; Boncyk, Christina; Defresne, Aline; Tran, Gabriel; Tasbihgou, Seth; Meier, Sascha; Vlisides, Phillip E; Fardous, Hussein; Hess, Aaron; Bauer, Rebecca M; Absalom, Anthony; Mashour, George A; Bonhomme, Vincent; Coburn, Mark; Sleigh, Jamie

2017-02-01

The isolated forearm technique allows assessment of consciousness of the external world (connected consciousness) through a verbal command to move the hand (of a tourniquet-isolated arm) during intended general anesthesia. Previous isolated forearm technique data suggest that the incidence of connected consciousness may approach 37% after a noxious stimulus. The authors conducted an international, multicenter, pragmatic study to establish the incidence of isolated forearm technique responsiveness after intubation in routine practice. Two hundred sixty adult patients were recruited at six sites into a prospective cohort study of the isolated forearm technique after intubation. Demographic, anesthetic, and intubation data, plus postoperative questionnaires, were collected. Univariate statistics, followed by bivariate logistic regression models for age plus variable, were conducted. The incidence of isolated forearm technique responsiveness after intubation was 4.6% (12/260); 5 of 12 responders reported pain through a second hand squeeze. Responders were younger than nonresponders (39 ± 17 vs. 51 ± 16 yr old; P = 0.01) with more frequent signs of sympathetic activation (50% vs. 2.4%; P = 0.03). No participant had explicit recall of intraoperative events when questioned after surgery (n = 253). Across groups, depth of anesthesia monitoring values showed a wide range; however, values were higher for responders before (54 ± 20 vs. 42 ± 14; P = 0.02) and after (52 ± 16 vs. 43 ± 16; P = 0.02) intubation. In patients not receiving total intravenous anesthesia, exposure to volatile anesthetics before intubation reduced the odds of responding (odds ratio, 0.2 [0.1 to 0.8]; P = 0.02) after adjustment for age. Intraoperative connected consciousness occurred frequently, although the rate is up to 10-times lower than anticipated. This should be considered a conservative estimate of intraoperative connected consciousness.

Psychological traits influence autonomic nervous system recovery following esophageal intubation in health and functional chest pain.

PubMed

Farmer, A D; Coen, S J; Kano, M; Worthen, S F; Rossiter, H E; Navqi, H; Scott, S M; Furlong, P L; Aziz, Q

2013-12-01

Esophageal intubation is a widely utilized technique for a diverse array of physiological studies, activating a complex physiological response mediated, in part, by the autonomic nervous system (ANS). In order to determine the optimal time period after intubation when physiological observations should be recorded, it is important to know the duration of, and factors that influence, this ANS response, in both health and disease. Fifty healthy subjects (27 males, median age 31.9 years, range 20-53 years) and 20 patients with Rome III defined functional chest pain (nine male, median age of 38.7 years, range 28-59 years) had personality traits and anxiety measured. Subjects had heart rate (HR), blood pressure (BP), sympathetic (cardiac sympathetic index, CSI), and parasympathetic nervous system (cardiac vagal tone, CVT) parameters measured at baseline and in response to per nasum intubation with an esophageal catheter. CSI/CVT recovery was measured following esophageal intubation. In all subjects, esophageal intubation caused an elevation in HR, BP, CSI, and skin conductance response (SCR; all p < 0.0001) but concomitant CVT and cardiac sensitivity to the baroreflex (CSB) withdrawal (all p < 0.04). Multiple linear regression analysis demonstrated that longer CVT recovery times were independently associated with higher neuroticism (p < 0.001). Patients had prolonged CSI and CVT recovery times in comparison to healthy subjects (112.5 s vs 46.5 s, p = 0.0001 and 549 s vs 223.5 s, p = 0.0001, respectively). Esophageal intubation activates a flight/flight ANS response. Future studies should allow for at least 10 min of recovery time. Consideration should be given to psychological traits and disease status as these can influence recovery. © 2013 John Wiley & Sons Ltd.

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial.

PubMed

Portas, M; Canal, M I; Barrio, M; Alonso, M; Cabrerizo, P; López-Gil, M; Zaballos, M

2018-03-01

Airway management is still a major cause of anesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q ® and the LMA Fastrach™ for fiberoptic guided tracheal intubation. Thirty-three anesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fiberoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q ® /LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anesthesia trainees were measured. There was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q ® and 11±3s for the LMA Fastrach™, P=.07. Time taken to intubate the trachea was shorter with the air-Q ® , 38±15 s, than with the LMA Fastrach™, 47±19s, P=.017. Overall procedure time was significantly shorter with the Air-Q ® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, P=.002. Air-Q ® removal was considered easier than LMA Fastrach™ removal, P=.005. There were no tube dislodgements during the removal of the dedicated airways. Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q ® and LMA Fastrach™ in a clinically acceptable time with high success. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Transfer of skills and comparison of performance between king vision® video laryngoscope and macintosh blade following an AHA airway management course.

PubMed

Wolf, Lukas E; Aguirre, José A; Vogt, Christian; Keller, Christian; Borgeat, Alain; Bruppacher, Heinz R

2017-01-10

To potentially optimize intubation skill teaching in an American Heart Association® Airway Management Course® for novices, we investigated the transfer of skills from video laryngoscopy to direct laryngoscopy and vice versa using King Vision® and Macintosh blade laryngoscopes respectively. Ninety volunteers (medical students, residents and staff physicians) without prior intubation experience were randomized into three groups to receive intubation training with either King Vision® or Macintosh blade or both. Afterwards they attempted intubation on two human cadavers with both tools. The primary outcome was skill transfer from video laryngoscopy to direct laryngoscopy assessed by first attempt success rates within 60 s. Secondary outcomes were skill transfer in the opposite direction, the efficacy of teaching both tools, and the success rates and esophageal intubation rates of Macintosh blade versus King Vision®. Performance with the Macintosh blade was identical following training with either Macintosh blade or King Vision® (unadjusted odds ratio [OR] 1.09, 95% confidence interval [95% CI] 0.5-2.6). Performance with the King Vision® was significantly better in the group that was trained on it (OR 2.7, 95% CI 1.2-5.9). Success rate within 60 s with Macintosh blade was 48% compared to 52% with King Vision® (OR 0.85, 95% CI 0.4-2.0). Rate of esophageal intubations with Macintosh blade was significantly higher (17% versus 4%, OR 5.0, 95% CI 1.1-23). We found better skill transfer from King Vision® to Macintosh blade than vice versa and fewer esophageal intubations with video laryngoscopy. For global skill improvement in an airway management course for novices, teaching only video laryngoscopy may be sufficient. However, success rates were low for both devices.

Endoscopic Cold Incision, Balloon Dilation, Mitomycin C Application, and Steroid Injection for Adult Laryngotracheal Stenosis

PubMed Central

Parker, Noah P.; Bandyopadhyay, Dipankar; Misono, Stephanie; Goding, George S.

2017-01-01

Objectives/Hypothesis To describe the presentation, stenosis characteristics, etiological differences, and outcomes of adult laryngotracheal stenosis treated with endoscopic cold incision, balloon dilation, topical mitomycin C application, and steroid injection. Study Design Retrospective chart review. Methods Demographic and clinical data were extracted for patients treated between March 2000 and December 2010. Prolonged intubation and idiopathic patient data were utilized for comparative analysis. Results Eighty patients (65 females; 15 males; 220 procedures; 2.9 years mean follow-up) presented with dyspnea (81%) and/or exercise intolerance (40%). Most commonly, etiologies were idiopathic (53 of 80; 66%) or prolonged intubation (14 of 80; 18%). Mean procedures per patient and interval between procedures were 2.8 procedures and 405 days, respectively. Mean stenosis length and distance from the caudal phonating edge of the true vocal folds were 9 mm and 19 mm. Complication, tracheotomy, and open-procedure rates were 1.8%, 1.4%, and 10.0%, respectively. Patients with more than two procedures demonstrated a mean 4-mm reduction in stenosis length and a 2-mm cephalad progression of stenosis over time. More caudal stenoses required more frequent procedures. Procedures were less frequent as more procedures were performed. Stenosis characteristics, interval between procedures, and total procedures were similar between idiopathic patients with or without intubation histories, but different between idiopathic and prolonged intubation patients. Conclusions This procedure was shown to be a viable option in adult laryngotracheal stenosis. Repeat dilation was likely, but was performed without adversely affecting stenosis characteristics. Stenoses farther from the vocal folds required procedures more frequently. Idiopathic patients with a history of brief, elective intubation had stenosis characteristics and responses to therapy similar to idiopathic patients without an intubation history. Both idiopathic groups together demonstrated stenosis characteristics and responses to therapy dissimilar to patients with a history of prolonged intubation. PMID:23086662

Transoral tracheal intubation of rodents using a fiberoptic laryngoscope.

PubMed

Costa, D L; Lehmann, J R; Harold, W M; Drew, R T

1986-06-01

A fiberoptic laryngoscope which allows direct visualization of the deep pharynx and epiglottis has been developed for transoral tracheal intubation of small laboratory mammals. The device has been employed in the intubation and instillation of a variety of substances into the lungs of rats, and with minor modification, has had similar application in mice, hamsters, and guinea pigs. The simplicity and ease of handling of the laryngoscope permits one person to intubate large numbers of enflurane anesthetized animals either on an open counter top or in a glove-box, as may be required for administration of carcinogenic materials. Instillation of 7Be-labeled carbon particles into the lungs of mice, hamsters, rats, and guinea pigs resulted in reasonably consistent interlobal distribution of particles for each test animal species with minimal tracheal deposition. However, actual lung tissue doses of carbon exhibited some species dependence.

Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial

PubMed Central

Öztürk, T.; Ağdanlı, D.; Bayturan, Ö.; Çıkrıkcı, C.; Keleş, G.T.

2015-01-01

Myocardial ischemia, as well as the induction agents used in anesthesia, may cause corrected QT interval (QTc) prolongation. The objective of this randomized, double-blind trial was to determine the effects of high- vs conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias following anesthesia induction and intubation. Fifty patients about to undergo coronary artery surgery were randomly allocated to receive conventional-dose (0.6 mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure were recorded before induction (T0), after induction (T1), after rocuronium (just before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation (T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was significantly longer at T3 than at baseline [475 vs 429 ms in group C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after high-dose rocuronium was not significantly longer than after conventional-dose rocuronium in patients about to undergo coronary artery surgery who were induced with etomidate and fentanyl. In both groups, compared with baseline, QTc was most prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to the nociceptive stimulus of intubation. PMID:25714880

An active simulator for neonatal intubation: Design, development and assessment.

PubMed

Baldoli, Ilaria; Tognarelli, Selene; Vangi, Ferdinando; Panizza, Davide; Scaramuzzo, Rosa T; Cuttano, Armando; Laschi, Cecilia; Menciassi, Arianna

2017-01-01

This study describes the technical realization and the pre-clinical validation of a instrumented neonatal intubation skill trainer able to provide objective feedback for the improvement of clinical competences required for such a delicate procedure. The Laerdal ® Neonatal Intubation Trainer was modified by applying pressure sensors on areas that are mainly subject to stress and potential injuries. Punctual Force Sensing Resistors (FSRs) were characterized and fixed on the external side of the airway structure on the dental arches and epiglottis. A custom silicone tongue was designed and developed to integrate a matrix textile sensor for mapping the pressure applied on its whole surface. The assessment of the developed tool was performed by nine clinical experts who were asked to practice three intubation procedures apiece. Median and maximum forces, over threshold events (i.e. 2N for gingival arch sensors and 7N for epiglottis and tongue sensors respectively) and execution time were measured for each trainee. Data analysis from training sessions revealed that the epiglottis is the point mainly stressed during an intubation procedure (maximum value: 16.69N, median value: 3.11N), while the analysis carried out on the pressure distribution on the instrumented tongue provided information on both force values and distribution, according to clinicians' performance. The debriefing phase was used to enhance the clinicians' awareness of applied force and gestures performed, confirming that the present study is an adequate starting point for achieving and optimizing neonatal intubation skills for both residents and expert clinicians. Copyright © 2016 IPEM. Published by Elsevier Ltd. All rights reserved.

A new universal laryngoscope blade: a preliminary comparison with Macintosh laryngoscope blades.

PubMed

Gerlach, Klaus; Wenzel, Volker; von Knobelsdorff, Georg; Steinfath, Markus; Dörges, Volker

2003-04-01

The Dörges universal laryngoscope blade has several features designed to facilitate tracheal intubation. The number of laryngoscope blades may be reduced from four to two, or even one, which indicate less space requirement and costs. This new universal laryngoscope blade, has a lower profile (height 15 vs. 22 mm) than a Macintosh laryngoscope blade size 3 and 4, which may facilitate manoeuvring of the laryngoscope in the mouth. In random order, 40 non-anaesthesia senior house officers used a Macintosh laryngoscope blade size 3 or 4 in an adult airway management trainer, a Macintosh laryngoscope blade size 2 in a paediatric airway management trainer, and the Dörges universal laryngoscope blade for both airway management trainers to perform orotracheal intubation. The number of intubation attempts and failures was counted. Participants reported the laryngoscopic view according to Cormack and Lehane. The time from touching the laryngoscope to the first adequate lung insufflation was measured, and subjective assessment regarding handling of both blades was recorded. Number of intubation failures, the laryngoscopic view according to Cormack and Lehane, and subjective assessment was comparable between groups. Orotracheal intubation of the adult airway management trainer with the Dörges universal laryngoscope blade took significantly less time compared to the Macintosh laryngoscope blades (14 (7-57) vs. 20 (8-43) s; P<0.001); all other intubating times were comparable. In conclusion, in this model, the Dörges universal laryngoscope blade was comparable to the Macintosh laryngoscope blades size 2-4, and may save time, cost and space.

Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?

PubMed

Varghese, Elsa; Kundu, Ratul

2014-08-01

Both Miller and Macintosh blades are widely used for laryngoscopy in small children, though the Miller blade is more commonly recommended in pediatric anesthetic literature. The aim of this study was to compare laryngoscopic views and ease and success of intubation with Macintosh and Miller blades in small children under general anesthesia. One hundred and twenty children aged 1-24 months were randomized for laryngoscopy to be performed in a crossover manner with either the Miller or the Macintosh blade first, following induction of anesthesia and neuromuscular blockade. The tips of both the blades were placed at the vallecula. Intubation was performed following the second laryngoscopy. The glottic views with and without external laryngeal maneuver (ELM) and ease of intubation were observed. Similar glottic views with both blades were observed in 52/120 (43%) children, a better view observed with the Miller blade in 35/120 (29%) children, and with the Macintosh blade in 33/120 (28%). Laryngoscopy was easy in 65/120 (54%) children with both the blades. Restricted laryngoscopy was noted in 55 children: in 27 children with both the blades, 15 with Miller, and 13 with Macintosh blade. Laryngoscopic view improved following ELM with both the blades. In children aged 1-24 months, the Miller and the Macintosh blades provide similar laryngoscopic views and intubating conditions. When a restricted view is obtained, a change of blade may provide a better view. Placing the tip of the Miller blade in the vallecula provides satisfactory intubating conditions in this age group. © 2014 John Wiley & Sons Ltd.

Using King Vision video laryngoscope with a channeled blade prolongs time for tracheal intubation in different training levels, compared to non-channeled blade.

PubMed

Kriege, Marc; Alflen, Christian; Noppens, Ruediger R

2017-01-01

It is generally accepted that using a video laryngoscope is associated with an improved visualization of the glottis. However, correctly placing the endotracheal tube might be challenging. Channeled video laryngoscopic blades have an endotracheal tube already pre-loaded, allowing to advance the tube once the glottis is visualized. We hypothesized that use of a channel blade with pre-loaded endotracheal tube results in a faster intubation, compared to a curved Macintosh blade video laryngoscope. After ethical approval and informed consent, patients were randomized to receive endotracheal Intubation with either the King Vision® video laryngoscope with curved blade (control) or channeled blade (channeled). Success rate, evaluation of the glottis view (percentage of glottic opening (POGO), Cormack&Lehane (C&L)) and intubating time were evaluated. Over a two-month period, a total of 46 patients (control n = 23; channeled n = 23) were examined. The first attempt success rates were comparable between groups (control 100% (23/23) vs. channeled 96% (22/23); p = 0.31). Overall intubation time was significantly shorter with control (median 40 sec; IQR [24-58]), compared to channeled (59 sec [40-74]; p = 0.03). There were no differences in glottis visualization between groups. Compared with the King Vision channeled blade, time for tracheal intubation was shorter with the control group using a non-channeled blade. First attempt success and visualization of the glottis were comparable. These data do not support the hypothesis that a channeled blade is superior to a curved video laryngoscopic blade without tube guidance. ClinicalTrials.gov NCT02344030.

Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients.

PubMed

Green, Robert S; Fergusson, Dean A; Turgeon, Alexis F; McIntyre, Lauralyn A; Kovacs, George J; Griesdale, Donald E; Zarychanski, Ryan; Butler, Michael B; Kureshi, Nelofar; Erdogan, Mete

2017-05-01

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians. A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from "always" to "never" to capture usual practice. The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would "always/often" be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would "always/often" administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00). Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Selective molecularly imprinted polymer combined with restricted access material for in-tube SPME/UHPLC-MS/MS of parabens in breast milk samples.

PubMed

Souza, Israel D; Melo, Lidervan P; Jardim, Isabel C S F; Monteiro, Juliana C S; Nakano, Ana Marcia S; Queiroz, Maria Eugênia C

2016-08-17

A new molecularly imprinted polymer modified with restricted access material (a hydrophilic external layer), (MIP-RAM) was synthesized via polymerization in situ in an open fused silica capillary. This stationary phase was used as sorbent for in-tube solid phase microextraction (in-tube SPME) to determine parabens in breast milk samples by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Scanning electron micrographs (SEM) illustrate MIP surface modification after glycerol dimethacrylate (hydrophilic monomer) incorporation. The interaction between parabens and MIP-RAM was investigated by Fourier-transform infrared (FTIR) spectroscopy. The Scatchard plot for MIP-RAM presented two linear parts with different slopes, illustrating binding sites with high- and low-affinity. Endogenous compounds exclusion from the MIP-RAM capillary was demonstrated by in-tube SPME/LC-UV assays carried out with blank milk samples. The in-tube SPME/UHPLC-MS/MS method presented linear range from 10 ng mL(-1) (LLOQ) to 400 ng mL(-1) with coefficients of determination higher than 0.99, inter-assay precision with coefficient of variation (CV) values ranging from 2 to 15%, and inter-assay accuracy with relative standard deviation (RSD) values ranging from -1% to 19%. Analytical validation parameters attested that in-tube SPME/UHPLC-MS/MS is an appropriate method to determine parabens in human milk samples to assess human exposure to these compounds. Analysis of breast milk samples from lactating women demonstrated that the proposed method is effective. Copyright © 2016 Elsevier B.V. All rights reserved.

Variable stiffness colonoscope versus regular adult colonoscope: meta-analysis of randomized controlled trials.

PubMed

Othman, M O; Bradley, A G; Choudhary, A; Hoffman, R M; Roy, P K

2009-01-01

The variable stiffness colonoscope (VSC) may have theoretical advantages over standard adult colonoscopes (SACs), though data are conflicting. We conducted a meta-analysis to compare the efficacies of the VSC and SAC. We searched Medline (1966 - 2008) and abstracts of gastroenterology scientific meetings in the 5 years to February 2008, only for randomized clinical trials (RCTs) of adult patients. Trial quality was assessed using the Delphi list. In a meta-analysis with a fixed effects model, cecal intubation rates, cecal intubation times, abdominal pain scores, sedation used, and use of ancillary maneuvers, were compared in separate analyses, using weighted mean differences (WMDs), standardized mean differences (SMDs), or odds ratios (ORs). Seven RCTs satisfied the inclusion criteria (1923 patients), four comparing VSC with SAC procedures in adults, and three evaluating the pediatric VSC. There was no significant heterogeneity among the studies. The overall trial quality was adequate. Cecal intubation rate was higher with the use of VSC (OR = 2.08, 95 % confidence interval [CI] 1.29 to 3.36). The VSC was associated with lower abdominal pain scores and a decreased need for sedation during colonoscopy. Cecal intubation time was similar for the two colonscope types (WMD = - 0.21 minutes, 95 % CI - 0.85 to 0.43). Because of the nature of the intervention no studies were blinded. There was no universal method for using the VSC. Compared with the SAC, VSC use was associated with a higher cecal intubation rate, less abdominal pain, and decreased need for sedation. However, cecal intubation times were similar for the two colonoscope types.

Desflurane or isoflurane for paediatric ENT anaesthesia. A comparison of intubating conditions and recovery profile.

PubMed

Wilhelm, W; Berner, K; Grundmann, U; Palz, M; Larsen, R

1998-12-01

The inhaled anaesthetic desflurane is characterized by a rapid wash-in and wash-out and may be useful for short paediatric ENT procedures. Therefore, this study was designed to compare the effects of desflurane or isoflurane on intubating conditions and recovery characteristics in paediatric ENT patients. In this prospective, randomised investigation, we studied 44 children scheduled for ENT surgery, aged 4-12 yr and classified ASA I-II. After thiopentone induction (5-8 mg/kg) the lungs were ventilated by face mask and the vaporizer was dialed to 1 MAC (age-adapted) of desflurane of isoflurane. A reduced dose of vecuronium (0.05 mg/kg) was administered, and intubating conditions were rated 3 min later. Following tracheal intubation, 50% nitrous oxide were added, and the concentration of desflurane or isoflurane was adjusted according to clinical needs. At the end of surgery all anaesthetics were discontinued simultaneously and recovery times were recorded. Intubating conditions were rated significantly better for desflurane (excellent or good 20 of 22) than for isoflurane (12 of 22). Recovery times were significantly shorter for desflurane than for isoflurane (mean +/- SE): spontaneous ventilation 4.0 +/- 0.5 min vs. 6.0 +/- 0.7 min, extubation 8.4 +/- 0.7 vs. 11.4 +/- 1.1 min and arrival at PACU 11.5 +/- 0.8 vs. 16.6 +/- 1.5 min. No airway complications (coughing, laryngospasm, or desaturation < 97%) were noted for either anaesthetic. Following an intravenous induction improved intubating conditions, shorter recovery times and the lack of airway complications make desflurane a suitable alternative to isoflurane for paediatric ENT anaesthesia.

Comparison of wiping and rinsing techniques after oral care procedures in critically ill patients during endotracheal intubation and after extubation: A prospective cross-over trial.

PubMed

Muramatsu, Keita; Matsuo, Koichiro; Kawai, Yusuke; Yamamoto, Tsukasa; Hara, Yoshitaka; Shimomura, Yasuyo; Yamashita, Chizuru; Nishida, Osamu

2018-06-26

Endotracheal intubation of critically ill patients increases the risk of aspiration pneumonia, which can be reduced by regular oral care. However, the rinsing of the residual oral contaminants after mechanical cleaning carries the risk of aspirating the residue during the intubation period. Removing the contaminants by wiping with mouth wipes could be an alternative to rinsing with water because of no additional fluid. This study tested: (i) the amount of oral bacteria during endotracheal intubation and after extubation; and (ii) the changes in the bacterial count during oral care procedures. Thirty-five mechanically ventilated patients in the intensive care unit were enrolled. The amount of bacteria on the dorsal tongue surface was counted before and following oral care and then after the elimination of contaminants either by rinsing with water and suctioning or by wiping with mouth wipes. The oral bacterial amount was compared statistically between the intubation and extubation status and among set time points during the oral care procedure. The oral bacterial count was significantly decreased after extubation. During the oral care procedure, the oral bacterial amount was significantly lower after eliminating the contaminants either by rinsing or wiping, with no remarkable difference between the elimination techniques. The findings suggest that the oral bacterial amount is elevated during endotracheal intubation, which could increase the risk of aspiration pneumonia. The significant reduction in the bacterial count by wiping indicates that it might be a suitable alternative to rinsing for mechanically ventilated patients. © 2018 Japan Academy of Nursing Science.

Critical Airway Team: A Retrospective Study of an Airway Response System in a Pediatric Hospital.

PubMed

Sterrett, Emily C; Myer, Charles M; Oehler, Jennifer; Das, Bobby; Kerrey, Benjamin T

2017-12-01

Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.

Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients.

PubMed

Salata, R A; Lederman, M M; Shlaes, D M; Jacobs, M R; Eckstein, E; Tweardy, D; Toossi, Z; Chmielewski, R; Marino, J; King, C H

1987-02-01

The clinical distinction between bacterial colonization of the tracheobronchial tree and nosocomial pneumonia is difficult, especially in intubated patients. We studied 51 intubated, intensive care unit patients prospectively by serial examinations of tracheal aspirates for elastin fibers, graded Gram's stains, and quantitative bacterial cultures in conjunction with clinical and radiologic observations in an attempt to develop criteria for the early detection of pulmonary infection. Patients with infection had new or progressive pulmonary infiltrates plus 1 of the following: positive blood culture results, radiographic evidence of cavitation, or histologic evidence of pneumonia, or 2 or more of the following: new fever, new leukocytosis, or grossly purulent tracheal aspirates. Twenty-one patients developed infection, 22 remained colonized, and 8 had an uncertain status. Infiltrates developed in 34 patients (21 infected, 8 colonized, 5 uncertain status). Gram-negative bacilli were most commonly isolated and were more frequent in infected patients (81 versus 47%, p less than 0.05); Pseudomonas aeruginosa and Serratia marcescens were most often associated with infection. No differences were observed between infected and colonized patients in demographic features, smoking history, underlying disease, previous antibiotic therapy, days in hospital before intubation, preexisting pneumonia upon intubation, or highest temperature or leukocyte count during course. By univariate analysis, infected patients had a longer duration of intubation (p less than 0.05), higher Gram's stain grading for neutrophils (p less than 0.05) or bacteria (p less than 0.005), higher bacterial colony counts (p less than 0.05), and more frequent detection of elastin fibers in tracheal aspirates (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions

PubMed Central

Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz

2016-01-01

Abstract Background: Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR. Methods: ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario. Results: The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5–22] sec, when compared to that of sETT at 21.5 [IQR, 20–25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5–24.5] sec (p < .001) and sETT was 27 [IQR, 24.5–31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19–25.5] sec for the ETView and 42.5 [IQR, 35–49.5] sec for sETT. Conclusions: In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView. Trial Registration: clinicaltrials.gov Identifier: NCT02733536. PMID:27858851

A comparison of a traditional endotracheal tube versus ETView SL in endotracheal intubation during different emergency conditions: A randomized, crossover cadaver trial.

PubMed

Truszewski, Zenon; Krajewski, Paweł; Fudalej, Marcin; Smereka, Jacek; Frass, Michael; Robak, Oliver; Nguyen, Bianka; Ruetzler, Kurt; Szarpak, Lukasz

2016-11-01

Airway management is a crucial skill essential to paramedics and personnel working in Emergency Medical Services and Emergency Departments: Lack of practice, a difficult airway, or a trauma situation may limit the ability of paramedics to perform direct laryngoscopy during cardiopulmonary resuscitation. Videoscope devices are alternatives for airway management in these situations. The ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel) is a new, single-lumen airway tube with an integrated high-resolution imaging camera. To assess if the ETView VivaSight SL can be a superior alternative to a standard endotracheal tube for intubation in an adult cadaver model, both during and without simulated CPR. ETView VivaSight SL tube was investigated via an interventional, randomized, crossover, cadaver study. A total of 52 paramedics participated in the intubation of human cadavers in three different scenarios: a normal airway at rest without concomitant chest compression (CC) (scenario A), a normal airway with uninterrupted CC (scenario B) and manual in-line stabilization (scenario C). Time and rate of success for intubation, the glottic view scale, and ease-of-use of ETView vs. sETT intubation were assessed for each emergency scenario. The median time to intubation using ETView vs. sETT was compared for each of the aforementioned scenarios. For scenario A, time to first ventilation was achieved fastest for ETView, 19.5 [IQR, 16.5-22] sec, when compared to that of sETT at 21.5 [IQR, 20-25] sec (p = .013). In scenario B, the time for intubation using ETView was 21 [IQR, 18.5-24.5] sec (p < .001) and sETT was 27 [IQR, 24.5-31.5] sec. Time to first ventilation for scenario C was 23.5 [IQR, 19-25.5] sec for the ETView and 42.5 [IQR, 35-49.5] sec for sETT. In normal airways and situations with continuous chest compressions, the success rate for intubation of cadavers and the time to ventilation were improved with the ETView. The time to glottis view, tube insertion, and cuff block were all found to be shorter with the ETView. clinicaltrials.gov Identifier: NCT02733536.

Effect of gabapentin pretreatment on the hemodynamic response to laryngoscopy and tracheal intubation in treated hypertensive patients.

PubMed

Bala, Indu; Bharti, Neerja; Ramesh, Nanjangud P

2015-09-01

This randomized, double-blind study was conducted to evaluate the effect of gabapentin pretreatment on the hemodynamic response to laryngoscopy and endotracheal intubation (LETI) in treated hypertensive patients undergoing surgery. A total of 100 controlled hypertensive patients aged 35-60 years, undergoing elective surgery under general anesthesia with endotracheal intubation, were randomly allocated into three groups. Group 1 patients received placebo at night and 2 hours prior to induction of anesthesia. Group 2 patients received placebo at night and 800 mg gabapentin 2 hours prior to induction of anesthesia. Group 3 patients received 800 mg gabapentin at night and 2 hours prior to induction of anesthesia. Anesthesia was induced with thiopentone, fentanyl, and vecuronium and maintained with isoflurane in oxygen and nitrous oxide. Patients' heart rate (HR), blood pressure (BP), and electrocardiography (ECG) changes were recorded prior to induction, after induction, and at 0 minutes, 1 minute, 3 minutes, 5 minutes, and 10 minutes after intubation. Any episodes of hypotension, bradycardia, tachycardia, hypertension, arrhythmia, and ST-T wave changes were recorded and treated accordingly. The HR was comparable among groups, with a transient rise just after intubation, followed by a gradual fall thereafter at 3 minutes, 5 minutes, and 10 minutes compared with baseline. A significant increase in BP after intubation was reported in Group 1 but not in Group 2 and Group 3. The mean arterial pressure (MAP) was significantly higher in Group 1 at 0 minute, 1 minute and 3 minutes postintubation as compared with Group 2 and Group 3 (p=0.014). Three patients in Group 1, four patients in Group 2, and 10 patients in Group 3 developed hypotension and were treated with ephedrine, whereas five patients in Group 1 and one patient in Group 2 had hypertension after tracheal intubation. There was no significant difference between the groups with respect to the number of patients who received ephedrine boluses and in whom isoflurane had to be increased due to hypertension. No episode of bradycardia, tachycardia, dysrhythmia, or ST-T wave changes was reported. Gabapentin 800 mg in a single or double dose was equally effective in attenuating the hypertensive response to laryngoscopy and tracheal intubation in treated hypertensive patients. Copyright © 2015. Published by Elsevier B.V.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit.

PubMed

Joshi, Raj; Hypes, Cameron D; Greenberg, Jeremy; Snyder, Linda; Malo, Josh; Bloom, John W; Chopra, Harsharon; Sakles, John C; Mosier, Jarrod M

2017-03-01

Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

Effects of Reading Strategy Instruction on Attitude toward Strategies and Performance in Reading Texts of Different Difficulty Levels

ERIC Educational Resources Information Center

Shorkaee, Hossein Zabihi; Talebi, Seyed Hassan

2018-01-01

This study investigated the effects of Reading Strategy Instruction (RSI) on reading performance and attitude toward reading strategies while reading texts of different difficulty levels. Fifty-five university students studying Political and Basic Sciences took part in this study. After homogenizing the participants, 24 students were in the…

Legacy of the Rural Systemic Initiatives: Innovation, Leadership, Teacher Development, and Lessons Learned

ERIC Educational Resources Information Center

Harmon, Hobart L.; Smith, Keith C.

2012-01-01

This monograph offers an in-depth look at the National Science Foundation's (NSF) Rural Systemic Initiative (RSI) efforts, an investment of more than $140 million to reform mathematics and science programs in rural K-12 public education and tribal education. The authors seek to promote a foundation of contextual understanding for improving public…

Tube introducer and modified Celestin tube for use in palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy.

PubMed Central

Atkinson, M; Ferguson, R; Parker, G C

1978-01-01

A new method for palliative intubation of inoperable neoplasms at or near the cardia is described. A guidewire is passed through the stricture, which is dilated using Eder Puestow metal olive dilators. The tube to be inserted is mounted on an introducer, which grips its distal end from inside, and is slid into position along the wire under radiological control. Twenty-five patients have been intubated with one death directly resulting from the procedure. The method provides a simple and relatively safe means of relieving dysphagia and improving nutrition. Images Fig. 2 PMID:79517

Long term intubation and successful weaning in two children with Guillain-Barre syndrome.

PubMed

Javed, H; Nair, M P; Koul, R L; Chacko, A; Fazalullah, M

2000-07-01

No definite criteria exists in Guillian-Barre syndrome in children regarding prolonged ventilation through an endo-tracheal tube without tracheostomy and successful weaning using a T-piece. Here we report two such cases of Guillian-Barre syndrome requiring prolonged intubation for 56 days and ventilation for 30 days and ultimately successfully weaning them using the T-piece. Both the children eventually made a complete recovery, highlighting the point that in children prolonged intubation and ventilation using the portex tube is equally good, if not, better than tracheostomy with its attendant risks.