Changes in blood gas in supine and prone positions in percutaneous stone surgery: does position have any advantage for hemodynamics?

To evaluate whether different positions are advantageous for hemodynamics and respiratory balance in patients undergoing percutaneous nephrolithotomy (PCNL) procedures. Pre- and postoperative arterial blood gas data obtained during spontaneous breathing for 67 prone (Group 1) and 56 supine (Group 2) patients undergoing PCNL were analyzed. Additionally data on all patients' gender, age, body mass index, stone size, access and surgical duration, volume of irrigation fluid, length of hospital stay, requirement for blood transfusion, and residual stones were recorded: There were no differences between the groups in terms of age, stone size, operation time, access time, radiation exposure, transfusion requirements, stone-free rate, and length of hospitalization. A statistically significant pH decrease was observed in both groups in the postoperative period (p = 0.001 and p = 0.001, respectively). There was a statistically significant increase in pCO2 values in both groups in the postoperative period (p = 0.001 and p = 0.024, respectively), and that increase did not differ significantly between the groups (p = 0.624). A statistically significant decrease in pO2 and SpO2 values was observed in both groups in the postoperative period compared to the preoperative period. Again, no statistical difference was observed between the groups for these values. There was a statistically significant decrease in bicarbonate in both groups period (p < 0.001 and p = 0.001, respectively). Hemodynamics and the respiratory balance of the patient are impaired in both prone and supine positions. Neither position is superior to the other in this respect.

Assessment of arthrogenic quadriceps muscle inhibition by physical examination in the supine position during isometric contraction is feasible as demonstrated by electromyography: a cross-sectional study.

BACKGROUND: Preventing severe arthrogenic muscle inhibition (AMI) after knee injury is critical for better prognosis. The novel Sonnery-Cottet classification of AMI enables the evaluation of AMI severity but requires validation. This study aimed to investigate the electromyography (EMG) patterns of leg muscles in the examination position from the classification during isometric contraction to confirm its validity. We hypothesised that the AMI pattern, which is characterised by quadriceps inhibition and hamstring hypercontraction, would be detectable in the supine position during isometric contraction. METHODS: Patients with meniscal or knee ligament injuries were enrolled between August 2023 and May 2024. Surface EMG was assessed during submaximal voluntary isometric contractions (sMVIC) at 0° extension in the supine position for the vastus medialis (VM) and vastus lateralis (VL) muscles and at 20° flexion in the prone position for the semitendinosus (ST) and biceps femoris (BF) muscles. Reference values for normalisation were obtained from the EMG activity during the gait of the uninjured leg. The Kruskal-Wallis test was used to compare the activation patterns of the muscle groups within the same leg, and the post-hoc tests were conducted using the Mann-Whitney U test and Bonferroni correction. RESULTS: Electromyographic data of 40 patients with knee injuries were analyzed. During sMVIC, the extensor and flexor muscles of the injured leg showed distinct behaviours (P < 0.001), whereas the uninjured side did not (P = 0.144). In the injured leg, the VM differed significantly from the ST (P = 0.018), and the VL differed significantly from the ST and BF (P = 0.001 and P = 0.026, respectively). However, there were no statistically significant differences within the extensor muscle groups (VM and VL, P = 0.487) or flexor muscle groups (ST and BF, P = 0.377). CONCLUSION: AMI was detectable in the examination position suggested by the Sonnery-Cottet classification. The flexor and extensor muscles of the injured leg exhibited distinct activation behaviours, with inhibition predominantly occurring in the quadriceps muscles, whereas the hamstrings showed excitation.

The effect of different bed head angles on the hemodynamic parameters of intensive care patients lying in the supine position: A quasi-experimental study.

AIMS: The aim of this study was to research the effect of different bed head angles on the hemodynamic parameters of intensive care patients lying in the supine position. METHODS: This study was a non-randomized and non-controlled, quasi-experimental repeated measures study. The study was conducted with 50 intensive care patients aged 18 and over in a general surgery intensive care unit in Turkey. With each patient in the supine position, the bed head was raised to an angle of 0°, 20°, 30°, and 45° without a pillow, and the hemodynamic parameters of central venous pressure, systolic and diastolic blood pressure, heart rate, breathing rate, and peripheral oxygen saturation were recorded after 0 and 10 min. RESULTS: It was found that the mean central venous pressure value measured at min 0 and 10 was higher when the intensive care patients' bed head angle was raised to 45° than when the bed head was at an angle of 0° or 20° (p < .05). It was found that the patients' other hemodynamic parameters were not affected by different bed head angles. CONCLUSIONS: It was concluded as a result of this research that in intensive care patients in the supine position, only central venous pressure was affected by bed head angle, and that central venous pressure measurement can be reliably made at a bed head angle of 30°.

Anesthesiology trainees performing flexible scope intubation in spontaneously breathing patients in the left lateral position and the supine position: a prospective randomized trial.

BACKGROUND: Flexible scope intubation is an important airway management skill that requires hands-on training in a real airway. We compared flexible scope intubation by trainees between patients in the left lateral and supine positions. METHODS: Forty patients aged 20 to 80 years with American Society of Anesthesiologists physical status class I to III were scheduled for elective surgery under general endotracheal anesthesia in Ramathibodi Hospital from February 2020 to June 2020. Patients were randomly assigned to be intubated in one of two positions: supine (Group S) or left lateral (Group L). Trainees performed flexible scope intubation in sedated patients under the supervision of an attending anesthesiologist. Intubation success, time to successful intubation, number of attempts, airway adjustment maneuvers, and hemodynamic changes were compared between groups. RESULTS: Patient characteristics did not differ between groups except for Mallampati airway classification. The rate of successful intubation on the first attempt and intubation time did not significantly differ between groups. The proportion of patients who required a jaw thrust during intubation was significantly lower in Group L (10.5% vs. 85%; P < 0.01). Blood pressure and oxygen saturation declined in both groups after intubation. The relative risk of desaturation in patients in the left lateral position compared with the supine position was 0.44 (0.1649-1.1978). CONCLUSION: The rate of successful flexible scope intubation on the first attempt and intubation time did not differ between the groups. The proportion of patients who required a jaw thrust maneuver was significantly lower in patients in the left lateral position. TRIAL REGISTRATION: https://www.thaiclinicaltrials.org/ ( TCTR20200208001 ) on 08/02/2020.

Comparison of Effects of Extubation in Prone and Supine Positions in Patients Operated for Lumbar Disc Herniation.

AIM: To observe the effects of prone position extubation on respiratory side effects and hemodynamic parameters in patients who underwent lumbar spinal surgery. MATERIAL AND METHODS: This prospective observational study included 60 patients extubated in either the prone (n=30) or supine (n=30) positions. Heart rate, noninvasive arterial blood pressure, peripheral oxygen saturation, train of four values, and bispectral index values were measured and recorded in all patients during operation and at the time of anesthetic agent discontinuation, before and after extubation. The Aldrete recovery score was recorded together with the severity of cough during emergence and recovery. Sore throat visual analog scale (VAS) score was recorded at the first and sixth hours after extubation. Incidents such as nausea, vomiting, respiratory failure, uncontrolled airway, and decreased saturation were also recorded. RESULTS: The number and severity of cough (p < 0.05) and sore throat VAS (p < 0.001) were lower in the prone group. Postextubation breath holding was more frequent in the supine group (p < 0.001). Aldrete recovery scores were higher in the prone group (p < 0.05). Heart rate and mean arterial pressure values were not significantly different in the prone group during the emergence and recovery period as compared with the supine group (p > 0.05). CONCLUSION: Extubation in the prone position after lumbar spinal surgery provides more comfortable emergence and recovery periods with less alteration of respiratory status and a better recovery profile.

Intraoperative pressure monitoring of the lower leg for preventing compression-related complications associated with the lithotomy position.

BACKGROUND: Several serious complications are associated with the lithotomy position, including well-leg compartment syndrome and peroneal nerve paralysis. The aims of this study were to identify risk factors for the intraoperative elevation of lower leg pressure and to evaluate the effectiveness of monitoring external pressure during surgery for preventing these complications. METHODS: The study included 106 patients with a diagnosis of sigmoid colon or rectal cancer who underwent elective laparoscopic surgery between June 2019 and December 2020. We divided the posterior side of the lower leg into four parts (upper outside, upper inside, lower outside, lower inside) and recorded the peak pressure applied to each area at hourly intervals during surgery (called "regular points") and when the operating position was changed (e.g., by head-tilt or leg elevation; called "points after change in position"). When the pressure was observed to be higher than 50 mmHg, we adjusted the position of the leg and re-recorded the data. Data on postoperative leg-associated complications were also collected. RESULTS: The pressure was measured at a total of 1125 points (regular, n = 620; after change of position, n = 505). The external pressure on the upper outer side of the right leg (median, 36 mmHg) was higher than that on any other area of the lower leg. The pressure increase to more than 50 mmHg was observed not only during the change of position (27.5%) but also during regular points (22.4%). Bodyweight, strong leg elevation, and low head position were identified as factors associated with increased external pressure. There have been no compression-related complications in 534 cases at our institution since the introduction of intraoperative pressure monitoring. CONCLUSIONS: Several risk factors associated with increased external pressure on the lower leg were identified. Intraoperative pressure monitoring might help reduction of pressure-related complications, needing further and larger prospective data collections.

Spleen emptying does not correlate with faster oxygen kinetics during a step-transition supine cycling.

This manuscript quantified spleen volume changes and examined the relationship between those changes and oxygen uptake kinetics during supine cycling. Ten volunteers (age = 22 ± 3), completed 3 step transitions from 20 W to their power output at 90% gas exchange threshold. Ultrasonic measurements of the spleen were performed each minute. The largest spleen volume reduction was 105 mL (p = 0.001). No associations existed between i) spleen volumes at rest; and ii) spleen volume changes (%) and tau pulmonary oxygen uptake (τV̇O2p). Larger resting spleen volume and greater emptying do not correlate with a faster τV̇O2p. Novelty: Greater splenic contractions do not augment τV̇O2p, irrespective of spleen emptying and subsequent erythrocyte release.

Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications.

OBJECTIVES: To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN: Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS: Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS: In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.

Truth or Myth: Intra-abdominal Pressure Increases in the Lithotomy Position.

STUDY OBJECTIVE: To determine if there were differences in intra-abdominal pressure (IAP) in the supine, low lithotomy, and high lithotomy positions. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Twenty-nine women undergoing surgery for prolapse or stress incontinence. INTERVENTIONS: Relevant medical history, including the pelvic organ prolapse quantification stage, body mass index, and airway grade (Mallampati score), was abstracted from patients' medical charts. IAP was measured in centimeters of water (cmH2O) on the day of their surgery before induction of general or intravenous anesthesia using a T-doc air charged urodynamic catheter (Laborie Aquarius; Ontario, Canada) placed in a patient's vagina (for patients with incontinence) or rectum (for patients with prolapse). MEASUREMENTS AND MAIN RESULTS: IAP was measured in 3 positions: supine (legs at 0°), low lithotomy (legs in Yellowfin stirrups at 45°; Allen Medical, Acton, MA), and high lithotomy (legs at 90°). The means ± SDs IAP for the groups were as follows: in the supine position, 18.6 cmH2O ± 7.6; low lithotomy, 17.7 cmH2O ± 6.6; and high lithotomy, 17.1 cmH2O ± 6.3. In the same women, there was a significant decrease in IAP from the supine to high lithotomy positions, with a mean difference of 1.4 cmH2O ± 3.7, p = .05. Similarly, there was a significant, though smaller, decrease in mean IAP when moving from the supine to low lithotomy positions in these same women (mean decrease of 0.9 cmH2O ± 1.5, p = .004). Neither change is clinically significant based on previous research that suggests 5 cmH2O is a clinically significant change. CONCLUSION: Placing patients' legs in a low or high lithotomy position does not result in a clinically significant increase in IAP. Therefore, surgeons and anesthesiologists can consider positioning patients' lower extremities in stirrups while patients are awake to minimize discomfort and possibly reduce the risk of nerve injuries.

Effect of Head-of-Bed Elevation on Nocturnal Reflux Symptoms of Esophageal Cancer Patients With Esophagectomy and Reconstruction.

BACKGROUND: Studies revealed the symptom of gastroesophageal reflux (GE reflux) disturb patients following esophageal reconstruction. OBJECTIVE: To examine the effect of head-of-bed elevation by using the wedge-shaped pillow (WSP) on the reflux symptoms of patients with esophageal cancer following esophagectomy and reconstruction. METHODS: Fourteen patients with nocturnal reflux symptoms following esophagectomy and gastric tube reconstruction were enrolled and randomized into 2 groups. A 2-week crossover trial was performed using 2 sequences (drug only and drug plus WSP). The WSP was designed with a height of 20 cm, a length of 62 cm, and an elevation angle of 20 degrees and used with fabricated from memory foam. After 2 weeks, all of the patients received combined drug and WSP intervention for 3 months. Reflux symptoms were measured by Dysfunction After Upper Gastrointestinal Surgery for Cancer and examined by endoscopic observations prior to intervention and follow-up for 3 months. RESULT: The average reflux symptom score for the combined drug and WSP treatment in the beginning 2 weeks was lower than that for the drug-only sequence. The severity of esophagitis was improved in 46.1%, and 38.5% showed a stabilization after 3 months. CONCLUSIONS: Combined drug and WSP treatment may be beneficial in improving GE reflux symptoms. IMPLICATIONS FOR PRACTICE: Nursing care professionals would suggest patients find a similar WSP to elevate the head of the bed to reduce the severity of nocturnal reflux symptoms after esophagectomy and gastric tube reconstruction.

Crawl positioning improves set-up precision and patient comfort in prone whole breast irradiation.

Prone positioning for whole-breast irradiation (WBI) reduces dose to organs at risk, but reduces set-up speed, precision, and comfort. We aimed to improve these problems by placing patients in prone crawl position on a newly developed crawl couch (CrC). A group of 10 right-sided breast cancer patients requiring WBI were randomized in this cross-over trial, comparing the CrC to a standard prone breastboard (BB). Laterolateral (LL), craniocaudal (CC) and anterioposterior (AP) set-up errors were evaluated with cone beam CT. Comfort, preference and set-up time (SUT) were assessed. Forty left and right-sided breast cancer patients served as a validation group. For BB versus CrC, AP, LL and CC mean patient shifts were - 0.8 ± 2.8, 0.2 ± 11.7 and - 0.6 ± 4.4 versus - 0.2 ± 3.3, - 0.8 ± 2.5 and - 1.9 ± 5.7 mm. LL shift spread was reduced significantly. Nine out of 10 patients preferred the CrC. SUT did not differ significantly. The validation group had mean patient shifts of 1.7 ± 2.9 (AP), 0.2 ± 3.6 (LL) and - 0.2 ± 3.3 (CC) mm. Mean SUT in the validation group was 1 min longer (P < 0.05) than the comparative group. Median SUT was 3 min in all groups. The CrC improved precision and comfort compared to BB. Set-up errors compare favourably to other prone-WBI trials and rival supine positioning.

Three-dimensional alignment changes of the shoulder girdle between the supine and standing positions.

BACKGROUND: Although humans spend most of their day in a standing or sitting position, it is difficult to accurately evaluate the alignment of the shoulder girdle during daily activity, and its alignment changes between positions. The purpose of this study was to evaluate the 3-dimensional alignment of the shoulder girdle in the supine and standing positions by computed tomography (CT) and to assess the alignment changes of the shoulder girdle between these two positions. METHODS: CT scans of both shoulders of 100 healthy volunteers were prospectively taken in both supine and standing positions on the same day. The local 3-dimensional coordinate systems of the thorax, clavicle, and scapula were defined from the specific bony landmarks, and 3-dimensional angular rotations and positions of the clavicle and scapula were calculated. Differences in rotations and positions of the clavicle and scapula were evaluated between the supine and standing positions. RESULTS: Compared with the supine position, the clavicle showed significantly less elevation and greater retraction, and the scapula showed significantly less upward rotation, anterior tilting, and internal rotation in the standing position. Compared with the supine position, the clavicle center was located more inferiorly, posteriorly, and laterally, and the scapula center was located more inferiorly, posteriorly, and medially in the standing position. CONCLUSIONS: The present study showed that angular rotations and positions of the clavicle and scapula change significantly with position due to the effect of gravity.

Impaired orthostatic heart rate recovery is associated with smaller thalamic volume: Results from The Irish Longitudinal Study on Aging (TILDA).

The thalamus is a central hub of the autonomic network and thalamic volume has been associated with high-risk phenotypes for sudden cardiac death. Heart rate response to physiological stressors (e.g., standing) and the associated recovery patterns provide reliable indicators of both autonomic function and cardiovascular risk. Here we examine if thalamic volume may be a risk marker for impaired heart rate recovery in response to orthostatic challenge. The Irish Longitudinal Study on Aging involves a nationally representative sample of older individuals aged ≥50 years. Multimodal brain magnetic resonance imaging and orthostatic heart rate recovery were available for a cross-sectional sample of 430 participants. Multivariable regression and linear mixed-effects models were adjusted for head size, age, sex, education, body mass index, blood pressure, history of cardiovascular diseases and events, cardiovascular medication, diabetes mellitus, smoking, alcohol intake, timed up-and-go (a measure of physical frailty), physical exercise and depression. Smaller thalamic volume was associated with slower heart rate recovery (-1.4 bpm per 1 cm3 thalamic volume, 95% CI -2.01 to -0.82; p < .001). In multivariable analysis, participants with smaller thalamic volumes had a mean heart rate recovery -2.7 bpm slower than participants with larger thalamic volumes (95% CI -3.89 to -1.61; p < .001). Covariates associated with smaller thalamic volume included age, history of diabetes, and heavy alcohol consumption. Thalamic volume may be an indicator of the structural integrity of the central autonomic network. It may be a clinical biomarker for stratification of individuals at risk of autonomic dysfunction, cardiovascular events, and sudden cardiac death.

An accelerometer-based navigation system provides acetabular cup orientation accuracy comparable to that of computed tomography-based navigation during total hip arthroplasty in the supine position.

BACKGROUND: Inadequate acetabular component orientation is associated with postoperative impingement, dislocation, and accelerated polyethylene wear. Computed tomography (CT)-based navigation systems provide accuracy for total hip arthroplasty (THA) but are not available in all facilities. Accelerometer-based navigation systems are inexpensive, but their accuracy remains undetermined. This study compares the accuracy of cup orientation in THA using CT-based and accelerometer-based navigation systems. METHODS: This retrospective study included 35 consecutive patients (11 males, 24 females; mean age, 65 years) who underwent primary cementless THA via an anterolateral approach in the supine position. Both CT-based and accelerometer-based navigation systems were used simultaneously. The accuracy of cup orientation was compared between the two systems using postoperative CT. RESULTS: The accuracy of cup inclination was 2.7° ± 2.0° in the CT-based group and 3.3° ± 2.4° in the accelerometer-based group. The accuracy of cup anteversion was 2.8° ± 2.6° in the CT-based group and 3.4° ± 2.2° in the accelerometer-based group. No significant difference was observed in cup inclination (p = 0.29) or cup anteversion (p = 0.34) between CT-based and accelerometer-based navigation. CONCLUSIONS: The accuracy of cup positioning did not differ significantly between CT-based and accelerometer-based navigation systems.

Supine flexibility predicts curve progression for patients with adolescent idiopathic scoliosis undergoing underarm bracing.

AIMS: The aim of this study was to assess whether supine flexibility predicts the likelihood of curve progression in patients with adolescent idiopathic scoliosis (AIS) undergoing brace treatment. METHODS: This was a retrospective analysis of patients with AIS prescribed with an underarm brace between September 2008 to April 2013 and followed up until 18 years of age or required surgery. Patients with structural proximal curves that preclude underarm bracing, those who were lost to follow-up, and those who had poor compliance to bracing (<16 hours a day) were excluded. The major curve Cobb angle, curve type, and location were measured on the pre-brace standing posteroanterior (PA) radiograph, supine whole spine radiograph, initial in-brace standing PA radiograph, and the post-brace weaning standing PA radiograph. Validation of the previous in-brace Cobb angle regression model was performed. The outcome of curve progression post-bracing was tested using a logistic regression model. The supine flexibility cut-off for curve progression was analyzed with receiver operating characteristic curve. RESULTS: A total of 586 patients with mean age of 12.6 years (SD 1.2) remained for analysis after exclusion. The baseline Cobb angle was similar for thoracic major curves (31.6° (SD 3.8°)) and lumbar major curves (30.3° (SD 3.7°)). Curve progression was more common in the thoracic curves than lumbar curves with mean final Cobb angles of 40.5° (SD 12.5°) and 31.8° (SD 9.8°) respectively. This dataset matched the prediction model for in-brace Cobb angle with less mean absolute error in thoracic curves (0.61) as compared to lumbar curves (1.04). Reduced age and Risser stage, thoracic curves, increased pre-brace Cobb angle, and reduced correction and flexibility rates predicted increased likelihood of curve progression. Flexibility rate of more than 28% has likelihood of preventing curve progression with bracing. CONCLUSION: Supine radiographs provide satisfactory prediction for in-brace correction and post-bracing curve magnitude. The flexibility of the curve is a guide to determine the likelihood for brace success. Cite this article: Bone Joint J 2020;102-B(2):254-260.

Comparison of Macintosh Laryngoscopy in Bed-up-Head-Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial.

BACKGROUND: Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head-elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)-assisted intubation with regard to laryngeal exposure. METHODS: A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack-Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed -15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation. RESULTS: Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of -6.3% (98% CI, -13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054). CONCLUSIONS: In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population.

Floppy epiglottis during drug-induced sleep endoscopy: an almost complete resolution by adopting the lateral posture.

PURPOSE: To analyze the presence of a floppy epiglottis (FE) during drug-induced sleep endoscopy in non-apneic snoring patients, non-positional obstructive sleep apnea (OSA) patients (NPP), and position-dependent OSA patients (PP) and to evaluate the impact of maneuvers and body position during drug-induced sleep endoscopy, including jaw thrust and supine and lateral head (and trunk) position. METHODS: Retrospective cohort study. RESULTS: In total, 324 patients were included. In 60 patients (18.5%), a FE was found in supine position: seven non-apneic snoring patients and 53 OSA patients. When performing lateral head rotation only, a FE was present in four patients (NPP, N = 0; PP, N = 4). When patients were tilted to both lateral head and trunk position, a FE was found in only one subject. After applying jaw thrust, a FE was still present in 10 patients. The prevalence of a FE did not differ between NPP and PP. When comparing baseline characteristics between patients with and without a FE in supine position, no significant differences were found. CONCLUSION: A FE appears almost exclusively in supine position. In patients with a FE, positional therapy can be a promising alternative as a standalone treatment, but also as part of combination therapy with for example mandibular advancement devices or less invasive forms of upper airway surgery.

Modified inspiratory muscle training (m-IMT) as promising treatment for gastro-oesophageal reflux disease (GERD).

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is one of the most common diseases, but is still a challenge to cure. Different medical treatments are used, first of all Proton pump inhibitors (PPIs), however these are sometimes ineffective and long-term intake can lead to underestimated complications. Recently, some studies investigated the role of inspiratory muscle training (IMT) in the medical treatment of GERD. It seems that IMT is able to increase the pressure generated by the lower oesophageal sphincter (LES), reduce spontaneous releases of LES, acid exposure, use of PPIs, and improve symptoms and quality of life for GERD patients. OBJECTIVE: The aim of this study was to evaluate the effectiveness of IMT in association with myofunctional therapy exercises of swallowing set by Daniel Garliner (m-IMT) on the symptoms of patients with non-erosive gastro-oesophageal reflux disease (NERD). METHODS: Twenty-one adult patients with NERD were enrolled from May to December 2017 and performed m-IMT over a period of 4 weeks. Before and after treatment, all the patients completed the following questionnaires: GERD oesophageal symptomatology (GERDQ), extra-oesophageal GERD symptomatology (RSI), quality of life (GERD-Health Related Quality of Life Questionnaire (GERD-HRQL), and underwent laryngeal endoscopy. RESULTS: Nineteen patients completed m-IMT. GERDQ (from 8.36±3.94 to 1.7±3.41; p<.05), RSI (from to 21.68±10.26 to 6.93±8.37; p<.05) and GERDHRQL (from 25.68±16.03 to 8.4±11.06; p<.05) the questionnaire scores significantly reduced after treatment. In addition, the laryngeal endoscopy score greatly improved (from 14.24±4.15 to 7.4±1.77; p<.05). CONCLUSIONS: m-IMT is a low cost therapy without side effects. It could be useful in association with PPI or alone for selected GERD cases and for mild NERD forms, in association with diet. Further studies are required to prove the effects of m-IMT on GERD symptoms and decide the best treatment schedule.

Development of positional obstructive sleep apnea (POSA) after upper airway surgery in OSA patients.

PURPOSE: Positional therapy (PT) has become more reliable for obstructive sleep apnea (OSA) patients with the use of new devices. The objectives of this study were to determine the preoperative prevalence of positional OSA (POSA) in our population of surgically treated patients and the proportion of patients who developed POSA after surgery and might improve with additional positional therapy. METHODS: This was a retrospective study of surgically treated OSA patients from 1999 to 2017. The Cartwright definition was used to define POSA. All patients completed a sleep study before and 6 months after surgery and a complete upper airway (UA) exploration (awake ± DISE). A total of 125 patients were included. RESULTS: The global prevalence of POSA before surgery was 31.2%. In those who were cured by surgery, the preoperative prevalence of POSA was 38.3%. Having POSA was not related with surgical success outcome. For patients not cured by surgery, the proportion of POSA significantly increased from 25.64 to 53.85% after surgery. Eighteen patients of them (23.1%) achieved AHI < 5/h in a lateral position. In those patients, PT with Night-Shift™ was suggested, 50% of them accepted it and 88.9% of them experienced excellent satisfaction. Lateral velum collapse and the absence of concentric collapse at the tongue base had statistical relationships with the development of POSA. CONCLUSIONS: The prevalence of POSA is increased after surgery in patients with persistent OSA after surgery. In these patients, the development of POSA gives an extra therapeutic chance as 23.1% of these cases can be successfully treated by using PT.