Ventilation through small-bore airways in children by implementing active expiration.

Management of narrowed airways can be challenging, especially in the smallest patients. This educational review focusses on active expiration through small-bore airways with the Ventrain (Ventinova Medical, Eindhoven, The Netherlands). Manual ventilation with the Ventrain establishes inspiratory and expiratory flow control: By setting an appropriate flow, the volume of gas insufflated over time can be controlled and expiration through a small-bore airway is expedited by jet-flow generated suction, coined "expiratory ventilation assistance" (EVA). This overcomes the inherent risks of emergency jet ventilation especially in pediatric airway emergencies. Active expiration by EVA has been clinically introduced to turn a "straw in the airway" into a lifesaver allowing not only for quick and reliable reoxygenation but also adequate ventilation. As well as managing airway emergencies, ventilating through small-bore airways by applying EVA implements new options for pediatric airway management in elective interventional procedures. Safe application of EVA demands a thorough understanding of the required equipment, the principle and function of the Ventrain, technical prerequisites, clinical safety measures, and, most importantly, appropriate training.

Visually guided inspiration breath-hold facilitated with nasal high flow therapy in locally advanced lung cancer.

BACKGROUND AND PURPOSE: Reducing breathing motion in radiotherapy (RT) is an attractive strategy to reduce margins and better spare normal tissues. The objective of this prospective study (NCT03729661) was to investigate the feasibility of irradiation of non-small cell lung cancer (NSCLC) with visually guided moderate deep inspiration breath-hold (IBH) using nasal high-flow therapy (NHFT). MATERIAL AND METHODS: Locally advanced NSCLC patients undergoing photon RT were given NHFT with heated humidified air (flow: 40 L/min with 80% oxygen) through a nasal cannula. IBH was monitored by optical surface tracking (OST) with visual feedback. At a training session, patients had to hold their breath as long as possible, without and with NHFT. For the daily cone beam CT (CBCT) and RT treatment in IBH, patients were instructed to keep their BH as long as it felt comfortable. OST was used to analyze stability and reproducibility of the BH, and CBCT to analyze daily tumor position. Subjective tolerance was measured with a questionnaire at 3 time points. RESULTS: Of 10 included patients, 9 were treated with RT. Seven (78%) completed the treatment with NHFT as planned. At the training session, the mean BH length without NHFT was 39 s (range 15-86 s), and with NHFT 78 s (range 29-223 s) (p = .005). NHFT prolonged the BH duration by a mean factor of 2.1 (range 1.1-3.9s). The mean overall stability and reproducibility were within 1 mm. Subjective tolerance was very good with the majority of patients having no or minor discomfort caused by the devices. The mean inter-fraction tumor position variability was 1.8 mm (-1.1-8.1 mm;SD 2.4 mm). CONCLUSION: NHFT for RT treatment of NSCLC in BH is feasible, well tolerated and significantly increases the breath-hold duration. Visually guided BH with OST is stable and reproducible. We therefore consider this an attractive patient-friendly approach to treat lung cancer patients with RT in BH.

Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction.

PURPOSE: During difficult airway management, oxygen insufflation through airway-exchange and intubating catheters (AEC/IC) can lead to life-threatening hyperinflation. Ventrain® was originally designed to facilitate emergency ventilation using active expiration through short, small-bore cannulas. Herein, we studied its efficacy (oxygenation and ventilation) and safety (avoidance of hyperinflation) in a long, small-bore AEC. METHODS: In six anesthetized pigs, the upper airway was obstructed, except for a 100 cm long, 3 mm internal diameter AEC. After apneic desaturation to a peripheral oxygen saturation (SpO2) of < 70%, ventilation through the AEC was started with Ventrain at an oxygen flow of 15 L·min-1, a frequency of 30 breaths·min-1, and an inspiration/expiration ratio of approximately 1:1. It was continued for ten minutes. RESULTS: Within one minute, severe hypoxia was reversed from a median [interquartile range] arterial saturation (SaO2) of 48 [34-56] % before initiation of Ventrain ventilation to 100 [99-100] % afterward (median difference 54%; 95% confidence interval [CI] 44 to 67; P = 0.028). In addition, hypercarbia was reversed from PaCO2 of 59 [53-61] mmHg to 40 [38-42] mmHg (median difference of -18 mmHg; 95% CI -21 to -15; P = 0.028). After ten minutes of Ventrain use, peak inspiratory and end-expiratory pressures were lower than during baseline pressure-controlled ventilation (8 [7-9] mmHg vs 12 [10-14] mmHg and -2 [-3 to +1] mmHg vs 4 [2 to 4] mmHg, respectively; P = 0.027 for both). No hemodynamic deterioration occurred. CONCLUSION: Ventrain provides rapid reoxygenation and effective ventilation through a small-bore AEC in pigs with an obstructed airway. In clinical emergency situations of obstructed airways, this device may be able to overcome problems of unintentional hyperinflation and high intrapulmonary pressures when ventilating through long, small-bore catheters and could therefore minimize the risks of barotrauma and hemodynamic instability.

The ocular disease of Aristodemus and Eurytus 480 BC: diagnostic considerations.

OBJECTIVE: In the historic description of Herodotus on the battle of Thermopylae at 480 BC two formerly healthy warriors suffer from "ophthalmia". The purpose of this study is to assess the possible aetiologies of this disease. DESIGN: We studied Herodotus' description in translation and offer a differential diagnosis. RESULTS: From the text we deduced that the "ophthalmia" was a condition in two physically fit males with a bilateral decreased or distorted vision, lasting longer than an hour, with an acute or subacute onset in Ancient Greece. The condition ultimately went into remission in one of the two patients, whereas the other subject deceased in combat not long after the onset of the disease, still suffering from the disease. The differential diagnosis consists of (1) anticholinergic syndrome secondary to an intoxication with the berries of the plant Atropa belladonna, (2) automutilation and (3) psychogenic loss of visual acuity. CONCLUSION: It is impossible to assess the ultimate cause of the "opthalmia" after 2500 years, but we suggest the anticholinergic syndrome by intoxication with Atropa belladonna is the most likely.