Hyperbaric oxygen therapy to prevent central airway stenosis after lung transplantation.

BACKGROUND: Central airway stenosis (CAS) is a severe airway complication after lung transplantation associated with bronchial ischemia and necrosis. We sought to determine whether hyperbaric oxygen therapy (HBOT), an established treatment for tissue ischemia, attenuates post-transplant bronchial injury. METHODS: We performed a randomized, controlled trial comparing usual care with HBOT (2 atm absolute for 2 hours × 20 sessions) in subjects with extensive airway necrosis 4 weeks after transplantation. Endobronchial biopsies were collected at 4, 7, and 10 weeks after transplantation for a quantitative polymerase chain reaction. Coprimary outcomes were incidence of airway stenting and acute cellular rejection (ACR) at 1 year. RESULTS: The trial was stopped after enrolling 20 subjects (n = 10 per group) after a pre-planned interim analysis showed no difference between usual care and HBOT groups in stenting (both 40%), ACR (70% and 40%, respectively), or CAS (40% and 60%, respectively). Time to first stent placement (median [interquartile range]) was significantly shorter in the HBOT group (150 [73-150] vs 186 [167-206] days, p < 0.05). HIF gene expression was significantly increased in donor tissues at 4, 7, and 10 weeks after transplantation but was not altered by HBOT. Subjects who developed CAS or required stenting had significantly higher HMOX1 and VEGFA expression at 4 weeks (both p < 0.05). Subjects who developed ACR had significant FLT1, TIE2, and KDR expression at 4 weeks (all p < 0.05). CONCLUSIONS: Incidence of CAS is high after severe, established airway necrosis after transplantation. HBOT does not reduce CAS severity or stenting. Elevated HMOX1 and VEGFA expressions appear to associate with airway complications.

Airway Blocks Vs LA Nebulization- An interventional trial for Awake Fiberoptic Bronchoscope assisted Nasotracheal Intubation in Oral Malignancies.

BACKGROUND: Patients with intra-oral malignancies warrants use of awake Fiberoptic assisted naso-thracheal intubation to secure an airway due to multiple risk factors leading to anticipated difficult airway. Different techniques such as airway blocks, local anesthesia (LA) gargles, spray, nebulization and  mild  sedation are in practice to improve  the success rate of fiberoptic assisted intubation. METHODS: Sixty patients  of  ASA I and II with Mallampatti score 3 and above, posted for Commando operations were enrolled in this study and were divided into 2 groups. Group AB (Airway Block, n=30) were given Superior laryngeal nerve block bilaterally and recurrent laryngeal nerve block  transtracheally  with Inj  2% Lignocaine. Second Group AN (Airway Nebulization, n=30)  patients airway was nebulized with 4% Lignocaine  with ultrasonic nebulizer. After confirmation of satisfactory anesthesia clinically Fiber-optic assisted naso-tracheal intubation was attempted. Hemodynamic monitoring, total time taken for intubation, patients comfort and any complications occurred were noted. Statistical Analysis- All the observed values were tabulated and analyzed using software SPSS version 17.0. RESULTS: Demography and Hemodynamic observations were comparable in the groups.  The time taken for intubation, patient comfort score, intubation conditions were excellent in AB group than in group AN. Airway complications like laryngospasm and cough were noted in AN Group. CONCLUSIONS: Judicial use of combined Airway blocks such as Bilateral Superior and trans-tracheal recurrent laryngeal nerve blocks could facilitate a successful fiber-optic assisted awake naso-tracheal intubation in anticipated difficult intubation with negligible complications.
.

Can exercise replace airway clearance techniques in cystic fibrosis? A survey of patients and healthcare professionals.

Airway clearance techniques (ACTs) are recommended in cystic fibrosis (CF) to prevent accumulation of secretions and lung infection. "Can exercise replace chest physiotherapy for people with CF?" is one of the CF community's top 10 research questions. We conducted an online survey of the CF community to gather data on current ACT use, recommendations, reported adherence levels and exercise strategies used. There were 488 respondents: 194 (40%) people with CF (pwCF), 141 (29%) family and 153 (31%) healthcare professionals (HCPs) (mostly physiotherapists). Only 10/285 (4%) of pwCF do no exercise at present and 163/303 (54%) already incorporate exercise into ACTs. ACTs were omitted by 128/267 (48%) of pwCF when they exercised. Nearly all (110/129, 93%) of HCPs currently recommend exercise to support ACTs. A trial replacing some or all ACTs with exercise, was supported by 80/110 (73%) of HCPs, with an additional 9/110 (8%) willing to consider in selected patients.

How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6-8†months.

OBJECTIVES: To compare the food, nutrient and 'family meal' intakes of infants following baby-led weaning (BLW) with those of infants following a more traditional spoon-feeding (TSF) approach to complementary feeding. STUDY DESIGN AND PARTICIPANTS: Cross-sectional study of dietary intake and feeding behaviours in 51 age-matched and sex-matched infants (n=25 BLW, 26 TSF) 6-8 months of age. METHODS: Parents completed a questionnaire, and weighed diet records (WDRs) on 1-3 non-consecutive days, to investigate food and nutrient intakes, the extent to which infants were self-fed or parent-fed, and infant involvement in 'family meals'. RESULTS: BLW infants were more likely than TSF infants to have fed themselves all or most of their food when starting complementary feeding (67% vs 8%, p<0.001). Although there was no statistically significant difference in the large number of infants consuming foods thought to pose a choking risk during the WDR (78% vs 58%, p=0.172), the CI was wide, so we cannot rule out increased odds with BLW (OR, 95% CI: 2.57, 0.63 to 10.44). No difference was observed in energy intake, but BLW infants appeared to consume more total (48% vs 42% energy, p<0.001) and saturated (22% vs 18% energy, p<0.001) fat, and less iron (1.6 vs 3.6 mg, p<0.001), zinc (3.0 vs 3.7 mg, p=0.001) and vitamin B12 (0.2 vs 0.5 µg, p<0.001) than TSF infants. BLW infants were more likely to eat with their family at lunch and at the evening meal (both p≤0.020). CONCLUSIONS: Infants following BLW had similar energy intakes to those following TSF and were eating family meals more regularly, but appeared to have higher intakes of fat and saturated fat, and lower intakes of iron, zinc and vitamin B12. A high proportion of both groups were offered foods thought to pose a choking risk.

Continuous negative external pressure (cNEP) reduces respiratory impairment during screening colonoscopy: a pilot study.

BACKGROUND AND STUDY AIMS: Drugs administered during gastrointestinal procedures cause increased collapsibility of the upper airway, which may lead to respiratory impairment. We evaluated the ability of continuous negative external pressure (cNEP) to lessen respiratory impairment during screening colonoscopy. PATIENTS AND METHODS: The initial 24 patients served as controls, while the next 30 received cNEP. cNEP was delivered by a soft silicone collar placed over the anterior neck. The primary endpoint was the frequency of respiratory impairment, defined as either: (i) a decline from baseline of > 4 % in oxygen saturation, or (ii) apnea lasting ≥ 20 seconds. RESULTS: Mean respiratory impairment episodes were 3.50 in the no-cNEP group vs. 1.92 in the cNEP group, a reduction of 45 % (P = 0.022). Apneas ≥ 20 seconds occurred in 74 % of the no-cNEP group and 28 % of the cNEP group (P = 0.002). While 42 % of the no-cNEP group required increased supplemental oxygen, this was true for only 10 % of the cNEP group (P = 0.01). cNEP adverse events were minimal. CONCLUSIONS: During screening colonoscopy, sedation-related respiratory impairment is significantly reduced by cNEP.ClinicalTrials.gov NCT01895062.

Using low level laser therapy to reduce early postoperative airway obstruction following modified Hogan's flap.

INTRODUCTION AND OBJECTIVE: The most common postoperative complications of velopharyngeal insufficiency surgery are postoperative bleeding and airway obstruction or obstructive sleep apnoea. Consequently, the aim of this study was to evaluate the effect of low level laser therapy (LLLT) during the first postoperative days in children undergoing superiorly based pharyngeal flap (SBF) surgery. MATERIALS AND METHODS: A randomized double blind clinical study on 30 children divided on two groups 15 patients each, who underwent SBF. LLLT was used in a group and the other was a control group. The study was conducted in academic tertiary care medical centres between 2013 and 2015. The degree of edema, oxygen saturation, occurrence of obstructive sleep apnoea (OSA) and steroid administration were recorded. RESULTS: The mean of the average oxygen saturation was significantly less in the control group in the 1st and 2nd day as compared to the laser group. The need for oxygen and the incidence of OSA in the first 3 days were significantly higher in the control group as compared to the laser group. The degree of edema showed no significant difference in the first day but was significantly higher in the control group in the 2nd and 3rd days. Hence, the need of steroids was significantly higher in the control group in the first 3 days. CONCLUSIONS: Preliminary results showed that low level laser therapy is effective in reducing the incidence of early postoperative airway obstruction after SBF operations.

Development and pilot testing of Baby-Led Introduction to SolidS--a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking.

BACKGROUND: In Baby-Led Weaning (BLW), infants are offered 'finger' foods from the start of the complementary feeding period instead of being spoon-fed. Healthcare professionals have expressed concerns about adequacy of iron and energy intake, and about choking, for infants following Baby-Led Weaning. METHODS: We developed a modified version of BLW, Baby-Led Introduction to SolidS (BLISS), to address these concerns. In a 12-week pilot study, families who had chosen to use a BLW approach were assigned to BLISS (n = 14) or BLW (n = 9). BLISS participants received 2 intervention visits, resources and on-call support. BLW participants received no intervention. Participants were interviewed weekly for 12 weeks and completed a three-day weighed record or three 24-h iron questionnaires. RESULTS: Compared to the BLW group, the BLISS group were more likely to introduce iron containing foods during the first week of complementary feeding, and to offer more serves per day of iron containing foods at 6 months (2.4 vs 0.8 serves/day; P = 0.001); and less likely to offer high-choking-risk foods (3.24 vs 0.17 serves/day; P = 0.027). CONCLUSIONS: This pilot study suggests BLISS may result in higher iron intakes and lower choking risk than unmodified BLW. However, the results need to be confirmed in a large randomised controlled trial.

Complementary home mechanical ventilation techniques. SEPAR Year 2014.

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.

Promising future therapies for asthma.

Asthma affects 300 million people worldwide and that number has been increasing especially in developed countries. The current standard of care for asthma treatment is based on 2 key pathological features of asthma, airway inflammation and airway obstruction. Improving bronchodilation can be accomplished with ultra-long acting beta2 agonists or long-acting muscarinic agonists used in combination with inhaled corticosteroids. These combinations have already been used effectively for the treatment of COPD. An inhaled phosphodiesterase inhibitor has been shown to improve bronchodilation and decrease airway inflammation. Directly altering the airway smooth muscle with bronchial thermoplasty in select patients has demonstrated long-term benefits but must be measured with immediate post procedure complications. The development of monoclonal antibodies to directly target specific cytokines has had mixed results. In eosinophilic asthma blocking IL-4, IL-5 and IL-13 have improved asthma outcomes. The promise of more directed therapy for asthma appears closer than ever with increased options available for the clinician in the near future.

Submental sensitive transcutaneous electrical stimulation (SSTES) at home in neurogenic oropharyngeal dysphagia: a pilot study.

OBJECTIVE: Oropharyngeal dysphagia is frequent in chronic neurological disorders and increases mortality, mainly due to pulmonary complications. Our aim was to show that submental sensitive transcutaneous electrical stimulation (SSTES) applied during swallowing at home can improve swallowing function in patients with chronic neurological disorders. METHODS: Thirteen patients were recruited for the study (4 f, 68 ± 12 years). They all suffered from neurogenic oropharyngeal dysphagia. We first compared the swallowing of paste and liquid with and without SSTES. Thereafter, the patients were asked to perform SSTES at home with each meal. Swallowing was evaluated before and after six weeks of SSTES using the SWAL-QoL questionnaire. RESULTS: With the stimulator switch turned on, swallowing coordination improved, with a decrease in swallow reaction time for the liquid (P<0.05) and paste boluses (P<0.01). Aspiration scores also decreased significantly with the electrical stimulations (P<0.05), with no change in stasis. At-home compliance was excellent and most patients tolerated the electrical stimulations with no discomfort. A comparison of the SWAL-QoL questionnaires after 6 weeks revealed an improvement in the burden (P=0.001), fatigue (P<0.05), and pharyngeal symptom (P<0.001) scales. CONCLUSION: The present study demonstrated that SSTES is easy to use at home and improves oropharyngeal dysphagia quality of life.

Baby-led weaning: transitioning to solid foods at the baby's own pace.

Baby-led weaning is an approach to the introduction of solid foods that is being followed by increasing numbers of parents, but what is it, and should health visitors be encouraging it? This paper aims to refresh practitioners' background knowledge of complementary feeding and to outline the key features of baby-led weaning, as well as to explore the evidence that supports this approach as a logical adjunct to the move to six months for the introduction of solid foods. The more common concerns of parents and professionals, such as choking and iron intake, are addressed. Tips for implementing baby-led weaning are included and some of the potential benefits identified.

Deep neck infections: clinical considerations in aggressive disease.

Deep neck infections are common and occur as a consequence of several etiologies. Antibiotic therapy, interventional radiology, and patient support modalities have become increasingly sophisticated, although surgery continues to be the mainstay of treatment for most patients. Today, neck infections are rarely life threatening when sound and timely management is applied.

L-arginine attenuates acute lung injury after smoke inhalation and burn injury in sheep.

Thermal injury results in reduced plasma levels of arginine (Arg). With reduced Arg availability, NOS produces superoxide instead of NO. We hypothesized that Arg supplementation after burn and smoke inhalation (B + S) injury would attenuate the acute insult to the lungs and, thus, protect pulmonary function. Seventeen Suffolk ewes (n = 17) were randomly divided into three groups: (1) sham injury group (n = 6), (2) B + S injury plus saline treatment (n = 6), and (3) B + S injury plus L-ARG infusion at 57 mg.kg(-1).h(-1) (n = 5). Burn and smoke inhalation injury was induced by standardized procedures, including a 40% area full thickness flame burn combined with 48 breaths of smoke from burning cottons. All animals were immediately resuscitated by Ringer solution and supported by mechanical ventilation for 48 h, during which various variables of pulmonary function were monitored. The results demonstrated that Arg treatment attenuated the decline of plasma Arg concentration after B + S injury. A higher plasma Arg concentration was associated with a less decline in Pao2/Fio2 ratio and a reduced extent of airway obstruction after B + S injury. Histopathological examinations also indicated a remarkably reduced histopathological scores associated with B + S injury. Nitrotyrosine stain in lung tissue was positive after B + S injury, but was significantly reduced in the group with Arg. Therefore, L-Arg supplementation improved gas exchange and pulmonary function in ovine after B + S injury via its, at least in part, effect on reduction of oxidative stress through the peroxynitrite pathway.

[What physical therapy techniques can be used to improve airway freedom in amyotrophic lateral sclerosis?]. / Quelles sont les modalités de thérapie physique symptomatique incluant les techniques de désencombrement bronchique?

In individuals with ALS rehabilitation is mainly designed to prevent fatigue and contracture, to improve independence and activities for as long as possible, to optimize ability to live with the handicap, and finally to maximize quality of life. The functional impairment must be defined and physical therapy techniques have to be adapted to each patient and reevaluated frequently during the course of the disease. Various types of massage and exercise, monitored by a physical therapist are effective. Strengthening or endurance exercises are controversial as exercise may injure muscle fibres and motor neurons. Isometric exercise, short of fatigue, of unaffected muscles is recommended. Range of motion exercise is critically important for preventing contraction. Assistive and adaptative equipments are essential for maintaining the patient's activities of daily living and home equipment preserves independence. Several orthoses for hand, arm, foot or cervical weakness are available. A wheelchair is an important adaptative device when walking becomes too fatiguing or impossible. Choice for special options and features may require attention. Pulmonary complications are prevented with adapted techniques for bronchic obstruction. Based on the degree of weakness of limb and axial muscles six stages of functional impairment can be defined ranging from fully ambulatory in stage I to bedridden and totally dependent in stage VI. This staging provides a framework for physical therapy evaluation and guidance for appropriate rehabilitation in ALS patients.

Feeding-facilitating techniques for the nursing infant with Robin sequence.

OBJECTIVE: To determine the effectiveness of feeding-facilitating techniques in children with Robin sequence. SETTING: Hospital de Reabilitação de Anomalias Craniofaciais, University of São Paulo, Bauru, São Paulo, Brazil. PATIENTS: Twenty-six children less than 2 months of age with Robin sequence, whose only cause of respiratory obstruction was glossoptosis. Thirteen infants were treated by being placed in the prone position (Group 1), and 13 were treated by nasopharyngeal intubation (Group 2). INTERVENTIONS: During hospitalization, the following feeding-facilitating techniques were applied daily to all children: pacifier, massage to relax and anteriorize the tongue, long and soft bottle nipple with original or enlarged hole, global symmetric position, rhythmic movement of the nipple during suction, and insertion of the nipple on the tongue. RESULTS: During the first evaluation, Group 1 patients accepted 36.15 +/- 33.05 mL milk orally within a period of 44.62 +/- 42.94 minutes, whereas Group 2 ingested 20.00 +/- 20.51 mL milk within 30.38 +/- 25.77 minutes. A significant increase (p < .01) in the volume of ingested milk was observed for the two groups at hospital discharge after a mean treatment period of 10.7 days (Group 1: 63.46 +/- 22.58 mL and Group 2: 55.00 +/- 13.07 mL). The mean duration of feeding decreased in the two groups, with a value of 21.54 +/- 7.18 minutes for Group 1 and of 20.28 +/- 8.53 minutes for Group 2. CONCLUSION: The results showed that feeding-facilitating techniques can foster oral feeding in infants with Robin sequence.

Management of airway in patients with laryngeal tumors.

STUDY OBJECTIVE: To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period. DESIGN: Retrospective analysis. SETTING: University-affiliated veterans administration medical center. PATIENTS: Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia). INTERVENTIONS: Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia. MEASUREMENTS AND MAIN RESULTS: When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next. CONCLUSIONS: With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.

Para-Bromophenacyl bromide alleviates airway hyperresponsiveness and modulates cytokines, IgE and eosinophil levels in ovalbumin-sensitized and -challenged mice.

Airway hyperresponsiveness, airway eosinophilia and increased IgE levels in serum are the important characteristic features of asthma. We evaluated the potential of para-Bromophenacyl bromide (PBPB), a known phospholipase A(2) inhibitor, on allergen-induced airway hyperresponsiveness in a mouse model. We sensitized and challenged mice with ovalbumin (OVA) to develop airway hyperresponsiveness as assessed by airway constriction and airway hyperreactivity (AHR) to methacholine (MCh) induced by allergen. The mice were orally treated with PBPB (0.1, 1 and 10 mg/kg) during or after OVA-sensitization and OVA-challenge to evaluate its protective or reversal effect on airway constriction and AHR to MCh. Determination of OVA-induced airway constriction and AHR to MCh were performed by measuring specific airway conductance (SGaw) using non-invasive dual-chamber whole body-plethysmography. We observed that PBPB (1 mg/kg) significantly reduced OVA-induced airway constriction and AHR to MCh (p<0.01). PBPB (1 mg/kg) treatment significantly inhibited PLA(2) activity in the BAL fluid. Cytokine analysis of the BAL fluid revealed that PBPB caused an increase in interferon-gamma (IFN-gamma) (p<0.02) and a decrease in interleukin-4 (IL-4) (p<0.05) and interleukin-5 (IL-5) (p<0.05) levels. The OVA-specific serum IgE levels (p<0.01) and the BAL eosinophils (p<0.001) were also reduced significantly. Thus, PBPB is capable of modulating allergen induced cytokine levels and serum IgE levels, and alleviating allergen induced airway hyperresponsiveness and eosinophils in mice. These data suggest that PBPB could be useful in the development of novel agents for the treatment of allergen induced airway hyperresponsiveness.

Nitroglycerin for relaxation to establish a fetal airway (EXIT procedure).

BACKGROUND: The ex utero intrapartum treatment (EXIT) procedure is a technique designed to establish an airway at the time of delivery in fetuses at risk of airway obstruction and requires maintenance of uterine relaxation to continue placental perfusion and prevent placental separation. We describe the use of intravenous nitroglycerin to maintain uterine relaxation during the EXIT procedure. CASE: A 17-year-old primigravida with a fetus known to have an anterior neck mass was admitted for a scheduled operative delivery at 38 weeks of gestation using a modified EXIT procedure. Anesthesia was administered with a combined spinal-epidural technique. Intravenous nitroglycerin was administered as a bolus and then as a continuous infusion to maintain uterine relaxation until evaluation of the neonatal airway was completed. CONCLUSION: Intravenous nitroglycerin is an effective agent for maintenance of uterine relaxation and placental perfusion during the EXIT procedure.

Prevención y tratamiento de las emergencias en odontología: 1ra parte / Prevention and treatment of emergencies in dentistry: 1st part

Es sumamente importante reconocer las urgencias en nuestra profesión y poder resolverlas eficientemente, pero más aún lo es poseer la capacidad, conocimiento y manejo adecuado de las emergencias que pueden presentarse en nuestra vida profesional, sea o no en nuestro ámbito laboral. Si es seguro que con un manejo adecuado de la mayoría de las emergencias el resultado será exitoso

Prevención y tratamiento de las emergencias en odontología: 1ra parte / Prevention and treatment of emergencies in dentistry: 1st part

Es sumamente importante reconocer las urgencias en nuestra profesión y poder resolverlas eficientemente, pero más aún lo es poseer la capacidad, conocimiento y manejo adecuado de las emergencias que pueden presentarse en nuestra vida profesional, sea o no en nuestro ámbito laboral. Si es seguro que con un manejo adecuado de la mayoría de las emergencias el resultado será exitoso (AU)