A novel technique for assessment of post-extubation airway obstruction can successfully replace the conventional cuff leak test: a pilot study.

BACKGROUND: Post-extubation airway obstruction is an important complication of tracheal intubation. The cuff leak test is traditionally used to estimate the risk of this complication. However, the cuff leak test parameters are not constant and may depend on the respiratory system and ventilator settings. Furthermore, deflating the cuff also be a risk factor for patient-ventilator asynchrony and ventilator-associated pneumonia. Instead of using the cuff leak test, we measured the pressure of the leak to the upper airway through the gap between the tube and glottis with a constant low flow from the lumen above the cuff without deflating the cuff and called it "pressure above the cuff." The purpose of this study was to investigate whether pressure above the cuff can be used as an alternative to the cuff leak volume. METHODS: This prospective observational study was conducted at Kumamoto University Hospital after obtaining approval from the institutional review board. The pressure above the cuff was measured using an endotracheal tube with an evacuation lumen above the cuff and an automated cuff pressure modulation device. We pumped 0.16 L per minute of air and measured the steady-state pressure using an automated cuff pressure modulation device. Then, the cuff leak test was performed, and the cuff leak volume was recorded. The cuff leak volume was defined as the difference between the expiratory tidal volume with the cuff inflated and deflated. The relationship between the pressure above the cuff and cuff leak volume was evaluated. The patient-ventilator asynchrony during each measurement was also examined. RESULTS: The pressure above the cuff was measured, and the cuff leak volume was assessed 27 times. The pressure above the cuff was significantly correlated with the cuff leak volume (r = -0.76, p < 0.001). Patient-ventilator asynchrony was detected in 37% of measurements during the cuff leak test, but not during the pressure above the cuff test. CONCLUSIONS: This study suggests that pressure above the cuff measurement may be a less complicated alternative to the conventional cuff leak test for evaluation of the risk of post-extubation airway obstruction. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN000039987; March 30, 2020). https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000044604.

High cell-autonomy of the anterior endomesoderm viewed in blastomere fate shift during regulative development in the isolated right halves of four-cell stage Xenopus embryos.

The isolated right half (RH) or left half (LH) of Xenopus embryos can undergo regulation so as to form well-proportioned larvae. To assess how the combined actions of maternal determinants and cell-cell interactions contribute to form the well-proportioned larvae, we quantitatively compared four-cell stage blastomere fate between normal larvae and regulated larvae from RH embryos. In normal larvae, the clones of the right dorsal blastomere (RD) and right ventral blastomere (RV) were located unilaterally. In contrast, in regulated larvae: (i) the RD clone exclusively occupied the anterior endomesoderm (AE) derivatives, coinciding no RV progeny in those derivatives of normal larvae. The clone bilaterally populated tissues along the dorsal midline, which characteristically included the medial regions of both somites adjoining the notochord, with higher percentages on the right and anterior sides. (ii) The RV clone extensively compensated for the missing left side at the expense of its right side contribution, and bilaterally occupied the ventroposterior and also dorsal regions excluding the AE derivatives. This clone considerably populated, with altered orientations, the derivatives of the left half gastrocoel roof plate (GRP), the left half GRP being essential for laterality determination. These results show that the high cell-autonomy in the AE constitutes a mechanism common to both normal and regulative development. In regulated larvae, cell-cell interactions shifted the midlines on the dorsal side slightly and the ventral side to a greater extent. The cell lineage difference in the left half GRP could result in a different utilization of maternal determinants in that area.

Cervical cord injury complicated by acute mesenteric ischemia.

Acute mesenteric ischemia is a rare, life-threatening complication of cervical cord injury. This case report emphasized the importance of prompt diagnosis and treatment of this complication. A 60-year old Japanese man with no co-morbidities was diagnosed as a C2 cervical cord injury and traumatic brain injury after a fall-down trauma. He was admitted to the intensive care unit after cord decompression surgery. Nine days later, he presented tachycardia and hypotension. Ultrasound showed dilated intestines and ascites. Intestinal ischemia was suspected based on the contrast-enhanced computed tomography scan. We performed prompt surgical resection of a broad part of the small intestines. The ischemic region of the intestines was segmental and the cause was attributed to a non-occlusive mechanism. Acute mesenteric ischemia can be fatal and a delay in diagnosis leads to poor outcomes. We focus on predisposing factors in patients with cervical cord injuries and how to prevent this serious diagnosis.