Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís / Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: a randomized cross-over manikin trial

Introducción. Los dispositivos supraglóticos forman parte esencial en el manejo de la vía aérea difícil. El objetivo del presente estudio fue comparar las características de la intubación con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ (ML-Fastrach™) por residentes de anestesia en maniquís. Métodos. Estudio aleatorizado y cruzado en el que participaron 33 residentes de anestesia. Se midió el tiempo de inserción (inserción del dispositivo en el maniquí y administración de 2 insuflaciones), el tiempo hasta la intubación traqueal (intubación guiada con el fibrobroncoscopio) y el tiempo para retirar los dispositivos (retirada de la Air-Q®/ML Fastrach™ sobre el tubo endotraqueal). Se evaluó la opinión de la facilidad de utilización. Resultados. Hubo una tasa de éxito del 100% para la intubación traqueal con ambos dispositivos al primer intento. El tiempo de inserción y administración de 2 ventilaciones fue de 10±3s para Air-Q® y de 11±3s para la ML-Fastrach™, p=0,07. El tiempo de intubación traqueal fue más corto con Air-Q®, 38±15s, que con la ML-Fastrach™, 47±19s, p=0,017. El tiempo total fue significativamente más corto con Air-Q® en comparación con la ML-Fastrach™, con un tiempo medio de 74±21 y 87±28s respectivamente, p=0,002. La retirada de la Air-Q® se consideró más fácil que la de la ML-Fastrach™, p=0,005. No se registraron desplazamientos del tubo endotraqueal durante la extracción de los dispositivos. Conclusiones. Los residentes de anestesia pueden realizar la intubación con fibrobroncoscopio a través de la Air-Q® y de la ML-Fastrach™ de forma exitosa y con tiempos clínicamente aceptables (AU)

Introduction. 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. Methods. 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. Results. 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. Conclusions. Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success (AU)

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial. / Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success.

Más de 3 horas y menos de 3 años. Seguridad de procedimientos anestésicos en niños menores de 3 años, sometidos a cirugías de más de 3 horas / More than 3 hours and less than 3 years old. Safety of anesthetic procedures in children under 3 years of age, subject to surgeries of more than 3 hours

No disponible

Miocardiopatía hipertrófica severa familiar y muerte súbita / Familial severe hypertrophic cardiomyopathy and sudden cardiac death

No disponible

Predicted end-tidal sevoflurane concentration for insertion of a Laryngeal Mask Supreme: a prospective observational study.

CONTEXT: The single-use Laryngeal Mask Airway (LMA) Supreme is a new supraglottic airway device. It has been reported to be reliable and easy-to-use in clinical practice; however, the anaesthetic techniques for its insertion are not standardised. OBJECTIVES: The purpose of this study was to determine the ED50 of end-tidal sevoflurane concentration for successful LMA Supreme insertion without the use of neuromuscular blockade. DESIGN: A prospective observational study. SETTING: A single tertiary care surgical centre. PATIENTS: Thirty-one consecutive elective patients scheduled for minor elective surgery under general anaesthesia. INTERVENTION: Patients were preoxygenated with 100% oxygen and anaesthetised using normal tidal volume inhalation of sevoflurane. The target sevoflurane concentration was determined using a modified Dixon's 'up-and-down' method (starting at 2.5% with 0.5% as the step size). After the predetermined end-tidal concentration had been established and maintained for 10 min, LMA Supreme insertion was attempted. MAIN OUTCOME MEASURE: The main outcome measure was the patient's response to LMA Supreme insertion, classified as either 'movement' or 'no movement'. The mean of the concentrations of seven cross-overs from 'movement' to 'no movement' was used to estimate the ED50. RESULTS: The estimated sevoflurane concentration for successful LMA Supreme insertion in 50% of adults was 3.03 ± 0.75% (95% confidence interval 2.3 to 3.7%). The values of the ET50 and ET95 obtained by logistic regression were 2.83 and 5.30%, respectively. CONCLUSION: Sevoflurane alone can provide acceptable conditions for insertion of the LMA Supreme in adults, at an estimated minimum alveolar anaesthetic concentration of 3% with minimal adverse effects.

Impacto sobre el cuidador principal de una intervención realizada a personas mayores dependientes / Impact on the primary carer of an intervention carried out on depenedent elderly people

Objetivos: Evaluar el impacto de un programa de atención domiciliaria de personas mayores dependientes sobre el cuidador principal.DiseñoEstudio de intervención «antes-después».EmplazamientoAtención primaria.ParticipantesCuidadores principales de personas dependientes mayores de 65 años incluidas en un programa de atención domiciliaria (n=156; 7,8% de pérdidas durante el seguimiento).IntervencionesPrograma de atención domiciliaria de personas mayores dependientes.Mediciones principalesSe realizó una medición basal y una evaluación al año de seguimiento. Se evaluaron la salud percibida, la frecuentación, y la satisfacción con la atención recibida, y se administraron los cuestionarios de calidad de vida de Nottingham, de salud psíquica de Golberg, de apoyo social de Duke-UNC y de sobrecarga del cuidador de Zarit).ResultadosNo se observó una modificación significativa de la salud percibida. Mejoraron (p<0,05) las esferas de energía, sueño, emocional y relación social de la calidad de vida. Disminuyó la frecuentación (8,4 vs 7,5; p<0,05) y el porcentaje de hiperfrecuentadores (30,1% vs 6,9%; p<0,01). Se redujo el porcentaje que expresan escaso apoyo social (8,3 vs 2,8%; p<0,05) y sobrecarga del cuidador (56,4 vs 44,4%; p<0,05). El 90,3% consideran que la asistencia mejoró, con mejora significativa de la asistencia recibida global, médica y de enfermería (7,6 vs 8,4; 7,9 vs 8,5 y 7 vs 8,5; p<0,05).ConclusionesLa incorporación a un programa de atención domiciliaria de personas dependientes repercute positivamente sobre su cuidador principal, mejorando su percepción sobre la asistencia recibida, reduciendo su utilización de los servicios sanitarios, disminuyendo el grado de sobrecarga y su percepción de falta de apoyo social(AU)

Objective: To evaluate the impact of joining a home care program on primary caregivers of dependent elderly people.DesignNon-randomised “before-after” intervention study.SettingPrimary Care.ParticipantsPrimary carers of elderly dependent people included in a home care program (n=156; 7.8% loss to follow up).InterventionsInclusion in a home care program for chronically dependent elderly and the assessment of the primary carer in the same year.Variables assessedperceived health, frequency of visits, questionnaires of quality of life (Nottingham questionnaire), psychological health (Goldberg questionnaire), social support (Duke-UNC scale) and overburden of caregivers (Zarit questionnaire) and satisfaction with care received.ResultsThere were no significant changes in perceived health. Improvement in the areas of energy, sleep, emotional and social relationship of the quality of life. Decreased attendance (8.4 vs. 7.5, p<0.05) and the percentage of overusers (30.1 vs 6.9%, P<.01). A reduced percentage of caregivers expressed low social support (8.3 vs 2.8%, P<.05) and caregiver overburden (56.4 vs 44.4%, P<.05). 90.3% of caregivers believed that care had improved at the end of intervention, with a significant improvement of satisfaction of overall medical and nursing care received (7.6 vs 8, 4, 7.9 vs 8.5 and 7 vs 8.5; P<.05).ConclusionsJoining a home care program for dependents has a positive impact on their primary caregiver and improves their perception of care received, reducing their use of health services, reducing the level of overburden and their perceived lack of social support(AU)

Nuevas aportaciones de la mascarilla laríngea en cirugía ambulatoria. Contribución de la mascarilla laríngea Supreme / No disponible

Desde la introducción de la mascarilla laríngea, su uso se ha expandido especialmente en el contexto de la cirugía ambulatoria. La mascarilla laríngea representa el “patrón oro” de los dispositivos supraglóticos, y es la referencia con la que los nuevos dispositivos deben ser comparados. La presente revisión es una actualización de las principales indicaciones de la mascarilla laríngea en usos avanzados, incluyendo el abordaje de la vía aérea difícil en el paciente intervenido de forma ambulatoria. Así mismo se incluye una revisión de las indicaciones, aportaciones, y ventajas de la mascarilla laríngea Supreme aplicadas al contexto de la cirugía sin ingreso (AU)

Since the introduction of the original laryngeal mask airway(LMA) in the nineties in our country, its use has expanded especially in the context of outpatient surgery. The LMA remains the “gold standard” of the supraglotic devices and the standard by which all other devices should be compared. This review is an update of the main indications of the LMA in advanced applications, including addressing the difficult airway in the patient operated on an outpatient basis. Also includes a review of the information, contributions, and advantages of the LMA supreme applied to the context of day surgery (AU)

[Impact on the primary carer of an intervention carried out on dependent elderly people]. / Impacto sobre el cuidador principal de una intervención realizada a personas mayores dependientes.

OBJECTIVE: To evaluate the impact of joining a home care program on primary caregivers of dependent elderly people. DESIGN: Non-randomised "before-after" intervention study. SETTING: Primary Care. PARTICIPANTS: Primary carers of elderly dependent people included in a home care program (n=156; 7.8% loss to follow up). INTERVENTIONS: Inclusion in a home care program for chronically dependent elderly and the assessment of the primary carer in the same year. VARIABLES ASSESSED: perceived health, frequency of visits, questionnaires of quality of life (Nottingham questionnaire), psychological health (Goldberg questionnaire), social support (Duke-UNC scale) and overburden of caregivers (Zarit questionnaire) and satisfaction with care received. RESULTS: There were no significant changes in perceived health. Improvement in the areas of energy, sleep, emotional and social relationship of the quality of life. Decreased attendance (8.4 vs. 7.5, p<0.05) and the percentage of overusers (30.1 vs 6.9%, P<.01). A reduced percentage of caregivers expressed low social support (8.3 vs 2.8%, P<.05) and caregiver overburden (56.4 vs 44.4%, P<.05). 90.3% of caregivers believed that care had improved at the end of intervention, with a significant improvement of satisfaction of overall medical and nursing care received (7.6 vs 8, 4, 7.9 vs 8.5 and 7 vs 8.5; P<.05). CONCLUSIONS: Joining a home care program for dependents has a positive impact on their primary caregiver and improves their perception of care received, reducing their use of health services, reducing the level of overburden and their perceived lack of social support.

¿Qué cualidades valoran más los Pacientes de su Médico de Familia? / What qualities do patients value more in a Family Doctor?

Objetivo. Conocer qué cualidades del Médico de Familia son más valoradas por los pacientes y en qué medida son cumplidas. Diseño. Estudio descriptivo transversal. Emplazamiento. Atención Primaria. Área de Toledo. Participantes. Mayores de 14 años del Área, seleccionados por muestreo aleatorio sistemático. Mediciones principales. Encuesta telefónica diseñada ad hoc con ítems sobre las características relevantes del médico y el cumplimiento de las mismas, en escala de 0 a 10. Se recogieron también variables sociodemográficas, enfermedades crónicas y utilización de consultas. Resultados. Fueron entrevistados 161 pacientes, con edad media de 42,6 años. El 55,7% mujeres. El 69,7% tenía alguna enfermedad crónica. El 38,6% de ellos había acudido a su médico en el último mes, mientras que el 90,4% lo había hecho en el último año. Las características más valoradas fueron la ‘confiabilidad’ y el ‘trato respetuoso’; las menos valoradas fueron la ‘participación en la toma de decisiones’ y la ‘aceptación de pruebas demandadas por el paciente’. Respecto al grado de cumplimiento de dichas cualidades, destacan el ‘trato respetuoso’ y la ‘confiabilidad’. Conclusiones. La utilización de consulta es muy elevada en nuestro medio. Los pacientes valoran más cualidades de “índole personal” del médico que las de tipo técnico u organizativo. La participación en la toma de decisiones es de las menos valoradas. En general, los médicos del Área de Toledo cumplen en buena medida las expectativas planteadas en lo que a las cualidades personales se refiere (AU)

Objective. To determine what qualities patients value most in a Family Doctor and to what extent their doctors meet these expectations. Design. Cross sectional, descriptive study. Setting. Primary care. Toledo. Participants. Patients over 14 years old, selected by a random sampling method. Main measurements. An ad hoc telephone survey with items on the characteristics of a doctor and compliance to them, measured on a scale of 1 to 10. Socio-demographic variables, chronic diseases and use of doctors’ surgeries were also recorded. Results. A total of 161 patients with a mean age of 42.5 years were interviewed. 55.7% were women. 69,7% had a chronic disease. 38,6% had visited their doctor in the last month, whilst 90.4% had done so in the last year. The most valued characteristics were ‘reliability’ and ‘respectful treatment’; the least valued were “participation in making decisions” and “agreeing to tests requested by the patients”. “Respectful treatment” and “reliability” were the characteristics that most met the patients’ expectations. Conclusions. The use of doctors’ surgeries is very high in our area. The patients valued qualities of a “personal nature” more than technical or organizational qualities. Participation in the decision making process was less valued. In general doctors in the Toledo health area met patients’ expectation as regards personal characteristics (AU)

[Anesthesia for cesarean section in a patient with recessive dystrophic epidermolysis bullosa]. / Tratamiento anestésico para cesárea en una paciente con epidermolisis bullosa distrófica recesiva.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

[Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications]. / Dos casos de obstrucción congénita de la vía aérea sometidos a E.X.I.T. ("ex-utero intrapartum treatment"): implicaciones anestésicas.

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.

Dos casos de obstrucción congénita de la vía aérea sometidos a E.X.I.T. ("ex-utero intrapartum treatment"): implicaciones anestésicas / Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications

El procedimiento E.X.I.T. (“Ex-Utero Intrapartum Treatment”) proporciona un tiempo adecuado para conseguir el control de una vía aérea fetal potencialmente obstruida mientras se mantiene la circulación útero-placentaria durante la cesárea. Describimos dos casos clínicos de fetos con obstrucción congénita de la vía aérea alta en los que la estrategia E.X.I.T. permitió permeabilizar con éxito y sin complicaciones en la vía aérea. Además de tomarse las consideraciones generales de la paciente obstétrica y de realizarse anestesia fetal intramuscular, previamente a la histerotomía se administró sevofluorano a 1,5 CAM para conseguir una adecuada relajación uterina durante el procedimiento. Las dos gestantes permanecieron hemodinámicamente estables durante el procedimiento con una adecuada perfusión útero-placentaria. En un feto la intubación nasotraqueal fue posible tras disecar la masa cervical mientras que en el otro se realizó una traqueostomía. Tras el clampaje del cordón umbilical se redujo la concentración de halogenado y se administraron oxitocina y metilergometrina para conseguir una contracción uterina adecuada en pocos minutos. Ambos neonatos sobrevivieron al procedimiento sin complicaciones

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterectomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications

Bougie-guided insertion of the ProSeal laryngeal mask airway has higher first attempt success rate than the digital technique in children.

BACKGROUND: We tested the hypothesis that bougie-guided insertion of the ProSeal laryngeal mask airway (ProSeal LMA) has higher success rate than the digital technique in children. METHODS: One hundred and twenty children (ASA I-II, aged 1-16 yr) were randomly allocated for ProSeal LMA insertion using the digital or bougie-guided technique. The digital technique was performed according to the manufacturer's instructions. The bougie-guided technique involved priming the drain tube with a bougie, placing the bougie in the oesophagus under direct vision and railroading the ProSeal LMA into position. Unblinded data were collected about ease of insertion (number of attempts and time taken to provide an effective airway), efficacy of seal, ease of gastric tube placement, haemodynamic responses and blood staining. Blinded data were collected about postoperative airway morbidity. RESULTS: The first attempt success rate was higher for the bougie-guided technique (59/60 vs 52/60, P=0.015), but effective airway time was longer (37 vs 32 s, P<0.001). There were no differences in efficacy of seal, ease of gastric tube placement, haemodynamic responses, blood staining or postoperative airway morbidity. CONCLUSION: We conclude that bougie-guided insertion of the ProSeal LMA has a higher first attempt success rate than the digital technique in children.

A randomized non-crossover study comparing the ProSeal and Classic laryngeal mask airway in anaesthetized children.

BACKGROUND: We tested the hypothesis that ease of insertion, oropharyngeal leak pressure, fibreoptic position, gastric insufflation, and the frequency of mucosal trauma differ between the ProSeal laryngeal mask airway (PLMA) and the classic laryngeal mask airway (cLMA) in anaesthetized children. For the PLMA, we also assessed the ease of gastric tube placement via the PLMA drain tube and measure residual gastric volume. METHODS: 240 consecutive ASA I-III children aged 1-16 yr were randomized for airway management with the ProSeal or cLMA. RESULTS: The time taken to provide an effective airway, the number of insertion attempts, fibreoptic position of the airway tube and frequency of mucosal trauma were similar, but oropharyngeal leak pressure was higher (33 vs 26 cm H(2)O, P<0.0001) and gastric insufflation less common (0 vs 6%, P<0.01) for the PLMA. Gastric tube insertion was successful at the first attempt in 106 of 120, and at the second attempt in 14 of 120. The mean (sd; range) value for residual gastric volume was 2.2 (5.9; 0-30) ml. There were no differences in performance among sizes for the PLMA and the cLMA. CONCLUSIONS: We conclude that ease of insertion, fibreoptic position, and frequency of mucosal trauma are similar for the PLMA and cLMA in children, but oropharyngeal leak pressure is higher and gastric insufflation less common for the PLMA. Gastric tube insertion has a high success rate, provided the PLMA is correctly positioned.

The ProSeal laryngeal mask airway in children.

BACKGROUND: The ProSeal (PLMA) is a new laryngeal mask device with a modified cuff to improve the seal and a drain tube to provide access to the gastrointestinal tract. We assessed the performance of the size 2 (which has no dorsal cuff) and size 3 (which has a dorsal cuff) in terms of insertion success, efficacy of seal, tidal volume, gas exchange, fiberoptic position, gastric tube placement and frequency of problems. METHODS: Eighty children undergoing minor surgery were studied (n = 40, size 2 PLMA, weight 10-25 kg; n = 40, size 3 PLMA, weight >25-50 kg). Induction was with remifentanil and propofol. Insertion was with the introducer tool and by experienced users. Maintenance was with propofol or sevoflurane and pressure controlled ventilation. RESULTS: The first-time and overall insertion success rate was 84 and 100%, respectively. Oropharyngeal leak pressure was 31 +/- 5 cmH2O. There were no gastric or drain tube air leaks. Tidal volume and gas exchange was adequate in all patients, other than two brief episodes of hypoxia because of airway reflex activation. The vocal cords and epiglottis were visible in 99 and 80%, respectively, via the airway tube. The first-time and overall insertion success rate for gastric tube insertion was 87 and 100%, respectively. During maintenance, the PLMA was removed in one patient with airway reflex activation and another required epinephrine for bronchospasm. There were no differences in performance between the sizes 2 and 3 PLMA. CONCLUSION: The PLMA is an effective airway device in children and isolates the glottis from the esophagus when correctly positioned. Despite the lack of a dorsal cuff, the performance of the size 2 was similar to the size 3 PLMA in the age groups tested.