Comparative Evaluation of Difficult Intubation Predictors in Children Under Two Years of Ages

Background: Tracheal intubation is the most reliable way of securing an airway. Pediatric airway management is one of the significant challenges, especially for non-pediatric anesthesiologists. Early airway evaluation for detecting difficult intubation and preventing catastrophic events is necessary before anesthesia, especially in children. Objectives: Therefore, this study was done to compare some valuable adult predictors in children under two years of age. Methods: This prospective descriptive-analytical study was performed on 405 children under two years of age that were referred for elective surgery under general anesthesia with endotracheal intubation in Imam Hossein Hospital, Isfahan. Under sedation in a supine position, we measured items, including age, weight, height, stern omental distance (SMD), mouth opening (MO), neck circumference (NC), acromio-axillo-suprasternal notch index (AASI), and intubation difficulty scale score (IDS). An expert anesthesiologist did laryngoscopy and intubation, and difficult cases were recorded. Results: Our study showed that the frequency of difficult intubation with IDS > 4 was %16, and with IDS > 5 was %3. The variables, including age, weight, height, and SMD, significantly predicted difficult intubation. The cut-off points for age < 6 months, weight < 5/9 kg, height < 61 cm, and SMD < 5/3 cm were obtained, respectively. Other variables, such as MO, AASI, NC, and sex, were unreliable predictors for difficult intubation. Conclusions: We found that IDS > 4, age< 6-month, weight < 5/9 kg, and SMD < 5/3 cm are predictors for difficult intubation. It is helpful for the anesthesiologist to measure these predictions before anesthesia is started to find who has difficult intubation.

Comparative study of the reliability of ultrasound to confirm the position of endotracheal tube with cuff inflated with saline versus air

Aim: To compare the reliability of transtracheal ultrasound to confirm the endotracheal tube position with saline versus air inflated cuff. Methods: This was a prospective randomized cadaveric study. Four techniques were randomized: endotracheal tube in the trachea with air or saline inflated cuff, and endotracheal tube in the esophagus with air or saline inflated cuff. The investigator used the Mcgrath to randomly place the endotracheal tube in the trachea or in the esophagus with saline or air inflated cuff. During the first series of measurements, nine residents performed transtracheal ultrasound with linear transducer placed transversely at the suprasternal notch. They were recorded with a cut off fixed to 30 seconds, and a questionnaire was completed by the residents after each transtracheal ultrasound in order to report where the endotracheal tube is positioned according to them. The second series followed the same protocol and included three residents who had participated in the first series. The primary outcome was the success rate in determining the position of the endotracheal tube. Results: In the first series, the success rate was 46.5%. In the second series, the success rate was 72.9%. There was no significant difference between cuff inflated with saline and air (p = 1.00). The overall mean time required was 20.6 s (95% CI 13.0–28.2 s). Based on an empirical data set, transtracheal ultrasound had a sensitivity of 62.2%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 26.08%. Conclusion: This investigation shows that regardless of the contents of the endotracheal tube cuff, the use of transtracheal ultrasound to confirm the position of endotracheal tube reports disappointing results.

The Assessment of Nipple Areola Complex Sensation with Semmes-Weinstein Monofilaments—Normative Values and Its Covariates

Objective: To establish normative data for nipple-areola complex (NAC) sensibility examined with Semmes-Weinstein monofilament test (SWMT) and two-point discrimination (TPD) in women with varying breast sizes, including women with gigantomastia. We also aimed to identify clinical variables influencing NAC sensation. Methods: A total of 320 breasts in 160 Caucasian women (mean age 33.6 years, SD 11 years) were examined (including 50 hypertrophic breasts). NACs sensation was examined using Semmes-Weinstein monofilaments (SWM) and the Weber Two-Point Discrimination Test. Results: The nipple appeared to be the most sensitive part of NAC. In normal-sized breasts, sensation thresholds (SWM) correlated with: age, BMI, history of births, breast size and ptosis (for all locations), breastfeeding history (for nipple and upper areola) and areola diameter (for all locations apart from the nipple). Regression analysis showed that age, cup size and suprasternal notch-to-nipple distance are risk factors for diminished NAC sensation. Sensation thresholds in all NAC locations of hypertrophic breasts were significantly higher compared to normal-sized breasts, while TPD tests did not differ between the groups. Conclusions: We provided normative values of NAC sensation (tactile threshold and TPD) for different NAC areas. Our investigation indicated that SWM are useful diagnostic tools when the following factors are considered while examining NAC sensation: location (nipple vs. areola), age, breast size, suprasternal notch-to-nipple distance, history of births and breastfeeding. Hypertrophic breasts presented significantly higher sensation thresholds for all NAC locations. The report may serve as a reference data for further investigations regarding NAC sensation after different breast surgeries.

ACROMIO-AXILLO-SUPRASTERNAL NOTCH INDEX [AASI] : A SCREENING METHOD TO PREDICT DIFFICULT LARYNGOSCOPY IN PATIENT UNDERGOING GENERAL ANAESTHESIA AND REQUIRING ENDOTRACHEAL INTUBATION

Introduction and Aims: Difficult laryngoscopy [poor visualisation of larynx] is a surrogate indicator of difficult intubation and inability to manage difficult visualisation of larynx (DVL) can be life threatening. This study is performed to assess the ability of new index –Acromio -Axillo-Suprasternal Notch Index to predict difficult laryngoscopy in patient undergoing general anaesthesia in addition to other common predictors. Material and Methods: 100 patients with ASA class I and II candidate for general anaesthesia with endotracheal intubation were enrolled to this study. The four usual tests Modified MallampatiTest[MMT], Ratio Of Height to Thyromental Distance[RHTMD], Neck Circumference/ Thyromental distance, Sternomental distance difference were assessed before induction of anaesthesia. The new test AASI is calculated as follow: 1) Using a ruler a line is drawn vertically from the top of the acromion process to the superior border of the axilla at the pectoralismajor muscle named as line A. 2) A second line is drawn perpendicular to line A from the suprasternal notch (line B) and 3)That portion of line A that lies above where line B bisects line A is line C. AASI is calculated from the length of line C divided by line A[AASI = C/A]. By a skilled anaesthesiologist with more than 5 years of experience & who was unaware of the study, A laryngoscopy was done and based on Cormack-Lehane classification, grading of laryngoscopy was recorded. Sensitivity, specificity, positive predictive value and negative predictive value with 95% Confidence Interval for each airway predictor in isolation was studied. Results: DVL observed in 12% patients. We observed that sensitivity,specificity,PPV,NPV,AUC of Roc[95% confidence interval] of AASI was 80%[44.4-97.5%], 95.56%[89-98.8%],66.67%[42.22-84.6%],97.7%[92.6-99.33%},0.985[0.898-0.988]respectively & these results are better than other conventional methods of difficult airway predictors. Conclusion: AASI more than or equal to 0.5 is a good predictor of difficult visualisation of larynx (DVL) at direct laryngoscopy.

Tissue Mobilization During Double Source of Vibration Semioccluded Vocal Tract Exercises: A Neck and Face Surface Acceleration Study

Purpose This study primarily aimed at observing the possible tissue mobilization on facial, neck, and chest tissues caused by different double source of vibration semioccluded vocal tract exercises (DSV-SOVTEs). Another goal was to inspect the degree of self-perceived sensation of a massage-like sensation. Method Fifty-five participants engaged in a set of several DSV-SOVTEs: (a) phonation with a silicone tube submerged 2 and 8 cm below water surface, (b) Acapella Choice device, (c) lip trills, and (d) tongue trills. A self-perceived massage-like sensation was also assessed. All exercises were performed at three loudness levels. Tissue mobilization signal was captured by four accelerometers placed in four different body regions: (a) over the cheek, (b) over the neck, (c) over the thyroid cartilage, and (d) over the suprasternal notch. Results There is a differential effect of all DSV-SOVTEs on tissue mobilization. All four observed dependent variables from tissue oscillation modulation (frequency, amplitude, jitter, and shimmer) showed significant three-way interactions. In general, amplitude and frequency of tissue oscillation modulation increases with loudness. A self-perceived massage-like sensation showed highly significant differences between DSV-SOVTEs. Conclusions All DSV-SOVTEs do mobilize tissues. Type of exercise, loudness level, and body region produce an effect on all tissue oscillation variables. Acapella device produces the largest amplitude of vibration, lowest frequency, and more regular oscillation of tissue. Water resistance therapy showed the most irregular tissue oscillation. Control of these variables is likely to be relevant to obtain the best outcomes in patients.

Anatomical and positional variants of the brachiocephalic trunk in a Mexican population

Background Brachiocephalic trunk (BCT) variants may have a clinical impact during surgical procedures, some of which could be fatal. The objective of this study was to classify height positions of the BCT and report their prevalence in a Mexican population. Methods Patients: A retrospective, descriptive, observational, and cross-sectional was performed using computed tomography angiography (CTA) of adult (> 18 years of age) patients, without gender distinction, of Mexican origin. Measuring techniques were standardized using the suprasternal notch to analyze linear and maximum heights, linear and curved lengths, and the vertebral origin and bifurcation levels of the BCT. Results A total of 270 CTA were obtained (66.7% men and 33.3% women). A high position of BCT was present in 64.81% (n 175/270). The mean linear medial height was 0.58 ± 1.91 cm, the maximum height of the free edge was 3.85 ± 2.04 cm, side length of the midline at the maximum height of the free edge was 1.46 ± 2.59, linear length 3.72 ± 0.70, and a curve length 3.99 ± 0.79. The BCT origin was most predominant at the T3 (57.9%) and T4 (27.0%) vertebral levels, with the bifurcation at T2 (57.9%) and T1 (36.2%). Conclusions There is a high prevalence of high position BCT in our population. Patients should be assessed before any procedures in the area, due to the potential risk of complications.

Estimation of stature from outstretched arm span and measurement of component/s of upper limb in the natives of Gujarat

The outstretched arm span and measurement of components of the upper limb are a reliable predictors of stature when fragmentary remains of the human body are found. However, this relationship can be affected by age, sex, diet, racial and geographical differences, etc. Hence, a regional database is necessary to be more accurate. This cross-sectional, prospective analytical study included 200 students pursuing MBBS (Male = 100, Female = 100), natives of Gujarat, aged between 18 - 24 years with normal developmental history. Rich bells stature meter, Anthropometric metal rods (scaled), and Vernier caliper were used for taking measurements. SPSS software version 26 was used for statistical analysis. The findings showed a positive correlation between stature and the outstretched arm span as well as stature and various components of the upper limb. Except for the correlation between stature and the length of the shoulder to mid suprasternal notch in males, all of the results were statistically significant (p &#60; 0.05). Regression equations were derived and verified.Outstretched arm span is the most reliable indicator of stature whereas the length of the shoulder to mid suprasternal notch is the least reliable indicator of stature in both sexes in the natives of Gujarat. This study can be used as a reference in the future for medico-legal purposes.

Accurate arterial path length estimation for pulse wave velocity calculation in growing children and adolescents

Background: Most adult cardiovascular disease begins in childhood. Given the burgeoning obesity pandemic in children worldwide, there is a need for precise and scalable surveillance methods to detect subclinical cardiovascular disease in children and adolescents. Early detection allows early intervention and intensified primary prevention strategies in affected individuals. Carotid-femoral pulse wave velocity (PWV) directly measures arterial wall stiffness, an early feature of atherosclerosis. Calculation of PWV in growing children requires an accurate estimation of the true distance travelled by the aorto-femoral pressure wave, using surface anatomy landmarks. However, a variety of methods are used to estimate this distance, and these have not previously been investigated in growing children and adolescents. We sought to investigate this by comparing true arterial path length measured on computerized tomography (CT) scans, with a variety of estimations based on surface anatomy landmarks. Methods: Arterial path lengths were measured using multi-planar reformation (MPR) imaging software. These measurements were then compared with the surface anatomy measurements obtained using the same MPR imaging software. The fidelity of a variety of arterial path length estimation methods was tested. Results: The surface anatomy distance between the suprasternal notch and the angle of the mandible (PWV recording site in the neck), should be adjusted using the formula y=4.791+(1.0534*x). This value subtracted from the unadjusted distance from the suprasternal notch to the umbilicus, through the mid-inguinal crease to the femoral PWV recording site, provides the simplest reliable approximation of true intraluminal distance travelled. Conclusions: There is high correlation between the surface anatomy distances and the arterial path lengths they represent; however, these are not equal. Most surface anatomy measurements require adjustment using the formulae that we have provided, to accurately estimate the true distance travelled by the pulse wave.

Effect of Mouth Mask and Face Shield on Speech Spectrum in Slovak Language

In this paper, with the aim of assessing the deterioration of speech intelligibility caused by a speaker wearing a mask, different face masks (surgical masks, FFP2 mask, homemade textile-based protection and two kinds of plastic shields) are compared in terms of their acoustic filtering effect, measured by placing the mask on an artificial head/mouth simulator. For investigating the additional effects on the speaker’s vocal output, speech was also recorded while people were reading a text when wearing a mask, and without a mask. In order to discriminate between effects of acoustic filtering by the mask and mask-induced effects of vocal output changes, the latter was monitored by measuring vibrations at the suprasternal notch, using an attached accelerometer. It was found that when wearing a mask, people tend to slightly increase their voice level, while when wearing plastic face shield, they reduce their vocal power. Unlike the Lombard effect, no significant change was found in the spectral content. All face mask and face shields attenuate frequencies above 1–2 kHz. In addition, plastic shields also increase frequency components to around 800 Hz, due to resonances occurring between the face and the shield. Finally, special attention was given to the Slavic languages, in particular Slovak, which contain a large variety of sibilants. Male and female speech, as well as texts with and without sibilants, was compared.

The role of bedside ultrasound during tracheal intubation procedure

Tracheal intubation in complex settings (i.e. difficult airway, hemodynamic instability) means a challenging procedure [1]. It must be performed very quickly, being obviously essential to confirm the adequate positioning of the tube tip as soon as possible. Capnography is the most recommended tool in spite proper evaluation also includes clinical exam and X-ray, which implies some delay [2]. When capnography is not available and/ or misleading readings are present, bedside ultrasound can be extremely useful. The T.R.U.E. (Tracheal Rapid Ultrasound Exam) protocol consists on performing transverse bedside upper airway ultrasonography, by placing a linear transducer over the suprasternal notch [3]. At this level, tracheal and oesophagus are easily identified. In case of unnoticed oesophageal intubation, a gas art fact emerges in the oesophagus lumen. To definitively confirm the optimal tracheal tube position, regardless the absence of oesophageal gas artifact, left lung sliding must be checked in order to rule in/out a selective bronchial intubation.