Ventilation Airway Research Articles

IL-17 Aggravates Pseudomonas aeruginosa Airway Infection in Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

Pseudomonas aeruginosa airway infection increases risks of exacerbations and mortality in chronic obstructive pulmonary disease (COPD). We aimed to elucidate the role of IL-17 in the pathogenesis. We examined the expression and influences of IL-23/IL-17A in patients with stable COPD (n = 33) or acute COPD exacerbations with P. aeruginosa infection (n = 34). A mouse model of COPD (C57BL/6) was used to investigate the role of IL-17A in host inflammatory responses against P. aeruginosa infection through the application of IL-17A–neutralizing antibody or recombinant IL-17A. We found that P. aeruginosa infection increased IL-23/17A signaling in lungs of both COPD patients and COPD mouse models. When COPD mouse models were treated with neutralizing antibody targeting IL-17A, P. aeruginosa induced a significantly less polymorphonuclear leukocyte infiltration and less bacterial burden in their lungs compared to those of untreated counterparts. The lung function was also improved by neutralizing antibody. Furthermore, IL-17A-signaling blockade significantly reduced the expression of pro-inflammatory cytokine IL-1β, IL-18, TNF-α, CXCL1, CXCL15 and MMP-9, and increased the expression of anti-inflammatory cytokine IL-10 and IL-1Ra. The application of mouse recombinant IL-17A exacerbated P. aeruginosa-mediated inflammatory responses and pulmonary dysfunction in COPD mouse models. A cytokine protein array revealed that the expression of retinol binding protein 4 (RBP4) was down-regulated by IL-17A, and exogenous RBP4-recombinant protein resulted in a decrease in the severity of P. aeruginosa-induced airway dysfunction. Concurrent application of IL-17A-neutralizing antibody and ciprofloxacin attenuated airway inflammation and ventilation after inoculation of P. aeruginosa in COPD mouse models. Our results revealed that IL-17 plays a detrimental role in the pathogenesis of P. aeruginosa airway infection during acute exacerbations of COPD. Targeting IL-17A is a potential therapeutic strategy in controlling the outcomes of P. aeruginosa infection in COPD patients.

Influence of different head and neck positions on oropharyngeal leak pressures and cuff positions with Ambu® AuraGainTM laryngeal airway in children

Background: Ambu® AuraGain™ laryngeal airway is a supraglottic airway device designed to provide better airway protection and airway seal pressures. Aim of Study: To quantify oropharyngeal leak pressures (OPLPs), fibreoptic view, peak airway pressure and ventilation scoring with Ambu® AuraGain™ in children in different head and neck positions such as maximum flexion, maximum extension and lateral rotation. Patients and Methods: Sixty-eight children aged between 1 and 6 years posted for surgery were enrolled. Ambu® AuraGain™ was inserted after the induction of anaesthesia and ventilation was confirmed. OPLP, fibreoptic view, peak airway pressure and ventilation scores were noted in different head and neck positions such as maximum flexion, maximum extension and lateral rotation. Results: The OPLP significantly increased in flexion (P < 0.001) and significantly decreased in extension (P < 0.001) when compared to the neutral position. Airway pressure (Paw) increased significantly in flexion (P < 0.001) and decreased in extension (P = 0.04) when compared to the neutral position. Tidal volume delivery was comparable in all positions. There was a statistically significant decrease in ventilation scoring in the flexed position when compared to the neutral position (P = 0.005). There was a significant worsening of fibreoptic view in flexion when compared to the neutral position (P < 0.001). Fibreoptic view in the lateral position and extension was comparable with the neutral position. Conclusions: Use of Ambu® AuraGain™ laryngeal airway provides the best ventilatory parameters and Paw in children with head in the neutral and lateral position but lower OPLP with head in extension. However, flexing the head results in the worst ventilatory parameters and Paw among the positions studied.

Numerical assessment of a 3D human upper respiratory tract model: effect of anatomical structure on asymmetric tidal pulmonary ventilation characteristics

The analysis of airway ventilation characteristic is important for diagnosis and pathological assistance for respiratory diseases. It is therefore imperative to study the impact of anatomical features on the internal flow field. The article is focused on an in-silico study on impact of anatomical structure of human upper respiratory tract on transient asymmetric tidal pulmonary ventilation characteristics. Therefore, a three-dimensional human airways model is reconstructed from nasal cavity up to seventh generation bronchi from computed tomography (CT) images of a 48-year-old healthy man using computational modelling technique. A validated low Reynolds number (LRN) realisable k - ε turbulence model is used to capture the internal flow mixed turbulence characteristics. The numerical simulations were performed for asymmetric low and high tidal pulmonary ventilation (ALTPV, 10 L/min and AHTPV, 40 L/min). The numerical analysis assists to predict the near realistic airway ventilation phenomena and internal flow physics in the upper respiratory tract.

ACTUALIZACIÓN DEL MANEJO PREHOSPITALARIO DEL PACIENTE CON TRAUMA GRAVE

INTRODUCTION The goals of pre-hospital care for severe trauma are the detection of lifethreatening injuries, the early application of therapeutic measures and the timely transfer to an appropriate hospital centre. The response of the emergency services to major trauma incidents involves different responders with specific functions and in a variety of often challenging contexts. Therefore, a common language, preparation and coordination are essential to ensure compliance with the goals and quality of care. OBJECTIVE To carry out an update on the management of the adult trauma patient based on new evidence and practices. METHODS Literature review search mainly through PubMed. A secondary search on UptoDate and the latest editions of reference books on prehospital and advanced major trauma, and in reference organizations such as Difficult Airway Society, Advanced Trauma Life Support, European Trauma Course, and Anaesthesia, Trauma and Critical Care Course (ATACC). A tertiary search through the references in the UpToDate guidelines to identify new sources. Search terms included: prehospital care, major trauma, difficult airway, permissive hypotension, immobilization, both in Spanish and English. RESULTS The management of catastrophic bleeding is the first step in the primary assessment, because it can cause death even before an obstructed airway. Airway management and ventilation remain a priority. Permissive hypotension is increasingly accepted in the management of major trauma with hypovolemic shock except in the case of patients with head trauma. Prevention and control of the deadly triad (acidosis, hypoxia and hypothermia) improve the prognosis. An “excessive stabilization” approach should be avoided, so that access to definitive treatment is not delayed. CONCLUSIONS Prehospital trauma care is necessarily multidisciplinary, requiring coordination and communication between teams to ensure quality of care.

Airway Management During Cardiopulmonary Resuscitation.

Purpose of the reviewThis review summarizes the updated literature on airway management during cardiopulmonary resuscitation (CPR). It provides guidance for clinicians to carefully incorporate the most recent recommendations related to airway management, oxygenation, and ventilation both during CPR and after return of spontaneous circulation.Recent FindingsThe American Heart Association and the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care provide updated recommendations related to airway management during CPR, which focus on advanced airway strategies in out-of-the hospital cardiac arrest and in-hospital cardiac arrest. There is no evidence that any single advanced airway technique is superior to the other in terms of survival and neurological outcomes. There is controversy as to whether early advanced airway management could lead to favorable outcome.SummaryAdvanced airway strategies and alternatives to airway management (including passive oxygenation) can be utilized in different settings while minimizing interruption in chest compressions.

Findings of Maxillofacial and Occlusal Development by Evaluation of Pharyngeal Airway Ventilation in Children

Findings of Maxillofacial and Occlusal Development by Evaluation of Pharyngeal Airway Ventilation in Children

Airway Management: A Case of Desmoplastic Ameloblastoma of Right Mandibular Body

Background- Desmoplastic ameloblastoma (DA) is an uncommon variety of ameloblastoma that accounts for 4–13% of all cases, with notable differences in anatomical location, imaging, and histologic appearance. It is classified as a variety of ameloblastoma in the WHO classification of head and neck tumours (WHO-2005). Because it commonly occurs in the anterior region of the jaws as a mixed radio-opaque-radiolucent lesion, the tumour resembles a benign fibro-osseous lesion.&#x0D; Case report- We present a case of desmoplastic ameloblastoma in a 51-year-old female with a painless swelling in the lower right region of mandible. Fine needle aspiration revealed no fluid. Both panoramic radiographs and a computed tomography scan revealed a mixed lesion with a multilocular appearance. Desmoplastic ameloblastoma was confirmed after an incisional biopsy. From teeth 41 to the angle of the jaw, a composite resection of the lesion was performed with segmental mandibulectomy. With a peek implant, it was repaired. The possibility for a problematic airway is emphasised in this case, with great surgical results.&#x0D; Conclusion: Desmoplastic ameloblastoma is a kind of ameloblastoma with unique clinic radiographic and histologic characteristics. Despite its rarity, the tumour necessitates a thorough examination due to the challenges it poses with airway ventilation and intubation.

FEATURES OF CARDIOPULMONARY RESUSCITATION IN PATIENTS WITH MORBID OBESITY

Resume. Resuscitation of the obese patient presents a challenge for even the most skilled physician. Changes in anatomy, metabolic, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the obese patient, namely circulatory resuscitation, defibrillation, approach to the obese airway and mechanical ventilation, pharmacotherapy of cardiovascular drugs. Materials and methods: Electronic databases of Scopus and PubMed were searched using keyword searches Conclusions. Obesity causes important anatomical and physiological changes that affect resuscitation measures. Healthcare professionals should take into account the specifics of cardiopulmonary resuscitation in patients with morbid obesity to increase the effectiveness of resuscitation in this group of patients

Laryngeal mask ventilation with chest compression during neonatal resuscitation: randomized, non-inferiority trial in lambs.

Background:Effective positive pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC).Methods:Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 minutes of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till return of spontaneous circulation (ROSC) or 20 minutes.Results:Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min – 9.1 min) in the LMA group and 7.50 min (5.33 min – 18 min) in the ETT group (p = 0.65).Conclusion:LMA ventilation during CC is feasible and non-inferior to ETT in this model.

Тривалість штучної вентиляції легень та функціонування діафрагми у дітей з гострою дихальною недостатністю

Актуальність. Пацієнти з комбінованими формами дихальної недостатності часто мають довготривале чи навіть невдале відлучення від штучної вентиляції легень (ШВЛ). Мета дослідження: порівняти тривалість проведення ШВЛ, а також показники функціонування діафрагми при використанні технологій P-SIMV та BIPAP у пацієнтів на етапі відлучення від ШВЛ. Матеріали та методи. Проведено проспективне обсерваційне нерандомізоване когортне дослідження серед 27 пацієнтів з гострою дихальною недостатністю. До І (режим P-SIMV) та ІІ груп пацієнтів (режим BIPAP ) увійшло по 10 пацієнтів. Первинними точками оцінювання результатів лікування були тривалість проведення інвазивної ШВЛ; вторинними точками — амплітуда рухів обох куполів діафрагми, фракція стоншення діафрагми, виникнення декомпенсованого респіраторного чи змішаного ацидозу. Результати. Середня тривалість проведення ШВЛ у пацієнтів першої групи становила 14,14 ± 1,83 доби, у пацієнтів другої групи — 13,2 ± 2,56 доби (p = 0,32). Амплітуда рухів куполів діафрагми в першу добу дослідження становила в І групі пацієнтів 7,2 ± 1,8 мм, у ІІ групі — 6,8 ± 1,5 (p = 0,42); на 5-ту добу лікування цей показник вірогідно не відрізнявся між групами та в І групі зростав до 8,1 ± 2,1 мм, у ІІ — до 8,4 ± 1,9 мм (p = 0,12 та p = 0,89). Вже на 9-ту добу лікування амплітуда рухів правого купола діафрагми вірогідно (р = 0,04) відрізнялася у І групі пацієнтів щодо ІІ групи (9,0 ± 2,1 мм та 10,0 ± 1,3 мм відповідно) та щодо попереднього етапу обстеження (p = 0,05 та p = 0,04). Амплітуда рухів правого купола діафрагми залишалася на рівні понад 10 мм у ІІ групі пацієнтів і на 13-ту та 17-ту добу спостереження за пацієнтами. Висновки. Тривалість проведення ШВЛ у дітей з поєднанням обструктивного та рестриктивного типів дихальної недостатності в І та ІІ групах вірогідно не відрізнялася. Спонтанні дихальні зусилля були вірогідно вищими у пацієнтів ІІ групи починаючи з 9-ї доби порівняно з пацієнтами І групи.

Emergency Thoracotomy for Congenital Lobar Emphysema – Anesthesiology Concerns

Congenital lobar emphysema (CLE) is a rare malformation of lungs, which presents usually in neonatal period or infancy as acute hypoxia and respiratory distress. It is characterized by the lobar over aeration of the normal lung followed by respiratory distress due to partial obstruction of bronchus by ball-valve effect. We would like to present the case of a 3-month-old female preterm (31 weeks) baby who presented to our neonatal intensive care unit with respiratory distress for 1 day. The baby was diagnosed with left-sided CLE having severe mediastinal shift to the right side and a dextroposition heart. Her venous blood gas showed PaCO2 of 70 mmHg and SpO2 of 70% with 15 L high-flow nasal oxygen. We would like to highlight the anesthesia techniques of airway management and ventilation during the critical period of induction till thoracotomy and exteriorizing the emphysematous lobe.

A narrative review of advanced ventilator modes in the pediatric intensive care unit.

Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.

Perioperative Management of Percutaneous Dilated Tracheostomy for Patient during Intensive Care after Ventriculoperitoneal (VP) Shunt Installation

Background: Tracheostomy is a technique used to treat patients with inadequate ventilation and upper airway obstruction by making air passage through the neck directly into the trachea. Percutaneous dilated tracheostomy is usually performed in patients requiring long-term use of a ventilator in an intensive care unit. Basic knowledge of perioperative management of percutaneous dilated tracheostomy is fundamental and must be mastered by anesthesiologists. Case: A woman, 45 years old is treated at dr. Moewardi hospital with decreased consciousness E2V2M3, non-communicant hydrocephalus, and intraventricular hemorrhage. The patient underwent ventriculoperitoneal shunt surgery and was admitted to the intensive care unit. Patients require long-term use of a ventilator and thus require percutaneous dilated tracheostomy. The percutaneous dilated tracheostomy procedure was successfully performed and there were no complications after the procedure. Conclusion: Percutaneous dilated tracheostomy is a minimally invasive tracheostomy technique as an alternative to conventional techniques, with lower complications and shorter time.

The Usefulness of Laryngeal Tube in Airway Maintenance and Intermittent Positive Pressure Ventilation for Paramedics

Background: Supraglottic airway devices (SADs) are used to keep the upper airway open and to provide unobstructed ventilation. The recent addition to SADs is the laryngeal tube (LT). It can be inserted blindly past the oropharynx into the hypopharynx to provide a patent airway and mechanical ventilation during emergency conditions and cardiopulmonary resuscitation. Aim: To evaluate the success rate and usefulness of LT insertion for airway maintenance and intermittent positive pressure ventilation on manikins by paramedical personnel. Methods: The technique of LT insertion was explained to 200 paramedical personnel, all of whom attempted its insertion three times; the maximum time allowed for 3 attempts was 3 min. The success rate in terms of ease of insertion, adequacy of ventilation and the audible leak was assessed. The average time taken for insertion and success rate in the first, second and third attempts was assessed. Confirmation was done by ventilation with a self-inflating bag and adequate lung inflation. Results: Average time taken for insertion of LT was 14.66 ± 4.96 s. With progressive attempts, the success rate improved to 86.5%, adequacy of ventilation to 96.5% and only a minimal leak was appreciated in all. Conclusion: The LT could be a reliable device for airway management in emergencies by paramedical personnel as all participants successfully placed it within three attempts with a very good success rate.

Singapore Advanced Cardiac Life Support Guidelines 2021.

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

Reversibility of total airway closure and alveolar consolidation in a COVID‐19 patient: A case study

Coronavirus disease 2019 (COVID‐19) may be complicated by life‐threatening pneumonia requiring tracheal intubation, mechanical ventilation and veno‐venous extracorporeal membrane oxygenation (vvECMO). It is not yet clear to what extent and after which delay the most severe cases of COVID‐19 pneumonia are reversible. Here, we present a 39‐year‐old patient who developed a severe COVID‐19‐attributed acute respiratory distress syndrome (ARDS) resulting in complete alveolar consolidation and airway closure for several weeks. His remarkable ventilatory pattern was established using ventilator airway pressure curve analysis and computed tomography imaging. The patient was managed with supportive care, mechanical ventilation and vvECMO. He received dexamethasone and tocilizumab as immunomodulatory drugs. Despite multiple complications, he recovered and was weaned from vvECMO, ventilator and oxygen on days 75, 95 and 99 post‐intubation, respectively. He was discharged from hospital on day 113. This case study strongly supports the remarkable potential for reversibility of ARDS in COVID‐19 patients and discusses the implications for critical care nursing regarding mechanical ventilation and ECMO device management in patients who may become entirely dependent on vvECMO for oxygenation and carbon dioxide elimination.

The Urinary Uric Acid / Cr ratio as a marker of morbidity and mortality of preterm infants: a case\u2014control study

BackgroundPerinatal asphyxia is one of the main causes of preterm infant mortality. Some studies have shown that The Urinary Uric Acid / Cr (UUA/Cr) ratio may be used as an additional marker for perinatal asphyxia.This study intend to investigate the relationship of this ratio with outcomes of preterm infants admitted to NICU.MethodsThis case–control study was carried on 102 preterm newborn infants with gestational age of 30 weeks to 33 weeks and 6 days admitted in the neonatal intensive care unit.The case group, consisted of 51 premature neonates with a history of intubation, cardiopulmonary resuscitation, mechanical ventilation and Nasal continuous positive airway pressure (NCPAP) at birth, were compared with 51 matched neonates. The UUA/Cr ratio was measured in the first 24 h after birth. Complications during hospitalization, duration of hospitalization, and final outcome were evaluated.ResultsThe mean level of UUA/Cr ratio in case and control group were 5.4 ± 4.1 and 3.6 9 ± 2.9 respectively and this difference was statistically significant (p = 0.014). The UUA/Cr ratio were significantly higher in females, cesarean section delivery, Apgar score ≥ 8, neonates without any complication and neonates with less than 10 days of hospitalization. However, this ratio has no predictive value for the incidence of complications during hospitalization and long-term hospital stay for infants of the case group.ConclusionsThe Urinary Uric Acid / Cr ratio in the first 24 h after birth in preterm neonates who underwent intubation, NCPAP or cardiopulmonary resuscitation was higher than healthy neonates.

Large variations of oxygen delivery in self-inflating resuscitation bags used for preoxygenation - a mechanical simulation

BackgroundSelf-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency anaesthesia outside the operating theatre. There is a common notion that all SIRBs applied with a tight sealed mask will deliver close to 100 % oxygen during spontaneous breathing. The aim of the study was to measure the oxygen delivery of six commonly used SIRBs in a mechanical spontaneous breathing adult in vitro model.MethodsThree SIRBs of each of the six models were evaluated for oxygen delivery during simulated breathing with an adult mechanical lung. The test was repeated three times per device (54 tests in total). The breathing profile was fixed to a minute volume of 10 L/min, a tidal volume of 500 mL and the SIRBs supplied with an oxygen fresh gas flow of 15 L/min. The fraction of delivered oxygen (FDO2) was measured over a three-minute period. Average FDO2 was calculated and compared at 30, 60 and 90 s.ResultsAt 90 s all models had reached a stable FDO2. Average FDO2 at 90 s; Ambu Oval Plus 99,5 %; Ambu Spur II 99,8 %; Intersurgical BVM Resuscitator 76,7 %; Laerdal Silicone 97,3 %; Laerdal The Bag II 94,5 % and the O-Two Smart Bag 39,0 %. All differences in FDO2 were significant apart from the two Ambu models.Conclusions In simulated spontaneous breathing, four out of six (by Ambu and Laerdal) Self-Inflating Resuscitation Bags delivered a high fraction of oxygen while two (Intersurgical and O-two) underperformed in oxygen delivery. These large variations confirm results reported in other studies. It is our opinion that underperforming Self-Inflating Resuscitation Bags might pose a serious threat to patients’ health if used in resuscitation and anaesthesia. Manufacturers of Self-Inflating Resuscitation Bags rarely provide information on performance for spontaneous breathing. This poses a challenge to all organizations that need their devices to deliver adequate oxygen during spontaneous breathing.

Non-invasive duo positive airway pressure ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: a randomized controlled trial

BackgroundThe most common cause of respiratory failure in premature infants is respiratory distress syndrome. Historically, respiratory distress syndrome has been treated by intratracheal surfactant injection followed by mechanical ventilation. In view of the risk of pulmonary injury associated with mechanical ventilation and subsequent chronic pulmonary lung disease, less invasive treatment modalities have been suggested to reduce pulmonary complications.Methods148 neonates (with gestational age of 28 to 34 weeks) with respiratory distress syndrome admitted to Imam Khomeini Hospital in Ahwaz in 2018 were enrolled in this clinical trial study. 74 neonates were assigned to duo positive airway pressure (NDUOPAP) group and 74 neonates to nasal continuous positive airway pressure (NCPAP) group. The primary outcome in this study was failure of N-DUOPAP and NCPAP treatments within the first 72 h after birth and secondary outcomes included treatment complications.Resultsthere was not significant difference between DUOPAP (4.1 %) and NCPAP (8.1 %) in treatment failure at the first 72 h of birth (p = 0.494), but non-invasive ventilation time was less in the DUOPAP group (p = 0.004). There were not significant differences in the frequency of patent ductus arteriosus (PDA), pneumothorax, intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD), apnea and mortality between the two groups. Need for repeated doses of surfactant (p = 0.042) in the NDUOPAP group was significantly lower than that of the NCPAP group. The duration of oxygen therapy in the NDUOPAP group was significantly lower than that of the NCPAP group (p = 0.034). Also, the duration of hospitalization in the NDUOPAP group was shorter than that of the NCPAP group (p = 0.002).ConclusionsIn the present study, DUOPAP compared to NCPAP did not reduce the need for mechanical ventilation during the first 72 h of birth, but the duration of non-invasive ventilation and oxygen demand, the need for multiple doses of surfactant and length of stay in the DUOPAP group were less than those in the CPAP group.Trial registrationIRCT20180821040847N1, Approved on 2018-09-10.

Anesthetic Management of a Juvenile Hyaline Fibromatosis Patient With Trismus and Cervical Movement Limitation.

Juvenile hyaline fibromatosis (JHF) is a rare autosomal recessive disease characterized by the presence of tissue nodules, joint contractures, and gingival hyperplasia. With a 1-year-9-month-old female patient scheduled for a gingivectomy and excision of a lower lip mass under general anesthesia, it was anticipated that airway management would be difficult because of trismus and limited cervical movement. Intubation with video-laryngoscopic assistance could not be achieved because gingival hyperplasia and trismus prevented blade insertion and manipulation. Therefore, 2 endotracheal tubes were used: 1 used as a nasopharyngeal airway for assisted ventilation, and 1 used for intubation along with a flexible fiberoptic scope. This case demonstrated a useful method for managing ventilation and intubation in patients with JHF, particularly when the use of oral airway devices is difficult.