Secretion Clearance Research Articles

Impaired Insulin Clearance as the Initial Regulator of Obesity-Associated Hyperinsulinemia: Novel Insight Into the Underlying Mechanism Based on Serum Bile Acid Profiles.

To investigate the roles of insulin clearance and insulin secretion in the development of hyperinsulinemia in obese subjects and to reveal the association between insulin clearance and bile acids (BAs). In cohort 1, insulin secretion, sensitivity, and endogenous insulin clearance were evaluated with an oral glucose tolerance test in 460 recruited participants. In cohort 2, 81 participants underwent an intravenous glucose tolerance test and a hyperinsulinemic-euglycemic clamp to assess insulin secretion, endogenous and exogenous insulin clearance, and insulin sensitivity. Based on insulin resistance levels ranging from mild to severe, obese participants without diabetes were further divided into 10 quantiles in cohort 1 and into tertiles in cohort 2. Forty serum BAs were measured in cohort 2 to examine the association between BAs and insulin clearance. All obese participants had impaired insulin clearance, and it worsened with additional insulin resistance in obese subjects without diabetes. However, insulin secretion was unchanged from quantile 1 to 3 in cohort 1, and no difference was found in cohort 2. After adjustments for all confounding factors, serum-conjugated BAs, especially glycodeoxycholic acid (GDCA; β = -0.335, P = 0.004) and taurodeoxycholic acid (TDCA; β = -0.333, P = 0.003), were negatively correlated with insulin clearance. The ratio of unconjugated to conjugated BAs (β = 0.335, P = 0.002) was positively correlated with insulin clearance. Hyperinsulinemia in obese subjects might be primarily induced by decreased insulin clearance rather than increased insulin secretion. Changes in circulating conjugated BAs, especially GDCA and TDCA, might play an important role in regulating insulin clearance.

Delayed hypersensitivity to the Comirnaty coronavirus disease 2019 vaccine presenting with pneumonitis and rash

Delayed hypersensitivity to the Comirnaty coronavirus disease 2019 vaccine presenting with pneumonitis and rash

“A STUDY OF CORRELATION BETWEEN CLINICAL FEATURES, RADIOLOGICAL FINDINGS AND SPIROMETRY PARAMETERS IN PATIENTS OF BRONCHIECTASIS”

INTRODUCTION: Bronchiectasis is dened as an irreversible dilation and destruction of one or more bronchi with a reduction in clearance of secretions and in the expiratory airow. Etiologies include prior lung infection, systemic inammatory disorders, and genetic disorders of host defense. METHODOLOGY: This is an Observational study of 160 patients patient who were diagnosed with Bronchiectasis in tertiary health care centre over a period of 15 months. Data was collected and analyzed for correlation between clinical features, radiological ndings and spirometry parameters. RESULT: Mean age of presentation was 21-30 years. Most important etiology was post-infections, pulmonary tuberculosis followed by pneumonia. The cardinal symptoms of bronchiectasis were productive cough followed by dyspnoea on exertion. The most common bacteria isolated from sputum culture was Haemophilus Inuenzae. The commonest radiological pattern of bronchiectasis was cylindrical followed by cystic and varicose. Most of the patients had obstructive pattern in spirometry tests. CONCLUSION: Radiological ndings and spirometry test are more valuable for early and accurate diagnosis of bronchiectasis which help in early and prompt management. Cases of bronchiectasis have repeated history of admissions in the hospital thus all options of treatment including surgical intervention must be taken into consideration for good quality life and healthy.

Comparison of inhaled mannitol/dornase alfa combination and daily dornase alfa alone in children with cystic fibrosis.

Inhaled recombinant human deoxyribonuclease (dornase alfa) and osmotic agents such as inhaled mannitol are used for improving the clearance of secretions of cystic fibrosis (CF) patients. We aimed to evaluate the long-term clinical effects of adding dry powder inhaled (DPI) mannitol in subjects with CF who are taking daily dornase alfa. We conducted a retrospective case-control study on subjects with CF. The effect of DPI mannitol was assessed by comparing DPI mannitol and dornase alfa combination with daily dornase alfa alone in children with CF during a 12-month period. The primary outcome measures of the study were absolute changes in percent predicted forced expiratory volume in 1 s (FEV1) and FEV1 z-scores and the secondary outcomes included other spirometry indices, body mass index, frequency of pulmonary exacerbations, SPO2 , and sputum microbiology. Of a total of 28 patients who committed to use DPI mannitol treatments during the study period, five had a positive challenge with DPI mannitol and two were aged over 18 years. Therefore, the mannitol treatment group consisted of 21 patients. However, the effect of DPI mannitol was analyzed using 15 patients in the mannitol treatment group who received DPI mannitol for at least 12 months, and 18 patients who only used dornase alfa constituted the control group. The median absolute change in FEV1 between baseline and the third month; and baseline and the 12th month were significantly higher in the mannitol treatment group (p = 0.038, p = 0.004, respectively). When the groups are compared with respect to absolute z-score changes, all spirometry indices, except FVC at the end of 3 months, showed statistically significant improvements in the mannitol treatment group. Some secondary outcomes like pulmonary exacerbation frequency during the study year and median absolute body mass index z-score changes from baseline to the end of the study showed no significant differences between the groups (p = 0.735, p = 0.161, respectively). No colonization changes were observed in the treatment group. This study showed that in those patients who tolerated long-term (12 months) treatment with DPI mannitol and dornase alfa made greater improvements in FEV1, FVC, FEV1/FVC, FEF25-75 z-scores than treatment with dornase alfa alone in children with CF.

Effect of Capsaicin Atomization-Induced Cough on Sputum Excretion in Tracheotomized Patients After Hemorrhagic Stroke: A Randomized Controlled Trial.

Background Timely and effective removal of respiratory secretions is of great significance for tracheotomized patients. The purpose of this study is to investigate the effectiveness of capsaicin nebulization to stimulate cough to promote early clearance of respiratory secretions in tracheotomized patients after hemorrhagic stroke. Method This study implemented a randomized controlled design. Sixty-three patients who were tracheotomized following a hemorrhagic stroke completed this randomized controlled trial. In the control group, 33 cases were given a routine care after tracheotomy. In the intervention group, 30 cases were given a capsaicin solution nebulization in addition to the routine care. The daily sputum output and the number of sputum suctioning were observed. The differences in sputum viscosity, cough function, and Clinical Pulmonary Infection Score (CPIS) were compared between the two groups before and after the intervention. Vital sign changes during capsaicin nebulization and suctioning were compared between the two groups in a pilot study. Results The daily sputum output of the capsaicin intervention group was significantly higher than that of the control group (p < .05). The number of sputum suctioning of capsaicin group was less than that of the control group after intervention (p < .05). The CPIS score of the capsaicin group was lower than that of the control group (p < .05) after a 1-week intervention. Patients' heart rate, respiratory rate, and oxygen saturation during capsaicin nebulization were not statistically different from those during routine sputum suctioning (p > .05). Conclusions Capsaicin atomization-induced cough can effectively promote sputum excretion of hemorrhagic stroke patients undergoing tracheotomy and has a good safety profile. The Clinical Trial registration number of this study is ChiCTR2000037772 (http://www.chictr.org.cns). Supplemental Material https://doi.org/10.23641/asha.16821352.

Evaluation of a novel endotracheal tube suctioning system incorporating an inflatable sweeper.

IntroductionAccumulation of secretions in an endotracheal tube can increase the resistance to flow resulting in an increased patient work of breathing when the patient is interacting with the ventilator. Retained secretions can also serve as an infection risk. Standard suction catheters are limited in their ability to keep the lumen of the endotracheal tube clear. A novel closed-suction catheter has been introduced that incorporates a balloon at its distal end that, when inflated, physically scrapes secretions out of the endotracheal tube (CleanSweep catheter (CSC), Teleflex, Morrisville NC). We hypothesized that the CSC would be more efficient at removing secretions from inside the endotracheal tube than a standard suction catheter (SSC).MethodsWe performed a bench study examining resistive pressures across different sizes of endotracheal tubes when cleaned by the CSC as compared with an SSC. This study was followed by a prospective crossover study again comparing the CSC with an SSC in intubated intensive care unit patients receiving mechanical ventilation and requiring frequent suctioning.ResultsFor the bench study the CSC was significantly better in reducing airway resistive pressures (P < 0.001). In the prospective crossover study the CSC over 2 h also removed significantly more secretions than the SSC (P < 0.05).ConclusionBoth our bench and crossover clinical study demonstrated improved clearance of secretions with the CSC vs an SSC. Further research is needed to ascertain the clinical outcome benefits of enhanced secretion removal.

5-IP7 is a GPCR messenger mediating neural control of synaptotagmin-dependent insulin exocytosis and glucose homeostasis.

5-diphosphoinositol pentakisphosphate (5-IP7) is a signalling metabolite linked to various cellular processes. How extracellular stimuli elicit 5-IP7 signalling remains unclear. Here we show that 5-IP7 in β cells mediates parasympathetic stimulation of synaptotagmin-7 (Syt7)-dependent insulin release. Mechanistically, vagal stimulation and activation of muscarinic acetylcholine receptors triggers Gαq-PLC-PKC-PKD-dependent signalling and activates IP6K1, the 5-IP7 synthase. Whereas both 5-IP7 and its precursor IP6 compete with PIP2 for binding to Syt7, Ca2+ selectively binds 5-IP7 with high affinity, freeing Syt7 to enable fusion of insulin-containing vesicles with the cell membrane. β-cell-specific IP6K1 deletion diminishes insulin secretion and glucose clearance elicited by muscarinic stimulation, whereas mice carrying a phosphorylation-mimicking, hyperactive IP6K1 mutant display augmented insulin release, congenital hyperinsulinaemia and obesity. These phenotypes are absent in mice lacking Syt7. Our study proposes a new conceptual framework for inositol pyrophosphate physiology in which 5-IP7 acts as a GPCR second messenger at the interface between peripheral nervous system and metabolic organs, transmitting Gq-coupled GPCR stimulation to unclamp Syt7-dependent, and perhaps other, exocytotic events.

DIAPHRAGM DYSFUNCTION: A SEQUELA OF SARS-COV-2 INFECTION

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: The clinical spectrum of SARS-CoV-2 infection varies from asymptomatic infection to critical illness and death. Many patients report persistent dyspnea and fatigue for months following their acute illness. SARS-CoV-2 has an affinity for neural and muscular tissue which may lead to persistent dyspnea and fatigue among the survivors. Here, we discuss a case of diaphragmatic dysfunction due to COVID-19 infection contributing to persistent dyspnea. CASE PRESENTATION: A 49-year-old male smoker with medical history notable only for COVID-19 infection 5 months prior, was admitted for worsening shortness of breath associated with right sided chest discomfort and cough for several months. On evaluation, he was found to be tachypneic and tachycardic with mild hypoxia.Four weeks prior, he was hospitalized with similar complaints and was noted to have a newly found right middle and lower lobe atelectasis with elevation of right hemidiaphragm on chest x-ray (CXR) and CT. Bronchoscopy done during that admission revealed mucus plugs in the right middle and lower lobes which were evacuated. At that time, he was discharged with prednisone and ICS/LABA inhaler which did not improve his symptoms. At current presentation, CTA of the chest revealed persistent but improved atelectasis compared to CT imaging from previous admission, but the right hemidiaphragm elevation persisted. Subsequent sniff test was positive for paradoxical motion of the right hemidiaphragm with normal movement of the left hemidiaphragm suggestive of right diaphragmatic paralysiCardiologic evaluation, including echocardiogram and stress test were unremarkable. The patient failed conservative management and pulmonary rehabilitation. He then underwent surgical plication of the right hemidiaphragm. Post-operative CXR showed improved right lung atelectasis and improved position of the right hemi diaphragm, with subsequent amelioration of his symptoms. DISCUSSION: The mechanism of neuromuscular involvement in COVID-19 infection is not fully understood. The viral spike protein unique to SARS-CoV-2 has high affinity to ACE2 receptors on skeletal muscle fibers1. Direct neuromuscular involvement by SARS-CoV-2 virus has been postulated to cause diaphragmatic paralysis1. Viral replication activates an inflammatory response leading to myotoxic injury via a cytokine storm2. CONCLUSIONS: Diaphragm dysfunction can be one of the consequences of COVID-19 infection. Neuromuscular injury impairs contraction of the diaphragm, which inhibits lung movement and contributes to impaired clearance of secretion leading to persistent dyspnea. REFERENCE #1: Paliwal VK, Garg RK, Gupta A, Tejan N. Neuromuscular presentations in patients with COVID-19. Neurol Sci. 2020;41(11):3039-3056. doi:10.1007/s10072-020-04708-8 REFERENCE #2: Ramani SL, Samet J, Franz CK, et al. Musculoskeletal involvement of COVID-19: review of imaging. Skeletal Radiol. Published online 2021. doi:10.1007/s00256-021-03734-7 DISCLOSURES: No relevant relationships by Ammar Ahmed, source=Web Response No relevant relationships by Madeeha Banu, source=Web Response No relevant relationships by Clifford Hecht, source=Web Response No relevant relationships by Kenneth Joseph, source=Web Response No relevant relationships by Swetha Paduri, source=Web Response No relevant relationships by Azib Shahid, source=Web Response

REAL-WORLD OUTCOMES IN VETERANS USING HIGH FREQUENCY CHEST WALL OSCILLATION FOR AIRWAY CLEARANCE

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Veterans have a high COPD prevalence compared to the civilian population. In COPD, excess sputum production and accumulation in the lungs is a commonly reported symptom. Several neuromuscular disorders are also known to present the clinician with airway clearance management challenges. High Frequency Chest Wall Oscillation (HFCWO) therapy is a noninvasive airway clearance therapy that directly addresses the issues associated with excess sputum production. There is limited information regarding outcomes of HFCWO therapy within the veteran population. To address this evidence gap, we established an ongoing VA outcomes program to better understand patient-reported outcomes in the veteran population receiving HFCWO therapy. METHODS: Self-reported hospitalization patterns and metrics of airway clearance from veterans were assessed before and after initiation of HFCWO therapy in a data set drawn from the HFCWO Outcomes Registry (HFCWO-OR). Variables collected included demographics, hospitalizations, and respiratory symptoms. The study was comprised of patients with a blended mix of diagnoses (e.g., COPD, bronchiectasis, and various neuromuscular disorders) who received the Philips InCourage vest therapy system. RESULTS: 323 veterans met inclusion criteria in this retrospective analysis. In the 12-month interval prior to initiating HFCWO therapy, the number of patients who reported zero hospitalizations was 46.4% (149/321), compared with 75.0% (21/28) of patients who reported zero hospitalizations in the subsequent 12 months (p=0.005). Conversely, 20.9% (67/321) of patients reported three or more hospitalizations in the prior 12 months, compared with only 3.6% (1/28) in the subsequent 12 months (p=0.001). There was an overall 66.3% reduction in the annualized hospitalization rate after 12 months (0.357 hospitalizations/patient/year at 12 months, compared to 1.059 hospitalizations/patient/year prior to initiating vest therapy) (p=0.001). Those patients who subjectively rated their "overall respiratory health" as good, very good, or excellent increased from 10.5% (34/323) upon initiation of therapy to 60.7% (17/28) within 12 months (p=0.0002). Those who rated the "ability to clear your lungs" as good, very good, or excellent increased from 8.4% (27/322) to 67.9% (19/28) within 12 months. (p<.0001). CONCLUSIONS: Our analysis indicates that outcomes in a veteran population, as measured by the number of self-reported hospitalizations, respiratory health, and the ability to clear secretions, improved substantially after the initiation of HFCWO therapy. These improvements were sustained for at least one year and provide valuable insights into the value of HFCWO in the population served by the VA health system. CLINICAL IMPLICATIONS: In a veteran population, positive outcomes are associated with the use of high frequency chest wall oscillation. DISCLOSURES: Consultant relationship with Respirtech Technologies Please note: $5001 - $20000 by Tara Barto, source=Web Response, value=Consulting fee No relevant relationships by Sarah Daignault, source=Web Response Employee relationship with RespirTech Please note: 2015-Present Added 04/16/2021 by Gary Hansen, source=Web Response, value=Salary Employee relationship with RespirTech, A Philips Company Please note: 2019 - present Added 04/16/2021 by PRITESH PANDYA, source=Web Response, value=Salary No relevant relationships by Frederic Seifer, source=Web Response

Regulation of airway immunity by epithelial miRNAs.

The airway epithelium is essential to protect the host from inhaled pathogens and particles. It maintains immune homeostasis and mediates tissue repair after injury. Inflammatory diseases of the airways are associated with failure of epithelial functions, including loss of barrier integrity that results in increased tissue permeability and immune activation; excessive mucus secretion and impaired mucociliary clearance that leads to airflow obstruction and microbial overgrowth; and dysregulation of cellular signals that promotes inflammation and alters tissue structure and airway reactivity. MicroRNAs play crucial roles in mounting appropriate cellular responses to environmental stimuli and preventing disease, using a common machinery and mechanism to regulate gene expression in epithelial cells, immune cells of hematopoietic origin, and other cellular components of the airways. Respiratory diseases are accompanied by dramatic changes in epithelial miRNA expression that drive persistent immune dysregulation. In this review, we discuss responses of the epithelium that promote airway immunopathology, with a focus on miRNAs that contribute to the breakdown of essential epithelial functions. We emphasize the emerging role of miRNAs in regulation of epithelial responses in respiratory health and their value as diagnostic and therapeutic targets.

Bronchoscopy in Patients With Known or Suspected COVID-19: Results From the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD).

Amid the Coronavirus Disease 2019 (COVID-19) pandemic, the benefits and risks of bronchoscopy remain uncertain. This study was designed to characterize bronchoscopy-related practice patterns, diagnostic yields, and adverse events involving patients with known or suspected COVID-19. An online survey tool retrospectively queried bronchoscopists about their experiences with patients with known or suspected COVID-19 between March 20 and August 20, 2020. Collected data comprised the Global Pandemic SARS-CoV-2 Bronchoscopy Database (GPS-BD). All bronchoscopists and patients were anonymous with no direct investigator-to-respondent contact. Bronchoscopy procedures involving 289 patients from 26 countries were analyzed. One-half of patients had known COVID-19. Most (82%) had at least 1 pre-existing comorbidity, 80% had at least 1 organ failure, 51% were critically ill, and 37% were intubated at the time of the procedure. Bronchoscopy was performed with diagnostic intent in 166 (57%) patients, yielding a diagnosis in 86 (52%). and management changes in 80 (48%). Bronchoscopy was performed with therapeutic intent in 71 (25%) patients, mostly for secretion clearance (87%). Complications attributed to bronchoscopy or significant clinical decline within 12 hours of the procedure occurred in 24 (8%) cases, with 1 death. Results from this international database provide a widely generalizable characterization of the benefits and risks of bronchoscopy in patients with known or suspected COVID-19. Bronchoscopy in this setting has reasonable clinical benefit, with diagnosis and/or management change resulting from about half of the diagnostic cases. However, it is not without risk, especially in patients with limited physiological reserve.

Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery

This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). This was a single-center, randomized, unblinded clinical trial. The study was performed in a teaching hospital. Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.

All You Need Is Evidence: What We Know About Pneumonia in Children With Neuromuscular Diseases.

Neuromuscular diseases may involve all major respiratory muscles groups including inspiratory, expiratory, and bulbar muscles. Respiratory complications are the major cause of morbidity and mortality. Pneumonia represents a frequent cause of morbidity in children with neuromuscular disease. The aim of this review is to collect knowledge about pneumonia in children with neuromuscular diseases. Pneumonia usually follows viral respiratory infections of the upper respiratory tract, due to the combination of an increased amount of nasal and oral secretions and an impairment of the cough efficiency and of the clearance of secretions due to the muscle weakness, further compromised by the infection itself. The accumulation of bronchial secretions leads to atelectasis and promote bacterial infection. Moreover, dysfunction of swallowing mechanism exposes these children to the risk of developing aspiration pneumonia. However, etiology of viral and bacterial respiratory infection in these patients is still poorly studied.

Periprocedural Management of Electroconvulsive Therapy in Pregnancy during COVID-19 Outbreak: The First Case Report in Thailand

Objective: To described the periprocedural electroconvulsive therapy (ECT) management of a patient in the 3rd trimester of pregnancy, the ECT complications, and their treatment. Materials and Methods: A retrospective chart review was conducted of a 26-year-old parturient with bipolar I disorder with psychotic features during the coronavirus disease 2019 (COVID-19) outbreak. Case Report: The patient was admitted and scheduled for ECT. Fifteen ECT sessions (eight on her first admission, and another seven on a second admission) were performed. General anesthesia with endotracheal intubation was conducted after sufficient preoxygenation. Complications were observed: prolonged seizure, decreased fetal heart rate, and hypersecretion. Nonetheless, good outcomes were achieved after treated with thiopental to terminate the seizure, intravenous crystalloid loading and left uterine displacement to stabilize the fetus, and suctioning and an antisialagogue for secretion clearance. Conclusion: In ECT during pregnancy, it can be challenging to apply electrical current, induce anesthesia and airway management to achieve safe patient care and ensure adequate seizure duration. Moreover, the ECT is conducted in a non-operating room setting where equipment may be deficient. A prerequisite is good periprocedural collaboration among members of the multidisciplinary team which include a psychiatrist, an anesthesiologist, and an obstetrics-gynecologist, as well as proper protective equipment to prevent the contamination to the environment. Keywords: Coronavirus disease 2019 (COVID-19); Electroconvulsive therapy (ECT); Multidisciplinary team; Periprocedural management; Pregnancy

Characterization and Prediction of the Clinical Outcome of Intense Pulsed Light-Based Treatment in Dry Eye Associated to Meibomian Gland Dysfunction

This non-comparative prospective case series was conducted to characterize the clinical impact of intense pulsed light (IPL)-based treatment in dry eyes associated to Meibomian gland dysfunction (MGD), defining the predicting factors for a successful outcome with this therapy in a large case series. A total of 390 eyes (195 patients, range: 23–93 years) received four sessions of Optima IPL system (Lumenis, Yokneam, Israel). Significant changes were observed in tear film osmolarity in both eyes (p < 0.001) and in meibum quality (p < 0.001), with more eyes showing clear or yellow secretions after therapy. Mean change in the ocular surface disease index (OSDI) was −8.61, ranging from −27.00 to 11.00. This change was significantly correlated with the baseline value of OSDI (r = −0.489, p < 0.001). The change in osmolarity correlated significantly with the baseline osmolarity in both eyes (right r = −0.636, left r = −0.620, p < 0.001). A linear predicting model of the change in OSDI with therapy was obtained: change OSDI = 10.99 − 0.35 × OSDI − 1.03 × NIBUTRE-LE (mean non-invasive break up time of right and left eye) − 2.03 × Meibum quality grade (p = 0.001; R2: 0.325). In conclusion, the improvement in symptomatology achieved with an IPL-based therapy can be predicted at baseline using a linear model considering the level of MGD and the magnitude of OSDI and NIBUT (non-invasive break-up time).

Intrapulmonary percussive ventilation via Mini-Trach II in critical care: a case report

BackgroundIntrapulmonary percussive ventilation (IPV) facilitates the mobilization and clearance of bronchial secretions. Cricothyroidotomy using a Mini-Trach II device is a minimally invasive method used for secretion clearance. To our knowledge, there are no previous reports regarding IPV combined with Mini-Trach II.Case presentationAn 82-year-old man underwent controlled mechanical ventilation and IPV via an endotracheal tube to treat atelectasis following emergency surgical repair of a traumatic diaphragm laceration. He underwent cricothyroidotomy using Mini-Trach II for ensuring airway management after extubation. On resumption, IPV through a mouthpiece or face mask was unsuccessful owing to air leakage from his mouth. However, IPV via the already inserted Mini-Trach II could deliver the percussion flow and led to a marked improvement in his condition.ConclusionThis experience indicates that Mini-Trach II is beneficial as a minimally invasive interface for IPV that can deliver percussion flow efficiently.

Oral Hygiene Care to Prevent Ventilator-Associated Pneumonia in Critically Ill Patients.

Oral Hygiene Care to Prevent Ventilator-Associated Pneumonia in Critically Ill Patients.

Anesthetic management of thoracoscopic procedures in neonates: a retrospective analysis of 45 cases.

BackgroundAdvances in medical techniques and equipment have enabled the thoracoscopic repair of certain congenital abnormalities in neonates including congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH). A retrospective analysis was conducted to examine the anesthetic management of neonates (7 days or younger) undergoing thoracoscopic surgery in our hospital department, and to determine the efficacy of anesthetic management in neonates.MethodsClinical data from 45 neonates who underwent thoracoscopic surgery in our hospital from December 2015 to March 2020 were retrospectively analyzed. A total of 25 patients underwent repair of CDH and 20 underwent repair of an EA/TEF.ResultsAll patients received general anesthesia with endotracheal intubation, standard ASA monitoring, and arterial blood gas (ABG) analysis. All patients survived the surgery. A total of 14 patients experienced decreases in SpO2, pH, PaO2, and increases in PETCO2 and PaCO2 30 minutes after CO2 insufflation. Our anesthetic management protocols are outline and analyzed.ConclusionsThorough preoperative preparation is critical for a desirable outcome in neonates undergoing a thoracoscopic repair of CDH or EA/TEF. In our cohort, intraoperative ventilation strategies included pressure control ventilation with peak airway pressure maintained at 15–25 cmH2O, a respiratory rate of 35–55 breaths/minute, a fraction of inspired oxygen (FiO2) of 60–80%, an inspiratory/expiratory ratio (I:E) of 1:1–1.5, and careful airway suctioning to clear secretions. Postoperatively, maintaining normovolemia and hemodynamic stability are critical for successful weaning of ventilatory support and extubation.

Hyperinsulinemia and Its Pivotal Role in Aging, Obesity, Type 2 Diabetes, Cardiovascular Disease and Cancer.

For many years, the dogma has been that insulin resistance precedes the development of hyperinsulinemia. However, recent data suggest a reverse order and place hyperinsulinemia mechanistically upstream of insulin resistance. Genetic background, consumption of the “modern” Western diet and over-nutrition may increase insulin secretion, decrease insulin pulses and/or reduce hepatic insulin clearance, thereby causing hyperinsulinemia. Hyperinsulinemia disturbs the balance of the insulin–GH–IGF axis and shifts the insulin : GH ratio towards insulin and away from GH. This insulin–GH shift promotes energy storage and lipid synthesis and hinders lipid breakdown, resulting in obesity due to higher fat accumulation and lower energy expenditure. Hyperinsulinemia is an important etiological factor in the development of metabolic syndrome, type 2 diabetes, cardiovascular disease, cancer and premature mortality. It has been further hypothesized that nutritionally driven insulin exposure controls the rate of mammalian aging. Interventions that normalize/reduce plasma insulin concentrations might play a key role in the prevention and treatment of age-related decline, obesity, type 2 diabetes, cardiovascular disease and cancer. Caloric restriction, increasing hepatic insulin clearance and maximizing insulin sensitivity are at present the three main strategies available for managing hyperinsulinemia. This may slow down age-related physiological decline and prevent age-related diseases. Drugs that reduce insulin (hyper) secretion, normalize pulsatile insulin secretion and/or increase hepatic insulin clearance may also have the potential to prevent or delay the progression of hyperinsulinemia-mediated diseases. Future research should focus on new strategies to minimize hyperinsulinemia at an early stage, aiming at successfully preventing and treating hyperinsulinemia-mediated diseases.

The roles of sodium-potassium-chloride cotransporter isoform-1 in acute lung injury.

Acute lung injury (ALI) is often characterized by severe lung inflammation and pulmonary edema with poor gas exchange and hypoxemia. Alveolar inflammation and water flooding are, in fact, notable features of ALI pathogenesis. The sodium-potassium-chloride co-transporter isoform 1 (NKCC1), localized at the basolateral surface of the lung epithelium, drives water transport via back transport of Na+ and Cl− to the alveolar air space. NKCC1, therefore, is crucial in regulating alveolar fluid. Increased expression of NKCC1 results in increased alveolar fluid secretion and impaired alveolar fluid clearance. During ALI, the with no lysine kinase (WNK), oxidative stress responsive kinase 1 (OSR1), and STE20/SPS1-related proline/alanine-rich kinase (SPAK) pathways are activated, which upregulates NKCC1 expression. Proinflammatory cytokines also enhance the expression of NKCC1 via c-Jun N-terminal kinase-and p38-dependent pathways. NKCC1 activation also increases the expression of proinflammatory cytokines via cell rupture and activation of macrophages. Increased proinflammatory cytokines, in turn, recruit inflammatory cells to the site of injury and cause further lung damage. Animals with high expression of NKCC1 show more severe lung injury with presentations of more severe pulmonary edema and microvascular permeability, higher expression of proinflammatory cytokines, and greater neutrophilic infiltration. In contrast, animals with low expression of NKCC1 or those treated with NKCC1 inhibitors show less severe lung injury with milder levels of presentations of ALI. These reports collectively highlight a novel role of NKCC1 in ALI pathogenesis. Manipulation of NKCC1 expression levels could, therefore, represent novel modalities for effective ALI treatment.