Cuff Pressure Research Articles

Association of enteral feeding with microaspiration in critically ill adults

AimThis study explored relationships between enteral feeding and tracheal pepsin A. BackgroundMechanically ventilated (MV) patients receiving enteral feeding are at risk for microaspiration. Tracheal pepsin A, an enzyme specific to gastric cells, was a proxy for microaspiration of gastric secretions. MethodsSecondary analysis of RCT data from critically ill, MV adults was conducted. Microaspiration prevention included elevated head of bed, endotracheal tube cuff pressure management, and regular oral care. Tracheal secretions for pepsin A were collected every 12 h. Microaspiration was defined as pepsin A ≥ 6.25 ng/mL. Positive pepsin A in >30 % of individual tracheal samples was defined as abundant microaspiration (frequent aspirator). Chi-squared, Fisher's Exact test, and generalized linear model (GLM) were used. ResultsTracheal pepsin A was present in 111/283 (39 %) mechanically ventilated patients and 48 (17 %) had abundant microaspiration. Enteral feeding was associated with tracheal pepsin A, which occurred within 24 h of enteral feeding. Of the patients who aspirated, the majority received some enteral feeding 96/111 (86 %), compared to only 15/111 (14 %) who received no feeding. A greater number of positive pepsin A events occurred with post-pyloric feeding tube location (55.6 %) vs. gastric (48.6 %), although significant only at the event-level. Frequent aspirators (abundant pepsin A) had higher pepsin A levels compared to infrequent aspirators. ConclusionsOur findings confirmed the stomach as the microaspiration source. Contrary to other studies, distal feeding tube location did not mitigate microaspiration. Timing for first positive pepsin A should be studied for possible association with enteral feeding intolerance.

The Relationship between Cuff Pressure and Air Injection Volume of Endotracheal Tube: A Study with Sheep Trachea Ex Vivo.

Endotracheal intubation is a widely used treatment. Excessive pressure of the endotracheal tube cuff leads to a series of complications. Here, we used tracheae of sheep to analyze the relationship between the air injection volume and endotracheal tube cuff pressure so as to guide the doctors and nurses in controlling the pressure of the endotracheal tube cuff during clinical work and minimise the risk of complications. Forty sheep tracheae were utilised and were divided into five groups according to their diameters. Different sizes of endotracheal tubes were inserted into each trachea, and the cuff pressure with the increase of air injection volume was recorded. The formulas that reflect the relationship between air injection volume and cuff pressure were obtained. Then, sheep tracheae were randomly selected; different types of tubes were inserted, and the stipulated volume of air was injected. The actual pressure was measured and compared with the pressure predicted from the formulas. Statistical analysis was conducted to verify whether the formulas obtained from the first part of the experiment were in accordance with the expert evaluation table, which consists of opinions of several experts. After obtaining 15 formulas, we collected the differences between the theoretical cuff pressure and the actual cuff pressure that satisfied the expert evaluation. Relying on the formulas, the medical turntable was obtained, which is a tool that consists of two round cards with data on them. The top card has a notch. The two cards are stacked together, and as the top card rotates, the data on the bottom card can be easily seen in a one-to-one relationship. The formulas are capable of showing the relationship between the cuff air injection volume and pressure of endotracheal tube cuff. The medical turntable can estimate the air injection volume to ensure that the pressure stays in an acceptable range.

A Tapered Cuff Tracheal Tube Decreases the Need for Cuff Pressure Adjustment After Surgical Retraction During Anterior Cervical Spine Surgery: A Randomized Controlled, Double-Blind Trial.

BackgroundSurgical retraction to expose the vertebrae during anterior cervical spine surgery increases tracheal tube cuff pressure and may worsen postoperative sore throat and dysphonia. This randomized double-blind study investigated the effect of cuff shape on intraoperative cuff pressure and postoperative sore throat and dysphonia.MethodsEighty patients were randomized to tracheal intubation with a tapered cuff or a conventional cylindrical high-volume low-pressure cuff (control) during anesthesia. Intraoperative cuff pressures were compared. The primary outcome was the incidence of pressure adjustment needed when the cuff pressure increased to > 25 mm Hg after surgical retraction. The secondary outcome was the incidence of postoperative sore throat and dysphonia.ResultsThe incidence of pressure adjustment after surgical retraction was significantly lower in the tapered group than in the control group (13% vs. 48%; P = 0.001; relative risk reduction, 74%). The median [interquartile range (IQR)] cuff pressure (mm Hg) was significantly lower for the tapered cuff than for the control cuff before surgical retraction [9 (7–12) vs. 12 (10–15); P < 0.001] and after retraction [18 (15–23) vs. 25 (18–31); P = 0.007]. The median (IQR) postoperative dysphonia score assessed by a single speech-language pathologist was lower in the tapered group than in the control group [4 (3–6) vs. 5.5 (5–7); P = 0.008].ConclusionA tapered cuff tracheal tube decreased the need for the adjustment of cuff pressure after surgical retraction during anterior cervical spine surgery, thereby avoiding intraoperative pressure increase. It also has a better outcome in terms of dysphonia.Clinical Trial Registration[www.clinicaltrials.gov], identifier [NCT04591769].

Compare the Mean Cuff Pressure in Endotracheal Tube Cuff Filled with Air vs Saline in Patients Undergoing Surgery under GA

Background: Securing and maintaining airway and ventilating the patients by placement of endotracheal1tube is common practice in the operation1theater for delivery of general anesthesia and in the critical care settings. The primary role of endotracheal tube (ETT) cuff's primary role is to seal the airway, preventing leaks and pharyngeal contents aspiration into the trachea1during ventilation. Aim: To compare the mean cuff pressure in endotracheal1tube cuff filled with air vs saline in patients undergoing surgery under general anesthesia. Study Design: Randomized control trail Place and Duration of Study: Department of Anesthesia, National Hospital, Lahore from 1st July 2016 to 31st December 2016. Methodology: One hundred patients undergoing surgery under general anesthesia were enrolled. They were divided into two groups and each group comprised equal number of patients. In group A, endotracheal tube was inserted with air filled cuff while in group B, endotracheal tube was inserted by using 0.9%saline solution. On follow-up outcome was noted. Results: The average age of the air filled cuff was 38.24±12.22 years and in saline filled cuff group was 39.68±13.79 years. Insignificant (p=0.269) difference statistically was found between the groups with cuff pressure at baseline of the patients and insignificant difference was noted at baseline. Conclusion: The mean cuff pressure in ETT was significantly less with saline than air filled cuff in patients undergoing surgery under general anesthesia. Key words: General anesthesia, Endotracheal tube, Saline, Cuff pressure

Comparative evaluation of three methods of endotracheal tube cuff inflation for adequacy of seal.

Intubation with cuffed endotracheal tube (ETT) is common in operation rooms, critical care, and emergency rooms. The pressure exerted by the cuff on the tracheal mucosa can lead to a reduction in blood flow to the tracheal wall and result in mucosal ischemia. There are many methods for ETT cuff inflation. Aim of the study was to compare the cuff pressures and volumes between the three methods of ETT cuff inflation. One hundred and twenty patients were randomized into three groups: Group SG (stethescope guided), group AL (audible leak), and group P (palpation). In group SG, the cuff was inflated by auscultating with the bell of the stethoscope over the thyroid cartilage for leak around cuff. In group AL, the cuff was inflated by listening for an audible leak around the cuff with observer's ear 5 cm away from the mouth of the patient. In group P, the cuff was inflated by palpating for a leak over the cricoid and trachea. The adequacy of the cuff seal was compared between the groups by assessing the volumes of additional air needed to stop the leak around the cuff as confirmed by supraglottic capnometry. The initial volumes needed to inflate the cuff were significantly more in the stethoscope (SG) and hearing (AL) groups than in the palpation (P) group (SG = 5.1 ± 1.4 ml, AL = 4.6 ± 1.6 ml, P = 3.1 ± 0.9 ml; SG and AL vs. P, P < 0.001). Additional cuff volumes required to achieve zero leak around cuff by supraglottic capnometry were 0.85 ± 1 ml in group SG, 1.3 ± 1.1 ml in group AL, and 2.237 ± 0.8 ml in group P (SG vs. P and AL vs. P; P < 0.001). Out of the auscultation-guided, audible leak-guided, and palpation-guided methods of ETT cuff inflation, the auscultation-guided and audible leak-guided methods achieve significantly better tracheal seal than the palpation-guided method.

Blood Flow Restriction Training for the Intervention of Sarcopenia: Current Stage and Future Perspective.

Sarcopenia is a geriatric syndrome that is characterized by a progressive and generalized skeletal muscle disorder and can be associated with many comorbidities, including obesity, diabetes, and fracture. Its definitions, given by the AWGS and EWGSOP, are widely used. Sarcopenia is measured by muscle strength, muscle quantity or mass and physical performance. Currently, the importance and urgency of sarcopenia have grown. The application of blood flow restriction (BFR) training has received increased attention in managing sarcopenia. BFR is accomplished using a pneumatic cuff on the proximal aspect of the exercising limb. Two main methods of exercise, aerobic exercise and resistance exercise, have been applied with BFR in treating sarcopenia. Both methods can increase muscle mass and muscle strength to a certain extent. Intricate mechanisms are involved during BFRT. Currently, the presented mechanisms mainly include responses in the blood vessels and related hormones, such as growth factors, tissue hypoxia-related factors and recruitment of muscle fiber as well as muscle satellite cells. These mechanisms contribute to the positive balance of skeletal muscle synthesis, which in turn mitigates sarcopenia. As a more suited and more effective way of treating sarcopenia and its comorbidities, BFRT can serve as an alternative to traditional exercise for people who have marked physical limitations or even show superior outcomes under low loads. However, the possibility of causing stress or muscle damage must be considered. Cuff size, pressure, training load and other variables can affect the outcome of sarcopenia, which must also be considered. Thoroughly studying these factors can help to better determine an ideal BFRT scheme and better manage sarcopenia and its associated comorbidities. As a well-tolerated and novel form of exercise, BFRT offers more potential in treating sarcopenia and involves deeper insights into the function and regulation of skeletal muscle.

The Elevation of Double-Lumen Tube Cuff Pressure During Lung Surgery: A Single-Center Prospective Observational Study☆,☆

Excessive tracheal tube cuff pressure can cause postoperative complications; however, the variations in the double-lumen tube cuff pressure in lung surgery have not been investigated. This study aimed to determine the incidence and variations in excess double- lumen tube cuff pressure during one-lung ventilation. A prospective observational study. Single secondary-care hospital. Patients aged ≥18 years scheduled for elective lung surgery using a left-sided double-lumen tube. None MEASUREMENTS AND MAIN RESULTS: Each cuff of the double-lumen tube was connected to a pressure transducer, and the cuff pressure was continuously measured. The excess cuff pressure and its duration (%) were defined as ≥22 mmHg, and the ratio of the duration of excess cuff pressure to the duration of one-lung ventilation, respectively. In total, 147 patients were included in the final analysis. Eighty patients (54.5%) developed cuff pressure elevation in either cuff and 28 patients (19%) in both cuffs. Younger age, male sex, and left-sided surgery were associated with elevated bronchial cuff pressure. Concurrently, younger age, maximal peak inspiratory pressure, and obstructive respiratory dysfunction were associated with an elevated tracheal cuff pressure. A duration of excess cuff pressure >50% in either cuff was found in 34 patients (23%), and both cuffs in 5 patients (3.4%). The correlation between the duration of tracheal and bronchial excess cuff pressure was poor. A high incidence and long duration of excess tracheal and bronchial cuff pressure were observed during one-lung ventilation for lung surgery.

Establishment of two canine models of benign airway stenosis and the effect of mitomycin C on airway stenosis

ObjectivesCuffed endotracheal intubation and stent implantation were employed to simulate two types of benign airway stenosis and further to analysis the different features between them from trachecscopic characteristics, gross anatomy to histopathological changes. In addition, our study explored the therapeutic effect of mitomycin C at different concentrations on granulation tissue caused by stent implantation in order to provide a new therapeutic strategy for clinical treatment of benign airway stenosis. MethodsTwelve beagle dogs were randomly divided into four groups, with three dogs in each group. Group A: Three beagle dogs were intubated through oral trachea after general anesthesia and cuff pressure maintained at 200 mmHg for 24 h. Group B, Group C and Group D: endotracheal coated self-expanding metal stents were placed after general anesthesia under the guidance of bronchoscope. On the Day7 after stent implantation, Group B, as control group, was injected phosphate buffer solution of 1 ml into granulation tissue at the end of stent; Group C was injected mitomycin C of 1 ml at 0.4 mg/ml and Group D was injected mitomycin C of 1 ml at 0.8 mg/ml into granulation tissue at the end of metal airway stent respectively, the same method as Group B. Bronchoscopy was used to observe tracheal lumen on the seventh day, fourteenth day and twenty-first day after modeling and pathological changes were examined on twenty-first day. ResultsTwo models of benign airway stenosis can be established by cuffed endotracheal intubation and stent implantation. There was tracheal rupture in the trachea cartiage ring in the cuffed endotracheal intubation group, but was't in stent implantation group. Histopathological characteristics were different between cuffed endotracheal intubation and stent implantation groups. In stent placement groups, we found that the stenosis degree of mitomycin C at 0.4 mg/ml was approximately 19%–32%, mitomycin C at 0.8 mg/ml was approximately 16%–21% and the control group was approximately 36%–47%. ConclusionThe two models of canine benign tracheal stenosis induced by cuffed endotracheal intubation and stent implantation are relatively simple, reliable and reproducible and have different characteristics. Mitomycin C could inhibit proliferation of granulation tissue and attenuate the degree of airway stenosis caused by stent implantation.

Venous volume and compliance in the calf and forearm does not change after acute endurance exercise performed at continuous or interval workloads.

Short‐term endurance exercise training for 6–8 weeks leads to increases in venous volume and compliance in the limbs. However, it is not known whether these venous vascular properties are improved by acute endurance exercise. We examined the effects of acute endurance exercise involving continuous or interval workloads on venous volume and compliance in the exercising (calf) and non‐exercising (forearm) limbs. Sixteen healthy young volunteers performed cycling exercise involving a continuous workload of 60% heart rate (HR) reserve or an interval workload of 40% HRreserve and 80% HRreserve, alternating every 2 min, for a total of 32 min each. Before and 60 min after acute cycling exercise, venous volume in the calf and forearm was measured by venous occlusion plethysmography during a cuff‐deflation protocol with a venous collecting cuff wrapped to the thigh and upper arm and strain gauges attached to the calf and forearm. The cuff pressure was maintained at 60 mmHg for 8 min and was then deflated to 0 mmHg at a rate of 1 mmHg/s. Venous compliance was calculated as the numerical derivative of the cuff pressure–limb venous volume curve. In both the calf and forearm, the cuff pressure–venous volume curve and the cuff pressure–venous compliance relationship did not differ between before and 60 min after exercise involving continuous or interval workloads. These results suggest that acute exercise does not improve venous volume and compliance in both the exercising and non‐exercising limbs.

Active Relative to Passive Ischemic Preconditioning Enhances Intense Endurance Performance in Well-Trained Men.

This study tested the hypothesis of whether ischemic exercise preconditioning (IPC-Ex) elicits a better intense endurance exercise performance than traditional ischemic preconditioning at rest (IPC-rest) and a SHAM procedure. Twelve men (average V˙O2max ∼61mL·kg-1·min-1) performed 3 trials on separate days, each consisting of either IPC-Ex (3 × 2-min cycling at ∼40W with a bilateral-leg cuff pressure of ∼180mmHg), IPC-rest (4 × 5-min supine rest at 220mmHg), or SHAM (4 × 5-min supine rest at <10mmHg) followed by a standardized warm-up and a 4-minute maximal cycling performance test. Power output, blood lactate, potassium, pH, rating of perceived exertion, oxygen uptake, and gross efficiency were assessed. Mean power during the performance test was higher in IPC-Ex versus IPC-rest (+4%; P = .002; 95% CI, +5 to 18W). No difference was found between IPC-rest and SHAM (-2%; P = .10; 95% CI, -12 to 1W) or between IPC-Ex and SHAM (+2%; P = .09; 95% CI, -1 to 13W). The rating of perceived exertion increased following the IPC-procedure in IPC-Ex versus IPC-rest and SHAM (P < .001). During warm-up, IPC-Ex elevated blood pH versus IPC-rest and SHAM (P ≤ .027), with no trial differences for blood potassium (P > .09) or cycling efficiency (P ≥ .24). Eight subjects anticipated IPC-Ex to be best for their performance. Four subjects favored SHAM. Performance in a 4-minute maximal test was better following IPC-Ex than IPC-rest and tended to be better than SHAM. The IPC procedures did not affect blood potassium, while pH was transiently elevated only by IPC-Ex. The performance-enhancing effect of IPC-Ex versus IPC-rest may be attributed to a placebo effect, improved pH regulation, and/or a change in the perception of effort.

Effects of Low-Load Blood Flow Restriction Training on Hemodynamic Responses and Vascular Function in Older Adults: A Meta-Analysis.

Background: The combination of low-load (LL) training with blood flow restriction (BFR) has recently been shown to trigger a series of hemodynamic responses and promote vascular function in various populations. To date, however, evidence is sparse as to how this training regimen influences hemodynamic response and vascular function in older adults. Objective: To systematically evaluate the effects of LL-BFR training on hemodynamic response and vascular function in older adults. Methods: A PRISMA-compliant systematic review and meta-analysis were conducted. The systematic literature research was performed in the following electronic databases from their inception to 30 February 2022: PubMed, Web of Science, Scopus, EBSCO host, the Cochrane Library and CNKI. Subsequently, a meta-analysis with inverse variance weighting was conducted. Results: A total of 1437 articles were screened, and 12 randomized controlled trials with a total 378 subjects were included in the meta-analysis. The meta-analysis results showed that LL-BFR training caused a significant acute increase in heart rate (WMD: 4.02, 95% CI: 0.93, 7.10, p < 0.05), systolic blood pressure (WMD: 5.05, 95% CI: 0.63, 9.48, p < 0.05) and diastolic blood pressure (WMD: 4.87, 95% CI: 1.37, 8.37, p < 0.01). The acute hemodynamic response induced by LL-BFR training is similar to that elicited by high-load (HL) training. Training volume, cuff pressure and width were identified as significant moderators in our subgroup and meta-regression analyses. After 30 min of training, resting systolic blood pressure significantly decreased (WMD: −6.595, 95% CI: −8.88, −3.31, p < 0.01) in the LL-BFR training group, but resting hemodynamic indexes exhibited no significant differences compared with common LL and HL training; long-term LL-BFR training resulted in significant improvements in flow-mediated vasodilation (FMD) (WMD: 1.30, 95% CI: 0.50, 2.10, p < 0.01), cardio ankle vascular index (CAVI) (WMD: 0.55, 95% CI: 0.11, 0.99, p < 0.05) and ankle brachial index (ABI) (WMD: 0.03, 95% CI: 0.00, 0.06, p < 0.05) in older adults. Conclusion: This systematic review and meta-analysis reveals that LL-BFR training will cause an acute hemodynamic response in older adults, which can return to normal levels 30 min after training, and systolic blood pressure significantly decreased. Furthermore, the beneficial effect of LL-BFR training on vascular function is to improve FMD, CAVI and ABI of older adults. However, due to the influence of the quality of the included studies and the sample size, more high-quality studies are needed to confirm such issues as BFR pressure and training risk.

Is endotracheal tube displacement during head and neck extension due to ascending movement or tracheal lengthening? An observational ultrasonographic study.

Complications of the endotracheal tube (ETT) displacement during head and neck positional changes are related to not only the tip position but also the cuff pressure against the larynx. Here, we evaluated movement of the ETT cuff relative to laryngeal structures as well as tip displacement from the carina.Sixty-two patients scheduled for thyroidectomy were recruited. The distance from the cricoid cartilage to the upper margin of the cuff (CC) and that from the ETT tip to the carina (TC) were measured using ultrasonography and fiberoptic bronchoscopy, respectively, during flexion and extension. The total tracheal length (TTL) was defined as the combination of CC, TC, and the distance from the upper margin of the cuff to the tip.During flexion, the CC and TC were 1.5 ± 0.6 and 2.9 ± 1.0cm respectively. Seven patients (11.7%) exhibited excessively deep intubation. After adjusting the cuff position under ultrasonography (CC = 0), the tip position was corrected in 96.7%. While the TC increased by 2.1 ± 1.0cm after the positional change in extension, the CC decreased by 0.6 ± 0.7cm because the TTL lengthened (1.4 ± 1.1cm). Four patients (6.7%) exhibited excessive cuff displacement beyond the cricoid cartilage, which could have been corrected under ultrasonography.In conclusion, the ETT cuff displaced toward the larynx in a less degree than the tip did from the carina due to the tracheal lengthening during head and neck extension. Nevertheless, we suggest that ultrasonographic assessment of cuff position may avoid ETT misplacement. Trial registration https://cris.nih.go.kr/ (approval no. KCT0005319); registered on May 14, 2019.

“Study on Device System to Reduce Tracheal Mucosal Injury in Intubation Patients” [ASME Journal of Medical Devices, 2022, 16(3), p. 031006; DOI: 10.1115/1.4054334

Abstract The purpose of this study was to develop an automatic bronchial aspiration system to minimize tracheal mucosal damage in ventilator patients. Operation performances of the system's suction pressure, bronchial intubation depth, suction cycle, and tube cuff pressure were tested. To check the clinical results, subjects underwent endoscopy after applying the previous manual method for 24 h. After that, they underwent endoscopy after applying the proposed suction system for 24 h. For quantitative evaluation of test results, the tracheal mucosal injury was divided into the following five grades: grade 0 = normal, grade 1 = erythema or edema, grade 2 = erosion, grade 3 = hemorrhage, and grade 4 = ulcer or necrosis. In the performance test, an error of up to 12 mmHg occurred within the normal operation error range for suction pressure control. The insertion depth control had a maximum error of 7.0 mm within the normal operation error range. On the other hand, there was no error in the time control or the tube cuff pressure control. In the clinical trial, after using the proposed system for five subjects to find changes in tracheal mucosal injury by endoscopy, reduced injury or no change in injury was found. The system proposed in this study is confirmed to be able to remove the sputum while minimizing tracheal mucosal injury that can occur while using the previous manual suction device.

How the Patient-clinician Relationship Influences Treatment Experiences and Outcomes in Chronic Pain Patients: An fMRI Hyperscan Study

The patient-clinician therapeutic alliance is a powerful modulator shaping patients' treatment experience and clinical outcomes. Before and after a 3-week electro-acupuncture intervention (6 sessions), fMRI hyper-scanning was applied to investigate the influence of either an Augmented (warm/attentive) or a Limited (neutral/business-like) clinician interaction style. Eighteen women with fibromyalgia (mean age=41.41, SD=12.20, each group N=9), randomly assigned to an Augmented or Limited patient-clinician dyadic interaction style (trained acupuncturists), underwent a simultaneously recorded fMRI hyper-scanning procedure with a video connection between two scanners and an evoked cuff pressure pain/treatment paradigm. Questionnaires were used to assess the patients' experience by targeting treatment-related changes such as clinical pain levels, therapeutic alliance, trust, the clinician's warmth and competence, and the probability of continuing the treatment with this clinician after study participation. As rated by patients, pooled therapeutic alliance and clinicians' warmth in the Augmented (mean_alliance=43.21, SD=2.40; mean_warmth=4.00, SD=0.0) were significantly higher than in the Limited group (mean_alliance=22.79, SD=13.15; mean_warmth=2.54, SD=1.10; t_alliance(16)=4.31, p<0.001; t_warmth(16)=3.74; p=0.002). Additionally, over the course of all 6 acupuncture treatment sessions, most patients experienced immediate clinical pain relief after each treatment session (p<0.001), irrespective of augmented or limited group assignment. Pain catastrophizing was significantly reduced after the intervention (t(16)=3.79; p=0.002) in the Augmented (∆-7.88) but not the Limited group (∆1.44). Importantly, only the Augmented group reported a high probability to continue with the treatment after the study as well as a high pain relief expectation for future acupuncture treatments even though both groups experienced similar pain relief treatment outcomes over the course of the study intervention. Brain imaging data analysis focused on social mirroring areas such as the temporo-parietal junction (TPJ). In summary, this study highlights the importance of investigating variable interaction quality during longitudinal clinical therapies and its influence on clinical outcomes, treatment compliance, and brain processing of nociceptive signaling. Grant support from NIH - National Center for Complementary and Integrative Health (NCCIH: R61-AT009306, R33-AT009306), Neuroimaging Pilot Funding Initiative at the Martinos Center for Biomedical imaging (MGH R90DA023427), Korea Institute of Oriental Medicine (KIOM), Foundation for the Science of the Therapeutic Encounter, National Center for Research Resources (P41RR14075; CRC 1 UL1 RR025758), Harvard Clinical and Translational Science Center, Martinos Computing facilities, and National Institutes of Health (Grant Nos. S10RR023401, S10RR019307, S10RR019254, and S10RR023043). The funders had no role in study design, data collection and/or interpretation of the results. Also, all authors declare no existence of competing conflicts of interest.

Post-intubation Tracheoesophageal Fistula In Severe Sars-cov-2 Covid-19 Patient: An Unexpected Finding During Swallowing Test

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) has cause the COVID-19 pandemic that had led to an increase in intensive care unit admission for massive interstitial pneumonia. Many patients underwent mechanical ventilation and endotracheal intubation for a prolonged period of time followed by a subsequent tracheostomy. The most common complications related to these maneuvers are stenosis, malacia, laryngotracheal granulomas, webs. The least common complications are tracheal necrosis due to tracheo-arterial or trachea-esophageal fistulas, caused by compression between the nasogastric tube and the orotracheal tube cuff. A case of 58-year-old female COVID-19 patient with severe pneumonia who underwent prolonged mechanical ventilation and intubation and for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal x-ray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient's bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

Sex‐specific Consequences of Psychosocial Stress on Cardiorespiratory Control: a Comparison with Intermittent Hypoxia

Sleep apnea (SA) is a complex, multifactorial and a sex‐specific respiratory disorder; sexual dimorphism being present both in its prevalence and in the presentation of the pathology. To this day, the origins of SA remain unknown. While intermittent hypoxia (IH) is commonly used to assess the pathophysiology of SA, this systemic stress is a consequence, not a cause of SA. The psychosocial stress of social isolation (SI) and the recent COVID pandemic showed how SI increases the risk for a broad range of diseases, including hypertension and obesity, which are common comorbidities of SA. While there is growing evidence linking psychosocial stress and SA, its effect on cardiorespiratory function is yet to be established. To address this issue, we tested the hypothesis that SI is sufficient to induce sex‐specific cardiorespiratory and metabolic disturbances similar to those seen in patients with SA. We then compared the effects of SI with those observed following moderate IH.Adult (8 weeks old) rats were subjected to either three weeks of social isolation or standard housing. SI consisted of single housing without visual contact with other rats (n = 22); the control rats were housed in pairs (n = 22), both groups under normoxic conditions. The third group (n = 18) housed in pairs was exposed to intermittent hypoxia (IH: FiO2 = 0.10 – 30s, 10 cycles/hour, 8 hours/day, 7 days). Apneas were quantified by whole body plethysmography during sleep. Cardiovascular measurements were then measured by tail cuff pressure and body composition by magnetic resonance. Blood samples were obtained at the end of the protocol to measure plasma corticosterone and ACTH with a multiplex assay.Male rats subjected to SI had an apnea index 27% higher than controls, were hypertensive (+ 15mmHg) and gained 6% more weight than males in pair housing. The body fat and fluid gains of SI males were, respectively, 21% and 38% higher than their controls. Yet, food consumption did not differ between the two groups. SI augmented plasma ACTH and corticosterone. The SI protocol had no significant effect in females. IH males (but not females) were hypertensive (+ 9mmHg), and their heart rate was 54 bpm greater than controls but no significant change in the number of apneas. Moderate IH did not augment stress hormone levels. Unlike SI, IH reduced food consumption and weight gain in both sexes. IH reduced body fat by 18% and body fluids by 30% compared to controls. Body composition of IH females was not different from controls.Our results demonstrate that SI is sufficient to activate the neuroendocrine stress response and induce sex‐specific cardiorespiratory and metabolic disturbances similar to those reported in SA patients. Our observations also suggest that the cardiovascular disturbance in IH occurs before respiratory disruption, and that and the activation of the stress pathways is necessary to augment apneic events. A longer or more severe protocol should be considered. These results indicate that stress hormones play an important role in the etiology of respiratory disorders and key comorbidities such as hypertension and obesity. We propose that SI is a valuable model to investigate the origins and pathophysiology of SA.

A Practical Application of Blood Flow Restriction Exercise

Exercise with blood flow restriction (BFR) is emerging as an effective training option to increase muscle size and strength, in healthy, clinical, and athletic populations. However, the need for specialized equipment and associated costs present a major barrier to its accessibility. The purpose of this study was to develop a practical method to implement BFR in the lower body using a thigh sphygmomanometer. Specifically, we aimed to 1) explore what factors should be accounted for when setting pressures with this type of restrictive cuff and 2) generate both a lab‐based and field‐based prediction equation to estimate arterial occlusion pressure (AOP). We hypothesized that measures of limb size and blood pressure would constitute significant predictors of lower body AOP. We also hypothesized that a multiple linear regression model including significant predictors would explain approximately 50% of the variance in AOP. Thirty‐eight normotensive healthy adults (age: 24±5 yrs, BMI: 25±4) visited the laboratory for one testing session. Brachial and femoral systolic (SBP) and diastolic (DBP) blood pressures were taken in the seated position. Next, thigh circumference, muscle thickness of the anterior thigh, and maximal isometric knee extension strength was assessed. Lean thigh volume was estimated using anthropometric measures. Lastly, lower body AOP was assessed in the seated position using an 18cm wide thigh sphygmomanometer and Doppler ultrasound (156±12 mmHg). A multiple linear regression analysis including brachial and femoral SBP and DBP, thigh circumference, muscle thickness, lean thigh volume, and maximal isometric knee extension strength was performed to assess which variables constituted significant predictors of AOP. Regression analysis was then repeated with only significant variables to generate both a lab‐based and field‐based prediction equation for AOP. Thigh circumference (β = 0.322, part = 0.876), brachial SBP (β = 0.362, part = 0.463) and isometric knee extension strength (β = 0.421, part = 0.076) constituted significant predictors of AOP. A lab‐based model including thigh circumference (β=0.278, part = 0.754), brachial SBP (β=0.492, part = 0.549), and isometric knee extension strength (β=0.306, part = 0.055) explained 56% of the variance in AOP. A field‐based model including only thigh circumference (β=0.316, part = 0.857) and brachial SBP (β=0.515, part = 0.658) explained 47% of the variance in AOP. Our results indicate that thigh circumference, brachial SBP, and isometric knee extension strength serve as predictors of AOP in the lower body when utilizing an 18cm wide sphygmomanometer as a restrictive cuff. Further, a field‐based prediction equation including thigh circumference and brachial SBP offers a practical way to estimate AOP. Future work will build upon this prediction equation by utilizing subjective measures of cuff tightness, effort, and muscle pain to further adjust exercising cuff pressures to an appropriate level. Results will help to provide researchers and practitioners with a practical way to implement BFR without the need for specialized equipment.

Blood Pressure in Patients with Arterial Hypertension and Overweight or Obesity During Office Measurement and Daily Monitoring

Arterial hypertension (AH) is one of the most common chronic diseases in the world. More than 1.5 billion people suffer from hypertension. According to official statistics, in Ukraine in 2021 more than 13 million patients with AH were registered, and annually this disease is detected in 1 million Ukrainians. The objective: to determine the levels of blood pressure (BP) in overweighted or obese patients with AH who use antihypertensive drugs during office measurement and 24-hours monitoring of BP. Materials and methods. The study analyzed the results of treatment of 395 overweighted or obese patients (139 women and 236 men) with essential AH. All patients received antihypertensive treatment for at least 3 months before study start. Patients were divided into five groups depending on blood pressure. The control group included 33 age-matched individuals. During the study BP was measured in physician’s office with use of mechanical tonometer with a shoulder cuff and ambulatory 24-hours blood pressure monitoring (ABPM) was performed for all patients. Results. The results of office blood pressure measurement and ABPM were analyzed. Normal BP was detected in 34.7% of patients with AH and high BMI. In 10.9% of patients systolic blood pressure (SBP) remains above 139 mm Hg despite of drug use, in 16.3% of patients the grade 1 AH was diagnosed, in 23.2% – grade 2, and in 14.9% – grade 3 AH was deter mined during office blood pressure measurement. It was found that men are 1.7 times more likely had uncontrolled AH comparing to women. The further analyze of the BP data showed that office BP levels were higher then home. Target blood pressure levels were found in 87% of patients during ABPM, although in the office measurement this figure was 54%, 5% of patients could not withstand the BP monitoring during the day with an automatic device due to pain. No difference in heart rate was determined in study patients by different types of measurement. Conclusions. In patients with AH and high body mass index, office measurement reveals insufficient reduction of blood pressure (BP) in 35% of patients despite of antihypertensive drugs use. At the same time ABPM found target BP achievement in 87% of patients. Thus, ABPM should be performed in overweighted or obese patients with AH before making the decision to increase the antihypertensive drug dose to avoid possible undesirable BP decrease.

Post-intubation tracheoesophageal fistula in severe SARS-CoV-2 - COVID-19 patient: Unexpected finding during swallowing test

Introduction: COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, led to an increase in intensive care admission for massive interstitial pneumonia. Many patients underwent long periods of endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common complications related to these maneuvers are known: laryngotracheal granulomas, webs, stenosis and malacia. Less common complications are tracheal necrosis with trachea-esophageal or tracheo-arterial fistulas, caused by compression between the orotracheal tube cuff and the nasogastric tube. Case report: We present the case of a patient with severe COVID-19 associated pneumonia who underwent orotracheal intubation and prolonged mechanical ventilation for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal xray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. Discussion: TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient’s bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

Echocardiographic Normal Reference Ranges for Non-invasive Myocardial Work Parameters in Pediatric Age: Results From an International Multi-Center Study.

AimsThis international multi-center study aimed to demonstrate the feasibility and reliability of non-invasive myocardial work (MW) parameters in the pediatric population, and to provide normal reference ranges for this useful echocardiographic tool in this specific subset of patients.Methods and ResultsIn this retrospective multi-center study involving three pediatric laboratories, 150 healthy children and adolescents (mean age of 10.6 ± 4.5, 91 males) were enrolled. A complete echocardiographic examination has been performed, including global longitudinal strain (GLS) assessment. The following parameters of non-invasive MW have been obtained through a dedicated software: global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE), using left ventricular (LV) strain loops and non-invasive brachial artery cuff pressure values. The lowest expected values were for GWI 1,723 mmHg% in males and 1,682 mmHg% in females, for GCW 2,089 and 2,106 mmHg%, for GWE 95.9 and 95.5% whereas the highest expected value for GWW was 78 mmHg% in men and 90 mmHg% in women. The univariable and multivariable analysis showed significant associations between either GWI or GCW with SBP (β coefficient = 0.446, p < 0.001; β coefficient = 0.456, p < 0.001, respectively) and LV GLS (β coefficient = −0.268, p = 0.001; β coefficient = −0.233, p = 0.003, respectively). Inter- and intra-observer variability showed good reproducibility of non-invasive MW parameters.ConclusionNon-invasive MW parameters were feasible and reliable in the pediatric population. This study provided normal reference ranges of these useful echocardiographic indices.