Episodes Of Airway Obstruction Research Articles

Simulation Training for Airway Obstruction in Pediatrics

Foreign body airway obstruction is the 4th leading cause of death in children and adolescents. Despite the development and dissemination of emergency aid methods, the introduction of endoscopic examination and treatment methods, and the increased knowledge of medical personnel and the population in providing first aid, this problem is extremely relevant at present. This study included a detailed analysis of foreign body airway obstruction episodes in children in the Ryazan region over a 5-year period, and described clinical cases that allow us to assess the importance of early diagnosis and treatment.

The relationship between obstructive sleep apnea syndrome severity and vitamin D levels in sera

Aims: Obstructive Sleep Apnea Syndrome (OSAS) is a disorder characterized by complete or partial upper airway obstruction episodes and frequently decreased arterial oxygen saturation. Etiological factors and risk factors of OSAS are still investigated and studies in this topic continue. Until recently, researches were focused on the major effects of vitamin D on the bone metabolism and calcium homeostasis. Today; it has been found that vitamin D plays roles in many cells and tissues of human body additional to its functions in the musculoskeletal system. In our study, we aimed to examine vitamin D levels in patients who are diagnosed as OSAS and to investigate the relationship between OSAS and vitamin D deficiency. Methods: 83 volunteers, who were suspected to have OSAS, were included in the study. They all underwent polysomnography (PSG) in the Sleep Disorders Center in Pulmonary Department, between January 2015 – May 2015. Twenty cases with apnea hypopnea index (AHİ) < 5/hour were evaluated as simple snoring/control group. Cases with AHİ > 5/hour were diagnosed as OSAS; 22 patients were diagnosed as mild, 20 patients were diagnosed as moderate and 21 patients were diagnosed as severe OSAS. Blood samples of these patients were studied for the measurement of vitamin D [25(OH)D3], parathormone (PTH) , calcium (Ca), phosphor (P) levels and the samples were quickly delivered to biochemistry laboratory Results: A statistically significant difference in vitamin D levels were observed (p<0.05) between the control and OSAS groups. However, no statistically significant difference was found in PTH, Ca, P levels among these groups (p>0.05). Vitamin D levels in the control group were significantly higher than the mild and the severe OSAS patients. No statistically significant difference was observed in PTH, Ca, P levels between these patients. Conclusion: Our study indicates that there is a significant relationship between vitamin D deficiency and OSAS. This finding suggests that vitamin D deficiency may play a role in the OSAS physiopathology. There are few studies exists about the association between vitamin D deficiency and OSAS. In this regard, we think our study will contribute to the literature. Moreover; prospective, randomized, controlled studies with large series were needed.

New Approaches to the Management of Cardiovascular Risk Associated with Sleep Respiratory Disorders in Pediatric Patients.

Exposure to risk factors in youth can exacerbate the development of future cardiovascular disease (CVD). Obstructive sleep apnea (OSA), characterized by repetitive episodes of airway obstructions, could trigger said CVD acting as a modifiable risk factor. Measurements from echocardiography have shown impairments in the anatomy and function of the heart related to the severity of OSA. Therefore, the aim of this review was to propose a new clinical approach to the management of cardiovascular risk (CVR) in children based on treating OSA. The review includes studies assessing echocardiographic parameters for cardiac function and structure in pediatric OSA diagnosed using the apnea-hypopnea index (AHI) ≥ 1/h using polysomnography (PSG) and conducted within a year. Based on the reviewed evidence, in addition to PSG, echocardiography should be considered in OSA children in order to indicate the need for treatment and to reduce their future CVR. A follow-up echocardiography after treatment could be performed if impairments in the anatomy and function were found. Prioritizing parameters intimately connected to comorbidity could propel more effective patient-centered care. In conclusion, a reevaluation of pediatric OSA strategies should be considered, emphasizing comorbidity-related parameters in the cardiovascular field. Further studies are needed to assess this approach, potentially leading to enhanced protocols for more effective pediatric OSA treatment and CVR prevention.

Group III secreted phospholipase A2 -driven lysophospholipid pathway protects against allergic asthma.

Asthma is a chronic inflammatory disease of the airways characterized by recurrent episodes of airway obstruction, hyperresponsiveness, remodeling, and eosinophilia. Phospholipase A2 s (PLA2 s), which release fatty acids and lysophospholipids from membrane phospholipids, have been implicated in exacerbating asthma by generating pro-asthmatic lipid mediators, but an understanding of the association between individual PLA2 subtypes and asthma is still incomplete. Here, we show that group III-secreted PLA2 (sPLA2 -III) plays an ameliorating, rather than aggravating, role in asthma pathology. In both mouse and human lungs, sPLA2 -III was expressed in bronchial epithelial cells and decreased during the asthmatic response. In an ovalbumin (OVA)-induced asthma model, Pla2g3-/- mice exhibited enhanced airway hyperresponsiveness, eosinophilia, OVA-specific IgE production, and type 2 cytokine expression as compared to Pla2g3+/+ mice. Lipidomics analysis showed that the pulmonary levels of several lysophospholipids, including lysophosphatidylcholine, lysophosphatidylethanolamine, and lysophosphatidic acid (LPA), were decreased in OVA-challenged Pla2g3-/- mice relative to Pla2g3+/+ mice. LPA receptor 2 (LPA2 ) agonists suppressed thymic stromal lymphopoietin (TSLP) expression in bronchial epithelial cells and reversed airway hyperresponsiveness and eosinophilia in Pla2g3-/- mice, suggesting that sPLA2 -III negatively regulates allergen-induced asthma at least by producing LPA. Thus, the activation of the sPLA2 -III-LPA pathway may be a new therapeutic target for allergic asthma.

Eosinophil Cationic Protein Variation in Patients with Asthma and CRSwNP Treated with Dupilumab.

Asthma is a clinical syndrome characterized by recurrent episodes of airway obstruction, bronchial hyperresponsiveness and airway inflammation. Most patients with asthma present a "type 2" (TH2) inflammation. ILC2 and TH2 cells release cytokines IL4, IL-13 and IL-5. CRSwNP is a condition characterized by hyposmia or anosmia, nasal congestion, nasal discharge, and face pain or pressure that last for at least 12 weeks in a row without relief. Both asthma and CRSwNP are often characterized by a type 2 inflammation endotype and are often present in the same patient. Dupilumab is a fully human monoclonal antibody targeting the interleukin-4 receptor α (IL-4Rα) subunit, blocking IL4/IL-4Rα binding and IL13. It has been labelled for the treatment of moderate to severe asthma in patients from the age of 12 years with an eosinophilic phenotype, and it has demonstrated efficacy and acceptable safety. Our study aims to investigate the effects of dupilumab on type 2 inflammatory biomarkers, such as eosinophils and eosinophil cationic protein (ECP). ECP is an eosinophil-derived substance contained in granules that are released during inflammation and causes various biological effects, including tissue damage in asthmatic airways. ECP, Eosinophil counts (EOS), and total immunoglobulin E (IgE) levels were longitudinally measured using immunoassays in the serum of 21 patients affected by CRSwNP, of which 17 had asthma as a comorbidity, receiving 300 mg dupilumab every two weeks. The EOS and ECP, after a first phase of significant increase due to the intrinsic characteristic of the block of IL-4 and IL-13, returned to the baseline 10 months after the initial administration of dupilumab. Fractional exhaled nitric oxide (FeNO) and serum total IgE decreased significantly after 9 months. Asthma Control Test (ACT) scores improved after dupilumab treatment. FEV1% and FEV1 absolute registered a significant improvement at 10 months. Patients who received 300 milligrams of dupilumab every two weeks first experienced a temporary increase in eosinophils (EOS) and eosinophil cationic protein (ECP), then exhibited a gradual decline in these variables with a subsequent return to the initial baseline levels. When compared to the baseline, we observed that the levels of IgE and FeNO decreased over time, while there was an increase in both FEV1 and FEV1%.

The Role of Systems Biology in Deciphering Asthma Heterogeneity.

Asthma is one of the most common and lifelong and chronic inflammatory diseases characterized by inflammation, bronchial hyperresponsiveness, and airway obstruction episodes. It is a heterogeneous disease of varying and overlapping phenotypes with many confounding factors playing a role in disease susceptibility and management. Such multifactorial disorders will benefit from using systems biology as a strategy to elucidate molecular insights from complex, quantitative, massive clinical, and biological data that will help to understand the underlying disease mechanism, early detection, and treatment planning. Systems biology is an approach that uses the comprehensive understanding of living systems through bioinformatics, mathematical, and computational techniques to model diverse high-throughput molecular, cellular, and the physiologic profiling of healthy and diseased populations to define biological processes. The use of systems biology has helped understand and enrich our knowledge of asthma heterogeneity and molecular basis; however, such methods have their limitations. The translational benefits of these studies are few, and it is recommended to reanalyze the different studies and omics in conjugation with one another which may help understand the reasons for this variation and help overcome the limitations of understanding the heterogeneity in asthma pathology. In this review, we aim to show the different factors that play a role in asthma heterogeneity and how systems biology may aid in understanding and deciphering the molecular basis of asthma.

This Month in Anesthesiology

This Month in Anesthesiology

Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review.

Over the past five decades, quantitative neuromuscular monitoring devices have been used to examine the incidence of postoperative residual neuromuscular block in international clinical practices, and to determine their role in reducing the risk of residual neuromuscular block and associated adverse clinical outcomes. Several clinical trials and a recent meta-analysis have documented that the intraoperative application of quantitative monitoring significantly reduces the risk of residual neuromuscular blockade in the operating room and postanesthesia care unit. In addition, emerging data show that quantitative monitoring minimizes the risk of adverse clinical events, such as unplanned postoperative reintubations, hypoxemia, and postoperative episodes of airway obstruction associated with incomplete neuromuscular recovery, and may improve postoperative respiratory outcomes. Several international anesthesia societies have recommended that quantitative monitoring be performed whenever a neuromuscular blocking agent is administered. Therefore, a comprehensive review of the literature was performed to determine the potential benefits of quantitative monitoring in the perioperative setting.

Prevalence of Obstructive Sleep Apnea Syndrome in Psoriasis Patients

Aim: Psoriasis is a frequently seen chronic systemic inflammatory disease accompanied by several comorbid conditions that affects 2-3% of the general population. One of the comorbidities rarely accompanying psoriasis is obstructive sleep apnea syndrome (OSAS). OSAS is a disease characterized by recurrent complete (apnea) or partial (hypopnea) upper airway obstruction episodes and frequently by decreased blood oxygen saturation. The purpose of this study was to evaluate the risk factors for OSAS by investigating OSAS symptoms in psoriasis patients.Material and Methods: Eighty-two patients aged over 16, diagnosed with psoriasis, and under follow-up by the Duzce University Medical of Faculty, Dermatology and Venereal Diseases Polyclinic, Turkey, were included in the study. Patients’ OSAS symptoms were investigated. The Epworth Sleepiness Scale was used to assess excessive daytime somnolence.Results: Of the patients 51.2% (n=42) were male and 48.8% (n=40) female. Patients’ mean age was 47.09±14.10 years. Patients’ mean time of psoriasis diagnosis was 16.97±10.55 years, and mean Psoriatic Area Severity Index (PASI) score was 11.25±6.32. Severe disease was present in 54.9% of patients (n=45) based on PASI classification. Prevalence of 56.1% for snoring, 25.6% for excessive daytime sleepiness, and 15.9% for witnessed apnea were determined in these patients. Forty-seven (57.3%) cases had at least one major symptom. The most common minor symptoms were inability to sleep with 25.6% (n=21) and insufficient disrupted sleep with 22.0% (n=18).Conclusion: Prevalence of OSAS symptoms in psoriasis patients were found high. Psoriasis patients with OSAS symptoms must be referred to relevant specialists for polysomnographic evaluation.

The Results of Surgical Treatment of Hypertension in Mild and Moderate Obstructive Sleep Apnea Syndrome

Background: Obstructive sleep apnea syndrome (OSAS) is the most common respiratory disorder related to sleep. It is characterized by recurrent upper airway obstruction episodes and a decrease in arterial oxygen saturation during sleep. The most important complications of OSAS are related to the cardiovascular system. Hypertension (30% - 60%) is the leading cause of these complications. Objectives: This study aimed to investigate the removal of upper airway obstruction through surgical operations in the tension treatment of OSAS patients with hypertension. Methods: This retrospective study included 42 patients with hypertension from 2008 to 2017 who were diagnosed with OSAS based on the result of polysomnogram (PSG) test. All the patients were examined in detail in otorhinolaryngology and cardiology clinics, their endoscopic and imaging evaluations were carried out and their blood pressure was followed-up. Preoperative and postoperative arterial blood pressure values for upper airway obstruction were statistically analyzed. Results: The mean preoperative systolic and diastolic arterial blood pressure values of the patients with hypertension were 152.3 ± 21.2 and 97.2 ± 12.3 mmHg, respectively. Their postoperative systolic and diastolic arterial blood pressure levels were found to be 124.5 ± 19.3 and 86.4 ± 12.1 mmHg, respectively (P < 0.05). This decrease in the arterial blood pressure was significant. Conclusions: Removal of upper airway obstruction through a surgical operation was found to play an important role in the blood pressure treatment of OSAS patients with hypertension.

Cardiovascular Complications in Obstructive Sleep Apnea Syndrome

: Obstructive sleep apnea syndrome (OSAS) is the most common respiratory disorder related to sleep. It is characterized by recurrent upper airway obstruction episodes and hypoxemia attacks during sleep. Cardiovascular complications are rather frequent in OSAS. This compilation study aimed to show cardiovascular pathologies occurring during OSAS in detail and emphasize the need of treating OSAS during the treatment of these pathologies

OBSTRUCTIVE SLEEP APNEA;

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are two different diseases that may coexist within an individual and is known as overlap syndrome. Treatment of choice for overlap patients is CPAP along with supplemental oxygen for correction of upper airway obstructive episodes and hypoxemia during sleep, which is different from the treatment of COPD or OSA alone so detection of these cases is important for proper management of these patients. Objectives: To find out the frequency of obstructive sleep apnea in patients with COPD. Study Design: Cross section study. Setting: Department of Pulmonology Multan Medical and Dental College; Tertiary care hospital. Period: Six months from July to Dec 2017. Materials &amp; Methods: 151 consecutive patients with diagnosed COPD attending our Pulmonology Outpatient Department and fulfilling the inclusion and exclusion criteria were included in the study. All the patients were asked questions from Berlin Sleep Questionnaire and categorized into high or low likelihood for having OSA. Overnight polysomnography was done in those with high likelihood to confirm the diagnosis of obstructive sleep apnea. Results: There were 151 patients. Males were 125 (82.8%) whereas females were 26 (17.2%). Mean age of all patients was 54.49+10.33 years. Mean values for height and weight were 160.9+1.05cm and 62.33+1.39kg respectively. Mean BMI was 24.13+5. Mean for number of smoking pack years was 16.45+7.22. We found 16 patients (10.5%) to have OSA. Conclusion: Frequency of OSA in COPD patients is high and needs special attention while managing these patients. This can be achieved by routine use of screening questionnaires and by conducting polysomnography where indicated.

Is There Still a Role for Succinylcholine in Contemporary Clinical Practice?

Succinylcholine is a depolarizing muscle relaxant that has been used for rapid sequence induction and for procedures requiring only a brief duration of muscle relaxation since the late 1950s. The drug, however, has serious side effects and a significant number of contraindications. With the recent introduction of sugammadex in the United States, a drug that can rapidly reverse even large amounts of rocuronium, succinylcholine should no longer be used for endotracheal intubation and its use should be limited to treating acute laryngospasm during episodes of airway obstruction. Given the numerous risks with this drug, and the excellent ablation of airway reflexes with dexmedetomidine, propofol, lidocaine and the larger amounts of rocuronium that can now be administered even for an anesthesia of short duration. The use of succinylcholine for endotracheal intubation should disappear from clinical practice.

Does recurrent endogenous hypoxia protect the heart?

Obstructive sleep apnea (OSA) is characterized by episodic airway obstruction resulting in intermittent hypoxia and disrupted sleep. The associated activation of the sympathetic nervous system may lead to acute blood pressure elevation and metabolic disturbances, including lipolysis and insulin resistance (1).

Neostigmine Administration after Spontaneous Recovery to a Train-of-Four Ratio of 0.9 to 1.0: A Randomized Controlled Trial of the Effect on Neuromuscular and Clinical Recovery.

When a muscle relaxant is administered to facilitate intubation, the benefits of anticholinesterase reversal must be balanced with potential risks. The aim of this double-blinded, randomized noninferiority trial was to evaluate the effect of neostigmine administration on neuromuscular function when given to patients after spontaneous recovery to a train-of-four ratio of 0.9 or greater. A total of 120 patients presenting for surgery requiring intubation were given a small dose of rocuronium. At the conclusion of surgery, 90 patients achieving a train-of-four ratio of 0.9 or greater were randomized to receive either neostigmine 40 μg/kg or saline (control). Train-of-four ratios were measured from the time of reversal until postanesthesia care unit admission. Patients were monitored for postextubation adverse respiratory events and assessed for muscle strength. Ninety patients achieved a train-of-four ratio of 0.9 or greater at the time of reversal. Mean train-of-four ratios in the control and neostigmine groups before reversal (1.02 vs. 1.03), 5 min postreversal (1.05 vs. 1.07), and at postanesthesia care unit admission (1.06 vs. 1.08) did not differ. The mean difference and corresponding 95% CI of the latter were -0.018 and -0.046 to 0.010. The incidences of postoperative hypoxemic events and episodes of airway obstruction were similar for the groups. The number of patients with postoperative signs and symptoms of muscle weakness did not differ between groups (except for double vision: 13 in the control group and 2 in the neostigmine group; P = 0.001). Administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness. An online visual overview is available for this article.(Figure is included in full-text article.).

Prevalence of childhood asthma and its immediate outcome - At tertiary care rural hospital

Introduction: Asthma is a chronic inflammatory disorder of the airways resulting in episodic airway obstruction. Globally, childhood asthma is increasing in the prevalence, despite improvements in investigation and treatment. Childhood asthma seemed more prevalent in urban population and now even in rural areas of India. Objectives: To know the prevalence, assess the risk factors, severity, and immediate outcome of the treatment offered to asthmatic children in a tertiary rural hospital. Materials and Methods: All the diagnosed asthmatic children up to 18 years were enrolled in the study. All the patients of pulmonary Koch’s, congenital heart disease and chronic lung disease were excluded from the study. Clinical profile was noted in recruited patients. Results: The prevalence of childhood asthma among children visiting to our department was 3.93%. 58 (48.33%) had age of onset before the age of 6 years. Asthma was more prevalent in boys. 116 (96.66%) children presented with complain of cough, and 118 (98.33%) children had associated breathlessness. Common precipitating factors were change in season (71.66%), pollen allergy (58.33%), air pollutieon (45.00%), and passive smoking (23.33%). Exercise-induced asthma was seen in 55% cases, diurnal variation in 60% and 28.33% children had family history of atopic disease. Majority of the patient was undernourished. The average duration of stay in persistent asthma is 1.8 times more than in intermittent asthma. Conclusion: Significant number of patient becomes symptomatic before the 6 years of age. Prevention of child from exposure to passive smoking, environmental improvement, and allergen avoidance are major aspects for prevention of asthma exacerbations.

Airway Microbiota and Allergic Diseases: Clinical Implications

Bronchial Asthma is an airway disease with variable degrees of bronchial mucosal inflammation and intermittent episodes of airway obstruction and bronchial hyperesponsivness. That asthma is a syndrome consisting of different phenotypes has been recognized for a long time by clinicians [1].

High-accuracy detection of airway obstruction in asthma using machine learning algorithms and forced oscillation measurements

Background and ObjectivesThe main pathologic feature of asthma is episodic airway obstruction. This is usually detected by spirometry and body plethysmography. These tests, however, require a high degree of collaboration and maximal effort on the part of the patient. There is agreement in the literature that there is a demand of research into new technologies to improve non-invasive testing of lung function. The purpose of this study was to develop automatic classifiers to simplify the clinical use and to increase the accuracy of the forced oscillation technique (FOT) in the diagnosis of airway obstruction in patients with asthma. MethodsThe data consisted of FOT parameters obtained from 75 volunteers (39 with obstruction and 36 without). Different supervised machine learning (ML) techniques were investigated, including k-nearest neighbors (KNN), random forest (RF), AdaBoost with decision trees (ADAB) and feature-based dissimilarity space classifier (FDSC). ResultsThe first part of this study showed that the best FOT parameter was the resonance frequency (AUC = 0.81), which indicates moderate accuracy (0.70–0.90). In the second part of this study, the use of the cited ML techniques was investigated. All the classifiers improved the diagnostic accuracy. Notably, ADAB and KNN were very close to achieving high accuracy (AUC = 0.88 and 0.89, respectively). Experiments including the cross products of the FOT parameters showed that all the classifiers improved the diagnosis accuracy and KNN was able to reach a higher accuracy range (AUC = 0.91). ConclusionsMachine learning classifiers can help in the diagnosis of airway obstruction in asthma patients, and they can assist clinicians in airway obstruction identification.

Videolaryngoscopy With Noninvasive Ventilation in Subjects With Upper-Airway Obstruction.

Noninvasive ventilation (NIV) titration may be difficult when dynamic airway obstruction episodes persist, even with high expiratory positive airway pressure (EPAP). We aimed to determine the usefulness of videolaryngoscopy during NIV for identifying mechanisms and sites of obstruction and for providing a guide for their resolution in difficult-to-titrate subjects. When obstructions during NIV were present in the built-in software, EPAP was raised to 12 cm H2O. If obstructions persisted, a polygraphy during NIV was performed; if the events occurred with effort, a videolaryngoscopy with nasal and oronasal masks in awake subjects was performed. In a population of 208 subjects in whom NIV was initiated, 13 were identified as difficult to titrate with persistent obstructions during NIV despite an EPAP of 12 cm H2O. Videolaryngoscopy during NIV was able to identify the mechanism and the site of obstruction in all cases. The obstruction under oronasal mask ventilation was due to soft-palate (velum) collapse in 4 subjects, to epiglottic backward movement in 5 other subjects, and to tongue-base obstruction reducing the retroglossal space in 3 more. Videolaryngoscopy during NIV demonstrated improvement in 9 subjects (69%) upon changing to nasal mask and suggested a possible surgical approach in 2 (15%); in one of these 2 subjects, a successful uvulopalatopharyngoplasty was performed. The use of videolaryngoscopy during NIV in difficult-to-titrate patients may help to identify the sites and mechanisms of obstruction and in some cases may improve quality of ventilation.

Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. Association, consequences and treatment

Obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD) are two diseases that often co-exist within an individual. This co-existence, known as overlap syndrome (OS), is the result of chance rather than a pathophysiological linkage and epidemiological studies indicate a prevalence of 1% in adult males. Patients vith OS have a more important sleep-related O2 desaturation than COPD patients with the same degree of bronchial obstruction and show an increased risk of developing hypercapnic respiratory failure and pulmonary hypertension when compared with patients affected by only one of he diseases. COPD and OSAS are independent risk factors for cardiovascular events and their co-existence in OS probably increases this risk. Evidence of systemic inflammation in COPD and sleep apnea and consequentely OS, is interesting because it may contribute to the pathogenesis of cardiovascular diseases. Treatment consists of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV), with or without associated O2, for correction of the upper airway obstructive episodes and hypoxemia during sleep.