Esophageal Probe Research Articles

Respiratory and hemodynamic changes during lung recruitment maneuvering through progressive increases and decreases in PEEP level

ObjectiveTo evaluate the respiratory and hemodynamic changes during lung recruitment maneuvering (LRM) through stepwise increases and decreases in PEEP level. Design and settingA retrospective study in a 17-bed ICU was carried out. PatientsTwenty-one patients with acute respiratory failure and bilateral pulmonary infiltration. InterventionLRM was carried out, consisting of stepwise increases in PEEP (4cmH2O every 3min), with fixed ventilation pressure, until reaching a maximal value of 36cmH2O PEEP (ascending branch), followed by progressive decreases in PEEP (2cmH2O every 3min) until establishing the open-lung PEEP at the value associated to maximum respiratory compliance (Crs) (descending branch). Continuous hemodynamic monitoring was performed using an esophageal echodoppler probe. ResultsCrs gradually decreased in the ascending branch of the LRM, and progressively increased surpassing the initial value after establishing the open-lung PEEP in the descending branch, reducing the ventilation pressure and increasing the SpO2/FiO2 ratio. Hemodynamic changes primarily consisted of a fall in cardiac output and left ventricular preload, together with an increased heart rate and cardiac contractility. At comparable levels of PEEP and mean airway pressure, these changes were more pronounced during the descending branch of the LRM. Conclusions(1) LRM increased Crs, improving oxygenation and decreasing ventilation pressure; (2) the main hemodynamic consequence was the drop in cardiac output and left ventricular preload; and (3) the unequal hemodynamic derangement in both branches, at the same level of PEEP and mean airway pressure, showed that, along with intrathoracic pressure, other factors such as Crs and hypercapnia may have influenced the hemodynamic consequences of this type of LRM.

An esophageal probe for measuring three-dimensional electric fields during external cardiac defibrillation

External defibrillation is a common treatment for the cardiac arrhythmia atrial fibrillation. Electrode placement has been shown to affect defibrillation efficacy and required energy levels. We suggest investigating the relationship between esophageal electric fields (EEFs) and atrial defibrillation thresholds to determine the feasibility of creating patient-specific electrode placements using EEFs. This study presents the design and implementation of an esophageal probe (EP) that accurately measures three-dimensional electric fields. The root-mean-square error of the EP was 1.69% as determined by measurements performed in an electrolytic tank. The EP also performed well during in vivo testing in a pig. There was a strong positive relationship between EEF2s and applied energy during defibrillation strength shocks. The EEF measurements were also repeatable, with less than 4.24% difference between repeated shocks. This is the first description of a probe designed specifically for measuring electric fields in the esophagus.

Performance Validation of a Modified Magnetic Resonance Imaging–Compatible Temperature Probe in Children

During magnetic resonance imaging (MRI), children are at risk for body temperature variations. The cold MRI environment that preserves the MRI magnet can cause serious hypothermia. On the other hand, hyperthermia may also develop because of radiofrequency-induced heating of the tissues, particularly in prolonged examinations. Because of a lack of MRI-compatible core temperature probes, temperature assessment is unreliable, and specific absorption rate-related patient heat gain must be calculated to determine the allowable scan duration. We compared an MRI-compatible temperature probe and a modification thereof to a standard esophageal core body temperature probe in children. Children undergoing general anesthesia were recruited, each patient serving as his/her own control. Core body temperature was measured using 3 different devices: (1) a fiberoptic MRI-compatible skin surface temperature probe (MRI-skin) located on the child's skin surface; (2) a fiberoptic MRI-compatible temperature probe modified with a single-use sleeve at the tip (MRI-core), located in the nasopharynx; and (3) a standard temperature monitor (STRD) located in the esophagus or nasopharynx. The Bland-Altman method was used for statistical analysis. We enrolled 60 children aged 7.8 ± 6 years (mean ± SD) weighing 32.4 (±26.4) kg. The estimated difference between the STRD and MRI-core measurements of core temperature was 0.06°C (confidence interval [CI]: -0.02, 0.15), and between the STRD and the MRI-skin 1.19°C (CI: 0.97, 1.41). According to the Bland-Altman analysis, the 95% limits of agreement ranged from -0.9 to 3.4 and from -1.3 to 1.2 between the STRD and the MRI-skin probe and the MRI-core probe, respectively. Our results show good agreement between standard esophageal measurements of core temperature and core temperature measured using a modified MRI-core probe during general anesthesia in a general surgical pediatric population. The ability to accurately assess core temperature in the MRI suite may safely allow longer scan times and therefore reduce repeat anesthetic exposure, improve patient safety, and enhance the quality of care in children.

Placement of an Esophageal Temperature Probe by Nurses

Background Current guidelines support therapeutic hypothermia after cardiac arrest. An esophageal temperature probe (ETP) provides a core temperature assessment; however, accurate placement is necessary. Objectives To demonstrate accurate placement of an ETP and evaluate the effectiveness of high-fidelity simulation with anatomic imaging. Methods Registered nurses (RNs) were educated using 3-dimensional, high-fidelity simulation with VH Dissector technology (Touch of Life Technologies, Aurora, Colorado) to demonstrate ETP placement. The RNs provided survey responses on the effectiveness of simulation before and after using the simulator. Results Thirty-two RNs participated and did not demonstrate difficulties with the skill; however, 53.1% required more than 1 attempt for accurate placement in the distal esophagus. Survey results found that participants had increased confidence and high satisfaction with simulation and 3-dimensional imaging (P < .001). Conclusions Literature is lacking to guide ETP placement. In this study, RNs overestimated the depth for ETP insertion. Accurate temperature readings are highly dependent on accurate anatomical location placement. Providing skill competency training that incorporated anatomical imaging technology enhanced RNs’ awareness for effective skill acquisition.

Placement of an Esophageal Temperature Probe by Nurses

Current guidelines support therapeutic hypothermia after cardiac arrest. An esophageal temperature probe (ETP) provides a core temperature assessment; however, accurate placement is necessary. To demonstrate accurate placement of an ETP and evaluate the effectiveness of high-fidelity simulation with anatomic imaging. Registered nurses (RNs) were educated using 3-dimensional, high-fidelity simulation with VH Dissector technology (Touch of Life Technologies, Aurora, Colorado) to demonstrate ETP placement. The RNs provided survey responses on the effectiveness of simulation before and after using the simulator. : Thirty-two RNs participated and did not demonstrate difficulties with the skill; however, 53.1% required more than 1 attempt for accurate placement in the distal esophagus. Survey results found that participants had increased confidence and high satisfaction with simulation and 3-dimensional imaging (P < .001). Literature is lacking to guide ETP placement. In this study, RNs overestimated the depth for ETP insertion. Accurate temperature readings are highly dependent on accurate anatomical location placement. Providing skill competency training that incorporated anatomical imaging technology enhanced RNs' awareness for effective skill acquisition.

Clinical review: Update on neurally adjusted ventilatory assist - report of a round-table conference

Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.

Effect of Hydrogel Pad and Conventional Method on the Induction Time of Therapeutic Hypothermia in Patients with Out-of-Hospital Cardiac Arrest

o C. The esophageal temperature probe insertion to the target temperature time (ET to target BT time) was defined as the time from the esophageal probe insertion to the core temperature below 33.5 o C. We compared these times and cooling rates between the two groups. Results: Eighty one patients were enrolle d. Fifty seven patients were included in the hydrogel pad group and 24 patients were in the conventional group. There were no statistical differences of baseline characteristics between the two groups. The induction time of the conventional group (138 min., IQR 98-295) was shorter than that of the hydrogel pad group (190 min., IQR 140-250). The ET to target BT time of the conventional group (106 min., IQR 68-249) was shorter than that of the hydrogel pad group (163 min., IQR 108-222). The cooling rate of the conventional group (0.93 o C/hr., IQR 0.58-2.08) was lower than that of the hydrogel pad group (1.05 o C/hr., IQR 0.74-1.96). However, there were no statistical differences in the induction time, the ET to target BT time and the cooling rate between the two groups. Conclusions: There was no significant statistical difference of the cooling rate of the hydrogel pad and conven- tional method on the induction time of therapeutic hypothermia in Patients with OHCA. The conventional cooling method can be used as an effective and efficient way to lower O HCA patient's core body temperature during the induction phase of therapeutic hypothermia.

Case of leptosuccin induced malignant hyperthermia in a patient with GIST of the rectum

Malignant hyperthermia (MH) is a form of myopathy that is usually triggered by volatile anaesthetics such as halothane, sevoflurane and desflurane and depolarising muscle relaxants such as succinylcholine. Pathologic response in MH include increase in oxygen consumption, increase in endtidal CO2, tachycardia, hyperthermia, hyperkalemia and muscle rigidity. Immediate recognition and treatment are crucial to avoid lethal outcome. Molecular genetic studies have confirmed that ryanodine muscle receptors are responsible for MH. We present a case of leptosuccin induced MH with masseter muscle rigidity, mild pCO2 increase (6.3 kPa), elevated body temperature measured with esophageal temperature probe (39.5 degrees C), tachycardia (115 beats/min) and respiratory and metabolic acidosis (pH was 7,23) in a patient who underwent low anterior resection of the rectum for gastrointestinal stromal tumor (GIST) of the rectum.

Residents and ICU nurses get reliable static and dynamic haemodynamic assessments with aortic oesophageal Doppler

Aortic oesophageal Doppler (ODM) allows continuous non-invasive haemodynamic monitoring. We tested to confirm if residents and nurses were able to reposition oesophageal probe (OP), obtain aortic blood flow of good quality and so perform reliable static and dynamic haemodynamic assessments. Prospective observational study assessing ODM measurements were obtained by six residents and three nurses after they have participated in training. Measured (aortic diameter) and calculated haemodynamic data [indexed stroke volume (SVI), cardiac index] were directly obtained from ODM, after residents and nurses repositioned the OP. In a second group of patients, we tested the ability of residents and nurses to detect rapid haemodynamic changes after a passive leg raising. SVI comparison was the primary end point. Statistical analysis was performed using the method of Bland and Altman. Sixty-six haemodynamic measurements were performed on 42 patients. Mean bias for SVI between the skilled physician and residents, and between the skilled physician and nurses were -0.9 ± 5.2 ml/m(2) (P = 0.15), with a percentage error of 31%, and 0.9 ± 5.1 ml/m(2) (P = 0.14), with a percentage error of 33%, respectively. There was an excellent correlation for SVI between the physician and residents (r = 0.9; P < 0.0001) and between the physician and nurses (r = 0.9; P < 0.0001). Induced changes in SVI measured by residents and nurses strongly followed those of our skilled physician. Residents and nurses get reliable static and dynamic haemodynamic assessments with ODM compared to our skilled physician.

Therapeutic hypothermia: heat transfer from warmed endotracheal tubes to oesophageal temperature probes poses risk of life-threatening overcooling

Therapeutic hypothermia: heat transfer from warmed endotracheal tubes to oesophageal temperature probes poses risk of life-threatening overcooling

Abstract 41: Liquid Convection Surface Cooling Leads to High Rate of Recovery of Post-VT/VF Patients

Introduction: Therapeutic hypothermia is an accepted standard of care for patients resuscitated from VT (ventricular tachycardia) and/or VF (ventricular fibrillation). Some prior studies have suggested that a faster time to target temperature may improve the chances of favorable neurological recovery. Hypothesis: We hypothesized that rapid cooling of post VT/VF patients using liquid convection surface cooling would lead to a high rate of recovery of such patients, compared to historical results with slower cooling methods. Methods: The Life Recovery Systems ThermoSuit System® was used to induce therapeutic hypothermia (approximately 33°C, maintained for 12 to 24 hours) in 37 post-resuscitation patients in 4 hospitals. Patient temperatures were monitored with an esophageal probe. Results were retrospectively analyzed for cooling rates, cardiac rhythm of VT/VF, favorable neurologic recovery (CPC 1 or 2), and adverse events. Results: Of the 37 patients, the mean cooling rate was 3.4 °C/hr (range 1.3-8.8). Of the 37 patients, 20 were resuscitated from VT or VF. Of these, 17 (85%) survived with favorable outcomes following the ThermoSuit treatment. There were no adverse events. Conclusions: Rapid induction of therapeutic hypothermia with the ThermoSuit System was associated with a very high rate of favorable neurologic recovery and an absence of adverse events in post-VT/VF patients. When compared with results of similar studies of slower cooling methods, these results suggest an advantage of faster cooling methods for the treatment of post-VT/VF patients.

Abstract 17786: Presence of an Esophageal Temperature Probe During Pulmonary Vein Isolation: Is There an Increased Risk for Esophageal Lesion Development?

Background: Luminal esophageal temperature (LET) measurement is investigated as a tool to decrease risk of esophageal lesion formation during pulmonary vein isolation using radiofrequency (RF) current. However, recent evidence from duty-cycled phased RF ablation revealed a possible contributing role of the esophageal probe to lesion formation by direct tissue heating or interaction with the ablation device. Whether the presence of a LET probe may increase lesion formation during conventional irrigated RF ablation has not yet been investigated. Methods and Results: 62 patients (65% male, age 63±11 years, LA 44±10 mm) with drug-resistant atrial fibrillation underwent circumferential pulmonary vein isolation (PVI) using irrigated RF energy and a 3D-mapping system. A maximum power of 30 Watts was applied at the left atrial posterior wall (LAPW). In 30 patients a LET probe with 5 metal electrodes (3 thermistors) was placed in the esophagus and continuously adjusted to the level of the target pulmonary vein (group 1). LET measurement was observational only and no temperature cutoff was used. In the remaining 32 patients, no LET probe was placed (group 2). All patients underwent gastro-esophagoscopy 2±1 days after the procedure. The cumulative RF energy applied to the LAPW was 21368±9449 Joules (group 1) and 18092±8143 Joules (group 2, p=0,15). Esophageal lesions were found in 12 patients (40%) of group 1 (ulcerations: 4, erythema: 8), and 11 patients (34%) of group 2 (ulcerations: 5, erythema: 4); p=0,65. Lesions healed without clinical sequelae on proton pump inhibitor therapy in all patients. Within group 1, maximum LET in patients with and without lesions was 45,7±3,7 °C and 43,8±3,9 °C, respectively (p=0,20). Conclusion: The incidence of reversible esophageal lesions after circumferential PVI using irrigated RF energy was similar whether or not a temperature probe was present in the esophagus when no temperature cutoff was used.

Abstract 98: Initiation of Large-Volume, Ice-Cold Saline Infusion During Initial Resuscitation Attempts for Out-of-Hospital Cardiac Arrest Results in Near-Target Temperatures for Therapeutic Hypothermia Upon Emergency Department Arrival

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol in the New York City 9-1-1 System on August 1, 2010 that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume, pressure infused, ice-cold saline administration. Purpose: We sought to assess the effects of the intra-arrest initiation of an infusion of up to 30cc/kg of ice-cold saline on core body temperature for out-of-hospital cardiac arrest (OOHCA). Methods: A convenience sample of out-of-hospital cardiac arrest patients for whom core temperature monitoring via esophageal temperature probes was available were analyzed. Results: There were a total of 78 patients for whom core temperature (esophageal) data was available both at the time hypothermia induction and upon ED arrival. Eight patients (10.3%) were reported to have developed clinical signs of pulmonary edema during the infusion and were excluded from this analysis due to the discontinuation of the large-volume infusion. Among the remaining 70 patients, an average of 1,361mls of ice-cold saline was administered prior to emergency department arrival. The average initial temperature for these patients at the time hypothermia induction was 35.1 o C (range 32.7-38.0 o C). The average temperature reduction as a result of the large-volume, ice-cold saline infusion was -0.92 o C, with an average core temperature upon emergency department arrival of 34.2 o C. Conclusion: Large volume, ice-cold saline infusion during initial resuscitation efforts allows patients to arrive in the emergency department with a core temperature near the target range for therapeutic hypothermia. Further study is needed to assess the effects of early induction of hypothermia on immediate and long-term survival.

Cambios respiratorios y hemodinámicos durante una maniobra de reclutamiento pulmonar mediante incrementos y decrementos progresivos de PEEP

ObjectiveTo evaluate the respiratory and hemodynamic changes during lung recruitment maneuvering (LRM) through stepwise increases and decreases in PEEP level. Design and settingA retrospective study in a 17-bed ICU was carried out. PatientsTwenty-one patients with acute respiratory failure and bilateral pulmonary infiltration. InterventionLRM was carried out, consisting of stepwise increases in PEEP (4cmH2O every 3minutes), with fixed ventilation pressure, until reaching a maximal value of 36cmH2O PEEP (ascending branch), followed by progressive decreases in PEEP (2cmH2O every 3minutes) until establishing the open-lung PEEP at the value associated to maximum respiratory compliance (Crs) (descending branch). Continuous hemodynamic monitoring was performed using an esophageal echodoppler probe. ResultsCrs gradually decreased in the ascending branch of the LRM, and progressively increased surpassing the initial value after establish the open-lung PEEP in the descending branch, reducing the ventilation pressure and increasing the SpO2/FiO2 ratio. Hemodynamic changes primarily consisted of a fall in cardiac output and left ventricular preload, together with an increased heart rate and cardiac contractility. At comparable levels of PEEP and mean airway pressure, these changes were more pronounced during the descending branch of the LRM. Conclusions1) LRM increased Crs, improving oxygenation and decreasing ventilation pressure; 2) the main hemodynamic consequence was the drop in cardiac output and left ventricular preload; and 3) the unequal hemodynamic derangement in both branches, at the same level of PEEP and mean airway pressure, showed that, along with intrathoracic pressure, other factor such as Crs and hypercapnia may have influenced the hemodynamic consequences of this type of LRM.

The Proseal™ laryngeal mask airway and the transesophageal Doppler probe: the TED-PLMA Technique

To the Editor, We read with great interest the article by Hwang et al. about the use of the McIvor blade to improve insertion of the Proseal laryngeal mask airway (PLMA) in children. We suggest that complementary information on other devices used together with the PLMA may help readers in clinical practice. In our institution, we have extensive experience in the insertion of supraglottic airway devices in pediatric patients. It is well known that the PLMA has a higher oropharyngeal leak pressure compared with the Classic laryngeal mask airway, and this relatively high PLMA leak pressure can be useful clinically. We completed a study using a PLMA and an esophageal Doppler probe concurrently in 102 pediatric patients aged four months to eight years. The children underwent genitourinary and abdominal surgery under general anesthesia with or without caudal or epidural block. The preliminary results of this study have since been published. It is important to point out that the probe is placed immediately after PLMA insertion, and it is advanced under the dorsal cuff, not through the drainage gastric port. The measured oropharyngeal leak pressures were 23 (7) cm H20 with the PLMA cuff inflated to 60 cm H20. No gas leak was registered with adequate volumeor pressurecontrolled ventilation (end-tidal CO2 was 4.6-5.8 kPa in all children). Uda et al. reported a negative experience when they advanced a probe with the PLMA, but probe insertion was done through the drainage port, hence our technique is different and unique. The concurrent use of both a PLMA and an esophageal Doppler probe has become routine in our pediatric clinical practice, allowing us to ventilate and measure hemodynamic parameters without having to intubate the trachea. This technique is possible owing to the higher leak pressure of the PLMA. We decided to name our technique ‘‘TEDPLMA’’ (TransEsophageal Doppler Proseal Laryngeal Mask Airway).

Left, Right and Out: Esophageal Probe Aspiration

Purpose: A 61 year old woman, with a longstanding history of heartburn, regurgitation, and intermittent chest pain unresponsive to proton pump inhibitors was being evaluated with an upper endoscopy and placement of a wireless esophageal pH probe (28 x 6 x 7 mm). The endoscopy was performed under conscious sedation without difficulty. Once the endoscope was withdrawn, a wireless esophageal pH probe was introduced through the mouth and attached to the esophageal mucosa. Following probe placement, the patient started coughing. To confirm placement of the wireless pH probe the endoscope was reintroduced; the wireless pH probe was not seen in the esophagus, stomach, or duodenum. At this time, the patient was continuing to cough but her vital signs were stable. A fluoroscopic image of the chest (Panel A) demonstrated the pH probe to be in the left mainstem bronchus. The patient was transferred to the intensive care unit for rigid bronchoscopy. The patient continued with intermittent coughing spells, however, her vitals signs remained stable and she remained alert, oriented and calm. A repeat chest radiograph prior to proceeding with a rigid bronchoscopy (Panel B) showed the capsule to be in the right mainstem bronchus. After being assessed by anesthesiology, the patient subsequently coughed up the pH probe (Panel C).Figure

Digestibilidade dos aminoácidos do milho, farelo de soja e gérmen integral de milho em galos e frangos de corte cecectomizados

Este experimento foi conduzido para avaliar a digestibilidade dos aminoácidos do milho, farelo de soja e gérmen integral de milho em galos e frangos de corte cecectomizados. Foram utilizados 16 galos Lohmann-LSL com 45 semanas de idade, 40 frangos de corte machos AgRoss 508, sendo 20 com 21 dias de idade e outros 20 com 42 dias de idade, todos cecectomizados. Adotou-se delineamento inteiramente casualizado com três categorias animais (galos; frangos aos 21 dias; e frangos aos 42 dias de idade) para cada alimento avaliado e cada ave considerada uma unidade experimental. O ensaio durou 84 horas: nas 36 horas iniciais, as aves foram submetidas a jejum e nas 48 horas subsequentes, à ingestão forçada dos alimentos, feita com sonda esofágica introduzida diretamente no inglúvio das aves. As excretas produzidas foram colhidas duas vezes ao dia nas 48 horas subseqüentes. Os valores de aminoácidos digestíveis verdadeiros determinados para o milho e gérmen integral de milho determinados com frangos submetidos ao procedimento experimental aos 21 dias de idade foram inferiores aos do grupo controle (galos). Contudo, os mesmos resultados não foram observados para o farelo de soja. O aproveitamento de aminoácidos foi maior nos frangos submetidos ao procedimento experimental aos 42 dias de idade em comparação aos do grupo controle (galos adultos), independentemente do alimento avaliado. O teor de aminoácidos digestíveis verdadeiros totais obtidos foi de 7,24; 6,25 e 7,33% para o milho, 9,66; 9,14 e 9,91% para o gérmen integral de milho e 41,82; 41,78 e 42,02% para o farelo de soja, valores determinados com galos, frangos aos 21 e aos 42 dias de idade, respectivamente. Observou-se que, com o amadurecimento do trato digestório, aumenta o aproveitamento proteico em aves que consomem milho e gérmen integral de milho.

Effects of Obstructive Sleep Apnea and Gastroesophageal Reflux Disease on Asthma Control in Obesity

Background. Obesity is a risk factor for asthma. Obese asthmatics often have poor asthma control and respond poorly to therapy. It has been suggested that co-morbidities associated with obesity, such as reflux and obstructive sleep apnea, could be important factors contributing to poor asthma control in obese patients. Objectives. The purpose of this study was to determine if (1) reflux and/or (2) symptoms of sleep apnea contribute to poor asthma control in obesity. Methods. We studied asthmatic subjects participating in a trial of reflux treatment. Participants underwent baseline evaluation of asthma symptoms and lung function. Overall 304 participants underwent esophageal pH probe testing; 246 participants were evaluated for obstructive sleep apnea symptoms. Results. Of 402 participants in this trial, 51% were obese. Role of reflux in asthma control. Those with higher body mass index (BMI) reported a higher prevalence of reflux symptoms, but the prevalence of pH probe acid reflux was similar in all groups. Reflux was not associated with measures of asthma control in obese patients. Role of obstructive sleep apnea in asthma control. Symptoms and self-report of obstructive sleep apnea were more common with increasing BMI and associated with worse asthma control as measured by the Juniper Asthma Control questionnaire and Asthma Symptom Utility Index. Conclusions. Our data suggest that obstructive sleep apnea, but not gastroesophageal reflux disease, may contribute significantly to poor asthma control in obese patients.

Fundoplication After Lung Transplantation Prevents the Allograft Dysfunction Associated With Reflux

Gastroesophageal reflux disease (GERD) in lung recipients is associated with decreased survival and attenuated allograft function. This study evaluates fundoplication in preventing GERD-related allograft dysfunction. Prospectively collected data on patients who underwent transplantation between January 2001 and August 2009 were included. Lung transplant candidates underwent esophageal pH probe testing before transplantation and surveillance spirometry evaluation after transplantation. Bilateral lung transplant recipients who had pretransplant pH probe testing and posttransplant 1-year forced expiratory volume in the first second of expiration (FEV1) data were included for analysis. Of 297 patients who met study criteria, 222 (75%) had an abnormal pH probe study before or early after transplantation and 157 (53%) had a fundoplication performed within the first year after transplantation. Patients with total proximal acid contact times greater than 1.2% or total distal acid contact times greater than 7.0% demonstrated an absolute decrease of 9.4% (±4.6) or 12.0% (±5.4) in their respective mean 1-year FEV1 values. Patients with abnormal acid contact times who did not undergo fundoplication had considerably worse predicted peak and 1-year FEV1 results compared with recipients receiving fundoplication (peak percent predicted=75% vs. 84%; p=0.004 and 1-year percent predicted=68% vs. 77%; p=0.003, respectively). Lung transplant recipients with abnormal esophageal pH studies attain a lower peak allograft function as well as a diminished 1-year FEV1 after transplantation. However a strategy of early fundoplication in these recipients appears to preserve lung allograft function.

Severity of esophageal injury predicts time to healing after radiofrequency catheter ablation for atrial fibrillation

The delivery of radiofrequency (RF) energy to the posterior left atrium creates a risk of injury to the adjacent esophagus. Esophageal endoscopy (EGD) is used to screen patients at risk for esophageal thermal injury after RF ablation. The purpose of this study was to analyze the macroscopic features of the severity of esophageal injuries induced by RF ablation to the left atrium as seen by EGD and evaluate the association of these descriptions with the time elapsed until complete healing. This study analyzed 219 patients undergoing RF ablation for atrial fibrillation. Esophageal temperature probes were used during each ablation, and EGD was performed in cases with intraesophageal temperature ≥39°C. Repeat EGD was obtained at 10 days to evaluate for healing in all cases demonstrating esophageal injury. Serial endoscopies were repeated every 2 weeks until complete healing was documented. Lesions were classified according to severity as superficial or deep ulceration; size and shape were also noted. We found 37.4% of patients (82 of 219) with esophageal intraluminal temperatures ≥39°C. Of these, 22 patients (27%) were identified with esophageal injury, with 68% being superficial ulcerations and 32% deep. On repeat EGD at 10 days, only 29% of deep ulcerations were healed, as compared with 87% of the superficial injuries (P = .0136). No difference in healing was found when analyzed for size or shape. The macroscopic severity of esophageal lesions detected on endoscopy the day after RF ablation can predict the time to resolution, with severe, deep ulcerations requiring a longer time to heal.