BACKGROUND Tracheal tube cuff pressure exceeding mucosal perfusion pressure during surgery is associated with complications such as sore throat, mucosal ulcers, rupture, and subglottic stenosis. This study aimed to evaluate factors affecting changes in endotracheal cuff pressures in 27 patients during laparoscopic bariatric surgery and their relationship to surgical stages and airway pressures. MATERIAL AND METHODS A prospective, observational study was conducted on 27 patients, and data were collected on endotracheal cuff pressures, airway pressures, intra-abdominal pressures, respiratory rates, surgical table tilt, and patient demographics. The surgical procedure was divided into 4 stages: (1) pre-abdominal insufflation, (2) abdominal insufflation, (3) surgical table positioning, and (4) peritoneal exsufflation. Patients' perioperative findings were evaluated. RESULTS The mean age of the patients was 36.14±9.46 years, and 92.59% of patients had overinflated cuffs after intubation. Endotracheal tube cuff pressures varied significantly throughout the surgical phases. Before peritoneal insufflation, the mean (SD) cuff pressure was 28.66 (1.41) cmH₂O. This increased significantly during peritoneal insufflation to 41.59 (6.43) cmH₂O. Following the application of the reverse Trendelenburg position, the cuff pressure decreased to 37.11 (5.63) cmH₂O, and after peritoneal deflation, it returned to 29.81 (5.41) cmH₂O (P<0.0001). Multilevel mixed regression analysis revealed that cuff pressure changes were significantly associated with surgical phases (P<0.001) but not with surgical duration or peak airway pressure. CONCLUSIONS Based on the results of our study, endotracheal cuff pressures change significantly during laparoscopic bariatric surgery. Routine monitoring may help clinicians manage patients to minimize postoperative complications.

Background/Objectives: Chronic pelvic pain (CPP) is defined as pelvic pain lasting longer than six months and is a common yet often overlooked condition, affecting over 40% of women worldwide and accounting for about 10% of gynecological consultations. Despite extensive investigation, including laparoscopy, no cause is identified in up to half of cases. Pelvic congestion syndrome (PCS), also referred to as pelvic venous insufficiency (PVI), has been estimated to account for up to 30% of CPP cases, although it remains underdiagnosed. PCS is caused by venous reflux or obstruction in pelvic veins and is characterized by dull, aching pain worsened by standing, intercourse, post-orgasm, and the premenstrual period. It occurs predominantly in premenopausal women, often after pregnancy. This narrative review aims to improve understanding of PCS and provide practical guidance to support diagnosis and treatment in routine gynecologic practice. Methods: We performed a comprehensive review of the current literature focusing on the clinical presentation, pathophysiology and diagnostic and treatment performance of various modalities. Special emphasis was placed on identifying accessible, non-interventional tools suitable for primary gynecological care. Results: PCS, CPP and endometriosis exhibit significant clinical overlap, including dysmenorrhea, dyspareunia and chronic pain. However, pathognomonic features like post-coital pain and pain-exacerbation by prolonged standing, combined with specific ultrasound markers, allow for early differentiation. While laparoscopy is often used to investigate CPP, it has limited sensitivity for PCS due to CO2-pneumoperitoneum-induced venous compression, and Trendelenburg position, compared to venography, the diagnostic gold standard. In contrast, transvaginal ultrasound (TVUS) serves as a potent first-line tool. Key diagnostic criteria include ovarian vein diameter (>7-8 mm), low flow velocity (<3 cm/s), and myometrial vein dilatation (>5 mm). Furthermore, the frequent co-occurrence of endometriosis and PCS requires a multimodal diagnostic approach to avoid "diagnostic bias." Conclusions: To improve patient outcomes and reduce diagnostic delay, office-based gynecologists should integrate specific vascular TVUS into the routine workup of CPP, not only to diagnose endometriosis but also to identify PCS. Future efforts should focus on standardized TVUS protocols and interdisciplinary care pathways involving gynecologists and interventional radiologists to enable integrated diagnostic and therapeutic approaches for patients with coexisting endometriosis and PCS, addressing both surgical and non-surgical options, as well as the bidirectional relationship and mutual pathophysiological influence between these entities.

Benign ureteroenteric anastomosis stricture (BUES) is a well-recognized long-term complication following urinary diversion (1). While endourological interventions are often first-line, their success rates are limited (2, 3). Open uretero-ileal reimplantation remains the gold standard but is technically challenging and carries high complication risks (2). Robotic surgery offers a promising alternative with comparable success rates and minimally invasive benefits (4). In addition to the da Vinci® system, several new surgical robotic systems have been developed, demonstrating comparable safety and efficacy (5-7). This study reports our experience with robotic-assisted Boari-flap using the KangDuo-Surgical-Robot-01 (KD-SR-01) System in managing long-segment BUES after radical cystectomy with orthotopic neobladder. A 64-year-old man developed left BUES 2.5 years after robot-assisted radical cystectomy with orthotopic neobladder. After nephrostomy drainage for 6 months, a robotic-assisted Boari-flap was performed using the KD-SR-01 system in the Trendelenburg position. Surgical steps included: neobladder mobilization, distal ureter dissection, neobladder flap creation, ureter-flap anastomosis, and flap tubularization. Surgery was successful without conversion. The stricture length was 5 cm. The neobladder flap measured 5 × 3 cm (length × width). Operating time was 145 minutes, with 30 mL of blood loss. The nephrostomy tube and double-J stent were removed two months postoperatively. At three-month follow-up, the patient remained asymptomatic with stable serum creatinine. Cine magnetic resonance urography demonstrated normal ureteral peristalsis and ureteral jets. No postoperative complications occurred. Robotic-assisted Boari-flap after radical cystectomy with orthotopic neobladder is technically feasible. A larger cohort with longer follow-up is necessary to assess its safety and effectiveness.

To report our institutional technique for robot-assisted kidney transplantation (RAKT) (1, 2) in a detailed, step-by-step manner. This is a case of RAKT from a living donor successfully performed at our institution. A 29-year-old male with end-stage renal disease secondary to focal segmental glomerulosclerosis, undergoing hemodialysis with a baseline serum creatinine of 1035 μmol/L at admission, received a left kidney donated by his 55-year-old mother. Preoperative evaluation confirmed one HLA mismatch (0-0-1) and ABO compatibility, making the patient suitable for living donation. The procedure was performed using the da Vinci Xi robotic system (Intuitive, Sunnyvale, CA, USA). The recipient was placed in a 23° Trendelenburg position. Four robotic ports were aligned above the umbilicus, and two additional ports were used for the assistant. Graft introduction was performed via a 7-cm Pfannenstiel incision using an Alexis O Wound Protector-Retractor with Laparoscopic Cap (Applied Medical, Rancho Santa Margarita, CA, USA). Following robotic living donor nephrectomy, extracorporeal bench preparation was performed (warm ischemia time = 4 min; cold ischemia time = 239 min). RAKT was then completed with intracorporeal vasculares anastomoses using 5-0 Gore-Tex sutures (warm ischemia time = 45 min), and ureteral reimplantation according to the Lich-Gregoire technique, performed with 4/0 monofilament suture (3). The surgery was uneventful, with excellent graft reperfusion and no perioperative complications. Postoperative renal Doppler ultrasound and radionuclide renal scan were normal. Serum creatinine and eGFR at discharge were 1.45 mg/dL and 62 mL/min, respectively (4). Our experience confirms the feasibility and safety of RAKT with a living donor in a selected setting, supporting further integration of robotic assistance into renal transplantation programs.

Microgravity exposure during spaceflight induces a thoracocephalic fluid shift that affects the cardiovascular system both during flight and after return to Earth. As the proportion of female astronauts increases, it is essential to understand how altered gravity impacts cardiovascular function across sexes. In this study, we examined sex differences in central hemodynamics, vascular morphology of the common carotid artery and internal jugular vein (IJV), and IJV pressure during graded head-up to head-down tilt (+45° to -45° in 15° increments) in healthy participants (12 female and 12 male adults). A strong gravitational dependence on almost all variables was observed, except for oxygen consumption. Only a few variables showed significant sex differences, and these include cardiac output, total peripheral resistance, rate pressure product, oxygen consumption, and sympathovagal balance (LF/HF ratio). Overall, hemodynamic, vascular morphology, and IJV pressure responses to tilt were largely similar between sexes. The additional female gravitational dose-response curves augment our previous, male-only database of cardiovascular responses to tilt. Together, these results provide a unique and more comprehensive normative baseline to support the development of spaceflight countermeasures as well as other terrestrial clinical applications, such as surgery in Trendelenburg or prone positioning.

Republication de : Effect of 10 and 20 degrees reverse Trendelenburg position on surgical field quality during ear surgery. A randomized-controlled trial

Pneumoperitoneum and the reverse Trendelenburg (RT) position during laparoscopic sleeve gastrectomy (LSG) can induce autonomic instability and increase the risk of arrhythmias by reducing venous return. This study aimed to evaluate the impact of surgical positioning during LSG on autonomic cardiac function, using hemodynamic parameters and the cardiac electrophysiological balance index (iCEB = QT/QRS) as a biomarker. This prospective observational study included 66 patients with severe obesity who underwent LSG. Measurements were recorded at five distinct time points, corresponding to specific patient positioning during the procedure: P-baseline (before induction, supine), P1 (after induction, supine), P2 (after pneumoperitoneum, supine), P3 (during pneumoperitoneum, RT), and P4 (after desufflation, RT). Systolic, diastolic, and mean arterial pressures (SAP, DAP, and MAP) significantly decreased at all positions compared to baseline (p < 0.001 for each). Compared to post-induction (P1), SAP values were substantially higher in the P2 and P4 positions (p < 0.05, p < 0.001, respectively). Heart rate significantly decreased at P1 compared to baseline (p < 0.004) and subsequently increased at P2 and P3 relative to P1 (p < 0.001 and p < 0.009, respectively). A notable increase in iCEB was observed at P4 when compared to P1, P2, and P3 (p < 0.003, p < 0.001, and p < 0.021, respectively). Despite these changes, iCEB values remained within the reference range across all measured positions. Despite the observed effects of positional changes and pneumoperitoneum on hemodynamic and cardiac electrical parameters during LSG, most patients tolerated these changes well. Crucially, iCEB values remained within the normal reference range throughout the procedure, indicating preserved cardiac autonomic regulation.

Aim: The main purpose of this study is to investigate the effect of different methods that may affect pain after laparoscopic sleeve gastrectomy surgery. Methods: Patients who were treated for morbid obesity in our clinic between January 2016 and January 2020 were analyzed retrospectively. The 90 patients who participated in the study were divided into three groups: Group 1: The active aspiration group; Group 2: The pulmonary recruitment maneuver (PRM) group; and Group 3: The intraperitoneal normal saline infusion (INSI) group. After completion of the operative procedures; residual gas was aspirated in Group 1. In the Group 2; the patients were placed in the Trendelenburg position (30°); and a pulmonary recruitment maneuver consisting of 5 manual pulmonary inflations was performed with a maximum pressure of 40 cm H2O. In the Group 3; the upper part of the abdominal cavity was even and bilaterally filled with isotonic normal saline (1000 mL); which was then left in the abdominal cavity. The patients (in all groups) were then placed in the level position; the trocar was removed; and the abdominal incisions were closed. Results: There was no statistical difference between the groups in terms of the duration of surgery; duration of hospital stay; and return to normal activity. Although pain levels were found to be high in all groups within 4 hours; no statistical differences were observed. Despite this; the pain levels at 24 hours; 48 hours; and 3 days showed no difference between Groups 1 and 2; while Group 3 was lower. The amount and frequency of analgesics used are less in Group 3. This situation is statistically significant. Conclusion: The INSI maneuver seemed to be much more effective in reducing upper abdominal and shoulder pain caused by laparoscopy; and the effect lasted longer.

Background/Objectives: Surgery performed in the steep Trendelenburg position is considered potentially detrimental to ocular structures. This study aimed to evaluate morphological changes in the anterior segment during robot-assisted laparoscopic prostatectomy (RALP). Methods: This was a single-center, prospective observational study involving 60 eyes of 30 consecutive patients undergoing RALP between May and November 2021. Anterior segment images were obtained using a Smart Eye Camera before surgery (supine and awake), during surgery (supine and steep Trendelenburg under anesthesia), and after surgery (supine). Assessed parameters included the iridocorneal angle, the ratio of peripheral anterior chamber depth to peripheral corneal thickness based on Van Herick Plus grading, and pupil diameter. Each parameter in the steep Trendelenburg position under anesthesia was compared with measurements obtained in the supine position under anesthesia and in the awake condition. The primary outcome was the comparison of anterior segment morphological changes between the supine and steep Trendelenburg positions during RALP. Results: Upon transition to the steep Trendelenburg position, anterior chamber depth significantly decreased (p < 0.001), recovering after returning to the supine position. The proportion of eyes classified as having narrowed anterior chambers increased significantly (p < 0.001), with more than 60% showing shallower chambers relative to preoperative measurements. Extreme anterior chamber narrowing occurred in 3 out of 410 intraoperative assessments (1%). Pupils were uniformly constricted under anesthesia. Conclusions: Steep Trendelenburg positioning significantly reduces anterior chamber depth. This morphological alteration may contribute to the marked increase in intraocular pressure observed during RALP.

The aim of our study was to evaluate the changes of IOP during laparoscopic surgery in pediatric patients. We enrolled thirty-six patients, ranging in-between 15 months-16 years, undergoing elective abdominal surgery. Eighteen received laparoscopic surgery (LS) and eighteenlaparotomy surgery (LT). In the LS group, IOP was measured before and after induction, during mechanical ventilation, after established pneumoperitoneum, in the Trendelenburg position after 5, 10 and 30 min (15. T10, T30), and at extubation time. In the LT group OP was measured before and after induction, during surgical incision, after 5, 10, 30 min and at extubation time in supine position.Compared to LT group, where IOP (baseline: 10.9‡1.7 mmHg) was unchanged during the whole procedure, in the LS group(baseline: 10.8+2.4 mmHg), IOP increased significantlyafter established pneumoperitoneum and during Trendelenburg positioning (maximal mean value at T5: 14.6 +2.1 mmHg).In pediatric patients that receive laparoscopic surgery, IOP increases by some mmHg.

One of the most common complications of rhinoplasty and septorhinoplasty is intraoperative bleeding, which poses challenges for both surgeons and patients. This systematic review and meta-analysis aimed to evaluate the effectiveness of various bleeding control methods in rhinoplasty and septorhinoplasty surgeries. This study conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed in reputable international databases to identify relevant studies. Ultimately, 16 randomized controlled trials (RCTs) with 933 patients were included in the analysis. The bleeding control methods evaluated included tranexamic acid (TXA), desmopressin, steroids, magnesium sulfate, clonidine, remifentanil, and patient positioning (reverse Trendelenburg position). Data were combined using meta-analysis methods in STATA version 17, and the standardized mean difference (SMD) with 95% confidence intervals (CIs) was calculated to assess the effects of the methods. The results showed that TXA (SMD: -1.31; 95% CI: -2.01 to -0.62) and steroids (SMD: -1.07; 95% CI: -1.70 to -0.43) had the most significant impact on reducing bleeding. Patient positioning also showed a considerable effect (SMD: -0.65; 95% CI: -1.01 to -0.30), and desmopressin had a positive impact (SMD: -1.53; 95% CI: -3.12 to 0.06), though this effect was not statistically significant. This study demonstrates that pharmacological and non-pharmacological interventions, such as TXA and patient positioning, can significantly reduce intraoperative bleeding. However, further studies with larger sample sizes and standardized designs are recommended for magnesium sulfate, clonidine, and remifentanil methods. Level of Evidence I.

Effect of 10 and 20 degrees reverse Trendelenburg position on surgical field quality during ear surgery. A randomized-controlled trial.

Impact of mannitol on intracranial pressure assessed by optic nerve sheath ultrasonography during video-laparoscopic prostatectomy: a randomized clinical trial.

BackgroundThe emergence of new multi-modular robotic surgical systems, such as Hugo RAS and Versius, introduces architectural and ergonomic variations compared with the established Da Vinci platform. While their surgical performance has been widely investigated, limited data exist regarding anesthesiological outcomes. This study aimed to compare intraoperative anesthetic parameters across three robotic platforms in a tertiary academic center.MethodsA retrospective observational analysis was conducted on 258 consecutive patients who underwent robotic abdominal, urological, or gynecological surgery between January 2024 and June 2025. Patients were stratified according to the robotic platform used—Da Vinci, Hugo RAS, or Versius. Intraoperative variables, including Trendelenburg angle, anesthesia duration, pneumoperitoneum time, urine output, and fluid balance, were compared among groups.ResultsThe Da Vinci system was used in 68.6% of cases, followed by Versius (15.9%) and Hugo RAS (15.5%). No major differences were observed in anesthesiological or postoperative outcomes across platforms, except for a higher intraoperative urine output with Versius in gynecological surgery. Minor variations included a steeper Trendelenburg position in colorectal surgeries performed with Da Vinci and shorter operative and pneumoperitoneum times with Versius in abdominal wall procedures.ConclusionDespite structural and ergonomic differences, the Hugo RAS and Versius systems demonstrated anesthesiological safety and intraoperative performance comparable to the Da Vinci platform, supporting their safe integration into clinical practice.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11701-025-03060-3.

This multicenter retrospective study investigates the utility of routine lower abdominal diagnostic laparoscopy (DL) during sleeve gastrectomy (SG) for identifying and managing incidental intra-abdominal pathologies in a high-risk obesity cohort. Data from 371 patients undergoing SG with concurrent DL across three Libyan centers (January 2021-December 2024) were analyzed. DL involved systematic abdominal exploration using a 180° camera rotation in a 45° reverse Trendelenburg position using a 300 lens. Incidental findings were detected in 6.5% (n = 24), including cysts/masses (45.8%, n = 11), adhesions (29.2%, n = 7), hernias (16.7%, n = 4), and other pathologies (8.3%, n = 2). These findings prompted and one procedure abortion, one precancerous mass excision through left side oophorectomy-pathology revealed mature teratoma-and was rescheduled for SG later. The median operative time increased by 3-7 minutes, with no morbidity or mortality related to DL. Two patients with incidental hernias required emergency repair within 90 days. Patients requiring intervention had similar hospital stays (1-2 days). Preoperative ultrasound failed to detect all laparoscopically identified pathologies. Routine DL during SG proved feasible and safe, adding minimal operative time while enabling timely interventions that potentially averted long-term morbidity. The findings underscore DL's critical role in detecting occult pathologies in obese populations, particularly where preoperative diagnostic accuracy is limited. Standardizing DL in bariatric protocols is advocated to enhance intraoperative decision-making and patient safety.

Position-related complications of robot-assisted radical prostatectomy (RARP) include rhabdomyolysis and well leg compartment syndrome (WLCS). This study aimed to explore a method for preventing rhabdomyolysis and WLCS, focusing on external pressure on the lower leg during surgery. Three hundred patients who underwent RARP performed in the steep Trendelenburg position with a 25-degree head-down tilt between June 2018 and June 2022 were examined. The patients were divided into pressure-controlled and non-pressure-controlled groups. In the pressure-controlled group, external pressure on the lower leg was measured using the Portable Interface Pressure Sensor (Palm Q®) while creating the surgical position. The patient was placed in the required surgical position ensuring that external pressure on the lower leg was maintained below 20mmHg. In the non-pressure-controlled group, external pressure on the lower leg was not measured. Postoperative outcomes, including creatine kinase (CK) levels and incidence of rhabdomyolysis and WLCS were compared. CK levels on postoperative days (POD) 1 and 2 were significantly lower in the pressure-controlled group (median: 342 and 352IU/L, respectively) than in the non-pressure-controlled group (837 and 708IU/L, respectively) (P < 0.05 for both comparisons). The incidence of rhabdomyolysis was lower in the pressure-controlled group, and no cases of WLCS were observed, in contrast to two cases identified in the non-pressure-controlled group. Maintaining external pressure on the lower legs below 20mmHg during RARP may contribute to preventing rhabdomyolysis and WLCS after RARP. This method can be applicable to other surgeries performed in the Trendelenburg position.

Effects of sustained Trendelenburg position on the spectral signatures of the EEG: implications for the consistency of the level of anesthesia, an observational study.

To evaluate the safety and efficacy of a novel combined retrograde intrarenal surgery (RIRS) technique utilizing a tip-bendable suction ureteral access sheath (S-UAS) and ±20° gravity-assisted (Trendelenburg/reverse Trendelenburg) supine positioning for treating renal stones ≥3 cm. A retrospective multicenter study (3 centers) was conducted in 73 patients between October 2023 and January 2025 with renal stones ≥3 cm. A two-phase surgical approach was employed: initial lithotripsy in 20° Trendelenburg position, followed by fragment evacuation in 20° reverse Trendelenburg using S-UAS suction. All procedures utilized flexible ureteroscopy and a 12/14F S-UAS. Perioperative variables-including operative time, hemoglobin drop, need for second-stage procedures, 3-month stone-free rate (SFR), and complications (fever, subcapsular hematoma, and septic shock) graded by the Clavien-Dindo system-were recorded. A total of 73 patients (mean stone size ∼34 mm) were included. Mean operative time was 125 ± 39 minutes. A second-stage RIRS was required in 32.9% of cases. The overall SFR at 3 months was Grade A (60.3%), Grade B (90.4%), and Grade C (97.3%) after one or two sessions. Postoperative fever occurred in 12.3% and subcapsular hematoma in 1.4% of patients; one patient (1.4%) developed urosepsis (septic shock, Clavien IVa) requiring intensive care unit care. No patients had long-term sequelae or required open surgery. On subgroup analysis, patients with high stone density (≥700 Hounsfield units) had higher second-stage RIRS rate. RIRS with a tip-bendable suction sheath combined with gravity-assisted supine positioning (±20° Trendelenburg/Reverse Trendelenburg) for renal stones appears to be a feasible option for managing stones >3 cm and may be particularly suitable for lower-density calculi. Further studies are needed to validate its effectiveness and safety in broader populations.

The STP significantly increases IOP during TLH, with a more pronounced effect observed in patients with a high BMI. The present study sought to determine the impact of steep Trendelenburg position (STP) on intraocular pressure (IOP) in patients undergoing total laparoscopic hysterectomy (TLH) and to establish the relationship between age, body mass index (BMI), iridocorneal angle, and surgical duration about position-related intraocular pressure changes. Preoperative ophthalmologic evaluation was performed 1 day before surgery (T0). IOP was measured using a handheld contact tonometer at T1 (5 min after anesthesia), T2 (5 min after pneumoperitoneum), T3 (5min in STP), T4 (after pneumoperitoneum release), T5 (at the end of surgery in supine position), and T6 (10min after returning to supine). Surgery duration and patient demographics were recorded. The IOP values were found to be considerably elevated in comparison to the baseline (T0) at all designated time points (T1-T6). There was a progressive decrease in intra-abdominal pressure after the pneumoperitoneum was released (T4-T6). The findings revealed no statistically significant correlation between age and iridocorneal angle on the one hand and IOP values on the other. At T6, a negative correlation was observed between IOP and surgical duration and a positive correlation with BMI. The STP significantly elevates IOP during TLH, and this effect is more pronounced in patients with higher BMI. Identifying such risk factors may guide anesthetic and surgical strategies to minimize ocular complications in procedures requiring this position.

Background: Hemothorax represents a rare but serious complication after posterior correction surgery (PCS) for spinal deformities, occurring in roughly 0.1% of cases. When diagnosis is delayed or the condition is missed, the clinical consequences can be severe. In this retrospective review, we evaluated pediatric patients who developed hemothorax after PCS, aiming to describe the perioperative diagnostic difficulties and management experiences encountered. Methods: From 2016 to 2021, we retrospectively reviewed the records of 135 children who underwent posterior correction surgery for spinal deformity. Five of these patients were diagnosed with postoperative hemothorax and were included in the study. The variables assessed comprised demographic information, intraoperative imaging findings, the onset of hemodynamic deterioration, and the treatments applied. Results: The mean patient age at the time of surgery was 12.4 ± 2.9 years. Intraoperative posteroanterior chest radiographs were routinely obtained to confirm the placement of spinal instrumentation. A retrospective review of these films showed clear signs of hemothorax in four children and suspicious findings in one. None of the cases received intraoperative intervention for hemothorax. Because of subsequent hemodynamic instability, all five were transferred from the ward to the intensive care unit at different times after surgery. Chest tube drainage was required in three patients, thoracentesis in one, and surgical decortication in another. Conclusion: Early recognition of hemothorax plays a key role in preventing postoperative complications. For patients considered at higher risk, intraoperative bedside thoracic ultrasonography should be routinely employed. When this option is not accessible, performing a chest X-ray in the reverse Trendelenburg position before extubation may help reduce the likelihood of a missed diagnosis