Non invasive mechanical ventilation in patients with respiratory failure of neuromuscular origin

The boundaries for the use of the non invasive ventilation [NIV] continue to expand, till now a few number of trials studied the application of NPPV in specific neuromuscular disorders [NMD] as myasthenia gravis and Guillain-Barre Syndrome, while many studies supported the use of NPPV in Duchenne muscular dystrophy. For chronic respiratory failure, a wide consensus now favors the use of NPPV as the ventilatory mode of the first choice for patients with neuromuscular diseases. It is important to predict those likely to fail with NPPV due to the expensive and intensive medical care used for these patients. The aim of this study was to evaluate the efficacy of NPPV specially in correcting gas exchange abnormalities and in avoidance of tracheal intubation in the management of respiratory failure of neuromuscular origin. This study was carried out on 13 patients with respiratory failure [6 patients with ARF, 7 patients with CRF] of neuromuscular origin. These patients fulfilled the diagnostic criteria for each specific disorder [9 with GB syndrome, 3 with MG, and one with DMD] with either acute or chronic respiratory failure. The patients were classified into 2 main groups; group I with ARF [6 patients] and group II with CRF [7 patients]. They all received NPPV using bilevel positive pressure ventilation plus standard medical treatment. All cases were subjected to thorough history taking and physical examination, chest x-ray, neuro-physiological studies, ABG, some hematological and biological indices, derived variables with regular follow up and recording of ventilator variables with detection of associated complications of NPPV. The overall success rate of NPPV was 69.2%, this was 50%for group I with ARF and 85.7%, for group II with CRF. In group I with ARF when compared with the base line values, there was a significant decrease in RR, HR, MAP, and PaO2 after one hour of the study, while the rise in SaO2, pH and the decrease in PaCO2 were significant after the 2nd hour of the study. In group II with CRF when compared with the base line values, we have observed a significant reduction in RR after the first day, while both the rise in PaO2 and the decrease in PaCO2 were significantly after the second day of the study. Also SaO2 and HR were improved only after the 7th day of the study while, on the other hand, PH and MAP were unchanged significantly till the end of the study. Application of NPPV as a safe and a routine line of therapy in patients with respiratory failure of neuromuscular origin for correction of arterial blood gas abnormalities, stabilizing vital signs, and avoiding tracheal intubations and its complications in these patients. Results of NPPV therapy in chronic respiratory failure of NM origin is much better than in acute respiratory failure of NM origin. Use of NPPV in ARF due to Guillain-Barre Syndrome with a great precaution especially with those having severe bulbar palsy for fear of aspiration events

Morphometric and radiological study of the foramen transversorium of the axis vertebra

In this work 250 dried axis vertebrae and CT scan for 50 patients were used to study the foramen transversorium on both sides regarding the presence of erosion, the dimensions of the foramen and its openings, the shape of the openings, the dimensions of the pedicle, the costotransverse bar and the external height of the lateral mass.The anatomical results showed that 6% of the foramina on the left side were markedly eroded [opened] due to the absence of the costo-transverse bar while no erosion was found on the right side. The foramen with its two openings were larger on the left side than on the right side. The right foramen transversorium had a mean height of 0.57 +/- 0.14cm and a mean width of 0.55 +/- 0.11cm while the left foramen had a mean height of 0.61 +/- 0.17cm and a mean width of 0.60 +/- 0.12cm. The diameter of the superior opening of the foramen was wider on the left side [mean = 0.58 +/- 0.I4 cm] than on the right side [mean = 0.54 +/- 0.14cm]. Also, the diameter of the inferior opening had a mean of 0.60 +/- 0.12cm on the left side and 0.55 +/- 0.IIcm on the right side. The superior opening was oval in the majority of the cases [96.80% on the right side and 97.45% on the left side] while-the inferior opening was mostly circular [91.60% on the right side and 92.34% on the left side]. The height of the pedicle had a mean of 0.83 +/- 0.09cm on the right side and 0.78 +/- 0.09cm on the left side while the width of the pedicle had a mean of 0.82 +/- 13cm on the right side and 0.77 +/- 0.17cm on the left side. The costotransverse bar had a mean width of 0.51 +/- 0.l5cm and 0.36 +/- 0.14 on the right and left sides respectively. The lateral mass had a mean height of 0.87 +/- 0.11 and 0.82 +/- 0.14cm on the right and left sides respectively. All these findings may be attributed to the tortuosity of the larger left vertebral artery than the right one. The radiological results were more or less similar to the anatomical results.These results should be taken into consideration in transarticular screw fixation at C1- C2 segment as there is no enough bone to allow adequate fixation. So, CT and vertebral artery angiography should be recommended before any instrumental fixation to avoid injury of the vertebral artery and to ensure a more accurate surgical accurate surgical approach

Neurovascular supply of the dorsal skin of the proximal and middle phalanges of the middle finger

The skin on the back of the proximal phalanx of the middle finger had dual cutaneous nerve supply from both the median and radial nerves, 3 small arterioles from the palmar digital artery and 3 longitudinal veins draining into a dorsal venous arch which in turn drained into 2 veins, one on each side of the digit. The skin of the middle phalanx was only supplied by the dorsal sensory branch of the median nerve, a very minute arterial network and 3 longitudinal veins. The present work recommends extension of the dorsal middle phalangeal finger flap of the middle finger to include part of the skin of the proximal phalanx in the form of 3 x 5 cm2 flap in the extended digit to benefit from its nervous and arterial supply and its venous drainage