A feasibility study of jaw thrust as an indicator assessing adequate depth of anesthesia for insertion of supraglottic airway device in morbidly obese patients / 中华医学杂志(英文版)

Background@#Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction. This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.@*Methods@#Thirty morbidly obese patients with a body mass index 40 to 73 kg/m2 undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study. After adequate pre-oxygenation, 5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min. After motor responses to jaw thrust disappeared, a SAD was inserted and insertion conditions were graded. The anatomic position of SAD was assessed using a fiberoptic bronchoscope.@*Results@#The SAD was successfully inserted at the first attempt in all patients. Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%), respectively. The fiberoptic views of SAD position were adequate in 28 patients (93%).@*Conclusions@#Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.@*Clinical trial registration@#ChiCTR1800016868; http://www.chictr.org.cn/showproj.aspx?proj=28646.

Difficult laryngoscopy and tracheal intubation: observational study / Dificuldade na laringoscopia e na intubação orotraqueal: estudo observacional

Abstract Introduction: Since anesthesia complications associated with unexpected difficult airway are potentially catastrophic, they should be avoided. The modified Mallampati test and jaw-thrust maneuver enable the identification of difficult airway. The aim of this study was to associate the modified Mallampati test and the jaw-thrust maneuver with laryngoscopy (Cormack-Lehane) in an attempt to identify a better predictor of difficult airway in an adult population undergoing elective surgery. Method: A cross-sectional study in which 133 adult patients undergoing elective surgery requiring tracheal intubation were analyzed. The accuracy and specificity of the modified Mallampati test and jaw-thrust maneuver were assessed by correlating them with difficult laryngoscopy (Cormack-Lehane Degrees 3 and 4). Results: In the 133 patients evaluated the difficult intubation rate found was 0.8%; there was association between the two predictive tests proposed (p = 0.012). The values of 94.5% for specificity and 95.4% for accuracy were found for the jaw-thrust maneuver and for the modified Mallampati test, the values found were 81.1% and 81.2%, respectively. Kappa agreement identified a result of 0.240 between jaw-thrust maneuver and Cormack-Lehane, which was considered reasonable. On the other hand, a poor agreement (κ = 0.06) was seen between modified Mallampati test and Cormack-Lehane test. Conclusion: The jaw-thrust maneuver presented superior accuracy and agreement than the modified Mallampati test, showing the ability to identify a difficult airway. It is necessary to emphasize the association of tests in the evaluation of patients, emphasizing their complementarity to minimize the negative consequences of repeated laryngoscopies.

Resumo Introdução: As complicações anestésicas associadas às vias aéreas difíceis inesperadas por serem potencialmente catastróficas devem ser evitadas. O teste de Mallampati modificado e a manobra de protrusão mandibular possibilitam a identificação da via aérea difícil. O objetivo deste estudo foi associar o teste de Mallampati modificado e a manobra de protrusão mandibular com a laringoscopia (Cormack-Lehane) e tentar identificar um melhor preditor de via aérea difícil na população adulta submetida à cirurgia eletiva. Método: Estudo corte transversal, foram analisados 133 pacientes adultos submetidos a cirurgias eletivas que necessitavam de intubação orotraqueal. Avaliaram-se a acurácia e especificidade do teste de Mallampati modificado e da manobra de protrusão mandibular, correlacionados com laringoscopia difícil (Cormack-Lehane Graus 3 e 4). Resultados: Entre os 133 pacientes avaliados, a taxa de intubação difícil encontrada foi 0,8%, houve associação entre os dois testes preditores propostos (p = 0,012). Foram encontrados os seguintes valores para a especificidade 94,5% e a acurácia 95,4% na manobra de protrusão mandibular. Já para o teste de Mallampati modificado valores de 81,1% e de 81,2% respectivamente. A análise de concordância Kappa identificou entre manobra de protrusão mandibular e Cormarck-Lehane um resultado de 0,240; considerado razoável. Por outro lado, observou-se uma fraca (κ = 0,06) concordância entre o teste de Mallampati modificado e o Cormarck-Lehane. Conclusão: A manobra de protrusão mandibular apresentou acurácia e concordância superiores ao teste de Mallampati modificado, mostrou a capacidade de identificar uma via aérea difícil. Faz-se necessário enfatizar a associação dos testes na avaliação do paciente, destacar a complementariedade deles, minimizar as consequências negativas de laringoscopias repetidas.

A Case of Acquired Ocular Motor Apraxia Accompanied with Esotropia due to Multiple Brain Infarcts

PURPOSE: We present a case of acquired ocular motor apraxia accompanied with esotropia due to multiple brain infarcts. CASE SUMMARY: A 59-year-old male was referred for diplopia that started 9 years before presentation and continued after multiple brain infracts including right cerebellum, right occipital lobe, medulla oblongata and inferior pons. At initial examination, his best corrected visual acuity was 20/22 in the right eye and 20/25 in the left eye and he had 12 prism diopter (PD) esotropia at distance and near in primary gaze with correction. His duction and version were normal; however, his horizontal saccade was notably decreased. Two years and 8 months after presentation, the patient had 15 PD esotropia at distance and near with correction. His duction and version were normal and vertical saccadic eye movements were observed. However, horizontal saccade disappeared. The patient also exhibited a distinguishing head thrust following the order for saccadic eye movement. He was diagnosed with an acquired ocular motor apraxia accompanied with esotropia. During the follow-up period the patient underwent bilateral recession of the medial rectus. The usual diplopia and his horizontal esodeviation improved to 3 PD of esotropia at distance. CONCLUSIONS: Multiple brain infarcts can result in an acquired ocular motor apraxia accompanied with esotropia. Varying types of ocular motor disorders should be considered in patients with a previous medical history of brain infarct.

Jaw-thrust induces sympathetic responses during induction of general anesthesia / 대한마취과학회지

BACKGROUND: Jaw-thrust is a noxious stimulus that might induce sympathetic responses. The purpose of this study, was to evaluate the effects of jaw-thrust on sympathetic responses. METHODS: We investigated seventy three patients. Patients who received general anesthesia were randomly divided into a control group (maintenance of combined airway maneuver with head tilt, open mouth by mouthpiece, and chin-lift, n = 30) and jaw-thrust group (maintenance of head tilt, open mouth and jaw-thrust, n = 30). In the jaw-thrust group, four minutes of endoscopy-guided force to the mandible to get the best laryngeal view were applied. For the control group, the combined airway maneuver was maintained during the same period. Arterial blood pressure (AP) and heart rate (HR) were recorded at predetermined time points (1 min before anesthesia induction, 2 min after fiberoptic bronchoscopy placement, and thereafter 1 min-interval during each airway maneuver) during jaw-thrust and chin-lift maneuver. The force amplitude applied for best laryngeal view during jaw-thrust was also measured. RESULTS: Peak systolic and diastolic AP increased 39.0 +/- 17.6 and 39.9 +/- 22.8 mmHg from the baseline (P 0.05). CONCLUSIONS: Performing the jaw-thrust maneuver induces significant sympathetic responses, irrespective of the force magnitude.

Comparison of the trapezius squeezing test and jaw thrust as indicators for laryngeal mask airway insertion in adults / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the effectiveness of the trapezius squeezing test with that of the jaw thrust maneuver as clinical indicators of adequate conditions for laryngeal mask airway (LMA) insertion in adults under sevoflurane anesthesia. METHODS: One hundred adult patients of ASA physical status 1 or 2 undergoing minor surgical procedures were randomly allocated to the T (trapezius squeezing, n = 50) group or the J (jaw thrust, n = 50) group. The LMA was inserted immediately after the loss of response to trapezius squeezing or jaw thrust. Successful and unsuccessful attempts were recorded. An unsuccessful attempt was defined as the occurrence of coughing, gagging, gross purposeful movements, breath-holding, laryngospasm, or an SpO2 < 90% during LMA insertion. Insertion time, end-tidal sevoflurane concentration, mean arterial pressure, and heart rate were recorded. RESULTS: The incidence of successful attempts was significantly higher in the T than in the J group (48/50 vs. 36/50, respectively). CONCLUSIONS: The trapezius squeezing test is a superior indicator of an adequate condition for LMA insertion compared to the jaw thrust maneuver in adults under sevoflurane anesthesia.

TONGUE THRUST HABIT - A review.

There is interrelation ship between the form and function. The different abnormal habits may effect the form of orofacial structures. The presence of one oral habit may induce the other. In this review article a new induction chart is prepared to show the interrelation between different abnormal habits and their effect on form. The chart also in turn explains how form can lead to development of different habits. Thus there is interrelation ship between form and function.

O efeito imediato da manipulação talocrural na estabilidade unipodal de tornozelo / Immediate effects of talocrural manipulation on ankle monopodalic stability

A articulação talocrural é essencial para o desenvolvimento da marcha, adaptando-se aos diversos tipos de superfícies, estando diretamente relacionada com o equilíbrio e estabilidade. Técnicas de manipulação osteopática têm sido usadas para tratar distúrbios e restaurar a mecânica articular, e podem influenciar diretamente o sistema de controle postural. O objetivo do estudo foi analisar as alterações na estabilidade unipodal de tornozelo geradas por meio da aplicação de uma técnica de thrust. Participaram deste estudo 20 homens com idade 22±2 anos, divididos em dois grupos: G1 (n=10) grupo que recebeu a técnica manipulativa e G2 (n=10) controle. A técnica utilizada foi a manipulação talocrural no membro inferior dominante. Os valores estabilométricos foram obtidos pela plataforma Cibex Reactor antes e cinco minutos após a aplicação da técnica em G1. Os voluntários de G2 foram submetidos ao mesmo protocolo de avaliação, porém sem receber a técnica thrust. Foram obtidos os seguintes resultados: Em G1, observou-se diferenças estatisticamente signifi cantes após a manipulação talocrural (p<0,05), antes os voluntários apresentaram valores estabilométricos de 8.169 pontos. Após a intervenção experimental houve uma queda de 14,35% (6.996 pontos), indicando que houve uma alteração na estabilidade quando comparado ao grupo controle, o qual não obteve diferenças nos resultados. Assim, sugere-se que a manipulação pode ser eficaz na melhora do equilíbrio e estabilidade unipodal de tornozelo.

The talocrural joint is essential for the gait development. It adapts itself to the various areas and types of terrain where you walk and is directly related to balance and stability. Manipulative techniques were used to treat disorders and restore the joint movements, and may influence the postural control system. The study’s goal was to evaluate the immediate changes in stability generated by the application of thrust technique. Twenty men, 22±2 years old, were separated into two groups: G1 (n=10) manipulated group, and G2 (n=10) control group. The technique used was the talocrural thrust in the dominant leg. The data was collected by the stabilometric platform Cibex Reactor before and five minutes after the application of the technique in G1. The group G2 performed only the stabilometric test at the same time, without receiving the thrust. The values obtained were statistically signifi cant for G1 after the manipulation (P<0,05), the stabilometric values before the technique was 8.169 points, and after was a decline of 14.35% (6,996 points), indicating that there was a change in the stability when compared to the control group, which there were no differences between the results. The results of this study suggest that the manipulation can be effective in improving balance and stability.

Transient facial nerve palsy after general anesthesia: A case report / 대한마취과학회지

A 44-year-old woman underwent a breast cancer operation under general anesthesia. We performed bronchoscope guided intubation along with a jaw thrust maneuver on the patient to achieve a good visual field. The patient complained of left lower lip weakness after the operation. The lower lip of the patient was deviated to the right. The cause might have been a temporary compression of the left facial nerve at the mandibular angle during performance of the jaw thrust maneuver. Fortunately, the patient's palsy recovered completely during the following one month. We report here on a case of transient facial nerve palsy after general anesthesia, and this occurred despite performing a very short duration of jaw thrust.

Study on lift-up speed of aerodynamic compliant foil thrust bearings / 药物分析学报

Objective The experimental study on the lift-up speed of a new kind of compliant aerodynamic foil thrust bearings was performed on the multifunctional test rig established for testing the performances of foil gas bearings. Methods The lift-up speed of foil gas thrust bearing under given axial load was analyzed through the spectrum of axial displacement response in frequency domain. Results The test results indicated that the difference in the spectrum of axial displacement responses before and after lifting up of the rotor was obvious. After lifting up of the rotor, there were only larger components of rotation frequency and lower harmanic frequencies. If the rotor wasn't lift-up, there were also larger components of other frequencies in the spectrum. Conclusion So by analyzing the spectrum of axial displacement response, the results showed that the lift-up speed was about 1 860 rpm when the axial load was 31N.

Lateral thrust of varus knees treated with lateral closing wedge high tibial osteotomy / 中国矫形外科杂志

[Objective]To assess the functional outcome,influence factors and its management of lateral wedge high tibial osteotomy(HTO)in patients with symptomatic lateral thrust and varus malalignment.[Method]The results of 19 lateral closing wedge HTOs in patients with a symptomatic hyperextension-varus thrust were evaluated from 2000 to 2004.The average age of the patients at the time of surgery was 49 years(ranged,47~54 years).Radiographs were analyzed to compare changes in femorotibial angle,tibial slope,and the height of the fibular head pre-and postoperatively.Functional results were evaluated according to the scoring system of HSS.The varus stress test was used to evaluated the posterolateral knee injury.We used a 5-point visual analogue scale to assess change in knee stability.[Result]Patients were followed for an average of 21 months.Femorotibial axis alignment was 184.5?～197?preoperatively and 167?～176?postoperatively;Posterior tibial slope was 2?～17?preoperatively and-4?～13?postoperatively;The height of fibular head was 7.7～18.5 mm preoperatively and-3.5～10.7 mm postoperatively(P=0.00).All patients had an increase in their HSS score postoperatively.Sixteen patients had Grade 1 posterolateral injuries and 3 patients had Grade 2 injures preoperatively,9 patients had Grades 1 injures and 10 patients had Grade 2 injures(P

The Effect of Intratracheal Pulmonary Ventilation on the Decrease of Dead Space in Rabbits with Acute Respiratory Failure / 대한마취과학회지

BACKGROUND: A technique that improves the efficiency of alveolar ventilation should decrease the pressure required and reduce the potential for lung injury during mechanical ventilation. High PaCO2 can be permitted to lower airway pressures as in permissive hypercapnia (PH). Intratracheal pulmonary ventilation (ITPV) was developed to allow a decrease in physiological dead space during mechanical ventilation. We compared the effect of hybrid ventilation (HV) as a modification of ITPV with PH on the decrease of tidal volume and airway pressures in rabbits with acute respiratory failure. METHODS: Tracheostomy was performed in 7 rabbits ventilated under volume-controlled mode in the supine position. Arterial blood gas analysis, airway pressures, and dead space ventilation were measured at respiratory rate of 20/min as control values. Oleic acid (OA) of 0.06 ml/kg was injected to induce acute respiratory failure. Tidal volume (VT) was elevated to maintain PaCO2 in the normal range. The same parameters were measured as OA values. Then VT was reduced to the control level to allow PH. HV was initiated by inserting a reverse thrust catheter (RTC) into the endotracheal tube. HV consists of a pressure-controlled mode of mechanical ventilation and ITPV while flushing fresh gas continuously via the RTC. Respiratory parameters were compared under control, OA, PH and HV conditions. RESULTS: Oleic acid injection decreased PaO2 from 401+/-35 mmHg to 129+/-39 mmHg, increased VT from 42+/-5 ml to 52+/-10 ml, and increased VD/VT ratio from 0.65+/-0.07 to 0.71+/-0.07. During PH, the increase in PaCO2 was accompanied by the increase in VD/VT ratio from 0.71+/-0.07 to 0.79+/-0.03 and by the decrease of peak inspiratory pressure (PIP) from 19.4+/-4.0 cmH2O to 16.8+/-3.1 cmH2O. PaCO2 was lowered from 50+/-5 mmHg in PH to 39+/-5 mmHg in HV with a lower VT. VD/VT ratio in HV was as low as that in control. CONCLUSION: HV is an effective and easy-to-use ventilatory modality to reduce PaCO2 and airway pressures by the reduction in VD/VT ratio in acute respiratory failure model.

A Comparison of Pressure Controlled Ventilation and Hybrid Ventilation in Rabbits / 대한마취과학회지

BACKGROUND: Intermittent positive pressure is required to overcome pulmonary airway resistance during inspiration and to deliver an adequate tidal volume. Previous animal experiments have shown that mechanical ventilation may worsen the lung injury when high airway pressure and large tidal volume are required to achieve adequate ventilation and oxygenation. Many ventilatory strategies have been developed to minimize airway pressure increase for the less compliant lung. Intratracheal pulmonary ventilation (ITPV) was developed to allow a decrease in physiological dead space during mechanical ventilation. METHODS: Pressure controlled ventilation (PC) has been compared with hybrid ventilation (HV) which consists of PC and ITPV in 7 rabbits. A reverse thrust catheter (RTC) was introduced into an endotracheal tube (ETT) through an adapter and positioned just above the carina inside the ETT. Fresh gas flowed continuously along the gap between inner cannula and outer cap in the expiratory direction. Gas was intermittently re-directed into the lung as a tidal volume by a valve on the expiratory circuit with ventilatory mode of PC to make HV. Peak inspiratory pressure (PIP) and dead space (VD) at various respiratory rates (RR) of 20/min, 40/min, 80/min and 120/min were compared between PC and HV while maintaining normal PaCO2. RESULTS: The PIPs of PC were 12.4 +/- 3.4 cmH2O, 9.0 +/- 2.7 cmH2O, 8.8 +/- 2.7 cmH2O, and 7.6 +/- 2.5 cmH2O at RR of 20/min, 40/min, 80/min and 120/min, respectively. The PIPs of HV were 9.2 +/- 3.2 cmH2O, 6.2 +/- 1.7 cmH2O, 5.0 +/- 2.0 cmH2O, and 4.5 +/- 1.8 cmH2O at the same RR of 20/min, 40/min, 80/min and 120/min, respectively. The VDS of HV were lower than those of PC. CONCLUSION: It can be concluded that ITPV can be applied as a HV to minimize airway pressure under the setting of PC.

Two Cases of Acute Epiglottitis with Sitting up Position, Chin Thrust Forward, Having Dyspnea / 결핵

Acute epiglottitis is a life threatening inflammatory disease of the upper airway mainly in children, however, the recent reports about acute epiglottitis in adults are increasing. The common symptoms are sore throat, dysphagia, dyspnea and salivary drooling. As the laryngeal edema progresses, the patient sits up, leans forward, with the chin thrust forward, having obvious difficulty breathing. Early recognition and proper airway maintenance until the inflammatory edema subsides are essential steps to avoid a possible life threatening upper airway obstruction. We experienced two cases of acute epiglottitis with sitting up position, chin thrust forward, having dyspnea.

Unilateral congenital ocular motor apraxia: a case report

Congenital ocular motor apraxia (COA), first described by Cogan in 1953, is a rare disorder which shows characteristic defects of the horizontal voluntary saccades, and compensatory head thrust. Until now, most cases have showed a presumably congenital origin, bilaterality, and a tendency to various stages of recovery with aging. But the cause and mechanism of COA are not completely known. Occasionally, it combines with other neurologic abnormalities and metabolic diseases such as Gaucher's disease exhibit similar clinical characteristics to COA. We recently experienced a case of a 3-year-old girl who showed the clinical features of unilateral congenital ocular motor apraxia.

Congenital Ocular Motor Apraxia

Congenital ocular motor apraxia (COA), first described by Cogan in 1953, is a rare disorder which shows characteristic defect of horizontal voluntary saccades and head thrust. Until now, most cases have showed presumably congenital in origin, bilaterality, and tendency of various recovery with aging. But the causes and mechanisms of COA are not known. Occasionally, it combines with other neurologic abnormalities and the metabolic diseases such as Gaucher's disease which exhibits similar clinical characteristics of COA. We recently experienced a 3 years old girl who showed clinical features of unilateral congenital ocular motor apraxia.

Congenital Ocular Motor Apraxia

Congenital ocular motor apraxia (COA), first described by Cogan in 1953, is a rare disorder which shows characteristic defect of horizontal voluntary saccades and head thrust. Until now, most cases have showed presumably congenital in origin, bilaterality, and tendency of various recovery with aging. But the causes and mechanisms of COA are not known. Occasionally, it combines with other neurologic abnormalities and the metabolic diseases such as Gaucher's disease which exhibits similar clinical characteristics of COA. We recently experienced a 3 years old girl who showed clinical features of unilateral congenital ocular motor apraxia.