Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease.

OBJECTIVE: Evaluate the potential safety and efficacy of transtracheal augmented ventilation (TTAV), which is the transtracheal delivery of high flows of a humidified air-oxygen blend. METHODS: The first of 2 observational studies evaluated patients before and after a 3-month intervention with the nocturnal (Noc) administration of TTAV at 10 L/min. Resting physiologic studies evaluated standard low-flow transtracheal oxygen (LFTTO), TTAV, and breathing without transtracheal flow via mouthpiece (MP). Patients also underwent nocturnal polysomnography, bronchoscopy, ventilatory drive evaluation, and treadmill exercise. The second study assessed the safety of Noc TTAV for up to 60 months. Each study evaluated 15 different transtracheal patients with severe lung disease. RESULTS: Pleural pressure-time index and respiratory duty cycle were significantly lower (p < 0.05) when comparing MP to TTAV. TTAV contributed more (p < 0.05) than LFTTO to the total volume delivered to the lung (V(L)). Arterial blood gases and (V(L)) were unaltered by TTAV. Sleep quality and nocturnal oxygenation with TTAV were similar to LFTTO, and Noc TTAV had no effect on ventilatory drive. Bronchoscopy showed no evidence of substantial injury. Treadmill exercise tests showed a longer exercise time (p < 0.005) and greater total work (p < 0.05) following Noc TTAV. During exercise, the changes in slope for heart rate and pH were less steep (p < 0.05) following Noc TTAV. The 3-month study and a long-term evaluation showed that Noc TTAV was well-tolerated and safe, with a reported high compliance. CONCLUSIONS: Patients with chronic hypoxemia and severe respiratory insufficiency may benefit from Noc TTAV.

The use of intrathecal morphine for analgesia after posterolateral lumbar fusion: a prospective, double-blind, randomized study.

STUDY DESIGN: A prospective, randomized, double-blind, placebo-controlled study was undertaken to evaluate the efficacy and safety of intrathecal morphine for postoperative analgesia after posterolateral lumbar fusion. OBJECTIVES: To compare the early postoperative analgesia in patients who receive a single dose of intrathecal morphine intraoperatively with that of patients using a patient-controlled analgesia pump only. SUMMARY OF BACKGROUND INFORMATION: Although intrathecal morphine is used as an analgesic in a variety of medical and surgical conditions, very little has been published on its use after posterior lumbar spine surgery. Because the thecal sac is readily available during these procedures, the addition of a single injection of morphine before wound closure can be done with technical ease. If its efficacy and safety can be verified, then it could serve as a useful adjuvant to the postoperative analgesia regimen. METHODS: Sixty-eight consecutive patients undergoing posterolateral lumbar fusion were randomly assigned to two groups. The experimental group was injected intrathecally with morphine 30 minutes before wound closure, and the control group was similarly injected with a placebo of normal saline solution. All patients were connected to an on-demand patient-controlled analgesia pump to provide any additional necessary analgesia. Their use of the patient-controlled analgesia pump was tabulated by counting the number of demands and the actual amount of morphine delivered. Additionally, a visual analog scale was used to assess pain levels at pre-established regular intervals. RESULTS: The visual analog scale measurements were significantly lower for the intrathecal morphine group initially, but they surpassed those of the control group after 24 hours. Likewise, the number of patient-controlled analgesia pump demands and the amount of narcotic delivered initially were significantly lower in the experimental patients, but again reversed after the first postoperative day. The late rebound in pain and patient-controlled analgesia pump use did not reach statistical significance. There were no significant complications related to the analgesia. CONCLUSIONS: Intrathecal morphine can be safe and efficacious as an early postoperative analgesic after lumbar fusion when respiratory monitoring is used.

Otolaryngologist's role in transtracheal oxygen therapy: the minitrach procedure.

The modified Seldinger technique for transtracheal oxygen catheter insertion is relatively straightforward, but tract problems during subsequent oxygen therapy are not uncommon. With the modified Seldinger technique method, transtracheal oxygen is not initiated until 1 week after the procedure. Six to 8 weeks are required for tract epithelialization, which allows routine catheter removal and cleaning by the patient. Without removal, mucus tends to collect and form balls on the catheter tip, creating a management problem. Previous studies suggest a significant incidence of tracheal chondritis, keloid formation, and inadvertent catheter dislodgment. In 7% to 10% of patients, the epithelial tract cannot be recovered by medical personnel, and complete closure occurs. We have developed a surgical technique for the creation of a controlled tracheocutaneous tract. Highlights of the minitrach include skin flap elevation, cervical lipectomy, resection of a small window of tracheal cartilage, and approximation of the skin flaps to the window. We evaluated 33 patients who underwent the minitrach procedure as an access method for receiving transtracheal oxygen. When compared with results from 64 patients followed up for a similar period with the modified Seldinger technique, results with minitrach showed that transtracheal oxygen could be instituted sooner (<24 hours), and symptomatic mucus balls were reduced because the tract matured more quickly (approximately 14 days). With the minitrach there were no inadvertent catheter dislodgments, as compared with 41% of modified Seldinger technique patients who had one or more episodes of catheter dislodgment. Twelve percent of minitrach patients had a single episode of chondritis, as compared with 25% of the modified Seldinger technique patients, who had one or more episodes. The minitrach was well tolerated in this group of patients with severe pulmonary and/or cardiovascular disease. In 12 of these patients, a minitrach revision of their previous modified Seldinger technique tracts resolved recurrent problems with chondritis, lost tracts, and keloids. We conclude that the minitrach promotes early institution of transtracheal oxygen, simplifies an intense postprocedure educational and management process, facilitates tract maturation, and reduces the incidence of problems related to mucus balls, lost tracts, chondritis, and keloids. The minitrach can be used as a revision procedure to resolve tract problems encountered with modified Seldinger technique. We are now using the minitrach as the preferred procedure for the institution of transtracheal oxygen. The minitrach greatly improves and simplifies the transtracheal oxygen program, and the otolaryngologist becomes an important member of the transtracheal oxygen team.

The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders.

We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both.

A prospective analysis of autograft versus allograft in posterolateral lumbar fusion in the same patient. A minimum of 1-year follow-up in 144 patients.

STUDY DESIGN: One hundred forty four patients who underwent lumbar spine fusions had autografts placed on one side as a control and on the opposite side one of the following types of graft material was placed: iliac autograft, demineralized cancellous chips, demineralized cortical powder, demineralized cortical powder mixed with autograft, or mineralized cancellous chips. Alar anteroposterior and lateral postoperative radiographs were reviewed by three independent observers and graded for quality of fusion mass bilaterally. The follow-up was 14 to 27 months. OBJECTIVES: This study evaluated the efficacy of various types of ethylene oxide-sterilized allograft bone used for spine fusions and compared them with autograft iliac bone in the same patient. SUMMARY OF BACKGROUND DATA: Previous studies comparing autograft with allograft showed poorer fusion rates with allograft with posterior fusions. Most of the previous studies included smaller numbers of patients. No previous studies compared ethylene oxide-treated allograft with autograft. RESULTS: An analysis of the radiographs at a minimum of 1 year postoperatively revealed significantly lower values when allograft alone or in combination with autograft was used in comparison to autograft alone. CONCLUSIONS: Ethylene oxide-treated allograft is inferior to autograft and should not be used for posterior lumbar fusions.

Auditory stroop effects in children with hearing impairment.

The accurate perception of speech involves the processing of multidimensional information. The aim of this study was to determine the influence of the semantic dimension on the processing of the auditory dimension of speech by children with hearing impairment. The processing interactions characterizing the semantic and auditory dimensions were assessed with a pediatric auditory Stroop task. The subjects, 20 children with hearing impairment and 60 children with normal hearing, were instructed to attend selectively to the voice-gender of speech targets while ignoring the semantic content. The type of target was manipulated to represent conflicting, neutral, and congruent relations between dimensions (e.g., the male voice saying "Mommy," "ice cream," or "Daddy" respectively). The normal-hearing listeners could not ignore the irrelevant semantic content. Instead, reaction times were slower to the conflict targets (Stroop interference) and faster to the congruent targets (Stroop congruency). The subjects with hearing impairment showed prominent Stroop congruency, but minimal Stroop interference. Reduced Stroop interference was not associated with chronological age, a speed-accuracy tradeoff, a non-neutral baseline, or relatively poorer discriminability of the word input. The present results suggest that the voice-gender and semantic dimensions of speech were not processed independently by these children, either those with or those without hearing loss. However, the to-be-ignored semantic dimension exerted a less consistent influence on the processing of the voice-gender dimension in the presence of childhood hearing loss. The overall pattern of results suggests that speech processing by children with hearing impairment is carried out in a less stimulus-bound manner.