Tracheal intubation of a difficult airway using Airway Scope, Airtraq, and Macintosh laryngoscope: a comparative manikin study of inexperienced personnel.

BACKGROUND: The Airway Scope (AWS) (Pentax-AWS, Hoya Corp., Tokyo, Japan) and the Airtraq (ATQ) (Prodol, Vizcaya, Spain) have similarities in the novel structures of their blades. In this study, we evaluated the ease of use of the AWS and ATQ compared with the Macintosh laryngoscope (ML) by inexperienced personnel in a simulated manikin difficult airway. METHODS: Twenty-four fifth-year medical students with no previous experience in tracheal intubation participated in this study. We used an advanced patient simulator (SimMan(R), Laerdal Medical, Stavanger, Norway) to simulate difficult airway scenarios including cervical spine rigidity, limited mouth opening, and pharyngeal obstruction. The sequences in selecting devices and scenarios were randomized. Success rates for tracheal intubation, and the time required for visualization of the glottis, tracheal intubation, and inflation of the lungs, and the number of optimization maneuvers and dental click sounds were analyzed. The 3 different intubation devices were tested in 4 different scenarios by 24 students. RESULTS: Both the AWS and ATQ had very high success rates of tracheal intubation compared with the ML (AWS 100%*; ATQ 98%*; and ML 89%; *P < 0.05 AWS, ATQ versus ML). The time to intubation with the AWS was significantly shorter than with the ATQ and ML (AWS 11 +/- 6 seconds; ATQ 16 +/- 12 seconds; and ML 16 +/- 11 seconds; *P < 0.05 AWS versus ATQ, ML). The number of optimization maneuvers with the AWS was significantly lower than with the ATQ and ML. There were significantly more audible dental click sounds with the ML than with the AWS and ATQ. CONCLUSION: Both the AWS and ATQ may be suitable devices for difficult intubation by inexperienced personnel in this manikin simulated scenario. Further studies in a clinical setting are necessary to confirm these findings.

Hyperstability and crystal structure of cytochrome c(555) from hyperthermophilic Aquifex aeolicus.

In order to elucidate the relationship between the stability and the structure of the monohaem cytochrome c(555) (AA c(555)) from the hyperthermophilic bacterium Aquifex aeolicus, chemical denaturation and crystal structure determination were carried out. AA c(555) exhibited higher stability than the thermophilic Hydrogenobacter thermophilus cytochrome c(552) (HT c(552)), which is one of the most stable cytochromes c. The three-dimensional crystal structure of AA c(555), which was determined using the multiple anomalous dispersion technique at 1.15 A resolution, included a unique 14-residue extra helix, while the side-chain interactions of several amino-acid residues responsible for the stability of HT c(552) were conserved in AA c(555). The side chain of the Met61 residue in the extra helix was aligned towards the haem, forming a coordination bond between the Met S and haem Fe atoms. In other cytochromes c the corresponding regions always form Omega loops which also include the haem-liganding Met residue and are known to be involved in the initial step in cytochrome c denaturation. The formation of the extra helix in AA c(555) results in the highest helix content, 59.8%, among the monohaem cytochromes c. The extra helix should mainly contribute to the hyperstability of AA c(555) and is presumed to be a novel strategy of cytochromes c for adaptation to a hyperthermophilic environment.

Effects of cysteine introduction into three homologous cytochromes C.

A cysteine residue was systematically introduced into three homologous cytochromes c from Hydrogenobacter thermophilus, Hydrogenophilus thermoluteolus, and Pseudomonas aeruginosa at a conserved position. The H. thermoluteolus variant showed the most decreased thermal stability as compared with the wild type, which might have been due in part to crosslinked polymer formation. The effects of cysteine introduction differed even at the conserved position in these homologous proteins.

Correlation between the stability and redox potential of three homologous cytochromes c from two thermophiles and one mesophile.

The stability of the oxidized and reduced forms of three homologous cytochromes c from two thermophiles and one mesophile was systematically monitored by means of Soret absorption measurements in the presence of various concentrations of a denaturant, guanidine thiocyanate, at pH 7.0 at 25 degrees C. Thermophilic Hydrogenobacter thermophilus cytochrome c(552) was the most stable in both redox states, followed by moderately thermophilic Hydrogenophilus thermoluteolus cytochrome c(552), and then mesophilic Pseudomonas aeruginosa cytochrome c(551). Further stability and electrochemical analysis of the three proteins and the reciprocal variants, which exhibited a different hydrophobic interaction with the heme, showed that the one with the higher stability in both redox states had the lower redox potential. Consequently, these cytochromes c probably adapted to the cellular environments of the original bacteria with correlated stability and redox potential constraints, which are in part regulated by the hydrophobicity around the heme.

Practical use of airway pressure release ventilation for severe ARDS--a preliminary report in comparison with a conventional ventilatory support.

Airway pressure release ventilation (APRV) is a ventilatory mode that allows unsupported spontaneous breathing at any phase of the ventilatory cycle with high mean airway pressures. We hypothesized that use of APRV might produce potential beneficial effects on oxygenation, reducing mortality in patients with severe acute respiratory distress syndrome (ARDS) in comparison with synchronized intermittent mandatory ventilation (SIMV) as a conventional mode of ventilation. We retrospectively reviewed data of 58 patients with severe ARDS (the ratios of partial arterial oxygen tension to fraction of inspired oxygen, PaO2/F(I)O2 ratio <150). The patients' data were divided into two groups: SIMV-group and APRV-group. Patients' backgrounds, oxygenation on day 0, 1, 3, 5 and 7 following initiation of each mode, vasopressor dependence, duration of ventilation, duration of ICU stay, and mortality in ICU were analyzed. PaO2/F(I)O2 ratios were statistically higher in the APRV-group (APRV vs. SIMV on day 1, 3, 5, 7: 201.6 +/- 76 vs.150 +/- 59.1, 256.7 +/- 71.5 vs.182.1 +/- 65.4, 268.8 +/- 73.3 vs. 204.6 +/- 72.8, and 263 +/- 74.5 vs. 204.1 +/- 67.1, respectively, p<0.05). Vasopressors were less used (p=0.018), and mortality in ICU tended to be lower in the APRV group (31%) than in the SIMV group (59%) (p=0.050). Use of APRV in patients with severe ARDS appears to be associated with improvements in oxygenation, and a trend toward lower mortality in ICU. No significant adverse effects were observed. Prospective controlled studies are required to confirm the benefits of this ventilatory mode in comparison with conventional methods for severe ARDS.

Airway Scope for emergency intubations: usefulness of a new video-laryngoscope.

The Airway Scope (AWS-S100, Pentax, Tokyo, Japan) is a new video-laryngoscope, which has a specially designed blade and a portable, battery-powered, 2.4-inch built-in liquid crystal device (LCD) full-color video screen at the top of the handle. In this study, we tested the usefulness of the AWS for tracheal intubation in acute, urgent situations. Patients admitted to the Advanced Emergency and Critical Care Center at Hiroshima University Hospital and who required orotracheal intubations were prospectively enrolled. Tracheal intubations were performed using the AWS by residents (the novice group) or staff physicians (the experienced group), who received a brief instruction in the AWS. We enrolled 38 patients (23 males, 15 females; age, 60 +/- 19 years). Intubations were attempted by 22 intubators (11 residents and 11 experienced personnel). The durations from inserting the blade via the oral cavity until observing the glottis (T1), inserting the tube into the trachea (T2), and confirming the chest rise (T3) were 22 +/- 15, 34 +/- 21 and 49 +/- 27 sec, respectively. When the results were classified into t experienced and novice groups, T1, T2 and T3 were 17 +/- 10 vs. 26 +/- 17, 32 +/- 23 vs. 36 +/- 20, and 45 +/- 25 vs. 53 +/- 27 sec, respectively (the experienced vs. the novice group, n.s.). These results suggested that the AWS may be a suitable device particularly for less experienced personnel, such as novice Advanced Life Support providers.

Traumatic mesenteric bleeding managed solely with transcatheter embolization.

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated solely with transcatheter arterial embolization (TAE) of the right colic marginal artery. A 56-year-old woman presented with mesenteric bleeding after being involved in a car accident. Computed tomography (CT) showed a large mesenteric hematoma and hemoperitoneum with no associated major injuries to other organs. There was a pseudoaneurysm with extravasation inside the hematoma. TAE was attempted to control bleeding during the preparation for surgical laparotomy. A superior mesenteric angiogram revealed a right colic marginal artery pseudoaneurysm. After successful TAE with microcoils, the affected colon perfusion was preserved via collateral circulation from the ileocolic artery. No ischemic gastrointestinal complications have occurred, and laparotomy has not been necessary during the 6 months after TAE. In isolated mesenteric injury cases, TAE may be a reasonable alternative to emergency laparotomy.

Roles of a short connecting disulfide bond in the stability and function of psychrophilic Shewanella violacea cytochrome c (5).

Cys-59 and Cys-62, forming a disulfide bond in the four-residue loop of Shewanella violacea cytochrome c (5) (SV cytc (5)), contribute to protein stability but not to redox function. These Cys residues were substituted with Ala in SV cytc (5), and the structural and functional properties of the resulting C59A/C62A variant were determined and compared with those of the wild-type. The variant had similar features to those of the wild-type in absorption, circular dichroic, and paramagnetic (1)H NMR spectra. In addition, the redox potentials of the wild-type and variant were essentially the same, indicating that removal of the disulfide bond from SV cytc (5) does not affect the redox function generated in the vicinity of heme. However, calorimetric analysis of the wild-type and variant showed that the mutations caused a drastic decrease in the protein stability through enthalpy, but not entropy. Four residues are encompassed by the SV cytc (5) disulfide bond, which is the shortest one that has been proved to affect protein stability. The protein stability of SV cytc (5) can be controlled without changing the redox function, providing a new strategy for regulating the stability and function of cytochrome c.

Unicortical transverse osteochondral fracture of the patella: a case report.

Chondral lesions are relatively common and they usually occur as a result of high energy trauma. Chondral fractures of the patella ordinarily occur during an acute dislocation of the patella. Patellar chondral fractures without either a dislocation or a patella fracture are extremely rare. We have treated a 25-year-old male who had a unicortical transverse osteochondral fracture of the patella without a dislocation which was produced by high energy trauma. Chondral fractures of the patella are often overlooked because they are difficult to detect on plain radiographs. A persistent cartilaginous irregularity from either a chondral or osteochondral fracture may lead to the development of secondary osteoarthrosis. In this case, restoration of the articular surface was achieved by elevation of the compressed osteochondral fragment. This case demonstrates that understanding the mechanism of injury can be helpful in the treatment of osteochondral lesions.

The assessment of three methods to verify tracheal tube placement in the emergency setting.

We studied prospectively the reliability of clinical methods, end-tidal carbon dioxide (ETCO(2)) detection, and the esophageal detector device (EDD) for verifying tracheal intubation in 137 adult patients in the emergency department. Immediately after intubation, the tracheal tube position was tested by the EDD and ETCO(2) monitor, followed by auscultation of the chest. The views obtained at laryngoscopy were classified according to the Cormack grade. Of the 13 esophageal intubations that occurred, one false-positive result occurred in the EDD test and auscultation. In the non-cardiac arrest patients (n=56), auscultation, the ETCO(2), and EDD test correctly identified 89.3, 98.2*, and 94.6%* of tracheal intubations, respectively (*, P<0.05 vs. the cardiac arrest patients). In the cardiac arrest patients (n=81), auscultation, the ETCO(2), and the EDD tests correctly identified 92.6**, 67.9, and 75.3% of tracheal intubations, respectively (**, P<0.05 vs. EDD and ETCO(2)). The frequencies of Cormack grade 1 or 2 were 83.9% in the non-cardiac arrest, and 95.1% in the cardiac arrest patients. In conclusion, the ETCO(2) monitor is the most reliable method for verifying tracheal intubation in non-cardiac arrest patients. During cardiac arrest and cardiopulmonary resuscitation, however, negative results by the ETCO(2) or the EDD are not uncommon, and clinical methods are superior to the use of these devices.