Low-positive pressure ventilation improves non-hypoxaemic apnoea tolerance during ear, nose and throat pan-endoscopy: A randomised controlled trial.

BACKGROUND: It has been suggested that oxygenation using pressure support ventilation (PSV) before general anaesthesia can reduce the duration of non-hypoxaemic apnoea. OBJECTIVE: The objective was to determine whether or not pre-oxygenation with PSV increases the duration of non-hypoxaemic apnoea in non-obese patients during pan-endoscopy. DESIGN: A randomised, controlled trial. SETTING: Amiens University Hospital, France. PATIENTS: Fifty patients scheduled for ENT pan-endoscopy with a BMI lower than 35  kg  m(-2). INTERVENTION: Patients scheduled for pan-endoscopy were enrolled to receive either 100% oxygen at neutral pressure (the control group) or 100% oxygen with positive-pressure ventilation (a positive inspiratory pressure of 4  cmH2O and a positive end-expiratory pressure of 4  cmH2O; the PSV group) during spontaneous ventilation with a face mask. The goal of pre-oxygenation was to obtain an end-tidal oxygen concentration of more than 90% prior to induction of anaesthesia. MAIN OUTCOME MEASURES: The primary efficacy criterion was the duration of non-hypoxaemic apnoea (i.e. before the peripheral capillary oxygen saturation fell to 90%). Secondary outcomes were duration of pre-oxygenation, pre-oxygenation failure and tolerance. RESULTS: The mean (interquartile range) duration of non-hypoxaemic apnoea was longer in the PSV group [598 (447 to 717) s] than in the control group [310 (217 to 451) s] (P < 0.001). Oxygenation time was shorter in the PSV group [190 (159 to 225) s] than in the control group [245 (151 to 435) s] (P = 0.037). Pre-oxygenation was unsuccessful (i.e. end-tidal oxygen concentration was < 90%) in 20% of the patients in the control group but none in the PSV group. The intergroup difference in the duration of pan-endoscopy was not significant. Tolerance was good or very good in all patients. CONCLUSION: Our results show that pre-oxygenation with PSV is associated with a longer duration of non-hypoxaemic apnoea and a lower frequency of manual reventilation during ENT pan-endoscopy. CLINICALTRIALS. GOV REGISTRATION NUMBER: NCT02167334.

Ultrasound-guided percutaneous tracheostomy in critically ill obese patients.

INTRODUCTION: The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous tracheostomy (PCT) and the incidence of complications in critically ill, obese patients. METHODS: Fifty consecutive patients were included in a prospective study in two surgical and critical care medicine departments. Obesity was defined as a body mass index (BMI) of at least 30 kg/m². The feasibility of PCT and the incidence of complications were compared in obese patients (n = 26) and non-obese patients (n = 24). Results are expressed as the median (25th-75th percentile) or number (percentage). RESULTS: The median BMIs were 34 kg/m² (32-38) in the obese patient group and 25 kg/m² (24-28) in the non-obese group (p < 0.001). The median times for tracheostomy were 10 min (8-14) in non-obese patients and 9 min (5-10) in obese-patients (p = 0.1). The overall complication rate was similar in obese and non-obese patient groups (35% vs. 33%, p = 0.92). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding), with no differences between obese and non-obese groups. Bronchoscopic inspection revealed two cases of granuloma (8%) in obese patients. One non-obese patient developed a peristomal skin infection, which was treated with intravenous antibiotics. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths. CONCLUSIONS: This study demonstrated that US-guided PCT is feasible in obese patients with a low complication rate. Obesity may not constitute a contra-indication for US-guided PCT. A US examination provides information on cervical anatomy and hence modifies and guides choice of the PCT puncture site. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01502657.

[Management of the papillary microcarcinoma of the thyroid gland]. / Microcarcinomes papillaires de la thyroïde: quelle attitude thérapeutique?

OBJECTIVES: To study the management and treatment of papillary microcarcinoma of the thyroid. MATERIAL AND METHODS: Retrospective study of 57 patients operated on their thyroid gland between 1995 and 2004. All patients had a frozen section of the specimen. Procedure varied according to histology results and presence of adenopathy. RESULTS: Procedure planned initially was a total thyroidectomy in 75% of patients (the other 25% were planned as hemi-thyroidectomy). Frozen section was positive in 46% of patients. We proceeded with 16 selective neck dissections (levels 2-3-4) and 10 bilateral "level 6" . Microcarcinomas were unique in 77% of cases. Extra-capsular spreading was noted in 39% of cases. Adjuvant Iodine 131 was administered to 36 patients (63%). Follow-up included clinic visits, ultra-sound and Tg levels. With a follow-up of 3 to 12 years, no recurrence or metastasis has been identified. CONCLUSION: Treatment of papillary microcarcinomas of the thyroid is controversial. If surgery is chosen as treatment, the extent both regarding the thyroid itself and the cervical nodes is debated. Because of the excellent prognosis, some authors have recommended, when risk factors are absent, to limit the treatment to the thyroidectomy. Others, because of the risk of local recurrence and distal metastasis, have recommended a very aggressive approach.

Subjective voice assessment after thyroid surgery: a prospective study of 395 patients.

BACKGROUND: Total thyroidectomy has become a routine surgical procedure. However, postoperative complications are not rare and can lead to voice disorders. AIM: To study voice quality after total thyroidectomy. SETTINGS AND DESIGN: Prospective study over a period of 5 years in 395 surgical patients undergoing total thyroidectomy. MATERIALS AND METHODS: The voice quality of patients was based on systematic preoperative and postoperative laryngeal and voice examination. Voice assessment was performed by means of a voice quality questionnaire and recovery time within 12 months postoperatively. Patients who had inferior laryngeal nerve palsy were excluded from the study. RESULTS: Preoperative subjective voice disorders were found in 21% of patients and 49% had voice impairment after surgery. The recovery time was less than 1 month for one-half of the patients with impaired voices and 85% of the patients had recovered their voice after 5 months. At the 1-year postoperative examination, the permanent impaired voice rate was 1.26%. CONCLUSION: Voice impairment is common after thyroidectomy but usually transient and less than 20% persist at 6 months. Patients must be informed about the risk of voice impairment after thyroid surgery. An objective voice assessment is desirable to monitor the presence and progress of voice disorders.