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Chen CM, Chen HS, Chen PJ, Hsu KJ. Maturation of the Female Pharyngeal Airway from Adolescence to Adulthood. J Clin Med 2024; 13:434. [PMID: 38256567 PMCID: PMC10816711 DOI: 10.3390/jcm13020434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The present study aimed to investigate developmental changes in the female pharyngeal airway from adolescence to adulthood, considering variations in the anatomical structures related to the airway dimensions. METHODS Lateral cephalograms of 214 females were analyzed and categorized into five developmental stages: early adolescence (10-13 years), middle adolescence (14-17 years), late adolescence (18-21 years), early adulthood (22-30 years), and middle adulthood (31-50 years). The focus of the analysis included the point A-Nasion-point B (ANB) angle, tongue pharyngeal airway space (TPS), epiglottis pharyngeal airway space (EPS), soft palate airway space (SPS), and the horizontal and vertical positions of the hyoid bone. RESULTS The ANB angle exhibited significant variation across groups, being significantly larger in the early-adolescence group (4.22°) compared to the middle-adolescence, late-adolescence, and early-adulthood groups. The TPS and EPS were significantly shorter in the early-adolescence group. Negative correlations were observed between the ANB angle and the lengths of the pharyngeal airway spaces (SPS, TPS, and EPS). The horizontal and vertical positions of the hyoid bone remained stable after middle adolescence. CONCLUSION The maturation of the ANB angle and pharyngeal airway in females seems nearly completed during middle adolescence (14-17 years). Additionally, a significant and negative correlation was identified between the ANB angle and the lengths of various pharyngeal airway spaces (SPS, TPS, and EPS). The horizontal and vertical positions of the hyoid bone showed stability after middle adolescence.
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Affiliation(s)
- Chun-Ming Chen
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (C.-M.C.); (H.-S.C.)
- Department of Oral and Maxillofacial Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807506, Taiwan
| | - Han-Sheng Chen
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (C.-M.C.); (H.-S.C.)
- Dental Department, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung 81253, Taiwan
| | - Pei-Jung Chen
- Dental Department, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung 81253, Taiwan
| | - Kun-Jung Hsu
- School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (C.-M.C.); (H.-S.C.)
- Department of Dentistry, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
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Ebenebe CU, Schriever K, Apostolidou S, Wolf M, Herrmann J, Singer D, Deindl P. Recommendations for endotracheal tube insertion depths in children. Emerg Med J 2023; 40:583-587. [PMID: 37336629 PMCID: PMC10423483 DOI: 10.1136/emermed-2022-212494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Endotracheal tube (ETT) malposition is frequent in paediatric intubation. The current recommendations for ETT insertion depths are based on formulae that hold various limitations. This study aimed to develop age-based, weight-based and height-based curve charts and tables for ETT insertion depth recommendations in children. METHODS In this retrospective single-centre study, we determined the individual optimal ETT insertion depths in paediatric patients by evaluating postintubation radiographic images. Age-based, weight-based and height-based ETT insertion depth recommendations were developed using regression analysis. We compared the insertion depths predicted by the models with previously published formulae. RESULTS Intubations of 167 children (0-17.9 years) were analysed. Best-fit curves generated with logistic regression analysis revealed R2 values between 0.784 and 0.880. The insertion depths predicted by the models corresponded well with published age-based and height-based formulae. However, they demonstrated the unsuitability of weight-related linear formulae to predict ETT depth in children. CONCLUSION The recommendations developed in this study facilitate a fast and accurate determination of recommended ETT insertion depths in children. Our recommendations provide greater accuracy than previously published formulae and demonstrate that weight-related linear formulae are unsuitable for predicting ETT depth in children.
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Affiliation(s)
| | - Kristina Schriever
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sofia Apostolidou
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Wolf
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Herrmann
- Department of Interventional and Diagnostic Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominique Singer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Deindl
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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3
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Kolewe EL, Padhye S, Woodward IR, Feng Y, Briddell JW, Fromen CA. A Pediatric Upper Airway Library to Evaluate Interpatient Variability of In Silico Aerosol Deposition. AAPS PharmSciTech 2023; 24:162. [PMID: 37523076 PMCID: PMC10660588 DOI: 10.1208/s12249-023-02619-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
The airway of pediatric patients' changes through development, presenting a challenge in developing pediatric-specific aerosol therapeutics. Our work aims to quantify geometric variations and aerosol deposition patterns during upper airway development in subjects between 3.5 months-6.9 years old using a library of 24 pediatric models and 4 adult models. Computational fluid-particle dynamics was performed with varying particle size (0.1-10 μm) and flow rate (10-120 Lpm), which was rigorously analyzed to compare anatomical metrics (epiglottis angle (θE), glottis to cricoid ring ratio (GC-ratio), and pediatric to adult trachea ratio (H-ratio)), inhaler metrics (particle diameter, [Formula: see text], and flow rate, Q), and clinical metrics (age, sex, height, and weight) against aerosol deposition. Multivariate non-linear regression indicated that all metrics were all significantly influential on resultant deposition, with varying influence of individual parameters. Additionally, principal component analysis was employed, indicating that [Formula: see text], Q, GC-ratio, θE, and sex accounted for 90% of variability between subject-specific deposition. Notably, age was not statistically significant among pediatric subjects but was influential in comparing adult subjects. Inhaler design metrics were hugely influential, thus supporting the critical need for pediatric-specific inhalable approaches. This work not only improves accuracy in prescribing inhalable therapeutics and informing pediatric aerosol optimization, but also provides a framework for future aerosol studies to continue to strive toward optimized and personalized pediatric medicine.
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Affiliation(s)
- Emily L Kolewe
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Saurav Padhye
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Ian R Woodward
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Yu Feng
- Department of Chemical Engineering, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Jenna W Briddell
- Division of Otorhinolaryngology, Department of Surgery, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Catherine A Fromen
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA.
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Schwake I, Sprinz M, Scaal M, Eifinger F. Anatomical investigations on the upper airway in premature and newborn babies. Clin Anat 2023; 36:42-49. [PMID: 36177789 DOI: 10.1002/ca.23955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Abstract
Safe intubation of newborns remains a challenge. This investigates the upper airway anatomy of (pre-)term infants was investigated to improve airway management and the development of airway devices. Angles and diameters of both oral and nasal intubation pathways of 22 cadavers of premature and term stillborn infants were measured, relative to their gestational age (GA) and tested for statistical significance. The systematic influence of sex on the distribution of values was examined. Cast models of the oral and nasal intubation pathway were (produced using a silicone dental impression material) 3D-scanned. No significant correlation with GA was seen in the angles studied. However, four distances around the hard and soft palate did show statistically significant positive correlations with GA. Regarding differences between the sexes, only the angle between the entrance of the trachea and the esophagus was greater for male cadavers. The angles of the ventilation pathway of (pre-)term infants do not depend systematically on GA. Anatomically, laryngeal masks might therefore also be well-suited ventilators for preterm infants. Alterations in the size but not the shape of laryngeal masks for small preterm infants is recommended. The data obtained may thus be used as a basis for the development of airway devices and airway simulators for medical education and clinical training.
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Affiliation(s)
- Ida Schwake
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maria Sprinz
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Scaal
- Department of Anatomy, Institute of Anatomy II, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Frank Eifinger
- Department of Pediatric Critical Care Medicine and Neonatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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5
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Yogo N, Mizutari S, Honda K, Asai H. Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation. BMJ Case Rep 2022; 15:e250399. [PMID: 35835483 PMCID: PMC9289016 DOI: 10.1136/bcr-2022-250399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.
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Affiliation(s)
- Naoki Yogo
- Department of Pediatrics, Division of Pediatric Emergency and Critical Care, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Sachiko Mizutari
- Otolaryngology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kei Honda
- Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Hidetoshi Asai
- Otolaryngology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
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Chuang YJ, Hwang SJ, Buhr KA, Miller CA, Avey GD, Story BH, Vorperian HK. Anatomic development of the upper airway during the first five years of life: A three-dimensional imaging study. PLoS One 2022; 17:e0264981. [PMID: 35275939 PMCID: PMC8916633 DOI: 10.1371/journal.pone.0264981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 02/21/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose Normative data on the growth and development of the upper airway across the sexes is needed for the diagnosis and treatment of congenital and acquired respiratory anomalies and to gain insight on developmental changes in speech acoustics and disorders with craniofacial anomalies. Methods The growth of the upper airway in children ages birth to 5 years, as compared to adults, was quantified using an imaging database with computed tomography studies from typically developing individuals. Methodological criteria for scan inclusion and airway measurements included: head position, histogram-based airway segmentation, anatomic landmark placement, and development of a semi-automatic centerline for data extraction. A comprehensive set of 2D and 3D supra- and sub-glottal measurements from the choanae to tracheal opening were obtained including: naso-oro-laryngo-pharynx subregion volume and length, each subregion’s superior and inferior cross-sectional-area, and antero-posterior and transverse/width distances. Results Growth of the upper airway during the first 5 years of life was more pronounced in the vertical and transverse/lateral dimensions than in the antero-posterior dimension. By age 5 years, females have larger pharyngeal measurement than males. Prepubertal sex-differences were identified in the subglottal region. Conclusions Our findings demonstrate the importance of studying the growth of the upper airway in 3D. As the lumen length increases, its shape changes, becoming increasingly elliptical during the first 5 years of life. This study also emphasizes the importance of methodological considerations for both image acquisition and data extraction, as well as the use of consistent anatomic structures in defining pharyngeal regions.
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Affiliation(s)
- Ying Ji Chuang
- Vocal Tract Development Lab, Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Seong Jae Hwang
- Department of Computer Science, University of Pittsburgh, Pittsburg, Pennsylvania, United States of America
| | - Kevin A. Buhr
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Courtney A. Miller
- Vocal Tract Development Lab, Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Gregory D. Avey
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Brad H. Story
- Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona, United States of America
| | - Houri K. Vorperian
- Vocal Tract Development Lab, Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
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Trachsel D, Erb TO, Hammer J, von Ungern‐Sternberg BS. Developmental respiratory physiology. Paediatr Anaesth 2022; 32:108-117. [PMID: 34877744 PMCID: PMC9135024 DOI: 10.1111/pan.14362] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 12/25/2022]
Abstract
Various developmental aspects of respiratory physiology put infants and young children at an increased risk of respiratory failure, which is associated with a higher rate of critical incidents during anesthesia. The immaturity of control of breathing in infants is reflected by prolonged central apneas and periodic breathing, and an increased risk of apneas after anesthesia. The physiology of the pediatric upper and lower airways is characterized by a higher flow resistance and airway collapsibility. The increased chest wall compliance and reduced gas exchange surface of the lungs reduce the pulmonary oxygen reserve vis-à-vis a higher metabolic oxygen demand, which causes more rapid oxygen desaturation when ventilation is compromised. This review describes the various developmental aspects of respiratory physiology and summarizes anesthetic implications.
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Affiliation(s)
- Daniel Trachsel
- Pediatric Intensive Care and PulmonologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Thomas O. Erb
- Department AnesthesiologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Jürg Hammer
- Pediatric Intensive Care and PulmonologyUniversity Children’s Hospital of Basel UKBBBaselSwitzerland
| | - Britta S. von Ungern‐Sternberg
- Department of Anaesthesia and Pain ManagementPerth Children’s HospitalPerthWAAustralia,Division of Emergency Medicine, Anaesthesia and Pain MedicineMedical SchoolThe University of Western AustraliaPerthWAAustralia,Perioperative Medicine TeamTelethon Kids InstitutePerthWAAustralia
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Mason EC, Wu Z, McGhee S, Markley J, Koenigs M, Onwuka A, Chiang T, Zhao K. Computational Fluid Dynamic Modeling Reveals Nonlinear Airway Stress during Trachea Development. J Pediatr 2021; 238:324-328.e1. [PMID: 34284034 PMCID: PMC8551055 DOI: 10.1016/j.jpeds.2021.07.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/21/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
Normative trachea dimensions and aerodynamic information during development was collected to establish clinical benchmarks and showed that airway development seems to outpace respiratory demands. Infants and toddlers' trachea exhibit higher aerodynamic stress that significantly decreases by teenage years. This implies large airway pathology in younger children may have a more substantial clinical impact.
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Affiliation(s)
- Eric C Mason
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Zhenxing Wu
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Sam McGhee
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Jennifer Markley
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Maria Koenigs
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Amanda Onwuka
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Tendy Chiang
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH; Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH; Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Kai Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.
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Green J, Ross PA, Newth CJ, Khemani RG. Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children. Pediatr Crit Care Med 2021; 22:e502-e512. [PMID: 33833205 PMCID: PMC8490268 DOI: 10.1097/pcc.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction. DESIGN Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children's Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation. SETTING Single center, tertiary, 391-bed children's hospital. PATIENTS From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50-9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67-11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36-8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46-8.34) remained independently associated with the diagnosis of new airway anomalies. CONCLUSIONS Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.
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Affiliation(s)
- Jack Green
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Patrick A. Ross
- Department of Anesthesiology Critical Care Medicine, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
| | - Christopher J.L. Newth
- Department of Anesthesiology Critical Care Medicine, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
| | - Robinder G. Khemani
- Department of Anesthesiology Critical Care Medicine, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Children’s Hospital Los Angeles, Los Angeles, California
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Wani TM, Simion C, Rehman S, John J, Guruswamy V, Bissonnette B, Tobias JD. Mainstem Bronchial Diameters and Dimensions in Infants and Children: A Systematic Review of the Literature. J Cardiothorac Vasc Anesth 2021; 35:3078-3084. [DOI: 10.1053/j.jvca.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
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Iwasaki T, Papageorgiou SN, Yamasaki Y, Ali Darendeliler M, Papadopoulou AK. Nasal ventilation and rapid maxillary expansion (RME): a randomized trial. Eur J Orthod 2021; 43:283-292. [PMID: 33564835 DOI: 10.1093/ejo/cjab001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess three rapid maxillary expansion (RME) appliances in nasal ventilation. TRIAL DESIGN Three-arm parallel randomized clinical trial. METHODS Sixty-six growing subjects (10-16 years old) needing RME as part of their orthodontic treatment were randomly allocated (1:1:1 ratio) to three groups of 22 patients receiving Hyrax (H), Hybrid-Hyrax (HH), or Keles keyless expander (K). The primary outcome of nasal ventilation (pressure and velocity) and secondary outcomes (skeletal, dental, soft tissue, and nasal obstruction changes) were blindly assessed on the initial (T0) and final (T1, 6 months at appliance removal) cone-beam computed tomography (CBCT) data by applying computational fluid dynamics (CFD) method. Differences across groups were assessed with crude and adjusted for baseline values and confounders (gender, age, skeletal maturation, expansion amount, mucosal/adenoid hypertrophy, nasal septum deviation) regression models with alpha = 5%. RESULTS Fifty-four patients were analysed (19H, 21HH, 14K). RME reduced both nasal pressure (H: -45.8%, HH: -75.5%, K: -63.2%) and velocity (H: -30%, HH: -58.5%, K: -35%) accompanied with nasal obstruction resolution (H: 26%, HH: 62%, K: 50%). Regressions accounting for baseline severity indicated HH expander performing better in terms of post-expansion maximum velocity (P = 0.03) and nasal obstruction resolution (P = 0.04), which was robust to confounders. Mucosal/adenoid hypertrophy and nasal septum deviation changes were variable, minimal, and similar across groups. The HH resulted in significantly greater increase in the nasal cross-sectional area (62.3%), anterior (14.6%), and posterior (10.5%) nasal widths. Nasal obstruction resolution was more probable among younger (P = 0.04), skeletally immature (P = 0.03), and male patients (P = 0.02) without pre-treatment mucosal hypertrophy (P = 0.04), while HH was associated with marginal greater probability for obstruction resolution. CONCLUSIONS RME resulted in improvement of nasal skeletal parameters and simulated ventilation with the former being in favour of the HH and the latter not showing significant differences among the three appliances. LIMITATION Attrition in the K group due to blocked activation rods possibly leading to limited sample to identify any existing group differences. HARMS Replacement of blocked Keles expanders for finalizing treatment. PROTOCOL The protocol was not published before the trial commencement. REGISTRATION Australian and New Zealand Clinical Trial Registry; ACTRN12617001136392.
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Affiliation(s)
- Tomonori Iwasaki
- Department of Pediatric Dentistry, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Spyridon N Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Youichi Yamasaki
- Field of Developmental Medicine, Health Research Course, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - M Ali Darendeliler
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney, Australia
- Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Australia
| | - Alexandra K Papadopoulou
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney, Australia
- Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Australia
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12
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Cheung GC, Dalci O, Mustac S, Papageorgiou SN, Hammond S, Darendeliler MA, Papadopoulou AK. The upper airway volume effects produced by Hyrax, Hybrid-Hyrax, and Keles keyless expanders: a single-centre randomized controlled trial. Eur J Orthod 2021; 43:254-264. [PMID: 32377675 DOI: 10.1093/ejo/cjaa031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess upper airway volume changes after rapid maxillary expansion (RME) with three different expanders. TRIAL DESIGN Three-arm parallel randomized clinical trial. METHODS Sixty-six patients, 10-16 years old, in permanent dentition, with maxillary transverse deficiency were recruited and assigned with block randomization (1:1:1 ratio) and allocation concealment to three groups of 22 patients each (Hyrax, Hybrid-Hyrax, and Keles keyless expander). The primary outcome (overall upper airway volume change) and secondary outcomes (volume changes in the nasal cavity, nasopharynx, oropharynx, and hypopharynx) were blindly assessed on the initial (T0) and final (T1, 6 months at appliance removal) cone beam computed tomography. Differences across groups were assessed with crude or adjusted for confounders (gender, age, growth stage, skeletal pattern, baseline airway volume, and amount of expansion) linear regression models. RESULTS Fifty-one patients were analysed (19, 19, and 13 in the Hyrax, Hybrid-Hyrax, and Keles groups). Maxillary expansion resulted in considerable increases in total airway volume in the Hybrid-Hyrax group (+5902.1 mm3) and less in the Hyrax group (+2537.9 mm3) or the Keles group (+3001.4 mm3). However, treatment-induced changes for the primary and all secondary outcomes were of small magnitude and no significant difference was seen among the three expanderes in the total airway volume in either crude or adjusted analyses (P > 0.05 in all instances). Finally, among pre-peak patients (CVM 1-3), the Hybrid-Hyrax expander was associated with significantly greater increases in total airway volume compared to the Hyrax expander (P = 0.02). CONCLUSIONS RME resulted in relatively small increases in total upper airway volume and its separate compartments, with mostly no statistically significant differences across the Hyrax, Hybrid-Hyrax, and Keles groups. LIMITATIONS Significantly greater attrition was found in the Keles group due to appliance failure. The current trial might possibly be under-powered to detect differences between groups, if such exist. HARMS Keles expanders blocked during activations and required substitution for completion of treatment. PROTOCOL The protocol was not published before trial commencement. REGISTRATION Australian and New Zealand Clinical Trial Registry (ACTRN12617001136392).
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Affiliation(s)
- Gordon C Cheung
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
| | - Oyku Dalci
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
| | - Simone Mustac
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
| | - Spyridon N Papageorgiou
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Shanya Hammond
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
| | - M Ali Darendeliler
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
| | - Alexandra K Papadopoulou
- Discipline of Orthodontics and Paediatric Dentistry, School of Dentistry, Faculty of Medicine and Health, The University of Sydney; Department of Orthodontics, Sydney Dental Hospital, Sydney Local Health District, Surry Hills, Australia
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13
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Propst EJ, Gorodensky JH, Wolter NE. Length of the Cricoid and Trachea in Children: Predicting Intubation Depth to Prevent Subglottic Stenosis. Laryngoscope 2021; 132 Suppl 2:S1-S10. [PMID: 33973659 DOI: 10.1002/lary.29616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Define the length of the subglottis and trachea in children to predict a safe intubation depth. METHODS Patients <18 years undergoing rigid bronchoscopy from 2013 to 2020 were included. The carina and inferior borders of the cricoid and true vocal folds were marked on a bronchoscope and distances were measured. Patient age, weight, height, and chest height were recorded. Four styles of cuffed pediatric endotracheal tubes (ETT) were measured and potential positions of each cuff and tip were calculated within each trachea using five depth of intubation scenarios. Multivariate linear regression was performed to identify predictors of subglottic and tracheal length. RESULTS Measurements were obtained from 210 children (141 male, 69 female), mean (SD) age 3.21 (3.66) years. Patient height was the best predictor of subglottic length (R2 : 0.418): Lengthsg (mm) = 0.058 * height (cm) + 2.8, and tracheal length (R2 : 0.733): Lengtht (mm) = 0.485 * height (cm) + 21.3. None of the depth of intubation scenarios maintained a cuff-free subglottis for all ETT styles investigated. A formula for depth of intubation: Lengthdi (mm) = 0.06 * height (cm) + 8.8 found that no ETT cuffs would be in the subglottis and all tips would be above the carina. CONCLUSION Current strategies for determining appropriate depth of intubation pose a high risk of subglottic ETT cuff placement. Placing the inferior border of the vocal cords 0.06 * height (cm) + 8.8 from the superior border of the inflated ETT cuff may prevent subglottic cuff placement and endobronchial intubation. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Evan Jon Propst
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonah Haskel Gorodensky
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Ernst Wolter
- Department of Otolaryngology - Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Abstract
PURPOSE OF REVIEW Children are at risk of severe hypoxemia in the perioperative period owing to their unique anatomy and physiology. Safe and effective airway management strategies are therefore key to the practice of pediatric anesthesia. The goal of this review is to highlight recent publications (2019-2021) aimed to advance pediatric airway safety and to highlight a proposed simple, pediatric-specific, universal framework to guide clinical practice. RECENT FINDINGS Recent investigations demonstrate that infants with normal and difficult airways experience high incidences of multiple laryngoscopy attempts and resulting hypoxemia. Video laryngoscopy may improve tracheal intubation first attempt success rate in infants with normal airways. In infants with difficult airways, standard blade video laryngoscopy is associated with higher first attempt success rates over non-standard blade video laryngoscopy. Recent studies in children with Pierre Robin sequence and mucopolysaccharidoses help guide airway equipment and technique selection. Department airway leads and hospital difficult airway services are necessary to disseminate knowledge, lead quality improvement initiatives, and promote evidence-based practice guidelines. SUMMARY Pediatric airway management morbidity is a common problem in pediatric anesthesia. Improvements in individual practitioner preparation and management strategies as well as systems-based policies are required. A simple, pediatric-specific, universal airway management framework can be adopted for safe pediatric anesthesia practice.
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Isa M, Holzki J, Hagemeier A, Rothschild MA, Coté CJ. Anatomical In Vitro Investigations of the Pediatric Larynx: A Call for Manufacturer Redesign of Tracheal Tube Cuff Location and Perhaps a Call to Reconsider the Use of Uncuffed Tracheal Tubes. Anesth Analg 2021; 133:894-902. [PMID: 33901057 DOI: 10.1213/ane.0000000000005565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Some in vivo studies question the traditional "funnel-shaped" infant larynx; further anatomic examinations were warranted. Examination of fixative free fresh autopsy laryngeal and upper tracheal specimens and multiple measurements was needed to determine consistency between current tracheal tube designs and anatomic observations. METHODS Larynges from 19 males and 11 females (Caucasian term newborn to 126 months) were examined by the same forensic pathologist. Measurements included anterior/posterior (A/P) and transverse (T) diameters of the cricoid outlet (CO), interarytenoid diameter (IAD), cricothyroid membrane (CTM), distance from the vocal cords (VC) to CO (VC-CO), and calibration of the larynx lumen with uncuffed tracheal tubes as measuring rods. Assessment of "safe tracheal tube placement" was assessed using manufacturer recommended cuffed Microcuff (Kimberly-Clark, Koblenz, Germany) tubes. RESULTS In 77% (95% confidence interval [CI], 58-90) of specimens, the proximal end of the cuff was within the CO and in 23% even with or close to the CO. The VC-CO varied from 9.1 to 13.17 mm in infants, 11.55 to 15.17 mm in toddlers, and 13.19 to 18.34 mm in children. The AP/T ratio of the CO was nearly 0.99 in most larynges; the IAD was greater than CO in all specimens. The CTM could be minimally distended in all specimens. CONCLUSIONS First, despite being marketed as a safer tracheal tube design, the proximal end of the Microcuff cuff rested within or close to the cricoid cartilage theoretically increasing potential cuff-induced injury when using the VC markings for positioning. Our data suggest that the optimal cuff free distance (VC-CO) would be ~13.5 mm for a Microcuff internal diameter (ID) size 3.0, ~15 mm for size 3.5, and ~16 to 19 mm for greater sizes.Second, the CO was virtually circular in all specimens, suggesting that appropriately sized uncuffed tubes should provide an adequate seal in most neonates and toddlers, thus avoiding the potential for cuff-related necrosis injury.Third, the IAD was always greater than CO confirming that the narrowest point of the infant larynx is the nondistensible cricoid cartilage and not the easily distended glottis.Fourth, appropriately sized Microcuff tubes with the cuff deflated completely filled the lumen of the CO and proximal trachea in all specimens. Our data suggest the need for all manufacturers to further evaluate tracheal tube cuff locations and lengths in relation to the VC safe insertion markings, particularly for neonates and toddlers.Fifth, the CTM is minimally distensible, thus having important implications for emergency surgical airway access with most currently available emergency airway devices.
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Affiliation(s)
- Malaak Isa
- From the Institute of Legal Medicine, Medical Faculty, University of Cologne, Germany
| | - Josef Holzki
- Department of Pediatrics, Centre Hospitaliere de Liège, Chenée, Belgium
| | - Anna Hagemeier
- Institute of Medical Statistics and Computational Biology, Medical Faculty, University of Cologne, Germany
| | - Markus A Rothschild
- From the Institute of Legal Medicine, Medical Faculty, University of Cologne, Germany
| | - Charles J Coté
- Department of Anesthesia, Mass General Hospital for Children at the Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Goetschi M, Kemper M, Kleine-Brueggeney M, Dave MH, Weiss M. Inflation volume-balloon diameter and inflation pressure-balloon diameter characteristics of commonly used bronchial blocker balloons for single-lung ventilation in children. Paediatr Anaesth 2021; 31:474-481. [PMID: 33406307 DOI: 10.1111/pan.14123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Balloon-tipped bronchial blocker catheters are widely used in pediatric thoracic anesthesia to establish single-lung ventilation. In clinical practice, their balloons demonstrate sudden expansion when inflated with air. In addition, there are concerns related to the high inflation pressures required to expand the balloons. METHODS This in vitro study assessed inflation volume- and inflation pressure-balloon diameter characteristics of the Fogarty arterial embolectomy catheters and Arndt endobronchial blockers. Balloon diameters were photographically assessed during unrestricted volume- and pressure-guided inflation, using air up to the maximum allowed inflation volume as indicated by the manufacturers. Inflation pressures required to open the blocker balloons and inflation pressures needed to expand them to maximum indicated diameter were measured. RESULTS Volume-guided inflation demonstrated a late acute rise in diameter in Fogarty blocker balloons, whereas in the Arndt endobronchial blocker balloons almost linear inflation volume-to-diameter characteristics were observed. Pressure-guided inflation on the other hand demonstrated low-volume, high-pressure characteristics in the Fogarty blocker balloons, with inflation pressures required to expand the balloons to maximum diameters ranging from (mean (SD)) 636 (75) to 947 (152) cmH2 O. The inflation pressures required to open the Fogarty blocker balloons were even >1000 cmH2 O. Inflation pressures required to expand the 5 F, 7 F, and 9 F Arndt endobronchial blocker balloons to maximum indicated diameter were much lower, namely at 218 (15), 252 (28), and 163 (8) cmH2 O. CONCLUSION Based on these study findings, the balloons of Fogarty arterial embolectomy catheters represent high-pressure devices and do not permit stepwise controlled bronchial blockage. The Arndt endobronchial blockers have some advantages over the Fogarty blocker devices, but also represent high-pressure equipment and must be used with caution and limited duration. Manufacturers are asked to design pediatric endobronchial blocker catheters with truly high-volume, low-pressure balloons in accordance to age-related pediatric airway dimensions.
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Affiliation(s)
- Markus Goetschi
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Michael Kemper
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland.,Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | | | - Mital H Dave
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
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17
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Di Cicco M, Kantar A, Masini B, Nuzzi G, Ragazzo V, Peroni D. Structural and functional development in airways throughout childhood: Children are not small adults. Pediatr Pulmonol 2021; 56:240-251. [PMID: 33179415 DOI: 10.1002/ppul.25169] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/30/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022]
Abstract
Children are not small adults and this fact is particularly true when we consider the respiratory tract. The anatomic peculiarities of the upper airway make infants preferential nasal breathers between 2 and 6 months of life. The pediatric larynx has a more complex shape than previously believed, with the narrowest point located anatomically at the subglottic level and functionally at the cricoid cartilage. Alveolarization of the distal airways starts conventionally at 36-37 weeks of gestation, but occurs mainly after birth, continuing until adolescence. The pediatric chest wall has unique features that are particularly pronounced in infants. Neonates, infants, and toddlers have a higher metabolic rate, and consequently, their oxygen consumption at rest is more than double that of adults. The main anatomical and functional differences between pediatric and adult airways contribute to the understanding of various respiratory symptoms and disease conditions in childhood. Knowing the peculiarities of pediatric airways is helpful in the prevention, management, and treatment of acute and chronic diseases of the respiratory tract. Developmental modifications in the structure of the respiratory tract, in addition to immunological and neurological maturation, should be taken into consideration during childhood.
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Affiliation(s)
- Maria Di Cicco
- Allergology Section, Paediatrics Unit, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ahmad Kantar
- Paediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, Gruppo Ospedaliero San Donato, Bergamo, Italy.,Nursing School, Vita-Salute San Raffaele University, Milan, Italy
| | - Beatrice Masini
- Allergology Section, Paediatrics Unit, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Nuzzi
- Allergology Section, Paediatrics Unit, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Vincenzo Ragazzo
- Paediatrics and Neonatology Division, Women's and Children's Health Department, Versilia Hospital, Lido di Camaiore, Italy
| | - Diego Peroni
- Allergology Section, Paediatrics Unit, Pisa University Hospital, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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18
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Padmanabhan S. Effect of functional appliances on the airway in Class II malocclusions. J World Fed Orthod 2020; 9:S27-S30. [PMID: 33023728 DOI: 10.1016/j.ejwf.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
The proximity of the orofacial structures to the upper airway has led to enormous interest in their influence on the airway maintenance mechanism. The recognition of Sleep disorders and the evolution of dental sleep medicine has fueled further interest in the role of orthodontic treatment on the airway particularly in Class II malocclusions. With abundant literature on class II malocclusions and growth modification, it is natural that focus would shift on the effect of functional appliances on the airway. Most studies on the subject show an improvement in the airway in response to functional appliances and these include both two dimensional and three dimensional study of the airway. This review showcases the most significant literature on this field of study against the background of the information that is needed to gauge its clinical relevance.
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Affiliation(s)
- Sridevi Padmanabhan
- Professor, Department of Orthodontics, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.
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19
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Thierry B, Luscan R. Use of Computed Tomography Scan in Pediatric Bronchial Measurements. J Cardiothorac Vasc Anesth 2020; 35:1553-1554. [PMID: 33082096 DOI: 10.1053/j.jvca.2020.09.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Briac Thierry
- Pediatric Otorhinolaryngology Department, APHP, Hôpital Universitaire Necker - Enfants Malades; Human Immunology, Pathophysiology and Immunotherapy, Division Stem Cell Biotechnologies, INSERM, UMR976, Université de Paris, Paris, France
| | - Romain Luscan
- Pediatric Otorhinolaryngology Department, APHP, Hôpital Universitaire Necker - Enfants Malades
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