Upper airway endoscopy at rest has been the diagnostic method of choice for diagnosing equine upper respiratory tract (URT) disease since its development in the 1970´s. The development of high-speed treadmill endoscopy (HSTE) improved the sensitivity of URT endoscopy by allowing the examiner to observe the horse’s nasopharynx and larynx during exercise. However, the level of exertion achieved during HSTE may not always represent that achieved during normal exercise as surface, rider, tack, and environmental variables are altered. Recently, the development of dynamic overground endoscopy (DOE) has addressed some of those shortcomings. A retrospective study was undertaken to describe the upper airway abnormalities detected during DOE in horses presenting with poor performance and/or abnormal respiratory noise in South Africa. Patient records of Thoroughbred racehorses undergoing DOE from November 2011 to August 2012 by the Onderstepoort Veterinary Academic Hospital were reviewed. Data collected included signalment, primary complaint, distance exercised, maximum speed attained, and dynamic airway abnormalities detected. XIII A second study was carried out to evaluate agreement within and among examiners of three grading systems for laryngeal function at exercise. The grading systems assessed were an existing system for grading axial deviation of aryepiglottic folds (ADAF), a modified system for grading recurrent laryngeal neuropathy (RLN) at exercise, and a proposed system for grading vocal cord collapse (VCC). For investigation of intra-observer variability, recordings were watched by two of the investigators at the same time, on two different occasions, in real time, slow motion, and at frame-by-frame speed. To evaluate inter-observer variability, recordings were watched by four investigators on one occasion, as described for investigation of intra-observer variability, and scoring sheets completed. Kappa agreement was calculated for both intra- and inter-observer sessions. Fifty-two horses that underwent DOE for investigation of poor performance and/or abnormal respiratory noise were identified. The main abnormalities detected included dorsal displacement of the soft palate (DDSP) (13/52 horses, 25%); recurrent laryngeal neuropathy (RLN) (17/52 horses, 33%); axial deviation of the aryepiglottic folds (ADAF) (21/52 horses, 40%) and vocal cord collapse (VCC) (18/52 horses, 35%). A total of 40 horses presented one or more abnormalities of the URT (77%). Fifteen horses (29%) had a single abnormality, and 25 horses (48%) had multiple abnormalities. Results at frame-by-frame speed from the intra-observer evaluations for all the conditions showed substantial agreement for RLN by both observers (K = 74 - 80). Intra-observer evaluations for VCC were moderate to substantial (K 53 – 63). ADAF was the most difficult URT abnormality to assess for both observers, and agreement within observers was only fair to moderate (K = 36 - 52). Inter-observer evaluations for RLN showed substantial to moderate agreement (K = 62). Inter-observer evaluations for VCC showed moderate agreement (K = 47 – 54), and inter-observer evaluations for ADAF showed only slight to fair agreement and were the lowest for all the conditions (K = 14 – 22). This study showed that DOE is a useful technique for providing valuable information about disease of the URT. Finding multiple abnormalities in 48% of horses examined using DOE suggests that DOE may be indicated even for those horses with an obvious abnormality found during resting endoscopy. The intra-observer evaluations showed that RLN had higher agreement values than those for ADAF and VCC at all speeds, and that ADAF had lower agreement values than those for VCC and RLN at all speeds. Inter-observer agreement was less than intra-observer agreement, presumably because more observers were involved in the inter-observer assessment. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Companion Animal Clinical Studies / unrestricted

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13325号 / 論医博第2193号 / 新制||医||1043(附属図書館) / (主査)教授 黒田 知宏, 教授 藤渕 航, 教授 別所 和久 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22306号 / 医博第4547号 / 新制||医||1040(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 妻木 範行, 教授 平井 豊博, 教授 川口 義弥 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22728号 / 医博第4646号 / 新制||医||1045(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 伊達 洋至, 教授 萩原 正敏, 教授 松田 道行 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Zusammenfassung der Habilitationsschrift von Dr. rer. nat. Julia Hentschel mit dem Titel: „Die Bedeutung der oberen Atemwege bei zystischer Fibrose – Pathomechanismen, Monitoring und Therapie“, Universität Leipzig Lange Jahre standen rezidivierende Infekte der Lunge und Gedeihstörung durch Maldigestion als lebensbegrenzende Symptome eines Patienten mit Mukoviszidose (Cystische Fibrose/CF) im Vordergrund. Das Hauptaugenmerk in der Diagnostik und Therapie von CF-Patienten lag daher zumeist auf den unteren Atemwegen bzw. dem Verdauungstrakt. Verbesserte Therapiemöglichkeiten und eine erhebliche Steigerung der Lebenserwartung brachten andere Symptome in den klinischen und wissenschaftlichen Fokus. Seit 2005 untersuchen wir systematisch die Rolle der oberen Atemwege bei Patienten mit CF, indem wir bei jeder Routinevorstellung Material der oberen Atemwege nicht-invasiv gewinnen, analysieren und asservieren. Wir konnten Methoden etablieren, um nasale Lavagen mit wenig Aufwand auch für große Studien einfach und schnell zu gewinnen und zu asservieren. Wir konnten zeigen, dass sich diese nasalen Lavagen eignen, um eine Besiedlung mit Pathogenen zu erfassen und die resultierende inflammatorische Wirtsantwort zu untersuchen. Wir konnten erstmals beweisen, dass die oberen Atemwege ein Keimreservoir darstellen und von dort aus Keime die Lunge (wieder) besiedeln können. Dies fand Eingang in aktuelle Leitlinien zur Mukoviszidosebetreuung und Lungentransplantation und hat Einfluss auf den Erfolg dieses ohnehin schon stark risikobehafteten Eingriffs. CF ist eine Erkrankung, bei der häufig eine überschießende Entzündungsreaktion beobachtet wird. Unsere Studien legten dabei den Schluss nahe, dass in den oberen Atemwegen andere Imbalancen eine Rolle spielen als in den unteren Atemwegen und sich daraus auch unterschiedliche therapeutische Ansätze ergeben könnten. Weiterhin konnten wir verdeutlichen, dass sich auch der Einfluss therapeutischer Interventionen in den Inflammationsmediatoren der oberen Atemwege widerspiegelt. Eine wichtige Erkenntnis daraus war, dass v.a. systemische Antibiosen deutlich langsamer und/oder schlechter in den Nasennebenhöhlen und den oberen Atemwegen wirken als auf die unteren und dass hier ein Umdenken in der antibiotischen Therapie der oberen Atemwege erfolgen muss. Unsere Studien beweisen einmal mehr das Kontinuum der Atemwege von der Nasenspitze über die paranasalen Sinus bis in die distalen Alveolen und dass ein gutes Therapiekonzept immer das große Ganze im Blick haben sollte. Schlussendlich stellt die CF hier ein Modellsystem dar. Viele unserer Erkenntnisse können auch Nicht-CF-Patienten mit Erkrankungen der oberen Atemwege zugutekommen.

Předkládaná Diplomová práce se zabývá analýzou a tvorbou modelů dýchacích cest předčasně narozených dětí. Nejprve je položen teoretický základ v oblasti vývoje dýchacího ústrojí a tvorby modelů dýchacích cest. Poté jsou představeny využité zobrazovací modality a popsány metody pro práci s obrazovými daty. Praktická část práce se zabývá vytvořením modelů dýchacích cest tří novorozenců. Všechny tyto modely jsou vytvořeny na základě klinických CT a MRI dat novorozenců narozených ve 30. týdnu gestačního věku. U těchto vytvořených modelů jsou dále analyzovány vybrané parametry související s anatomickou strukturou dýchacích cest. Na základě analýzy těchto parametrů byl následně navrhnut reprezentativní model, odpovídající dýchacím cestám novorozence daného gestačního věku.

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Airway hyperresponsiveness (AHR) is a hallmark of asthma where constriction of airway smooth muscle (ASM) causes excessive airway narrowing. Asthmatics, unlike healthy subjects, cannot prevent or reverse this narrowing by stretching their airways with a deep inspiration (DI). Since stretching of isolated ASM causes dramatic reductions in force generation and asthmatics tend to have stiffer airways, researchers hypothesize that reduced ASM stretching during breathing and DIs results in hyperreactive airways. However, counterintuitively, excised measurement on intact airways show narrowing is minimally reversed by pressure oscillations simulating breathing and DIs. We hypothesized that AHR does not result from reduced capacity to stretch the airways; furthermore, each constituent of the airway wall experiences different strain magnitude during breathing and DIs. To test this, we used an intact airway system which controls transmural pressure (Ptm) to simulate breathing while measuring luminal diameter in response to ASM agonists. An ultrasound system and automated segmentation algorithm were implemented to quantify and compare the ability of Ptm fluctuations to reverse and prevent narrowing in larger (diameter=5.72±0.52mm) relative to smaller airways (diameter=2.92±0.29mm). We found the ability of Ptm oscillations to reverse airway narrowing was proportional to strain imposed on the airway wall. Further, tidal-like breathing Ptm oscillations (5-15cmH2O) after constriction imposed 196% more strain in smaller compared to larger airways (14.6% vs. 5.58%), resulting in 76% greater reversal of narrowing (41.2% vs. 23.4%). However, Ptm oscillations applied before and during constriction resulted in the same steady-state diameter as when Ptm oscillations were applied only after constriction. To better understand these results, we optimized an ultrasound elastography technique utilizing finite element-based image registration to estimate spatial distributions of displacements, strains, and material properties throughout an airway wall during breathing and bronchoconstriction. This required we formulate and solve an inverse elasticity problem to reconstruct the distribution of nonlinear material properties. Strains and material properties were radially and longitudinally heterogeneous, and patterns and magnitudes changed significantly after induced narrowing. Taken together, these data show AHR likely does not emerge due to reduced straining of airways prior to challenge, but remodeling that stiffens airway walls might serve to sustain constriction during an asthmatic-like attack.

Bakgrund. Bilden av svensk ambulanssjukvård idag visar att vissa regioner ökat kraven på legitimerad kompetens i ambulanserna, samt att vissa också kräver specialistsjuksköterskeutbildning. I samband med den utvecklingen har även kraven på den medicinska nivån på omhändertagandet höjts. Sjuksköterskor i ambulans verkar ofta i miljöer som skiljer sig tydligt från sjukhusen. Detta kan medföra stressade situationer, påverka beslutsfattandet och det medicinska omhändertagandet. Kunskap inom luftvägshantering är en av de viktigaste kompetenserna för patientens fortsatta överlevnad. Att säkerställa fri luftväg kan vara en uppgift på tio sekunder till en livshotande faktor under hela uppdraget och därför viktig att bedöma och åtgärda. Syfte. Att beskriva specialistsjuksköterskors erfarenhet av prehospital luftvägshantering. Metod. En kvalitativ studiedesign med induktiv forskningsansats. Datainsamlingen genomfördes genom tio stycken semistrukturerade intervjuer med specialistsjuksköterskor som är verksamma i prehospital verksamhet i Mellersta Norrland. Dataanalysen genomfördes med en manifest kvalitativ innehållsanalys. Resultat. I analysen framkom två kategorier: Prehospitala erfarenheter för luftvägshantering och förutsättningar för trygghet i luftvägshantering prehospitalt samt åtta subkategorier. Dessa var erfarenhet har betydelse för luftvägshantering, erfarenhet av enkla luftvägshjälpmedel, erfarenhet av avancerade luftvägshjälpmedel, hantering av stress, vikten av kollegial kompetens vid luftvägshantering, utbildning och mängdträning skapar trygghet och bristande stöd vid upprätthållande av kompetens. Majoriteten ansåg att de enkla luftvägshjälpmedlen oftast skapar mest trygghet, men att erfarenhet och kollegors kompetens har stor betydelse för lyckat resultat samt ökad trygghet. Bristande stöd vid upprätthållande av luftvägskompetens visades och förslag för ökad trygghet och erfarenhet var att få öva luftvägshantering på anestesin. Slutsats. Erfarenhet ger ökad trygghet hos samtliga specialistsjuksköterskor oavsett typ av luftvägshjälpmedel. Dock visar resultatet att utbildning och upprätthållande av kompetens är av vikt för minskad stress.

Background In South Africa, hypertensive disorders of pregnancy are the leading cause of maternal mortality. More than 50% of anaesthesia-related deaths are attributed to complications of airway management. We compared the prevalence and risk factors for hypoxaemia (SpO2<90%) during induction of general anaesthesia in parturients with and without hypertensive disorders of pregnancy. We hypothesised that hypertensive disorders of pregnancy are associated with desaturation during tracheal intubation. Methods Data from 402 cases in a multicentre obstetric airway management registry were analysed. The prevalence of peri-induction hypoxaemia (SpO2<90%) was compared in patients with and without hypertensive disorders of pregnancy. Quantile regression of SpO2 nadir was performed to identify confounding variables associated with, and mediators of hypoxaemia.Results In the cohort of 402 cases, hypoxaemia occurred in 19% with and 9% without hypertension (estimated risk difference, 10%; 95% CI 2% to 17%; P=0.005). Quantile regression demonstrated a lower SpO2 nadir associated with hypertensive disorders of pregnancy as body mass index increased. Room-air oxygen saturation, Mallampati grade, and number of intubation attempts were associated with the relationship. Conclusions Clinically significant oxygen desaturation during airway management occurred twice as often in patients with hypertensive disorders of pregnancy, compounded by increasing body mass index. Intermediary factors in the pathway from hypertension to hypoxaemia were also identified.