Proton Based Stereotactic Radiotherapy for Skull Base Patients: Dosimetric Comparison to 4 Modern Radiation Treatment Modalities

PURPOSE/OBJECTIVE(S)

Re-irradiation with ablative doses to a smaller target volume and strict critical structure constraint is a challenge for modern radiation planning and delivery systems. Several advanced radiation treatment techniques can be used for fractionated stereotactic ablative radiosurgery (FSRS) in select patients with unresectable recurrent head and neck tumors. In this study, in order to better understand the dosimetry advantage of each technique, we compare the stereotactic treatment plans of our new small spot size Hitachi proton treatment unit to those of CyberKnife stereotactic radiosurgery (CK), Gamma Knife radiosurgery (GK), volumetric modulated arc therapy (VMAT), and MR Linac radiotherapy (MRL).

MATERIALS/METHODS

Ten FSRS skull base patients treated at our institution using VMAT (n = 5) or GK (n = 5) techniques. Intensity-modulated proton therapy (IMPT) plans were created in Raystation using Monte Carlo dose calculation algorithm. VMAT, CK, GK and MRL plans were generated in RayStation, Accuray Precision, Leksell Gamma Plan, and Monaco treatment planning systems, separately. Planning goals were to achieve the best target coverage of prescribed dose without compromising the critical organs at risk dose volume constraints of the clinical treatment plans. Plans were compared based on percent CTV coverage, Paddick conformity index (PCI), gradient index (GI, V50/V100), dose homogeneity index (HI, (D2-D98)/D50), low dose bath volume (LDBV, ratio of total volume irradiated between 20% and 50% prescription dose and the target volume), beam-on-time (BOT), and mean/maximum doses to brainstems.

RESULTS

The median target volume was 15.5 cm3 (range 1.0 - 36.23 cm3). The prescription was 45 Gy in 5 fractions for VMAT patients, and 21 - 27 Gy in 3 fractions for GK patients. The comparison of the treatment plans of these 5 delivery modalities was shown in table. All techniques achieved comparable CTV coverage. GI was superior for GK plans and outstanding in CK and IMPT plans. IMPT plans were also outstanding in regard to BOT and PCI. Significantly improved HI, LDBV and brainstem mean doses were achieved in IMPT plans. For adjacent brainstem and other OARs, maximum doses were comparable among all techniques.

CONCLUSION

In these five advanced radiation therapy modalities, proton therapy SBRT showed dosimetric advantage over other modalities to spare nearby OARs without sacrifice of target coverage. Further studies are needed to utilize this clinical benefit and investigate plan robustness.

The utilization of small amounts of residual endodontic material for dental identification

Dental information is one of the three scientific methods of identifying a deceased person. However, when an investigator is faced with dental ante-mortem information that indicates the deceased has had all his teeth extracted, it may be assumed that the dental information will not be useful, especially if no retained roots are visible in the post-mortem triage. The following case report highlights that careful examination including radiography, may reveal specific detailed information which was useful for identification to be established. Two small radiopaque objects were located in the apical area where the upper left canine root apex would have been. The radiopacities size, location, positioning to both each other and to the left maxillary sinus corresponded to ante-mortem radiographs. This case reveals an unusual use of extruded root canal material being of evidential value even though the tooth was extracted.

Wedgie Gold: Using metal detectors to recover PIT tags under areas used by wedge-tailed eagles and barn owls

A metal detector was used to recover passive integrated transponder (PIT) tags from below wedge-tailed eagle and barn owl nests and roost trees. The effectiveness of four different metal detectors to locate PIT tags and Australian Bird and Bat Banding Scheme (ABBBS) bands were compared. Twenty PIT tags from 14 golden bandicoots, five burrowing bettongs and one rufous hare-wallaby were recovered from wedge-tailed eagle sites. One unreadable PIT tag was recovered from a barn owl site. This technique has potential for use in determining the survivorship of translocated threatened species.

Abstract P1-09-18: A clinically validated DNA microarray for high-resolution HER2 testing defines a new genomic subtype in high-risk breast cancer with equivocal results by IHC and FISH

Background: In all stages of breast cancer, the HER2 status of a patient's tumor is critically important as both a prognostic indicator, and for predicting response to targeted anti-HER2 therapies. CAP/ASCO 2013 guidelines recommend that newly diagnosed, recurrent, and metastatic breast tumors be evaluated for HER2 positivity by protein-based immunohistochemistry (IHC) and/or chromosome-based fluorescence in situ hybridization (FISH). In the majority of cases, these testing modalities provide a clearly actionable “positive” or “negative” answer. However, in an estimated 10- to 20% of breast cancers, both tests are reported as “equivocal” leaving the clinician with a treatment decision dilemma and no definitive alternative testing method. Here we report validation of an IHC-targeted DNA microarray comparative genomic hybridization (array CGH) assay for HER2 equivocal breast cancer, and definition of a new genomic subtype of HER2 status in high-risk breast cancer with equivocal IHC and FISH results.

Methods: IHC-targeted HER2 receptor “hot spot” DNA samples extracted from 25 formalin fixed paraffin embedded (FFPE) breast tumor tissue samples previously characterized by IHC and FISH, were analyzed by array CGH. Eight tumors were known to be highly HER2 positive, seven tumors had IHC scores of 0 with negative FISH, and ten tumors had HER2 receptor staining by IHC (1-2+) and equivocal results by FISH (4-6 HER2 gene copies.) Tumor DNA (test) and human genomic DNA (reference) were fluorescently labeled, and competitively hybridized to a custom-designed genomic DNA microarray with high-density probe coverage of the HER2 amplicon on chromosome 17 (Agilent Technologies, Santa Clara CA). The array design includes over 4,600 chromosome 17 probes representing the p arm, q arm, telomeric and centromeric regions with 66 tiling probes over the HER2 (ERBB2) gene. Following hybridization, average HER2 gene copy number was calculated for each tumor sample by converting mean log2 signal intensity ratio value into genomic region copy number adjusted for % clonal fraction and experimentally established log2 ratio compression of the assay.

Results: 25/25 (100%) of samples yielded adequate DNA for analysis and all highly HER2 positive and HER2 negative results were confirmed by array CGH. In 10/10 IHC equivocal cases with HER2 gene copy number 4-6 by FISH, CGH results confirmed HER2-Low gene copy number.

Results for 25 Validation SamplesNumber of CasesIHC ScoreFISHCGH Copy NumberResult83+Positive> 6HER2-Positive101-2+Equivocal4-6HER2-Low70Negative< 6HER2-Negative

Conclusions: High-resolution HER2 testing by IHC-targeted DNA microarray analysis accurately classifies HER2 status in breast cancer and better defines the HER2-Low genomic subtype most often called “equivocal” by standard IHC and FISH testing. This subcategory is characterized at the protein level by IHC evidence of anti-HER2 therapy target receptor expression on the surface of the cells, and at the genomic level by HER2 gene copy number < 6. Results of the NSABP-B47 clinical trial and further studies with larger numbers of HER2-Low patients are needed to determine if these patients benefit from anti-HER2 therapy.

Citation Format: Gunn S, Yaziji H, Sims C, Govender S, Moore M, Cotter P, Jones S. A clinically validated DNA microarray for high-resolution HER2 testing defines a new genomic subtype in high-risk breast cancer with equivocal results by IHC and FISH [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-18.

A review of daycase GA services for Special Care patients at University Hospital, Bristol

This paper describes and discusses a review of adult special care dentistry day cases in a UK hospital over a two year period and makes recommendations for other such reviews and for practice. Dental public health competencies illustrated: oral health needs assessment and evaluation of dental health services.

Prolonged Fasting of Children before Anaesthesia is Common in Private Practice

Fasting guidelines for children are well established. Despite these guidelines, previous studies have shown children are often fasted for prolonged periods before anaesthesia, potentially causing discomfort and distress. Moreover, recent publications indicate shorter fasting times for oral clear fluids in children may be safe. We audited fasting times of children having elective surgery at a local large private hospital that provides care for both adults and children. We gave feedback and education to our caregivers, then repeated the audit. Data were collected from 307 children (age 6.0 ± 4.1 years) in an initial eight-week audit, and from 153 children (age 6.7 ± 4.5 years) in a follow-up four-week audit. We found fasting durations were excessive in many children. Sixty-two percent of children in each audit fasted longer than four hours for clear fluids. Children on morning lists fasted longer than children on afternoon lists. Fasting from solids was also excessively long. In the initial audit, 30% fasted more than 12 hours for solids, including 18 who last ate more than 16 hours before surgery. Data from the follow-up audit were similar. We conclude that fasting of children at our hospital is excessive, despite our efforts to shorten the duration. We suspect that our hospital is not the only one with a high incidence of prolonged fasting for children and suggest possible solutions.

Development and evaluation of a cabrito smoked sausage product

In order for the meat goat producer to survive, new avenues for marketing goats must be created. Currently, the live animal is sold directly to consumers, or to brokers who in turn sell the animal directly to consumers or retail stores that cater to various ethnic groups. The production of value-added products with appeal to North American consumers, as well as current ethnic consumers, should result in increased profitability of the meat goat. The objectives of this study were to develop a value added product, cabrito smoked sausage, using goat meat as the sole meat ingredient; evaluate soy protein concentrate (SPC) at various levels in an effort to reduce product cost; determine consumer acceptability; and conduct a cost analysis to determine the approximate market price for the product. Three fermented cabrito smoked sausage products were manufactured containing 0, 1.75 or 3.50% SPC and stored at 2±1°C until evaluated. The sausages were evaluated for sensory characteristics, proximate analysis, pH, water activity and smokehouse yields. Trained panelists detected no significant flavor differences (P > 0.05) between the products. As a result of these findings, sausages formulated with 0 and 3.50% SPC were compared in a consumer sensory evaluation. Consumer panelists detected no significant differences (P > 0.05) in flavor, texture and overall acceptance between the snack sticks. Approximately 65% of the panelists commented that they would purchase the value added products. Proximates, pH, water activity and smokehouse yields were similar (P > 0.05) for the sausages formulated with 0 and 3.50% SPC. The addition of SPC resulted in an 8.79% reduction in the price of the 3.50% SPC formulation when compared to the sausage formulated with no SPC.

Quantifying nonhomogeneous colors in agricultural materials. Part II: comparison of machine vision and sensory panel evaluations

The average colors of mangos and apples were measured using machine vision. A method to quantify the perception of nonhomogeneous colors by sensory panelists was developed. Three colors out of several reference colors and their perceived percentage of the total sample area were selected by untrained panelists. Differences between the average colors perceived by panelists and those from the machine vision were reported as DeltaE values (color difference error). Effects of nonhomogeneity of color, and using real samples or their images in the sensory panels on DeltaE were evaluated. In general, samples with more nonuniform colors had higher DeltaE values, suggesting that panelists had more difficulty in evaluating more nonhomogeneous colors. There was no significant difference in DeltaE values between the real fruits and their screen image, therefore images can be used to evaluate color instead of the real samples.

Cutaneous papillomatosis and carcinomatosis in the Western barred bandicoot (Perameles bougainville)

A progressive wart-like syndrome in both captive and wild populations of the Western barred bandicoot (WBB) is hindering conservation efforts to prevent the extinction of this endangered marsupial. In this study, 42 WBBs exhibiting the papillomatosis and carcinomatosis syndrome were examined. The disease was characterized by multicentric proliferative lesions involving cutaneous and mucosal surfaces, which were seen clinically to increase in size with time. Grossly and histologically the smaller skin lesions resembled papillomas, whereas the larger lesions were most commonly observed to be squamous cell carcinomas. Large amphophilic intranuclear inclusion bodies were observed in hyperplastic conjunctival lesions of 8 WBBs under light microscopy. Conjunctival lesions from 2 WBBs examined using transmission electron microscopy contained a crystalline array of spherical electron-dense particles of 45-nm diameter, within the nucleus of conjunctival epithelial cells, consistent with a papillomavirus or polyomavirus. Conjunctival samples from 3 bandicoots that contained intranuclear inclusion bodies also demonstrated a positive immunohistochemical reaction after indirect immunohistochemistry for papillomavirus structural antigens. Ultrastructural and/or immunohistochemical evidence of an etiologic agent was not identified in the nonconjunctival lesions examined. Here we describe the gross, histopathologic, ultrastructural, and immunohistochemical findings of a papillomatosis and carcinomatosis syndrome recently identified in the WBB.

High latent drug administration error rates associated with the introduction of the international colour coding syringe labelling system 1

BACKGROUND AND OBJECTIVES

The potential for increased drug administration errors during the transition to the International Colour Coding syringe labelling system has been highlighted. The purpose of this study was to assess the potential effects before their introduction into our department.

METHODS

Thirty-one anaesthetists, 19 with no previous practical experience of the new labelling system (Group 1), and 12 with previous experience (Group 2), volunteered to induce general anaesthesia for a standardized simulated patient in a designated theatre. They were presented with a scenario designed to suggest the need for a rapid sequence induction and provided with drug syringes labelled with the International Colour Coding system. All drug administrations were recorded. Active error was defined as the injection of the wrong drug. Latent error was defined as the selection of a syringe in error but stopping short of administering the drug.

RESULTS

In Group 1 a total of 107 drug injections were recorded of which 1 (0.9%) was an active error and 16 (15%) involved latent errors. Eleven anaesthetists (58%) performed at least one latent error. Group 2 had an error rate of 3%, a 6.9 (1.3-26.7) fold reduction in the rate of error (P = 0.023).

CONCLUSIONS

Although only one drug was given in active error, latent errors occurred in 15% of drug administrations. The only factor conferring protection against error was prior experience of the new labelling system. The period of transition to the International Colour Coding syringe labelling system represents a time of increased risk of drug administration error.

The frequency of and indications for general anaesthesia in children in Western Australia 2002-2003

We conducted a retrospective database search of the Hospital Morbidity Data System at the Health Department of Western Australia to determine the number of anaesthetics given to children aged 16 years or less in Western Australia over a twelve-month period. Information was also collected to assess the types of surgery for which anaesthesia was being provided, and the categories of hospital in which children were being anaesthetized. We found that 28,522 anaesthetics were given to 24,981 children, and 2,462 (9.9%) children had more than one anaesthetic. Five and a half percent of the children in Western Australia had an anaesthetic during the twelve months studied. The most common types of surgery were ear nose and throat (28% of anaesthetics), general (21%), dental/oral procedures (17%) and orthopaedic (15%). There was a bimodal distribution in the incidence of anaesthesia versus age, with peaks at 4 years and at 16 years. The most common category of hospital that children were anaesthetized in was private metropolitan (40%) followed by tertiary (38%), rural (14%) and public metropolitan (8%). One thousand, seven hundred and seven children aged less than one year were given an anaesthetic. These anaesthetics were most frequently given to children in tertiary hospitals (62%) followed by private metropolitan (30%), public metropolitan (6%) and rural hospitals (2%).

Histologic characteristics of laparoscopic saline-enhanced electrosurgery of liver and splenic injuries

BACKGROUND

Hemostasis is crucial during laparoscopic surgery. Unlike conventional electrosurgery, saline-enhanced electrosurgery (SEE) improves the electrode-to-tissue interface. This study investigated SEE as a means of achieving hemostasis in liver and splenic injuries and assessed the associated histologic changes.

METHODS

Nine anesthetized pigs underwent laparoscopic liver tip and splenic wedge amputations. Injuries were treated with SEE (25-35 and 35-45 W, respectively). Animals were sacrificed postprocedure and at 1 and 4 weeks. Depth of necrosis was analyzed using a mixed model analysis of variance.

RESULTS

Liver mean depth of necrosis was 5.3 mm (acute), 6.0 mm (1 week), and 5.3 mm (4 weeks) ( p = not significant). Splenic mean depth of necrosis was 7.0 mm (acute), 7.0 mm (1 week), and 2.7 mm (4 weeks). ( p < 0.01) Acute injuries demonstrated thermal coagulation necrosis that healed with well-defined bands of collagen at 1 and 4 weeks.

CONCLUSIONS

SEE provides effective hemostasis and results in an acceptable depth of necrosis with satisfactory wound healing in a porcine model of solid organ injury.

Preparing a new generation anaesthetic machine for patients susceptible to malignant hyperthermia

Anaesthetic machines are prepared for use with patients who are susceptible to malignant hyperpyrexia (MH) by flushing with oxygen at 10 l/min for ten minutes to reduce the anaesthetic concentration to 1 part per million (ppm) or less. Anaesthetic workstations are now often used in place of traditional machines. Workstations have greater internal complexity, and it is not known if they can be made safe for susceptible patients by flushing with oxygen. We used a high sensitivity infrared gas analyser to measure the washout of isoflurane from five Datex-Ohmeda workstations. Measurements were then repeated with a patient breathing circuit. Isoflurane washout occurred in an exponential manner. The time to reach a concentration of 1 ppm at the fresh gas outlet was 17 +/- 7 minutes, and all machines had reached less than 2 ppm by ten minutes. The washout of isoflurane from the machine and patient breathing circuit was much slower than from the machine alone, with a concentration less than 2 ppm reached only after 30 minutes. We conclude that the Datex-Ohmeda workstation can be prepared for use in MH susceptible patients by flushing with oxygen at 10 l/min for ten minutes. Flushing of the patient breathing system is not straightforward, and we recommend using a clean T-piece circuit. If the circle system and ventilator are required for anaesthesia, we suggest using new breathing hoses, rebreathing bag and soda lime cartridge, and ventilating an artificial lung for 30 minutes with a fresh gas flow rate of 10 l/min and tidal volume of 1 litre.

Role of tyrosine kinase activity in alpha-adrenergic inhibition of the beta-adrenergically regulated L-type Ca(2+) current in guinea-pig ventricular myocytes

1. The purpose of this study was to investigate the hypothesis that tyrosine kinase activity contributes to alpha(1)-adrenergic inhibition of beta-adrenergic responses in cardiac myocytes. We addressed this question by studying the pharmacological regulation of the L-type Ca(2+) current in acutely isolated adult guinea-pig ventricular myocytes using the whole-cell patch-clamp technique. 2. The selective alpha(1)-adrenergic receptor agonist methoxamine had no effect on the basal L-type Ca(2+) current. Methoxamine also had no effect on cAMP-dependent stimulation of the Ca(2+) current mediated by H(2) histamine receptor activation. However, methoxamine did inhibit cAMP-dependent stimulation of the Ca(2+) current mediated by beta-adrenergic receptor activation. The ability of methoxamine to inhibit beta-adrenergic regulation of the Ca(2+) current was significantly antagonized by the tyrosine kinase inhibitors genistein and lavendustin A. 3. The inhibitory effect of methoxamine was also mimicked by the phosphotyrosine phosphatase inhibitor pervanadate (PVN). PVN had no effect on basal Ca(2+) current or Ca(2+) current stimulated by histamine, but it did inhibit Ca(2+) current stimulated by beta-adrenergic receptor activation. Furthermore, the ability of PVN to inhibit beta-adrenergic stimulation of the Ca(2+) current was antagonized by lavendustin A. 4. These results are consistent with the conclusion that in guinea-pig ventricular myocytes alpha-adrenergic inhibition of beta-adrenergic responses involves a tyrosine kinase-dependent signalling pathway. The fact that methoxamine and PVN antagonized cAMP-dependent responses mediated by beta-adrenergic, but not H(2) histamine, receptor activation suggests that the inhibitory effect of alpha-adrenergic stimulation and tyrosine kinase activity is at the level of the beta-adrenergic receptor.

Skeletal muscle acidosis correlates with the severity of blood volume loss during shock and resuscitation

BACKGROUND

Continuous assessment of tissue perfusion and oxygen utilization may allow for early recognition and correction of hemorrhagic shock. We hypothesized that continuously monitoring skeletal muscle (SM) PO2, PCO2, and pH during shock would provide an easily accessible method for assessing the severity of blood loss and the efficacy of resuscitation.

METHODS

Thirteen anesthetized pigs (25-35 kg) underwent laparotomy and femoral vessel cannulation. Multiparameter fiberoptic sensors were placed in the deltoid (SM) and femoral artery. Ventilation was maintained at a PaCO2 of 40-45 mm Hg. Total blood volume (TBV) was measured using an Evans blue dye technique. Animals were bled for 15 minutes, maintained at a mean arterial pressure (MAP) of 40 mm Hg for 1 hour, resuscitated (shed blood + 2 times shed volume in normal saline) and observed for 1 hour. Four animals served as controls (sham hemorrhage). Blood and tissue samples were taken at each time point.

RESULTS

Blood loss ranged from 28.5-56% of TBV. SM pH and SM PO2 levels fell rapidly with shock. SM PO2 returned to normal with resuscitation; however, SM pH did not return to baseline. SM PCO2 significantly rose with shock, but returned to baseline promptly with resuscitation. There was a significant correlation between SM pH and blood volume loss at end shock (r2 = 0.73, p < 0.001) and recovery (r2 = 0.84, p < 0.001). Animals (n = 2) whose SM pH did not recover to 7.2 were found to have ongoing blood loss from biopsy sites and persistent tissue hypercarbia despite normal MAP.

CONCLUSION

Continuous multiparameter monitoring of SM provides a minimally invasive method for assessing severity of shock and efficacy of resuscitation. Both PCO2 and PO2 levels change rapidly with shock and resuscitation. SM pH is directly proportional to lost blood volume. Persistent SM acidosis (pH < 7.2) and elevated PCO2 levels suggest incomplete resuscitation despite normalized hemodynamics.

ACh-induced rebound stimulation of L-type Ca(2+) current in guinea-pig ventricular myocytes, mediated by Gbetagamma-dependent activation of adenylyl cyclase

1. The effects that muscarinic receptor stimulation have on the cAMP-dependent regulation of L-type Ca(2+) currents were studied in isolated guinea-pig ventricular myocytes using the whole-cell configuration of the patch-clamp technique. 2. The muscarinic agonist ACh inhibited the Ca(2+) current stimulated by the beta-adrenergic agonist isoprenaline (Iso), and washout of ACh revealed a stimulatory response that appeared as a transient rebound increase in the amplitude of the Ca(2+) current. The ACh-induced stimulatory effect was not observed in the absence of Iso. 3. ACh-induced rebound stimulation was also observed in the presence of H(2) histamine receptor activation and cholera toxin treatment, which like beta-adrenergic receptor activation enhance adenylyl cyclase (AC) activity in a stimulatory G protein (G(s))-dependent manner. ACh-induced rebound stimulation was not observed in the presence of forskolin, which enhances AC activity in a G(s)-independent manner. 4. Pertussis toxin (PTX) treatment blocked both the stimulatory and inhibitory effects of ACh. Intracellular dialysis with QEHA, a peptide that binds free G protein betagamma subunits, selectively antagonized the stimulatory effect, leaving an enhanced inhibitory effect. 5. Evidence for the expression of AC4, an isoform of AC that can be stimulated by Gbetagamma but only in the presence of Galpha(s), was obtained by Western blot analysis of guinea-pig ventricular myocyte membrane preparations. 6. These results suggest that muscarinic receptor stimulation facilitates as well as inhibits cAMP-dependent regulation of the Ca(2+) current and that the net response is a balance between these two actions. We suggest that the stimulatory effect is due to a direct activation of AC4 by the betagamma subunits of a PTX-sensitive G protein.

Electroosmotic properties of microfluidic channels composed of poly(dimethylsiloxane)

Microfluidic devices fabricated from polymers exhibit great potential in biological analyses. Poly(dimethylsiloxane) (PDMS) has shown promise as a substrate for rapid prototyping of devices. Despite this, disagreement exists in the literature as to the ability of PDMS to support electroosmotic (EO) flow and the stability of that flow over time. We demonstrate that in low ionic strength solutions near neutral in pH. oxidized PDMS had a four-fold greater EO mobility (mu(eo)) compared to native PDMS. The greater mu(eo) was maintained irrespective of whether glass or PDMS was used as a support forming one side of the channel. This enhanced mu(eo) was preserved as long as the channels were filled with an aqueous solution. Upon exposure of the channels to air, the mobility decreased by a factor of two with a half-life of 9 h. The EO properties of the air-exposed, oxidized PDMS were regenerated by exposure to strong base. High ionic strength, neutral in pH buffers compatible with living eukaryotic cells diminished the EO flow in the oxidized PDMS devices to a much greater extent than in the native PDMS devices. For analyses utilizing intact and living cells, oxidation of PDMS may not be an effective strategy to substantially increase the mu(eo).

Salbutamol prevents the increase of respiratory resistance caused by tracheal intubation during sevoflurane anesthesia in asthmatic children

Asthmatic children having their tracheas intubated with sevoflurane often have an increase in respiratory system resistance (Rrs). In this randomized, placebo-controlled, double-blinded study, we investigated the protective effect of an inhaled beta2-adrenergic agonist. Either salbutamol or placebo was administered 30 to 60 min before anesthesia to 30 mildly to moderately asthmatic children scheduled for elective surgery. Induction was performed with sevoflurane in a mixture of 50% nitrous oxide in oxygen and maintained at 3%, with children breathing spontaneously via a face mask and Jackson-Rees modification of the T-piece. Airway opening pressure and flow were measured before and after insertion of an oral endotracheal tube. Rrs and respiratory system compliance were calculated with multilinear regression analysis. The groups were comparable with respect to age, weight, asthma history, and breathing pattern. Intubation induced a different Rrs response in the two groups: children treated with salbutamol showed a 6.0% (-25.2% to +13.2%) decrease (mean, 95% confidence interval), whereas in the Placebo group there was a 17.7% (+4.4% to +30.9%) increase (P = 0.04). Neither asthma history nor the serum inflammation marker eosinophilic cationic protein was predictive for this response. We conclude that when using sevoflurane in mildly to moderately asthmatic children, a preanesthetic treatment with inhaled salbutamol is protective of an increase in Rrs.

IMPLICATIONS

Tracheal intubation with sevoflurane as the sole anesthetic is now often performed in children. It can induce an increase in respiratory system resistance in children with asthma. This study shows that in children with mild to moderate asthma, a preanesthetic treatment with inhaled salbutamol can prevent the increase of respiratory system resistance.