A quantitative evaluation of aerosol generation during awake tracheal intubation

Aerosol-generating procedures are medical interventions considered high risk for transmission of airborne pathogens. Tracheal intubation of anaesthetised patients is not high risk for aerosol generation; however, patients often perform respiratory manoeuvres during awake tracheal intubation which may generate aerosol. To assess the risk, we undertook aerosol monitoring during a series of awake tracheal intubations and nasendoscopies in healthy participants. Sampling was undertaken within an ultraclean operating theatre. Procedures were performed and received by 12 anaesthetic trainees. The upper airway was topically anaesthetised with lidocaine and participants were not sedated. An optical particle sizer continuously sampled aerosol. Passage of the bronchoscope through the vocal cords generated similar peak median (IQR [range]) aerosol concentrations to coughing, 1020 (645-1245 [120-48,948]) vs. 1460 (390-2506 [40-12,280]) particles.l^-1 respectively, p = 0.266. Coughs evoked when lidocaine was sprayed on the vocal cords generated 91,700 (41,907-166,774 [390-557,817]) particles.l^-1 which was significantly greater than volitional coughs (p < 0.001). For 38 nasendoscopies in 12 participants, the aerosol concentrations were relatively low, 180 (120-525 [0-9552]) particles.l^-1 , however, five nasendoscopies generated peak aerosol concentrations greater than a volitional cough. Awake tracheal intubation and nasendoscopy can generate high concentrations of respiratory aerosol. Specific risks are associated with lidocaine spray of the larynx, instrumentation of the vocal cords, procedural coughing and deep breaths. Given the proximity of practitioners to patient-generated aerosol, airborne infection control precautions are appropriate when undertaking awake upper airway endoscopy (including awake tracheal intubation, nasendoscopy and bronchoscopy) if respirable pathogens cannot be confidently excluded.

Quantitative evaluation of aerosol generation from upper airway suctioning assessed during tracheal intubation and extubation sequences in anaesthetized patients

BACKGROUND

Open respiratory suctioning is defined as an aerosol generating procedure (AGP). Laryngopharyngeal suctioning, used to clear secretions during anaesthesia, is widely managed as an AGP. However, it is uncertain whether upper airway suctioning should be designated as an AGP due to the lack of both aerosol and epidemiological evidence.

AIM

To assess the relative risk of aerosol generation by upper airway suctioning during tracheal intubation and extubation in anaesthetized patients.

METHODS

This prospective environmental monitoring study was undertaken in an ultraclean operating theatre setting to assay aerosol concentrations during intubation and extubation sequences, including upper airway suctioning, for patients undergoing surgery (N=19). An optical particle sizer (particle size 0.3-10 μm) sampled aerosol 20 cm above the patient's mouth. Baseline recordings (background, tidal breathing and volitional coughs) were followed by intravenous induction of anaesthesia with neuromuscular blockade. Four periods of laryngopharyngeal suctioning were performed with a Yankauer sucker: pre-laryngoscopy, post-intubation, pre-extubation and post-extubation.

FINDINGS

Aerosol was reliably detected {median 65 [interquartile range (IQR) 39-259] particles/L} above background [median 4.8 (IQR 1-7) particles/L, P<0.0001] when sampling in close proximity to the patient's mouth during tidal breathing. Upper airway suctioning was associated with a much lower average aerosol concentration than breathing [median 6.0 (IQR 0-12) particles/L, P=0.0007], and was indistinguishable from background (P>0.99). Peak aerosol concentrations recorded during suctioning [median 45 (IQR 30-75) particles/L] were much lower than during volitional coughs [median 1520 (IQR 600-4363) particles/L, P<0.0001] and tidal breathing [median 540 (IQR 300-1826) particles/L, P<0.0001].

CONCLUSION

Upper airway suctioning during airway management was not associated with a higher aerosol concentration compared with background, and was associated with a much lower aerosol concentration compared with breathing and coughing. Upper airway suctioning should not be designated as a high-risk AGP.

Accurate Measurement of the Optical Properties of Single Aerosol Particles Using Cavity Ring-Down Spectroscopy

New approaches for the sensitive and accurate quantification of aerosol optical properties are needed to improve the current understanding of the unique physical chemistry of airborne particles and to explore their roles in fields as diverse as chemical manufacturing, healthcare, and atmospheric science. We have pioneered the use of cavity ring-down spectroscopy (CRDS), with concurrent angularly resolved elastic light scattering measurements, to interrogate the optical properties of single aerosol particles levitated in optical and electrodynamic traps. This approach enables the robust quantification of optical properties such as extinction cross sections for individual particles of known size. Our measurements can now distinguish the scattering and absorption contributions to the overall light extinction, from which the real and imaginary components of the complex refractive indices can be retrieved and linked to chemical composition. In this Feature Article, we show that this innovative measurement platform enables accurate and precise optical measurements for spherical and nonspherical particles, whether nonabsorbing or absorbing at the CRDS probe wavelength. We discuss the current limitations of our approach and the key challenges in physical and atmospheric chemistry that can now be addressed by CRDS measurements for single aerosol particles levitated in controlled environments.

A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.

Analysis of body condition indices reveals different ecotypes of the Antillean manatee

Assessing the body condition of wild animals is necessary to monitor the health of the population and is critical to defining a framework for conservation actions. Body condition indices (BCIs) are a non-invasive and relatively simple means to assess the health of individual animals, useful for addressing a wide variety of ecological, behavioral, and management questions. The Antillean manatee (Trichechus manatus manatus) is an endangered subspecies of the West Indian manatee, facing a wide variety of threats from mostly human-related origins. Our objective was to define specific BCIs for the subspecies that, coupled with additional health, genetic and demographic information, can be valuable to guide management decisions. Biometric measurements of 380 wild Antillean manatees captured in seven different locations within their range of distribution were obtained. From this information, we developed three BCIs (BCI₁ = UG/SL, BCI₂ = W/SL³, BCI₃ = W/(SL*UG²)). Linear models and two-way ANCOVA tests showed significant differences of the BCIs among sexes and locations. Although our three BCIs are suitable for Antillean manatees, BCI₁ is more practical as it does not require information about weight, which can be a metric logistically difficult to collect under particular circumstances. BCI₁ was significantly different among environments, revealing that the phenotypic plasticity of the subspecies have originated at least two ecotypes-coastal marine and riverine-of Antillean manatees.

High time resolution measurements of droplet evaporation kinetics and particle crystallisation

A refined technique for observing the complete evaporation behaviour of free-falling droplets, from droplet generation to complete solvent evaporation, with ultra-high time resolution is introduced and benchmarked. High-resolution phase-delay stroboscopic imaging is employed to simultaneously resolve the evolving droplet morphology, geometric and aerodynamic diameters, throughout the evaporative lifetime with a user-controlled < μs timescale. This allows rapid, complex morphological changes, such as crystallisation events, to be clearly observed and the corresponding mechanisms to be inferred. The dried particles are sampled for offline SEM analysis and the observed morphologies compared to the inflight imaging. Density changes can be calculated directly from the deviation between the geometric and aerodynamic diameters. The full capabilities of the new technique are demonstrated by examination of the different evaporation behaviours and crystallisation mechanisms for aqueous sodium chloride droplets evaporating under different ambient relative humidity (RH) conditions. The crystallisation window, defined as the time taken from initial to complete crystallisation, is shown to be RH dependent, extending from 0.03 s at 20% RH and 0.13 s at 40% RH. The different crystallisation mechanisms observed during the experiments are also clearly reflected in the final structure of the dry particles, with multi-crystal structures produced at low RH compared to single-crystal structures at higher RH. It is anticipated that this technique will unlock measurements which explore the evaporation behaviour and crystallisation mechanisms for rapid, complex droplet drying events, and with increasingly non-ideal solutions, relevant to industrial applications.

A quantitative evaluation of aerosol generation during tracheal intubation and extubation

The potential aerosolised transmission of severe acute respiratory syndrome coronavirus‐2 is of global concern. Airborne precaution personal protective equipment and preventative measures are universally mandated for medical procedures deemed to be aerosol generating. The implementation of these measures is having a huge impact on healthcare provision. There is currently a lack of quantitative evidence on the number and size of airborne particles produced during aerosol‐generating procedures to inform risk assessments. To address this evidence gap, we conducted real‐time, high‐resolution environmental monitoring in ultraclean ventilation operating theatres during tracheal intubation and extubation sequences. Continuous sampling with an optical particle sizer allowed characterisation of aerosol generation within the zone between the patient and anaesthetist. Aerosol monitoring showed a very low background particle count (0.4 particles.l⁻¹) allowing resolution of transient increases in airborne particles associated with airway management. As a positive reference control, we quantitated the aerosol produced in the same setting by a volitional cough (average concentration, 732 (418) particles.l⁻¹, n = 38). Tracheal intubation including facemask ventilation produced very low quantities of aerosolised particles (average concentration, 1.4 (1.4) particles.l⁻¹, n = 14, p < 0.0001 vs. cough). Tracheal extubation, particularly when the patient coughed, produced a detectable aerosol (21 (18) l⁻¹, n = 10) which was 15‐fold greater than intubation (p = 0.0004) but 35‐fold less than a volitional cough (p < 0.0001). The study does not support the designation of elective tracheal intubation as an aerosol‐generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high‐risk aerosol‐generating procedure. These novel findings from real‐time aerosol detection in a routine healthcare setting provide a quantitative methodology for risk assessment that can be extended to other airway management techniques and clinical settings. They also indicate the need for reappraisal of what constitutes an aerosol‐generating procedure and the associated precautions for routine anaesthetic airway management.

Distinguishing bone and soft tissue infections mimicking sarcomas requires multimodal multidisciplinary team assessment

INTRODUCTION

The aims of this study were to report the presenting characteristics and identify how best to distinguish bone and soft-tissue infections that mimic sarcomas.

MATERIALS AND METHODS

A total of 238 (211 osteomyelitis and 27 soft-tissue infections) patients referred to a tertiary sarcoma multidisciplinary team with suspected sarcoma who were ultimately diagnosed with a bone or soft tissue infection were included. Data from a prospectively collated database was analysed retrospectively.

RESULTS

Of all possible bone and soft-tissue sarcoma referrals, a diagnosis of infection was made in 2.1% and 0.7%, respectively. Median age was 18 years in the osteomyelitis group and 46 years in the soft-tissue infection group. In the osteomyelitis group, the most common presenting features were pain (85.8%) and swelling (32.7%). In the soft-tissue infection group, the most common clinical features were swelling (96.3%) and pain (70.4%). Those in the soft-tissue group were more likely to have raised inflammatory markers. Radiological investigations were unable to discern between tumour or infection in 59.7% of osteomyelitis and 81.5% of soft-tissue infection cases. No organism was identified in 64.9% of those who had a percutaneous biopsy culture.

CONCLUSIONS

This study has highlighted that infection is frequently clinically indistinguishable from sarcoma and remains a principle non-neoplastic differential diagnosis. When patients are investigated for suspected sarcoma, infections can be missed due to falsely negative radiological investigations and percutaneous biopsy. As no single clinical, biochemical or radiological feature or investigation can be relied upon for diagnosis, clinicians should have a low threshold for tissue biopsy and discussion in a sarcoma multidisciplinary team meeting.

Studies of competing evaporation rates of multiple volatile components from a single binary-component aerosol droplet

The simultaneous evaporation and condensation of multiple volatile components from multicomponent aerosol droplets leads to changes in droplet size, composition and temperature. Measurements and models that capture and predict these dynamic aerosol processes are key to understanding aerosol microphysics in a broad range of contexts. We report measurements of the evaporation kinetics of droplets (initially ∼25 μm radius) formed from mixtures of ethanol and water levitated within a electrodynamic balance over timescales spanning 500 ms to 6 s. Measurements of evaporation into a gas phase of varied relative humidity and temperature are shown to compare well with predictions from a numerical model. We show that water condensation from the gas phase can occur concurrently with ethanol evaporation from aqueous-ethanol droplets. Indeed, water can condense so rapidly during the evaporation of a pure ethanol droplet in a humid environment, driven by the evaporative cooling the droplet experiences, that the droplet becomes pure water within 0.4 s.

Temperature effects on the blood oxygen affinity in sharks

In fish, regional endothermy (i.e., the capacity to significantly elevate tissue temperatures above ambient via vascular heat exchangers) in the red swimming muscles (RM) has evolved only in a few marine groups (e.g., sharks: Lamnidae, Alopiidae, and teleosts Scombridae). Within these taxa, several species have also been shown to share similar physiological adaptations to enhance oxygen delivery to the working tissues. Although the hemoglobin (Hb) of most fish has a decreased affinity for oxygen with an increase in temperature, some regionally endothermic teleosts (e.g., tunas) have evolved Hbs that have a very low or even an increased affinity for oxygen with an increase in temperature. For sharks, however, blood oxygen affinities remain largely unknown. We examined the effects of temperature on the blood oxygen affinity in two pelagic species (the regionally endothermic shortfin mako shark and the ectothermic blue shark) at 15, 20, and 25 °C, and two coastal ectothermic species (the leopard shark and brown smooth-hound shark) at 10, 15, and 20 °C. Relative to the effects of temperature on the blood oxygen affinity of ectothermic sharks (e.g., blue shark), shortfin mako shark blood was less affected by an increase in temperature, a scenario similar to that documented in some of the tunas. In the shortfin mako shark, this may act to prevent premature oxygen dissociation from Hb as the blood is warmed during its passage through vascular heat exchangers. Even though the shortfin mako shark and blue shark occupy a similar niche, the effects of temperature on blood oxygen affinity in the latter more closely resembled that of the blood in the two coastal shark species examined in this study. The only exception was a small, reverse temperature effect (an increase in blood oxygen affinity with temperature) observed during the warming of the leopard shark blood under simulated arterial conditions, a finding that is likely related to the estuarine ecology of this species. Taken together, we found species-specific differences in how temperature affects blood oxygen affinity in sharks, with some similarities between the regionally endothermic sharks and several regionally endothermic teleost fishes.

A randomised, controlled study to quantify the benefits of community pharmacist interventions on the prescribing of cardiovascular drugs in general practice

Focal points

Longitudinal optical trapping and sizing of aerosol droplets

We present evidence that aerosol droplets, approximately 1-2microm in diameter, can be optically bound over a 4mm distance within a volume formed by the overlap of the central cores and rings of two counterpropagating Bessel beams. The sizes of the individual polydisperse aerosol particles can be estimated from the angular variation of the elastic light scattering. Scattered light from the two orthogonally polarized trapping beams and from a Gaussian probe beam of different wavelength can be used to provide independent estimations of size. The coalescence of two droplets was observed and characterized.

Optical properties of micrometer size water droplets studied by cavity ringdown spectroscopy

Optical extinction by homogeneous, pure water droplets of 30 to 70 microm diameter produced by a vibrating orifice aerosol generator has been studied by pulsed cavity ringdown (CRD) spectroscopy at lambda=560 nm under ambient conditions. Experimental sensitivity of better than 1% achieved in measurements of CRD times enabled detection of changes in laser light losses per pass due to changes in the number and size of particles within the laser beam volume. By systematically changing the droplet size in the cavity while recording the CRD time, a periodic modulation in the value of the loss per pass was observed. The modulation is caused by the oscillatory nature of the extinction efficiency, which was subsequently inferred and compared with the results of theoretical calculations based on Mie theory.

Optical guiding of aerosol droplets

We characterize the ability of Gaussian and Bessel beams to guide water, ethanol and dodecane aerosol droplets. Droplets produced from a nebuliser source are trapped using radiation pressure and then by varying the beam power are controllably guided in a vertical direction. The use of a zeroth-order Bessel beam, which has a non-diffracting thin core, is shown to improve guiding distances over a comparable Gaussian beam by more than three times with guiding distances of up to 2.75mm for dodecane droplets. We discuss the applications for this work in the context of tools for optically manipulating airborne particles.

Combinations of paclitaxel and etoposide in the treatment of lung cancer

Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and etoposide are two chemotherapy agents with broad cytotoxic activity but different mechanisms of action and resistance. Previous in vitro studies of their combined cytotoxicity have yielded conflicting results. We evaluated the effects of drug scheduling in cell growth inhibition in lung and breast human cancer cell lines. A clonogenic assay with either simultaneous or sequential 24-hour incubation of paclitaxel and etoposide was used to assess growth inhibition, and the combination index was used to evaluate drug interactions. In these studies, including the A549 human lung cancer cell line, mild antagonism (combination index, > 1) was observed with concurrent exposure of paclitaxel and etoposide, but synergism (combination index, < 1) was observed when the drugs were incubated sequentially. In view of the wide range of antitumor activity of both paclitaxel and etoposide, and the potential importance and clinical impact of optimizing drug doses and schedules, we recently completed a phase I study with the following objectives: (1) to determine the maximum tolerated dose of paclitaxel given intravenously on day 10 after 10 days of oral etoposide and (2) to investigate the toxicity profile of this combination of agents. Three consecutive cohorts consisting of a total of 29 patients with various measurable or assessable tumors were treated with paclitaxel by intravenous infusion over 3 hours after receiving 10 days of etoposide 50 mg orally twice daily. Conclusions for this clinical study were that the combination was feasible and tolerable and had demonstrated antitumor activity in a group of mostly pretreated patients. The recommended doses for phase II studies were etoposide 50 mg twice daily for 10 days followed by paclitaxel 150 mg/m2 intravenously over 3 hours. A phase II study in patients with extensive small cell lung cancer, with appropriate translational studies, has been initiated.

Variations in general practice prescribing costs and implications for budget setting

Indicative prescribing amounts, and the equivalent prescribing element of funds in the case of fund-holding practices, are now an established part of UK general practice. This paper examines the implications of variations in GP prescribing behaviour for the determination of prescribing budgets. Using regression analysis, the extent to which variations in total practice prescribing costs can be explained by factors suggested for inclusion in a weighted capitation formula is established. The results indicate that 97% of the variation in practice prescribing costs can be explained by differences in practice list size, the proportion of patients aged 65 years and over, the proportion of patients living in 'deprived areas' and whether or not the practice qualifies for 'inducement payments'. The implications of the results for budget setting are discussed. A resource allocation formula based on regression analysis of expenditures can be used to promote horizontal equity in terms of equal budgets for equal need. However, its implications for vertical equity and efficiency are more ambiguous.