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Introduction New training devices have been introduced to help in inhaler counseling by addressing the inspiratory flow through the metered-dose inhaler (MDI), which is the most important problem of the MDI inhalation technique. This study aims to compare the effects of MDI traditional verbal counseling and advanced counseling using training devices with a smartphone application in pediatric asthmatic patients. Methods A total of 201 pediatric asthmatic subjects (8–18 years) were divided into two groups: a verbal counseling group, who received only MDI verbal counseling training (n = 101), and an advanced counseling group who received counseling using a training device (Flo-Tone with Trainhaler smartphone application) in addition to the traditional MDI verbal counseling (n = 100). Every patient in the two groups attended three counseling visits, 1 month apart. At each visit, pulmonary functions [peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV1) as % of predicted] were measured. Also, patients were asked to perform their normal inhalation technique using their MDI, and mistakes were detected and recorded by the investigator. Then, patients were trained on the correct steps of the MDI inhalation technique using either verbal counseling or advanced counseling depending on their study group. In the advanced group, the Flo-Tone was connected to the mouthpiece of the MDI to blow a whistle while the patient inhaled from the MDI. That whistle was detected by the Trainhaler smartphone application and the duration of inhalation determined by the application was recorded. Results Both groups showed a gradual significant decrease (p

Background Intrapulmonary percussive ventilation (IPV) facilitates the mobilization and clearance of bronchial secretions. Cricothyroidotomy using a Mini-Trach II device is a minimally invasive method used for secretion clearance. To our knowledge, there are no previous reports regarding IPV combined with Mini-Trach II. Case presentation An 82-year-old man underwent controlled mechanical ventilation and IPV via an endotracheal tube to treat atelectasis following emergency surgical repair of a traumatic diaphragm laceration. He underwent cricothyroidotomy using Mini-Trach II for ensuring airway management after extubation. On resumption, IPV through a mouthpiece or face mask was unsuccessful owing to air leakage from his mouth. However, IPV via the already inserted Mini-Trach II could deliver the percussion flow and led to a marked improvement in his condition. Conclusion This experience indicates that Mini-Trach II is beneficial as a minimally invasive interface for IPV that can deliver percussion flow efficiently.

Several case studies and anecdotal reports have shown assorted motor and quality of life benefits from use of a dental mouthpiece among people with Parkinson disease (PD). A larger exploratory study is necessary to assess potential efficacy and feasibility of this treatment strategy. If shown to be effective and feasible in a larger sample of people with PD, mechanistic studies may be warranted to examine a potential relationship between orofacial sensory input and motor function in people with PD.This study was registered on clinicaltrials.gov (NCT: 04082663). Twenty people with PD, Hoehn and Yahr stages I-III, participated in this study. Each participant completed various baseline motor and quality of life assessments before being fitted with a custom mouthpiece. Motor assessments were completed a second time after 25 min of mouthpiece wear. Participants were asked to wear the mouthpiece for 1 month before completing follow-up quality of life assessments and providing feedback about the mouthpiece. Wilcoxon signed-rank tests were used to compare results across conditions.Gait velocity and cadence showed significant (These results do not provide adequate evidence to pursue further this type of mouthpiece as a treatment strategy for motor signs and symptoms or quality of life in people with PD.

Our aim was to synthesize the published literature on factors that potentially affect the delivery of bronchodilators using valved holding chambers (VHC) in preschool children. We also aimed to identify those attributes that are not yet incorporated or clearly stated in the guidelines and those topics that are still lacking sufficient data. There is strong evidence supporting several recommendations in current guidelines. Based on present knowledge, bronchodilators should be delivered by VHC administering each puff separately. Face mask should be omitted as soon as the child can hold the mouthpiece of the VHC tightly between the lips and teeth. Based on the review, we suggest adding a specific note to current guidelines about the effect of chamber volume and the impact of co-operation during drug administration. Calming the child and securing a tight face-to-mask seal is critical for successful drug delivery. There is not enough evidence to make specific recommendations on the most reliable VHC and face mask for children. There is an urgent need for studies that evaluate and compare the effectiveness of VHCs in various clinical settings in wide age-groups and respiratory patterns. In addition, there is insufficient data on ideal chamber volume, material, and effective antistatic treatment. What is Known:• Valved holding chambers (VHC) should not be considered interchangeable when used with pressurized metered dose inhalers (pMDI).• Drug delivery is influenced by VHC volume, aerodynamic and electrostatic properties; mask fit; respiratory pattern and co-operation during inhalation; and the number of puffs actuated.What is New:• The impact of co-operation, VHC volume, and good mask-to-face fit during drug inhalation is not stressed enough in the guidelines.• Studies are urgently needed to evaluate the effectiveness of different VHCs in various clinical settings focusing on VHC electrostatic properties, respiratory patters, face masks, and ideal pMDI+VHC combinations.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy has been broadly used. However, no consensus has been achieved on the practical implementation of HFNC and how to provide aerosol delivery during HFNC therapy in adult patients. METHODS: An online anonymous questionnaire survey endorsed by 4 academic societies from America, Europe, mainland China, and Taiwan was administered from May to December 2019. Clinicians who had worked in adult ICUs for > 1 year and had used HFNC to treat patients within 30 days were included. RESULTS: A total of 2,279 participants clicked on the survey link, 1,358 respondents completed the HFNC section of the questionnaire, whereas 1,014 completed the whole survey. Postextubation hypoxemia and moderate hypoxemia were major indications for HFNC. The initial flow was mainly set at 40–50 L/min. Aerosol delivery via HFNC was used by 24% of the participants (248/1,014), 30% (74/248) of whom reported reducing flow during aerosol delivery. For the patients who required aerosol treatment during HFNC therapy, 40% of the participants (403/1,014) reported placing a nebulizer with a mask or mouthpiece while pursuing HFNC (a method shown to reduce inhaled dose), whereas 33% (331/1,014) discontinued HFNC to use conventional aerosol devices. A vibrating mesh nebulizer was the most commonly used nebulizer (40%) and was mainly placed at the inlet of the humidifier. CONCLUSIONS: The clinical utilization of HFNC was variable, as were indications, flow settings, and criteria for adjustment. Many practices associated with concomitant aerosol therapy were not consistent with available evidence for optimal use. More efforts are warranted to close the knowledge gap.

Le document qui suit est la traduction intégrale du compte rendu établi à l’occasion du 252eatelier international ENMC consacré, du 6 ou 8 mars 2020, au « Développement de recommandations pour l’utilisation de la ventilation par embout buccal dans les maladies neuromusculaires », et publié très récemment dans la revueNeuromuscular Disorders(M. Chatwin, M. Gonçalves, J. Gonzalez-Bermejo, M. Toussaint, et al. 252ndENMC international workshop: Developing best practice guidelines for management of mouthpiece ventilation in neuromuscular disorders. March 6thto 8th2020, Amsterdam, the Netherlands.Neuromuscular Disorders2020 ; 30 : 772–81.https://doi.org/10.1016/j.nmd.2020.07.008).

Background Fluid Resistant Surgical Masks have been implemented in UK personal protective equipment (PPE) guidelines for COVID-19 for all care sites that do not include aerosol-generating procedures (AGPs). FFP3 masks are used in AGP areas. Concerns from the ENT and plastic surgery communities out with intensive care units have questioned this policy. Emerging evidence on cough clouds and health care worker deaths has suggested that a review is required. Aims To test the efficacy of Fluid Resistant Surgical Mask with and without adaptions for respiratory protection. To test the efficacy of FFP and FFP3 regarding fit testing and usage. Methods A smoke chamber test of 5 min to model an 8-h working shift of exposure while wearing UK guideline PPE using an inspiratory breathing mouthpiece under the mask. Photographic data were used for comparison. Results The Fluid Resistant Surgical Mask gave no protection to inhaled smoke particles. Modifications with tape and three mask layers gave slight benefit but were not considered practical. FFP3 gave complete protection to inhaled smoke but strap tension needs to be ‘just right’ to prevent facial trauma. Facial barrier creams are an infection risk. Conclusions Surgical masks give no protection to respirable particles. Emerging evidence on cough clouds and health care worker deaths suggests the implementation of a precautionary policy of FFP3 for all locations exposed to symptomatic or diagnosed COVID-19 patients. PPE fit testing and usage policy need to improve to include daily buddy checks for FFP3 users

Highlights • Pre workshop international survey on MPV • Best practice guidline on the provision of MPV in NMD's by reviewing and recommend the most appropriate monitoring, mode, settings and equipment required for MPV. • Best practice algorithm on MPV for daytime ventilatory support (see Figure 1 ).Figure 1Figure 1 shows the best practice algorithm for the initiation of mouthpiece ventilation (MPV) in the long-term setting. For each stage of the algorithm there is a description to assist in the provision of this service.Figure 1 • Future studies in MPV.

Background: Thelarynx is an inevitable mouthpiece of the human body which has to execute very associated assignment like protection, respiration, and phonation. To fulfill this mission, the larynx should be accommodated, integrated, and sensible. The vocal cord is the concern of larynx, which served all-purpose. If any occurrence due to iatrogenic, idiopathic, or any other causes shut down the vocal cord mobility, the patient is facing miserable complexity in their life. Methods: It is a cohort retrospective study of 67 cases in the department of otolaryngology and Head-Neck Surgery, Bangladesh, from 01 July 2016 to 31 June 2019. Results: Incidence among outpatient was 0.06%, inpatient was 0.37%, and total laryngeal disorder, and thyroid operation was 6.51%. Of them unilateral was 64(95.52%) in which both right and left were equal 32(50%) bilateral were 3(2.99%), male were 28(41.79%), and females were 39(58.21%). Amidst them 00-18 years were 2(2.99%), 19-40 years were 21(31.34), 41-60 years 36(53.73%) and above 60 years 8(11.94%), smokers were 34(50.74%), betel leaf chewer 26(38.81%), diabetic were 27(40.30%), hypertensive were 19(28.36%), iatrogenic were 33(49.25%), idiopathic 20(29.85%) and others 14(20.90%), 61(91.05%) treated conservatively, 5(7.46%) surgical, and 1(1.49%) denied the repeated surgery.

Metachronous cancer rate in the pharynx is high before and after the treatment of esophageal cancer. Endoscopic observation is difficult in the pharynx especially in the postcricoid area. Pharyngeal cancer in the postcricoid area has been often found in advanced stage. Valsalva maneuver has been reported to improve the visibility. From May 2017 we introduced a dedicated mouthpiece to conduct Valsalva maneuver. One hundred consecutive patients who had been observed throughout the pharynx by one endoscopist were enrolled. A total of 200 image files before and after introduction were made and reviewed by three endoscopists. We retrospectively evaluated the utility and safety of Valsalva maneuver. The visibility before introduction was Good in three cases, Moderate in 12 cases and Poor in 85 cases. Meanwhile, the visibility after introduction was Good in 58 cases, Moderate in 23 cases, and Poor in 19 cases (P

Purpose: To investigate how the materials of mouthpieces used for proton therapy of head and neck cancer affect the dose distribution in surrounding normal tissue by focusing on the CT values of the materials.Methods: Six dental materials were used to measure CT values: temporary relining resin, tissue conditioner, vinyl polysiloxane, thermoplastic ethylene vinyl acetate copolymer splint, silicone rubber impression material, and a composite impression material. Among these materials, three of the dental materials were investigated further: one material with the CT value closest to water, and the materials with the highest and lowest CT values. Based on these results, we investigated the effect of the CT value of the mouthpiece on the dose distribution in 17 cases in which a mouthpiece was used during proton therapy for head and neck cancers, the treatment plans were recalculated by changing the CT values of the mouthpiece to that of the three identified dental materials. For each cancer case, the irradiation dose to normal tissue was calculated for the treatment plans. The evaluation indices were set to the mandible max dose (GyE), the mandible mean dose (GyE), the volume of the mandible irradiated above 60 GyE (mandible V-60GyE), the parotid affected side mean dose (GyE), the parotid unaffected side mean dose (GyE), and the oral mean dose (GyE). The Wilcoxon’s rank sum test was used to analyze the significance of the differences between treatment plans.Results: The temporary relining resin with the CT value closest to water was 36.9 HU, the vinyl polysiloxane with the highest CT value was 985 HU, and the thermoplastic ethylene vinyl acetate copolymer splint with the lowest CT value was -89.7 HU. The maximum absolute difference among the treatment plans per case was 4.18 GyE for the oral mean dose. The radiation dose for the evaluation indices did not differ significantly among the treatment plans. Conclusion: In the range of CT values from -89.7 HU to 985.0 HU covered in this study, the effect of the CT value of the mouthpiece on the dose distribution may be considered to have no clinical impact.

Ice hockey has one of the highest concussion rates among youth sports. Sensor technology has been implemented in contact and collision sports to inform the frequency and severity of head impacts experienced on-ice. However, existing studies have utilized helmet-mounted sensors with limited accuracy. The objective of this study was to characterize head kinematics of contact events in a sample of youth boys' hockey players using a validated instrumented mouthpiece with improved accuracy. Head kinematics from 892 video-verified events were recorded from 18 athletes across 127 sessions. Median peak resultant linear acceleration, rotational velocity, and rotational acceleration of video-verified events were 7.4 g, 7.7 rad/s, and 576 rad/s2, respectively. Contact events occurred at a higher rate in games (2.48 per game) than practices (1.30 per practice). Scenarios involving head contact had higher peak kinematics than those without head contact. This study improves our understanding of head kinematics in boys' youth hockey.

Background New training devices were introduced to help in the inhaler counseling by addressing the inspiratory flow through the metered-dose inhaler (MDI), which is the most important problem of the MDI inhalation technique. This study aimed to compare the effects of MDI traditional verbal counseling and advanced counseling using training devices with a smartphone application in pediatric asthmatic patients. Methods A total of 201 pediatric asthmatic subjects (8-18 years) were divided into 2 groups: a verbal counseling group, who received only MDI verbal counseling training (n=101), and an advanced counseling group who received counseling using a training device (Flo-Tone with Trainhaler smartphone application) in addition to the traditional MDI verbal counseling (n=100). Every patient in the 2 groups attended three counseling visits, one month apart. At each visit pulmonary functions [peak expiratory flow (PEF), forced expiratory volume in one second (FEV1 ) as % of predicted] were measured. Also, patients were asked to perform their normal inhalation technique using their MDI, and mistakes were detected and recorded by the investigator, then patients were trained on the correct steps of the MDI inhalation technique using either verbal counseling or advanced counseling depending on their study group. In the advanced group, the Flo-Tone was connected to the mouthpiece of the MDI to blow a whistle while the patient inhaling from MDI. That whistle was detected by the Trainhaler smartphone application and the duration of inhalation determined by the application was recorded. Results Both groups showed a gradual significant decrease (p Conclusion The addition of training devices and smartphone applications to traditional verbal counseling of MDI inhalation technique in asthmatic children resulted in significant improvements in lung functions, and duration of inhalation, and progressive decreases in the average number of MDI inhalation techniques errors compared to the verbal counseling group.

A great amount of research looks at whether information about lung mechanics can be obtained using spirometry, as these mechanics give clinically useful information about lung condition and disease progression. This study uses a time-varying elastance, single compartment lung model to calculate lung mechanics of 15 tidally breathing healthy subjects. A plethysmograph with a built-in shutter was used to induce an exponentially decaying airflow. Lung elastance and respiratory system resistance were separated from the decay rate of flow caused by the shutter. Occlusion resistance was calculated at shutter closure. To simulate upper airway obstruction, progressively larger resistances were added to the plethysmograph mouthpiece. Decay rates measured ranged from 5-42, with large intra-subject variation associated with muscular breathing effort. Measured lung elastance ranged from 3.9-21.2 cmH2O/L and often remained constant as resistance was increased. Resistance calculated from the decay rate was very small, ranging from 0.15-1.95 cmH2Os/L. The low resistance is due to the airflow measured originating from low resistance areas in the centre of airways. Occlusion resistance measurements were as expected for healthy subjects, and followed the expected resistance trend as resistance was increased.

While many research efforts have focused on head impact exposure in professional soccer, there have been few studies characterizing exposure at the youth level. The aim of this study is to evaluate a new instrumentation approach and collect some of the first head impact exposure data for youth female soccer players. Athletes were instrumented with custom-fit mouthpieces that measure head impacts. Detailed video analysis was conducted to identify characteristics describing impact source (e.g., kick, header, throw). A total of 763 verified head impacts were collected over 23 practices and 8 games from 7 athletes. The median peak linear accelerations, rotational velocities, and rotational accelerations of all impacts were 9.4 g, 4.1 rad/s, and 689 rad/s2, respectively. Pairwise comparisons resulted in statistically significant differences in kinematics by impact source. Headers following a kicked ball had the highest accelerations and velocity when compared to headers from thrown or another header.

The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.

BACKGROUND Children suffering from bronchial diseases need assistance from nurses in the use of inhalation devices. PURPOSE We aimed to assess nurses' skills and knowledge concerning drug administration with inhalation devices in hospitalized pediatric patients. METHODS An expert panel defined medication errors in drug administration with inhalation devices in children. We monitored 241 inhalation procedures to investigate nurses' inhalation technique skills. Twenty-nine nurses completed a questionnaire to assess nurses' knowledge. RESULTS Skills: In 93 of 241 (39%) inhalation procedures, the mask/mouthpiece did not fit airtight. In none of the 11 inhalations administering a glucocorticoid, the patient's mouth was thoroughly cleaned afterward. Knowledge: Ten of 29 nurses (34%) thought a distance between mask and the patient's face was acceptable. Only 16 of 29 (55%) knew that it is necessary to thoroughly clean the patient's mouth after the inhalation of budesonide. CONCLUSIONS We found that education on inhalation procedures including practical training is required to increase patient safety.

Asthma is one of the most common respiratory diseases in the world. It is caused by the swelling of the airways that result in the narrowness of the lung. Self-record and monitor of lung condition are essential for asthmatic patients to well control the disease. One way to monitor asthma condition is by using a spirometer. In this project, a digital spirometer with a mobile application that can help asthmatic patients to self-monitor and keep track of their lung condition has been developed. The device can be divided into three parts: hardware, mobile application and database. The hardware consists of NodeMCU, a pressure sensor and a mouthpiece. The analog signal from the sensor was converted to digital by the NodeMCU and sent wirelessly using wifi to smartphone and stored in a database. The lung function parameters calculated are displayed using mobile application. One normal subject aged 24 has been recruited to perform three categories of severity test using the mobile application. The categories are normal, moderate and severe, and the result showed the severity correctly according to the category compared to the theory.

Objectives: Measurement of electronic cigarette (ECIG) puff topography provides an under- standing of how product characteristics and user behavior affect nicotine delivery. However, mouthpiece-based topography devices may affect natural puffing behavior. This study was designed to compare ECIG topography measured by mouthpiece-based eTop computerized de- vice and mouthpiece-free video recordings. Methods: ECIG-naïve cigarette smokers (N = 18) and ECIG-experienced users (N = 25) puffed on a standardized ECIG via eTop or conventionally; both sessions were videotaped. Following overnight abstinence, participants experienced one directed (10 puffs, 30 sec IPI) and 2 ad libitum puffing bouts. Heart rate and subjective response were measured throughout sessions. Results: No statistically significant differences between methods were observed for topography, heart rate, or abstinence-related subjective effects, and both methods were accurate and reliable. Use of a mouthpiece was perceived to alter aspects of ECIG puffing (eg, "reduce enjoyment). Conclusions: The mouthpiece-based eTop measures ECIG topography precisely as when no mouthpiece is used, and interferes minimally with subjective ECIG experience. Reliable and valid ECIG topography measurement methods are an important regulatory tool, as they can be used to understand the interplay between product design and user behavior to predict toxicant exposure.

IntroductionLung function tests are fundamental diagnostic and monitoring tools for patients with respiratory symptoms. There is significant uncertainty around whether potentially infectious aerosol is produced during different lung function testing modalities; and limited data on possible mitigation strategies to reduce risk to staff and limit fallow time.MethodsHealthy volunteers were recruited in an ultraclean, laminar flow theatre and had standardised spirometry as per ERS/ATS guidance, as well as peak flow measurement and FENO assessment of airway inflammation. Aerosol emission was sampled minimum once each second using both an Aerodynamic Particle Sizer (APS) and Optical Particle Sizer (OPS), and compared to breathing, speaking and coughing. Mitigation strategies such as a peak flow viral filter and a CPET facemask (to mitigate induced coughing) were tested.Results33 healthy volunteers were recruited. Aerosol emission was highest in cough (1.61 particles/cm3/sample), followed by unfiltered peak flow (0.76 particles/cm3/sample). Filtered spirometry produced lower peak aerosol emission (0.11 particles/ cm3/sample) than that of a voluntary cough, and addition of a viral filter to the mouthpiece reduced peak flow aerosol emission to similar levels. The filter made little difference to recorded FEV peak flow values. Peak aerosol FENO measurement produced negligible aerosol. Reusable CPET masks with filter reduced aerosol emission when breathing, speaking, and coughing significantly.ConclusionsCompared to voluntary coughing, all lung function testing produced fewer aerosol particles. Filtered spirometry produces lower peak aerosol emission than peak voluntary coughing, and should not be deemed an aerosol generating procedure. The use of viral filters reduces aerosol emission in peak flow by > 10 times, and has little impact on recorded peak flow values. CPET masks are a useful option to reduce aerosol emission from induced coughing while performing spirometry.

Purpose The use of noninvasive ventilation (NIV) is on the rise as an alternative to tracheostomy for individuals with neuromuscular disorders with life-prolonging and quality-of-life benefits. This pilot study was designed to determine if mouthpiece NIV (M-NIV) alters speech in individuals with muscular dystrophy (MD). Method Eight men (23–44 years), seven with Duchenne MD and one with Becker MD, who used daytime M-NIV, were asked to sustain phonation, count, and read under three conditions: (a) Uncued (no instructions), (b) With M-NIV (cued to use M-NIV with all speaking breaths), and (c) Without M-NIV (as tolerated). Breath group and inspiratory durations, syllables/breath group, and relative sound pressure level were determined from audio and video recordings. Results Uncued condition: Participants used the ventilator for all inspirations that preceded sustained phonation and counting. During reading, four participants used M-NIV for all inspirations, one never used it, and three used it for some (19%–41%) inspirations. With- versus Without-M-NIV conditions: Breath group duration was significantly longer across all tasks, syllables per breath group were significantly greater during reading, and inspiratory pause duration during reading was significantly longer with M-NIV than without. Sound pressure level was significantly higher during the first second of sustained phonation with M-NIV (though not for counting and reading). Two participants were unable to complete the reading task audibly without using their M-NIV. Conclusions Speech may be better with M-NIV than without because it is possible to produce longer breath groups and some people with severe respiratory muscle weakness may not be able to speak at all without ventilator-supplied air. Nevertheless, the longer inspiratory pauses that accompany M-NIV may interrupt the flow of speech. Future research is needed to determine the most effective way to use M-NIV for speaking and whether training participants in its use can bring even greater speech benefits.

Background Airway clearance techniques are recommended for individuals with bronchiectasis both in stable state and during an acute exacerbation, however the current use of airway clearance techniques in the management of individuals during an acute exacerbation is unclear. The aims of this study were to establish what current physiotherapy clinical practice comprises for adults and paediatrics during an acute exacerbation of bronchiectasis; identify physiotherapist’s perceptions of the effectiveness of airway clearance techniques and identify what factors influence their treatment decisions in this population. Methods An anonymous online survey was distributed to the members of the Australian Physiotherapy Association and Physiotherapy New Zealand between August 2016 and April 2017. Results The survey was accessed by 130 physiotherapists and 121 of those deemed themselves eligible and consented to participate. Most participants (89%) reported prescribing airway clearance techniques for 81–100% of individuals during an acute exacerbation of bronchiectasis. The most commonly used airway clearance techniques with adults were huffing (92%), exercise (89%) and the active cycle of breathing technique (89%). The techniques perceived most effective for adults were physical exercise (100%), oscillating positive expiratory pressure devices (97%), directed huffing (95%) the active cycle of breathing technique (90%) and positive expiratory pressure (90%). The most commonly used airway clearance techniques for paediatric patients were: newborn-3 years - percussion (85%) and modified postural drainage (85%); 4–10 years - huffing (100%) and exercise (85%); 11–18 years - huffing (92%) and exercise (77%), active cycle of breathing technique (77%) and positive expiratory pressure therapy (77%). The techniques perceived most effective for paediatric patients were directed huffing (100%), percussion (100%) and positive expiratory pressure via a mask or mouthpiece (93%). The most commonly reported factors influencing choice of technique were patient clinical presentation (72%) and the presence/absence of contra-indications (72%). Conclusion This survey demonstrates that airway clearance techniques are routinely used as part of physiotherapy management of individuals experiencing an acute exacerbation of bronchiectasis, and that choice of technique and perceived effectiveness varies depending on the age of the patient.

Introduction Structured Light Plethysmography (SLP) is a novel non-invasive, contactless technique utilising only a grid of white light and cameras to track, measure, capture Throraco-Abdominal (TA) displacement and record quiet tidal breathing. Repeatability is used to assess the measurements from two devices for the same test subject when recorded simultaneously. Spirometry is considered to be the gold standard for measuring lung function but requires the application of forceful manoeuvres which might not be attainable by patients, and so SLP could provide an opportunity to evaluate these patients if successfully benchmarked to spirometry data. Aim To assess the correlation between SLP recordings with simultaneous spirometry measurement of quiet tidal breathing. Methods Quiet breathing in 14 healthy volunteers was simultaneously recorded via SLP ( Thora3Di, Pneumacare Ltd) and by spirometry (Power lab 4/20, AD Instruments Ltd). Statistical analysis using Wilcoxon paired signed-rank test to assess correlation and agreement of these techniques was assessed under three different breathing conditions: Normal, Deep & Shallow. Respiratory rate (RR), inspired, expired and total breathing times were analysed (Ti, Te, Ttot) and duty cycle (Ti/Ttot) was calculated under the three different breathing conditions. There was a good correlation between the techniques under normal and deep breathing conditions. Ethical Approval for the study was approved by Science, Technology, Engineering and Mathematics Ethical Review Committee at the University of Birmingham. Results There were only significant differences in shallow breathing measurements (Ti P=0.0015, Ti/Ttot P=0.0400) (see figure 1 A-E). Conclusions SLP shows good correlation with spirometry for all timing indices both under normal quiet breathing as well as deep breathing but showed a significant difference in shallow breathing indicating that it is a reliable technique during normal and deep breathing. However, during shallow breathing probably due to fast breathing the movement detection was disturbed as a result of the high frequency (50–60 bpm) or could be attributed to the effects of the mouthpiece and nose clip.

High level spinal cord injury drastically reduces the quality of life of the injured person. Various systems attempted to interface the still intact or residual abilities following injury in various monomodal or multimodal designs to compensate for the highly affected mobility. An intra-oral inductive tongue computer interface (ITCI) has been designed to provide real-time discrete and proportional control for computers and assistive devices and to meet specific requirements for individuals with tetraplegia. Operation of the ITCI for wheelchair control was demonstrated with two participants with tetraplegia in a short-term training study. Additionally, two non-disabled individuals participated in the study. For each participant, the ability to drive a Permobil C500 with the ITCI was compared to that when driving the wheelchair with joystick (mouth-stick in one case) along two different lanes of 39 m, by reporting the speed along the lanes and the number of obstacles hit. The lanes consisted of 90°, 360°, and complex maneuver segments linked by linear segments. The ITCI featured a mouthpiece encapsulating two pads of inductive sensors, driving electronics, and battery. The mouthpiece was attached to the palate of the participant's oral cavity with dental retainers. A piercing-like activation unit was attached to the tongue. Data were transmitted wirelessly to a central unit that controlled the wheelchair through wired interface. Among all participants, mean speeds along lane A or B reached maximal values between 0.42 and 0.74 m/s when driving with the ITCI, representing 41 to 71% of that obtained when driving with the joystick.

Background: There is an association between breathing and cognitive function. Increased inspiratory loads (IL) are related to decreased performance in locomotor tasks requiring cognitive inputs. We aimed to investigate this relationship by using cognitive mobile games (CMG) that assess changes in reaction time (RT) induced by various acute respiratory loads in healthy subjects. Methods: Twenty-four healthy subjects (25±4 years old, 12 women) were recruited. A set of two validated short CMG was used to assess the RT: Must Sort (task-shifting and inhibition) and True Color (stroop-test like) in control situation and at four different IL (through a mouthpiece without resistance (MP) and with 10, 50 and 70% of the maximal inspiratory pressure). Dyspnea was assessed after each session by A1 score (breathing discomfort) of the Multidimensional Dyspnea Profile questionnaire. Results: Increased RT after 4 different IL was observed in the Must Sort (p for linear trend Conclusion: Breathing with an inspiratory load is associated with increased dyspnea and increased reaction time. Dyspnea influences the reaction time suggesting interference with perceptual-motor tasks.

Background: Postural control can be influenced by breathing patterns. Increased inspiratory load, inspiratory muscle fatigue, and low tidal volume result in dyspnea which may latter disturb the balance. Therefore we aimed to analyze the impact of dyspnea on postural control. Methods: Thirty-seven healthy participants (aged: 25±4 years, 18 women) participated in this study. Five conditions were applied: (a) control, (b) breathing throughout a mouthpiece without resistance and at maximal inspiratory pressure of (c) 10%, (d) 40%, and (e) 60%. Each trial lasted for 60s, balance-related parameters were recorded and quantified using a Wii Balance Board [1]. The dyspnea perception during the trials was assessed by a Visual Analogic Scale. Results: There is a linear trend between the perception of dyspnea and the inspiratory loads (p Conclusion: The current findings suggest that dyspnea negatively affects postural control. This may partly explain the decrease of postural control in patients with chronic respiratory diseases [2]. This relationship should be better assessed with patients to decrease the risk of falls. Bonnechere, B. et al. Telemed J E Health. 2016; 22 (9): 709–717. Janssens, L. et al. PLoS One. 2013; 8(3): e57949

Deterioration of vital capacity (VC) in amyotrophic lateral sclerosis (ALS) signifies disease progression and indicates need for non-invasive ventilation. Weak facial muscles consequent to ALS, with resulting poor mouth seal, may interfere with the accuracy of VC measurements.To determine whether different interfaces affect VC measurements in ALS patients and whether the interface yielding the largest VC produces an even higher VC when re-measured after one week (learning effect). To explore the relationship between optimal interface VC and sniff nasal pressure (SNIP), a measurement of global inspiratory muscle strength.Thirty-five patients (17 bulbar and 18 spinal ALS) were studied. Three interfaces (rigid-cylindrical, flanged, oronasal mask) were tested. One week after the first visit, VC was recorded using the optimal interface. SNIP recordings were also obtained.In the bulbar ALS group, median (interquartile range) VC with the flanged mouthpiece was 8.4% (3.9-15.5) larger than with the cylindrical mouthpiece (p 0.001). VC values with oronasal mask were intermediate to VC with the other two interfaces. In spinal ALS, flanged mouthpiece VC was 4.6% (2.3-7.5) larger than with oronasal mask (p 0.0006). The latter was 4.5% (0.6-5.2) smaller than with the cylindrical mouthpiece (p = 0.002). In both groups, VC during the second visit was greater than during the first visit (p 0.025). SNIPs were logarithmically related to VC values recorded with the flanged mouthpiece.A flanged mouthpiece yields the largest values of VC in patients with bulbar and spinal ALS.

We tested a PEEP (4.2 cmH2O) mouthpiece (PMP) on maximal cycling performance in healthy adults. Experiment-1, PMP vs. non-PMP mouthpiece (CON) [n = 9 (5♂), Age = 30 ± 2 yr]; Experiment-2, PMP vs. no mouthpiece (NMP) [n = 10 (7♂), Age = 27 ± 1 yr]. At timepoint 1 in both experiments (mouthpiece condition randomized) subjects performed graded cycling testing (GXT) (Corival® cycle ergometer) to determine V˙O2peak (ml∗kg∗min−1), O2pulse (mlO2∗bt−1), GXT endurance time (GXT-T(s)), and V˙O2(ml∗kg∗min−1)-at-ventilatory-threshold (V˙O2 @VT). At timepoint 2 72 h later, subjects completed a ventilatory-threshold-endurance-ride [VTER(s)] timed to exhaustion at V˙O2 @VT power (W). One week later at timepoints 3 and 4 (time-of-day controlled), subjects repeated testing protocols under the alternate mouthpiece condition. Selected results (paired T-test, p

Background and aim Simultaneous and metachronous head and neck cancers are likely to develop in patients with current or previous esophageal cancer. The Valsalva maneuver facilitates the visualization of the hypopharyngeal area during endoscopic observation, but it requires transnasal endoscopy. We developed a novel Valsalva maneuver using transoral endoscopy with a lip cover-type mouthpiece. Methods Between March 2018 and July 2018, 107 patients with current or previous esophageal cancer who were scheduled to undergo upper gastrointestinal endoscopy were included in our pilot study. We performed the Valsalva maneuver using our newly developed mouthpiece and transoral endoscopy in the patients and evaluated the hypopharyngeal region, including the postcricoid area and the posterior wall of the hypopharynx. The outcome measure was procedural success rate, which was graded as "complete," "incomplete," and "none." Results Observation of the hypopharyngeal area was "complete" in 81 patients (76%) using the Valsalva maneuver. However, in 25 patients and in 1 patient, observation was "incomplete" and "none," respectively. Seven lesions were newly detected in seven patients during the study period. Conclusions The Valsalva maneuver using transoral endoscopy with a lip cover-type mouthpiece is feasible for the visualization of the postcricoid area and the posterior wall of the hypopharynx. Particularly, this technique would contribute to early detection of head and neck cancers.

In this study, twenty volunteers were subjected to three, non-injurious lateral head impacts delivered by a 3.7 kg padded impactor at 2 m/s at varying levels of muscle activation (passive, co-contraction, and unilateral contraction). Electromyography was used to quantify muscle activation conditions, and resulting head kinematics were recorded using a custom-fit instrumented mouthpiece. A multi-modal battery of diagnostic tests (evaluated using neurocognitive, balance, symptomatic, and neuroimaging based assessments) was performed on each subject pre- and post-impact. The passive muscle condition resulted in the largest resultant head linear acceleration (12.1 ± 1.8 g) and angular velocity (7.3 ± 0.5 rad/s). Compared to the passive activation, increasing muscle activation decreased both peak resultant linear acceleration and angular velocity in the co-contracted (12.1 ± 1.5 g, 6.8 ± 0.7 rad/s) case and significantly decreased in the unilateral contraction (10.7 ± 1.7 g, 6.5 ± 0.7 rad/s) case. The duration of angular velocity was decreased with an increase in neck muscle activation. No diagnostic metric showed a statistically or clinically significant alteration between baseline and post-impact assessments, confirming these impacts were non-injurious. This study demonstrated that isometric neck muscle activation prior to impact can reduce resulting head kinematics. This study also provides the data necessary to validate computational models of head impact.

The objective of this research was to characterize head impacts with a validated mouthpiece sensor in competitive youth female soccer players during a single season with a validated mouthpiece sensor. Participants included 14 youth female soccer athletes across 2 club-level teams at different age levels (team 1, ages 12–13 y; team 2, ages 14–15 y). Head impact and time-synchronized video data were collected for 66 practices and games. Video data were reviewed to characterize the type and frequency of contact experienced by each athlete. A total of 2216 contact scenarios were observed; heading the ball (n = 681, 30.7%) was most common. Other observed contact scenarios included collisions, dives, falls, and unintentional ball contact. Team 1 experienced a higher rate of headers per player per hour of play than team 2, while team 2 experienced a higher rate of collisions and dives. A total of 935 video-verified contact scenarios were concurrent with recorded head kinematics. While headers resulted in a maximum linear acceleration of 56.1g, the less frequent head-to-head collisions (n = 6) resulted in a maximum of 113.5g. The results of this study improve the understanding of head impact exposure in youth female soccer players and inform head impact exposure reduction in youth soccer.

Background and study aims Patients with esophageal squamous cell carcinoma (SCC) are at high risk of developing second primary SCCs in the hypopharynx. However, such second primary tumors are difficult to observe because of lumen closure. The Valsalva maneuver using a dedicated mouthpiece is a promising technique to visualize the hypopharynx during transoral endoscopy. In the current study, we investigated the utility of this method. Patients and methods The current study was a randomized, controlled, crossover trial. Patients with esophageal SCC were randomly assigned first to undergo pharyngeal observation using the dedicated mouthpiece followed by observation using a conventional mouthpiece, or vice versa. The primary endpoint was complete visualization of the hypopharynx, which was assessed blindly by three external evaluators. Results A total of 68 pharyngeal examinations were analyzed – 34 with the dedicated mouthpiece and 34 with a conventional mouthpiece. Complete visualization was achieved in 68 % of the examinations (23/34) using the dedicated mouthpiece, whereas none of the examinations using the conventional mouthpiece achieved complete visualization of the hypopharynx. Observation scores of the oropharynx were not significantly different between both types of examination (P = 0.50). No serious adverse events (AEs) occurred. Conclusions Endoscopic view of the hypopharynx was markedly improved by the Valsalva maneuver using the dedicated mouthpiece, with no serious AEs. This procedure should be included in the endoscopic examinations for the patients with esophageal SCCs.

OBJECTIVES/HYPOTHESIS Phonation threshold pressure (PTP), the minimum subglottal pressure (Ps ) required for phonation, is sensitive to changes in laryngeal biomechanics and is often elevated with pathology. Little is reported on PTP in children; challenges with task performance and measurement reliability represent barriers to routine clinical assessment. STUDY DESIGN Pilot study evaluating PTP and Ps measurement reliability in children using labial and mechanical interruption. METHODS Twenty-two subjects aged 4 to 17 years (10.7 ± 3.9 years) participated. Ten trials were performed for each method; task order was randomized. For labial interruption, subjects produced /pα/ five times at softest (onset PTP) and comfortable amplitude. For mechanical interruption, subjects produced a sustained /α/ while a balloon valve interrupted phonation five times for 250 ms each; mechanical interruption was performed with a mouthpiece and mask. PTP was recorded as the difference between Ps and supraglottal pressure at phonation cessation (offset PTP). Mean PTP and Ps and intrasubject coefficients of variation were compared. Correlations with age were evaluated. RESULTS Mean PTP (P

Although most head impacts in soccer are headers, limited knowledge exists about how header magnitude varies by on-field scenario. This study aimed to compare head kinematics during on-field headers by play state (i.e., corner kick, goal kick, free kick, throw-in, drill, or live ball), intent (i.e., pass, shot, or clearance), and outcome (i.e., successful or unsuccessful). Fifteen female collegiate soccer players were instrumented with mouthpiece-based head impact sensors during 72 practices and 24 games. A total of 336 headers were verified and contextualized via film review. Play state was associated with peak linear acceleration, rotational acceleration, and rotational velocity (all p .001) while outcome was associated with peak linear acceleration (p .010). Header intent was not significantly associated with any kinematic metric. Headers during corner kicks (22.9 g, 2189.3 rad/s

Background Dry powder inhalers (DPIs) are often used in asthma and chronic obstructive pulmonary disease (COPD) therapies. Using the discrete choice experiment (DCE) methodology, this study conducted in France was designed to assess patients’ preferences for different attributes of DPIs. Methods Attributes of DPIs were defined based on a literature review, patient focus group discussions and interviews with healthcare professionals (qualitative phase of the study). An online survey was then conducted among French patients with asthma or COPD to elicit patient preferences and willingness to pay (WTP) for these attributes using the DCE methodology (quantitative phase). A fractional factorial design including three blocks of 12 choice sets was created. Each choice set comprised three alternatives: two fictitious inhalers and the patient’s current inhaler. Marginal utilities were estimated using a ranked ordered logit model. Interactions between attributes and disease (asthma or COPD) were tested. Results Six DPI attributes were defined based on the qualitative phase: ease of use/fool-proof priming; accurate and easy-to-read dose counter; dose confirmation; hygiene of the mouthpiece; flexibility of the device handling; ability to use the inhaler with breathing difficulties. Overall, 201 patients with asthma and 93 with COPD were included in the online survey. Patients with asthma placed most value on an inhaler that requires one step for dose preparation (WTP €4.83 [95% CI: €3.77–€5.90], relative to an inhaler requiring four steps) and one that could be used during episodes of breathing difficulties (WTP €4.49 [95% CI: €2.95–€6.02]). Patients with COPD placed most value on an inhaler that could be used during episodes of breathing difficulties (WTP €7.70 [95% CI: €5.65–€9.76]) and on the accuracy of the dose counter (WTP €5.87 [95% CI: €3.98–€ 7.77]). Conclusion This study suggests that asthma and COPD patients would be willing to change their inhaler if they were offered the option of a new inhaler with improved characteristics and they place a high value on an inhaler with ease of use during breathing difficulty episodes. Electronic supplementary material The online version of this article (doi:10.1186/s12890-017-0439-x) contains supplementary material, which is available to authorized users.

Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method’s benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.

A 40-year-old male with Cystic Fibrosis developed a sudden onset choking, cough, dyspnea and hemoptysis after using his inhaler. He presented to A&E. CT scan located a foreign body in his right bronchus intermedius (RBI). Rigid bronchoscopy was performed and removed a plastic rawl plug with screw from his RBI. He made a rapid recovery. On questioning he mentioned he had stored his inhaler uncapped in the same pocket he had this screw which he found at work. Small objects can lodge in inhalers due to their design/mouthpiece uncapping. This can result in endobronchial foreign body aspiration. This case highlights the importance of replacing inhaler cap when not in use.

Background and objective Lung mechanics measurements provide clinically useful information about disease progression and lung health. Currently, there are no commonly practiced methods to non-invasively measure both resistive and elastic lung mechanics during tidal breathing, preventing the important information provided by lung mechanics from being utilised. This study presents a novel method to easily assess lung mechanics of spontaneously breathing subjects using a dynamic elastance, single-compartment lung model. Methods A spirometer with a built-in shutter was used to occlude expiration during tidal breathing, creating exponentially decaying flow when the shutter re-opened. The lung mechanics measured were respiratory system elastance and resistance, separated from the exponentially decaying flow, and interrupter resistance calculated at shutter closure. Progressively increasing resistance was added to the spirometer mouthpiece to simulate upper airway obstruction. The lung mechanics of 17 healthy subjects were successfully measured through spirometry. Results N = 17 (8 female, 9 male) healthy subjects were recruited. Measured decay rates ranged from 5 to 42/s, subjects with large variation of decay rates showed higher muscular breathing effort. Lung elastance measurements ranged from 3.9 to 21.2 cmH\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$_2$$\end{document}2O/L, with no clear trend between change in elastance and added resistance. Resistance calculated from decay rate and elastance ranged from 0.15 to 1.95 cmH\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$_2$$\end{document}2Os/L. These very small resistance values are due to the airflow measured originating from low-resistance areas in the centre of airways. Occlusion resistance measurements were as expected for healthy subjects, and increased as expected as resistance was added. Conclusions This test was able to identify reasonable dynamic lung elastance and occlusion resistance values, providing new insight into expiratory breathing effort. Clinically, this lung function test could impact current practice. It does not require high levels of cooperation from the subject, allowing a wider cohort of patients to be assessed more easily. Additionally, this test can be simply implemented in a small standalone device, or with standard lung function testing equipment.

We performed a bench (BS) and human (HS) study to test the hypothesis that estimation of tidal volume (VT) during noninvasive helmet pressure support ventilation (nHPSV) would be possible using a turbine driven ventilator (TDV) coupled with an intentional leak single-limb vented circuit. During the BS a mannequin was connected to a lung simulator (LS) and at different conditions of respiratory mechanics, positive end expiratory pressure (PEEP) levels and leaks (30, 50 and 80 L/min). All differences were within the 95% limits of agreement (LoA) in all conditions in the Bland-Altman plot. The overall bias (difference between VT measured by TDV and LS) was 35 ml (95% LoA 10 to 57 ml), 15 ml (95% LoA −40 to 70 ml), 141 ml (95% LoA 109 to 173 ml) in the normal, restrictive and obstructive conditions. The bias at different leaks flow in normal condition was 29 ml (95% LoA 19 to 38 ml). In the HS four healthy volunteers using nHPSV had a pneumotachograph (P) inserted through a mouthpiece to measure subject’s VT.The bias showed a scarce clinical relevance. In conclusions, VT estimation seems to be feasible and accurate in all conditions but the obstructive one. Additional leaks seem not to affect VT reliability.

Background: Our randomised controlled trial (RCT) evaluating the value of an inhaler-specific visual aid as adjunct to standard inhaler technique education, showed beneficial short-term (after 6-8 weeks) effects. Correct inhaler technique improved from 8% to 70% of patients with asthma or COPD. Aim: To evaluate the long-term effects of inhaler technique education in asthma or COPD. Methods: Patients who participated in our RCT and completed both visits (n=98) were invited for a 1-year follow-up (FU) visit as part of routine care. All patients had completed inhaler technique education, including the use of the visual aid at short-term FU. During long-term FU inhaler technique was (re)assessed using inhaler-specific checklists. Results: Inhaler technique was evaluated in 56 patients (mean age 64±12yrs, 52% male) with asthma (45%) or COPD (55%). Reasons for not attending long-term FU were: referral to primary care (n=13), unwilling (n=6), deceased (n=4), lost to follow-up (n=19). Inhaler technique was adequate in 37 patients (66%). The most common mistakes with incorrect technique (n=19) were: no complete exhalation before inhalation (n=10, DPI), no 5 times in- and exhaling through the mouthpiece (n=5, MDI with spacer). Incorrect technique occurred more in COPD (48%) as compared to asthma (16%). Patients with incorrect technique were significantly older (69yrs) as compared to patients with adequate technique (62yrs). Conclusion: This study demonstrates positive long-term effects of thorough inhaler technique education. Yet, the number of patients who inhaled incorrectly stresses the importance of monitoring and (repeatedly) educating correct inhaler technique, particularly in older COPD patients.

Background: SIMEOX produces a non-invasive succession of very short air depressions through a mouthpiece during expiration. Therefore, the SIMEOX technology claims to reduce expiratory flow limitation. Objective: To assess the safety and to measure expiratory volume and flow mobilized with SIMEOX. Methods: Non-smoker adults with no history of cardio-respiratory disease were recruited. Each participant performed 3 slow vital capacity (VC) maneuvers followed by 3 slow maximal exhalations from total lung capacity with SIMEOX. Flow and volume were measured using a pneumotachograph. The highest volume of each attempt was reported while flow was averaged from the 3 repetitions. Participants were further categorized according to the lower limit of normality (LLN) of VC calculated from ERS 1993 equations. Results: Thirty-two subjects (21F, 24 ± 8y) were recruited. Mean (±SD) volume during slow expiration with SIMEOX and slow VC was respectively 4.01 ± 0.93L and 4.05 ± 1.08L (p=0.55). Mean expiratory flow with SIMEOX was significantly lower than during slow VC (0.8 ± 0.1L/s vs 2 ± 0.9L/s, p Conclusions: Our preliminary data suggest that SIMEOX modifies the expiratory pattern and may be able to mobilize an extra volume of air in subjects with abnormal lung function. Collection of data in patients with COPD is ongoing.

Introduction or Background: Sex differences of neurological activity in brain on breathing effort without hypoxia are still unclear, although the differences have investigated on various external stimuli such as pain, emotion, fear and stress. Aims and Objectives: The aim of the study was to investigate sex difference of neurological activity and signaling in brain on breathing effort without hypoxia by brain functional magnetic resonance imaging (fMRI). Methods: Artificial breathing effort without hypoxia was prepared by an orifice device of mouthpiece type. Brain images with resting state were recorded with or without breathing effort for 7min by fMRI from 10 male and 10 female healthy volunteers. Dyspnea levels were assessed by modified Borgs scale. The area under the curves (AUC) of dyspnea levels and the data of fMRI were compared between male and female using by statistical software (JMP13, SAS Institute Inc. and FMRIB Software Library tools (Melodic ICA, dual regression, FSL Nets, respectively). Results: There was no difference in the AUC of dyspnea levels on breathing effort between male and female. Male had significant inter-network connectivity between the posterior cingulated gyrus and the front-orbital cortex, which corresponds to the Default mode network and Orbito-frontal network, whereas female showed significant inter-network connectivity between the posterior cingulated gyrus and the front-orbital cortex during breathing effort, corresponding to Sensory-motor network and Fronto-parietal network. Conclusion: Our study suggests sex difference that male may arouse the breathing effort as latent memories and female may feel intuitively it as external stimulation.

Gas-collection masks are used as a comfortable alternative to the traditional mouthpiece and noseclip during exercise testing protocols in human performance laboratories. However, these masks may introduce potential problems which could affect metabolic and ventilatory parameters, including gas leaks and added dead space. Therefore, the purpose of this study was to compare breathing mechanics, gas exchange variables and ratings of perceived breathlessness (RPB) during high-intensity exercise between a mouthpiece and face mask. Fourteen men [⩒O

Objective The aim of this work was to determine if scoring mechanisms embedded in cognitive mobile games (CMG) designed for cognitive training are sensitive enough to detect changes in cognitive function induced by various acute respiratory loads in healthy subjects. Material and methods Thirty healthy subjects participated in this study (25 ± 4 years old, 13 women). A set of three brief CMG was used to assess cognitive function (Rush Back, Must Sort, True Color) in control situation and at four different inspiratory loads (through a mouthpiece without resistance and with 10, 50 and 70% of the maximal inspiratory pressure). Results Statistically significant decreases in CMG scores were observed in Rush Back (p = 0.032) and True Color (p = 0.002) when the subjects breathed through the mouthpiece without resistance compared to the control condition. A statistical difference was observed for Must Sort (p = 0.003) between baseline and 10% of Inspiratory Threshold Load (ITL). Significant differences for the three games were observed between the baseline and 50% of ITL and between baseline and 70% of ITL. Conclusion CMG designed for cognitive training are sensitive in detecting transitional changes in cognitive function induced by low, medium and high acute respiratory loads in healthy subjects. This offers interesting new possibilities for the assessment and long-term follow-up of patients suffering from chronic respiratory disease, since this type of assessment could easily be completed independently by patients in their own homes, and could be combined with rehabilitation exercises as an evaluative measure.

Breath collection and analysis can be used to discover volatile biomarkers in a number of infectious and non-infectious diseases, such as malaria, tuberculosis, lung cancer, and liver disease. This protocol describes a reproducible method for sampling breath in children and then stabilizing breath samples for further analysis with gas chromatography-mass spectrometry (GC-MS). The goal of this method is to establish a standardized protocol for the acquisition of breath samples for further chemical analysis, from children aged 4–15 years. First, breath is sampled using a cardboard mouthpiece attached to a 2-way valve, which is connected to a 3 L bag. Breath analytes are then transferred to a thermal desorption tube and stored at 4–5 °C until analysis. This technique has been previously used to capture breath of children with malaria for successful breath biomarker identification. Subsequently, we have successfully applied this technique to additional pediatric cohorts. The advantage of this method is that it requires minimal cooperation on part of the patient (of particular value in pediatric populations), has a short collection period, does not require trained staff, and can be performed with portable equipment in resource-limited field settings.

Background: The objective was to investigate the respiratory function of professional divers by conducting spirometry and to compare the data obtained with those of non-divers. Materials and methods: This study involved 52 military divers who carried out dives at small and medium depths using a self-contained underwater breathing apparatus (SCUBA) with open-circuit regulators attached to a mouthpiece. The control group consisted of 48 persons from deck commands with similar physiological characteristics and lifestyle that were not divers and had never been under increased pressure. Results: It was found that, compared with non-divers, the spirometry parameters of the divers are charac- terised by higher values of forced vital capacity (FVC) of the lungs (p = 0.02), but significantly lower values of the mid-expiratory flow (MEF) parameters: MEF 25 (p = 0.06), MEF 50 (p = 0.04), and MEF 75 (p = 0.01), as well as for the ratio of forced expiratory volume in 1 second (FEV 1 ) to forced vital capacity (FEV 1 /FVC; p = 0.001) and MEF 25–75 /FVC ratio (p < 0.001). Conclusions: Hyperoxia, gas decompression bubbles, hypothermia, mouth-breathing dry, cold, compressed air, and other factors accompanying the diving activity are capable of initiating damage to the airways, which is reflected in characteristic changes in spirometry. The pattern of these changes is consistent with small airway obstruction and they could be related mostly to diving activities.

In the present study, the ROCF test was initially conducted involving 30 healthy young individuals, in a quiet environment as Experiment 1 to examine variations in the score among different methods to memorize the figure. In such an environment, no significant differences were observed in the score between the copying and outer speech groups, which suggested the possibility of some of the former groups having used outer speech in a voice too low to be heard or moving their lips without vocalization, achieving the same effect as outer speech, and consequently leading to the absence of differences from the outer speech group. On the other hand, the score markedly varied between the mouthpiece and copying or outer speech groups. As lip movements were suppressed in the former case, the unconscious use of outer speech was also prevented, possibly leading to poor results. Based on these findings, it may be possible to enhance the effects of rehabilitation in a clinical setting by promoting patients’ memorization using outer speech to vocalize the contents of training.

Objective To determine the prevalence of dental symptoms in recreational scuba divers and describe the distribution of these symptoms on the basis of diver demographics, diving qualifications and dive conditions during the episode of dental pain.Design A survey was designed and distributed through online social media platforms dedicated to scuba diving. A convenience sample of 100 recreational divers was obtained by this method.Main outcome measures The outcome measures of interest were: diver demographics, diving characteristics (level of certification, number of dives completed), occurrence of dental problems during a dive, and details of the episode.Results Forty-one percent of the respondents experienced dental symptoms during a dive. Barodontalgia was the most frequently experienced dental symptom during a dive.Conclusion Within the limits of the small sample size and online method of recruitment, the findings of this study suggest that a high proportion of recreational divers may experience dental symptoms during a dive. It would be meaningful to ensure that dental decay and damaged restorations are addressed before a dive and that the mouthpiece design be evaluated in case of complaints of temporomandibular discomfort during a dive.

Nebulized drugs are frequently administrated through tracheostomy in clinical routine. So far, the amount of drug deposited into the lung in these patients remains unknown. The aim of our pharmacokinetic study was to compare lung delivery of amikacin in the same subjects in two settings: spontaneously breathing through a tracheostomy and through the mouth.Lung delivery was measured by amikacin urinary drug concentration in nine patients who were transitory tracheostomized for the need of a head and neck oncologic surgery. Patients performed two nebulization sessions: with a mouthpiece (MB) and through tracheostomy (TB) using a adapted jet nebulizer (SidestreamLung delivery was similar with the two conditions of nebulization (6.5 ± 2.5% vs. 6.3 ± 2.0% of the nominal mass of amikacin, respectively, for MB and TB; p = 0.95). Duration of nebulization was also comparable (19.7 ± 1.6 vs. 20.1 ± 1.8 min, respectively, for mouth and tracheostomy breathing; p = 0.307). The half-life and elimination rate constant were not different between the two settings. We conclude that nebulized therapy can be administered in spontaneously breathing tracheostomized adults patients, with a similar amount of drug delivered to the lung compared with spontaneously mouth breathing patients.