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Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from pre-operative care to discharge/disposition are highlighted. The importance of effective business planning, personnel training, leadership, communication, teambuilding, quality of care and patient safety are also discussed.

Background: Cardiac auscultation is a frequent first step in diagnosing heart disorders. However, the lack of dependability of ordinary auscultation in the hands of inexperienced clinicians remains a problem. Objective: We sought to develop an inexpensive system for digital cardiac auscultation (digital phonocardiography) using a Windows laptop computer, freely downloadable software and an inexpensive USB microphone. Description: The system, based on the free open-source Audacity software package, offers advanced features such as phonocardiogram storage and retrieval, low-pass and high-pass waveform filtering and variable-speed signal playback with pitch preservation. Results: Sample results for both raw and digitally filtered phonocardiograms are provided. Conclusion: An innovative laptop-based phonocardiogram system offering advanced features can be easily produced at minimal cost.

This paper introduces the reader to some of the various methods that are available for the time-domain bio-acoustical monitoring of patient breathing. Technical details concerning microphone selection, calibration and characterization, signal amplification, signal filtering and waveform recording are presented. We also describe proof of concept recordings obtained from the neck, from the external ear canal, from a microphone embedded into an oxygen mask and from a leak-free microphone pneumatically connected to the cuff of a laryngeal mask airway. We recommend Audacity, an open-source digital audio editor and recording package that can be freely downloaded at https://www.audacityteam.org for investigators seeking to conduct research on breath sound analysis.

This brief review introduces the reader to some of the various historical and modern methods that are available for the bio-acoustical assessment of patient breathing, with other bio-acoustical processes discussed peripherally. Some simple methods of respiratory assessment of historical interest are first discussed, along with more modern methods of patient acoustical monitoring based on advanced analytic methods.

A synopsis of the latest research on the perioperative use of chewing gum by surgical patients is presented, focusing on the preoperative and postoperative periods. Current data now suggest that the preoperative use of chewing gum does not adversely affect gastric emptying and that the postoperative use of chewing gum may actually aid recovery from some forms of major surgery. Additionally, the use of chewing gum may increase alertness and serve to reduce stress, as well as offer important oral health benefits.

Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved.We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine.The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards, and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from preoperative care to discharge/disposition, are highlighted. The importance of effective business planning, personnel training, leadership, communication, team building, quality of care, and patient safety are also discussed.

As we deal with the COVID-19 pandemic we face a controversy concerning its pathophysiology and how to integrate available knowledge into practice while awaiting study outcomes. COVID-19’s pathophysiology remains elusive, as reflected in putative mechanisms that remain unsupported by robust evidence. Some models draw on clinical observations without reference to supporting data from genomic, proteomic, molecular, physiological, and other data pertaining to human coronaviruses. Consequently, some proposed models for COVID-19 pathophysiology and their corresponding treatment options remain highly divergent. To provide a pathophysiological model that better describes the different phenotypic presentations of the disease in concordance with existing research on the renin-angiotensin system, previously described pathophysiological processes for other human coronavirus infections and the genomic similarities between the SARS and SARS-CoV-2 viruses, we developed a conceptual model,“epithelial-endothelial crosstalk at alveolar-capillary membrane” that we believe can help explain the pathogenesis of COVID-19.

This brief review of the Ventrain ventilation system summarizes the main clinical and technical aspects of the device, with special emphasis on its role in the “Cannot Intubate, Cannot Oxygenate“ situation and in surgery involving the airway. Animal and bench studies characterizing the performance of the device, which is based on Bernoulli's Principle, are also discussed. It is concluded that as clinical experience is accumulated that this new device will play a special role in clinical airway management.

The properties of various acoustic interfaces (stethoscopes) for respiratory monitoring and phonocardiography are compared using a special-purpose custom-built electronic vibration platform that can be driven by an electronic test signal. Sample sensitivity data for various stethoscope designs are presented in this study.

The traditional renin-angiotensin system (RAS) is indispensable system in adjusting sodium homeostasis, body fluid volume, and controlling arterial blood pressure. The key elements are renin splitting inactive angiotensinogen to yield angiotensin (Ang-I). Ang-1 is then changed by angiotensin-1 converting enzyme (ACE) into angiotensin II (Ang-II). Using PubMed, Google Scholar, and other means, we searched the peer-reviewed literature from 1990 to 2013 for articles on newly discovered findings related to the RAS, especially focusing on how the system influences the central nervous system (CNS). The classical RAS is now considered to be only part of the picture; the discovery of additional RAS pathways in the brain and elsewhere has yielded a vastly improved understanding of how the RAS influences the CNS. Newly discovered effects of the RAS on brain tissue include neuroprotection, cognition, and cerebral vasodilation. A number of brain biochemical pathways are influenced by the brain RAS. Within various pathways, there are potential opportunities for classical pharmacologic interventions as well as the possibility of controlling gene expression.

The need for simple and reliable means of respiratory monitoring has existed since the beginnings of medicine. In the present study, we describe the use of color spectrographic analysis of breathing sounds recorded from the external ear canal as a candidate technology to meet this need. A miniature electret microphone was modified with the addition of an adapter to allow it to be placed comfortably in the external ear canal. The amplified signal was then connected to a real-time color spectrogram program running on a laptop personal computer utilizing the Windows operating system. Based on the results obtained, we hypothesize that the real-time display of color spectrogram breathing patterns locally or at a central monitoring station may turn out to be a useful means of respiratory monitoring in patients at increased risk of respiratory depression or other respiratory problems. Finally, we conducted a statistical analysis that suggests that significant spectrogram differences may exist among some groups investigated in the study.

We describe the novel combined use of a fiberoptic bronchoscope and a Fuji Uniblocker placed outside the endotracheal tube (ETT) for removal of a retained BioGlue polymerized tissue fragment (2.8 × 0.8 cm) from the right main bronchus (RMB). The patient was a trauma victim who presented with a diffuse axonal injury, cervical spine and maxillofacial injuries, and a flail chest, and the procedure we describe took place following the surgical repair of a disrupted left main bronchus. Endoscopic retrieval using different sizes of grasping forceps and a Dormia basket failed to remove the foreign body (FB). Under combined GlideScope videolaryngoscopic and bronchoscopic guidance, a 9.0 F Uniblocker was introduced outside the ETT, placed into the RMB beyond the FB, initially inflated, and then gradually increased in volume during withdrawal from the RMB into the trachea so as to trap the FB between the tip of the ETT and the blocker balloon. The ETT, bronchoscope, blocker catheter, and the FB were then removed from the glottis as a single unit. The FB was then removed using Magill forceps with the aid of a GlideScope. We conclude that the combined use of a GlideScope, bronchoscope, and an Uniblocker placed outside the ETT can be an effective method for removal of a retained FB.

Background The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. Methods We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. Results Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. Conclusion Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.

Although significant advances in clinical monitoring technology and clinical practice development have taken place in the last several decades, in this editorial we argue that much more still needs to be done. We begin by identifying many of the improvements in perioperative technology that have become available in recent years; these include electroencephalographic depth of anesthesia monitoring, bedside ultrasonography, advanced neuromuscular transmission monitoring systems, and other developments. We then discuss some of the perioperative technical challenges that remain to be satisfactorily addressed, such as products that incorporate poor software design or offer a confusing user interface. Finally we suggest that the journal support initiatives to help remedy this problem by publishing reports on the evaluation of medical equipment as a means to restore the link between clinical research and clinical end-users.

This chapter is primarily concerned with the issues associated with defining death and the philosophical debate on where the line between life and death should be drawn. While traditionally death has been defined as the permanent cessation of the heartbeat and respiration, modern clinical developments have forced a reevaluation of the both the concept of death in general and of brain death in particular. Future developments in cryonics and nanotechnology may require even further reappraisal of when a person is really dead. This chapter advances the philosophical position that organismal death is not an event so much as it is a process, and that life and death are not distinct binary states, but entities with degrees and gradations. Finally, it advances the notion that it is helpful to distinguish between the definition of death based on mere cessation of the heart beat and a “more substantial” form of death, such as exists following cremation (“absolutely irreversible death” or “information-theoretic death”).

Medical educators commonly place considerable importance on the notion of “interactivity” in the educational process. Interactivity may be defined as a reciprocally active situation whereby a two-way flow of information or opinion exists between a source and a user, and where the source responds to the user's input. Advocates of interactivity maintain that well-designed interactivity in educational systems helps capture the learner's interest, has the potential to speed the learning process, and even allows for continuous assessment of the degree to which the material is mastered. Medical educators also point out that technology can allow for high-quality interactivity by providing for frequent and relevant user feedback, by recognizing when students misunderstand a concept, and by providing learning aids such as animations or graphs that vary depending on user input. However, badly designed interactivity can also impede student progress.

This chapter introduces the reader to the field of transhumanism and some of the most important philosophers contributing to this recent movement. Related philosophical issues such as moral standing and personhood theory are presented. The possibilities of genetic engineering as a means to fundamentally alter the nature of humankind are discussed, along with the concepts of animal-human hybrids, computer-human hybrids, and fully artificial beings. These ideas are presented to support the premise that there is no unique and unalterable biological form that constitutes humanity, and that our concept of what it means to be human will be forced to evolve in the face of new biotechnologies such as genetic engineering, molecular biology, and nanotechnology, all of which have the potential to alter our nature and character in ethically profound ways.

This chapter is concerned with the intersection of transhumanism, neurology and religious belief. The role of various brain structures in religious experiences (especially the frontal lobes) is discussed, including a discussion of how pathological brain conditions such as epilepsy can influence religious beliefs. The chapter begins with a discusuion of how various thinkers such as Marx and Freud imagined that the influence of religion would weaken over time and continues on to discuss the evolutionary origins of religious belief, the nature of religious experience as well as neurological and pharmacological circumstances that may influence a person’s religious experiences, including hyper-religiosity syndromes and the central role of the frontal lobes in religiosity.

This chapter is one that is particularly rich in philosophical arguments and has as its main focus the critical evaluation of the arguments against transhumanism that have been raised by a number of prominent philosophers and other individuals. Based on the critiques of transhumanism offered by critics such as Leon Kass, Francis Fukuyama, and Michael Sandel, the chapter critically assesses five commonly raised arguments why human enhancement by artificial means should not be undertaken: fairness, human dignity issues, “slippery slope” arguments, the “repugnance” argument, and safety issues. The weakness of “slippery slope” arguments and “repugnance” arguments are given special attention. In the end it is concluded that safety issues are the most realistic concerns that the pursuit of transhumanism raises.