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The rhomboid intercostal block and the rhomboid intercostal subserratus block are novel blocks. These provide effective postoperative analgesia for a myriad of indications. It surpasses previous blocks by being away from the surgical site which soothes any fear of the surgeon – a possibility of infection at the site and also difficulty of postoperative catheter maintenance. The landmarks of this block are very lucid and understood easily. It is relatively a very safe block with rib acting as a safe barrier as well as a landmark. The catheter of the site does not interfere with patients' routine activity, thus increasing overall patient satisfaction. The authors discuss five cases in which RISS proved immensely effective in relieving pain from rib fractures and postoperative. Furthermore, details of the block including anatomical site, dermatomal coverage, and USG images are discussed. It has proved to be a boon for all patients offering an excellent analgesia. Rhomboid intercostal subserratus plane block is an excellent option for providing adequate postoperative analgesia for thoracoabdominal surgeries as well as patients with multiple rib fractures. More reporting of cases and randomized trials are needed to confirm the same. [ABSTRACT FROM AUTHOR]

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the 'safe zone' of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation. [ABSTRACT FROM AUTHOR]

Introduction: Mulligan therapy includes Sustained Natural Apophyseal Glides (SNAGs) and Mobilisation With Movement (MWM), which can be applied for spinal pain and Range of Motion (ROM). It helps to stretch the structures on the convex side of the offending movement and opens the intervertebral foramen. Pulmonary Function Test (PFT) is an important diagnostic test that helps guide decisions for management. Normal chest expansion is crucial for respiratory system function and tissue oxygenation. The contraction of external intercostal muscles moves the ribs upwards and outwards, causing the rib cage to expand, which increases the volume of the thoracic cavity. After the age of 25 years, normal pulmonary function begins to decline. Inappropriate posture leads to reduced thoracic cage mobility, thereby decreasing chest expansion. Thoracic SNAGs and MWM help stretch the structures, which will aid in chest expansion. Aim: To determine the effect of Mulligan therapy on pulmonary function and chest expansion in healthy individuals. Materials and Methods: A quasi-experimental study was conducted at Ramaiah Hospitals in Bengaluru, Karnataka, India over an 11-month period between July 2021 and June 2022. Based on the inclusion criteria, 103 participants were included, and Mulligan therapy was performed. Pre- and post-PFT and chest expansion measurements were taken and analysed using Student's t-test. Results: The results showed a statistically significant difference in chest expansion at all three levels (p

Objectives: We aimed to evaluate the ability of the parasternal intercostal (PIC) thickening fraction during spontaneous breathing trial (SBT) to predict the need for reintubation within 48 h after extubation in surgical patients with sepsis. Methods: This prospective observational study included adult patients with sepsis who were mechanically ventilated and indicated for SBT. Ultrasound measurements of the PIC thickening fraction and diaphragmatic excursion (DE) were recorded 15 min after the start of the SBT. After extubation, the patients were followed up for 48 h for the need for reintubation. The study outcomes were the ability of the PIC thickening fraction (primary outcome) and DE to predict reintubation within 48 h of extubation using area under receiver characteristic curve (AUC) analysis. The accuracy of the model including the findings of right PIC thickening fraction and right DE was also assessed using the current study cut-off values. Multivariate analysis was performed to identify independent risk factors for reintubation. Results: We analyzed data from 49 patients who underwent successful SBT, and 10/49 (20%) required reintubation. The AUCs (95% confidence interval [CI]) for the ability of right and left side PIC thickening fraction to predict reintubation were 0.97 (0.88–1.00) and 0.96 (0.86–1.00), respectively; at a cutoff value of 6.5–8.3%, the PIC thickening fraction had a negative predictive value of 100%. The AUCs for the PIC thickening fraction and DE were comparable; and both measures were independent risk factors for reintubation. The AUC (95% CI) of the model including the right PIC thickening fraction > 6.5% and right DE ≤ 18 mm to predict reintubation was 0.99 (0.92–1.00), with a positive predictive value of 100% when both sonographic findings are positive and negative predictive value of 100% when both sonographic findings are negative. Conclusions: Among surgical patients with sepsis, PIC thickening fraction evaluated during the SBT is an independent risk factor for reintubation. The PIC thickening fraction has an excellent predictive value for reintubation. A PIC thickening fraction of ≤ 6.5–8.3% can exclude reintubation, with a negative predictive value of 100%. Furthermore, a combination of high PIC and low DE can also indicate a high risk of reintubation. However, larger studies that include different populations are required to replicate our findings and validate the cutoff values. [ABSTRACT FROM AUTHOR]

BACKGROUND: Noninvasive ventilation (NIV) is a widely used and well-established treatment modality for respiratory failure. In patients with increased respiratory work of breathing, accessory muscles are commonly activated along with the diaphragm. Whereas diaphragm ultrasound has been utilized to assess outcomes of mechanical ventilation, the data on intercostal muscle ultrasound remain limited. We aimed to investigate the association between intercostal muscle thickening fraction (TF) and NIV failure in critical care patients with hypercapnic respiratory failure. METHODS: Critical care subjects receiving NIV for hypercapnic respiratory failure were enrolled in the study. The intercostal muscle TF was measured on admission day (day 0) and the following day (day 1). NIV failure was defined as the need for invasive mechanical ventilation or death during NIV therapy. RESULTS: A total of 158 subjects were enrolled, and 30 experienced NIV failure. Age, sex, and body mass index (BMI) were similar in the NIV success and failure groups. Acute Physiology And Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) scores were higher in the NIV failure group. In terms of causes of respiratory failure, the COPD exacerbation rate was higher in the NIV success group. TF was higher in the NIV failure group on both day 0 and day 1. The increased TF on the ICU admission day, with a cutoff value of 12%, was associated with NIV failure after adjusting for age, sex, BMI, APACHE II, and SOFA. Persistence of a higher TF value on both day 0 and day 1 was also associated with NIV failure risk. CONCLUSIONS: There was a positive relation between intercostal muscle TF measured by ultrasound and NIV failure, even after adjusting for APACHE II and SOFA scores. [ABSTRACT FROM AUTHOR]

Introduction: Mulligan therapy includes Sustained Natural Apophyseal Glides (SNAGs) and Mobilisation With Movement (MWM), which can be applied for spinal pain and Range of Motion (ROM). It helps to stretch the structures on the convex side of the offending movement and opens the intervertebral foramen. Pulmonary Function Test (PFT) is an important diagnostic test that helps guide decisions for management. Normal chest expansion is crucial for respiratory system function and tissue oxygenation. The contraction of external intercostal muscles moves the ribs upwards and outwards, causing the rib cage to expand, which increases the volume of the thoracic cavity. After the age of 25 years, normal pulmonary function begins to decline. Inappropriate posture leads to reduced thoracic cage mobility, thereby decreasing chest expansion. Thoracic SNAGs and MWM help stretch the structures, which will aid in chest expansion. Aim: To determine the effect of Mulligan therapy on pulmonary function and chest expansion in healthy individuals. Materials and Methods: A quasi-experimental study was conducted at Ramaiah Hospitals in Bengaluru, Karnataka, India over an 11-month period between July 2021 and June 2022. Based on the inclusion criteria, 103 participants were included, and Mulligan therapy was performed. Pre- and post-PFT and chest expansion measurements were taken and analysed using Student’s t-test. Results: The results showed a statistically significant difference in chest expansion at all three levels (p<0.001) and Forced Expiratory Volume (FEV1) in the first second/Forced Vital Capacity (FVC) (p=0.04), Peak Expiratory Flow (PEF) (p=0.03), Forced Inhibitory Volume in the first second (FIV1) (p=0.01), and FIV1/FIVC (p=0.03) values in the PFTs. Conclusion: Chest expansion and FEV1/FVC, PEF, FIV1, and FIV1/FIVC show a significant change post thoracic SNAGs, intercostal MWM, costochondral, and costovertebral MWM. However, no significant changes have been observed in the other parameters of pulmonary function. [ABSTRACT FROM AUTHOR]

Intercostal lung hernia and inverted intercostal hernia are rare chest wall hernias usually asymptomatic and detected incidentally on chest radiograph. In this case report, we discussed here on the chest radiograph and computed tomography imaging findings of two cases of these rare hernias with an emphasis being in differential diagnosis of chest tumors. [ABSTRACT FROM AUTHOR]

Whether performing open surgery or minimally invasive surgery, lost needles can cause operating surgeons' great anxiety and worry. The development of needle-retrieval techniques for misplaced needles have been attempted previously in a number of ways. Here, we report our experience with robot-assisted nephron sparing surgery in which the lost needle turned up in an unexpected anatomical spot. This case also emphasises the intra-operative manoeuvres that were employed to retrieve the needle. [ABSTRACT FROM AUTHOR]

This study aimed to assess the effect of parasternal intercostal block on postoperative wound infection, pain, and length of hospital stay in patients undergoing cardiac surgery. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP, and Wanfang databases were extensively queried using a computer, and randomised controlled studies (RCTs) from the inception of each database to July 2023 were sought using keywords in English and Chinese language. Literature quality was assessed using Cochrane‐recommended tools, and the included data were collated and analysed using Stata 17.0 software for meta‐analysis. Ultimately, eight RCTs were included. Meta‐analysis revealed that utilising parasternal intercostal block during cardiac surgery significantly reduced postoperative wound pain (standardised mean difference [SMD] = −1.01, 95% confidence intervals [CI]: −1.70 to −0.31, p = 0.005) and significantly shortened hospital stay (SMD = −0.40, 95% CI: −0.77 to −0.04, p = 0.029), though it may increase the risk of wound infection (OR = 5.03, 95% CI:0.58–44.02, p = 0.144); however, the difference was not statistically significant. The application of parasternal intercostal block during cardiac surgery can significantly reduce postoperative pain and shorten hospital stay. This approach is worth considering for clinical implementation. Decisions regarding its adoption should be made in conjunction with the relevant clinical indices and surgeon's experience. [ABSTRACT FROM AUTHOR]

Summary: We investigated the distribution of injected dye after deep serratus anterior plane and superficial parasternal intercostal plane blocks in 15 Thiel embalmed cadavers. We injected 0.4 ml.kg−1 of 0.25% aqueous methylene blue solution into the deep serratus anterior and superficial parasternal intercostal planes using real‐time ultrasound needle visualisation followed by posterior dissection to observe the distribution of the injected dye in the chest wall. The two blocks were performed bilaterally in 15 cadavers at the T5/T6 level, comprising 60 blocks in 30 hemithoraces in total. At dissection, the intercostal nerve territories were observed to be dyed completely from T2 to T6 in 28 of 30 hemithoraces, and extending caudal to T6 in 10 hemithoraces. Following the deep serratus anterior plane blocks in all cadavers, the dye was found to have spread to the axillae. Following the superficial parasternal intercostal plane blocks, the dye reached T7 in four cadaver dissections. We concluded that the territories innervated by the intercostal nerves (T2–T6 dermatomes) are dyed following the combination of the two blocks when performed at the T5–T6 intercostal space level. These techniques might provide an effective option for anaesthesia in breast surgery. [ABSTRACT FROM AUTHOR]

Background: Monitoring the function of parasternal intercostal muscles provides information on respiratory load and capacity and thus can be a weaning monitoring tool. Objective: The goal was to study the diagnostic accuracy of parasternal intercostal muscle thickness fraction (PICTF%) as a predictor of weaning. Materials and methods: A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. When an SBT was planned by the treating physician, the study examiner performed the ultrasound measurements of parasternal intercostal muscle thickness (inspiration and expiration) and thickening fraction using M-mode ultrasonography (USG). The PICTF% was calculated as"(peak inspiratory thickness - end-expiratory thickness)/end-expiratory thickness) x 100." Weaning failure was defined if the patient had a failed spontaneous breathing trial (SBT) or the need for a reintubation within 48 hours following extubation. The SBT failure was defined as the need to connect the patient back to the ventilator prior to its completion due to any reason as decided by the clinician. Results: Of 81 screened patients, 60 patients met the inclusion criteria, of whom 49 patients had successful SBT, and 48 patients could be successfully extubated. The PMTF% cut-off value more than or equal to 15.38% was associated with the best sensitivity (75%) and specificity (87.8%) in predicting extubation failure. Conclusion: The PICTF% has a good diagnostic accuracy in predicting weaning failure. [ABSTRACT FROM AUTHOR]

Background Embolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive. Objective To introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA. Methods In human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals). Results The human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6-7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans. Conclusions This PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists. [ABSTRACT FROM AUTHOR]

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the 'safe zone' of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation. [ABSTRACT FROM AUTHOR]

Background: Although mechanical ventilation is a lifesaving treatment, abundant evidence indicates that its prolonged use (one week or more) promotes respiratory muscle weakness due to both contractile dysfunction and atrophy. Along with the diaphragm, the intercostal muscles are one of the most important groups of respiratory muscles. In recent years, muscular ultrasound has become a useful bedside tool for the clinician to identify patients with respiratory muscle dysfunction related to critical illness and/or invasive mechanical ventilation. Objective: To assess the impact of mechanical ventilation on diaphragm and intercostal muscles using ultrasonography in preterm neonates. Patients and Methods: This observational prospective study was conducted at Neonatal Intensive Care Unit (NICU), Children's Hospital Ain Shams University over 6 months from October 2022 to April 2023, It included 60 preterm neonates, divided into two groups; 30 cases of respiratory distress syndrome (RDS) who were on mechanical ventilation for one week or less and 30 preterm infants of matched age and gender who didn't require respiratory support. Results: A total of 60 premature neonates participated in the study. Among them, 30 neonates required mechanical ventilation, whereas the other group consisted of 30 spontaneously breathing neonates of matched age and gender. The mean gestational age of both groups was 33 weeks, there was no statistical significant difference between our two groups as regards weight and gestational age. The relation between the right and left diaphragmatic thickness fraction (DTF) and parasternal intercostals muscle thickness fraction (TFiC) in the ventilated group in day 1 and day 3 was of non significance (p-value = 0.089 in left TFiC, p-value = 0.554 in right DTF), while the relation between them from day 1 to day 5 was significantly decreasing (p-value = 0.019 in left TFiC, p-value = 0.008 in left DTF), demonstrating the relation between the duration of ventilation and muscle function and that prolonged ventilation has a great impact on diaphragmatic effort and amplitude, on the other hand the control group measurements were significantly increasing at both right and left diaphragmatic and intercostals muscle fraction from day 1 to day 5 (p-value = 0.001 in left TFiC, p-value = 0.020 in left DTF). Conclusion: Musculoskeletal ultrasound can detect early diaphragm and intercostals muscle atrophy that was observed in most of the patients treated by invasive mechanical ventilation. [ABSTRACT FROM AUTHOR]

Background: We aimed to compare the effectiveness of bilateral erector spinae plane (ESP) block and superficial parasternal intercostal plane (S-PIP) + ESP block in acute post-sternotomy pain following cardiac surgery. Methods: Forty-seven patients aged between 18 and 80 years of age with American Society of Anesthesiologists class II–III due to undergo median sternotomy for cardiac surgery were included in this prospective, randomized, double-blinded study. Following randomization into two groups, one group received bilateral ultrasound-guided ESP and the other S-PIP plus ESP block. Morphine consumption within the first 24 h after surgery was the primary outcome of the study while NRS scores at rest, NRS scores when coughing, time taken until extubation, use of rescue analgesic, presence of nausea/vomiting, length of hospital and intensive care unit (ICU) stay, and patient satisfaction were secondary outcome measures. Results: Morphine use up to 24 h following surgery was statistically significantly different between the ESP block and ESP + S-PIP block groups (18.63 ± 6.60 [15.84–21.41] mg/24 h vs 14.41 ± 5.38 [12.08–16.74] mg/24 h, p = 0.021). The ESP + S-PIP block group had considerably reduced pain scores compared to the ESP block group across all time points. Rescue analgesics were required in 21 (87.5%) patients in the ESP block group and seven (30.4%) in the ESP + S-PIP group (p < 0.001). PONV, length of stay in the ICU and hospital, and time to extubation were similar between groups. Conclusions: In open cardiac surgery, the combination of ESP and S-PIP blocks lowers pain scores and postoperative morphine requirement of patients. Trial registration: Clinicaltrials Registration No: NCT05191953, Registration Date: 14/01/2022. [ABSTRACT FROM AUTHOR]

In the thorax of higher vertebrates, ribs and intercostal muscles play a decisive role in stability and respiratory movements of the body wall. They are derivatives of the somites, the ribs originating in the sclerotome and the intercostal muscles originating in the myotome. During thorax development, ribs and intercostal muscles extend into the lateral plate mesoderm and eventually contact the sternum during ventral closure. Here, we give a detailed description of the morphogenesis of ribs and thoracic muscles in the chicken embryo (Gallus gallus). Using Alcian blue staining as well as Sox9 and Desmin whole‐mount immunohistochemistry, we monitor synchronously the development of rib cartilage and intercostal muscle anlagen. We show that the muscle anlagen precede the rib anlagen during ventrolateral extension, which is in line with the inductive role of the myotome in rib differentiation. Our studies furthermore reveal the temporary formation of a previously unknown eighth rib in the chicken embryonic thorax. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the intra-rater reliability and agreement of diaphragm and intercostal muscle elasticity and thickness during tidal breathing. The diaphragm and intercostal muscle parameters were measured using shear wave elastography in adolescent athletes. To calculate intra-rater reliability, intraclass correlation coefficient (ICC) and Bland–Altman statistics were used. The reliability/agreement for one-day both muscle measurements (regardless of probe orientation) were at least moderate. During the seven-day interval between measurements, the reliability of a single measurement depended on the measured parameter, transducer orientation, respiratory phase, and muscle. Excellent reliability was found for diaphragm shear modulus at the peak of tidal expiration in transverse probe position (ICC3.1 = 0.91–0.96; ICC3.2 = 0.95), and from poor to excellent reliability for the intercostal muscle thickness at the peak of tidal inspiration with the longitudinal probe position (ICC3.1 = 0.26–0.95; ICC3.2 = 0.15). The overall reliability/agreement of the analysed data was higher for the diaphragm measurements (than the intercostal muscles) regardless of the respiratory phase and probe position. It is difficult to identify a more appropriate probe position to examine these muscles. The shear modulus/thickness of the diaphragm and intercostal muscles demonstrated good reliability/agreement so this appears to be a promising technique for their examination in athletes. [ABSTRACT FROM AUTHOR]

Case: The case of an active 16-year-old adolescent girl who presented with rib malunion and 1 year of unremitting intercostal nerve pain after sustaining multiple rib fractures is presented. She underwent successful bony and soft-tissue decompression of her eighth and ninth intercostal nerves to relieve neurogenic symptoms. Conclusion: When conservative treatment fails, chronic intercostal nerve pain due to chest wall trauma may be effectively managed with surgical bony decompression of the offending intercostal bundle(s). Anatomic knowledge of the intercostal nerve and a critical history and physical examination were critical for accurate diagnosis and surgical decompression of the patient's intercostal nerve. [ABSTRACT FROM AUTHOR]

This case report describes a 60-year-old female patient diagnosed with intercostal neuropathy and vertebral compression fractures which occurred following an electric shock injury. The patient received acupuncture, pharmacopuncture, and herbal medicine administration between February 10th, 2020 and April 25th, 2020. The pain level in the thoracic and left intercostal areas was assessed using the Numerical Rating Scale. The Self-report of the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale were used to diagnose neuropathic pain. The Neuropathic-Pain -Scale was used to evaluate the degree of neuropathic symptoms. The Oswestry Disability Index and the European Quality of Life-5 Dimensions were used to assess quality of life scales and functional disorder. Following combined Korean medicine treatment, the patient exhibited reduced levels of pain and significant improvement in functional disorder symptoms and quality of life.

To systematically evaluate the safety and advantages of subxiphoid approach video-assisted thoracic surgery (SA-VATS) compared with intercostal approach video-assisted thoracic surgery (IA-VATS) for lung resection, we conducted a meta-analysis of the current literature. The literature search was conducted in PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure. RevMan 5.3 software was used to perform this meta-analysis. Eleven studies involving 934 patients were included. Compared with patients in the IA-VATS group, those in the SA-VATS group had lower pain scores on the day of the operation and at 24 h, 48 h and 72 h after the operation (p <.001) and suffered from less postoperative paraesthesia at the first, third and sixth months after the operation (p <.001). Moreover, there was no statistically significant difference between the two groups regarding postoperative complications, intraoperative blood loss, length of hospital stay, drainage amount, or chest tube duration. However, SA-VATS had a longer operative time (p <.001). SA-VATS is a safe surgical technique and has superior postoperative outcomes over IA-VATS for lung resection in terms of acute postoperative pain and chronic postoperative paraesthesia. [ABSTRACT FROM AUTHOR]

OBJECTIVE: With this study, it was aimed to investigate whether the thoracic muscle mass of patients with coronavirus disease 2019 was related to disease severity and disease characteristics and to evaluate whether muscle mass measurement had a predictive effect on predicting disease severity. MATERIAL AND METHODS: Two hundred twenty-three subjects (patient group = 161 and control = 62) who presented to our coronavirus disease 2019 outpatient clinic between May 2020 and September 2020 were included in the study. The medication, oxygen, and intubation requirements of the patients and their disease duration and hospital stay were also recorded. At the T4 level, thoracic and back (pectoralis, intercostalis, paraspinals, serratus, and latissimus dorsi) muscles and at the T12 level erector spinae muscles were measured in terms of area (cm²). RESULTS: T4-level muscle cross-sectional area results were found to be negatively correlated with the presence of pneumonia and the requirement of oxygen and intubation. In addition, both T4- and T12-level muscle cross-sectional area results were factors associated with oxygen and intubation requirements. T4-level muscle cross-sectional area results were also associated with the presence of pneumonia. CONCLUSION: We predict that there may be a relationship between the decrease in the mass of the accessory respiratory muscles and the severity of the disease. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate cardiorespiratory responses and intercostal muscle oxygenation during normocapnic hyperpnea exercise in chronic obstructive pulmonary disease (COPD). Methods : Twenty-two patients with COPD performed a cardiopulmonary cycling exercise test to assess peak oxygen consumption (V[spacing dot above]O2peak) and minute ventilation (V[spacing dot above] Epeak). They also performed a normocapnic hyperpnea exercise alone, at 50%-60% of V[spacing dot above] Epeak to exhaustion, using a respiratory device (Spirotiger) connected to a gas analyzer to monitor V[spacing dot above]O2, V[spacing dot above] E, and end-tidal CO2 partial pressure. Cardiac output, and intercostal and vastus lateralis muscle oxygenation were continuously measured during exercise using finger photoplethysmography and near-infrared spectroscopy, respectively. Arterial blood gases (arterial PCO2) and inspiratory capacity were obtained at rest and at the end of hyperpnea exercise. Results : The hyperpnea exercise lasted 576 +/- 277 s at a V[spacing dot above] E of 34.5 +/- 12.1 L[middle dot]min-1 (58% +/- 6% of V[spacing dot above] Epeak), a respiratory rate of 22 +/- 4 breaths per minute, and a tidal volume of 1.43 +/- 0.43 L. From rest to the end of hyperpnea exercise, V[spacing dot above]O2 increased by 0.35 +/- 0.16 L[middle dot]min-1 (P < 0.001), whereas end-tidal CO2 partial pressure and arterial PCO2 decreased by ~2 mm Hg (P = 0.031) and ~5 mm Hg (P = 0.002, n = 13), respectively. Moreover, inspiratory capacity fell from 2.44 +/- 0.84 L at rest to 1.96 +/- 0.59 L (P = 0.002). During the same period, heart rate and cardiac output increased from 69 +/- 12 bpm and 4.94 +/- 1.15 L[middle dot]min-1 at rest to 87 +/- 17 bpm (P = 0.002) and 5.92 +/- 1.58 L[middle dot]min-1 (P = 0.007), respectively. During hyperpnea exercise, intercostal deoxyhemoglobin and total hemoglobin increased by 14.26% +/- 13.72% (P = 0.001) and 8.69% +/- 12.49% (P = 0.003) compared with their resting value. However, during the same period, vastus lateralis oxygenation remained stable (P > 0.05). Conclusions : In patients with COPD, normocapnic hyperpnea exercise provided a potent cardiorespiratory physiological stimulus, including dynamic hyperinflation, and increased intercostal deoxyhemoglobin consistent with enhanced requirement for muscle O2 extraction. [ABSTRACT FROM AUTHOR]

Study Objective We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block. Design A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block. Setting Cadaver lab and operating room. Patients Two unembalmed cadavers and 22 patients. Interventions Bilateral ultrasound-guided EOI blocks on cadavers with 29 mL of bupivacaine 0.25% with 1 mL of India ink; single-injection or continuous EOI blocks in patients. Measurements Dye spread in cadavers and loss of cutaneous sensation in patients. Main Results In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7 to T10. We also found consistent dermatomal sensory blockade of T6–T10 at the anterior axillary line and T6–T9 at the midline in patients receiving the EOI block. Conclusions We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7–T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6–T10 at the anterior axillary line and T6–T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia. [ABSTRACT FROM AUTHOR]

Needle decompression of tension pneumothorax in children is a rarely encountered but potentially life-saving procedure, that is accompanied by a certain risk of injury. We evaluated the nipple as a landmark for an alternative anterior insertion site and as an aid in localizing lateral insertion sites, as well as its influence on the safety profile of the procedure. In thoracic computer tomography scans of children aged 0–10 years, the distance to the closest vital structure was compared between the traditional anterior insertion site (2nd intercostal space midclavicular line) and an alternative anterior insertion site (2nd intercostal space at the nipple line). Furthermore, the level of the nipple at the midaxillary line was investigated as guidance in quickly localizing the lateral insertion site and ensuring an insertion site high enough to avoid intraabdominal injury by the decompression needle. Additionally, correlation of these measures with age was investigated. The distance to the closest vital structure at the 2nd intercostal space was significantly bigger at the nipple line compared to the midclavicular line (right: 2.23 ± 1.13 cm vs. 0.99 ± 0.80 cm, p < 0.0001; left: 1.92 ± 1.19 cm vs. 0.81 ± 0.70 cm, p < 0.0001). At the midaxillary line, the level of the nipple was at the 4th or 5th intercostal space in the majority of children (right: 83.8%; left: 88.1%). The mean distance from the nipple to the diaphragmatic cupola was 2.63 ± 1.85 cm on the right and 3.40 ± 1.86 cm on the left hemithorax. When performing anterior needle decompression in children, we recommend inserting the needle at the more lateral insertion site at the 2nd intercostal space at the nipple line. At the lateral decompression sites, the nipple can be used as a marker for localizing the correct intercostal space for insertion and thereby ensuring enough caudad distance to the diaphragm to avoid abdominal injury. [ABSTRACT FROM AUTHOR]

Purpose: Although breast‐conserving surgery‐axillary dissection (BCS‐AD) is a minimally invasive surgery, patients may suffer from moderate‐to‐severe pain. Several regional techniques can be used for pain control. The type II pectoral nerve block (PECS II) and the rhomboid intercostal block (RIB) are interfascial plane blocks that have been reported to provide effective analgesia after breast surgery. This study aims to compare the analgesic efficacy of the PECS II block and the RIB after breast surgery. Patients and Methods: Ninety female patients aged 18 to 65 years with American Society of Anesthesiologists (ASA) classes I and II physical status who underwent unilateral BCS‐AD surgery were included. Patients were divided into three groups (n = 30 in each): the PECS II group, the RIB group, or the control group. PECS II block and RIB were performed with 30 mL 0.25% bupivacaine. Ibuprofen 400 mg IV 3 × 1 was given in the postoperative period. A patient control analgesia device included a dose of 10 µg/mL fentanyl, which was prepared and connected to the patients. Results: There were no statistical differences between groups in terms of demographical data. Postoperative fentanyl consumption was significantly lower in the PECS II and RIB groups than the control group. The need for rescue analgesia use was significantly higher in the control group than the other groups. At all times, visual analog scale scores were significantly lower in the PECS II and RIB groups than the control group. Conclusions: The PECS II block and the RIB provide similar effective analgesia after BCS‐AD. [ABSTRACT FROM AUTHOR]

Background: To analyze the clinical effect of two different ways of minimally invasive transthoracic closure in children with ventricular septal defect (VSD).Methods: From January 2015 to July 2019, 294 children with VSD were enrolled in the Fujian Medical University Union Hospital. Patients were divided into two groups - those who underwent VSD closure through the left sternal fourth intercostal incision (group A: n = 95) and the lower sternal incision (group B: n = 129).Results: The operation time, bleeding volume, postoperative mechanical ventilation time, postoperative intensive care unit (ICU) monitoring time, postoperative hospitalization time and complication rate in group A were significantly lower than those in group B (P < 0.05). There was no significant difference between the two groups in the operation success rate, mechanical ventilation time and total hospitalization cost (P > 0.05).Conclusion: The transthoracic closure of ventricular septal defect through the left sternal fourth intercostal incision is feasible, safe, cosmetic, and worth popularizing. [ABSTRACT FROM AUTHOR]

The incidence of multiple lung cancer has been steadily increasing worldwide. Although cases of patients with lung cancers in the right upper and lower lobe have also become more frequently reported in clinical work, simultaneous right upper and lower lobectomy reports with the middle lobe preservation are still quite rare. A total of three patients with lung cancers in the right upper and lower lobe were included in the study. The patients underwent simultaneous right upper and lower lobectomy, whereas the remaining middle lobe was sutured and fixed to the intercostal muscle of the incision to prevent postoperative lobe torsion. There was no procedure to reduce residual space，such as phrenic nerve crush or thoracoplasty. All patients were discharged from the hospital 7 days after the operation. The chest tube was removed 5 days after the operation in two patients. One patient was discharged with the tube because of slight pulmonary leakage, and the tube was removed 2 weeks after the operation. Six months after the operation, the chest computer tomography showed that the middle lobe expanded well and no obvious cavity or pleural effusion was found. The suture of the remaining middle lobe and intercostal muscle of the incision is a simple and effective method that can be used to successfully avoid middle lobe torsion. This strategy is safe and can be used as the first choice for eligible patients. [ABSTRACT FROM AUTHOR]

The article presents the discussion on endotypic mechanisms of successful hypoglossal nerve stimulation for Obstructive Sleep Apnea. Topics include cuff electrode placing around the protruding branches of the hypoglossal nerve, a respiratory sensor placed in the intercostal muscles, and an implantable pulse generator generating the stimulation pulses; and pharyngeal muscle compensation calculating as the increase in airflow as ventilatory drive rising from normal level.

A posterior cervical defect featuring exposed spinal and occipital bone can be covered in various ways. The "ideal" flap should be a low-morbidity, pedicled locoregional flap that can reach the occiput. Cervical adjuvant radiation therapy may limit the coverage options, because many pedicles are located in areas that are often irradiated. Here, we describe a new surgical technique; we used a skin perforator flap pedicled by the intercostal muscle to cover a posterior cervical defect in a patient with metastatic squamous cell lung carcinoma. This technique is a valuable option; the flap originated from outside the irradiated area and reached the occiput. It adds to the options for cervical coverage in patients who require head-and-neck reconstruction. Level V: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. [ABSTRACT FROM AUTHOR]

Spine deformity during adolescent idiopathic scoliosis can induce a rib-cage deformity. This bone deformity can have direct consequences on the chest-wall muscles, including intercostal muscles, leading to respiratory impairments in individuals with severe cases. The aim of this study was to determine whether shear-wave elastography can be used to measure intercostal-muscle shear-wave speed (SWS) in healthy children and those with adolescent idiopathic scoliosis (AIS). Nineteen healthy participants and 16 with AIS took part. SWS measurements were taken by three operators, twice each. Average SWS was 2.3 ± 0.4 m/s, and inter-operator reproducibility was 0.2 m/s. SWS was significantly higher during apnea than in normal breathing (p < 0.01) in both groups. No significant difference was observed between groups in apnea or in normal breathing. Characterization of the intercostal muscles by ultrasound elastography is therefore feasible and reliable for children and adolescents with and without scoliosis. [ABSTRACT FROM AUTHOR]

Objective: Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space. Methods: A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient's axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces. Results: Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower. Conclusions: This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains. [ABSTRACT FROM AUTHOR]

Objective This study aimed to describe and validate a novel ultrasound-guided intercostal peripheral nerve stimulator implantation technique. Methods The fifth to tenth ribs on both sides of an unembalmed cadaveric specimen were localized using a 15–6-MHz linear array transducer, counting distally from T-1 bilaterally. A single interventionist then implanted 12 peripheral nerve stimulators on the fifth through tenth ribs, six MicroLeads on the left side and six StimRouters on the right side, using an in-plane lateral to medial approach to the inferior border of the corresponding rib. After all the stimulators were implanted, their location was confirmed using fluoroscopy. Gross anatomic dissection was later performed for each of the stimulators placed, and the distance of the lead from the intercostal nerve and pleura was noted. Results All leads were noted in an accurate position in the plane between the inner and innermost intercostal muscle, without any intrapleural placement. The distance of the leads from the intercostal nerves was on average 2.3 mm and 1.1 mm for MicroLead and StimRouter, respectively. Conclusions To our knowledge, this study is the first to determine the feasibility of ultrasound-guided peripheral nerve stimulator placement in close proximity to the pleura. All the stimulator leads were accurately placed using our ultrasound-guided technique and were within 0.5–3 mm from the intercostal nerve. Although this technique might prove technically challenging, the use of ultrasound for intercostal peripheral nerve stimulator implantation appears feasible and warrants further investigation to establish this as an acceptable technique for patients. [ABSTRACT FROM AUTHOR]

This study aimed to elucidate changes in diaphragm and accessory inspiratory muscle (sternocleidomastoid (SCM) muscle and intercostal muscle (IC)) function after a 6-week training program. Nineteen male elite collegiate swimmers were assigned to either a control group (n = 9) or training group (n = 10). The subjects in the training group performed 30 maximum inspirations at a load resistance of 50% of maximum inspiratory mouth pressure (PImax) using an inspiratory muscle training device. These were conducted twice per day and 6 days per week. At baseline and after 6 weeks, PImax, shear modulus of the diaphragm, and electromyograms (EMG) of the SCM and IC during a maximal inspiratory maneuver were evaluated. Relative change in PImax was greater in the training group than in controls. The shear modulus during a PImax maneuver had increased significantly in both groups after 6 weeks. EMG amplitudes of the SCM increased in the training group after 6 weeks, but not in the control group. EMG amplitudes of the IC did not change after 6 weeks in either group. These results suggest that 6-week inspiratory resistive training significantly improves the activation of the SCM, which could be one of the major mechanisms behind increases in inspiratory muscle strength after resistive training. Novelty Six-week inspiratory resistive training increased diaphragm stiffness during maximal inspiration maneuver. Six-week inspiratory resistive training increased electromyogram amplitudes of the sternocleidomastoid during maximal inspiration maneuver. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare muscle activation of the diaphragm (DIA), scalenes (SA), parasternal intercostals (PS), and sternomastoid (SM) during submaximal intermittent neck flexion (INF) versus submaximal inspiratory threshold loading (ITL) until task failure in healthy adults. Methods: Twelve healthy adults performed submaximal ITL or INF tests in random order for 2 d. Surface electromyography was monitored to acquire root mean square (RMS) and median power frequency (MPF) from the SA, PS, SM, and DIA. Maximal inspiratory pressures and maximal voluntary contraction for neck flexion were determined. Next, participants performed the first submaximal test—ITL or INF—targeting 50% ± 5% of the maximal inspiratory pressure or maximal voluntary contraction, respectively, until task failure. After a rest, they performed the other test until task failure. Two days later, they performed ITL and INF but in the opposite order. The Borg scale assessed breathlessness and perceived exertion. Results: Endurance times for ITL and INF were 38.1 and 26.3 min, respectively. INF activated three of four inspiratory muscles at higher average RMS (PS, SM, and SA) and at different MPF (PS, SM, and DIA but not SA) compared with ITL. During ITL, RMS did not change in the four inspiratory muscles over time, but MPF decreased in PS, SM, and SA (P < 0.04). In contrast, RMS increased in three of four inspiratory muscles (SM, PS, and SA) during INF, but MPF did not change throughout its duration. Borg rating was 3.9-fold greater than ITL compared with INF. Conclusion: At a similar percentage of maximal load, INF evokes greater activation of primary muscles of inspiration (PS and SA) and a major accessory muscle of inspiration (SM) compared with ITL during a prolonged submaximal protocol. [ABSTRACT FROM AUTHOR]

Background: The assessment of diaphragm function with diaphragm ultrasound seems to bring important clinical information to describe diaphragm work and weakness. When the diaphragm is weak, extradiaphragmatic muscles may play an important role, but whether ultrasound can also assess their activity and function is unknown. This study aimed to (1) evaluate the feasibility of measuring the thickening of the parasternal intercostal and investigate the responsiveness of this muscle to assisted ventilation; and (2) evaluate whether a combined evaluation of the parasternal and the diaphragm could predict failure of a spontaneous breathing trial.Methods: First, an exploratory evaluation of the parasternal in 23 healthy subjects. Second, the responsiveness of parasternal to several pressure support levels were studied in 16 patients. Last, parasternal activity was compared in presence or absence of diaphragm dysfunction (assessed by magnetic stimulation of the phrenic nerves and ultrasound) and in case of success/failure of a spontaneous breathing trial in 54 patients.Results: The parasternal was easily accessible in all patients. The interobserver reproducibility was good (intraclass correlation coefficient, 0.77 (95% CI, 0.53 to 0.89). There was a progressive decrease in parasternal muscle thickening fraction with increasing levels of pressure support (Spearman ρ = -0.61 [95% CI, -0.74 to -0.44]; P < 0.0001) and an inverse correlation between parasternal muscle thickening fraction and the pressure generating capacity of the diaphragm (Spearman ρ = -0.79 [95% CI, -0.87 to -0.66]; P < 0.0001). The parasternal muscle thickening fraction was higher in patients with diaphragm dysfunction: 17% (10 to 25) versus 5% (3 to 8), P < 0.0001. The pressure generating capacity of the diaphragm, the diaphragm thickening fraction and the parasternal thickening fraction similarly predicted failure or the spontaneous breathing trial.Conclusions: Ultrasound assessment of the parasternal intercostal muscle is feasible in the intensive care unit and provides novel information regarding the respiratory capacity load balance. [ABSTRACT FROM AUTHOR]

BACKGROUND: There are few reports in the literature supporting the understanding of the physiological mechanisms of intolerance in patients with COPD to perform unsupported upper limb activities. The aims of this study were to quantify the electrical activity and oxygenation of inspiratory and upper limb muscles, and to investigate whether electromyographic manifestations of muscle fatigue are related to upper limb function as assessed by the 6-min pegboard and ring test (6PBRT) in subjects with COPD and in healthy subjects. METHODS: Thirty subjects with COPD (FEV1 42.1 ± 16.4% predicted; 68.0 ± 7.6 y old) comprised the COPD group, and 34 healthy subjects (66.8 ± 8.0 y old) comprised the control group. Both groups were assessed for body composition with dual-energy radiograph absorptiometry and spirometry. The 6PBRT was performed with simultaneous assessment of electromyography, near-infrared spectroscopy, and gas analyses (expiratory minute volume). RESULTS: Differences were observed between groups for performance (number of rings) in the 6PBRT, with the COPD group achieving lower values than the control group (P < .001). The ventilatory demand (expiratory minute volume/maximum voluntary ventilation) and root mean square amplitude of the sternocleidomastoid muscle were higher in the COPD group than in the control group (P < .04). Lower values for oxyhemoglobin and total hemoglobin were found in intercostal muscles of the COPD group compared to the control group. The root mean square amplitude of the intercostal muscles was lower in the COPD group, while it was similar between groups for anterior deltoid and trapezius muscles. Median frequency of anterior deltoid muscles presented a decreased in both groups. CONCLUSIONS: Our results indicate that the 6PBRT was performed at a higher electrical activity in the accessory inspiratory muscles, such as the sternocleidomastoid muscle, and a lower oxygenation profile in the intercostal muscles in subjects with COPD compared with healthy controls, but without muscle fatigue signs. These findings suggest that the higher ventilatory demand presented in subjects with COPD could have contributed to the worse performance in this group without signals of peripheral muscle limitation. [ABSTRACT FROM AUTHOR]

This study assessed the intra-individual reliability of oxygen saturation in intercostal muscles (SmO2-m.intercostales) during an incremental maximal treadmill exercise by using portable NIRS devices in a test-retest study. Fifteen marathon runners (age, 24.9 ± 2.0 years; body mass index, 21.6 ± 2.3 kg·m−2; V̇O2-peak, 63.7 ± 5.9 mL·kg−1·min−1) were tested on two separate days, with a 7-day interval between the two measurements. Oxygen consumption (V̇O2) was assessed using the breath-by-breath method during the V̇O2-test, while SmO2 was determined using a portable commercial device, based in the near-infrared spectroscopy (NIRS) principle. The minute ventilation (VE), respiratory rate (RR), and tidal volume (Vt) were also monitored during the cardiopulmonary exercise test. For the SmO2-m.intercostales, the intraclass correlation coefficient (ICC) at rest, first (VT1) and second ventilatory (VT2) thresholds, and maximal stages were 0.90, 0.84, 0.92, and 0.93, respectively; the confidence intervals ranged from −10.8% – +9.5% to −15.3% – +12.5%. The reliability was good at low intensity (rest and VT1) and excellent at high intensity (VT2 and max). The Spearman correlation test revealed (p ≤ 0.001) an inverse association of SmO2-m.intercostales with V̇O2 (ρ = −0.64), VE (ρ = −0.73), RR (ρ = −0.70), and Vt (ρ = −0.63). The relationship with the ventilatory variables showed that increased breathing effort during exercise could be registered adequately using a NIRS portable device. [ABSTRACT FROM AUTHOR]

The importance of a procedure-specific pain management regime is being ardently discussed across diverse operative settings. The same becomes only more relevant in a peculiarly invasive cardiac surgical setting. In this context, we report the technical considerations of performing a rectus sheath block in cardiac surgery. [ABSTRACT FROM AUTHOR]