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The World Health Organization [WHO] estimates that more than half of medicines are either inappropriately prescribed, dispensed, or sold, as the vast majority of patients fail to take their medication properly [1]. Adding the fact that no drug, taken correctly, is completely risk-free, it becomes of the outmost importance to permanently monitor its safety, to ensure that, throughout its life cycle, the benefits of each drug outweigh the risks of its use [2]. Pharmacovigilance intends to promote patient care and safety as well as an effective assessment of the risk–benefit profile of drugs [3].
With declining fertility rates and greater and better access to health care, the population aged, and the number of older adults has increased globally [4].
Aging is a risk factor for the development of chronic diseases, and to an increased incidence of pathologies such as cardiovascular diseases, strokes, cancer, or dementias. In this sense, the older population is the age group that most needs health care and medicines [5, 6]. Polypharmacy, commonly defined as the concomitant use of at least five drugs, is thus prevalent in this age group [7, 8].
Associated with aging, pharmacodynamic and pharmacokinetic changes occur at physiological level, which implies modified pharmacological responses [9]. The older are much more susceptible to adverse reactions and drug interactions than any other age group [7, 8].
Since people aged 65 and older are underrepresented in clinical trials pharmacovigilance becomes essential to allow continuous monitoring of safety and the assessment of the benefit/risk of drugs in this population [10].
The impact of aging on the human organism brings together complex changes at the molecular, cellular and tissue levels in all systems of the organism, and the effects of the most varied existing environmental factors [11, 12].
The physiological changes associated with the aging process weaken the older population. These can cause significant changes in the pharmacokinetic and dynamic regimens of medications, making them more susceptible to adverse effects [13].
With aging, pharmacokinetics processes suffer modifications [9]. Bioavailability, the extent and rate at which the active substance enters the systemic circulation to reach the action site, can be modified [9, 14].
Absorption of most drugs does not appear to decrease significantly with age, but different pathologies of the digestive system may affect drug absorption [9]. Nevertheless, drugs administered intramuscularly or subcutaneously may have their absorption modified, due to the reduction in blood perfusion of the tissues [15].
After absorption, the drug enters the bloodstream and is distributed to different tissues and organs. With the increase in fat mass and reduction in the volume of water, the volume of distribution of fat-soluble medications increases [as does the half-life of the same], as in the case for the long-acting benzodiazepines [15, 16]. In contrast, water-soluble drugs may have a lower volume of distribution, with an increase in plasma concentrations, that can be toxic, as happens with gentamicin, digoxin, theophylline, and cimetidine [9, 16]. In addition to body composition, the two main proteins involved in the transport of drugs: albumin, which binds to acidic drugs [e.g. warfarin, digoxin, lorazepam], and α1-acid glycoprotein, which binds mainly to basic drugs [ex: lidocaine, propranolol] may have their plasma concentrations altered in older population with comorbidities [15, 17].
Although other organs can metabolize drugs, the liver is the main organ involved in the process. Metabolism consists of converting an active substance in simpler and more polar substances, called metabolites, from phase I and II reactions. These metabolites are inactive or have modified activity. In the liver, maintaining its functions during aging, there are changes that can reduce its functionality [18]. The hepatic volume decreases 20–30%, and the hepatic blood flow 20–50%. There is a reduction in the first-pass hepatic effect, and thus the bioavailability of drugs that are subjected to extensive first-pass metabolism may be increased, while others, which need activation in the liver, may be reduced [15]. In addition, the hepatic clearance of drugs subjected to limited flow metabolism [e.g., propranolol and amitriptyline] can be reduced by more than 40%. Age can significantly affect the pharmacokinetics of drugs with a narrow therapeutic index [reduced margin between an effective dose and a toxic dose]. Inflammatory conditions can also affect the function of the enzymes involved in metabolism. The microbial ecosystem also stands out, with many clinically relevant drugs being co-metabolized by microflora. With changes in the composition of the intestinal microbiome, the drug’s metabolism can also be altered with harmful consequences [19].
Excretion is also affected by the aging process. The kidney is the main organ in the removal of drugs and their metabolites and the pharmacokinetics are strongly influenced by the progressive loss of kidney function with age, thereby decreasing the excretion of drugs [20, 21]. Due to these changes, a decline in total clearance with age is expected for drugs predominantly excreted by this pathway. With the decrease in clearance, serum levels will increase, potentially causing ADR [22]. Therefore, the dosage of these drugs must be guided by kidney function and the glomerular filtration rate [GFR]. In addition, polypharmacy can increase the risk of kidney dysfunction, overloading the kidneys to excrete several drugs and their metabolites at the same time [23].
In older adults’ sensitivity, meaning the effects of the same concentration of a particular drug at the site of action, vary significantly when comparing with young or adult persons. This difference can be justified by changes in drug-receptor interaction, signal transduction, adaptive homeostatic responses and, among more fragile patients, by comorbidities [24, 25]. Although age-related pharmacokinetic changes are predictable, the complex interaction between pharmacokinetic changes and homeostatic changes makes it a difficult topic to study [15].
The most relevant pharmacodynamic changes are at the central nervous system [CNS] and cardiovascular level [15]. Older adults often demonstrate an exaggerated response to psychoactive drugs due to an underlying age-related decline in CNS function, and are also more prone to adverse effects with cognitive impairment, including confusion and drowsiness. At the cardiovascular level, they may experience a greater decline in blood pressure after administration of calcium channel blockers with or without dihydropyridine, which may be the result of related changes with age in the reflex of the baroreceptors, as well as a decreased clearance of these drugs [25, 26]. In addition, β-adrenergic receptors decrease in numbers and have less sensitivity and also show changes in the G-protein involved in signal transduction. As a result, β-adrenergic activity in vascular, cardiac and respiratory tissue decreases, altering the effect of β-blocking agents and β-agonists in general [26, 27].
Pharmacodynamics not only affects the therapeutic effects of the drug but can also change the magnitude of the effect with subsequent adverse effects [20, 25]. These changes in pharmacokinetics and pharmacodynamics can thus make the older population more prone and susceptible to ADRs, either in normal therapeutic doses or by drug interactions mechanisms [27].
As previous mentioned, physiological aging causes pharmacodynamic and pharmacokinetic changes, imposing different pharmacological responses [9]. The drug could trigger iatrogenic problems in the geriatric patient, increasing the risk of possible ADR [28].
The vast majority of ADRs can be divided in 2 types:
Dose-dependent, more frequent at higher doses, which can occur in any individual when exposed to a sufficient dose of the drug: Type A - Augmented, representing almost 80% of all ADR in older patients [29, 30]
Immune mediated or non-immunological hypersensitivity reactions, not dependent on the dose, which can occur in predisposed individual. These reactions are therefore unpredictable and more serious, usually detected only after the drug enters the market: Type B - Bizarre, representing 20% of all ADRs in older patients [29, 30, 31, 32].
Drugs associated with type A reactions are generally of low therapeutic index and are commonly used in older patients and therefore most ADRs in this age group are type A reactions with predictable pharmacological effect [30, 33]. Known homeostatic dysregulation, age-related changes in pharmacokinetics and pharmacodynamics and drug interactions make ADRs definitely or possibly preventable in this population. However, ADRs can be difficult to diagnose in older patients as they often have nonspecific symptoms, whether falls, fatigue, cognitive decline, or constipation, all of which have different etiologies [7]. Despite the difficulties it is estimated an average prevalence of 11% of ADR [33].
Most common ADRs causing hospitalization in older patients are related to Gastrointestinal complications [Gastrointestinal bleeding, peptic ulcer, erosive gastritis, nausea, vomiting]; Cardiovascular disorders [Hypotension, bradycardia, falls, arrhythmias] Metabolic/endocrine complications [Hypoglycemia]; Renal and urinary disorders [Renal impairment, acute renal failure]; Electrolyte disorders [Hypokalemia, hyperkalemia, hyponatremia]; Nervous system disorders [Depressed level of consciousness, mental status changes] [34]. Studies have shown that beta-blockers, antibiotics, oral anticoagulants, digoxin, ACE inhibitors, antineoplastics, calcium entry blockers, opioids, oral antidiabetics and most frequently NSAIDs as the main drug classes causing ADR hospitalization in older adults [33, 35].
ADRs cause a significant burden in healthcare services, representing 6.5% in hospital admissions, being responsible for death of 0.15% of the patients admitted. Besides, patients admitted with ADRs were significantly older than patients without ADRs, as hospitalization due to NSAIDs complications increases exponentially with aging, having an important impact in healthcare resources. The median prevalence of ADRs leading to hospitalization is 10%. Although some hospitalizations related to ADRs are inevitable, it is estimated that only 18.6–28% of ADR cases that caused hospitalization in older patients were considered inevitable. Severe ADRs are related mostly to hematological disorders and acute renal failure [33, 34].
Polypharmacy is one of the main risk factors for ADR in this population. The risk of ADR increases by 13% in patients taking two drugs to 58% when taking five and to 82% when taking seven or more drugs [4, 7]. Drug interactions, common in polypharmacy, can cause synergistic toxicity and thus be risk factors, such as the combination of corticosteroids and NSAIDs. Polypharmacy leads to problems in medication adherence and correct administration representing a risk for adverse events or ADR [31, 36, 37].
ADRs also have a strong economic impact in the health system. The costs involved in treatment are mainly associated with hospitalization, prolonged hospital stay and additional clinical investigations- Studies point to an average of 8 additional hospital stay days and costs of approximately 706 M € per year [38, 39]. Regarding avoidable ADRs, costs per hospitalization vary between € 2,851 - 9,015, with length of hospital stay between 4.2 and 13 days. In outpatient, the costs resulting from avoidable ADRs ranged between € 174 and € 8,515 [38]. Particularly in the elderly, an average cost of emergency care of 333 US $ is pointed, with severe ADR patients costing $ 691 per patient and $ 7,529 per patient with severe ADR during hospitalization [40].
ADRs can trigger cascades of prescription when new drugs are prescribed for problems resulting from another medication, which is usually an unknown ADR, increasing therapeutic costs, in addition to increasing the risk of new ADRs. Fever, hemorrhage, diarrhea and arrhythmia are those with the greatest economic burden in a hospital environment; and NSAIDs, antibiotics, anticoagulants and antineoplastics are the main classes involved in ADRs related costs [39].
Most drugs are suitable for the older, as long as they are used in the correct dose and for the necessary period. However, since they are more susceptible to adverse events, the potential risk of certain drugs may outweigh the potential benefit. When safer alternatives are available, these drugs are considered inappropriate [PIM] [28, 41].
In recent years, in order to reduce inappropriate prescribing, and in turn, to reduce the prevalence of PIM in older population, explicit and implicit criteria strategies and tools have been developed, being very useful in clinical practice, as decision support- Explicit criteria consists in lists of drugs applied with minimal information and clinical evaluation, not considering individual differences between patients, representing important alert mechanisms on the possibility of the inappropriate use of a medication just by itself, as where implicit criteria focus on the patient’s therapeutic regimen and clinical evaluation. Associating these criteria with information management tools such as Clinical decision support systems [CDSS] can allow improvements in patient therapy. These CSSDs, usually computerized, can verify interactions between medicine-disease or medicine-medicine, also detecting PIM [36].
Among the criteria most applied in research within this theme, Beers criteria stands out. In 1991, Beers and his research colleagues met with geriatric and pharmaceutical specialists to list the drugs to be avoided by older people. Explicit criteria were defined, considering 30 drugs/pharmacological groups considered inappropriate. These criteria have since been repeatedly reformulated and updated according to new information in the literature. Currently, these criteria are divided into 5 lists: Potentially inappropriate to be avoided in the elderly; Potentially inappropriate in the elderly due to drug–drug and/or drug-disease interactions; Those that should be prescribed with caution in the elderly; Combinations of drugs known to cause “drug–drug” interactions; Drugs to be avoided or whose dose adjustment is necessary when prescribed in elderly people with impaired renal function [42, 43]. However, its application in Europe is limited, where several of the drugs identified in these criteria are not commercialized in this continent and some of the drugs marketed in Europe are inappropriate and are not on the Beers list [44].
START/ STOPP criteria is also currently used. The STOPP [Screening Tool of Older Person’s potentially inappropriate Prescriptions] criteria are 80 parameters organized by physiological systems. The START [Screening Tool to Alert doctors to Right Treatment], on the other hand, identify potentially beneficial omissions [which should be prescribed to the elderly], with 34 criteria divided into six physiological systems [44]. STOPP/START have advantages over Beers because they are significantly associated with adverse drug reactions. In addition, they are more in line with the European reality, also having greater sensitivity demonstrated for the identification of inappropriate prescriptions. Although the STOPP criteria is explicit, only 29 of the 81 STOPP criteria can be applied only with information on the patient’s medication profile [36].
Recently, in order to develop a European list of potentially inappropriate drugs, 27 experts from 7 countries in Europe came together, creating the EU [7] -PIM list, with 282 drugs from 34 pharmacological classes in which it is found, for each drug, the justification for its inadequacy, as well as dose adjustments/special considerations of use [when applicable] and possible alternatives to that drug [45].
The EU [7]-PIM list has been used in some studies in Europe that show a range between 40.9 [Sweden] and 87% [Portugal] of older adults having PIM prescribed by the physician. Proton bomb inhibitors, Bromazepam, Diazepam, Lorazepam and Alprazolam are the most common [46].
ADRs related to PIMs were observed in some studies, with digoxin, benzodiazepines, and imipraminic antidepressants, being the most common. In hospitalized older patients, NSAIDs were the most common types of PIM-ADRs, inducing upper gastrointestinal bleeding. Benzodiazepines inducing falls with fractures and depressed mental status, as well as digoxin >0.125 mg/day inducing cardiac arrhythmias and visual disturbances due to digoxin poisoning are also common in hospital context [47, 48].
Older adults have a higher chronic diseases burden and consume more prescription drugs than any other age group. Besides drug–drug interactions, the prevalence of concurrent use of prescription drugs and herbal medicinal products [HMPs] by older adults is significant, and can also lead to serious ADR, as risk of bleeding due to the use concomitant use of
Including older patients in the clinical trial process is important, as on average older adults carry 60% of the national disease burden but represent only 32% of participants in Phase II and III clinical trials [50, 51]. This population is under-represented, especially the >75-year-old. and current guidelines recommend to have a significant number of older participants in the trials [that can be estimated with the help of epidemiological studies targeting the disease that the drug intends to treat] in order to assess the risk–benefit ratio of the drug in this age group. Phase I trials might not need older participants, but phase II and III clinical trials should include them, to assess dosage, safety, adverse effects, and effectiveness [52, 53]. Decentralized clinical trials could facilitate the appropriate inclusion of these patients [50].
Nevertheless, including this age group implies some methodological considerations. As it exists a progressive impairment of the renal or hepatic function or drug–drug interactions, an appropriate assessment of pharmacokinetic profiles and pharmacodynamic endpoints are needed [54, 55]. Besides, since they have a high risk of cognitive function impairment, determining adverse CNS events is of the outmost relevant clinical importance during the trial design. Aware of these needs, the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use [ICH] developed guidelines for studies in special populations, namely older adults, aiming for a sufficient representation in phase III. It is advisable 100 minimum participants and, when the disease is associated with aging, older people should form most of the participants [55, 56].
These studies should compare older and younger patients or evaluate drug disease interaction studies in older adults. Population pharmacokinetic analyses intends to determine the sources and correlation of variability of the drug concentration in the target patient population, comparing the older with the young group. Safety and efficacy should also be of the outmost importance, as outcomes must be explored to provide evidence base support to the dose selection during drug approval, impacting regulatory procedures. Finding significant differences in safety and efficacy outcomes between young and older patients, pharmacokinetic studies plays an important role to understand these differences and assess benefit–risk of a drug administration [55, 56, 57].
After drug development, providing quality information to health care professionals about the safe and effective use of drugs in geriatric patients is fundamental. And so, it is required by the Food and Drug Administration [FDA] and the European Medicines Agency [EMA] that the labeling of these drugs must have safety and efficacy information for the older. Particularly for EMA, it is mandatory to present on the Summary of Product Characteristics [SmPC] and the Patient Information Leaflet information regarding dosage, frequency and seriousness of ADR, or the need of monitoring in this population [57, 58].
Pharmacovigilance plays a key role in ADR detection in post authorization period, improving the safe and rational drug use and thereby improving patient care [59, 52]. In 2012, new legislation came into force within EU, creating the Pharmacovigilance Risk Assessment Committee and giving a central role to pharmacovigilance. A significant increase in the participation of health professionals and patients in the system was seen, and the electronic transmission of information from Pharmacovigilance became mandatory in November 2005, with EudraVigilance being the system for analyzing and managing information on suspected ADR, allowing the electronic exchange of reports of ADR cases, used by the various partners of the European regulatory network to monitor the safety of medicines [60].
A strong pharmacovigilance system can perform safety surveillance with processes, tools, and experts to monitor ADRs from medication taken by older patients. During this post-authorization surveillance, safety risks may be detected, particularly in patients with comorbidity and polypharmacy, suffering physiologic changes inherent to the aging process [61, 62]. Adequate pharmacovigilance systems considering HMPs is also necessary to increase the likelihood of ADR detection, and appropriately identify and manage older patients at risk [49, 63].
Risk management plans [RMP] must also be submitted to EMA when applying for a marketing authorization, including relevant information on medicine’s safety profile, how the risks will be prevented or minimized and how to promote knowledge regarding safety and efficacy of a determined drug. The elaboration of this document allows the understanding of safety concerns in older adults, planning how to reduce the possibility of suffering ADR. The RMP must be modified whenever it is determined important safety risks, as well as the labeling [54, 64].
Nevertheless, signal detection using spontaneous reporting systems is one of the most important sources for safety monitoring in post authorization “real-life” setting, especially in populations underrepresented in preapproval clinical trials such as older adults [61, 62]. Even tough underreporting, low sensitivity and selectivity are disadvantages to be considered regarding this reporting system, the fact that broadens all medicines on the market throughout all the life cycle, in all patients, not interfering with prescription habits, not only allows the identification of common ADR, as well as rare, unexpected ADRs in groups and scenarios not studied, as the older patients. This makes spontaneous reporting a fundamental report system for the safety monitoring of approved medicines [60, 65]. Due to the widespread of under-reporting of ADRs to spontaneous reporting systems, including serious or severe ADRs, the use of new technology is a great opportunity to empower patients to report, such as the programmes WEB-RADR [66] in Europe and Medwatch [67] in the United States. Although these tools were developed to facilitate reporting by both healthcare professionals and patients, a better understanding of the relation that the older patients have with health technologies is need [68].
In the European Economic Area [EEA], the electronic transmission of information from Pharmacovigilance became mandatory in November 2005, with EudraVigilance being the system for analyzing and managing information on suspected ADR, facilitating electronic exchange of individual case safety reports between EMA, national competent authorities, marketing authorization holders and sponsors of clinical trials in the EEA, as it allows early detection and evaluation of possible safety signals [60, 69].
EudraVigilance allows researchers and/or interested readers to perform same analysis in the ADR database EudraVigilance of the EMA, even though with different levels of access for different stakeholders. As some studies explore national databases, some studies have explored EudraVigilance database, accessing suspected medication and common ADR reported in older adults. Antineoplastic and immunomodulating agents, Nervous system, Cardiovascular system, Blood, and blood forming organs represent a significant part of suspected medication spontaneously reported in elderly. Rash, Confusional state, Dizziness, Pruritus, Pyrexia, Thrombocytopenia, Diarrhea, Vomiting, Dyspnea and Nausea are the most reported Preferred Terms in elderly spontaneous cases [62, 70, 71].
Older adults, having comorbidities, in polypharmacy regimens, associated with physiological age-related changes, are more susceptible to ADRs. With the demographic aging being a reality worldwide, the healthcare demand increases, as well as drug safety vigilance efforts.
Only recently older people start to have a significant presence in clinical trials. Pharmaceutical companies and the regulatory agencies joined efforts to provide evidence on the benefits and harms of medicines in older patients, giving more importance to efficacy and safety during drug development targeting diseases mostly related with aging or chronic diseases.
Pharmacovigilance regulatory agencies at a local and national level should promote monitoring and reporting programs of adverse effects observed, particularly in older populations, adding reliable safety data and identifying age related.
Drug safety studies in this age group need to be constantly improved to present evidence-based data to enhance quality of prescriptions in a highly healthcare demanding age group.
This work was financially supported by the project APIMedOlder [PTDC/MED-FAR/31598/2017], funded by FEDER, through COMPETE2020 – Programa Operacional Competitividade e Internacionalização [POCI-01-0145-FEDER-031598], and by national funds [OE], through FCT/MCTES. Replace the entirety of this text with acknowledgments.
The authors declare no conflict of interest.
ADR | Adverse drug reaction |
CDSS | Clinical decision support systems |
CNS | Central nervous system |
EEA | European Economic Area |
EMA | European Medicines Agency |
FDA | Food and Drug Administration |
GFR | Glomerular Filtration Rate |
ICH | International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use |
NSAID | Non-steroid anti-inflammatory drug |
RMP | Risk Management Plan |
SmPC | Summary of Product Characteristics |
WHO | World Health Organization |
Insertion of intercostal drainage (ICD) tube is a common procedure that is required to drain the abnormal intrapleural collection. As the name implies, it is insertion of a tube through the intercostal space to facilitate the drainage of abnormal collection in the pleural cavity. The procedure is also known as tube thoracostomy and thoracostomy drainage. The earliest reports of thoracic drainage dates back to 5th century BC [1, 2].
The aim of thoracostomy drainage is to:
Remove fluid and air from pleural cavity as promptly as possible.
Prevent drained air and fluid from returning to pleural cavity.
Restore negative pressure in pleural cavity to help re-expand the lung.
Although, the procedure has been in practice since long, there is still no consensus in the management of chest tubes and there remains great variability in practice. The procedure of inserting a chest tube is simple, definitive in treating a majority of thoracic pathologies and may be life-saving in certain situations. However, improperly placed chest tubes and poor post-procedural care may increase the morbidity and is associated with complications in up to 40% of patients [3, 4]. It is therefore imperative that all clinicians should be well versed with this simple yet life-saving procedure.
In this chapter, we will discuss various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.
An ideal thoracostomy tube should:
Allow collected air and fluid to drain out from the chest.
Contain a one-way valve to prevent air and fluid from returning back into the chest.
Allow maintenance of negative intra-pleural pressure (the normal intrapleural pressure is −3 mmHg that decreases further on inspiration).
Have provision for applying higher negative pressure to help in expanding the lung.
Allow accurate measurement of drained fluid and air.
Tube thoracostomy is required to drain any abnormal collection in the pleural cavity, that includes:
Air: Pneumothorax
Fluid: Pleural effusion
Blood: Hemothorax
Pus: Empyema
Chyle: Chylothorax
Prophylactically following cardio-thoracic surgery to drain post-operative collection of air, fluid or blood
The modern, commercially available chest tubes are soft and pliable that are either made up of Polyvinyl chloride (PVC) or silicone (Figure 1).
Intercostal drainage tube (chest tube).
The red rubber or malecot tube drains (Figure 2) are sometimes used as thoracostomy tubes mostly in resource constraint settings because of their low-cost, however their use is not advisable as they are difficult to retain, get kinked easily, wither rapidly and at times may break.
Malecot (red rubber) tube drain.
Chest tubes come in various sizes from 6 French gauge (F) to 40 F. Larger the size of the tube, greater is its diameter. One F is equal to 0.033 cm. To know the diameter of the tube from the F size, one need to multiply F size by a factor of 0.033, so a chest tube of size 24 F will have an internal diameter of approximately 0.8 cm.
Some chest tubes are available with metallic trocar that has a pointed end (Figure 3).
Chest tube with metallic trocar.
These are meant to insert in intercostal space after making a small skin incision, without dissecting the intercostal muscles. Although, this makes the procedure fast, there is a higher risk of injury to the intrathoracic organs and as such use of chest tubes with trocars should be discouraged [3, 5, 6]. Most of the chest tubes are open from one end while the other end is sealed. There are side holes or eyes on the tube and the markings are printed on it. There also is a radiopaque line all along the length of the tube that helps in identifying the position of the chest tube on X-ray (Figures 1 and 4).
Radiopaque line in the chest tube visible on x-ray (arrow).
Insertion of ICD tube is a surgical procedure and like any other surgery, a written informed consent is required prior to the procedure. Consent may not be possible in cases where the patient requires urgent tube thoracostomy as a lifesaving measure and when he/ she is unconscious, unattended or is in extremis.
Following instruments and equipment are required for inserting the chest tube. One must ensure the availability of all necessary equipment beforehand to avoid any difficulty during the procedure.
5 ml syringe with a suitable local anesthetic. Preferably 2% lidocaine with adrenaline.
Sponge holding forceps
Bowl with solution for painting
Number 11 surgical blade with handle
Sheets for draping
A pair of medium sized curved artery forceps
An appropriately sized chest tube: See the section on ‘selecting the size of chest tube.
Silk No.1 suture on cutting needle
Needle holder
A pair of tooth forceps
Prepared underwater seal bottle or bag.
Gauze pieces
Adhesive tape for dressing
The chest tubes are available in various sizes ranging from 6 F to 40 F. There is a general understanding that large-bore tubes are required to drain fluid and small-bore tubes are sufficient to drain air. There have been numerous studies on this issue, however there is no conclusive scientific data to support this idea. Large-bore tubes have been related to higher incidence of pain and patient discomfort without any significant advantage in draining the intra-pleural fluid. In various studies, small-bore tubes have been found to be equally effective to drain pleural effusion and hemothorax [7, 8, 9, 10, 11]. This has generated wider interest in use of small-bore tubes for thoracostomy. Conventionally, for most of the clinical conditions requiring tube thoracostomy a 24–32 F chest tube is inserted, depending on the expected underlying pathology, however tubes smaller than 24 F may be sufficient to drain pneumothorax.
The reservoirs for collecting the pleural drainage are available either in the form of bags or single or multiple chambered plastic bottles (Figure 5A and B).
A: Two chambered plastic bottle and B: ICD bag.
In both of these reservoirs, there are markings for calculation of effluent. In addition, there is also a marking for ‘initial fluid level’. Before connecting the reservoir to the chest tube, a sterile fluid like normal saline should be filled till this mark. As the chest tube is connected with the tube in the reservoir that remains below the ‘initial fluid level’, the air from the environment cannot gain access to the pleural cavity, however the intrapleural collection may egress easily into the reservoir, thus it functions as a one-way valve or ‘under water seal’.
Any suitable local anesthetic is appropriate for the procedure. Plain Lidocaine 2% solution and Lidocaine 2% with adrenaline are commonly used drugs for ICD insertion. A volume of nearly 5 ml is sufficient to anesthetize the local site. Local anesthesia may not be required where the patient is obtunded or unconscious and ICD insertion is required urgently.
The step by step procedure is demonstrated in the video supplemented with this article.
Inserting Intercostal drainage tube: step by step.
Although the ICD can be inserted while the patient is sitting, leaning forward with the forearms resting over a stool, the supine position is less cumbersome and more comfortable for both patient and the doctor. In addition, the patient may not be able to sit for the procedure due to the underlying clinical condition. We prefer to insert ICD tube in supine position. The patient lies on the table close to the edge with arm abducted over the head if possible.
The ideal site of inserting ICD is 4th or 5th intercostal space just anterior to the mid axillary line. One may calculate the desired intercostal space by considering sternal angle as landmark. The rib attached to the level of sternal angle is the second rib, subsequent ribs can be counted while palpating the chest wall distally and laterally. There is an alternative way of counting the ribs and the intercostal spaces which is quick and is particularly helpful in obese patients and in presence of subcutaneous emphysema. The level of the nipple in males and inframammary crease in females can be taken as a reference point- a line drawn from this point laterally to a point where it intersects the mid-axillary line is marked and the site for insertion of the chest tube is just anterior to this.
In case, the chest tube is being inserted prophylactically during thoracic surgery, the site of insertion is selected under vision in appropriate intercostal space.
A wide area around the predetermined site of ICD insertion is painted with a suitable antimicrobial solution (Chlorhexidine or Povidone-iodine) and is draped. If the patient is awake and conscious, 5 ml of local anesthetic solution (preferably 2% lidocaine with adrenaline) is infiltrated in the overlying skin, intercostal muscles and pleura at the site of ICD insertion. Before injecting the local anesthetic, one should ensure that the needle is not in a blood vessel by pulling the plunger of the syringe back. For the adequate effect of local anesthesia, it is prudent to wait for at least 2 minutes before making the incision.
An incision measuring nearly 1.5–2 cms is made by a number 11 surgical blade at the predetermined site of ICD insertion along the long axis of the rib in the intercostal space just over the upper border of the lower rib. This is done to prevent injury to the neurovascular bundle that runs along the lower border of the ribs.
Using a medium sized curved hemostatic clamp, the subcutaneous tissues and inter-costal muscles are dissected bluntly till the parietal pleura is reached. By the tip of the closed hemostatic clamp, gentle pressure is then applied till there is a feeling of ‘give way’ which marks the entry into the pleural cavity. The entry into the pleural cavity is also confirmed by the escape of intra-pleural collection like air, fluid or blood (as the case may be). One should be careful enough not to apply undue force while puncturing the pleura as this may cause injury to lungs or mediastinal structures. The jaws of the hemostatic clamp are then opened while withdrawing the instrument to increase the size of the thoracostomy wide enough to allow the entry of index finger. This should be followed by ‘finger thoracostomy’. The index finger is inserted through the thoracostomy site to explore the pleural cavity for presence of any pleuro-pulmonary adhesions. In case they are present, adhesiolysis is performed to create space inside the pleural cavity for the chest tube. This step is important as attempts to insert a chest tube without ensuring space between the lung and the chest wall may injure the lung, cause air leak from the damaged lung parenchyma and such improperly placed tube may fail to drain the intra-pleural collection.
Following finger thoracostomy and ensuring safe space inside the pleural cavity to accommodate the chest tube, an adequately sized chest tube is then taken. The tip of the tube from the open end (the end that should lie inside the thoracic cavity) is held with the tip of the hemostatic clamp and the rest of the tube is held parallel to the instrument. The tube is introduced inside the pleural cavity, the instrument is then released and the tube is inserted gradually by guiding it to lie posteriorly and superiorly by using the same instrument aided by the index finger of the opposite hand to the point till the last eye (hole) on the chest tube is at least 5 cms inside the pleural cavity (this can be confirmed by looking at the markings over the chest tube). The limit to which the ICD tube needs to be put in depends on the build of the patient. In a patient with an average built a length till 8–12 cms inside the chest is sufficient.
The tube is then clamped by using an artery forceps (hemostatic clamp) close to its distal (closed) end. The end of the chest tube is now cut and is connected with the tubing of the underwater seal using the connector provided with the chest tube. The length of the tube of under-water seal apparatus should not be unduly long as the fluid column in the tube will provide resistance to the egress of intrapleural collection compromising the drainage. A good rule is not to allow any loop in the draining tube between the connector and the tubing of the reservoir.
The chest tube is then fixed by silk suture no.1. For better fixity, it should be anchored on either side. While fixing, one must ensure to take deep bites through the soft tissues close to the tube. Fixing the tube by taking superficial bites (including skin only) may leave potential space around the tube at the site of entry in the intercostal space which may lead to subcutaneous emphysema in cases of pneumothorax and may increase morbidity. Some clinicians prefer purse string suture for fixation of the tube but that leaves an ugly scar following removal of the chest tube and as such is not necessary. A dressing is now applied at the ICD site and the tube may then firmly be reinforced at the site by using adhesive tapes. This completes the procedure.
The free drainage of the collected material from the pleural cavity and the movement of the column of the fluid in the tube confirms the adequate position of the chest tube. The chest should now be auscultated, improvement in the breath sounds suggests success of the procedure. A chest X-ray is then performed for confirmation of proper positioning of the tube radiologically.
Some authors advocate creation of an oblique passage or ‘tunnel’ in the chest wall to insert the tube, primarily to decrease the incidence of recurrent pneumothorax following removal of the chest tube [12]. In this technique incision is made one intercostal space below the pre-determined site of thoracostomy, the skin and soft tissues of the chest wall are then bluntly dissected to reach the site of thoracostomy thereby creating a curved passage through the chest wall for introduction of the chest tube. This requires additional time at the expense of no added advantage and therefore is not required.
Utmost care should be exercised while nursing a patient with chest tube. The reservoir should remain below the level of the chest at all times. Raising the reservoir above the chest level may result in passage of the fluid from the reservoir back into the pleural cavity. While turning or shifting the patient, one must ensure that the tube is not held or entangled in the patient’s bed. This may result in accidental displacement or dismantling of the tube. The outlet of the reservoir should remain open at all times especially in patients with pneumothorax or air leak. The closed outlet of the reservoir may lead to failure of decompression of pneumothorax leading to development of life-threatening tension pneumothorax. For the same reason, the tube should not be clamped at any time except while changing the fluid in the reservoir, collecting a sample of effluent or while planning to remove the chest tube. The patient should be closely monitored during this period.
The patient should be motivated for active physiotherapy and incentive spirometry (Figure 6).
Patient performing incentive spirometry.
This aids in faster resolution of pleural collection and thereby early removal of the ICD tube. In case, the patient is unable to do active physiotherapy, passive physiotherapy should be performed. All efforts must be made to ambulate the patient early. The chest tube must be secured carefully while patient mobilizes and the drainage bag (reservoir) should be kept well below the thoracostomy site.
The ICD site should be carefully examined every day for signs of local infection like peri-tubal inflammation or tenderness. The dressing needs to be changed in case it is soaked. Extreme care must be taken while dressing the ICD site lest the tube is displaced or dismantled. The patient should be clinically monitored every day and the volume of drained fluid should be charted carefully in the patient’s record. The reservoir should be emptied once it is full up to 3/4 of its capacity. A new reservoir with prepared under water seal or disposable reservoir (in case of digital chest tube drainage systems) is kept ready while changing the reservoir. In resource constraint settings the same reservoir may be reused. It is important to follow universal precautions while changing the reservoir. The chest tube is clamped and the filled reservoir is disconnected from the tube, the new reservoir is then connected or fluid is filled up to the ‘initial water level’ mark (or till the outlet tube is at least 2 cms below the water level) in case one contemplates to use the same reservoir. Once the reservoir is reattached, the tube is unclamped. It is important to prepare the equipment beforehand while changing the reservoir to keep the time of occlusion of the chest tube to minimum possible.
The practice of performing daily x-ray has been questioned by many authors and it is suggested that this may not be required if there is pleura to pleura apposition in the post-procedure x-ray and the patient is improving clinically [13].
Appropriate oral or parenteral analgesics are administered depending on the underlying condition for which tube thoracostomy was necessitated. There has been much debate on the use of antibiotics following tube thoracostomy. There is no evidence to support the routine use of prophylactic antibiotic therapy following the procedure [14, 15]. However, the antibiotics may be needed for other associated causes for which tube thoracostomy was performed like in empyema thoracis or in a patient of trauma with soft tissue injuries.
The use of controlled suction (−10 to −15 cm saline) to the outlet of the reservoir may help in faster resolution of intrapleural collection and promote early pleura to pleura approximation. This is most useful following pulmonary resections and may decrease the incidence of persistent post-operative space problems. In our practice, we apply overnight suction in patients undergoing pulmonary resection surgery (except following pneumonectomy). At times, the application of suction may result in pleural pain, the amount of suction should be decreased in such situations. In case of increased air leak on application of suction, the suction may be decreased or avoided altogether.
Blockage of thoracostomy tube is not uncommon and occur frequently in hemothorax. Careful observation of the ICD tube and the ensuring drainage of the fluid are paramount to detect this complication early. If appropriate measures are taken in time, the possibility of maintaining the tube patency are high.
Various manipulations can be performed to restore the patency of blocked ICD tube. These include tapping, milking and stripping of the tube. These measures are successful only with partial blockage of the tube and should not be performed routinely to prevent blockage. There is theoretical possibility of generation of high intrapleural pressures with stripping and milking. Some authors have raised concern that this may cause pulmonary injury, however we have not observed any clinically significant adverse effects of these procedures. The practice of flushing the blocked tube by instilling sterile solutions should be discouraged as this may increase the chances of introducing infection from outside with resultant increase in the incidence of empyema. Some clinicians have used novel methods like using a fogarty balloon catheter to unblock the chest tube [16] or use of advanced systems to either prevent clot formation inside the tube [17] or wipe the inside of tube to unblock it [18].
A loop is formed in the ICD tube and the intrapleural fluid is allowed to accumulate in this loop. The tube is then clamped proximal to this collected fluid. With all aseptic measures the external surface of the ICD tube near its connection with the tubing of the reservoir is cleaned with alcohol based antiseptic solution. The tube is then disconnected from this end and the sample is collected in a sterile container. The ICD tube is then reconnected with the reservoir tube and is unclamped.
There are no fixed or universally agreed criteria that applies to all patients for guiding removal of the thoracostomy tube. There is great heterogeneity in practice, however the rule of thumb is that the chest tube should be removed once it has served its purpose. If the patient is clinically well, there is no more air leak than on forced expiration, no expanding subcutaneous emphysema, no blood, pus or chyle in the effluent and the volume of the fluid being drained is less than 250 ml, the tube can be safely removed. In case of residual space following pulmonary resection with persistent low volume air leak (no more than on forced expiration) beyond day 5, the chest tube may be clamped for up to 24 hours and a repeat x-ray is performed. The patient should be closely monitored during this period for tachypnoea or dyspnea. In case the patient remains asymptomatic and the pneumothorax does not worsen, the chest tube may be removed. The same may be done in case of persistent non-expanding effusion. This practice however, carries the risk of serious side effects if the patient monitoring following clamping of the tube is not diligent. The use of digital chest tube drainage devices might obviate this risk. The chest tube may be safely removed if the air leak is <40 ml/ min over 24 hours [19]. Alternatively, in patients with prolonged air leak (beyond day 5), a Heimlich valve may be applied to the chest tube and the patient may be followed on outpatient basis with a plan to remove the tube later allowing more opportunity for the residual lung to expand. We have recently proposed a protocol for removal of chest tubes following thoracic surgery that have enabled us to decrease the chest tube indwelling time [20].
In some specialties like Colorectal and Gynecological Surgery, the Enhanced Recovery After Surgery (ERAS) protocol has been well established. This has recently been proposed for patients undergoing oncological major lung resection surgery too. The guidelines suggest that chest tubes may safely be removed with a non-chylous fluid output of up to 450 ml/ day in absence of air leak or minimal air leak detected by the digital chest tube drainage systems [21].
The view is equally divided regarding removal of the chest tube during end-inspiration or end-expiration [22, 23]. In a Randomized Controlled Trial by Bell RL et al., there was no significant difference between the complications following removal of the chest tube at either the height of inspiration or expiration and both methods were considered safe [23]. The incidence of recurrent pneumothorax is likely to be multifactorial and correlates poorly to the method of chest tube removal alone [23, 24]. We prefer to remove the chest tube by a swift motion followed immediately by sealing of the thoracostomy wound by appropriate dressing material irrespective of the phase of respiration.
The complications of tube thoracostomy may be divided into 3 phases:
During insertion of the tube:
Hemorrhage from the ICD site
Injury to the lung and the mediastinal structures
Misplacement of the tube
During the indwelling time of the chest tube:
Displacement or dislodgement of the tube
Subcutaneous emphysema
Kinking
Blockage
Fracture of the tube
Empyema thoracis
Wound infection
Re-expansion pulmonary edema
Following removal of the tube
Recurrent pneumothorax or pleural effusion
Thoracostomy site pain
Hemorrhage from the ICD site may be avoided by carefully siting the thoracostomy incision on the upper border of the lower rib in the desired intercostal space. This avoids the damage to the neurovascular bundle that runs along the lower border of the rib. All aseptic measures should be taken while inserting the chest tube and later while handling the tube during the post procedural care to prevent wound infection and empyema. Care should be exercised while nursing and mobilizing the patient with chest tube to prevent accidental displacement or dislodgement of the tube.
To prevent re-expansion pulmonary edema, the pleural cavity should be gradually decompressed. Sudden evacuation of more than one liter of fluid from the thoracic cavity should be avoided. It is desirable to monitor the intrapleural pressure while draining large amount of fluid from the pleural cavity. The intrapleural pressure should not be allowed to fall below −20 cm saline at any point of time.
A pitfall is different from complication and is defined as a hidden or unsuspected danger or difficulty that may lead to adverse events. The awareness of a pitfall and preparation to act swiftly in such eventuality may help in averting the complication arising from it. Following are the common pitfalls in ICD tube management:
Missed diagnosis: ICD tube placed in a patient with large diaphragmatic hernia suspecting it to be a loculated pneumothorax. A careful history and diligent look at the x-ray will avoid this pitfall (Figure 7A and B).
Placement of ICD on wrong side: One should confirm the side with pathology before putting the chest tube. The history of the patient, clinical notes and the radiological findings should be correlated to correctly identify the side of pathology.
A large thoracostomy incision may result in potential space around the chest tube. This coupled with fixation of the tube by superficial skin suturing results in development of a closed plane in the subcutaneous tissues. Peri-tubal air leak in this situation may lead to massive surgical emphysema with attended morbidity and mortality.
Avoiding digital exploration of the pleural cavity may result in injury to pulmonary parenchyma in addition to improper positioning and kinking of the tube (Figure 8).
One must perform ‘finger thoracostomy’ before inserting the chest tube to avoid this from happening.
Use of tubes with trocar and applying undue force while gaining entry to the pleural cavity may result in injury to various thoracic, mediastinal or intra-abdominal organs.
Poor placement result in a tube that may be:
Too in: may impinge on to the mediastinal structures (Figure 9A and B).
Too out: the eye (hole) of the tube may lie in the subcutaneous tissues with resultant subcutaneous emphysema (Figure 10).
Mispositioned or kinked resulting in poor drainage (Figures 11–14).
Poor fixation of the chest tube may result in accidental displacement or dislodgement (Figure 11). The chest tube should be anchored properly with number 1 silk suture. An additional suture from the opposite side improves the fixation and decreases the chances of this mishap.
Improper filling of the reservoir (under water seal) with sterile solution so that the outlet tube is not beneath the water column may result in pneumothorax.
Raising the reservoir above the level of the chest may result in drainage of the collected material back into the thoracic cavity. The reservoir should remain below the chest level of the patient at all times.
Clamping the tube while shifting or mobilizing the patient may result in tension pneumothorax. The outlet of the reservoir should be kept open at all times to prevent this.
A: Left sided diaphragmatic hernia with large gastric shadow. B: Chest tube inserted in a patient of diaphragmatic hernia misdiagnosed as hydropneumothorax.
A kinked chest tube.
A & B: Chest tube impinging on mediastinal structures.
Eye of chest tube in subcutaneous tissues with subcutaneous emphysema.
Chest tube (arrow) about to come out.
Chest tube lying outside the chest wall.
Mispositioned tube over the diaphragm (arrow).
Mispositioned tube lying in abdomen (arrow).
With the advancement in technology, newer equipment has become available that may help in decreasing some of the complications associated with the tube thoracostomy, make the assessment of drainage more objective and accurate thus helping in better management of ICD tubes. Some of the advancement in the recent times are:
Devices for better fixation of the chest tubes: Some devices are available that claim better fixation of the chest tubes [25], others have been tested on animal models and may soon become available [26].
Digital chest tube drainage systems: This has been perhaps the most significant advancement that is now the part of most modern thoracic surgery units (Figure 15).
A patient being managed on digital chest tube drainage system following thoracotomy.
The use of these drainage systems has been associated with improved decision-making regarding chest tube management, decrease complications, improved quality of life and reduce the hospital stay [27, 28, 29] These are light weight, portable system with a disposable reservoir that may be replaced once full. The main advantages of this system are:
It does not require an ‘underwater seal’ thus eliminating the risk of accidental pneumothorax and passage of drained material from the reservoir back to the chest.
It allows accurate measurement of drained fluid and air over time and thus helps in assessment of the trend of drainage (Figure 16A & B).
A & B: Objective depiction of air and fluid drainage and trend of drainage in digital chest tube drainage system.
This may help the clinician in making decision for removal of chest tube more objective and accurately.
Continuous controlled suction may be applied to the chest tube that remains constant irrespective of the position of the drainage system.
The patient may easily carry the device while ambulation without the risk of changes in pressure effecting drainage or accidental drainage of the collected material back in chest.
Chest tube systems with inbuilt mechanism to keep the inside of the tube clean to prevent clogging [16, 18].
Motion activated systems for prevention of clot formation inside the chest tube: This system uses motion-activated energy (vibration) primarily to prevent early adhesion of clots within the internal chest tube surface and thus maintains the patency of the chest tube [17].
Insertion of ICD is a common, simple yet lifesaving procedure. All clinicians should be well versed with the appropriate technique of inserting the thoracostomy tube and various aspects of its management. Although simple, it is associated with high rate of complications that primarily occur due to improper technique of insertion or poor post-procedural care. Awareness of these factors will make the procedure safer with improved outcome.
There are no conflicts of interest.
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On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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Already in the seventeenth century, hearing loss was described to be a side effect of quinine. The post- World War II pharmaceutical industry boomed with the production of aminoglycoside antibiotics followed by diuretics and cytostatic drugs. Wide-spread and long-term usage of these medications brought the knowledge about their unwanted ototoxic effects. In the last decades, several new drugs appeared on the shelves of pharmacies and the hearing loss or tinnitus have been among the side effects of many of them. However, the awareness of community about new ototoxic medications is still not sufficient. New ototoxic drugs may belong to the class of phosphodiesterase-5 (PDE5) inhibitors, used to improve microcirculation and to treat erectile dysfunction. Moreover, interferons used for the therapy of hepatitis B and C, common painkiller paracetamol and hydrocodone, synthetic opioid methadone and the inhibitors of reverse transcriptase were demonstrated to induce adverse effects on hearing. Lastly, hearing loss linked to immunosuppressive drugs was documented in patients undergoing organ transplantation. Making the patients aware of adverse drug reactions and offering them audiological monitoring and intervention should be considered by respective therapists.",book:{id:"5603",slug:"advances-in-clinical-audiology",title:"Advances in Clinical Audiology",fullTitle:"Advances in Clinical Audiology"},signatures:"Agnieszka J. Szczepek",authors:[{id:"193666",title:"Ph.D.",name:"Agnieszka",middleName:null,surname:"Szczepek",slug:"agnieszka-szczepek",fullName:"Agnieszka Szczepek"}]},{id:"53896",doi:"10.5772/67155",title:"Wideband Tympanometry",slug:"wideband-tympanometry",totalDownloads:2054,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"The wideband tympanometry (WBT) assesses the middle ear function with a transient wideband stimulus in order to capture the middle ear behavior at a wide range of frequencies. Data in the literature suggest that the WBT has more sensibility to detect middle ear disorders than the traditional tympanometry. In this context, pathologies, which might be more easily identified/monitored by WBT, include otosclerosis, flaccid eardrums, ossicular chain discontinuity with semicircular canal dehiscence, and negative middle ear pressure with middle ear effusion. The chapter presents information on classical tympanometry, the multifrequency tympanometry equivalent coded as WBT, clarification of terms used in WBT measurements, and a short overview of clinical applications in infants and adults.",book:{id:"5603",slug:"advances-in-clinical-audiology",title:"Advances in Clinical Audiology",fullTitle:"Advances in Clinical Audiology"},signatures:"Thais Antonelli Diniz Hein, Stavros Hatzopoulos, Piotr Henryk\nSkarzynski and Maria Francisca Colella-Santos",authors:[{id:"174266",title:"Prof.",name:"Stavros",middleName:null,surname:"Hatzopoulos",slug:"stavros-hatzopoulos",fullName:"Stavros Hatzopoulos"}]},{id:"53705",doi:"10.5772/66627",title:"Temporal Filterbanks in Cochlear Implant Hearing and Deep Learning Simulations",slug:"temporal-filterbanks-in-cochlear-implant-hearing-and-deep-learning-simulations",totalDownloads:1574,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"The masking phenomenon has been used to investigate cochlear excitation patterns and has even motivated audio coding formats for compression and speech processing. For example, cochlear implants rely on masking estimates to filter incoming sound signals onto an array. Historically, the critical band theory has been the mainstay of psychoacoustic theory. However, masked threshold shifts in cochlear implant users show a discrepancy between the observed critical bandwidths, suggesting separate roles for place location and temporal firing patterns. In this chapter, we will compare discrimination tasks in the spectral domain (e.g., power spectrum models) and the temporal domain (e.g., temporal envelope) to introduce new concepts such as profile analysis, temporal critical bands, and transition bandwidths. These recent findings violate the fundamental assumptions of the critical band theory and could explain why the masking curves of cochlear implant users display spatial and temporal characteristics that are quite unlike that of acoustic stimulation. To provide further insight, we also describe a novel analytic tool based on deep neural networks. This deep learning system can simulate many aspects of the auditory system, and will be used to compute the efficiency of spectral filterbanks (referred to as “FBANK”) and temporal filterbanks (referred to as “TBANK”).",book:{id:"5603",slug:"advances-in-clinical-audiology",title:"Advances in Clinical Audiology",fullTitle:"Advances in Clinical Audiology"},signatures:"Payton Lin",authors:[{id:"193354",title:"Ph.D.",name:"Payton",middleName:null,surname:"Lin",slug:"payton-lin",fullName:"Payton Lin"}]},{id:"66341",doi:"10.5772/intechopen.85572",title:"Introductory Chapter: Facial Nerve - An Overview",slug:"introductory-chapter-facial-nerve-an-overview",totalDownloads:1767,totalCrossrefCites:1,totalDimensionsCites:2,abstract:null,book:{id:"7131",slug:"selected-topics-in-facial-nerve-disorders",title:"Selected Topics in Facial Nerve Disorders",fullTitle:"Selected Topics in Facial Nerve Disorders"},signatures:"Isam Jaber Al-Zwaini and Mohammed Jalal Hussein",authors:[{id:"30993",title:"Prof.",name:"Isam Jaber",middleName:null,surname:"Al-Zwaini",slug:"isam-jaber-al-zwaini",fullName:"Isam Jaber Al-Zwaini"}]},{id:"66051",doi:"10.5772/intechopen.85076",title:"The Frequency Following Response: Evaluations in Different Age Groups",slug:"the-frequency-following-response-evaluations-in-different-age-groups",totalDownloads:946,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"In this chapter, recent data on the clinical application of the frequency following response (FFR) in different age groups will be presented. The chapter begins with the importance of using speech sounds in electrophysiological assessments. Then the FFR methodology is presented, giving normative data and the expected responses in different age groups: infants and young children, children and adolescents, and adults and the elderly. Finally, the unique responses of each age group are presented in order to show how this new technology can be an extremely useful tool for diagnosing hearing dysfunction.",book:{id:"7894",slug:"the-human-auditory-system-basic-features-and-updates-on-audiological-diagnosis-and-therapy",title:"The Human Auditory System",fullTitle:"The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy"},signatures:"Milaine Dominici Sanfins, Michele Vargas Garcia, Eliara Pinto Vieira Biaggio and Piotr Henryk Skarzynski",authors:[{id:"194610",title:"Prof.",name:"Milaine",middleName:"Dominici",surname:"Sanfins",slug:"milaine-sanfins",fullName:"Milaine Sanfins"}]}],mostDownloadedChaptersLast30Days:[{id:"65760",title:"Endoscopic Ear Surgery in Children",slug:"endoscopic-ear-surgery-in-children",totalDownloads:1042,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Endoscopic assistance is gradually gaining recognition in otology not only for office examinations but also during surgery. The first endoscopic surgical procedure that was started in our institution was endoscopic ventilation tube placement to manage children with stenotic and curved canals. Following this, endoscopy was used in all type I tympanoplasty and stage I cholesteatoma removals with the advantage of avoiding a postauricular or endaural approach. The last application of endoscopic assistance was to better visualize round window and scala tympani via posterior tympanotomy during cochlear implantation. There are several advantages in using endoscopes: the wide view obtained and the possibility to observe areas behind the angle with less invasiveness and its excellent resolution, in addition to its intense light and higher magnification that facilitates teaching and tutoring. The limits of endoscopic surgery are that one hand is always needed to hold the endoscope and the lack of a third dimension. Until miniaturization of 3D systems allow the possibility to work in the narrow external ear canal, in order to overcome the limitation that one hand is dedicated to the endoscope, we will describe the use of an endoscope holder in otologic procedures.",book:{id:"7894",slug:"the-human-auditory-system-basic-features-and-updates-on-audiological-diagnosis-and-therapy",title:"The Human Auditory System",fullTitle:"The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy"},signatures:"Luca Oscar Redaelli de Zinis and Nader Nassif",authors:[{id:"279417",title:"Prof.",name:"Luca Oscar",middleName:null,surname:"Redaelli De Zinis",slug:"luca-oscar-redaelli-de-zinis",fullName:"Luca Oscar Redaelli De Zinis"},{id:"279418",title:"Dr.",name:"Nader",middleName:null,surname:"Nassif",slug:"nader-nassif",fullName:"Nader Nassif"}]},{id:"66509",title:"Attention and Working Memory in Human Auditory Cortex",slug:"attention-and-working-memory-in-human-auditory-cortex",totalDownloads:1061,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"Human sensory systems are organized into processing hierarchies within cortex, such that incoming sensory information is analyzed and compiled into our vivid sensory experiences. Computations that are common to these sensory systems include the abilities to maintain enhanced focus on particular aspects of incoming sensory information (i.e., attention) and to retain sensory information in a short-term memory store after such sensory information is no longer available (i.e., working memory). In at least the auditory and visual systems, the necessary computational steps to create these experiences take place in cloverleaf clusters of cortical field maps (CFMs). The human auditory CFMs represent the spectral (i.e., tones) and temporal (i.e., period) aspects of sound, which are represented along the cortical surface as two orderly gradients that are physically orthogonal to one another: tonotopy and periodotopy, respectively. Knowledge of the properties of such CFMs is the foundation for understanding the specific sensory computations carried out in particular cortical regions. This chapter reviews current research into auditory nonverbal attention, auditory working memory, and auditory CFMs, and introduces the next steps to measure the effects of attention and working memory across the known auditory CFMs in human cortex using functional MRI.",book:{id:"7894",slug:"the-human-auditory-system-basic-features-and-updates-on-audiological-diagnosis-and-therapy",title:"The Human Auditory System",fullTitle:"The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy"},signatures:"Brian Barton and Alyssa A. 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The fluid homeostasis of the lymph spaces with its parameters volume, concentration, osmolarity and pressure, as well as the finely aligned hair cell receptors, their supporting cells and structures embedded in these unique fluid spaces, corresponds to the specific necessities for adequate response to continuous stimulation and the outstanding discrimination capacity of the hearing system. The manuscript gives an overview and describes the structural characteristics and distinct physiological hearing qualities of the cochlea in comparison with the other human receptor cells and sense organs.",book:{id:"5603",slug:"advances-in-clinical-audiology",title:"Advances in Clinical Audiology",fullTitle:"Advances in Clinical Audiology"},signatures:"Raphael R. 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