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• W2994360089 abstract "Editor, We thank Karim and Esquinas for their interest in our work1 and their valuable comments.2 We are pleased to respond to their letter as follows. The risk of aspiration must be considered throughout a modified electroconvulsive therapy procedure. Seet et al.3 reported that limiting peak airway pressure to less than 16 cmH2O may provide additional patient safety through eliminating gastric insufflation. Thus, we kept the adjustable pressure limiting valve at 15 cmH2O during manual ventilation. Positive pharyngeal pressure generated by a high-flow nasal cannula is affected by sex, BMI, degree of mouth opening and flow rate. In our institution, during electroconvulsive therapy, a bite block is inserted to prevent tongue bite and to protect the teeth of the patient. This solid bite block can significantly decrease the leakage from the mouth and weaken the positive end expiratory pressure leak effect. Every increase of 10 l min−1 of flow yields approximately 0.7 cmH2O of airway pressure when the mouth is closed and 0.35 cmH2O when the mouth is open.4 For patients who receive a 60 l min−1 flow rate, pharyngeal pressure remains below 5 cmH2O (2.1 to 4.2 cmH2O) which is clearly lower than with manual ventilation (15 cmH2O). There was no significant difference in the gastric antrum area between the two groups either. Accordingly, we believe that a short-term use of the high-flow nasal cannula does not increase the risk of aspiration. We agree with Karim and Esquinas that the choice of the induction agent should be tailored to the individual patient. Though evidence supports that methohexital is an appropriate choice,5 this agent is not widely used in China and propofol is still a commonly used alternative. Etomidate is a reasonable alternative but its adrenal suppressive effect makes it less attractive. It would be interesting to explore the effect of different induction agents in patients receiving a high-flow nasal cannula. Concerning our study, we think the selection of propofol did not affect the comparison of the two oxygen delivery methods. The recorded cardiac events in our study included hypertension, hypotension, bradycardia, tachycardia and other cardiac arrhythmias. Hypertension occurred in four patients in the control group and in five patients in the high-flow nasal cannula group. Bradycardia occurred in one patient in the high-flow nasal cannula group. All recorded cardiac events were mild and transient. In the control group, FiO2 was close to 100% during manual ventilation. However, FiO2 was difficult to assess accurately during the rest of the procedure because of air leak or improper fit of the mask. High-flow nasal cannula could provide stable a FiO2 with an adjustable inspired concentration of oxygen of up to 100%. But the safety of high FiO2 still remains controversial. Koo et al.6 recently reported that a high-inspired oxygen fraction during anaesthesia may impair postoperative pulmonary parameters including atelectasis. Hence, we set the FiO2 to 50% to prevent potential atelectasis. In conclusion, we agree that that the judgement of noninferiority or equivalence in a noninferiority trial needs various considerations. In our study, we focused on the use of high-flow nasal cannula in maintaining oxygen delivery compared with a current clinical standard procedure. As high-flow nasal cannula has become increasingly popular to improve airway management strategies, we are looking forward to more clinical research projects which could provide evidence to support or oppose the use of this new technique. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none." @default.
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• W2994360089 date "2020-01-01" @default.
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• W2994360089 doi "https://doi.org/10.1097/eja.0000000000001077" @default.
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