1/154. fibrinolytic agents: a new approach to the treatment of adult respiratory distress syndrome.Nineteen patients suffering from adult respiratory distress syndrome (ARDS) secondary to trauma or sepsis, or both, failed to respond to treatment with mechanical ventilation with oxygen and positive end-expiratory pressure. On the premise that ARDS may be caused by the microclots of disseminated intravascular coagulation obstructing the pulmonary microcirculation, the patients were treated with either streptokinase or urokinase. Eighteen patients responded with significant improvement in PaO 2 value. No bleeding occurred and clotting parameters remained normal.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/154. Right-to-left interatrial shunt in ARDS: dramatic improvement in prone position.The mechanisms leading to shunting through a patent foramen ovale include high right-sided cardiac pressures and respiratory factors due to mechanical ventilation and also anatomical changes in the right atrium as described in the platypnea-orthodeoxia syndrome. We report a patient with the adult respiratory distress syndrome (ARDS) who had a right-to-left atrial shunt which decreased in the prone position, after which oxygenation improved. The patient was admitted to the intensive care unit because of ARDS due to an invasive fungal infection. He had a history of chronic lymphocytic leukemia and paradoxical embolisms through a patent foramen ovale. Despite mechanical ventilation and antifungal treatment he developed severe ARDS. He was therefore turned to the prone position. Blood gas values improved dramatically (arterial oxygen tension/fractional inspired oxygen ratio increasing from 59 to 278 torr). Transcranial Doppler sonography was performed with bubble study, which confirmed a massive right-to-left shunt in the supine position and which instantaneously decreased in the prone position. This case suggests that a decrease in right-to-left shunt in patients who have a patent foramen ovale could partly explain the improvement in hypoxemia in the prone position.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/154. Combination of inhaled nitric oxide and intravenous prostacyclin for successful treatment of severe pulmonary hypertension in a patient with acute respiratory distress syndrome.OBJECTIVE: To investigate the combination of inhaled nitric oxide (iNO) and intravenously administered prostacyclin (i.v. PGI2) in a patient with severe pulmonary hypertension and acute respiratory distress syndrome (ARDS). DESIGN: Single case study. SETTING: intensive care unit of a university hospital. methods: In an ARDS patient with severe pulmonary hypertension, gas exchange and hemodynamics were measured during combined treatment with iNO and i.v. PGI2. On two subsequent days, a protocol consisting of four 20-min periods was performed: baseline, 10 ppm iNO, 10 ppm iNO plus 4 ng kg-1 min-1, and 4 ng kg-1 min-1 PGI2 alone. At the end of each period hemodynamic and gas exchange data were obtained. RESULTS: The combination of iNO and i.v. PGI2 resulted in a marked decrease in pulmonary artery pressure and a concomitant increase in cardiac output which was more pronounced than the effect of either drug alone. During iNO, as well as during the combination of iNO and i.v. PGI2, oxygenation was improved, whereas during i.v. PGI2 alone oxygenation was worse than baseline. CONCLUSION: We conclude that the combination of iNO and i.v. PGI2 might be more useful than either drug alone when severe pulmonary hypertension leading to impaired right ventricular function is present in ARDS. A systematic study of this observation is warranted.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/154. life-threatening reaction to vancomycin given for noninfectious fever.OBJECTIVE: To report a case of vancomycin-induced anaphylaxis (or anaphylactoid reaction) in a patient with a fever of unrecognized noninfectious origin. CASE SUMMARY: An 83-year-old white man, who was a patient of the veterans Affairs Medical Center, developed a serious anaphylactic (or anaphylactoid) reaction while receiving intravenous vancomycin as empiric therapy for a nosocomial fever of unknown origin. The fever was subsequently proved to have been due to acute polyarticular gout rather than an infection. DISCUSSION: This patient developed respiratory distress and an increased serum troponin concentration, suggestive of a myocardial enzymatic leak as a result of vancomycin therapy. Vancomycin was given before the noninfectious cause of his fever was recognized. CONCLUSIONS: Even with cautious slow infusion, intravenous vancomycin can precipitate life-threatening infusion-related reactions in some patients. Because of this, and to reduce selective pressure for vancomycin resistance, sources of fever that do not require treatment with vancomycin should be diligently investigated prior to the institution of empiric vancomycin therapy in febrile patients, particularly when the past medical history is suggestive of an alternative diagnosis.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/154. Successful treatment of a patient with ARDS after pneumonectomy using high-frequency oscillatory ventilation.High frequency oscillatory ventilation (HFOV) was used in a patient who developed the acute respiratory distress syndrome 5 days following a right pneumonectomy for bronchogenic carcinoma. When conventional pressure-controlled ventilation failed to maintain adequate oxygenation, HFOV dramatically improved oxygenation within the first few hours of therapy. Pulmonary function and gas exchange recovered during a 10-day period of HFOV. No negative side effects were observed. Early use of HFOV may be a beneficial ventilation strategy for adults with acute pulmonary failure, even in the postoperative period after lung resection.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/154. Surfactant treatment in a pediatric burn patient with respiratory failure.This report describes surfactant treatment in a burned infant with severe respiratory failure. In this patient the instillation of surfactant rapidly improved compliance, oxygen index (OI), and alveolar-capillary oxygen gradient (AaDO2), while the need for oxygen supplementation and peak positive pressure drastically decreased. The treatment was repeated after 12 hours. Although the baby had severe clinical course complications as a Gram-negative sepsis and a subglottic stenosis, she was weaned from oxygen therapy and mechanical ventilation in few weeks. Surfactant dysfunctions seem to play a central role in the respiratory insufficiency of burned patients, and its exogenous replacements could improve their outcome.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/154. Acute respiratory distress syndrome following cutaneous exposure to Lysol: a case report.Lysol (mixed cresols) is a brand of popular detergent commonly used to disinfect toilets and floors in taiwan. We report a patient with acute respiratory failure immediately following chemical burns caused by skin contact with Lysol solution. On admission, chest radiography showed bilateral diffuse pulmonary infiltrates and an arterial blood gas analysis disclosed hypoxemia refractory to a high concentration of oxygen by inhalation. Under the impression of acute respiratory distress syndrome, our patient was admitted to the intensive care unit for respiratory care. Poor clinical improvement was noted, despite aggressive respiratory therapy. High-dose steroid therapy (hydrocortisone 30 mg/kg/day) was administered from the seventh day after mechanical ventilation began and the ratio of arterial partial pressure of oxygen to fractional concentration of oxygen in inspired gas improved thereafter. The amount of steroid was gradually tapered to the maintenance dose and the patient was successfully weaned from the ventilator after a 93-day course of mechanical ventilation.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
8/154. Respirator triggering of electron beam computed tomography (EBCT): research on vital capacities.In this project we evaluate the dynamic changes during expiration at different levels of positive-end-expiratory pressure (PEEP) in ventilated patients. We wanted to discriminate between normal lung function and acute respiratory distress syndrome (ARDS). After approval by the local Ethic Committee we studied two ventilated patients: (one with normal lung function and one with ARDS) We used the 50 ms scan mode of the EBCT. The beam was positioned 1 cm above the diaphragm while the table position remained unchanged. We developed an electronic trigger that utilizes the respirator's synchronizing signal to start the EBCT at the onset of expiration. During controlled mechanical expiration at two levels of PEEP (0 and 15 cm H2O), pulmonary aeration was rated as: well-aerated (-900HU to -500HU), poorly aerated (-500HU to -100HU) and non-aerated (-100HU to 100HU). Pathological and normal lung functions showed different dynamic changes. The different PEEP levels resulted in a significant change of pulmonary aeration in the same patient. Although we studied only two patients, respiratory triggered EBCT may be accurate in discriminating pathological changes due to the abnormal lung function in a mechanically ventilated patient.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/154. Varicella pneumonia complicated by acute respiratory distress syndrome in an adult.Primary varicella infection is uncommon in adults, but carries a higher rate of morbidity and mortality than in children. pneumonia is the most common complication of primary varicella infection in adults. However, varicella pneumonia complicated with acute respiratory distress syndrome (ARDS) is very rare. We report a case of ARDS secondary to varicella pneumonia in a 26-year-old man with primary varicella. The patient was otherwise healthy and had no evidence of human immunodeficiency virus infection. The initial chest radiograph showed bilateral reticulonodular infiltrates, which quickly evolved to diffuse alveolar consolidations. Arterial blood gas analysis revealed a ratio of arterial partial pressure to fraction of inspired oxygen of 87. Abnormal liver function and thrombocytopenia were also noted. Treatment consisted of mechanical ventilatory support and intravenous administration of acyclovir. His pulmonary condition gradually improved and he was successfully weaned from the ventilator 1 week later. He was discharged on the 15th hospital day with a favorable outcome. His pulmonary function improved progressively, with normal spirometry and lung volumes, but persistent mild impairment of diffusing capacity, 6 months after discharge.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/154. Pressure limited ventilation with permissive hypoxia and nitric oxide in the treatment of adult respiratory distress syndrome.In the management of adult respiratory distress syndrome pressure limited mechanical ventilation may protect the lungs from overdistention injury. Unacceptable hypoxia may be avoided by adding nitric oxide to the inspiratory gas, and thus make pressure limited ventilation easier to perform. There exists no consensus about an acceptable lower limit of SaO2, and in the present case we gave preference to pressure limitation at the cost of oxygenation. A young woman with severe adult respiratory distress syndrome was set on pressure limited mechanical ventilation with peak pressures of 35-38 cm H2O, PEEP of 10-12 cm H2O, and FiO2 of 0.95 with 20 ppm nitric oxide. SaO2 varied between 75 and 85%, and cardiac output ranged between 5.2 and 7.5 L min-1. oxygen consumption was in the upper normal range, and she did not became acidotic. After 3 days, she started to improve. In conclusion, it seems that hypoxia might be well tolerated as long as the circulation is not compromised. It might prove beneficial to accept some hypoxia to avoid ventilator induced lung damage.- - - - - - - - - - ranking = 5keywords = pressure (Clic here for more details about this article) |
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