Acute neonatal respiratory distress in Italy: a one-year prospective study. Italian Group of Neonatal Pneumology

We treated two cases of primary pulmonary cryptococcosis with fluconazole (FLCZ), the clinical usefulness of FLCZ was evaluated. FLCZ was administered orally in doses of 300 mg daily for about six months. Concentrations of FLCZ were measured in the serum of the two cases and in the bronchoalveolar lavage (BAL) fluid in one case. The following results were obtained: 1. Clinical cures were obtained in the two cases. 2. The serum levels of FLCZ was 15.1 microliters/ml, 13.6 micrograms/ml two hours after administration of 100 mg in case 1, that of levels were 11.1 micrograms/ml, 8.9 micrograms/ml one hour and 4.5 hours, respectively, after administration of 100 mg in case 2. BAL was performed 4.5 hours after administration of 100 mg in case 2, the BAL fluid level of FLCZ was 0.7 microgram/ml. 3. The minimal inhibitory concentration of FLCZ against one strain obtained from the cytology brush in case 1 was 4.0 micrograms/ml. 4. The cryptococcal antigen titer decreased with the improvement of clinical signs and the resolution of chest X-ray abnormalities within about six months, and there was no relapse. From these results, we consider that FLCZ is a useful antifungal agent for primary pulmonary cryptococcosis, and we therefore recommend a six month treatment.     

Adult respiratory distress syndrome

In this article the authors present a case of successful treatment of a 54-year old male patient with non-insulin dependent diabetes mellitus (NIDDM) and triple-vessel coronary artery disease who underwent surgical myocardial revascularization and was reoperated on the same day because of excessive bleeding. The patient was given cca 5000 mL of whole blood and cca 3000 mL of blood derivatives. The first postoperative chest X-ray showed radiological signs of ARDS. The therapy was based upon authors' experience and was consisted of controlled mechanical ventilation (respiratory volume 12-15 mL/kg, 10-14 cycles/min, I/E ratio 1:2, FIO2 0.6, PEEP 2-5 cm H2O), daily bronchoscopies with bronchoaspiration, aggressive diuresis, negative fluid balance, specific antibiotic therapy, and last but not least, of prostaglandin E1 (PGE1) 0.5-20 micrograms/kg/min combined with dopamine inotropic support (2-5 micrograms/kg/h). Simple but careful clinical observation still remains a milestone for all therapeutic measures taken in ARDS patients.     

Traumatic adult respiratory distress syndrome

ARDS is the pulmonary manifestation of both direct and indirect insults to the lung. Trauma patients are at particular risk for ARDS from the direct effects of their injuries, as well as from complications that may occur during their hospital courses. ARDS prevention can be enhanced through diverse areas of medical focus. Public health issues addressing trauma prevention, improved understanding and treatment of trauma-related pathophysiology, as well as a better understanding of basic pathophysiology of this disease process will allow refinement and improvement of our management practices. Newer modes of mechanical ventilation may help us to avoid ventilator-induced exacerbation of lung injury. As we define the role of nonconventional therapies, such as anti-inflammatory and anticytokine therapies, our ability to actively interrupt and reverse the progression of the inflammatory cascade will be enhanced. As yet, ARDS continues to be a challenging disease process to both fully understand and successfully treat in our critically ill patients.     

Prevention of neonatal respiratory distress syndrome through the administration of prednisolone in the fetal period

The clinical effectiveness of antenatal prednisolone medication (prednisolone hemisuccinate) for the prophylaxis of idiopathic respiratory distress syndrome (IRDS) was studied in 114 premature infants with a gestational age between 28 and 36 weeks. There was a statistically significant difference (chi2 - test, p less than 0,01) between the frequency of IRDS in this group and in another one consisting of 137 premature babies with a nearly identical distribution of gestational age, whose mothers did not get prednisolone before delivery. It could be shown that the time interval between medical induction and delivery should not exceed 2 weeks, since the effect decreases with time. At present prednisolone medication during the fetal period may serve as useful prophylactic measure for IRDS in cases of premature birth. As there are a lot of contraindication against prednisolone and as we do know very much about side effects, it seems necessary to seek for other, less dangerous inductors.     

Phaeochromocytoma with adult respiratory distress syndrome mimicking septicaemic shock

Phaeochromocytomas are rare tumours that most commonly present with chronic sustained hypertension and hypertensive paroxysms or crises. We report a 49-year-old woman with unsuspected phaeochromocytoma who presented with sudden onset of profound hypotension and adult respiratory distress syndrome unresponsive to fluid and inotropic support. This case illustrates the diversity of presentations of phaeochromocytoma, depending on the type and amount of catecholamines secreted.     

Acute respiratory distress syndrome in children

In 1991, the Dental Implant Clinical Research Group initiated a long-term clinical study in cooperation with the Department of Veterans Affairs to investigate the influence of implant design, application, and site of placement on clinical performance and crestal bone height. As part of this investigation, Periotest values for 2,212 root from implants were determined at second-stage surgery and during a 24-month follow-up period. Mean Periotest values decreased for implants placed in quality 1 and 2 bone, did not change for implants in quality 3 bone, and increased for implants in quality 4 bone. Implants in the posterior maxilla and single implants in the anterior maxilla had increasing mean Periotest values as compared with decreasing values for implants in other regions. Mean Periotest values for uncoated implants decreased gradually to approach those of hydroxyapatite-coated implants.     

Open-lung biopsy in patients with acute respiratory distress syndrome

Occupational exposures contribute to the morbidity and mortality of many diseases. However, occupational diseases continue to be underrecognized even though they are responsible for an estimated 860,000 illnesses and 60,300 deaths each year. Family physicians can play an important role in improving the recognition of occupational disease, preventing progressive illness and disability in their own patients, and contributing to the protection of other workers similarly exposed. This role can be maximized if physicians raise their level of suspicion for workplace disease, develop skills in taking occupational histories and establish routine access to occupational health resources.     

Complications of laparoscopy: a prospective multicentre observational study

Extrahepatic obstruction of the portal vein is a well known cause of portal hypertension in childhood, that causes severe morbidity. We evaluated 34 children (24 boys, 10 girls, age 4.5 months to 12 years, mean 5.5 +/- 3.8 years) with this diagnosis, to define the clinical picture, laboratory changes, diagnostic tools and therapeutic modalities. Gastrointestinal bleeding was the commonest mode of presentation (64.7%), with the second being splenomegaly. The cause of the obstruction could be determined in 38.2% (13/34) of the subjects. At the beginning of the study the main diagnostic procedure was splenoportography although in more recent years pulsed duplex Doppler ultrasonography has been used. The follow up period was median of 5 years (range 1-11 years). The mean number of bleeding episodes was 4.7 +/- 5.9 (range 1-26), while nine patients never bled. There was no mortality. Ten patients underwent surgery, while sclerotherapy was performed on 10. Twenty-one patients received beta-blocker drugs. No difference was found among these therapeutic modalities. It is well established that the major risk for children with extrahepatic portal vein obstruction is gastrointestinal bleeding which is tolerated quite well. Surgery should be indicated only in children where bleeding cannot be controlled by medical means including sclerotherapy.     

A two year follow-up of infants with respiratory distress syndrome

Forty-seven of 74 infants with idiopathic respiratory distress syndrome who had received intensive care in the neonatal period were examined between the ages of 15 and 24 months to assess their progress. All the children (including the premature infants) had caught up with their peers in height, weight and head circumference. Although 11 infants had a history of respiratory problems, only two showed residual lung changes on radiological examination. Only one infant who had frequent apnoeic spells had serious eye problems due to retrolental fibroplasia. A definite neurological deficit was found in one case, in which a congenital infection could not be ruled out.     

Measurement of pulmonary status and surfactant protein levels during dexamethasone treatment of neonatal respiratory distress syndrome

PURPOSE: To study the effect of epidural buprenorphine on minimum alveolar concentration (MAC) of volatile anaesthetics, duration of analgesia and respiratory function in the perioperative period. METHODS: One hundred and twenty patients, ASA I-II undergoing gynaecological surgery were randomly divided into three studies. The forty patients in each study were randomly divided into four groups depending on the dosage; Group I (control), Group II (80 micrograms. kg-1 morphine), Group III (4 micrograms. kg-1 buprenorphine), Group IV (8 micrograms. kg-1 buprenorphine). The MAC of halothane was measured following epidural administration of the agents in each group. The duration of analgesia was assessed by the first request for pentazocine. Postoperative analgesic effects were assessed by the total dosage of pentazocine required for the 48 hr after surgery. Respiratory rate (RR), minute volume (MV), and PaCO2 were measured during surgery and the postoperative period. The MAC of halothane was reduced in Group IV (P < 0.01). The duration of analgesia was 10.0 +/- 5.1 hr (Mean +/- SE) in Group I, 37.7 +/- 4.7 hr in Group II, 27.1 +/- 7.1 hr in Group III, and 44.4 +/- 4.1 hr in Group IV. Total dosage of pentazocine was lower in Group IV (P < 0.05) than in the other groups. The decrease of RR, MV and the increase of PaCO2 were observed within 60 min in Group III and IV dose dependently. CONCLUSION: Epidural buprenorphine administered in a dose of 4 or 8 micrograms. kg-1 provides postoperative analgesia that is no less effective than that of morphine.     

Surfactant treatment in the neonate with severe respiratory distress syndrome

Eighteen preterm infants severely ill with respiratory distress syndrome who required assisted ventilaton were given modified natural surfactant (Survanta) endotracheally. They had a mean +/- SEM gestational age of 31.2 +/- 0.4 weeks (range 28-34) and a mean +/- SEM birthweight of 1562 +/- 71 g (range 1160-2010). Average time of initial surfactant administration was 15 +/- 1.7 hour (range 5-24). No significant side effects were found during surfactant instillation. Post surfactant, the air entry was improved, oxygenation and arterial/alveolar gradients increased, and the levels of inspired oxygen could be reduced. Some of the radiological abnormalities were resolved. In 13 infants, patent ductus arteriosus became clinically evident, seven of whom received Indomethacin. There were 4 cases of pulmonary air leak, 5 cases of pulmonary hemorrhage and 8 cases of bronchopulmonary dysplasia. Four infants expired, two were due to severe asphyxia/shock and two died of unrelated causes. Among the 14 survivors who came for follow-up, two cases of retinopathy of prematurity had gradually regressed, one had cerebral palsy and delayed development. Surfactant rescue therapy is a supplemental beneficial treatment for severe respiratory distress syndrome while newborn intensive care concept is necessary for efficient diagnosis and treatment of RDS.     

Improved oxygenation utilizing a prone positioner in patients with acute respiratory distress syndrome

OBJECTIVES: (a) To determine whether placing patients with acute respiratory distress syndrome in the prone position by a light-weight portable support frame improves oxygenation, (b) whether one can determine which patients benefit from prone positioning, and (c) to determine an effective technique for prone positioning of patients. DESIGN: Prospective, controlled trial without blinding. SETTING: Medical intensive care units in two urban university-affiliated hospitals. PATIENTS: Fifteen patients meeting a standard definition for acute respiratory distress syndrome were studied prospectively. Each patient acted as his own control for purposes of comparison. INTERVENTION: Patients were assigned randomly to begin in either supine or prone positions. The positioning frame was used to turn patients from one position to the other, and oxygenation, ventilation, respiratory mechanics, and hemodynamics were measured. RESULTS: Significantly better oxygenation was seen in the prone positions than in the supine (P < 0.05). In the overall population there was a decrease in AaDO2 of 21 mmHg when the patients were placed prone. The groups were then divided into responders (n = 9) and nonresponders (n = 6). There were significant differences between the groups (but not between positions) regarding PaO2, baseline, PaCO2, pulmonary artery pressures, and peak inspiratory pressures on the ventilator and in ICU length of stay and time on mechanical ventilatory support. CONCLUSION: Prone positioning improves oxygenation in the majority of patients studied and can be achieved relatively easily.     

Acute respiratory distress syndrome. Liquid ventilation

In summary, the use of partial liquid ventilation with perfluorocarbon seems to be safe in neonates, children, and adults with ALI or ARDS. Partial liquid ventilation can be used for the following goals: recruitment of lung volume; enhancement or uniformity of lung inflation; improved oxygenation; improved lung compliance; and prevention or minimization of lung damage induced by mechanical ventilation. Partial liquid ventilation improved gas exchange and lung mechanics in test subjects. Cardiopulmonary interaction and long-term safety require further study. Extrapolations from animal data, however, suggest that there are no long-term undesired effects. The current clinical data strongly suggest that close monitoring and adjustment of ventilator parameters during drug instillation are necessary to reduce hypoxia, bradycardia, and pneumothorax. Further studies are required to explore the efficacy of partial liquid ventilation with perfluorocarbon in ALI or ARDS subjects, in particular, to evaluate the safety and efficacy of smaller doses; mechanical ventilation strategies; and outcomes. Additional research including large randomized studies is clearly required to answer these and other questions.