Contribution of bronchoalveolar lavage and transbronchial biopsy to diagnosis and prognosis of drug-induced pneumopathies

OBJECTIVE: The purpose of this study was to evaluate three ventilator weaning strategies and to evaluate whether the use of continuous positive airway pressure (CPAP) via a nasopharyngeal or endotracheal tube would increase the likelihood of extubation failure in very low birth weight (VLBW) infants. STUDY DESIGN: We studied prospectively 87 preterm infants (mean +/- SD; birth weight: 1078 +/- 188 g; gestational age: 28.8 +/- 2.2 weeks) who were in the process of being weaned from intermittent mandatory ventilation (IMV). Infants were assigned by systematic sampling to one of the following three treatment groups: (1) direct extubation from IMV (D.EXT) (n = 30); (2) preextubation endotracheal CPAP (ET-CPAP) for 12-24 hr (n = 28); or (3) postextubation nasopharyngeal CPAP (NP-CPAP) for 12-24 hr (n = 29). Failure was defined as the need for resumption of mechanical ventilation within 72 hr of extubation due to frequent or severe apnea and/or respiratory failure (pH < 7.25, PaCO2 > 60 mm Hg, and/or requirement for oxygen FiO2 > 60%). RESULTS: There were no significant differences in failure rates among the three procedures. Failures were 2/30 (7%) in D.EXT; 4/28 (14%) in ET-CPAP; and 7/29 (24%) in the NP-CPAP. There were also no differences in FiO2, PaO2, and respiratory rates before and after discontinuation of IMV among the three groups. PaCO2 values were slightly higher in the NP-CPAP group 12-24 hr after weaning from IMV. CONCLUSION: We were unable to demonstrate a clear difference in extubation outcome by use of CPAP administered via an endotracheal or nasopharyngeal tube when compared to direct extubation from low-rate IMV in VLBW infants.     

The use of nasal CPAP in newborns with respiratory distress syndrome

The efficiency of applying continuous positive airway pressure (CPAP) by the nasal route was retrospectively nalyzed in 32 newborns with RDS (23 uncomplicated HMD with additional cardiac or pulmonary complications and 7 RDS of non-hyaline membrane etiology) who underwent nasal CPAP treatment at the Kinderspital Zurich from 1972--1974. 16 of the 23 infants with uncomplicated HMD were successfully treated with CPAP. They showed a significant rise in PaO2 as well as a significant drop in respiratory frequency during nasal CPAP application, the PaCO2 did not change significantly. The remaining 7 infants in this group (7/23) had to be intubated and mechanically ventilated owing to a persistent high FIO2 (4 infants), technical difficulties (1) or nasal hypersecretion (2). Two of these 23 infants died, one of meningitis, one of cerebral hemorrhage. The two infants with HMD and additional cardiac or pulmonary complications and 3 of 7 infants with RDS of non-hyaline membrane etiology had to be intubated and mechanically ventilated after failure of nasal CPAP. All 9 infants in these two groups survived. The nasal CPAP system as described is a simple, inexpensive and effective method of applying CPTPP in newborns with uncomplicated HMD, except radiological stage IV. In HMD with additional cardiac or pulmonary complications and in RDS of non-hyaline membrane etiology the results of nasal CPAP treatment were not convincing.     

Decrease in ventilation time with a standardized weaning process

OBJECTIVE: To test the hypothesis that standardizing the process of weaning from mechanical ventilation would decrease ventilation times and length of stay in a surgical intensive care unit. DESIGN: Comparison of historic ventilation times with physician-directed weaning with those obtained with protocol-guided weaning by respiratory therapists. SETTING: Urban, teaching surgical intensive care unit with open admission policy and no dominant diagnosis related group. RESULTS: From January 1, 1995, through December 31, 1995, 378 patients who underwent physician-directed weaning from a ventilator had 64488 hours of ventilation, compared with 57796 ventilation hours in 515 patients with protocol-guided weaning (April 1, 1996, through May 31, 1997). The mean hours of ventilation decreased by 58 hours, a 46% decrease (P<.001). The length of hospital stay decreased by 1.77 days (29% change), while the Acute Physiology and Chronic Health Evaluation III score remained at 50 to 51. The number of reintubations did not change. The marginal cost savings was $603580. CONCLUSION: Protocol-guided weaning from mechanical ventilation leads to more rapid extubation than physician-directed weaning and has great potential for cost savings.     

Combined effects of antenatal corticosteroids and surfactant supplementation on the outcome of very low birth weight infants

Antenatal corticosteroids in preterm pregnancy may result in the reduction of the incidence of respiratory distress syndrome (RDS) and neonatal mortality. It is well known that postnatal use of surfactant in very low birth weight (VLBW) infants with RDS results in decreased neonatal morbidity and mortality. To evaluate the additive beneficial effects of combined antenatal corticosteroids and postnatal use of rescue surfactant on the outcome of VLBW infants, we retrospectively reviewed 286 maternal/infant charts of preterm infants with gestational ages 23 to 32 weeks and birth weights 501 to 1500 gm who were born at our institution from 1991 through 1994. Of the 87 (30%) infants who were treated with corticosteroids before birth, 41 (47%) had RDS, and of the 199 (70%) infants who were not treated with corticosteroids before birth, 162 (81%) had RDS (p < 0.001). The infants who had RDS and who were treated with corticosteroids before birth had a decreased incidence of pulmonary air leaks and a decreased need for diuretic therapy. In addition, they had a significant reduction in O2 requirement and ventilator settings as reflected by FIO2, mean airway pressure, ventilator rate, O2 index, and A-aDO2 before they received the first dose of rescue surfactant (p < 0.05 to p < 0.01) in contrast to other VLBW infants who had RDS and who were not treated with corticosteroids before birth. We conclude that antenatal corticosteroid therapy in threatened premature labor combined with the use of postnatal rescue surfactant is associated with a decreased incidence of RDS and may be beneficial for reducing the severity of RDS and improving the eventual outcome of VLBW infants.     

Prediction of individual response to postnatal dexamethasone in ventilator dependent preterm infants

AIMS: To evaluate factors predictive of individual response to dexamethasone in preterm infants. METHODS: A cohort of 74 preterm infants born between January 1993 and February 1996 was studied retrospectively. All of them had received dexamethasone to facilitate weaning from artificial ventilation. Demographic factors, ventilation parameters, and details of dexamethasone administration were recorded from the medical and nursing notes. Radiographs were assessed by one observer who was unaware of the clinical condition of the infant or the outcome. Outcome variables examined included change in ventilation index (VI) at 36-48 hours, the number of days to extubation from the start of dexamethasone, and death before extubation. RESULTS: Most babies improved but changes in VI at 36-48 hours ranged from substantial deterioration to dramatic improvement. No identifiable factors were significantly associated with this range of response. The median time to extubation was 6 days. The 36 babies who extubated within the first 6 days were: significantly more mature; less likely to have pulmonary interstitial emphysema (PIE) or pneumothorax; and had significantly lower VIs in the 12 hours preceding dexamethasone treatment. The postconceptional age at extubation was the same whether babies were extubated within or after the first 6 days. Multiple linear regression confirmed a significant association between number of days to extubation and the three factors described above (adjusted R2 = 0.5126). CONCLUSIONS: Individual responses to dexamethasone can be partly predicted by gestation, the presence of PIE, and the VI before dexamethasone administration.     

Epidemiologic panorama of viral hepatitis in Mexico

The effects of continuous positive airway pressure (CPAP) provided by the Siemens Servo 900C ventilator were compared with a continuous flow system (CF-CPAP) in patients weaning from the ventilator. Thirteen patients were studied using both systems at a CPAP level of 0.5 kPa. Additional work of breathing (Wapp) and derived variables were determined in relation to the minute volumes of the patients. The Wapp imposed by the ventilator exceeded the Wapp of CF-CPAP in all patients. The difference in Wapp between ventilator- and CF-CPAP was greater at higher ventilatory needs. The increments in Wapp imposed by the ventilator were positively correlated with the actual end-expiratory pressures (EEP). The EEP increasingly exceeded the preset CPAP level of the ventilator at higher minute volumes. An inspiratory threshold due to a gradient between EEP and preset CPAP greatly increased the Wapp imposed by the ventilator. As this threshold was attributed to the resistance of the PEEP device of the ventilator, it indicates that the additional work related to the expiratory value should be taken into account when the Siemens Servo 900C ventilator is used for weaning purposes.     

Importance of pre- and perinatal risk factors in respiratory distress syndrome of premature infants. A logical regression analysis of 1100 cases

BACKGROUND: Respiratory distress syndrome (RDS) due to surfactant deficiency remains a cause of considerable mortality in the neonatal period. METHODS: In a retrospective study we analysed the records of 1109 premature newborns with a birth weight below 1500 g that were treated on our unit. RDS was assumed if the infants needed mechanical ventilation with oxygen supplementation and the typical radiological signs were present on chest x-ray. RESULTS: No changes in the incidence of RDS were found during the period of observation. Below 29 weeks gestational age 90% of infants suffered from RDS (55% severe RDS grade III or IV). The incidence was 75% (grade III or IV: 32%) for infants born at 29 and 30 weeks, 48% (grade III or IV: 15%) at 31 and 32 weeks and 33% (grade III or IV: 6%) for neonates born at 33 weeks of gestation. Using a logistic regression analysis model the following parameters were found to increase the risk for RDS significantly (p < 0.05): no prenatal steroid treatment, Cesarean section, male gender, APGAR at 5 min < 7, metabolic acidosis (base excess < or = -6 mval) and rectal temperature < 36 degrees C on admission. Following gestosis, insufficiency of the placenta and premature rupture of membranes a decrease in the incidence of RDS was observed. CONCLUSION: We conclude that although some risk factors for RDS will be difficult to exclude (e.g. maternal disease, gender) the incidence and severity of RDS can be reduced by measures like maternal antenatal steroid treatment. Perinatal asphyxia (low APGAR values and/or acidosis) and hypothermia should be avoided, as these conditions increase the relative risk for developing RDS.     

The future of genetic studies of complex human diseases: an epidemiologic perspective

Every intubated and mechanically-ventilated patient should be clinically evaluated, at least on a daily basis, by a skilled team in order to speed up the weaning process as much as possible. Again, it should be emphasized that the adoption of an active clinical strategy when faced with "difficult" to wean patients is of paramount importance. In one study, performed in Spain, analysing the prevalence of mechanical ventilation in intensive care units [3], reported the mean number of days that patients spent on mechanical ventilation was 27. In a more recent intervention study, in which a specific protocol was followed each day [2], the mean number of days on mechanical ventilation was only 12. These data have been confirmed by several authors [4, 40], and it has also been reported that a protocol-directed weaning strategy leads not only to a significant reduction in the duration of mechanical ventilation but also to a significant decrease in the number of complications and cost [4]. However, even following a protocol-directed weaning strategy, it is possible that weaning duration can be further reduced. In a prospective study performed in our institution [41] during 32 months, we reported that, following an episode of unplanned extubation, the only independent variables associated with the need for reintubation were the number of days of mechanical ventilation and the type of ventilatory support at the time of autoextubation. Indeed, when patients were in the weaning period only 16% (5 out of 32) needed reintubation, whereas reintubation was needed in 82% (22 out of 27) of patients who had an unplanned extubation during full mechanical ventilatory support. These data suggest that there are still some patients being on mechanical ventilation for a longer than necessary period of time. Finally, very recent advances in technological areas such as artificial intelligence, are proving to be useful in the management of the weaning process. When such systems are applied to modern microprocessor-controlled mechanical ventilators they can significantly help in the process of weaning [42] by automatically reducing the ventilatory assistance and by indicating the optimal time to withdraw the patient from the ventilator and proceed with extubation.     

Early treatment with nasal continuous positive airway pressure and "minimal handling". Early and late prognosis in children with birth weight under 1,501 g

During 1988 and 1989 a regional cohort of 81 infants with birth weights of less than 1501 g were treated with oxygen (n = 11), early continuous positive airway pressure (CPAP) (n = 68) or mechanical ventilation from birth (n = 2). We used an easily applicable lightweight CPAP system with nasal prongs and a gas jet supplemented with ventilator treatment if necessary, but with conservative criteria for ventilator treatment with tolerance of high PCO2. A total of 65 infants (80%) survived to discharge, 61 of whom were supported solely with CPAP or oxygen. Nineteen infants (26%) developed periventricular-intraventricular haemorrhage, but only four survivors (6%) developed prognostically significant bleedings of grade 2-4. No survivors had bronchopulmonary dysplasia. Follow-up at 1.5-5 years of age revealed definite disabilities in seven (11%). The results suggest that treatment by early CPAP with nasal prongs with tolerance of high PCO2 may be effective and lenient in most infants of more than 25 weeks' gestation.     

New interpretation and management of dry lung syndrome: a case report

A premature female infant with life-threatening respiratory distress which was diagnosed as 'dry lung syndrome' is reported. The mother had 4 weeks of large volume leakage of the amniotic fluid due to premature rupture of the fetal membranes (PROM) at 23 weeks' gestation. The infant was born after 27 weeks' gestation (birthweight, 1016 g) and was suffering severe respiratory distress. Although a chest radiogram and gastric juice microbubble test did not improve the possibility of respiratory distress syndrome (RDS), very high ventilator settings did not improve her respiratory disorders. Considering the infant's deteriorating respiratory status and the prolonged leakage of the amniotic fluid, we suspected the presence of pulmonary hypoplasia. Although an attempt at high frequency oscillation (HFO) to rescue this infant had no effect, intratracheal instillation of epinephrine (EP) showed dramatic improvement of her respiratory status. This clinical course showed that the patient did not have pulmonary hypoplasia but might have severe airway obstruction and this airway obstruction may be the major cause of 'dry lung syndrome'. We postulate that when a newborn with suspected pulmonary hypoplasia is unresponsive to respiratory support. HFO should be administered. If HFO is ineffective in relieving the respiratory distress, one should suspect the presence of airway collapse and administer a bronchodilator such as EP. If the infant improves, a diagnosis of 'dry lung syndrome' may be assumed.     

Doctoral education in nursing for practitioner knowledge and for academic knowledge: the University of Adelaide, Australia

A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU. Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3 +/- 2.8 (mean (SD) for Gp I vs 7.8 +/- 2.7 for Gp II (P = n.s.) and at elective tracheostomy (Gp III) was 5.4 +/- 2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P < 0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8 +/- 7.1 days in Gp II vs 11.7 +/- 2.9 days in Gp III (P < 0.05). In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.     

Airway occlusion pressure at 0.1 s (P0.1) after extubation: an early indicator of postextubation hypercapnic respiratory insufficiency

OBJECTIVE: To examine variables associated with postextubation respiratory distress in chronic obstructive pulmonary disease (COPD) patients. DESIGN: Prospective, clinical investigation. SETTING: Intensive care unit of a university hospital. PATIENTS: Forty COPD patients, considered ready for extubation. MEASUREMENTS AND MAIN RESULTS: We recorded, from the digital display of a standard ventilator, breathing frequency (f), tidal volume (VT) and f/VT for the respiratory pattern, airway occlusion pressure at 0.1 s (P0.1) for the respiratory drive and measured blood gases: i) before extubation, following 30 min of a 6 cm H2O pressure support (PS) ventilation trial, ii) 1 h after extubation, at the 30th min of a face mask 4 cm H2O PS ventilation trial. According to the weaning outcome, the patients were divided into two groups: respiratory distress, and non-respiratory distress within 72 h of the discontinuation of mechanical ventilation. The respiratory distress was defined as the combination of f more than 25 breaths/min, an increase in PaCO2 of at least 20% compared with the value measured after extubation, and pH lower than 7.35. We determined whether those patients who developed respiratory distress after extubation differed from those who did not. Respiratory pattern data and arterial blood gases recorded, either before or after extubation, and P0.1 recorded before extubation, were inadequate to differentiate the two groups. Only P0.1 recorded 1 h after the discontinuation of mechanical ventilation differentiated the patients who developed respiratory distress from those who did not (4.2+/-0.9 vs 1.8+/-0.8, p < 0.01). CONCLUSIONS: P0.1 recorded after extubation may be a good indicator of postextubation respiratory distress. Measuring P0.1 and/or the analysis of the evolution of this parameter could facilitate decisions during the period following extubation.     

Stress response and mode of ventilation in preterm infants

AIM: To assess the change in stress response in preterm babies changed from patient triggered ventilation (PTV) to conventional mandatory ventilation (CMV) and vice versa; to determine outcome in relation to stress hormone concentrations. METHODS: A randomised controlled study was conducted in two district general hospital neonatal intensive care units. Thirty babies, treated initially with CMV, were randomly assigned to remain on CMV or to change to PTV. A second group of 29 babies, treated initially with PTV, were randomly assigned to remain on PTV or to change to CMV. The babies were less than 32 weeks of gestation, ventilated within 72 hours of birth, with clinical and radiological features compatible with respiratory distress syndrome (RDS). Stress hormone concentrations and clinical distress score were measured before and 20 minutes after allocation of mode of ventilation. RESULTS: Babies changed from CMV to PTV had significantly reduced adrenaline concentrations (median change -0.4 nmol/l) compared with those who remained on CMV. There was no increase in adrenaline in babies changed from PTV to CMV. There were no significant changes in noradrenaline concentrations or clinical distress score. Babies who died had significantly higher adrenaline and noradrenaline concentrations than those who survived. CONCLUSION: A change in mode of ventilation significantly reduces adrenaline concentrations. Raised catecholamine values are associated with a poor outcome.     

Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g

AIM: To determine whether extubation to nasal continuous airway pressure (NCPAP) results in a greater proportion of infants remaining free of additional ventilatory support for one week after extubation compared with those extubated directly to headbox oxygen. METHODS: A randomised, controlled, clinical trial was conducted at the neonatal intensive care unit of the Royal Women's Hospital, Melbourne, of infants with birthweights between 600 and 1250 g, ventilated via an endotracheal tube for more than 12 hours, requiring less than 50% oxygen, a ventilator rate < or = 20/minute, considered by the clinical management team to be ready for extubation. Infants were randomly allocated either to NCPAP or to oxygen administered via a headbox. Success was defined by no requirement for additional ventilatory support over the week following extubation. Failure criteria were (i) apnoea; (ii) absolute increase in oxygen requirement greater than 15% above than required before extubation; or (iii) respiratory acidosis (pH < 7.25 with pCO2 > 6.67 kPa). RESULTS: Thirty one of 47 (66%) infants were successfully extubated to NCPAP compared with 18 of 45 (40%) for headbox oxygen. The increase in failure rate in the headbox group was due primarily to increased oxygen requirements in this group. Of the 27 who failed headbox oxygen, 26 were given a trial of NCPAP and 13 did not require endotracheal reintubation. There was no significant difference between the groups in the total number of days of assisted ventilation or the duration of inpatient stay. CONCLUSIONS: NCPAP applied prophylactically after endotracheal extubation reduces the incidence of adverse clinical events that lead to failure of extubation in the seven days after extubation. This reduction is clinically important. The benefits of NCPAP do not seem to be associated with an increased incidence of unwanted side effects.     

Predictors of extubation success and failure in mechanically ventilated infants and children

OBJECTIVE: To predict extubation success and failure in mechanically ventilated infants and children using bedside measures of respiratory function. DESIGN: Prospective collection of data. SETTING: A university-affiliated children's hospital with a 51-bed critical care unit. PATIENTS: All infants and children who were mechanically ventilated for at least 24 hrs, except neonates < or = 37 wks gestation and patients with neuromuscular disease. INTERVENTIONS: Bedside measurements of cardiorespiratory function were obtained immediately before extubation. MEASUREMENTS AND MAIN RESULTS: Extubation failure was defined as reintubation within 48 hrs of extubation in the absence of upper airway obstruction. Failure rates were calculated for different ranges (selected a priori) of preextubation measures of breathing effort, ventilatory support, respiratory mechanics, central inspiratory drive, and integrated indices useful in adults. Effort of spontaneous breathing was assessed by the respiratory rate standardized to age, the presence of retractions and paradoxical breathing, inspiratory pressure, maximal negative inspiratory pressure (maximal negative inspiratory pressure), inspiratory pressure/maximal negative inspiratory pressure ratio, and tidal volume indexed to body weight of a spontaneous breath. Ventilatory support was measured by the fraction of inspired oxygen (F10(2)), mean airway pressure, oxygenation index, and the fraction of total minute ventilation provided by the ventilator. Respiratory mechanics were assessed by determination of peak ventilatory inspiratory pressure and dynamic compliance. Central inspiratory drive was assessed by mean inspiratory flow. Frequency to tidal volume ratio and the compliance, rate, oxygenation, and pressure indexed to body weight, the integrated indices useful in predicting extubation failure in adults, were also calculated. Thirty-four of the 208 patients who were studied were reintubated for an overall failure rate of 16.3% (95% confidence interval 11.3% to 21.4%). The reasons for reintubation were poor effort (n = 8), excessive effort (n = 14), altered mental status or absent airway reflexes (n = 2), cardiovascular instability (n = 3), inadequate oxygenation (n = 3), respiratory acidosis (n = 3), and undocumented (n = 1). Extubation failure increased significantly with decreasing tidal volume indexed to body weight of a spontaneous breath, increasing F10(2), increasing mean airway pressure, increasing oxygenation index, increasing fraction of total minute ventilation provided by the ventilator, increasing peak ventilatory inspiratory pressure, or decreasing mean inspiratory flow (p < .05). Dynamic compliance showed a trend of increasing failure rate with decreasing dynamic compliance but did not reach statistical significance (p = .116). Respiratory rate standardized to age, inspiratory pressure, maximal negative inspiratory pressure, inspiratory pressure/maximal negative inspiratory pressure ratio, frequency to tidal volume ratio, and compliance, rate, oxygenation, and pressure did not show any trend in failure rate with increasing or decreasing values. Threshold values that defined a low risk (< or = 10%) and a high risk (> or = 25%) of extubation failure could be determined for tidal volume indexed to body weight of a spontaneous breath, F10(2), mean airway pressure, oxygenation index, fraction of total minute ventilation provided by the ventilator, peak ventilatory inspiratory pressure, dynamic compliance, and mean inspiratory flow. Neither a low nor a high risk of failure could be defined for frequency to tidal volume ratio or the compliance, rate, oxygenation, and pressure (CROP) index. CONCLUSIONS: Bedside measurements of respiratory function can predict extubation success and failure in infants and children. Both a low risk and a high risk of failure can be determined using these measures. Integrated indices useful in adults do not reliably predict extubation success or failure in     

A prospective study of unplanned endotracheal extubation in intensive care unit patients

OBJECTIVE: To evaluate incidence, factors associated with unplanned endotracheal extubation (UEE), and prognostic factors for reintubation. DESIGN: A prospective study over a 32-mo period. SETTING: A 16-bed general intensive care unit of a tertiary university hospital. PATIENTS: Adult subjects undergoing endotracheal intubation for >48 hrs. INTERVENTIONS: Observation of patients who presented unplanned extubation. MEASUREMENTS AND MAIN RESULTS: Over the 32-mo period, there were 59 episodes of UEE in 55 patients (frequency 7.3%). Deliberate self-extubation occurred in 46 episodes (77.9%), while there were 13 episodes (22.1%) of accidental extubation. Twenty-seven (45.8%) episodes occurred in patients who were receiving full mechanical ventilatory support and 32 (54.2%) episodes occurred during the weaning period from mechanical ventilation. Reintubation was required in 27 (45.8%) episodes of UEE. The need for reintubation after UEE was 36.9% in deliberate self-extubation patients and 76.9% in accidental extubation patients (p = .01). Only 15.6% (5/32) of patients who presented UEE during weaning required reintubation, while reintubation was mandatory in 81.5% (22/27) of patients who presented UEE during full mechanical ventilatory support (p < .001). A multiple logistic regression analysis was performed to determine the variables independently associated with the need for reintubation: days of mechanical ventilation were significantly associated with the need for reintubation, and weaning was associated with no need for reintubation. The model correctly classified the need for reintubation in 84.7% (50/59) of cases. CONCLUSIONS: Reintubation in UEE patients strongly depends on the type of mechanical ventilatory support. The probability of requiring reintubation if UEE occurs during full ventilatory support is higher than if UEE occurs during weaning. These data suggest that some patients are under mechanical ventilation longer than necessary.     

Compliance in treatment of the sleep apnea syndrome using continuous positive pressure respiration

BACKGROUND: Continuous positive airway pressure (CPAP) is the therapeutic method of choice in sleep apnoea syndrome (SAS) but involves at first discomfort for the patients. The correct indication, correct setting of the overpressure and good adaptation influence the application and therapeutic asset of CPAP. METHODS AND RESULTS: From a total number of 41 patients with SAS treated by CPAP 24 were examined (incl. three women), who had CPAP in domiciliary treatment for more than two months. The mean period of use was 288.2 days (range 52-824). 84% of the patients used CPAP daily, the mean number of applications per week was 6.26 (range 2-7). For the whole period of sleep CPAP was used by 75% patients and the mean sleep period with CPAP was 6 hours (range 2.5-8). None of the patients discontinued treatment completely. Four patients used CPAP inadequately (less than 25 hours per week) - one because of intolerance associated with severe CHOCHB, the second one for intolerance of overpressure of 15 mbar, the third one because of poor motivation and the fourth one because of dehydration of mucous membranes. All patients recorded the therapeutic effect of CPAP. Rhonchopathy disappeared in 87.5% patients, excessive somnolence improved in 91.7%, fatigue declined in 88.5%. The functional capacity and work performance improved in 95.8% patients. Undesirable effects were not serious nor frequent: escape of air from the mask (29.2%), dry mucosae (20.8%), pressure sores caused by the mask (20.8%), serous rhinitis (12.5%), burning sensation of the mucosae of the upper airways (8.3%) and conjunctivitis (4.2%) CONCLUSIONS: Adequate compliance with CPAP was recorded in 83.3% patients and a favourable effect of treatment was proved.     

Unusual complication of nasal CPAP: subcutaneous emphysema following facial trauma

Subcutaneous emphysema is an unusual complication of nasal continuous positive airway pressure (CPAP). We report a case of a 58-year-old man who fell and sustained mild facial trauma to the left side of his head. After using CPAP the following night, he developed diffuse subcutaneous emphysema of his face and left neck. He discontinued CPAP, and his symptoms improved. The potential mechanisms of this patient's subcutaneous emphysema and the prior reports of this complication following facial trauma or dental procedure without use of CPAP are reviewed. Although there are case reports of bacterial meningitis and pneumocephalus following use of nasal CPAP, we are not aware of any prior reports of subcutaneous emphysema following use of CPAP. In light of our experience and the above related case reports, we would suggest nasal CPAP be withheld temporarily in the setting of acute facial trauma.     

Cell and organ culture techniques applied to the study of carcinoma of colon and rectum

The hospital records of 197 infants with the respiratory distress syndrome (RDS) were reviewed and the families of 111 of them subsequently contacted to obtain a family history. After correcting for biasis of ascertainment, the incidence of RDS among the full sibs was found to be between 12 and 19% depending on whether the individuals diagnosed as "possible RDS" were counted as affected. Among the low birth weight (LBW, less than or equal to 2.5 kg) and/or preterm (less than or equal to 37 weeks gestation) infants in the sibships, the incidence of RDS was 32-50%. Considering only sibs born after the probands yielded the empiric recurrence risk of 17--27% for all younger sibs and 39--67% for LBW/preterm younger sibs. The risk for maternal half-sibs was of about the same magnitude as that for full sibs, while the risk for paternal half-sibs was minimal. Among the LBW/preterm first cousins of probands, only the infants of maternal aunts showed an RDS incidence clearly higher than that in the general population. We think these data suggest a genetically determined maternal factor predisposing the infants of certain mothers to RDS. Other significant findings include: 1) an excess of males among the probands but a normal sex ratio among the sibs of the probands; 2) a decrease in mean birth weight and mean length of gestation for not only the probands but also their sibs; 3) a decrease in the mean parental ages at the birth of the probands; 4) a relative dearth of first-born and an excess of second-born infants among the probands; 5) an increased incidence of stillbirths in the sibships; 6) an increased number of probands born by cesarean section; and 7) a twin concordance of 75%.     

Soluble L-selectin concentration in bronchoalveolar lavage fluid obtained from infants who develop chronic lung disease of prematurity

AIMS: To explore the changes in neutrophil adhesion molecule expression and release into bronchoalveolar lavage fluid (BAL) obtained from infants who developed chronic lung disease (CLD). METHODS: BAL fluid was obtained from 37 infants: 18 (median gestation 26 weeks, birthweight 835 g) who developed CLD, 12 (29 weeks, 1345 g) with respiratory distress syndrome (RDS) and seven control infants (33 weeks, 2190 g). RESULTS: Soluble L-selectin (sL-selectin) in BAL fluid from the CLD and non-CLD groups was similar immediately after birth, but in infants who subsequently developed CLD, sL-selectin remained persistently increased (at day 7: CLD 42.6 vs RDS 6.0 ng/ml, p < 0.05; CLD vs controls 1.5 ng/ml; p < 0.05). CD11b/CD18 expression on neutrophils obtained by BAL increased with time to reach a maximum at 17 days of age in infants who developed CLD. CONCLUSIONS: These results suggest that leucocyte traffic persists in infants who develop CLD and may have an important part to play in the pathogenesis of CLD.