Development of massive pneumopericardium after intubation and positive pressure ventilation

Pneumopericardium is a rare complication of chest trauma, mechanical ventilation and cavitating pneumonia. We report a case of a 7-year-old patient with chronic myeloid leukemia who developed massive pneumopericardium immediately after being electively intubated for a diagnostic radiological procedure in the setting of ongoing Enterococcal pneumonia. As intensive care medicine becomes more prevalent in hospitals, we believe that clinicians need to be aware of this uncommon but potentially fatal condition

Conventional Vs non invasive ventilation in acute respiratory failure

Treatment of patients with acute respiratory failure [ARF] often involves mechanical ventilation via endotracheal intubation. Non-invasive positive pressure ventilation [NIV] using Bi-level positive airway pressure [BiPAP] can be a safe and effective means of improving gas exchange. 1] Assess non-invasive positive pressure ventilation [BiPAP] as an alternative way for ventilation in ARF, and to 2] Determine factors that can predict the successful use of BiPAP. Thirty patients with acute respiratory failure [both type I and II] were enrolled in the study and divided into two groups. Group I included 10 patients who were subjected to invasive mechanical ventilation. Group II included 20 patients were subjected to NIV using BiPAP. Both groups were compared regarding the following parameters: Arterial blood gases [ABG] on admission, 30 minutes after beginning of mechanical ventilation, 1[1/2] hour then once daily. Complications namely ventilator associated pneumonia [VAP], skin necrosis and CO[2] narcosis; static compliance and resistance were measured at day one and day two. Compared to group I, group II patients were associated with similar improvement in ABGs data at 30 minutes and at discontinuation of ventilation [Table A]. Group II patients showed significantly lower incidence in VAP [20% Vs 80%], shorter duration of mechanical ventilation [3 +/- 3 Vs 6 +/- 5 days, p=0.006], with shorter length of hospital stay [5.8 +/- 3.6 Vs 8.9 +/- 2.7 days, p=0.011] when compared to group I. Skin necrosis [50%] and CO[2] narcosis [20%] occurred in group II only. Group II patients showed significant difference change in compliance and change in resistance from day I to day II when compared to group I Table [B]. On univariate basis, parameters were analyzed to choose those who were associated with outcome in concern [successful NIV]. The following parameters were identified: Level of consciousness, pH [7.3 +/- 0.03 Vs 7.26 +/- 0.1, p=0.009] PCO[2] [69.16 +/- 13.14Vs 100.97 +/- 12.04] on admission, 1[1/2] hour after NIV, pH [7.37 +/- 0.03 Vs 7.31 +/- 0.17, p=0.005], PCO[2] [53.98 +/- 8.95 Vs 77.47 +/- 5.22, p=0.0001] in whom NIV succeeded and failed respectively. Then multivariate analysis utilizing two different techniques namely [multivariate logistic regression and discriminate analysis] was used. The variable identified was PCO[2] after 1[1/2] hour in the two models with specificity 100%. In patients with acute respiratory failure, non-invasive ventilation was as effective as conventional ventilation in improving gas exchange, associated with fewer serious complications and shorter stay in intensive care. One and half hour trial with NIV can predict success with BiPAP, as shown by an improvement in pH and PCO[2] and overall clinical picture. PCO[2] after 1[1/2] hour could be the sole predictor of successful NIV with 100% specificity

Valoración de la asistencia ventilatoria en una unidad de tratamiento intensivo neonatal / Valuation of assisted ventilation in a neonatal intensive care unit

El objetivo principal de este trabajo fue realizar un estudio observacional sobre los parámetros ventilatorios utilizados en la asistencia ventilatoria en los RN ingresados en la UCIN del Servicio de Recién Nacidos del Centro Hospitalario Pereira Rossell, y su relación con las distintas complicaciones y evoluciones. Se observó una población de neonatos que ingresaron por primera vez a UCIN en un período de siete meses. Se siguió el protocolo en 103 casos (64 por ciento). Se evaluaron parámetros respiratorios y gasometrías en los primeros cinco días de ventilación, y las complicaciones y la evolución durante su estadía hospitalaria. De los resultados debemos destacar una alta frecuencia de pCO, menores de 40 mmHg en todo el período estudiado. La mortalidad en la muestra analizada fue de 38 por ciento, con una frecuencia de 54 por ciento y 26 por ciento en los neonatos con peso al nacer menores y mayores de 1.500 g respectivamente. El subgrupo con peor evolución fue el de peso al nacer menor de 1.000 g, con una mortalidad del 75 por ciento. No hubo diferencias significativas en los días de internación y ventilación, ni en los parámetros utilizados, así como tampoco en las complicaciones.

Presión media de la vía áerea: importancia clínica y pronóstica en pacientes con enfermedad pulmonar aguda / Midle pression of the aerial vial: clinic and pronostic importance in patients acute lung disease

Se trata de un estudio prospectivo de cohorte de tres meses de duración, de marzo a junio de 1995, realizado en la Unidad de Terapia Intensiva del Hospital Dr. Miguel Pérez Carreño, en la Ciudad de Caracas; donde se evaluó la Presión Media de la Vía Aérea (Pva) en 20 pacientes sometidos a ventilación mecánica. Separandolos en dos grupos de 10 denominados controles y casos, los primeros pacientes en post-operatorio inmediato de patología craneal, y los segundos pacientes con enfermedad pulmonar aguda, según escala de enfermedad pulmonar de Murray. Se determinó la Pva en pacientes controles cuyo valor fué de 4.38 con DS ñ 0.8 cm H20 así como la de los casos de 8.05 ñ 2.97 H20. Realizados los calculos estadísticos, concluimos que no hubo diferencia significativa en la ocurrencia de barotrauma entre los pacientes que presentaron elevación progresiva de la Pva y aquellos pacientes que mantuvieron niveles basales de la misma

Assisted ventilation in neonates: the Manipal experience.

Case records of 68 newborns who required assisted ventilation over a 24 month period were reviewed. Fortyfour (64.7%) received intermittent mandatory ventilation, 10 (14.7%) received nasal CPAP and the remaining 14 (20.58%) received a combination of the above. Some of the indications for ventilation were infections (21), hyaline membrane disease (16), problems related to asphyxia (11), apnea of prematurity (10) and persistent pulmonary hypertension of newborn (5). The overall survival rate was 41.17%. In the CPAP group 90% (9/10) survived, while in the remaining survival was 32.7% (19/58). The best outcome was observed in persistent pulmonary hypertension of newborn (80%) followed by apnea of prematurity (70%) and hyaline membrane disease (43.75). Outcome was poor in conditions related to birth asphyxia (27.2%) and infections (19.05%). Survival rates were higher (44.4%) in babies weighing > 1500g at birth as compared to 40.9% in babies < 1500g. Babies less than 32 weeks gestation had a survival rate of 32% as compared to 46.5% in those over 32 weeks. This difference was not statistically significant. Complications were seen in 12/68 patients (17.6%). Pneumothorax was the commonest followed by sepsis, intraventricular hemorrhage and blocked endotracheal tubes. Babies with hyaline membrane disease had the highest incidence of complications. Analysis of the data with regard to the indications, outcome and complications is presented.

Hipoventilacion alveolar central con cor pulmonale: tratamiento exitoso mediante ventilacion con presion positiva intermitente no invasiva / Central alveolar hypoventilation with cor pulmonale: successful treatment by non-invasive intermittent positive pressure ventilation

Una paciente de 62 años con atecedentes de PCC bilateral, presentó 2 años después de la remoción del derecho signos de insuficiencia cardíaca derecha. Se comprobó hipoxemia, hipercapnia e hipertensión pulmonar con volúmenes pulmonares normales. Por la ausencia de respuesta ventilatoria a la hipoxia y la hipercapnia provocadas, a la prolongación del tiempo de apnea voluntaria y la corrección de la hipercapnia por hiperventilación voluntaria se hizo diagnóstico de hipoventilación alveolar central. El tratamiento con progesterona (200 mg/d durante 3 semanas) y naloxona no mejoró los gases en sangre o la curva PO.1/PaCO2. Acetazolamida (250 mg/d) produjo acidosis respiratoria. La aplicación de CPAP nasal no controló los períodos de hipoventilación. Se inició ventilación mecánica con presión negativa (NPV) a través de un proncho. La paciente presentó severo disconfort con NPV y se verificaron apneas obstructivas durante su uso. La paciente se negó a continuar recibiendo NPV. Se inició ventilación mecánica con presión positiva intermitente (IPPV) a través de máscara nasal. La paciente tuvo excelente tolerancia al procedimiento. La SaO2 durante IPPV fue siempre superior a 95 por ciento. Durante el período de inducción del sueño (bajo IPPV) se observó respiración enfase con el ventilador 1: 1, en cambio durante el sueño consolidado, había dependencia completa del respirador con apnea de más de 2 min al interrumpir la IPPV. Después de 2 meses de tratamiento la paciente presentó desaparición de los signos de falla ventricular derecha y descenso del hematocrito a 39 por ciento...

Three-year experience with neonatal ventilation from a tertiary care hospital in Delhi.

Ninety neonates were ventilated over a period of 33 months of whom 50 (55.5%) survived. Fifty seven babies received IPPV while 33 CPAP. IPPV mode was being used more frequently recently and survival rates have steadily improved over past 3 years. Survival was cent per cent in babies above 1.5 kg on CPAP mode while 16/26 (57.7%) survived on IPPV mode. Of 22 extremely VLBW (< 1 kg) babies, six survived. HMD was the commonest indication of ventilation (50%), of which 53% (24/45) survived. The other important indications of ventilation were apnea in 13 and transient tachypnea in 11 babies. All babies requiring ventilation for transient tachypnea survived. Nosocomial infections were common in association with ventilation 34/90 (37.7%), out of which in 14 was responsible for about a third of deaths. Pulmonary air leaks developed in 12 babies of which 6 died. Two babies developed BPD and one ROP. Neonatal ventilation should be ventured in centres where basic facilities for level II care already exist. It may not be cost effective to ventilate extremely low birth weight neonates.