Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation.

Tracheostomy speaking valves consist of a one-way valve that closes upon exhalation, causing a redirection of exhaled gas into the upper airway, thus allowing for the primary benefit of speech. The present study was undertaken to test various hypotheses concerning the secondary benefits of speaking valves. We hypothesized that use of a speaking valve will result in a decrease in accumulated secretions, an increase in arterial oxygenation and an improvement in olfactory function. A total of 8 tracheotomized patients met the following inclusion criteria: age > 18; ability to tolerate wearing a speaking valve for at least 3 hours; no unstable medical conditions; no use of thrombolytic agents. While using the speaking valve patients accumulated fewer secretions (74.3 +/- 63.6 vs. 122.8 +/- 44.6 ml/day, p = 0.004, n = 7) and had improved olfactory function (accuracy = 28.4 +/- 5.2 vs 8.1 +/- 2.9%, p = 0.02; and percent correct = 64.2 +/- 2.6 vs 50.0 +/- 3.9%, p = 0.03, n = 6) than when off the speaking valve. No significant differences were found in 24-hour arterial oxygen saturation (pulse oximetry and ABG analysis respectively, n = 7), arterial PO2, pH, PCO2, HCO3, or 24-hour heart rate (n = 7). Thus, the present study found a significant decrease in secretions and improvements in olfaction when tracheotomized patients wore a speaking valve, but no difference in arterial oxygenation.

Exertional hypotension in spinal cord injury.

STUDY OBJECTIVE: To assess blood pressure (BP) response to continuous maximal arm ergometry in patients with spinal cord injury (SCI). DESIGN: Cross-sectional analysis of data collected for a prospective study of functional electrical stimulation in patients with SCI. SETTING: Short-term rehabilitation hospital. PARTICIPANTS: Twenty individuals with SCI; 4 cervical (C6 to C8), 10 high thoracic (T1 to T6), and 6 low thoracic (T7 to T12). MEASUREMENTS AND RESULTS: Each subject performed continuous maximal arm ergometry with expired gas analysis. Blood pressure was measured using a technician-assisted protocol. The BP at maximal exercise was compared with the highest submaximal BP reached during the test (delta BP = final BP minus highest submaximal BP). All 20 subjects had a negative delta BP (mean +/- SD; -22.8 +/- 12.1 mm Hg) for mean BP and 19 of 20 had a negative delta BP (-25.8 +/- 14.4 mm Hg) for systolic BP. The delta BP was not significantly related to maximum exercise parameters, resting BP, or level of lesion. Four able-bodied subjects and six wheelchair-bound individuals without SCI showed no exertional hypotension. Repeated testing on the four able-bodied subjects showed excellent reproducibility for mean BP (coefficient of variation [CV] = 3.6 percent; r = 0.98; p < 0.01) and systolic BP (CV = 2.2 percent; r = 0.99; p < 0.01) using this protocol. CONCLUSIONS: These data describe, for the first time to our knowledge, that exertional hypotension is present in all individuals with SCI during continuous arm ergometry. Further studies are needed to clarify the mechanisms responsible for this phenomenon and to evaluate the long-term consequences for individuals with SCI.

Exertional hypotension in thoracic spinal cord injury: case report.

Exertional hypotension is well described in quadraplegics, but there are few descriptions of this hemodynamic response in paraplegics or of treatment modalities to correct this condition. We describe a patient with a complete T3-4 spinal cord lesion who repeatedly demonstrated symptomatic hypotension with wheelchair sports and arm ergometry. We used gas exchange analysis and exercise echocardiography to delineate the mechanism for hypotension. These results enabled us to develop a simple treatment plan consisting of abdominal binding and elastic stockings to avoid recurrent symptoms.

Pulmonary malignant angioendotheliomatosis. Presentation with fever and syndrome of inappropriate antidiuretic hormone.

A 64-year-old man presented with protracted fever, hyponatremia, and mononeuritis multiplex. Inappropriate antidiuretic hormone secretion was established. The absence of pulmonary infiltrates precluded any lung biopsy. Autopsy revealed malignant angioendotheliomatosis involving multiple organs including the alveolar septa and pulmonary vasculature. An early diagnosis of MAE in the setting of fever and SIADH may be possible via transbronchial biopsy.

Hyperglucagonemia in hepatic cirrhosis: its relation to hepatocellular dysfunction and normalization on recovery.

Plasma glucagon, insulin and glucose concentrations, and liver function tests were determined after an overnight fast in 24 normal subjects and 50 male cirrhotic patients. In cirrhotic patients with normal liver profiles, plasma glucagon remained within normal limits, irrespective of the presence of portasystemic anastomoses either pathological or surgical. Hyperglucagonemia was documented in presence of advanced liver dysfunction alone. Significant correlations were established between plasma glucagon and several liver function tests, i.e., serum bilirubin, albumin/globulin ratio, and prothrombin time. Moreover, hyperglucagonemia normalized on recovery from clinical manifestations and improvement in liver profile. Plasma insulin was raised primarily in the presence of a significant portasystemic shunting and maximum levels were observed in patients manifesting advanced liver dysfunction as well. However, no correlation was evident between plasma insulin and any of the liver function tests. Fasting plasma glucose was not altered in cirrhotic patients. Therefore, it is concluded that in hepatic cirrhosis, glucagon secretion by pancreatic alpha-cell may be dependent on the severity of the hepatocellular damage whereas portasystemic shunting may be responsible for hyperinsulinemia which may be further exaggerated in presence of advanced liver dysfunction.