Pulmonary hyperinflation following Nd-YAG laser resection of an obstructing mainstem tumor.

Nd-YAG laser resection of a completely obstructing right mainstem tumor in a 36-year-old man was complicated by right lung hyperinflation and left lung collapse and accompanying ventilatory failure. This was attributed to obstruction of the right mainstem bronchus during exhalation, but not inhalation, in a patent but irregularly shaped bronchus postresection. Intubation, positive pressure breathing, bronchodilator therapy, and laser excision of residual right mainstem tumor resolved the ventilatory failure.

Bilateral otorrhagia associated with continuous positive airway pressure.

A patient had bilateral tympanic membrane rupture and otorrhagia, an unusual complication of continuous positive airway pressure (CPAP). CPAP, applied by a bag/mask system using disposable spring valves, was used to treat acute pulmonary edema during volume resuscitation and vasopressin therapy for bleeding from esophageal varices.

Critical care management of chest injury.

This article reviews the care of the chest-injured patient during the intensive care unit phase of his or her recovery. Special attention is given to the respiratory aspects of care; hemodynamic and nutritional aspects are also covered.

Distribution of pneumothorax in the supine and semirecumbent critically ill adult.

Although a number of radiologic signs of pneumothorax in the supine patient have been reported, the frequency of involvement of various pleural recesses has not been emphasized. In 88 critically ill patients with 112 pneumothoraces, the anteromedial (38%) and subpulmonic (26%) recesses were the most commonly involved in the supine and semirecumbent position. In this study, 30% of pneumothoraces were not initially detected by the clinician or radiologist, and half of these progressed to tension pneumothorax. Knowledge of the most common recesses involved in pneumothorax and aggressive use of additional radiographic views, including computed tomography, should increase detection of pneumothoraces in critically ill patients.

Pulmonary artery catheter occlusion as an indication of pulmonary embolus.

Two patients with respiratory failure had consistently reproducible findings on insertion of flow directed pulmonary artery catheters which led to the subsequent diagnosis of pulmonary embolus. Occlusion of the catheter tip and development of a rising "overwedge" tracing on deflation of the balloon may mean the catheter tip has become embedded in clot. When combined with the inability to obtain a wedge tracing, the deflation "overwedge" tracing should alert the physician to the possibility of unsuspected pulmonary embolus.

Intratracheal fire ignited by the Nd-YAG laser during treatment of tracheal stenosis.

Intratracheal combustion of a fiberoptic bronchoscope and an endotracheal tube occurred during the treatment of severe tracheal stenosis with the neodymium-YAG laser. This recognized hazard of CO2 laser surgery has not been reported previously with the use of the Nd-YAG laser. Fire hazard is inevitable when a laser is used in the airway, but the risk can be diminished. Rapid removal of the burning endoscope and endotracheal tube is essential to prevent serious complications.