Noninvasive positive pressure ventilation: what is its role in treating acute respiratory failure?

Noninvasive positive pressure ventilation (NIPPV) is a viable option in treating appropriately selected patients with acute respiratory failure. It is often well tolerated, and it avoids endotracheal intubation with its potential complications. Moreover, gas exchange is reportedly improved. Several issues relating to the use of NIPPV are unresolved, however. The optimal interface, best ventilator mode, and patient selection criteria have not been firmly established. Also, studies are needed to compare the efficacy, safety, and cost-effectiveness of NIPPV and standard endotracheal ventilation. Despite these unresolved issues, NIPPV clearly represents an important addition to the techniques available in managing acute respiratory failure. Except in situations in which immediate endotracheal intubation is required, it may become first-line therapy in elderly patients in whom resuscitation status is unsettled.

Use of capnography for assessment of the adequacy of alveolar ventilation during weaning from mechanical ventilation.

A prospective study was conducted to determine the reliability of noninvasive end-tidal CO2 (PETCO2) monitoring as a reflection of arterial CO2 tension (PaCO2) during weaning from mechanical ventilation (MV). Simultaneous PaCO2 and PETCO2 determinations were compared during MV and again during a spontaneous breathing trial just before returning the patient to MV. Three groups of patients recovering from acute respiratory failure were evaluated. Group 1 consisted of 16 patients (28 observations) without parenchymal lung disease. Group 2 consisted of 22 patients (31 observations) with alveolar filling diseases. Group 3 was composed of 13 patients (22 observations) with emphysema. Significant Pearson correlation coefficients were demonstrated between PaCO2 and PETCO2 during both MV and spontaneous breathing in all three groups. Significant correlation was also demonstrated between the change in PaCO2 and the change in PETCO2 associated with weaning for each group; however, the degree of correlation varied between groups. Our data suggest that capnography offers a reasonable estimate of PaCO2 and changes in PaCO2 during weaning in patients without parenchymal lung disease. However, PETCO2 is less sensitive to changes in PaCO2 for patients with parenchymal lung disease, particularly patients with emphysema. Interpretation of capnographic data requires a full understanding of its limitations. An approach to capnographic monitoring during weaning is discussed.

Benign metastasizing leiomyoma. A case report and review of the literature.

This is a case report of an asymptomatic, 65-year-old white female who was evaluated for multiple pulmonary nodules. This patient's presentation, clinical course and pathologic specimens are consistent with benign metastasizing leiomyoma. A review of this rare disorder is included in this report with emphasis on past cases, clinical overview and treatment.

Intoxicaçäo crônica por cobre em ovinos / Chronic coopper poisoning in sheep

Säo descritos dois surtos de intoxicaçäo crônica por cobre em ovinos no Rio Grande do Sul, causando a morte de pelo menos 21 animais. O s sinais clínicos incluíam depressäo, anorexia, icterícia e homoglobinúria; as mortes ocorrem 4 a 6 dias apòs o início dos sintomas. As lesöes mais consistentes vistas na necrópsia foram icterícia, fígado amarelo ou alaranjado, rins escuros e tumefeitos. O diagnóstico foi confirmado pelos altos níveis de cobre encontrados na raçäo e em fragmentos de fígado e rim dos animais afetados

Comparison of beta-adrenergic agents delivered by nebulizer vs metered dose inhaler with InspirEase in hospitalized asthmatic patients.

The present study was undertaken to determine if beta-agonists delivered by nebulizer provide better clinical responses than MDI therapy in status asthmaticus. We divided 28 hospitalized asthmatic patients into three groups. Group 1 received albuterol by MDI with InspirEase. Group 2 received nebulized albuterol. Group 3 received nebulized metaproterenol. Both nebulizer regimens resulted in significant improvements in both FVC and FEV1 by 30 min after initial hospital beta-agonist treatment. No significant improvement was noted in initial spirometry in the MDI with InspirEase group. In spite of the superiority of nebulizer therapy in the initial phase of hospitalization, the daily rates of spirometric improvement and duration of hospitalization were not significantly different among the three groups. Our results indicate that nebulizer therapy provides superior spirometric improvement in the initial phase of status asthmaticus. However, both MDI and nebulizer regimens provided similar rates of spirometric improvement and duration of hospitalization.

Multifocal eosinophilic granuloma.

A 22-year-old black male presented with progressive dyspnea, a nonproductive cough, and new skin lesions. He was severely hypoxic, and had a severe restrictive defect on pulmonary function testing. A 2-cm lytic defect was noted on skull radiographs. A lung biopsy demonstrated pulmonary fibrosis. A biopsy of a skin lesion was consistent with a diagnosis of multifocal eosinophilic granuloma, or disseminated histiocytosis X. The case presents several unusual features of this uncommon disorder.

Pulmonary vasodilator therapy for chronic obstructive pulmonary disease and cor pulmonale. Treatment with nifedipine, nitroglycerin, and oxygen.

The present study was undertaken to evaluate the short-term effects of nitroglycerin, nifedipine, and supplemental oxygen on hemodynamics and gas exchange in 11 patients in stable condition with chronic obstructive pulmonary disease and cor pulmonale. In general, both intravenous nitroglycerin and sublingual nifedipine significantly reduced the pulmonary vascular resistance index. For the group as a whole, nifedipine decreased the pulmonary vascular resistance index by significantly increasing the cardiac index, with minimal reductions in mean pulmonary arterial pressure. Conversely, nitroglycerin decreased the pulmonary vascular resistance index by markedly reducing the mean pulmonary arterial pressure but also decreased the cardiac index in some patients. Nitroglycerin also caused a significant decrease in mixed venous oxygen tension. Administration of oxygen did not cause any clinically significant improvement in resting hemodynamics following short-term administration. During the follow-up period, eight of 11 patients who were treated with pulmonary vasodilators in addition to long-term therapy with low-flow oxygen died within a mean of six months. This rate of survival was not significantly different than an age-matched and sex-matched control group with similar severity of disease who received only long-term therapy with low-flow oxygen. Based on these data, it seems unlikely that a substantial increase in survival will be obtained by combining pulmonary vasodilators with long-term oxygen therapy in patients with stable emphysema who have cor pulmonale and carbon dioxide retention.

Computed tomography for diagnosis of tracheoesophageal fistula.

Two patients developed tracheoesophageal fistula after prolonged nasotracheal intubation and tracheostomy. The use of computed tomography, a noninvasive technique, to document the size and location of tracheoesophageal fistula may be preferable to endoscopic examination in critically ill, ventilator-dependent patients.

Pulmonary gold toxicity.

A 52-year-old, white female developed low-grade fever, cough, and dyspnea after 8 weeks treatment with sodium aurothiomalate for rheumatoid arthritis. The patient had severe hypoxemia associated with bilateral pulmonary infiltrates. Dramatic clinical improvement followed prednisone therapy.

The relationship of low voltage on the electrocardiogram and chronic obstructive pulmonary disease.

A retrospective analysis was performed to analyze the relationship between low voltage on the electrocardiogram and chronic obstructive pulmonary disease. Subjects were 250 patients who had both pulmonary function tests and an electrocardiogram at UMDNJ-John F. Kennedy Memorial Hospital from the years 1975-1980. Low voltage was detected in only 13 of 250 patients. An attempt to define the relationship between the incidence of low voltage on the electrocardiogram and the severity of airway obstruction, as judged by the reduction in the FEV1, was unsuccessful. Concomitantly, a relationship could not be established between the incidence of low voltage and the degree of hyperinflation, as judged by the residual volume. In conclusion, the electrocardiographic evidence of low voltage does not represent either a sensitive or a specific finding for patients with chronic obstructive lung disease. It cannot be construed as either a useful or predictive parameter in the diagnostic evaluation of these patients.

Acute upper airway obstruction--fiberoptic bronchoscopy in diagnosis and therapy.

Twenty-two patients were referred over a 3-year period for endoscopic evaluation of the upper airways. The diagnosis of acute upper airway obstruction was suspected from clinical means, and 8 of the 22 did prove to have critical encroachment of the upper airways requiring tube passage for stabilization. This technique utilizing the fiberoptic bronchoscope for diagnosis and tube placement represents the approach of choice in the adult population with acute upper airway obstruction.