Noninvasive ventilation for post-pneumonectomy severe hypoxemia.

ARDS remains a lethal complication after major lung resections. The reported mortality ranges from 50% to 100%, with increased incidence and mortality rates in pneumonectomy patients. The pathogenesis of early ARDS is still not fully understood, and the majority of patients will require mechanical ventilation. A review of the literature reveals that the role of noninvasive ventilation (NIV) in ARDS after lung resection is unclear, in contrast to its well established benefits in other types of respiratory failure. NIV is a technique of augmenting alveolar ventilation delivered by face mask, without introducing an endotracheal tube. NIV may reduce the need for endotracheal mechanical ventilation and improve clinical outcome in patients with acute respiratory failure after lung resection, avoiding complications related to intubation. We present a case of early ARDS following left-sided pneumonectomy, where bi-level positive airway pressure ventilation prompted a successful outcome.

Clinical effectiveness of leukocyte filtration during cardiopulmonary bypass in patients with chronic obstructive pulmonary disease.

BACKGROUND: We tested the hypothesis that leukocyte filtration during pulmonary reperfusion preserves pulmonary function and results in improved oxygenation after cardiopulmonary bypass (CPB) in patients with chronic obstructive pulmonary disease (COPD). METHODS: In a prospective, randomized study, the treatment group consisted of 20 patients with COPD from consecutive open-heart procedures. A primed leukocyte filter was connected to the arterial line downstream of the standard arterial filter but was excluded from circulation. Circulated blood was directed through the leukocyte filter approximately 10 minutes before aortic cross-clamp removal and at early reperfusion for up to 30 minutes. These patients were compared to 20 additional COPD patients (controls) on whom systemic leukocyte filtration was not used during open-heart surgery. RESULTS: There was no significant difference in gender, age, left ventricular ejection fraction, type of procedure, aortic cross-clamp time, perfusion time, preoperative FEV1 and preoperative respiratory index (Pao2/FiO2 ratio) between treatment and control groups. The respiratory index changed in the treatment group by +9.8% of baseline after completion of CPB, by -14.2% upon arrival in the intensive care unit (ICU), and by -19.6% 12 hours later, whereas in the control group, it changed by -14.5% (p < 0.05), -27.7%, and -24%, respectively. Leukocyte-depleted patients required shorter intubation time (20.4 +/- 16.1 hours), ICU stay (46.2 +/- 40.1 hours) and length of hospitalization (8.3 +/- 2.8 days) than controls (29.5 +/- 21.9 hours, p < 0.05; 75.5 +/- 34.9 hours, p < 0.005; and 10.4 +/- 3.5 days, p < 0.05, respectively). Surgical (30-day) mortality was zero in both groups. CONCLUSIONS: In COPD patients having CPB, systemic leukocyte depletion at early reperfusion was associated with better oxygenation, shorter intubation time, and shorter ICU and hospital stays. Leukocyte filtration during CPB most likely preserves pulmonary function by ameliorating pulmonary reperfusion injury.