Perioperative complications of percutaneous dilational tracheostomy.

Percutaneous dilational tracheostomy (PDT) has replaced conventional tracheostomy for long-term intubated patients in many intensive care units (ICUs). In a prospective study carried out between September 1994 and August 1996, 76 patients underwent PDT. In 41 patients, PDT was performed "blind." In 35 patients it was executed with simultaneous bronchoscopic monitoring. The type and rate of complications of the two techniques were compared. Comparing the groups with and without bronchoscopy, the perioperative complication rate was equivalent (7% vs 6%); however, more severe complications occurred in the group without bronchoscopy (one death due to tension pneumothorax, two cases of perforating the rear tracheal wall) than in the group with bronchoscopy (two cases of intratracheal hemorrhage). PDT is a suitable bedside method for ICU patients undergoing long-term ventilation. Simultaneous endoscopy minimizes the severity of complications.

Multiple fistulas and tracheobronchial stenoses require extensive stenting of the central airways and esophagus in squamous-cell carcinoma.

We report here on two cases of double airway and esophageal stenting in patients with multiple esophagotracheal fistulas and stenoses of the airways and esophagus due to squamous-cell carcinoma. Dumon stents and a Strecker device were used for tracheobronchial stenting. Covered Gianturco Z-stents were implanted into the esophagus. In one case, extrinsic compression of the trachea and tumor progression required recanalization by Nd:YAG laser. Clinical improvement led to discharge of the patients within two weeks after the procedure. The results show that simultaneous implantation of stents in the central airways and covered Gianturco Z-stents in the esophagus is an effective therapeutic strategy in patients with tracheal and esophageal obstructions and esophagorespiratory fistulas. Further systematic studies evaluating double stenting are warranted.

[Current aspects in diagnosis of chronic cor pulmonale]. / Aktuelle Aspekte der Diagnostik des chronischen Cor pulmonale.

Pulmonary hypertension occurs frequently in patients with chronic obstructive lung diseases and contributes to a poor prognosis. Most common symptoms in addition to dyspnea, cough and expectoration are fatigue, syncopes, chest pain and peripheral oedema. No single non-invasive method such as lung function testing, blood gas analysis, ECG, chest x-ray, myocardial scintigraphy and isotopic radionuclide ventriculography is sufficiently reliable for predicting pulmonary hypertension. Only the combination leads to the diagnosis of pulmonary hypertension and cor pulmonale within acceptable limits. Echocardiography was found to be a reliable method of assessing right ventricular function. Doppler echocardiography is most useful with a specificity and sensitivity of about 80%. As "golden standard" cardiac catheterisation is still required for the measurement of pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) at rest and exercise.

[Modification of pulmonary hypertension in patients with chronic obstructive lung diseases by trapidil (Rocornal) in an acute trial]. / Die Beeinflussung der pulmonalen Hypertension bei Patienten mit chronisch obstruktiven Lungenkrankheiten (COLD) durch Trapidil (Rocornal) im Akutversuch.

Acute effects of Trapidil (Rocornal, Deutsches Hydrierwerk Rodleben) on pulmonary hemodynamics were studied in 47 patients. A marked decrease of pulmonary artery pressure, pulmonary vascular resistance and of right ventricular stroke work at rest and during exercise in different degrees of severity of pulmonary hypertension was shown. Especially the influence on stable pulmonary hypertension is of interest, but there was no statistical significance during exercise because of the small number of patients. Considerable objective or/and subjective side effects were not noticed. Possible multifactorial mechanisms of these effects including the left ventricular function and the role of prostaglandins are discussed. The effect of trapidil is compared with other investigated pulmonary vasodilators, such as nitrates and nifedipine. Because of hitherto there are no other studies with Rocornal in patients with COPD, further acute studies and placebo controlled long term studies with monitoring of pulmonary hemodynamic are necessary. Than it will be possible to clarify the role of trapidil in therapeutical concepts of pulmonary hypertension.

The influence of nifedipine (Corinfar) on pulmonary hypertension in chronic obstructive lung disease.

Calcium antagonists may provide an effective approach to the treatment of pulmonary hypertension disorders. Under this aspect we examined 44 patients by right heart catheterisation at rest and at exercise before and after sublingual application of a single dose of 20 mg nifedipine (Corinfar) as well as under continuous dosage of 30-60 mg daily. In patients with latent pulmonary hypertension we ascertained an efficient significant decrease of PAP, 15 of 18 patients were responders. This protective effect persists in the longterm studies after 1 year as well as after 2 years at equal magnitude. In patients with manifest pulmonary hypertension the influence on pulmonary hemodynamics was not so efficient. This behaviour is caused by morphological fixation of pulmonary hypertension. Therefore the determination of magnitude of pulmonary hypertension by right heart catheterisation is necessary for evaluation of nifedipine therapy.