Persistent type 2 respiratory failure on background of advanced thymoma with lung metastases

We report a patient in her 60s with history of end-stage thymoma with bilateral lung metastases on palliative chemotherapy presented to the hospital with sudden shortness of breath initially treated for probable pulmonary embolism (PE) pending CT of the pulmonary arteries which was subsequently negative for PE. During this admission, she developed transient right-sided facial droop and slurred speech which resolved spontaneously; however, the patient became unresponsive and desaturated with severe decompensated type 2 respiratory failure. Patient was supported with non-invasive ventilation (biphasic positive airway pressure) for few days. Myasthenia gravis was suspected due to clinical features and confirmed by the high titre of acetylcholine receptor antibody titre.

New Respiratory Failure Coding Affects Payments

Differences between ICD-9 and ICD-10 don't appear significant until healthcare organizations drill down to the specifics.

[Non-invasive ventilation: indication for acute respiratory failure]

Mask or Non-invasive ventilation (NIV) is used for critically ill patients with acute respiratory failure (ARF): acute exacerbation of chronic obstructive bronchopulmonary disease and severe cardiogenic pulmonary edema are considered as the best indications for NIV since it improves the outcome of these patients. This technique is also proposed for hypoxemic respiratory failure, with more various results. To be effective here, NIV must be established early enough and should not delay intubation if required. NIV is also proposed after invasive ventilation or in patients in whom endotracheal intubation is not desirable. Its use has increased and its effectiveness seems to have improved, due to a better understanding of the technique but also thanks to technological progress.

[Lung function testing in private practice]

According to the international guidelines of COPD (GOLD) and asthma (GINA) diagnosis and treatment of both diseases necessitate spirometry in the private practice as well as in hospital setting. However today, spirometry is not sufficiently used in Switzerland. This paper intends to give an easy overview how spirometry is performed and spirometric values can be interpreted.

[Chronic respiratory insufficiency and the elderly patient]

Chronic respiratory failure is a complex entity of varied etiology and physio-pathological mechanisms. It is mainly characterised by the respiratory system's difficulty in ensuring correct aeration at rest, resulting initially in insufficient oxygenation of arterial blood. Treatment is adapted to each etiology and aims to compensate for respiratory failure and to ensure the oxygenation of the organism.

[An external respiratory failure classification: scientific rationale for its clinical use]

The paper presents an external respiratory failure (ERF) classification, a scientific rationale for its use in the clinical practice of departments of different profiles. The setting up of interclinical functional diagnostic laboratories and preventive health care facilities for the preclinical diagnosis of ERF is substantiated. The introduction of the classification of ERF into wide clinical practice is intended to form a social order for the design and purchase of diagnostic equipment for therapeutic-and-prophylactic institutions and to stimulate researches in clinical respiratory physiology, and to improve physicians' knowledge of this section of clinical science.

Guideline of the Korean Academy of Medical Sciences for assessing respiratory impairment

The presently used impairment rating guidelines in Korea do not accurately reflect the injury in various lung diseases. Therefore, they need to be made more objective and quantitative with new measurements, using indicators to more precisely represent impairment in the major respiratory diseases. We develop a respiratory impairment rating guideline to ensure that the same grade or impairment rating would be obtained regardless of surgeons who determinate it. Specialists in respiratory medicine and thoracic surgeons determined the impairment grades. Moreover, the impairment should be irreversible for more than 6 months. The impairment rating depends on the level of forced vital capacity, forced expiratory volume 1 second, diffusion capacity of carbon monoxide, arterial oxygen pressure, and arterial carbon dioxide pressure. The degree of whole body impairment is defined by each grade: first 81-95%, second 66-80%, third 51-65%, fourth 36-50%, and fifth 21-35%. In conclusion, we develop a respiratory impairment rating guideline for Koreans. Any qualified specialist can easily use it and judge objective scoring.

Clinical features of respiratory and nocturnal panic disorder subtypes

Our aim is to compare the panic disorder (PD) respiratory subtype and the nocturnal panic subtype. A group of 193 PD patients (DSM-IV) was examined in the Laboratory of Panic and Respiration in the Institute of Psychiatry of the Federal University of Rio de Janeiro. The diagnoses were made using the SCID-I for DSM-IV. The subtypes were the respiratory (with 4 out of 5 prominent respiratory symptoms during the panic attacks [PA]) vs. non-respiratory, likewise PD with nocturnal (during sleep) PAs vs. PD with only diurnal PAs. The respiratory subtype accounted for 56.5% (n=109) of our sample; the non-respiratory subtype, 43.5% (n=84); the nocturnal subtype, 49.2% (n=95); and the non-nocturnal subtype, 50.8% (n=98). Despite a rich literature concerning correlations between the respiratory system and nocturnal panic attacks, our data do not support these findings, as the comparison of proportions in the respiratory and nocturnal groups did not differ. The non-nocturnal subtype was significantly associated with agoraphobia, and the respiratory subtype was not associated with these variables.

[A comparison of respiratory muscle strength, pulmonary function tests and endurance in patients with early and late stage ankylosing spodylitis]

BACKGROUND

Ankylosing spondylitis (AS) is a multisystemic disease in which pulmonary function is altered owing mainly to the restriction of chest wall involvement. A restrictive ventilatory defect has been extensively reported. This has been suggested to be a consequence of reduced mobility of the thoracic cage. Respiratory function in AS shows a typical restrictive pattern but pulmonary compliance, diffusion capacity, and arterial blood gases are normal.

OBJECTIVE

The objective of the present study was to compare pulmonary function tests (PFT), respiratory muscle strength (MIP, MEP) and endurance (MVV) in early and late AS.

METHODS

A total of 35 patients (30 males, 5 females) took part, all of whom met the New York criteria for AS. Patients were divided into two groups for the comparison of early (disease duration <10 years, 20 patients) and late (disease duration >10 years, 15 patients) manifestations in pulmonary function tests, respiratory muscle strength and endurance, dyspnea score, chest expansion, and BASFI score. In addition, 21 healthy controls were compared with the AS patients. Measurement of chest expansion was performed in all subjects. Pulmonary function tests were performed by spirometry. Respiratory muscle strength was evaluated by a mouth pressure meter (MPM). Functional status was assessed by BASFI in all AS patients.

RESULTS

There was no significant difference in body mass index between the groups. The FVC and FEV(1) were significantly lower in late AS (p=0.003, p=0.03, restrictive ventilatory defect ). Chest expansion was significantly lower in late AS (p<0.05). There was no significant difference for MIP or MEP values between late AS, early AS and the controls (p>0.05). Endurance (MVV) was significantly lower in late AS patients (p=0.05). Although the BASFI and dyspnea scores were higher in late AS, they did not reach significant levels. In addition, age was negatively correlated with MIP and MEP in late AS (r=-0.733; p=0.02, r=-0.667; p=0.05).

CONCLUSION

This study demonstrates that FVC and FEV(1) (hallmarks of a restrictive pattern), MVV (endurance) and chest expansion are especially involved in long-standing AS. Therefore, improvement of the thoracic cage should be taken into consideration, especially in early AS. These patients should be encouraged to make regular respiratory exercises for preventing the limitation of chest expansion and also improving cardiopulmonary fitness and respiratory endurance.

Ventilator weaning outcomes in chronic respiratory failure in children

The purpose of this study was to describe mechanical ventilation weaning outcomes for children with chronic respiratory failure discharged from one of six post-acute rehabilitation facilities. Demographic, clinical and outcome data were collected from the medical record. Forty-four children were included in this prospective series; 20 (45%) were weaned off the ventilator at discharge. Children required significantly lower levels of ventilatory support at discharge than admission. Hourly use on the ventilator decreased from admission to discharge for the full cohort and for the subgroup who required a ventilator at discharge. Seventy-five percent of the children discharged with a ventilator had a portable unit. We conclude that nearly half of the children using mechanical ventilation achieve weaning during a postacute rehabilitation admission, whereas others have positive outcomes in severity, hours off the ventilator or portability of equipment.

A population based study of respiratory function in motor neuron disease patients living in Tayside and North East Fife, Scotland

Respiratory failure is a major cause of morbidity and the principal cause of death in motor neuron disease; non-invasive ventilation is increasingly used worldwide to palliate the respiratory symptoms. This observational study was designed to evaluate the prevalence of respiratory insufficiency within the motor neuron disease population of Tayside and North East Fife, Scotland. Twenty-six patients were identified, their diagnosis confirmed according to agreed criteria and subjected to the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale, the Epworth Sleepiness questionnaire; spirometry, sniff nasal inspiratory pressure and nocturnal pulse oximetry measurements.Twenty-two (84.6%) patients reported one or more symptoms of respiratory insufficiency, 19 patients (73%) had forced vital capacity <80% of predicted in the sitting position and 10 (38.5%) had oxygen saturation <90% for >5% of night. On this basis a potential 10 patients required consideration for ventilation. As well as probable improvement in quality of life and survival for those patients this potential increase in workload has major educational, management and resource implications for health care providers.

[Six-minute-walking-test with and without oxygen in patients with COPD: comparison of walking distance and oxygen saturation in varying forms of application]

BACKGROUND

Patients afflicted with COPD and respiratory Failure often experience a decrease of oxygen saturation (SaO (2)) under physical strain. The aim of our study was to find out which changes occur in walking distance and SaO (2) under the application of Oxygen (O (2)) 2 l/min continous flow, under demand (D) and under normal air (RL) when performing the Six-Minute-Walking-Test (6MWT) and further, in which way do the 10 patients of the shortest walking distance group (group I) differ from the eo patients with the longest walking distance (group II) concerning the starter 6 MWT (under CF).

METHOD AND PATIENTS

27 patients undertook a 6MWT three days in a row with CF, D and (RL), 6 minutes before (phase I), during (phase II) and after (phase III) the 6MWT oxygen was applied in CF (day I), D (day II) and RL (day III), the mean oxygen saturation in each phase was measured and the change (DeltaSaO (2)) during and after the 6MWT was calculated. Additionally we measured the DeltaSaO (2) between start and middle, as well as between middle and end of each phase. In close proximity to the tests FEV (1) and pO (2) was determined.

RESULTS

In the total of all test persons there was no significant difference in the walking distance tetween the 3 forms of application. There was, however, a highly significant decrease of the oxygen saturation. The decrease in the two forms of oxygen application did not differ significantly. The decrease of SaO (2) under strain and the consecutive rise under rest occurred within the first 3 minutes of each phase. Patients of group II were often able to increase their walking distance under RL, whereas patients of group I decreased their walking distance further. In group II FEV (1) abs. was significantly higher, but FEV (1) % debit and pO (2) did not differ significantly between both groups.

CONCLUSIONS

Patients with a long walking distance showed a marked learning effect even under RL, they presented a higher FEV (1), but not an increased pO (2). The phase of resaturation after the end of strain is short. Oxygen application through a demand valve with a flow rate of 2 l/min is not inferior to a continuous flow. In more than half of all patients the SaO (2) fell below 90 % under both forms of oxygen application, in conclusion the flow rate should be increased in these cases.

Changes in lung volume with three systems of endotracheal suctioning with and without pre-oxygenation in patients with mild-to-moderate lung failure

OBJECTIVE

To compare changes in lung volume, oxygenation, airway pressure, and hemodynamic effects induced by suctioning with three systems in critically ill patients with mild-to-moderate lung disease, and also to evaluate the effects of hyperoxygenation applied prior to the maneuver as suggested by some guidelines.

DESIGN

Prospective crossover study.

SETTING

General intensive care department of a university-affiliated hospital.

PATIENTS

Ten mechanically ventilated patients with mild-to-moderate acute respiratory failure.

INTERVENTIONS

Patients were ventilated in volume control mode with a mean tidal volume of 490+/-88 ml, PEEP 7+/-4 cmH2O and FiO(2) 0.36+/-0.05. Suctioning was performed sequentially with a quasi-closed system, with an open system 10 min later, and finally with a closed system. Thereafter, pure oxygen was applied for 2 min and the whole suctioning sequence was repeated in reverse order.

MEASUREMENTS AND MAIN RESULTS

Patients' mean PaO(2)/FiO(2) ratio was 273+/-28 mmHg. The reductions in lung volume during suctioning were similar with the quasi-closed (386+/-124 ml) and closed system (497+/-338 ml), but significantly higher with the open system (1281+/-656 ml, P=0.022). We found no significant hemodynamic adverse effects, and no significant SpO(2) reductions with all the studied suctioning techniques. Pre-oxygenation with pure oxygen did not induce additive effects in lung volume changes. With and without pre-oxygenation, lung volume returned to baseline in every patient within 10 min.

CONCLUSIONS

Suctioning with closed and quasi-closed systems reduces the substantial losses in lung volume observed with the open system. Nevertheless, in patients without severe lung disease these changes were transient and rapidly reversible.

The use of noninvasive ventilation in acute respiratory failure at a tertiary care center

OBJECTIVE

Financial constraints and bed limitations frequently prevent admission of ill patients to a critical care setting. We surveyed the use of treatment with noninvasive ventilation (NIV) in clinical practice by physicians in a tertiary care, university-based teaching hospital and compared our findings with published recommendations for the use of NIV.

METHODS

Data were collected prospectively on all patients with acute respiratory failure (ARF) for whom NIV was ordered over a 5-month period. The respiratory therapy department was responsible for administering NIV on written order by a physician. The respiratory therapist completed a survey form with patient tracking data for each initiation of NIV. The investigators then surveyed the clinical chart for clinical data.

RESULTS

NIV was utilized for the treatment of ARF on 75 occasions during the 5-month period. Fourteen patients (18%) received NIV for a COPD exacerbation, and 61 patients (82%) received it for respiratory failure of other etiologies. NIV was initiated in the emergency department in 32% of patients, in a critical care setting in 27% of patients, in a ward observation unit in 23% of patients, and on a general medical or surgical ward in 18% of patients. Arterial blood gases (ABGs) were measured on 68 occasions prior to the initiation of NIV, and 51 patients had an ABG measurement within the first 6 h of treatment. The mean pH at baseline was 7.29, and 33% of patients had a baseline pH of < 7.25. Seven patients required endotracheal intubation (ETI) [13%], and there were 18 deaths (24%) with patients having do-not-resuscitate orders, accounting for 12 deaths.

CONCLUSION

NIV is commonly used outside of a critical care setting. Our outcomes of ETI and death were similar to those cited in the literature despite less aggressive monitoring of these patients.

Nasopharyngoscopy in Robin sequence: clinical and predictive value

OBJECTIVE

To correlate nasopharyngoscopic findings with clinical manifestations during the first month of life and study the course of respiratory obstruction during the first year in infants with Robin sequence (RS).

DESIGN

A longitudinal prospective study of children with RS.

SETTING

Hospital de Reabilitação de Anomalias Craniofaciais, University of São Paulo, Bauru-SP, Brazil, 1998 to 2000.

PATIENTS

Fifty-six children were studied from the age of 1 month to 12 months.

INTERVENTIONS

The type of respiratory obstruction was defined by nasopharyngoscopy. Patients for whom glossoptosis was the only mechanism of respiratory obstruction were classified as having mild, moderate, or severe glossoptosis by nasopharyngoscopy and as mild, moderate, or severe cases with respect to the clinical manifestations.

RESULTS

Forty-two (75%) patients showed respiratory obstruction caused by glossoptosis; seven (43.7%) of these infants with mild clinical manifestations showed moderate glossoptosis during the first month of life and five (31.3%) presented severe glossoptosis; 10 (45.5%) of the infants with severe clinical manifestations showed moderate and 11 (50.0%) severe glossoptosis. At 12 months of age, glossoptosis was mild or absent in 83.3% of the patients, moderate in 14.3% and severe in 2.4%.

CONCLUSIONS

A poor correlation between the severity of glossoptosis and the severity of clinical manifestations was observed for patients with respiratory obstruction caused by glossoptosis during the first month of life, but the correlation between glossoptosis and respiratory distress according to age was statistically significant. Nasopharyngoscopy is not a good method for predicting the severity of the clinical course of respiratory obstruction caused by glossoptosis.

PRISM score and factors predicting mortality of patients with respiratory failure in the pediatric intensive care unit

A total of 96 patients with respiratory failure who required mechanical ventilation admitted to the PICU, Chulalongkorn Hospital from July 1998 to June 1999 were reviewed to evaluate the PRISM score for mortality prediction and to identify factors that might influence the outcome. The statistical difference in outcome between the 2 groups (survivors and non-survivors) were underlying diseases, age, maximum positive inspiratory pressure (PIP), maximum positive end expiratory pressure (PEEP), maximum fractional inspiratory oxygen (FiO2) and PRISM score (p < 0.05). However, based on the original logistic regression equation, the predicted mortality from PRISM score in our study was much lower than our actual mortality (2.4% vs 26.0%). The sensitivity and specificity of mortality predicted by PRISM score calculated at cut-off r = 0.0 (expected mortality = 50%) was 4 per cent and 97 per cent respectively. In conclusion, the original PRISM score underpredicted the mortality outcome in our patients with respiratory failure. This suggests that PRISM score is population dependent and should be modified before being used with our patients.

Nasal mask positive pressure ventilation in paediatric patients with type II respiratory failure

We report our experience with nasal mask ventilation in children and adolescents with type II respiratory failure admitted to the paediatric intensive care unit (PICU) over an 18-month period. Seven patients were treated with nasal mask ventilation during part of their PICU stay. All showed significant improvement in arterial pH, PaCO2, and PaO2/FiO2 from presentation to discharge, although at discharge PaCO2 and PaO2/FiO2 fell outside of the normal range. Complications occurred in four patients. When compared to 11 patients with type II respiratory failure not treated with nasal mask ventilation, the nasal mask ventilation group had a similar PICU length of stay and incidence of complications. We conclude that nasal mask ventilation may be useful in maintaining near normal alveolar ventilation in selected children with type II respiratory failure and that a prospective study of this technique is indicated.

Introducing non-invasive positive pressure ventilation

Non-invasive ventilation techniques provide and enhance alveolar ventilation without the need for an endotracheal airway. These techniques are increasingly being used by nurses to manage patients with type 2 respiratory failure. The author outlines the advantages of, and criteria and contraindications for, using bi-level positive airway pressure (BiPAP).

Extracorporeal life support in pulmonary failure after trauma

OBJECTIVE

To present a series of 30 adult trauma patients who received extracorporeal life support (ECLS) for pulmonary failure and to retrospectively review variables related to their outcome.

METHODS

In a Level I trauma center between 1989 and 1997, ECLS with continuous heparin anticoagulation was instituted in 30 injured patients older than 15 years. Indication was for an estimated mortality risk greater than 80%, defined by a PaO2: FIO2 ratio less than 100 on 100% FIO2, despite pressure-mode inverse ratio ventilation, optimal positive end-expiratory pressure, reasonable diuresis, transfusion, and prone positioning. Retrospective analysis included demographic information (age, gender, Injury Severity Score, injury mechanism), pulmonary physiologic and gas-exchange values (pre-ECLS ventilator days [VENT days], PaO2:FIO2 ratio, mixed venous oxygen saturation [SvO2], and blood gas), pre-ECLS cardiopulmonary resuscitation, complications of ECLS (bleeding, circuit problems, leukopenia, infection, pneumothorax, acute renal failure, and pressors on ECLS), and survival.

RESULTS

The subjects were 26.3+/-2.1 years old (range, 15-59 years), 50% male, and had blunt injury in 83.3%. Pulmonary recovery sufficient to wean the patient from ECLS occurred in 17 patients (56.7%), and 50% survived to discharge. Fewer VENT days and more normal SvO2 were associated with survival. The presence of acute renal failure and the need for venoarterial support (venoarterial bypass) were more common in the patients who died. Bleeding complications (requiring intervention or additional transfusion) occurred in 58.6% of patients and were not associated with mortality. Early use of ECLS (VENT days < or = 5) was associated with an odds ratio of 7.2 for survival. Fewer VENT days was independently associated with survival in a logistic regression model (p = 0.029). Age, Injury Severity Score, and PaO2:FIO2 ratio were not related to outcome.

CONCLUSION

ECLS has been safely used in adult trauma patients with multiple injuries and severe pulmonary failure. In our series, early implementation of ECLS was associated with improved survival. Although this may represent selection bias for less intractable forms of acute respiratory distress syndrome, it is our experience that early institution of ECLS may lead to improved oxygen delivery, diminished ventilator-induced lung injury, and improved survival.

Major burns in Cape Town: a modified burns score for patient triage

Major burns equal to, or greater than, 30 per cent total body surface area (TBSA) constitute 23 per cent of the admissions to the adult burns unit in Cape Town. A retrospective review over a 28-month period identified 87 cases of major burns. This paper summarizes the epidemiology and mortality amongst this patient group over this period. Demand for treatment can exceed bed availability in the unit. The difficult issue, this raises, of patient triage in relation to the relatively limited resources is addressed and a simple modified burns score proposed for this unit. The effect this score would have in optimizing the use of our resources is demonstrated.

Acute hypoxemic respiratory failure in children: case mix and the utility of respiratory severity indices

OBJECTIVE

Acute hypoxemic respiratory failure (AHRF) is a common reason for emergency pediatric intensive care. An objective assessment of disease severity from acute physiological parameters would be of value in clinical practice and in the design of clinical trials. We hypothesised that there was a difference in the best early respiratory indices in those who died compared with those who survived.

DESIGN

A prospective observational study of 118 consecutive AHRF admissions with data analysis incorporating all blood gases.

SETTING

A pediatric intensive care unit in a national children's hospital.

INTERVENTIONS

None.

RESULTS

Mortality was 26/118, 22% (95 % confidence interval 18-26%). There were no significant differences in the best alveolar-arterial oxygen tension gradient (A-aDO2, torr), oxygenation index (OI), ventilation index (VI), or PaO2/FIO2 during the first 2 days of intensive care between the survivors and non-survivors. Only the mean airway pressure (MAP, cm H2O) used for supportive care was significantly different on days 0 and 1 (p < 0.05) with higher pressure being used in non-survivors. Multiple logistic regression analysis did not identify any gas exchange or ventilator parameter independently associated with mortality. Rather, all deaths were associated with coincident pathology or multi-organ system failure, or perceived treatment futility due to pre-existing diagnoses instead of unsupportable respiratory failure. When using previously published predictors of outcome (VI > 40 and OI > 40; A-aDO2 > 450 for 24 h; A-aDO2 > 470 or MAP > 23; or A-aDO2 > 420) the risk of mortality was overestimated significantly in the current population.

CONCLUSION

The original hypothesis was refuted. It appears that the outcome of AHRF in present day pediatric critical care is principally related to the severity of associated pathology and now no longer solely to the severity of respiratory failure. Further studies in larger series are needed to confirm these findings.

[An index assessment of the degree of the respiratory failure in funnel chest]

An evaluation was done of respiratory failure in 149 children aged 3 to 15 presenting with funnel-shaped chest deformity (FCD). An original classification is suggested of degree of respiratory failure in FCD in children. Based on the index assessment of clinical and functional parameters an outline has been worked out for degree of respiratory failure. The criteria obtained are statistically significant; being able of giving quantitative assessment of degree of respiratory failure they can serve as control figures to be used in evaluations designed to study time course of changes in respiratory failure.

Nonrespiratory predictor of mechanical ventilation dependency in intensive care unit patients

OBJECTIVE

To determine the role of serum albumin concentration as a predictor of mechanical ventilation dependency.

DESIGN

Prospective, observation trial.

SETTING

Multidisciplinary intensive care unit (ICU) in a university hospital.

PATIENTS

One hundred forty-five consecutive patients who required mechanical ventilation for > 72 hrs.

INTERVENTIONS

Patients were classified into five different groups based on the cause of respiratory failure. The following parameters were recorded daily: serum albumin concentration; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; and fluid balance. Using multiple regression, multiple logistic regression analysis, and the Anderson-Gill proportional hazards model, we determined the metabolic factors that could help predict weaning success.

MEASUREMENTS AND MAIN RESULTS

The mean length of ICU stay was 12.3 +/- 1.0 days. The duration of mechanical ventilation dependency was 10.5 +/- 1.0 days. The initial mean serum albumin concentration was 25.2 +/- 0.6 g/L. The APACHE II score on the first day of ICU stay was 19.1 +/- 0.6. Although albumin concentration was significantly lower and the APACHE II score was significantly higher in ICU nonsurvivors than in ICU survivors, albumin concentration on ICU admission was not a predictor of the length of time spent receiving mechanical ventilation. The profile of albumin concentration changes was different between weaned and mechanical ventilation-dependent patients. At the time of weaning patients from the ventilator, the median albumin concentration was higher than in those patients who continued to be supported by mechanical ventilation. This effect of albumin could not be attributed to patient fluid balance or to the severity of illness since each factor had an independent influence in predicting weaning, using the Anderson-Gill proportional hazards models.

CONCLUSIONS

Initial serum albumin concentration did not necessarily predict weaning success. However, when serum albumin concentration was assessed on a daily basis, its trend was important in determining the relative chance of being successfully weaned from the ventilator. This finding suggests that albumin may be an index of the metabolic status of the patient, which could be important in determining the weanability of the patients who are mechanically ventilated for prolonged periods of time.

[Are ISS and PTS unsuitable trauma scores for prediction of (possible) post-traumatic lung failure?]

Prostanoids are inflammatory mediators which originate from endothelial cells following local tissue damage. That is why plasma levels of prostanoids are possible markers of inflammatory response and severity of trauma. We were able to demonstrate that the systemic release of prostanoids does not depend on the score values (ISS, PTS) but rather on different trauma patterns (chest trauma, head injury). Influencing vascular permeability and resistance elevated plasma levels of prostanoids may explain the impairment of pulmonary function in traumatized patients. It seems to be useful to re-evaluate the scoring systems with respect to chest trauma and head injury.

[Clinical significance of detection of plasma fibronectin in respiratory failure]

Plasma fibronectin (PFn) level was measured with immumoelectrophoresis in 40 healthy adults and 174 patients (221 person-times) with respiratory insufficiency (R I). The levels of PFn in 40 healthy adults, 85 person-times of R I, 27 person-times of Type I respiratory failure (RF I), 82 person-times of RF II, and 27 person-times of iatrogenic RF (IRF) were 292.48 +/- 43.11 mg/L, 253.12 +/- 67.00 mg/L 141.97 +/- 70.84 mg/L, 180.48 +/- 49.96 mg/L and 263.49 +/- 70.05 mg/L respectively. The levels of PFn of patients with R I, RF I and RF II were significantly lower than that in healthy adults (P < 0.001). The level of PFn of patients with TRF was significantly lower than that in healthy adults (P < 0.05). There was positive correlation between the levels of PFn and PaO2 in 221 person-times of R I (r = 0.5358, P < 0.001), RF I r = 0.3822, P < 0.05). RF II (r = 0.3050, P < 0.01), and IRF (r = 0.4963, P < 0.02). There was negative correlation between the levels of PFn and PaCO2 in 221 person-times of R I (r = -0.2053, P < 0.005) and RF II (r = -0.2181, P < 0.05). In 34 patients with RF, the PFn before treatment was significantly lower than that two weeks after treatment (147.80 +/0 61.59 mg/L vs 214.56 +/- 56.12 mg/L) (P < 0.001). Among 33 cases of RF whose level of PFn was < 150 mg/L, 18 cases complicated multiple system organ failure and 4 cases complicated adult respiratory distress syndrome. The average level of PFn in 3 death cases was lower than 100 mg/L. It is suggested that PFn level might be used as an index in making early diagnosis, monitoring RF and predicating progosis of RF.

[A pathogenetic classification of closed thoracic trauma]

Based on experimental and clinical data the authors propose a classification of closed thoracic traumas which allow to form relatively similar groups among patients with closed thoracic traumas having orientation of the leading pathogenetic factor. The proposed classification allows to form rational curative programs as early as at the prehospital and early hospital stages.

Outcome from respiratory failure

A physician's assessment of the probable outcome of an episode of respiratory failure should be based on a combination of survival data from large studies and specific knowledge about the individual case in question. Clearly, mortality rates in cases of ARF are influenced by a number of factors. In general, only a minority of patients with ARF complicating COPD require mechanical ventilation. In these cases, mortality often is related to the nature of the precipitating illness and the severity of the patient's underlying chronic respiratory disease. The long-term prognosis in patients with COPD who survive an episode of ARF is related primarily to the severity of the patient's underlying disease. Acute mortality is higher in patients with ARDS than in patients with ARF complicating COPD. Although a significant number of ARDS patients die of their underlying illness, mortality in others more commonly appears to be related to sepsis and multiple organ failure rather than end-stage respiratory disease. Pulmonary function in survivors of ARDS is quite variable, and may be related to the severity of the acute episode. ARF has a particularly poor prognosis when associated with certain underlying illnesses such as hematologic malignancy.

Severe respiratory depression after epidural morphine in a patient with myotonic dystrophy

We describe a patient with myotonic dystrophy who underwent cholecystectomy, and developed severe respiratory depression following epidural administration of morphine to provide postoperative analgesia. At preoperative assessment, he demonstrated near normal vital capacity and maximal voluntary ventilation, but the presence of chronic ventilatory failure with a resting value of PaCO2 51 mmHg. Anaesthesia was produced by a combination of epidural and light general anaesthesia without intravenous anaesthetics, narcotics or neuromuscular relaxants. Five hours after epidural administration of 2 mg morphine, the patient developed severe respiratory depression with a PaCO2 of 93 mmHg. Intravenous naloxone resulted in transient improvement in minute volume, suggesting that epidural morphine was responsible for the depression. Epidural morphine can cause unexpected respiratory depression, even at a small dose, because of the sensitivity of the respiratory centre to morphine in patients with myotonic dystrophy.

Prospective evaluation of clinical scoring systems in infants and children with cardiopulmonary insufficiency after cardiac surgery

OBJECTIVE

To document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children with cardiopulmonary insufficiency after cardiac surgery.

DESIGN

Prospective study with follow up to hospital discharge.

SETTING

A multidisciplinary pediatric ICU in a University Hospital.

PATIENTS

Between 1/1989 and 4/1992 441 infants and children with congenital heart disease underwent open heart surgery. 128 of these patients developed postoperative cardiopulmonary insufficiency and were entered into this study.

METHODS

Data relevant to the Acute Physiologic Score for Children (APSC), Pediatric Risk of Mortality (PRISM), Therapeutic Intervention Scoring System (TISS) and Organ System Failure (OSF) score were collected in all patients during the first 4 days of postoperative intensive care.

RESULTS

The mean age of the patients was 1.5 +/- 0.2 years. The mean duration of mechanical ventilation and ICU care was 6.2 +/- 0.6 and 8.1 +/- 0.7 days, respectively. On the first postoperative day the mean APSC and PRISM scores of survivors and nonsurvivors were 13.9 +/- 1.3 vs 24.5 +/- 1.3 (p < 0.001) and 6.1 +/- 0.5 vs 19.6 +/- 1.9 (p < 0.001), respectively. The mean TISS and OSF scores of survivors and nonsurvivors were 46 +/- 0.8 vs 57.8 +/- 1.4 (p < 0.001), and 2.2 +/- 0.2 vs 3.4 +/- 0.2 (p < 0.001), respectively. The overall hospital mortality rate was 9.9%, the hospital mortality rate of patients with postoperative cardiopulmonary insufficiency 34%. Patients with an APSC score < 10 and a PRISM score < 5 had a survival rate of 100%, whereas patients with an APSC score > 30 and a PRISM score > 25 had a mortality rate of 100%. The area under the receiver operating characteristic (ROC) curve for APSC, PRISM and TISS was 0.847, 0.826 and 0.793, respectively.

CONCLUSION

APSC, PRISM and TISS describe accurately severity of illness in infants and children with cardiopulmonary insufficiency after cardiac surgery and all scores identify those patients at increased risk for mortality.

Management of respiratory failure

Hypoxaemia and hypercapnia are common clinical problems. A clear understanding of the diseases and pathophysiological processes that cause respiratory failure is important in making decisions about the concentration of oxygen to give, the type of face-mask to use, and the place of artificial ventilation.

[Radiological aspects of acute respiratory insufficiency after heart valve prosthesis]

Analysis of the x-ray findings in 156 patients with acute respiratory insufficiency (ART) in the immediate periods after implantation of heart valve prostheses has shown that various pulmonary complications, such as pulmonary edema (in 84% of cases), atelectasis, hypoventilation (5.1%), hemothorax (6.4%), pneumothorax (0.6%) were the prerequisites for the development of respiratory disorders. Pneumonias were not the primary cause of ART but an additional factor for the respiratory disorder progress, for they develop in the presence of previous pulmonary changes. The necessity and possibility of establishing the pathogenetic mechanism of pulmonary edema (cardiogenic or noncardiogenic one) is shown. The authors emphasize the desirability of regular x-ray examinations as a supplementary method in monitoring the patients with acute respiratory insufficiency.

Predicting survival in AIDS patients with respiratory failure. Application of the APACHE II scoring system

This article describes the APACHE II classification system as a measure of severity of illness applied to AIDS patients with respiratory insufficiency. Among 82 patients, observed mortality in patients with high APACHE II scores (greater than 30) and those with low scores (less than 18) was significantly higher than predicted. There was variable correlation between predicted and observed mortality in the other APACHE II score ranges. The usefulness of the APACHE II scoring system is reviewed as limited and inaccurate in predicting survival rates in AIDS patients with respiratory failure.

Early prognostic indices after cardiopulmonary resuscitation (CPR). The Cerebral Resuscitation Study Group

An early prediction score (EPS) is constructed as the sum of five events: the type of cardiac arrest is ventricular fibrillation; the type of respiratory arrest is gasping; pupil reaction is unequal, slow or normal, but present; swallowing activity is present and the cardiac arrest has been witnessed. Presence of any of these events contributes one point to the score, while absence contributes nothing to it. EPS during resuscitation results in a comparable amount of information, whether used to predict success, alive and conscious 14 days post-CPR or no-success. EPS early (10 min) after initially successful resuscitation is more effective in predicting no-success than success. EPS during CPR does not allow decision making as far as stopping or continuing CPR efforts. EPS early after CPR does neither allow decision making as far as stopping or continuing critical care efforts after initially successful CPR. EPS does, however, weigh the likelihood of success against that of no-success, which can be used when discussing the chances of the patient with his relatives.