Chest
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We report two patients who developed tension pneumothorax as a result of improper attachment of a Heimlich valve to a chest tube.
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Review
Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient.
Bronchopleural fistulas are associated with high morbidity and mortality and are particularly challenging in the ventilated patient. Familiarity with both basic and more technical medical management techniques may lessen morbidity and improve survival. ⋯ Appropriate conventional ventilator manipulations aimed at decreasing fistula air leak and maintaining adequate oxygenation and ventilation may fail and necessitate a trial of HFV. Definitive therapy by the bronchoscopic application of a sealing agent to occlude the fistula site can be used, particularly in the poor surgical candidate.
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Two adults and two children with life-threatening asthma refractory to maximal standard therapy were treated with the inhalational anesthetic agent isoflurane. In each case, the temporal response to the initiation of therapy was striking. All patients survived and none experienced adverse reactions attributable to the drug. Rapid therapeutic benefit, minimal side effects, absence of cumulative toxicity, and ease of administration are factors supporting the use of isoflurane for patients with severe asthma.
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Breathing is controlled by an automatic brain-stem controller acted on by higher neural influences that stabilize breathing and compensate for neuromechanical abnormalities. Loss of this wakefulness-dependent descending influences during nonrapid eye movement (NREM) sleep results in the appearance of a hypocapnic apnea threshold, which is associated with periodic breathing when the gain of chemical feedback loops is high. ⋯ REM sleep poses different problems for the respiratory control system owing to muscular atomia and suppression of chemical feedback. These changes are associated with respiratory deterioration in patients with compromised diaphragmatic function, eg, patients with chronic obstructive pulmonary disease.
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The purpose of this study was to evaluate the effectiveness of long-term tracheostomy intermittent positive pressure ventilation (TIPPV) with deflated cuffs or cuffless tracheostomy tubes for patients with neuromuscular ventilatory failure. One hundred four unweanable ventilator-dependent patients with neuromuscular ventilatory insufficiency were referred for pulmonary rehabilitation. Ninety-one of the 104 patients converted from TIPPV with an inflated cuff to either a deflated cuff (28 patients) or no cuff (63 patients). ⋯ Despite a mean vital capacity of 17 +/- 12.3 percent and the fact that 16 of the 21 patients could tolerate only 60 minutes or less of autonomous respiration (free time), ABG, daytime SaO2 and end-tidal PCo2 were within normal limits for all 21 patients and mean overnight SaO2 was 94 percent or greater for all except one patient who used a cuffless tracheostomy tube. Six patients experienced very transient desaturations below 90 percent but no one had a maximum end-tidal PCo2 greater than 47 mm Hg. Patients with adequate pulmonary compliance and sufficient oropharyngeal muscle strength for functional swallowing and articulation are candidates for conversion to TIPPV with deflated cuffs or cuffless tracheostomy tubes despite little or no autonomous respiration.