Chest
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Case Reports
Endotracheal tube and tracheobronchial obstruction as causes of hypoventilation with high inspiratory pressures.
Two cases of difficult ventilation are presented, the first caused by endotracheal tube obstruction with nasal turbinate, and the second caused by tracheobronchial obstruction with blood clots. The clinical presentation in each case was characterized by extreme difficulty in ventilating and severe hypercapnia despite vigorous ventilatory efforts with either a mechanical ventilator or resuscitator bag. A simple manipulation of the endotracheal tube cuff helped to differentiate between increased impedance caused by endotracheal tube obstruction as opposed to increased respiratory system impedance beyond the tip of tube. In the second patient, in whom even a short interruption of ventilation was poorly tolerated, simultaneous rigid bronchoscopy (for removal of intratracheal masses) and ventilation via endotracheal tube were successfully performed.
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The purpose of this descriptive study was to evaluate feeding aspirations in adult patients receiving long-term mechanical ventilatory support, including the incidence of aspirations, the frequency of silent (clinically inapparent) aspirations, and differences between aspirators and nonaspirators. Aspiration data were determined by review of videofluoroscopic (VF) tapes of modified barium swallow procedures performed on 83 medically stable patients admitted to a chronic ventilator unit. Demographic and clinical variables were obtained from review of subjects' medical records. ⋯ We conclude that feeding aspiration is seen frequently in patients with tracheostomies receiving prolonged positive pressure mechanical ventilation. Advanced age increases the risk of aspiration in this population. Episodes of aspiration are not consistently accompanied by clinical symptoms of distress to alert the bedside observer to their occurrence.
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To evaluate the incidence and cause of parenteral nutrition-induced lipogenesis. ⋯ Net fat synthesis was found in a surprisingly large number of critically ill patients receiving central venous nutrition. Many of these patients received carbohydrate calories in excess of their measured energy expenditure, even though it appeared that they needed this level of caloric intake by clinical assessment. The high carbohydrate total parenteral nutrition (TPN) solutions with lipids provided only for prevention of essential fatty acid depletion resulted in an unacceptably high incidence of fat synthesis. The results suggest that caloric intake may be optimized in critically ill patients using indirect calorimetry. When calorimetry is not available, a total caloric intake of up to 140 percent of the BEE with glucose infusion rates not exceeding 4 mg/kg-min and fats providing 40 to 60 percent of calories will meet the energy requirements of most critically ill patients without forcing the RQ > 1.
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Case Reports
Bilateral pneumothorax after percutaneous transthoracic needle biopsy. Evidence for incomplete pleural fusion.
Although the pleural cavities are anatomically separate in humans, we describe bilateral pneumothoraces that occurred after percutaneous needle biopsy of the lung. In some individuals, there may be communication between the pleural spaces; it is important for those performing interventional procedures to be aware of this uncommon anatomic variant.