Chest
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Case Reports
Facilitation of fiberoptic nasotracheal intubation in a morbidly obese patient by simultaneous use of nasal CPAP.
A morbidly obese patient was emergently nasotracheally intubated using a fiberoptic bronchoscope. Simultaneous application of 20 cm H2O nasal continuous positive airway pressure (CPAP) to the contralateral naris using a nasal pillow helped maintain ventilation of the patient during intubation and greatly facilitated visualization of anatomic landmarks and translaryngeal passage of the bronchoscope. Fiberoptic video images of this patient's hypopharynx demonstrate the pharyngeal splinting action of nasal CPAP thus applied. This is a novel approach to difficult intubation of the obese patient.
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Randomized Controlled Trial Clinical Trial
Midazolam attenuates the metabolic and cardiopulmonary responses to an acute increase in oxygen demand.
Critically ill patients are subjected to routine clinical activities that increase oxygen demand. This results in increased heart rate, blood pressure, minute ventilation, and oxygen delivery in patients with often already compromised cardiopulmonary systems. This study examines whether the benzodiazepine, midazolam, could attenuate the increase in metabolism, respiration, and circulation seen during chest physical therapy. ⋯ The cardiac output increase was also attenuated. Although midazolam reduced minute ventilation and respiratory rate, no excess CO2 retention occurred when the drug was administered likely as the result of reduced CO2 production. The administration of midazolam (0.015 mg/kg and 0.030 mg/kg) prior to chest physical therapy reduces metabolic, hemodynamic, and ventilatory responses to chest physical therapy.
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The purpose of this study was to prospectively see if quantitative computed tomography (QCT) could separate asthmatic patients from normal control subjects. The QCT results were also correlated with the pulmonary function tests (PFT) that were done on both the asthmatic patients and control subjects. ⋯ Expiratory QCT is a useful method to assess air trapping in asthmatic patients. The percent of abnormal lung in asthmatics as determined by QCT has a significant correlation with the PFTs that reflect air trapping in asthmatic patients. Quantitative CT may be helpful in assessing degrees of air trapping present in other diseases affecting the airways.
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During six consecutive months, seven patients admitted to our ICU (15 beds, general ICU, approximately 300 intubated patients per year) for acute respiratory failure requiring intubation and mechanical ventilation presented with a peculiar neuromuscular disorder. After the occurrence of this cluster group of patients, we detected two more similar but isolated cases in the following 18 months, ie, altogether 9 patients in 2 years of observation, or 1.55 percent of all intubated patients in our ICU. Sedation was achieved using midazolam, curarization was effected with the neuromuscular non-depolarizing agent pancuronium bromide (PB), and corticosteroids were administered to eight patients. ⋯ The CK enzyme seems to be a marker of the disorder. This disorder is associated with myopathic alterations and axonal degeneration in some patients. Pancuronium bromide should be used with caution, particularly when associated with steroids therapy, and it may cause difficulty in weaning patients from the respirator.
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Ventilator-associated pneumonia, a leading cause of sepsis in patients with acute respiratory failure, is difficult to distinguish clinically from other processes affecting patients receiving mechanical ventilation. We conducted a prospective study of patients with suspected ventilator-associated pneumonia to identify the causes of fever and densities on chest radiographs and to evaluate the diagnostic yield and efficiency of tests used alone and in combination. ⋯ The observations in this study document the complex nature of acute respiratory failure and fever and underscore the need for accuracy in diagnosis. The frequent occurrence of multiple infectious and noninfectious processes justifies a systematic search for source of fever, using a comprehensive diagnostic protocol. A simplified diagnostic protocol was devised based on the diagnostic value of individual tests.