Chest
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Hemidiaphragmatic paralysis occurs in some patients following CAB surgery, possibly related to an intraoperative stretch or cold-induced phrenic injury. To determine the time and extent of recovery of phrenic nerve function, we studied five patients with left phrenic paresis or paralysis after CAB. ⋯ Recovery of the left phrenic nerve occurred in all patients, complete in one and partial in four, but was delayed and continued for up to 12 months. We conclude that phrenic nerve recovery is delayed after CAB-associated injury and may be incomplete up to 14 months later, in keeping with rates of regeneration of other peripheral nerves.
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Seven patients with status asthmaticus intubated for respiratory failure who had elevated airway pressures and persistent respiratory acidosis were successfully ventilated using a mixture of 60 percent helium and 40 percent oxygen. All patients experienced a rapid reduction in airway pressures, CO2 retention, and resolution of acidosis while breathing a helium-oxygen mixture. ⋯ Helium's beneficial effects are due to its high kinematic viscosity, high binary diffusion coefficient for CO2, and high diffusivity. Helium-oxygen mixtures should be considered for use in mechanically ventilated asthmatics with respiratory acidosis who fail conventional therapy.
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The ventilation of 25 ventilator-dependent traumatic quadriplegic patients was supported by noninvasive means of ventilatory assistance. Twenty-four of the 25 were initially managed by endotracheal intubation, and 23 of these went on to tracheostomy intermittent positive pressure ventilation before being converted to NVA. Seventeen of the 23 patients had their tracheostomies closed. ⋯ Mouth IPPV was the most common form of NVA used both during the daytime and overnight. The wrap ventilators, intermittent abdominal pressure ventilator, and GPB were also employed for long-term respiratory support. It was concluded that, in general, because of their youth, intact mental status and bulbar musculature, and absence of obstructive lung disease, patients with traumatic high level spinal cord injury are candidates to benefit from these techniques.
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The oxygen cost of breathing and the time integral of the transdiaphragmatic pressure were measured at the onset of the weaning period in eight patients with chronic obstructive pulmonary disease requiring mechanical ventilation. Measurements were achieved during continuous positive airway pressure ventilation and during 15 cmH2O pressure support ventilation. For both periods, the O2COB was estimated as the difference between oxygen uptake of the period and that during controlled ventilation. ⋯ During PSV, it was only 6.3 +/- 1.3 percent, and PTdi decreased by 73 percent compared to the CPAP period. Both effects illustrate the ability of PSV to facilitate spontaneous breathing during weaning from mechanical ventilation. However, we found these measurements to be of no help in predicting the duration of the weaning process.
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A case report is presented of a 54-year old female patient with a history of acute-onset sharp retrosternal chest pain. Clinical examination was unremarkable, but the 12-lead ECG showed anterior T-wave inversion and the chest x-ray film showed gaseous dilatation of the stomach. ⋯ This case report documents marked T-wave changes and atypical chest pain with gastric dilatation. The possible causes of the ECG changes and chest pain are discussed.