Chest
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Comparative Study
Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema.
The efficacy of continuous positive airway pressure (CPAP) administered with a face mask was compared to oxygen supplementation in 40 patients with acute cardiogenic pulmonary edema. Baseline arterial blood gas values and pH, heart rate, respiratory rate, and blood pressure were recorded after patients breathed 28 percent oxygen with an ambient airway pressure for ten minutes. Thereafter, inspired oxygen concentration (FIO2) was increased by 0.10 and airway pressure was increased by 10 cm H2O in random sequence. ⋯ An increase in FIO2 and the application of CPAP both produced significant elevation in arterial blood oxygen tension. Use of CPAP was consistently associated with a decrease in respiratory rate, blood pressure, and rate pressure product, which were not observed with a mere enhancement of oxygen therapy. The improvement in the measured cardiopulmonary variables associated with CPAP therapy cannot be achieved by reversing hypoxemia with supplemental oxygen only.
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The effect of PEEP on the arterial minus end-tidal carbon dioxide gradient (PaCO2-PetCO2) was evaluated in 13 adult patients with acute respiratory failure. The morphologic study of the pressure-volume (P-V) curves allowed separation of the patients into two groups: group 1 (n = 7) with initial inflection point in the (P-V) curve, and group 2 without inflection point. ⋯ The PaCO2-PetCO2 gradient changed significantly in group 1 (ZEEP: 13.59 mm Hg; PEEPPi: 8.33 mm Hg; PEEPPi + 5 cm H2O: 10.54 mm Hg), but not in group 2 (ZEEP: 14.15 mm Hg; PEEP 6 cm H2O: 14.20 mm Hg; PEEP 12 cm H2O: 16.53 mm Hg). Our results show that the PaCO2-PetCO2 gradient may be useful in selecting a PEEP level which produces alveolar recruitment, but only in those patients with initial inflection point in the P-V curve.
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The incidence of scleroderma (systemic sclerosis) was found to be increased in a population of black men who were gold miners. Ten men with scleroderma were detected during a five-year period. The annual incidence of the disease in this population in the group aged 33 to 57 years was estimated to be 81.8 per million. ⋯ Not all of the subjects with scleroderma had silicosis, but all had been occupationally exposed to silica dust. There was a significant increase in the prevalence of tuberculosis in the past in the group with scleroderma, compared with a group of men with silicosis from the same population. The nature of the association of tuberculosis with scleroderma has not been defined.
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Recent reports suggest adrenal insufficiency in critically ill patients is common. We found only one case of de novo adrenal insufficiency using admission ACTH injection in 70 selected intensive care unit (ICU) patients. ⋯ Based on our results, routine screening for adrenal insufficiency in ICU patients is not warranted. If it is suspected, the cosyntropin test should be performed since low random cortisol levels (even to 5 micrograms/dl) are not diagnostic of adrenal insufficiency.
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Case Reports
Pulmonary hemorrhage and air embolism complicating transbronchial biopsy in pulmonary amyloidosis.
We describe a fatal complication of transbronchial biopsy in a patient with pulmonary parenchymal amyloidosis. Hemorrhage after biopsy required intubation and positive-pressure ventilation that resulted in massive arterial air embolism. Postmortem findings suggested that the bleeding and air embolism were related to persistent patency of biopsied blood vessels infiltrated with amyloid. Patients with pulmonary amyloidosis may be at increased risk of major complications after transbronchial biopsy.