Chest
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Comparative Study
Gas exchange during mechanical ventilation and spontaneous breathing. Intermittent mandatory ventilation after open heart surgery.
Pulmonary gas exchange rates in eight patients after open heart surgery were studied during weaning from the ventilator. We investigated continuous positive pressure ventilation (CPPV), intermittent mandatory ventilation (IMV) and spontaneous breathing with continuous positive airway pressure (CPAP). During each mode of ventilation we measured: CO2 production (VCO2), O2 consumption (VO2), cardiac output (CO), PaO2, Qs/QT and functional residual capacity (FRC). ⋯ The latter result is discussed on the basis of two mechanisms: Vds was reduced and alv eff CO2 was increased. We conclude that compared to CPPV, IMV decreases mean alveolar pressure and reduces dead space ventilation at constant FRC and with constant oxygenation. This may explain why, in the weaning process, IMV makes it possible to start spontaneous breathing very early.
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A 57-year-old woman with squamous carcinoma of the right lung (hilum) developed acute massive hemoptysis with syncope and hypotension. Resuscitation was complicated by the development of massive systemic air embolus, and the patient died.
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Continuous positive pressure ventilation is associated with a reduction in left ventricular preload and cardiac output, but the mechanisms responsible are controversial. The decrease in left ventricular preload may result exclusively from a decreased systemic venous return due to increased pleural pressure, or from an additional effect such as decreased left ventricular compliance. To determine the mechanisms responsible, we studied the changes in cardiac output induced by continuous positive pressure ventilation in eight patients with the adult respiratory distress syndrome. ⋯ As positive end-expiratory pressure increased from 0 to 20 cm H2O, stroke volume and biventricular end-diastolic volumes fell about 25 percent, and biventricular ejection fraction remained unchanged. At 20 cm H2O positive end-expiratory pressure, volume expansion for normalizing cardiac output restored biventricular end-diastolic volumes without markedly changing biventricular end-diastolic transmural pressures. The primary cause of the reduction in left ventricular preload with continuous positive pressure ventilation appears to be a fall in venous return and hence in right ventricular stroke volume, without evidence of change in left ventricular diastolic compliance.
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There is much recent evidence that patients with chronic pulmonary disease who are hypoxemic benefit from continuous therapy with oxygen. These benefits include reduction in symptoms of cor pulmonale, reduction in mortality, and improvement in quality of life. Oxygen therapy is very expensive, and steady-flow delivery of oxygen is wasteful, since almost the entire benefit of the oxygen presented to the patient occurs at the very beginning of inspiration. ⋯ At comparable workloads the SaO2 achieved by PNC required one third of the oxygen flow required by steady-flow oxygen to achieve an equivalent SaO2. These differences were statistically significant (p less than 0.01). We conclude that the PNC provides effective delivery of oxygen during exercise, as well as at rest, while minimizing oxygen flow rate and thus substantially reducing the economic burden normally associated with supplemental oxygen delivery.
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The Monaghan 225 ventilator was tested to ambient pressures of 6 atmospheres absolute (ATA) in a hyperbaric chamber. The ventilator would function with delivered tidal volume which was independent of ambient pressure. Ventilatory rate declined in an exponential fashion. ⋯ While using 100 percent O2 to power the ventilator at 2.82 ATA, the oxygen leakage was 57.7 L/min (converted to 1 ATA pressure, 20 degrees C), of which 33.7 L/min was successfully scavenged using simple techniques. A minor modification was made to the ventilator, allowing it to be driven by compressed air while maintaining complete flexibility in setting the FIo2. The ventilator has proven stable and reliable in clinical use at ambient pressures up to 6 ATA.