American journal of respiratory and critical care medicine
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Myocardial edema and histologic changes consistent with tissue injury are reported in association with sepsis-induced myocardial depression. The objective of the present study was to determine whether, in the absence of shock, such changes (assessed by studying microvascular albumin flux, tissue edema, and morphometry) are prerequisites for the development of contractile dysfunction in sepsis. Sprague-Dawley rats were randomized into groups for either cecal ligation and perforation (CLP) or sham study. ⋯ At 24 h, sepsis was not associated with myocardial edema (wet:dry weight ratio, sham = 4.094 +/- 0.098, n = 10; CLP = 4.185 +/- 0.066, n = 7), and tissue albumin flux was reduced (sham = 194 +/- 27 microliters. h-1. g dry wt-1, n = 10; CLP = 100 +/- 14 microliters. h-1. g dry wt-1, n = 7). In tissue processed for electron microscopy, we found no evidence of tissue injury or edema at either 24 or 48 h after CLP. We conclude that polymicrobial normotensive sepsis causes myocardial contractile depression in the absence of changes in myocardial structure.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Chronic bronchitis, shortness of breath, and airway obstruction by occupation in New Zealand.
The objectives of this study were to measure the population prevalence of symptoms of chronic obstructive lung disease and mild airway obstruction and to compare these between occupational groups. There were 1,609 subjects (63.9% response rate) who completed a respiratory questionnaire. Of these, 1,132 (70.4%) underwent pulmonary function testing (FEV1 and FVC). ⋯ Shortness of breath was associated with hairdressers (OR = 2.75; 0.80 to 9.42) and bakers (OR = 6.72; 0.57 to 79.66), and nursing was associated with lower levels of shortness of breath (OR = 0.42; 0.16 to 1.15). Working ever with vapors, gases, dust, or fumes was significantly associated with chronic bronchitis and airway obstruction (OR = 3.13; 1.07 to 9.12). This population-based study has identified certain occupations with increased prevalence of chronic bronchitis and COPD.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Randomized Controlled Trial Clinical TrialTemporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS.
The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. ⋯ A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Prognostic factors of severe Legionella pneumonia requiring admission to ICU.
Despite the fact that the epidemiology of community-acquired pneumonia and nosocomial Legionella infection is well known, there are no specific reports dealing with severe cases of Legionella pneumophila pneumonia admitted to intensive care units. We undertook a prospective study upon 84 patients with a reliable diagnosis of L. pneumophila pneumonia that required ICU admission. The study assessed the prognostic factors, clinical, radiological and outcome variables of both nosocomial (n = 33) and community-acquired (n = 51) cases of L. pneumophila pneumonia. ⋯ The logistic regression analysis demonstrated that APACHE II score > 15 at admission (RR: 11.5; 95% CI 1.75 to 76.1; p = 0.025), and serum Na levels < or = 136 (RR: 21.3; 95% CI 1.11 to 408; p = 0.023), were the only independent factors related to death. On the other hand, improving pneumonia is associated with better outcome in Legionnaires' disease than for patients not having improving pneumonia (RR: 0.019; 95% CI: 0.036 to 0.106; p < 0.0001). A better understanding of the prognostic factors in cases of severe Legionella pneumonia will optimize our therapeutic approach in this disease and help to decrease both its mortality and morbidity rates.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Comparative StudyComparison of train-of-four and best clinical assessment during continuous paralysis.
Train-of-four (TOF) monitoring is recommended in published guidelines during use of continuous-infusion neuromuscular blocking agents (NMB) in the intensive care unit (ICU). To test that recommendation, dual protocols were established in a medical ICU after intensive nursing education. Paralyzed patients received either TOF monitoring with a goal of three twitches or best clinical assessment while receiving atracurium by continuous infusion. ⋯ The time to clinical recovery was no different between groups (50 +/- 10 versus 45 +/- 12 min). Two complications occurred in the TOF group, with pulmonary emboli despite prophylaxis and an unrecognized cerebrovascular accident in one patient each. We conclude that careful titration of NMB using clinical bedside markers should remain the standard of care with these drugs.