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PubMed1986

Positive-pressure ventilation at moderately high frequency in newborn infants with respiratory distress syndrome (IRDS).

In 24 seriously ill newborn infants with respiratory distress syndrome (IRDS) and ensuing respiratory failure, high-frequency positive-pressure ventilation was administered. The mean gestational age of the infants was 32 +/- 3 weeks. In the infant ventilator employed, the compressible volume had been reduced in order to give higher flow rates but lower intratracheal pressures. The ventilation frequency was kept constant at 60-66 per min and the insufflation period at 32-35% of the ventilatory cycle. A positive end-expiratory pressure (PEEP) of 0.2-0.6 kPa was used. Arterial PCO2 was maintained at 4.0-5.3 kPa and PO2 at 8.5-10.5 kPa by adjusting the gas flow through the patient circuit, the peak tubing pressure, the PEEP and the oxygen concentration in inspired gas. High-frequency positive-pressure ventilation improved oxygenation and gave adequate alveolar ventilation in all infants, in most cases at a low peak pressure. Only one infant developed pneumothorax during intermittent positive pressure ventilation, and in no infant did bronchopulmonary dysplasia or retrolental fibroplasia occur. One infant died from intracranial hemorrhage during the ventilation period, giving a survival rate of 96%.

Female↗
PubMed1990

Physiology of aging related to outcome in the adult respiratory distress syndrome.

Thirty-nine patients with adult respiratory distress syndrome (ARDS) were enrolled in a study to identify potential age-related changes in organ system function that may help explain the apparent association between age and poor outcome in these patients. Criteria for enrollment included an arterial PO2-to-inspired O2 concentration ratio less than or equal to 200 in a clinical setting consistent with ARDS. Patients were excluded if they were less than 18 yr old, had clinical manifestations of congestive heart failure, were seropositive for the human immunodeficiency virus, or had stage II metastatic lung cancer. Patients were divided into two groups: those less than 60 yr old (mean 42 +/- 3 yr, n = 17) and those greater than or equal to 60 yr old (73 +/- 2 yr, n = 16). A group of six patients was analyzed as a separate subset based on a body temperature less than or equal to 97.5 degrees F at enrollment (hypothermic patients, 73 +/- 4 yr old). Sepsis was present in 67% of the nonhypothermic patients and in all the hypothermic patients. Mortality rates were 12% in the patients less than 60 yr and 69% in the nonhypothermic patients greater than or equal to 60 yr. All the hypothermic patients died. Sequential data obtained over 6 days were compared within and between groups. The following results were obtained. 1) The ratio of arterial PO2 to inspired O2 fraction was greater and the positive end-expiratory pressure used was significantly less in the patients greater than or equal to 60 yr old compared with the younger group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

[Computed tomography in the diagnosis of pulmonary barotrauma associated with the adult respiratory distress syndrome].

In the patients suffering from adult respiratory distress syndrome (ARDS), pulmonary barotrauma is a frequent and fearful complication, whose timely and accurate diagnosis is therefore needed. To this purpose, bedside chest films often exhibit some diagnostic drawbacks. Computed tomography (CT) of the chest is rarely used because of the problems concerning the transfer and the control of these critically ill patients outside the Intensive Care Unit. The chest CT findings of 84 ARDS patients were retrospectively reviewed, investigating: a) the presence of barotrauma (pulmonary bullae, pneumothorax, pneumomediastinum, subcutaneous emphysema); b) the positioning of thoracostomy tubes; c) the chest films performed on the same day as CT. CT showed the presence of barotrauma in 41 patients. Pulmonary bullae were seen in 26 cases (31%), pneumothorax (mainly in anteromedial location) in 27 cases (32%) and pneumomediastinum in 11 cases (13%). In 22 patients with thoracostomy tubes CT demonstrated the exact site of the drainages: in 7 cases only the tubes were correctly positioned, or were working properly. The presence of pulmonary bullae (regarded as the evidence of interstitial pulmonary emphysema) proved to be associated with a higher mortality rate than that of the entire sample (58% vs 38%); in 30 of 41 patients with barotrauma (73%) CT proved to be superior to chest films, especially to demonstrate pulmonary bullae (26 cases detected by CT vs 7 cases diagnosed by chest films). In 14 of 41 patients with barotrauma the information yielded by CT directed the choice of treatment: thoracostomy tubes were positioned in the cases of pneumothorax undetected by chest films and in the cases of only partially drained multilocular pneumothorax, or replaced in the event of tube mispositioning. In conclusions, in ARDS patients the use of chest CT is recommended in selected cases only, when complications (especially barotrauma) are suspected and unrevealed by bedside chest films.

Adult↗
PubMed1994

Cytokine, complement, and endotoxin profiles associated with the development of the adult respiratory distress syndrome after severe injury.

OBJECTIVE: The adult respiratory distress syndrome (ARDS) is a frequent complication after severe accidental trauma. This study examines the hypothesis that increased systemic concentrations of proinflammatory cytokines, endotoxin, or complement fragments may predict the development of ARDS. DESIGN: Prospective, observational study. SETTING: Two Level I university trauma centers. PATIENTS: Fifteen severely injured patients (Injury Severity Score of > or = 25). INTERVENTIONS: Standard emergency department, operating room, and intensive care unit management. MEASUREMENTS AND MAIN RESULTS: Plasma samples were obtained at 4-hr intervals from the time of injury and were assayed for concentrations of endotoxin, tumor necrosis factor-alpha, interleukin (IL)-1 beta, IL-6, IL-8, and complement fragments C3a and C4a. Hemodynamic and oxygen metabolism variables also were measured at 4-hr intervals after injury. Seven patients developed ARDS and eight patients did not. The PaO2/FIO2 ratio was significantly decreased in the patients with ARDS compared with non-ARDS patients as early as 4 hrs postinjury, and remained significantly decreased throughout the initial 24 hrs after severe accidental injury. Plasma IL-8, IL-6, C3a, and C4a concentrations were markedly increased starting in the immediate postinjury period in both ARDS and non-ARDS patients, but no significant differences were found between the two groups until 16 hrs after injury when plasma IL-8, C3a, and C4a concentrations became significantly higher in the ARDS group. Neither the ARDS nor non-ARDS patients showed the presence of circulating IL-1 beta, TNF-alpha, or endotoxin at any postinjury time point. CONCLUSIONS: These results demonstrate that measurements of plasma concentrations of proinflammatory cytokines, endotoxin, or complement fragments are not helpful in predicting the development of ARDS after severe accidental injury.

Adult↗
PubMed2000

[Adult respiratory distress syndrome after open heart surgery].

Cardiopulmonary bypass used in open heart surgery is responsible for nearly 15% of adult respiratory distress syndrome. The condition has a high mortality rate and still today we do not have a specific therapy for it. The aim of this study was to reveal the factors that are responsible for the adult respiratory distress syndrome developing after open heart operations. A retrospective statistical analysis of the database of 837 consecutive open heart operations was performed. Those patients in whom the adult respiratory distress syndrome has not developed have served as control group. chi 2 probe, Student t test and the Mann-Whitney test were used for the analysis. The authors applied logistic regression analysis for the multivariate investigation. Adult respiratory distress syndrome has developed in 10 patients (1.2%) in the postoperative period. One patient in whom the adult respiratory distress syndrome was accompanied by multiorgan failure has been lost. Between the two subgroups the authors found significant difference in the amount of blood and fresh frozen plasma transfusion, in the duration of ischaemic period and cardiopulmonary bypass, in anaesthesia time, and also in the occurrence of postoperative low cardiac output syndrome and acute myocardial infarction. Fresh frozen plasma can be a risk factor in the development of postoperative adult respiratory distress syndrome. In order to avoid the occurrence of this syndrome a great emphasis must be put on the pulmonary prevention.

Adult↗
PubMedDate not supplied

[Antepartum prevention and postnatal therapy of respiratory distress syndrome].

The introduction of surfactant in the therapy of respiratory distress syndrome (RDS) reduced mortality and long term complications in very premature infants. Nevertheless, the obstetric management influences critically the outcome. In a prospective study of 116 premature infants with RDS treated with natural surfactant preparations after birth, mortality was significantly reduced by antepartum corticosteroid therapy suggesting a synergistic effect of corticosteroids and surfactant on the immature lung. It is assumed that a preventive administration of surfactant immediately after birth would benefit neonates at risk for RDS more than a delayed surfactant replacement after the development of RDS. But without a reliable assessment of fetal lung maturity before birth more than 50% of our premature infants with birth weights less than 1500 g would be exposed to surfactant unnecessarily. It is important that fetal asphyxia is avoided. Acquired respiratory distress syndrome occur even in premature infants after shock or meconium aspiration and may respond poorly to surfactant replacement. This is also the case in lung hypoplasia or perinatal infection, where the combined efforts of obstetricians and neonatologists are needed to attain better results.

Adrenal Cortex Hormones↗
PubMed1990

Adult respiratory distress syndrome during pregnancy and immediately postpartum.

From 1976 to 1983, the adult respiratory distress syndrome occurred in 14 patients during pregnancy or within a month postpartum. There were 8 survivors, giving a 43% mortality. All but 2 patients had obstetric-related precipitating events--labor problems, infections, eclampsia-toxemia, and obstetric hemorrhages. During emergency cesarean sections, 3 patients had respiratory problems that may have caused their respiratory distress syndrome. The average duration of mechanical ventilatory support was 16 days. Six patients had barotrauma with 1 patient sustaining an irreversible anoxic central nervous system injury. Infections were documented in 8 patients, 6 of whom had obstetric foci. There is a lack of information regarding the adult respiratory distress syndrome in this patient group. Though uncommon, it can cause substantial mortality and morbidity.

Adult↗
PubMed1986

Surfactant-anti-surfactant immune complexes in infants with respiratory distress syndrome.

The authors sought to determine whether treatment of respiratory distress syndrome (RDS) with human surfactant resulted in the formation of detectable circulating immune complexes. Preterm infants with severe RDS were divided into two groups: one group received human surfactant by intratracheal instillation and the other group did not. Both groups received ventilatory management involving intermittent mandatory ventilation. Plasma samples were drawn from these babies prior to treatment and at intervals thereafter. The authors developed an ELISA assay specific for surfactant-anti-surfactant immune complexes and analyzed the plasma samples for such immune complexes. Complement levels were also measured. They found that with time plasma from RDS infants in both groups showed evidence of surfactant-anti-surfactant immune complex formation. The concentrations of immune complexes generally peaked within the first week of life and then appeared to diminish over 1-4 weeks after birth in RDS infants. There was no evidence at any time in either group of immune-complex-mediated injury or of decreased serum complement levels. It is concluded that circulating immune complexes between surfactant and antibodies to surfactant are probably found in most neonates with respiratory distress syndrome, that they do not produce pulmonary damage detectable by clinical and serologic means, and that treatment of neonatal RDS with human surfactant similarly does not produce lung injury as determined with these techniques.

Antibody Specificity↗
PubMed1995

[Prognosis of acute tuberculous respiratory distress syndrome. 4 cases].

OBJECTIVES: We examined the characteristics of 4 cases of adult respiratory distress syndrome in patients with tuberculosis in an attempt to improve prognosis. METHODS: Four new cases of adult respiratory distress syndrome were described together with a review of the cases reported in the literature. Inclusion criteria were the presence of the syndrome as defined according to the American-European consensus conference and the criteria described by Murray et al. and identification of the mycobacteria causing tuberculosis. RESULTS: A total of 52 cases were included in the study. The sex ratio was 0.71 and mean age 46 +/- 15 years. Eight patients had a past history of pulmonary tuberculosis. Alcoholism was the primary immunodepression factor observed (35%) followed by human immunodeficiency virus infection (13%). For 74% of the patients, the disease course lasted 7 days. The initial chest X-ray was suggestive of tuberculosis in 11. Intradermoreaction to tuberculin was positive in 2 out of 17 patients. Direct examination of non-invasive respiratory samples was positive in 44% for mycobacteria. Disseminated tuberculosis was seen in 64%. Anti-tuberculosis antibiotherapy was started on the first day of intensive care in 68% of the patients; rapid treatment was associated with better prognosis: 1.5 +/- 1.2 days versus 3 +/- 2.7 in fatal cases (p = 0.02). Adjuvant corticosteroid therapy was used in 46% of the cases and was apparently associated with unfavourable outcome: 74% mortality versus 58% without corticosteroids. Ventilatory assistance was required in 88% and associated with poor prognosis (13% survival versus 100% without assistance) (p < 10(-3)). Outcome was fatal in 36 cases (70%) with a mean delay of 9.7 +/- 10.8 days. CONCLUSION: The conditions required for improving the prognosis of adult respiratory distress syndrome in tuberculosis patients included suspecting tuberculosis in all cases of acute respiratory failure of unknown origin, particularly in the immunodepressed patient, and to avoid missing this diagnosis in case of a non-suggestive chest X-ray and a negative though exhaustive microbiology search. Adjuvant corticotherapy is uneffective and may be dangerous.

Acute Disease↗
PubMed1992

A randomized, placebo-controlled trial of betamethasone for the prevention of respiratory distress syndrome at 24 to 28 weeks' gestation.

Previous randomized controlled studies of corticosteroids for the reduction of respiratory distress syndrome have failed to demonstrate benefit in very early premature gestational age groups. A randomized, double-blind, placebo-controlled clinical trial of betamethasone given to mothers with intact membranes and threatened premature delivery between 24 and 28 weeks of pregnancy was conducted. Thirty-six patients were randomized to receive betamethasone, two doses of 12 mg, 24 hours apart, and 41 received placebo. No difference was found in the overall incidence of respiratory distress syndrome between the two groups (betamethasone vs placebo 0.55 vs 0.66) or in the incidence of respiratory distress syndrome in babies delivered between 1 and 7 days after the first dose of drug (betamethasone vs placebo 0.78 vs 0.88). Nor were there any differences observed in any measure of severity of respiratory distress syndrome between the groups. The neonatal death rates were also similar (betamethasone vs placebo 0.25 vs 0.24). The only difference seen was an unexpected reduction in the betamethasone group in the incidence of grades 3 and 4 intraventricular hemorrhage (betamethasone vs placebo 1/31 vs 9/36, p = 0.01). Therefore this study was unable to demonstrate any beneficial effect of corticosteroids in reducing respiratory distress syndrome at less than 28 weeks' gestation in spite of a sample size that had an 80% likelihood of detecting a 50% reduction in the incidence of respiratory distress syndrome with p = 0.05, which is the minimum reduction seen in virtually all randomized trials in other gestational age groups.

Adult↗
PubMed1976

Renal function in respiratory distress syndrome.

Renal function wa assessed in 20 newborn infants with idiopathic respiratory distress syndrome and compared to that of 10 neonates without respiratory distress or renal disease. Inulin and PAH clearances were markedly depressed in neonates with RDS as compared to controls (5.9 +/- 0.6 vs 9.3 +/- 0.8 ml/min/m2 (p less than 0.01) and 13.5 +/- 2.0 vs 23.2 +/- 1.2 ml/min/m2 ( p less than 0.01), respectively). The impairment of inulin and PAH clearances correlated with the severity of the pulmonary disease. Improvement of the respiratory distress was followed by a progressive rise of inulin and PAH clearances toward normal values. Intravenous administration of hypertonic mannitol in three patients resulted in an immediate increase in urine flow and inulin and PAH clearances. It is concluded that a state of acute, reversible, renal insufficiency can occur in the acute phase of idiopathic respiratory distress syndrome.

Body Weight↗
PubMed1996

Routine use of fentanyl infusions for pain and stress reduction in infants with respiratory distress syndrome.

OBJECTIVE: To determine whether fentanyl infusions given to premature infants with respiratory distress syndrome reduce stress and improve long- and short-term outcome. METHODS: Twenty premature infants undergoing mechanical ventilation for respiratory distress syndrome were randomly assigned, in a double-blind fashion, to receive fentanyl by continuous infusion or a volume-matched placebo infusion. A behavioral state score was used to assess the infants' behavior. Cortisol and 11-deoxycortisol levels were measured as physiologic markers of stress. Urinary 3-methyl histidine/creatinine molar ratio was determined and the fractional excretion of urea was measured to assess catabolic state. Ventilatory indexes were recorded for each infant. RESULTS: Infants receiving fentanyl showed significantly lower behavioral state scores (p < 0.04) and lower heart rates (p < 0.001) than those receiving placebo. 11-Deoxycortisol levels were lower in the fentanyl group on days 3, 4, and 5 of the study (p < 0.003). 3-Methyl histidine/creatinine ratios and fractional excretion of urea were not significantly different between the two groups. On the third day of the study, infants receiving fentanyl required a higher ventilator rate (p < 0.01), higher peak inspiratory pressures (p < 0.001), and higher positive end-expiratory pressure (p < 0.0001) than those receiving placebo. There was no difference in long-term outcome with respect to the incidence of bronchopulmonary dysplasia, intraventricular hemorrhage, or sepsis or with respect to the duration of ventilator use. CONCLUSIONS: Although there was a reduction in stress markers in the infants receiving fentanyl, we were unable to demonstrate an improvement in catabolic state or long-term outcome. In addition, the infants receiving fentanyl required higher ventilatory support in the early phase of respiratory distress syndrome than did those receiving placebo.

Analgesics, Opioid↗
PubMedDate not supplied

Adult respiratory distress syndrome (ARDS): the basics.

The term adult respiratory distress syndrome (ARDS) was first introduced by Ashbaugh and Petty more than two decades ago. Since then, our understanding of this clinicopathologic entity has increased significantly. However, little therapeutic progress has been achieved, and the mortality remains high. ARDS is characterized by diffuse pulmonary microvascular injury resulting in increased permeability and, thus, noncardiogenic pulmonary edema. Ventilation-perfusion lung studies have demonstrated that the predominant pathogenesis of hypoxemia in ARDS is related to intrapulmonary shunts. Common symptoms include dyspnea, tachypnea, dry cough, retrosternal discomfort, and moderate to severe respiratory distress. In most cases the diagnosis of ARDS is that of exclusion. The mainstay of therapy for this syndrome is the management of the underlying disorder causing it. To date, there are no specific pharmacologic interventions of proven value for the treatment of ARDS. Once the potentially treatable sources have been found and their therapy started, the main treatment for ARDS is supportive.

Algorithms↗
PubMed2002

Neutrophil activation in preterm infants who have respiratory distress syndrome.

OBJECTIVE: To study neutrophil activation in circulation as a sign of systemic inflammation in preterm infants with respiratory distress syndrome. METHODS: The study comprised very low birth weight preterm infants who had respiratory distress syndrome and required intubation and mechanical ventilation (n = 51), 1-day-old preterm infants who had no need for mechanical ventilation (n = 12), term infants (n = 47), and adult volunteers (n = 25). Neutrophil surface expression of CD11b was quantified with flow cytometry. RESULTS: In preterm infants with respiratory distress syndrome, neutrophil CD11b expression during the first day of life was higher than in cord blood (mean: 165 relative fluorescence units [RFU] [standard deviation [SD]: 53], n = 29 vs 83 RFU [SD: 21], n = 11; 95% confidence interval [CI] for difference: 59-106) or in preterm infants without mechanical ventilation (106 RFU [SD: 33], n = 12; 95% CI for difference: 17-90). CD11b expression decreased by age of 10 days. CD11b expression was lower in preterm cord than in term cord blood (95% CI for difference: 5-53). However, in preterm infants with respiratory distress syndrome aged 2 to 5 days, it was higher than in term infants of that age. CONCLUSIONS: The observations demonstrate an early transient postnatal neutrophil activation indicative of systemic inflammation that may contribute to the tissue injury in preterm infants with respiratory distress syndrome.

Age Factors↗
PubMed1984

Use of prostacyclin and ultrafiltration in adult respiratory distress syndrome.

A primigravida with severe kyphoscoliosis developed cardio-respiratory failure in pregnancy. Cardiac arrest occurred 10 days after Caesarean section; gastric acid was aspirated then and was followed by the development of adult respiratory distress syndrome. Initial recovery, with clearing of peripheral oedema, was followed by a recurrence of respiratory distress associated with infection. Profound hypoxaemia and oliguria unresponsive to diuretics were relieved by the infusion of prostacyclin combined with fluid removal by ultrafiltration. This treatment may be of value in the management of respiratory distress syndrome when pulmonary oedema is the dominant feature.

Adult↗
PubMed2002

Prone position in acute respiratory distress syndrome.

In the last few years prone positioning has been used increasingly in the treatment of patients with acute respiratory distress syndrome (ARDS) and this manoeuvre is now considered a simple and safe method to improve oxygenation. However, the physiological mechanisms causing respiratory function improvement as well as the real clinical benefit are not yet fully understood. The aim of this review is to discuss the physiological and clinical effects of prone positioning in patients with ARDS. The main physiological aims of prone positioning are: 1) to improve oxygenation; 2) to improve respiratory mechanics; 3) to homogenise the pleural pressure gradient, the alveolar inflation and the ventilation distribution; 4) to increase lung volume and reduce the amount of atelectatic regions; 5) to facilitate the drainage of secretions; and 6) to reduce ventilator-associated lung injury. According to the available data, the authors conclude that: 1) oxygenation improves in approximately 70-80% of patients with early acute respiratory distress syndrome; 2) the beneficial effects of oxygenation reduce after 1 week of mechanical ventilation; 3) the aetiology of acute respiratory distress syndrome may markedly affect the response to prone positioning; 4) extreme care is necessary when the manoeuvre is performed; 5) pressure sores are frequent and related to the number of pronations; 6) the supports used to prone and during positioning are different and nonstandardised among centres; and 7) intensive care unit and hospital stay and mortality still remain high despite prone positioning.

Acute Disease↗
PubMed2002

High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial.

Observational studies of high-frequency oscillatory ventilation in adults with the acute respiratory distress syndrome have demonstrated improvements in oxygenation. We designed a multicenter, randomized, controlled trial comparing the safety and effectiveness of high-frequency oscillatory ventilation with conventional ventilation in adults with acute respiratory distress syndrome; 148 adults with acute respiratory distress syndrome (Pa(O2)/fraction of inspired oxygen <or= 200 mm Hg on 10 or more cm H2O positive end-expiratory pressure) were randomized to high-frequency oscillatory ventilation (n = 75) or conventional ventilation (n = 73). Applied mean airway pressure was significantly higher in the high-frequency oscillation group compared with the conventional ventilation group throughout the first 72 hours (p = 0.0001). The high-frequency oscillation group showed early (less than 16 hours) improvement in Pa(O2)/fraction of inspired oxygen compared with the conventional ventilation group (p = 0.008); however, this difference did not persist beyond 24 hours. Oxygenation index decreased similarly over the first 72 hours in both groups. Thirty-day mortality was 37% in the high-frequency oscillation group and was 52% in the conventional ventilation group (p = 0.102). The percentage of patients alive without mechanical ventilation at Day 30 was 36% and 31% in the high-frequency oscillation and conventional ventilation groups, respectively (p = 0.686). There were no significant differences in hemodynamic variables, oxygenation failure, ventilation failure, barotraumas, or mucus plugging between treatment groups. We conclude that high-frequency oscillation is a safe and effective mode of ventilation for the treatment of acute respiratory distress syndrome in adults.

APACHE↗