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PubMed2003

Cephalad movement of endotracheal tubes caused by prone positioning pediatric patients with acute respiratory distress syndrome.

OBJECTIVE: To test the hypothesis that prone positioning of patients with acute respiratory distress syndrome results in significant cephalad movement of their endotracheal tubes (ETT). DESIGN: A retrospective review of chest radiographs and patient information. SETTING: Pediatric intensive care unit of a children's hospital. MEASUREMENTS AND MAIN RESULTS: Patients with acute respiratory distress syndrome had digital chest radiographs performed before and immediately after prone positioning as per our routine practice. Based on measurements of the length of the thoracic trachea and the length of the thoracic segment of the ETT, the movement of the ETT subsequent to prone positioning was calculated. Fifteen pairs of radiographs of 14 consecutive patients were evaluated. There were seven girls and seven boys, with ages ranging from 2 months to 18 yrs. All patients had a cephalad movement of their ETT ranging from 10% to 57% of their thoracic tracheal length (p < .001) associated with prone positioning. The mean amplitude of this movement was 34% +/- 16%, indicating that if the tip of the ETT is not deeper than one third of the thoracic tracheal length before prone positioning, it might slide into the cervical trachea as a result of this procedure. CONCLUSIONS: Prone positioning results in cephalad movement of ETT within the trachea. The tip of the ETT should be deeper than one third of the total length of the thoracic trachea before prone positioning to prevent it from moving into the cervical trachea. When prone positioning is done with an ETT originally not deeper than one third of the thoracic trachea, obtaining a chest radiograph immediately after prone positioning is important to determine whether the ETT remained safely situated in the trachea.

Adolescent↗
PubMed2001

Aerosolized prostacyclin in acute respiratory distress syndrome caused by Chlamydiaceae spp. pneumonia.

Management of respiratory failure in acute respiratory distress syndrome (ARDS) typically requires ventilatory assistance. If traditional approaches to mechanical ventilation and adjunctive measures fail to succeed in achieving adequate oxygenation, alternative measures should be considered. We describe an ARDS patient with respiratory failure caused by a severe Chlamydiaceae species community-acquired pneumonia (CAP). Aerosolized prostacyclin (PGI(2)) treatment was successfully instituted for refractory hypoxemia.

Administration, Inhalation↗
PubMed1999

Improvement in oxygenation by prone position and nitric oxide in patients with acute respiratory distress syndrome.

OBJECTIVE: Inhaled nitric oxide (NO) and prone position improve arterial oxygenation in patients with the acute respiratory distress syndrome. This study was undertaken to assess the combined effects of NO and prone position in these patients. DESIGN: Prospective clinical study. SETTING: General intensive care service in a community teaching hospital. PATIENTS: 14 mechanically ventilated adult patients with the acute respiratory distress syndrome (mean lung injury score 3.23+/-0.27). MEASUREMENTS AND RESULTS: We measured hemodynamic and oxygenation parameters in the supine position and 2 h later in the prone position, before and during inhalation of 10 ppm NO. A positive response in oxygenation was defined as a > or =20% increment in the arterial oxygen tension/fractional inspired oxygen ratio (PaO2/FIO2). In the prone position PaO2/FIO2 increased significantly (from 110+/-55 to 161+/-89 mm Hg, p<0.01) and venous admixture decreased (from 38+/-12 to 30+/-7%, p<0.01) compared to the supine position. Ten of the 14 patients were responders in the prone position. In the supine position, inhalation of NO improved oxygenation to a lesser extent, increasing PaO2/FIO2 to 134+/-64 mm Hg (p<0.01) and decreasing venous admixture to 35+/-12%, (p<0.01). Five of the 14 patients responded to NO inhalation supine and 8 of 14 responded prone (p = 0.22). The combination of NO therapy and prone positioning was additive in increasing PaO2/FIO2 (197+/-92 mm Hg) and decreasing venous admixture (27+/-8%) (p<0.01). This combination also showed a positive oxygenation response on compared to the supine value without NO in 13 of the 14 patients (93 %). NO-induced changes in PaO2/FIO2 were correlated to changes in pulmonary vascular resistance only in the prone position. CONCLUSIONS: In patients with the acute respiratory distress syndrome, the combination of NO and prone position is a valuable adjunct to mechanical ventilation.

Administration, Inhalation↗
PubMed1994

Lung structure and function in different stages of severe adult respiratory distress syndrome.

OBJECTIVE: To assess the clinical consequences of duration of adult respiratory distress syndrome (ARDS) on lung structure and function. DESIGN: Retrospective analysis. SETTING: A university hospital referral center for extracorporeal support. PATIENTS: A total of 84 patients with severe ARDS (Murray score > 2.5) recruited from 48 intensive care units (1979 to 1992), who suffered ARDS and underwent mechanical ventilation for up to 1 week (37 patients with early ARDS), between 1 and 2 weeks (24 patients with intermediate ARDS), or more than 2 weeks (23 patients with late ARDS) and subsequently underwent extracorporeal support. MAIN OUTCOME MEASURES: Before beginning extracorporeal support, we measured gas exchange, pulmonary mechanics, hemodynamics, oxygen transport and delivery, incidence of barotrauma (presence of one or more thoracic tubes for pneumothorax drainage), and organ dysfunctions. In a subgroup of 16 patients, we studied lung structure by computed tomographic scan, scoring the densities and quantifying the emphysemalike lesions (bullae). RESULTS: Late ARDS showed lower respiratory compliance, higher dead space, higher PaCO2, lower venous admixture, and lower positive end-expiratory pressure requirement compared with early ARDS (P < .01). The incidence of pneumothorax (48.8% of the entire population) was significantly (P < .01) higher in late ARDS (87%) vs intermediate ARDS (46%) and early ARDS (30%). The mortality of patients with pneumothorax (66%) was significantly (P < .01) higher compared with patients without pneumothorax (46%). The number of bullae per lung was significantly higher in late ARDS vs intermediate and early ARDS (mean [SD], 8 [4], 4.3 [5], and 1.9 [3.9], respectively; P < .01), and they were preferentially distributed in the dependent lung regions. The number of bullae per lung was significantly higher in patients with pneumothorax vs those without pneumothorax (mean [SD], 13.6 [9.8] vs 1.4 [2.1]; P = .007). The mean (SD) duration of ARDS in patients with pneumothorax was 15.3 (10.0) days vs 7.0 (6.6) days in those without pneumothorax (P = .0001). No differences within the three groups were found in computed tomographic scan densities, hemodynamics, and number of organ system dysfunctions. CONCLUSIONS: The lung structure and function changes markedly with ARDS duration, and the late stages may be described as restrictive lung disease with superimposed emphysemalike lesions. Presence of pneumothorax affects survival and appears to be related to the lung structural changes occurring with time.

Adolescent↗
PubMed1989

Factors associated with surfactant treatment response in infants with severe respiratory distress syndrome.

In a prospective, randomized study of 18 infants treated with bovine surfactant (surfactant TA, Tokyo Tanabe Co, Tokyo) for severe respiratory distress syndrome, a lasting response was found in 12 infants (66%), a transient response was found in two (11%), and no response was found in four (22%) when arterial to alveolar PO2 ratios were used to define responses during the first 48 hours after treatment. In contrast, three of 23 control infants (13%) had a transient or lasting "response" to sham treatment (Pediatrics 1987;79:31-37). To determine whether maldistribution of surfactant could explain lack of response or a transient response, surfactant TA was mixed with technetium-99m sulfur colloid (approximately 300 mu Ci per infant), and eight infants with severe respiratory distress syndrome were treated six to 58 hours after birth. Scintigraphy of the lungs was performed three to 15 hours after treatment. Although a lasting response was observed in three infants, a transient one in three, and no response in two, no gross maldistribution of the radioactive label was found. Either lung received from 37% to 62% of the total radioactivity. During the past 3 years, in all infants with severe respiratory distress syndrome who were treated with surfactant (n = 29), poor or transient responses were associated with early patent ductus arteriosus and air leaks (pulmonary interstitial emphysema and pneumothoraces). Pathophysiologic conditions associated with respiratory distress syndrome are more likely to explain suboptimal responses after surfactant treatment than gross maldistribution of surfactant in the lungs.

Administration, Inhalation↗
PubMed1991

Surfactant replacement therapy for severe neonatal respiratory distress syndrome: implications for nursing care.

This study, which was part of a European multicentre randomised controlled trial of surfactant administration for severe respiratory distress syndrome, monitored the progress and nursing care of the group of babies enrolled in Belfast. In total 33 preterm babies with birth weights between 700-2000 g were studied. Nineteen babies were treated with surfactant and fourteen acted as controls, receiving conventional therapy with mechanical ventilation alone. All the babies had severe respiratory distress syndrome requiring mechanical ventilation in oxygen concentrations greater than 60% by the age of fifteen hours. The aim of the study was to determine the effect on nursing workload of giving surfactant to babies with severe respiratory distress syndrome. The duration of care, such as the length of time the babies required intensive care and subsequent hospitalisation was calculated for each baby. The characteristics of the treated and control babies were similar but survival in the treated group was significantly greater (79% vs 36%, p less than 0.05). There were no significant differences between the groups for individual nursing requirements. However due to the increase in numbers of surviving surfactant treated babies there was a threefold increase in cumulative nursing workload. Surfactant replacement therapy effectively modifies the course of respiratory distress syndrome but also increases the nursing workload and the need for intensive care. This has implications for staffing and financial support of Neonatal Intensive Care Units once surfactant replacement becomes a routine treatment.

Humans↗
PubMed1981

Pulmonary function and exercise gas exchange in survivors of adult respiratory distress syndrome.

Pulmonary function studies were performed on 13 survivors of adult respiratory distress syndrome (ARDS). Six of these 13 patients had a forced vital capacity (FVC) and total lung capacity (TLC) less than 80% of predicted within 2 months of the onset of ARDS. Seven patients followed 6 months or more showed no significant difference between measured and predicted FVC (p = 0.26) or TLC (p = 0.12). The diffusing capacity of carbon monoxide was significantly lower than predicted normal values (p less than 0.001). Although the alveolar arterial oxygen tension gradient (delta AaPO2) was within the predicted normal range for 11 nonsmokers at rest, for 7 patients who exercised (1.0 less than VO2 less than 1.5 L/min), delta AaPO2 increased. The ratio of dead space to tidal volume decreased to less than 0.25 when VCO2 exceeded 1.0 L/min. We concluded that lung mechanics return to predicted normal values within 4 to 6 months after ARDS, but abnormalities of pulmonary gas exchange persist. Pulmonary vascular obstruction does not appear to explain persistent abnormalities of gas exchange.

Adolescent↗
PubMed1979

Treatment of the adult respiratory distress syndrome with continuous positive airway pressure.

Fifteen patients in the early stages of the adult respiratory distress syndrome with severe hypoxemia who were capable of maintaining adequate spontaneous ventilation were treated with continuous positive airway pressure (CPAP). The optimal level of CPAP was adjusted for each patient to achieve the highest oxygenation with the least adverse hemodynamic effects. The optimal intravascular volume, judged by pulmonary arterial occlusion pressure, was maintained by infusion of lactated Ringer's solution. Application of an optimal CPAP ranging between 10 and 25 cm H2O significantly reduced the intrapulmonary shunt, increased the forced vital capacity, and decreased the respiration rate. The improvement in pulmonary status was achieved with no significant changes in cardiac output or the arterial-mixed venous oxygen content difference. Early application of an adjusted level of positive end-expiratory pressure using CPAP in patients with adequate levels of fluid is an effective and safe method of treating selected groups of patients in the early stages of the adult respiratory distress syndrome.

Adolescent↗
PubMed2002

Sigh in supine and prone position during acute respiratory distress syndrome.

Interventions aimed at recruiting the lung of patients with acute respiratory distress syndrome (ARDS) are not uniformly effective. Because the prone position increases homogeneity of inflation of the lung, we reasoned that it might enhance its potential for recruitment. We ventilated 10 patients with early ARDS (PaO2/FIO2, 121 +/- 46 mm Hg; positive end-expiratory pressure, 14 +/- 3 cm H2O) in supine and prone, with and without the addition of three consecutive "sighs" per minute to recruit the lung. Inspired oxygen fraction, positive end-expiratory pressure, and minute ventilation were kept constant. Sighs increased PaO2 in both supine and prone (p < 0.01). The highest values of PaO2 (192 +/- 41 mm Hg) and end-expiratory lung volume (1840 +/- 790 ml) occurred with the addition of sighs in prone and remained significantly elevated 1 hour after discontinuation of the sighs. The increase in PaO2 associated with the sighs, both in supine and prone, correlated linearly with the respective increase of end-expiratory lung volume (r = 0.82, p < 0.001). We conclude that adding a recruitment maneuver such as cyclical sighs during ventilation in the prone position may provide optimal lung recruitment in the early stage of ARDS.

Aged↗
PubMed1985

The acute effects of prostaglandin E1 on the pulmonary circulation and oxygen delivery in patients with the adult respiratory distress syndrome.

Prostaglandin E1 was administered intravenously to 10 patients who had the adult respiratory distress syndrome associated with severe infection in order to investigate its hemodynamic effects. Infusion of PGE1 significantly decreased the mean pulmonary arterial pressure, mean systemic arterial pressure, pulmonary vascular resistance and systemic vascular resistance, and increased the cardiac index, oxygen delivery and oxygen consumption. No significant difference was noted in the intrapulmonary shunt fraction. These results indicate that administration of PGE1 improves pulmonary hemodynamics and tissue oxygenation in patients with acute respiratory distress syndrome, by reducing right ventricular afterload and increasing the cardiac index.

Aged↗
PubMed1997

Prediction of posttraumatic adult respiratory distress syndrome by albumin excretion rate eight hours after admission.

BACKGROUND: Adult respiratory distress syndrome (ARDS) in trauma victims carries a mortality on the order of 50%. An early feature is an increased capillary permeability causing an extravasation of plasma proteins and water, leading to interstitial edema. In the kidney, the increase in microvascular permeability is manifested as increased albumin excretion detectable by sensitive immunoassay. METHODS: Forty seven trauma victims were studied for 5 days; 32 of them had Injury Severity Scores > 18. A diagnosis of ARDS was made on the recommendations of the American-European Consensus Conference on ARDS (1994). Eight patients developed ARDS, five developed pulmonary dysfunction, and the remainder showed no significant pulmonary abnormality. RESULTS: Using the near patient urine albumin immunoassay, albumin excretion rate (AER) was measured after admission. For patients with Injury Severity Score > 18, the median (95% confidence interval) AER 8 hours after admission was 63 (range, 40-99) microg per minute for those without impaired lung function and 339 (range, 162-454) microg per minute for those in the combined ARDS and pulmonary dysfunction group (Mann-Whitney test, p = 0.0004). The median AER was 51 (range, 27-98) microg per minute for patients with Injury Severity Score < 18. The positive predictive value for the development of ARDS or pulmonary dysfunction of AER > 130 microg per minute was 85%, with a negative predictive value of 95%. CONCLUSIONS: These data indicate that the capillary leak associated with the subsequent development of pulmonary dysfunction and ARDS can be detected within 8 hours of admission at the patient's bedside, thus providing a means of early identification of patients at greatest risk and allowing for early intervention.

Adolescent↗
PubMed2006

Pleurodesis using autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome.

OBJECTIVE: Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax. DESIGN: The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1). SETTING: The study took place at the Torrecardenas Hospital (Andalusian Health Service, Almería, Spain). PATIENTS: Participants were 2 groups of 27 patients, all with ARDS, pneumothorax, and PAL. INTERVENTIONS: One group received conventional treatment whereas the other received PAB. MAIN RESULTS: The severity of the conditions of both groups is homogeneous, shown by sex; age; Murray, Marshall, and Acute Physiology and Chronic Health Evaluation II scores; and etiology of ARDS. The patients in the PAB group had a shorter stay in the ICU, shorter weaning time (WT), and lower death rate. The average differences between the groups were 11 days less WT (adjusted odds ratio [OR] = 0.1) and 9 days less on average time spent in the ICU (adjusted OR = 0.24). The death rates in the PAB group and the control group were 3.7% and 29.6%, respectively (adjusted OR = 0.6). CONCLUSIONS: The use of PAB makes possible a decrease in ventilator WT and a shorter stay in the ICU, with a resulting increase in functional recuperation and decrease in patient mortality.

Acute Kidney Injury↗
PubMed2001

Acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature.

Mississippi has the highest prevalence of blastomycosis in the country. In 20 years and 5 months there were 123 patients treated for blastomycosis at the University of Mississippi Medical Center. Among these, 107 patients had lung involvement and nine patients (8.4%) developed acute respiratory distress syndrome. Seven of the nine patients (78%) died of respiratory failure. In six patients, the lungs were the only organs involved. The three other patients had involvement of other organs as well. Average survival after the onset of acute respiratory distress syndrome was 6.9 days (range, 2 to 17 days). Acute respiratory distress syndrome can be triggered by pulmonary infections caused by bacterial diseases and other fungi. Massive proliferation of yeasts in the pulmonary parenchyma is the typical finding of patients with blastomycosis and acute respiratory distress syndrome. Underlying diseases that lead to immunodepression were present in only one patient and probable partial immunodepression was present in two other patients. Data from 19 other cases reported in the literature are discussed. Ann Diagn Pathol 5:1-9, 2001.

Adult↗
PubMed1991

[Icterohemorrhagic leptospirosis with acute respiratory distress syndrome and pulmonary hemorrhage].

We report a case of the respiratory distress syndrome occurring in a patient with leptospirosis ictero-haemorrhagica (LIH). The respiratory failure was associated with pulmonary haemorrhage. There was a rapid favourable outcome after treatment with antibiotics and artificial ventilation. The diagnosis of LIH has been confirmed by serological examination. The mechanisms of the pulmonary disorder during the course of LIH were discussed.

Adult↗
PubMed1984

Neonatal respiratory distress syndrome in the calf.

Thirty-five calves were delivered by caesarean section near to term. During the operation amniotic fluid was collected for determination of the lecithin/sphingomyelin (L/S) ratio. Clinical examination of the calves and analysis of blood gas concentration (venous blood) were carried out within the first hour of life. Fifteen out of 35 calves under examination did not show clinical or blood gas disorders in the course of the first hour of life. In these calves, the L/S ratio, which represents a measure for the maturity of the surfactant system, averaged 2.6. The other 20 calves, however, developed a respiratory distress syndrome together with a progressive respiratory and metabolic acidosis within the first hour of life. The L/S ratio in the animals affected with respiratory distress syndrome reached an average value of 1.5 which was significantly below that of the calves not suffering from respiratory distress. Eleven of the 20 calves which developed respiratory distress syndrome died within the first 60 hours of life. The most striking findings in the post mortem examinations of these animals were intracranial haemorrhages and pulmonary lesions (hyaline membranes, interstitial and alveolar oedema). On the basis of the significantly lower L/S ratio and the post mortem findings, it is to be assumed that the respiratory distress syndrome in calves, equally with that in infants, is attributable to a surfactant deficiency.

Amniotic Fluid↗
PubMed1993

[Importance of copper in respiratory distress syndrome in newborn rats].

To investigate the effect of copper-deficiency on Respiratory Distress Syndrome in newborn rats, 30 female Sprague-Dawley rats were used. The animals were divided at random into 3 groups of 10: The copper-deficient group was fed a copper-free diet from 35 days before gestation to delivery; the control group, fed a copper adequate diet and the pair-fed group was fed a limited copper adequate diet. After birth, an important percentage of the copper-deficient newborn showed symptoms of respiratory distress syndrome, such as apnoea, tachypnoea, and subcostal retraction; however, the pulmonary surfactant in the three groups did not present quantitative significant differences.

Animals↗
PubMed1999

The influence of liposome-encapsulated prostaglandin E1 on hydrogen peroxide concentrations in the exhaled breath of patients with the acute respiratory distress syndrome.

UNLABELLED: Hydrogen peroxide (H2O2) levels are increased in the exhaled breath of patients with the acute respiratory distress syndrome (ARDS). Because liposome-encapsulated prostaglandin E1 (PGE1) downregulates the CD11/CD18 receptor of the neutrophil, thereby limiting endothelial adhesion, the use of this drug should decrease the excretion of H2O2 in the expiratory condensate of patients with ARDS. Patients > 11 yr of age with ARDS (diffuse, patchy infiltrates by chest radiograph; Pao2/fraction of inspired oxygen [P/F] ratio < or = 200 mm Hg; pulmonary capillary wedge pressure < or = 18 mm Hg; and the requirement for mechanical ventilation) were randomized to receive placebo (n = 14) or escalating doses (0.15-3.6 micrograms/kg) of liposomal PGE1 (n = 14) every 6 h for up to 7 days. Condensate was collected every morning from the expiratory tubing that was submerged in an ice saltwater bath (-5 degrees C). H2O2 levels were measured by using a horseradish peroxidase assay. Other data collected included white blood cell count and P/F ratios. There was no significant difference in the concentration of H2O2 in the expiratory condensate between the liposomal PGE1 group and the control group either before (0.99 +/- 0.52 vs 0.93 +/- 0.48 mumol/L) or during treatment (1.04 +/- 0.45 vs 0.76 +/- 0.25 mumol/L). Liposomal PGE1 treatment improved the P/F ratio and decreased the white blood cell count over time. Despite its ability to downregulate the CD11/CD18 neutrophil receptor, liposomal PGE1 did not reduce exhaled H2O2 excretion. IMPLICATIONS: White blood cells (WBC) are thought to be part of the cause of the acute respiratory distress syndrome, a lung disease. WBC in the lung produce hydrogen peroxide, which is exhaled. Liposomal PGE1 inhibits WBC function but was found to have no effect in decreasing exhaled hydrogen peroxide in patients with the acute respiratory distress syndrome.

Adult↗
PubMed2000

The effects of synthetic and natural surfactant on fluid balance in acute respiratory distress syndrome.

UNLABELLED: To evaluate the effect of different surfactants on fluid balance in respiratory distress syndrome, we studied 24 premature infants who were randomised to receive either natural or synthetic surfactant. Data were collected on ventilatory parameters, daily urine output, daily weight, fluid intake and serum electrolytes. Ventilatory requirements decreased more rapidly in babies receiving natural surfactant, with significantly greater reductions in mean airway pressure from 1 to 48 h and oxygenation index from 1-18 h (P < 0.05). There were no differences in fluid intake and serum electrolytes. Mean daily urine output was higher in the group receiving natural surfactant (87 ml versus 61 ml, P < 0.05). This group also had a greater weight loss from birth weight (-146 g versus -65 g, P < 0.05). CONCLUSION: Natural surfactant produces an earlier reduction in ventilatory requirements with an earlier diuresis. This should influence fluid management in respiratory distress syndrome.

Biological Products↗