Chest
-
Nasal pressure support ventilation (NPSV) has been shown to be useful in the treatment of acute and chronic pulmonary failure. However, little is known about respiratory muscle activity during NPSV in stable patients with COPD. The aim of this study was to test the effect of two levels (10 and 20 cm H2O) of NPSV on diaphragmatic activity, in a group of seven stable, severe COPD patients (FEV1 20 percent +/- 7 of pred, FEV1/FVC 35 percent) with hypercapnic respiratory insufficiency. ⋯ A marked statistically significant reduction in diaphragmatic activity, as assessed by a decrease in Pdi swings, PTPdi, and Edi, was detected at the levels of 10 and 20 cm H2O; a further significant decrease in these values was observed when PEEPe was added. PEEPi decreased significantly only with the application of PEEPe, resulting in a small increase in end-expiratory lung volume. We conclude that NPSV improves diaphragmatic function in patients with severe stable COPD; this effect may be enhanced by the applications of external PEEP.
-
To assess the prevalence and severity of Doppler-detected valvular regurgitation, as assessed by multiple Doppler modalities, in patients with structurally normal hearts, we analyzed Doppler echocardiograms in a consecutive sample of 206 referred patients who were found to have completely normal M-mode and two-dimensional echocardiograms. Valvular regurgitation was detected by Doppler in 94 percent, and 56 percent had regurgitation in at least two valves (mitral, tricuspid, and/or aortic). Mitral, tricuspid, and aortic regurgitation was detected in 73 percent, 68 percent, and 12 percent, respectively, with moderate regurgitation occurring in 6 percent, 5 percent, and 2 percent, respectively. ⋯ Estimated right atrial pressure was > 10 mm Hg in only 7 percent, and only 13 percent had estimated pulmonary artery systolic pressure > or = 40 mm Hg. These data indicate a very high prevalence of trivial and mild mitral and tricuspid regurgitation in patients with otherwise "normal" hearts, suggesting that these findings are physiologically normal. These data should be considered when addressing management in patients with Doppler-detected valvular regurgitation in order to prevent "iatrogenic heart disease."
-
The Epworth Sleepiness Scale (ESS) is a simple questionnaire measuring the general level of daytime sleepiness, called here the average sleep propensity. This is a measure of the probability of falling asleep in a variety of situations. The conceptual basis of the ESS involves a four-process model of sleep and wakefulness. ⋯ ESS scores significantly distinguished patients with primary snoring from those with obstructive sleep apnea syndrome (OSAS), and ESS scores increased with the severity of OSAS. Multiple regression analysis showed that ESS scores were more closely related to the frequency of apneas than to the degree of hypoxemia in OSAS. ESS scores give a useful measure of average sleep propensity, comparable to the results of all-day tests such as the multiple sleep latency test.
-
Recurrent spontaneous pneumothorax often requires surgical treatment following variable periods of chest tube therapy. A limited axillary thoracotomy provides sufficient exposure to isolate or excise pulmonary blebs and perform a pleurodesis. Prompt use of this surgical approach in lieu of the initial placement of a thoracostomy tube avoids prolonged hospitalization and a significant failure rate of thoracostomy tubes to resolve this problem. ⋯ A limited axillary thoracotomy corrected the underlying pathology, hastened hospital discharge, limited pain, prevented short-term recurrence, and was cosmetically acceptable. A limited axillary thoracotomy is the operation of choice when a spontaneous pneumothorax requires surgery. This surgical approach has become our primary treatment for recurrent pneumothorax, avoiding the use of a preoperative thoracostomy tube and unnecessary delay, with excellent results for the patient.
-
Tube thoracostomy is a standard therapy for a number of pulmonary disorders. The procedure is associated with a certain incidence of morbidity related to the technique of insertion, the patient population selected, and the length of time the tube remains in place. ⋯ A case of a delayed pulmonary perforation developing several days after placement of a chest tube is described with a discussion of the clinical and radiographic findings associated with this complication. A possible pathophysiologic mechanism by which this complication may have occurred is proposed.