Chest
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Comparative Study
Poststernotomy fractures and pain management in open cardiac surgery.
To assess whether (1) there is an increased incidence of sternal fractures associated with internal mammary artery (IMA) revascularization in open heart surgery and (2) there is a higher incidence of pain in postoperative patients with sternal fractures. ⋯ The use of sternal retraction devices for IMA harvesting in coronary bypass procedures results in an increased incidence of sternal fractures when compared with conventional SVG bypass procedures. Although most sternal fractures are well tolerated, some patients with fractures can become a significant pain management problems. Epidural analgesia is a safe and effective treatment for severe pain associated with sternal fractures and provided improved postoperative pulmonary function.
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Randomized Controlled Trial Comparative Study Clinical Trial
Effect of bronchodilators on lung mechanics in the acute respiratory distress syndrome (ARDS).
The acute respiratory distress syndrome (ARDS) is a disorder of diffuse lung injury secondary to a wide variety of clinical insults (eg, sepsis) and is manifested by impaired oxygenation, pulmonary edema, and decreased static and dynamic compliance. More recently, airflow resistance has been shown to be increased in humans with ARDS. We designed a prospective, randomized, placebo-controlled, crossover trial to determine the presence and reversibility of increased airflow resistance in ARDS. ⋯ Metaproterenol tended to increase PaO2/PAO2, but had no effect on pulmonary shunt or dead space ventilation. We conclude that the increase in airflow resistance of ARDS is substantially reversed by aerosolized metaproterenol without affecting dead space. These data suggest that abnormalities of RL are at lest partially due to bronchospasm.
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Review Case Reports
Aortobronchial fistula 13 years following repair of aortic transection.
We describe a 56-year-old man with the new onset of hemoptysis, increasing in frequency and magnitude, initially diagnosed and treated as pulmonary embolism. Bronchoscopy, computed tomography, and thoracic aortography were performed twice before the diagnosis was made. Thirteen years previously, the patient underwent thoracic aortic interposition graft placement for aortic laceration as a result of a motor vehicle accident. ⋯ The patient underwent successful resection of the graft and placement of a new dacron interposition graft. All cultures, including blood, sputum, and operative specimen cultures, were negative. The patient is alive and well 1 year following surgery.
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Platypnea, or dyspnea in the upright position relieved by recumbency, is most commonly associated with cardiac or pulmonary disease. We describe a patient who presented to the emergency department with platypnea due to a laryngeal carcinoma. A tumor of the upper airway should be considered in any patient presenting with platypnea.
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Randomized Controlled Trial Clinical Trial
Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome.
In 12 patients with severe adult respiratory distress syndrome (ARDS), pulmonary gas exchange and hemodynamics were evaluated before, during, and after a 2-h period of pressure-controlled mechanical ventilation with the patient in the prone position. Ventilation-perfusion relationships (VA/Q) were assessed by a multiple inert gas elimination technique. Pressure-controlled mechanical ventilation in the prone position resulted in an overall increase (p < or = 0.05) of arterial oxygenation after 120 min (98.4 +/- 50.3 to 146.2 +/- 94.9 mm Hg). ⋯ The nonresponder group did not show any significant alteration in the distribution of VA/Q during the study. We concluded that improvement of oxygenation during pressure-controlled mechanical ventilation in the prone position is due to a shift of blood flow away from shunt regions, thus increasing areas with normal VA/Q. This redistribution of blood flow is most likely caused by a recruitment of previously ateletatic but nondiseased areas induced by altered gravitational forces.