Chest
-
Review Case Reports
Chylothorax in Gorham's syndrome. A common complication of a rare disease.
One hundred forty-six cases of Gorham's syndrome are documented in the literature. Twenty-five (17 percent) patients have been reported to have chylothorax as a complication. To our knowledge, this high incidence of chylothorax has not been reported previously. We describe two such patients treated by thoracic duct ligation and compared our results with others to support early surgical intervention via a low right-sided thoracotomy in these cases.
-
Clinical Trial
Early sepsis treatment with immunoglobulins after cardiac surgery in score-identified high-risk patients.
In patients at risk for sepsis after cardiac surgery, the efficacy of intravenous immunoglobulin (Ig) treatment was compared with a historical control population, equivalent in patient characteristics and disease severity. Using APACHE II scores, especially in the high-risk group (IgG), we could discriminate between low-risk patients (score < 19; mortality 1 percent) and the small groups at risk (score 19 to 23) and high risk (score > or = 24) with a significantly higher mortality (14 percent and 76 percent, respectively) [corrected]. ⋯ In this group, Ig therapy produced higher (p < 0.05) response rates (score decrease 7 within 4 days: IgG: 54 percent, IgGMA: 62 percent; controls: 19 percent) and reduced mortality (IgG: 46 percent, IgGMA: 46 percent; controls: 76 percent), statistically significant (p < 0.05) for Ig treatment overall. Thus, early Ig treatment improves disease severity and may improve prognosis in prospectively score-identified high-risk postcardiac surgical patients.
-
The purpose of this study was to determine the correlation between different intervals in the 12-min walk test, to determine which of the intervals best correlated with maximal oxygen intake (VO2max) and maximal CO2 expelled (VCO2max) and to determine the degree of correlation between changes in the VO2max and changes in the walk test and spirometry. Nine elderly (age, 67 +/- 4 years) patients with moderate COPD (FEV1, 1.32 +/- 0.28 L) who were ventilatory limited were seen 6 times over a 14-week period. At each visit they performed spirometry, a 12-min walk, and a symptom-limited maximal exercise test. ⋯ The correlation coefficients between the distance walked at various intervals and the oxygen consumption (VO2)/kg (approximately 0.65) and the VCO2/kg (approximately 0.52) were very similar. However, changes in the VO2/kg were more closely correlated with changes in the 12-min walk (r = 0.72), than with changes in the 6-min walk (r = 0.64), the 4-min walk (r = 0.59), or the 2-min walk (r = 0.53). This latter observation suggests that the 12-min walk may be preferable to tests in which the patient walks 4 or 6 min for documenting changes in the exercise capabilities.
-
Case Reports
Management of acute respiratory failure due to pulmonary edema with nasal positive pressure support.
The management of patients with respiratory failure from cardiogenic pulmonary edema may require intubation and mechanical ventilation. This provides both ventilatory assistance as well as the beneficial hemodynamic effects of positive intrathoracic pressure. As the need for ventilation is usually short term, noninvasive ventilatory support may be adequate. We report the use of biphasic positive airway pressure by nasal mask (BiPAP system) to successfully manage two patients with respiratory failure due to pulmonary edema.
-
To examine the relationship of expired capnograms and respiratory system resistance (Rrs) in intubated critically ill patients, we consecutively studied 41 mechanically ventilated patients to (1) analyze the association between expired CO2 slope and auto-positive end-expiratory pressure (auto-PEEP), between Rrs and auto-PEEP, between Rrs and expired CO2 slope, and between Rrs and arterial minus end-tidal PCO2 gradient (PaCO2-PETCO2 gradient) and (2) to investigate the capacity of the expired CO2 slope and PaCO2-PETCO2 gradient to predict Rrs during mechanical ventilation. Regression analysis found a close correlation between Rrs and expired CO2 slope (r = 0.86; p < 0.001), between Rrs and auto-PEEP (r = 0.75; p < 0.001), and between auto-PEEP and expired CO2 slope (r = 0.74; p < 0.001). ⋯ These observations suggest that CO2 elimination in critically ill patients is strongly modulated by lung, airway, endotracheal tube, and ventilator equipment resistances. Although continuous capnogram waveform monitoring at the bedside might be useful to assess Rrs, very accurate predictions could be done only in determinate patients.