Chest
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To test the hypothesis that, if apparent ventilatory insufficiency observed during a weaning or preextubation trial is due to a significant contribution of imposed work of the endotracheal tube and breathing apparatus (WOBImp), and the patient's actual physiologic work of breathing (WOBPhys) is not excessive, it should be possible to extubate these patients safely. ⋯ Increased WOBTOT may be misinterpreted as a patient failure (ie, tachypnea) and weaning halted or extubation not done, prolonging intubation. The ability to measure the contribution of WOBImp to WOBTOT can identify those patients who may be safely extubated when WOBphys (WOBTOT minus WOBImp) is acceptable and the apparent ventilatory insuffiency is related to significant WOBImp.
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The incidence of recurrent pneumothoraces was analyzed in mechanically ventilated patients with the adult respiratory distress syndrome (ARDS) or non-ARDS causes of respiratory failure who had ipsilateral chest tubes in place. The radiographs of 39 consecutive patients with 47 initial pneumothoraces were evaluated for pneumothorax recurrence and chest tube positioning, which was prospectively defined as having a "vertical" or "horizontal" orientation. "Horizontal" positioning indicated that the chest tube may have been placed into a major fissure or the posterior hemithorax. ⋯ Recurrent pneumothoraces occur commonly in mechanically ventilated patients with ARDS despite ipsilateral chest tubes. Because pneumothorax recurrences appear to be related to horizontal chest tube placement, imaging studies should verify that chest tubes are placed in optimally in the anterior hemithorax away from interlobar fissures in this patient population.
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Review Case Reports
A case of pancreatic carcinoma causing massive bronchial fluid production and electrolyte abnormalities.
A 39-year-old man developed massive bronchorrhea (2 to 3.5 L/d) with electrolyte and volume depletion about 2 years after undergoing a Whipple's procedure for pancreatic carcinoma. An open lung wedge biopsy specimen was consistent with metastatic adenocarcinoma with extensive growth along preexisting pulmonary architecture. ⋯ The mechanism of massive bronchorrhea is not known. Chemical analysis of bronchial fluid in comparison to serum and the temporary response to chemotherapy are most consistent with secretory and transudative mechanisms.
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Review Case Reports
Nephrobronchial fistula and lung abscess resulting from nephrolithiasis and pyelonephritis.
There are multiple etiologies reported as causes of lung abscess; however, this differential rarely includes intra-abdominal abnormalities other than extension of a hepatic process. We describe a patient who was found to have a lung abscess and empyema resulting from the development of a nephrobronchial fistula secondary to nephrolithiasis and pyelonephritis. The patient had no urinary symptoms or known abdominopelvic infection and the etiology of lung abscess was only incidentally discovered after chest CT revealed extension of pleural fluid below the diaphragm.