Articles: respiratory-distress-syndrome.
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Advances in cytokine biology and molecular biology have led to the development of novel immunologic approaches to the treatment of septic shock, ARDS, and MOF. These advances are necessary since improvements in supportive care clearly fall short of the hoped-for reductions in mortality associated with these disorders. As noted in this review, these new therapies are directed at three distinct levels of the inflammatory cascade: (1) the inciting event or insult (eg, endotoxin); (2) the mediators (eg, TNF, IL-1); and (3) the effector cells (eg, neutrophils). ⋯ That is, due to the complexity and redundancy of the inflammatory network, it is doubtful that a "magic bullet" will be found. However, it is also clear that advances in our understanding of the pathogenesis of ARDS, septic shock, and MOF at the molecular level have provided clinicians with powerful weapons with which to do battle. It remains to be seen which ones will work the best.
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The Clinical investigator · Mar 1993
ReviewAlveolar surfactant and adult respiratory distress syndrome. Pathogenetic role and therapeutic prospects.
The adult respiratory distress syndrome (ARDS) is characterized by extended inflammatory processes in the lung microvascular, interstitial, and alveolar compartments, resulting in vasomotor disturbances, plasma leakage, cell injury, and complex gas exchange disturbances. Abnormalities in the alveolar surfactant system have long been implicated in the pathogenetic sequelae of this life-threatening syndrome. This hypothesis is supported by similarities in pulmonary failure between patients with ARDS and preterm babies with infant respiratory distress syndrome, known to be triggered primarily by lack of surfactant material. ⋯ Persistent atelectasis of surfactant-deficient and in particular fibrin-loaded alveoli may represent a key event to trigger fibroblast proliferation and fibrosis in late ARDS ("collapse induration"). Overall, the presently available data on surfactant abnormalities in ARDS lend credit to therapeutic trials with transbronchial surfactant administration. In addition to the classical goals of replacement therapy defined for preterm infants (rapid improvement in lung compliance and gas exchange), this approach will have to consider its impact on host defense competence and inflammatory and proliferative processes when applied in adults with respiratory failure.
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Case Reports Comparative Study
Inverse ratio ventilation in ARDS. Improved oxygenation without autoPEEP.
Inverse ratio ventilation and related ventilatory modes (eg, pressure release ventilation) have been applied to patients with the adult respiratory distress syndrome (ARDS) with apparent beneficial effects on arterial oxyhemoglobin saturation. While several mechanisms of improved gas exchange have been postulated, many intensive care physicians believe that the development of occult PEEP (autoPEEP; intrinsic PEEP) leads to the observed rise in oxygen saturation. We report here our findings in a patient whose improved oxygenation on inverse ratio ventilation could not be attributed to autoPEEP.
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We present a technique to measure pulmonary microvascular permeability for albumin in patients with multiple trauma by means of bronchoalveolar lavage (BAL). Routine laboratory tests for the analysis of BAL fluids are used. The results were clinically validated in 10 healthy volunteers and 12 patients with multiple trauma in a first prospective study. ⋯ Normal values (> 0.09 +/- 0.02), posttraumatic physiological ranges (< 0.35), and a "high risk" range (> 0.5) for pulmonary microvascular permeability for albumin were developed. There was a high correlation between the first posttraumatic values of pulmonary microvascular permeability and the required duration of intensive care treatment (r = 0.81), the duration of continuous mandatory ventilation (r = 0.78) and the mean lung injury score by Murray (r = 0.76). We conclude that the presented method is harmless and useful to describe the post-traumatic course of pulmonary microvascular permeability.
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Comparative Study Clinical Trial
Inhaled nitric oxide for the adult respiratory distress syndrome.
The adult respiratory distress syndrome is characterized by pulmonary hypertension and right-to-left shunting of venous blood. We investigated whether inhaling nitric oxide gas would cause selective vasodilation of ventilated lung regions, thereby reducing pulmonary hypertension and improving gas exchange. ⋯ Inhalation of nitric oxide by patients with severe adult respiratory distress syndrome reduces the pulmonary-artery pressure and increases arterial oxygenation by improving the matching of ventilation with perfusion, without producing systemic vasodilation. Randomized, blinded trials will be required to determine whether inhaled nitric oxide will improve outcome.