Articles: respiratory-distress-syndrome.
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Clinics in chest medicine · Dec 1990
ReviewVentilatory strategies in the management of the adult respiratory distress syndrome.
This article review available strategies for mechanically ventilating patients with the adult respiratory distress syndrome. The authors first present the conventional strategies of mechanical ventilation: volume-limited mechanical ventilation with positive end-expiratory pressure (PEEP) at normal inspiratory-expiratory ratios, the approach that has been the mainstay of ventilatory support since the initial description of PEEP. This discussion attempts to summarize the rationale and goals of treatment in a practical, clinically useful manner. The second section of the article reviews less conventional ventilatory approaches, including inverse ratio ventilation, extracorporeal techniques, high-frequency ventilation, prone position, and fluctuating PEEP, and attempts to review critically the available literature regarding their application.
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A 23-year-old healthy woman in her third trimester of pregnancy developed adult respiratory distress syndrome secondary to Blastomyces dermatitides. Pregnancy-related immunosuppression was believed to be responsible for the fungal infection. ⋯ Although the fetal and maternal sides of the placenta demonstrated fungal spores, the child remained healthy. To our knowledge, this is the first report of blastomycosis-associated adult respiratory distress syndrome occurring during pregnancy.
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Most reports describe reduction in proximal airway pressures with high-frequency jet ventilation. This led us to speculate that high-frequency jet ventilation might reduce barotrauma by providing alveolar ventilation at lower airway pressures. We describe a group of patients in whom a high incidence of barotrauma was observed after institution of high-frequency jet ventilation despite reduction in measured airway pressures. ⋯ Five patients had bilateral pneumothorax and three developed tension pneumothorax. Despite reductions in proximal airway pressures, barotrauma is a significant potential complication of high-frequency jet ventilation in patients with noncompliant lungs. We currently place bilateral prophylactic thoracostomy tubes in patients with adult respiratory distress syndrome prior to initiation of high-frequency jet ventilation.
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The data recorded in 10 multitrauma patients who died of respiratory insufficiency (ARDS) were retrospectively compared with corresponding data recorded in 10 patients with similar injury scores who survived. All 20 patients had had respirator therapy from the 1st day onward. The criteria for ARDS were: (1) death in respiratory insufficiency after trauma. (2) chest X-rays showing signs of ARDS, (3) continuous decrease in the Horowitz quotient, and (4) autopsy (50% of the patients). ⋯ In survivors the Horowitz quotient increased up to physiological values on the 2nd day. A significantly higher PEEP from the 3rd posttraumatic day onward was needed in ARDS patients. The respiratory peak-pressure increased significantly from the 2nd posttraumatic day.
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Clinics in chest medicine · Dec 1990
ReviewPulmonary pathology of the adult respiratory distress syndrome.
Lung morphology in ARDS reflects the rapid evolution from interstitial and alveolar edema to end-stage fibrosis consequent to injury of the alveolocapillary unit. This morphologic progression, termed diffuse alveolar damage, has been subdivided into sequentially occurring exudative, proliferative, and fibrotic phases. Pulmonary lesions correlate with the phase of alveolar damage rather than with its specific cause. ⋯ It must be re-emphasized that the lung is stereotyped in its response to injury, and, consequently, descriptive, or even quantitative, studies of lung morphology can only provide clues regarding the initiating factors and pathogenetic mechanisms of ARDS. Progress in understanding the pathogenesis of ARDS and the devising of rational approaches to therapy will ultimately depend on careful clinical and experimental studies that unravel basic mechanisms of cellular injury and response. The course of these investigations must be guided by and constantly correlated with the pathologic features that occur in humans.