Permissive Hypercapnia and Intravascular Oxygenator in the Treatment of Patients with ARDS

Abstract: This open clinical study was aimed at testing the hypothesis that an intravascular oxygenator (IVOX) may help to perform permissive hypoventilation in 10 patients with severe ARDS. After initial evaluation, we tried to reduce ventilator settings before and after IVOX implantation. Before IVOX, poor clinical tolerance and worsening oxygenation did not allow for a significant decrease in ventilator settings. With IVOX, peak inspiratory pressure (PIP) was reduced from 47 to 39 cm H₂O (p = 0. 005) and minute ventilation from 13 ± 3. 5 to 11 ± 3 L/min. CO₂ removal by IVOX allowed a significant decrease in Paco₂ from 66 ± 15 to 59 ± 13 mm Hg. Improvement of oxygenation with IVOX was not signify cant. Furthermore, interruption of oxygen flow through IVOX did not change oxygenation variables. Tolerance of the IVOX device was good, but insertion of the device was followed by a significant decrease in both cardiac index and pulmonary wedge pressure. In conclusion, IVOX improves tolerance of hypoventilation by limiting hypercapnia in ARDS patients. These preliminary results must be confirmed by a randomized controlled study     

压力调节容量控制通气对肺损伤犬血流动力学、呼吸力学和呼吸功能的影响

目的 探讨压力调节容量控制(PRVC)通气模式对健康及急性肺损伤(ALI)模型犬的血流动力学、呼吸力学和呼吸功能的影响。方法 PRVC和间歇正压通气(IPPV)两种通气模式在呼气末压为0、0．5、1．0和1．5kPa时，分别测定健康犬及油酸诱发ALI犬的血流动力学、呼吸力学及血气参数。结果 健康犬PRVC较IPPV模式下除了在PEEP为0．5kPa时，气道峰压(PIP)、肺动态顺应性(Cdyn)和肺血管阻力(PVR)的影响差异有显著性，对血流动力学、呼吸力学及呼吸功能的影响差异均无显著性。ALI犬PRVC较IPPV模式下各PEEP水平的PIP、平均气道压(mPaw)、Cdyn、动脉血氧分压[pa(O2)]和氧耗(VO2)的影响均有显著意义，但两种通气模式对血流动力学的影响差异无显著性。结论 与IPPV相比，PRVC通气模式能降低PIP，增加Cdyn和提高pa(O2)，两模式对血流动力学的影响差异无显著性，PRVC更适用于ALI／ARDS的治疗。     

氯喹对全肝缺血再灌注大鼠肺损伤的保护作用

目的 探讨氯喹对全肝缺血再灌注大鼠急性肺损伤（Au）的保护作用及其机制。方法 健康SD大鼠90只，雌雄不拘，体重300～350g，随机分为3组：假手术组（A组）、全肝缺血再灌注组（B组）、全肝缺血再灌注＋氯喹组（C组），每组30只。阻断肝门及肝上、肝下下腔静脉20min时开放血流，建立大鼠全肝缺血再灌注模型。C组于缺血前即刻经股静脉注射氯喹10mg／kg，A、B组给予等量生理盐水。于缺血20min、再灌注4h时每组分别处死10只大鼠，抽取门静脉血，测定血浆D-乳酸、内毒素（ETX）、肿瘤坏死因子-a（TNF-a）浓度，另外10只用于观察再灌注48h时大鼠生存率，并在电镜下观察肺组织超微结构的改变。结果 缺血再灌注可导致大鼠缺血期和再灌注期门静脉血D-乳酸、ETX、TNF-a浓度升高，大鼠生存率降低，肺组织超微结构严重受损，氯喹可减弱全肝缺血再灌注导致的上述改变。结论 氯喹对全肝缺血再灌注大鼠ALI有一定的保护作用，通过抑制磷脂酶A2激活，降低肠粘膜屏障通透性升高，降低肠黏膜内毒素移位。     

Blastomycosis in solid organ transplant recipients

BACKGROUND: Blastomyces dermatitidis, the etiologic agent of blastomycosis, causes severe disease and substantial mortality in those immunocompromised by acquired immunodeficiency syndrome or malignancy. In solid organ transplant recipients, the epidemiology, clinical features, and outcomes have not been fully described. METHODS: We conducted a retrospective case-series at the University of Wisconsin Hospital and Clinics. Case patients were solid organ transplant recipients with blastomycosis. RESULTS: From 1986 to 2004, we identified 11 cases of post-transplant blastomycosis with 64% occurring between 2000 and 2004. Onset of infection occurred a median of 26 months post transplantation with near equal distribution before and after the first year of transplantation. Rejection did not precede any case of post-transplant blastomycosis. Opportunistic co-infections were common, occurring in 36% of patients. Pneumonia was the most common clinical presentation and was frequently complicated by acute respiratory distress syndrome (ARDS). Extrapulmonary disease predominantly involved the skin and spared the central nervous system. The overall mortality rate was 36%; however, this increased to 67% in those with ARDS. None of the surviving patients relapsed or received routine secondary antifungal prophylaxis. CONCLUSION: Blastomycosis is an uncommon infection following solid organ transplantation that is frequently complicated by ARDS, dissemination, and opportunistic co-infection. After cure, post-transplant blastomycosis may not require lifelong antifungal suppression.     

山莨菪碱和无创面罩正压通气治疗急性呼吸窘迫综合征的临床观察

目的比较山莨菪碱联合无创正压面罩通气（654-2＋NIPPV）和传统机械通气（CMV）治疗急性呼吸窘迫综合征（ARDS）的临床效果，评估山莨菪碱联合无创正压通气在ARDS治疗中的作用。方法将各种原因所致ARDS患者42例随机分为654-2＋NIPPV组（21例）和CMV组（21例），在给予病因治疗同时分别实施654-2＋NIPPV和CMV。观察分析两组患者在治疗过程中动脉血气变化、并发症的发生率及治疗效果。结果654-2＋NIPPV组有8例（38．1％）治疗失败转为气管插管实行CMV，其中6例（28．6％）死亡。CMV组死亡7例（33．3％），两组病死率无显著差异（P〉0.05）。两组治疗有效的患者在分别接受654-2＋NIPPV和CMV治疗后1h和6h动脉血气有相似的显著改善。654-2＋NIPPV组患者机械通气时间和住院时间短于CMV组（P〈0.05）。654-2＋NIPPV组的并发症发生率低于CMV组（P〈0.05）。结论在经过选择的ARDS患者中，应用654-2＋NIPPV治疗的临床效果与CMV相似。实施654-2＋NIPPV可缩短机械通气和住院时间，减少并发症。654-2＋NIPPV可作为经过选择的ARDS患者首选的通气支持治疗手段。     

Pulmonary effects of closure of patent ductus arteriosus in premature infants with severe respiratory distress syndrome

The pulmonary effects of closure of a patent ductus arteriosus (PDA) were investigated in 11 premature infants with severe respiratory distress syndrome. Successful closure of a PDA did not improve the short-term severity of pulmonary disease (24 and 48 h after treatment) as judged by the arterial/alveolar oxygen tension ratio or the amount of ventilatory support. Also, pulmonary mechanics measured 24 h before, 24 and 48 h after treatment, were not statistically different.Conclusion Infants with severe respiratory disease requiring high ventilation pressure and high oxygen concentration, where structural changes in the lungs are already established, will rarely show short-term improvement in pulmonary disease as a result of closure of a PDA. The overall clinical condition may, however, improve as a result of reduced cardiovascular strain. Earlier treatment of a PDA could reduce the ventilation period and the possible risk of developing chronic lung disease.     

Analysis of kidney volume growth during the fetal period in humans

Summary The growth of fetal kidney volume was studied in 290 specimens taken from 145 fresh human fetuses (85 males and 60 females) with gestational age ranging from 13 to 36 weeks postconception (WPC). Normative equations and curves of the growth of renal volume were obtained for male and female fetuses and for the whole sample in the second trimester (13–24 WPC) and in the third trimester (25–36 WPC) of gestation. There was no difference between the growth in volume of the right and left kidneys. Fetal kidney volume increases with a more intense rhythm in the early fetal period (13–24 WPC). During the second trimester, there was no difference between the values for renal volume of male and female fetuses. In the third trimester, male fetuses had renal volumes significantly greater than the female fetuses. The normative parameters of renal volume could have practical applications in detection and monitoring of renal anomalies in fetal and perinatal urology.Supported by grants 302, 369/86.4/BM-FV from the National Conucil of Scientific and Technological Development (CNPq, Brazil) and Grant E.29/170.787/89 from the Rio de Janeiro Foundation for Research Support (FAPERJ).     

胎儿宫内发育迟缓的实验动物模型

综述了至今已建立的IUGR实验动物模型并对几种常见的实验模型进行了比较。     

妇癌患者的社会心理因素调查

本文以自编病前负性情绪调查表、ＬＳＥ─Ｒ及ＥＰＱ对５６例妇癌住院病人进行了调查，并以５６例内科病住院病人作对照。结果显示，６９．６％的妇癌病人在病前有负性情绪，而内科病病人只有１６．１％；８５．７％的妇癌病人病前经历了负性生活事件，而内科病组则为５８．９％；ＥＰＱ评定结果神经质分亦为前者高于后者，均提示社会心理因素与妇癌的发生密切相关。     

双水平压力调节通气与反比通气对健康及急性肺损伤犬心肺功能影响的比较研究

目的 :比较双水平压力调节 (BIPAP)通气和反比通气 (IRV)对心肺功能的影响。方法 :在两种通气模式 0、0 .5和 1.0 k Pa呼气末压 (EEP)时 ,分别测定健康犬及油酸诱发急性肺损伤犬的呼吸力学、血流动力学及血气分析各参数。结果 :无论有无急性肺损伤 ,BIPAP通气时平均气道压 (m Paw )均明显低于 IRV时(P均 <0 .0 5 )。给健康犬用 IRV通气时 ,上述 3种 EEP水平的 m Paw分别为 (0 .437± 0 .10 3) k Pa、(0 .811±0 .0 93) k Pa和 (1.36 0± 0 .119) k Pa;用 BIPAP通气时则分别降为 (0 .2 2 5± 0 .0 71) k Pa、(0 .6 11± 0 .10 5 ) k Pa和(1.10 7± 0 .0 89) k Pa。油酸诱发急性肺损伤后 ,m Paw分别由 IRV时 (0 .72 5± 0 .2 2 2 ) k Pa、(1.186± 0 .2 98) k Pa和 (1.6 0 0± 0 .10 0 ) k Pa降至 BIPAP时 (0 .35 0± 0 .12 9) k Pa、(0 .6 2 5± 0 .15 0 ) k Pa和 (1.12 5± 0 .0 96 ) k Pa;但两种通气模式中气道峰压、心排血量并无明显差异。另外 ,急性肺损伤时 ,BIPAP通气的动脉血氧分压 (Pa O2 )分别为 (9.10± 1.79) k Pa、(11.43± 1.80 ) k Pa和 (13.40± 3.2 0 ) k Pa,较 IRV时 Pa O2 (7.87± 2 .33) k Pa、(9.0 7±3.0 5 ) k Pa和 (9.71± 1.85 ) k Pa增高 (EEP 1.0 k Pa时 ,P <0 .0 5 )。结论 :