用允许性高碳酸血症并机械通气治疗急性呼吸窘迫综合征疗效观察

目的：观察应用允许性高碳酸血症的机械通气方法治疗急性呼吸窘迫综合征（ＡＲＤＳ）的疗效。方法：９例ＡＲＤＳ患者，应用低潮气量（ＶＴ，平均为５．５２ｍｌ／ｋｇ），呼气末正压通气（ＰＥＥＰ）为（０．８６±０．１８）ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ），ＦｉＯ２为０．５５±０．１７，允许一定限度的呼吸性酸中毒存在（ｐＨ≥７．２０），使动脉血氧分压（ＰａＯ２）维持≥７．３０ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）。结果：９例患者中存活６例（６６．７％），其ｐＨ均值为７．４２±０．０５，ＰａＣＯ２均值为（５．６０±０．５７）ｋＰａ，ＰａＯ２均值为（９．１４±０．６７）ｋＰａ，ＳａＯ２均值为０．９２±０．０３。结论：允许性高碳酸血症的机械通气方法治疗ＡＲＤＳ值得推广。     

加用纳洛酮救治急性呼吸窘迫综合征的疗效分析

目的研究综合治疗同时加用纳洛酮（Ｎａｌｏｘｏｅｎ，ＮＬＸ）救治急性呼吸窘迫综合征（ＡＤＲＳ）的疗效。方法将我院同期ＡＤＲＳ患者随机分为综合治疗组（对照组，３１例），ＮＬＸ治疗组（３３例），于治疗前、治疗后４小时、１２小时、２４小时分别检测动脉血氧分压（ＰａＯ２）、动脉血氧合指数（ＰａＯ２／ＦｉＯ２）水平。结果ＮＬＸ治疗组及对照组治疗后２４小时，ＰａＯ２值分别为１１．８６±０．６４ｋＰａ，９．１４±０．２６ｋＰａ；ＰａＯ２／ＦｉＯ２值分别为３６．６±１．４ｋＰａ，２２．４±１．７ｋＰａ。两组病死率分别为１８．２％，４５．１％，差异均有显著性（Ｐ＜０．０５）。结论加用ＮＬＸ救治ＡＲＤＳ可快速纠正严重低氧血症，改善肺气体交换功能，明显降低病死率，是临床救治ＡＲＤＳ时一种安全、有效的方法     

一种新高频通气方法对实验性急性呼吸窘迫综合征的疗效观察

在高频喷射通气（ＨＦＪＶ）治疗犬实验性急性呼吸窘迫综合征（ＡＲＤＳ）时，采用连续ＨＦＪＶ基础上间歇叠加深吸气（ＨＦＪＶ＋ＤＩ）的新通气方法，以期为ＡＲＤＳ的治疗寻找一种新途径。用油酸复制犬ＡＲＤＳ模型，并随机分为３组。ＨＦＪＶ＋ＤＩ组（ｎ＝１０）：在连续ＨＦＪＶ基础上每隔１０分钟加入１次深吸气；常规机械通气组（ＣＭＶ，ｎ＝１０），给予０．７８５ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ）呼气末正压（ＰＥＥＰ）治疗；对照组（ｎ＝１０），未予通气治疗。每隔１小时测定１次氧合及血流动力学指标，共观察５小时。注射油酸后，动脉氧分压（ＰａＯ２）由１２．４００ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）降至６．５６０ｋＰａ（Ｐ＜０．０１），动脉二氧化碳分压（Ｐａ－ＣＯ２）未见明显变化。通气治疗后，ＣＭＶ和ＨＦＪＶ＋ＤＩ均使ＰａＯ２明显升高，ＰａＣＯ２无明显变化（Ｐ＞０．０５），ＨＦＪＶ＋ＤＩ的氧释放指数（ＤＯ２Ｉ）明显高于ＣＭＶ组（Ｐ＞０．０５），心脏指数（ＣＩ）在ＣＭＶ组及ＨＦＪＶ＋ＤＩ组均明显减低（Ｐ＜０．０５）。提示：ＨＦＪＶ＋ＤＩ时ＰａＯ２的提高大于ＣＩ下降所致的不利影响，在改善组织缺氧方面明显优于ＣＭＶ时加用ＰＥＥＰ     

BiPAP呼吸机经面（鼻）罩压力支持通气的调节及在慢性阻塞性肺病呼吸衰竭中的应用

为探讨ＢｉＰＡＰ呼吸机通气量调节及其在慢性阻塞性肺病呼吸衰竭中的应用，本研究通过８例健康志愿者用ＢｉＰＡＰ呼吸机经面罩（鼻）压力支持通气，观察到其潮气量随吸气相正压或吸气时间增加而提高；在面罩漏气的情况下，潮气量仍有明显提高，呼气末ＣＯ２浓度降低；未用单向活瓣时距呼气口１０ｃｍ和５０ｃｍ处管道内ＣＯ２浓度分别为３．９％和１．５％，应用单向活瓣后呼气瓣远端管道内ＣＯ２浓度降低为０，说明单向活瓣对于呼吸相正压无明显影响。６例慢性阻塞性肺病（慢阻肺）高碳酸血症患者用Ｂｉ－ＰＡＰ呼吸机吸气相正压１．５７～１．９６ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ）压力支持２０分钟后，尽管每分通气量无明显变化，但由于呼吸加深变慢，通气效率改善，ＰａＣＯ２由８．５０±０．６０ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）降为７．２０±０．３０ｋＰａ；吸气流速无明显变化，潮气量增加主要由于吸气时间延长所致；另外６例撤离常规呼吸机机械通气后用ＢｉＰＡＰ呼吸机成功地过渡到自主呼吸。提示：应用面罩机械通气有可能放宽气管插管的拔管指征     

改良凝胶吸附法制备的凝血酶原复合物

采用ＤＥＡＥ－ＳｅｐｈａｄｅｘＡ５０和ＤＥＡＥ－ＳｅｐｈａｒｏｓｅＣＬ－６Ｂ凝胶从人血浆中吸附制备经Ｓ／Ｄ病毒灭活处理后的ＰＣＣ制品，ＤＥＡＥ洗脱液经Ｓ／Ｄ处理（０．３％磷酸三丁脂和１％Ｔｗｅｎ８０，６～８ｈ，２４℃）后，使所加入具有感染剂量（＞１０６）的标志病毒ＶＳＶ、Ｓｉｎｄｂｉｓ、ＨＩＶ均被有效灭活；ＰＣＣ制品中Ⅱ、Ⅶ、Ⅸ、Ⅹ因子的比活性（Ｕ／ｍｇ）分别为０．７９９±０．３４９、０．３４３±０．２５２、０．７４７±０．３４８、０．５８０±０．１９９（ｎ＝７），均比传统ＰＣＣ提高１．５～２．５倍（其中ＦⅨ∶Ｃ的比活性提高有显著性，ｔ＝３．１０５，Ｐ＜０．０１），同时也优于国内同类制品（ｔ＝２．３６０，Ｐ＜０．０５），对其杂蛋白（ＡＴ－Ⅲ、Ｆｎ、ＰＫＡ、Ｐｌｇ、ⅧＲ∶Ａｇ抗Ａ、抗Ｂ凝集素）的分析也反映出ＰＣＣ纯度有所提高。ＳＤＳ－ＰＡＧＥ、ＩＥ、ＣＩＥ电泳图谱及ＨＰＬＣ层析图谱证实上述结果，ＰＣＣ中ＴＮＢＰ残留量≤１０μｇ／ｍｌ，Ｔｗｅｅｎ８０残留量≤１００μｇ／ｍｌ，均在安全范围内。     

正常妊娠妇女血中活化的蛋白C抵抗、狼疮样抗凝物质与血栓前状态分子标志物测定

目的研究活化的蛋白 Ｃ抵抗（Ａｃｔｉｖａｔｅｄ ｐｒｏｔｅｉｎ Ｃ ｒｅｓｉｓｔａｎｃｅ，ＡＰＧＲ）在正常妊娠中的发生情况，探讨狼疮抗凝物质（Ｌｕ－ｐｕｓ－ｌｉｋｅ ａｎｔｉｃｏａｇｕｌａｎｔ，ＬＡ）对妊娠性 ＡＰＣ－Ｒ的影响及二者与凝血酶生成、继发性纤溶的关系。方法采用 ＡＰＴＴ－ＡＰＣ法检测ＡＰＣ－Ｒ、ｄＲＶＶＴ法测定ＬＡ水平，并用 ＥＬＩＳＡ法测定了凝血酶原片段Ｆ１＋２和Ｄ－二聚体（Ｄ－ｄｉｍｅｒ，Ｄ－Ｄ）的含量。结果检测３０例正常妇女对照（ＮＣ）和５０例正常妊娠妇女，ＮＣ组ＡＰＣ－Ｒ比率为２．８８±０．３７，ＮＰ组为２．０４±０．３１（ＡＰＣ－Ｒ阳性率为４２％）；ＮＣ组 ＬＡ阳性率为 ０， ＮＰ组为 ３６．７％； ＮＣ组 Ｆ１＋２为（０．７３４ ± ０．４２） ｎｍｏｌ／Ｌ， ＮＰ组为（ １．０５ ± ０．６９） ｎｍｏｌ／Ｌ； ＮＣ组Ｄ－Ｄ为（０．４８±０．０５）ｍｇ／Ｌ，ＮＰ组为（０．６３±０．１１）ｍｇ/Ｌ；ＮＰ组的ＡＰＣ比率、Ｆ１＋２和Ｄ－Ｄ的测定结果均较ＮＣ组有显著性差异。结论妊娠可能发生与ＬＡ升高有关的ＡＰＣ－Ｒ，并导致了凝血酶激活物生成增加以及凝血酶、纤溶酶的激活和继发性纤溶的发生。     

特普他林对油酸性肺损伤鼠肺泡液体清除功能的影响

目的：观察特普他林对油酸致伤大鼠肺损伤后肺泡上皮液体清除能力的影响。方法：采用大鼠油酸型肺损伤模型。大鼠伤后２４小时经气管滴注特普他林（１×１０－ ４ ｍ ｏｌ／Ｌ）溶液５ ｍ ｌ／ｋｇ;１ 小时后检测肺泡内液体清除率（ＡＬＣ）、总肺水量（ＴＬＷ）、肺血管外肺水量（ＥＶＬＷ）和动脉血气参数。结果：大鼠伤后２４ 小时ＡＬＣ降低４９．２％ ,ＴＬＷ 和ＥＶＬＷ 明显增加〔分别由（３．１４±０．１４）ｍ ｌ／ｇ 和（２．２５±０．１１）ｍ ｌ／ｇ 增至（４．０４±０．１３）ｍ ｌ／ｇ和（４．３２±０．１１）ｍ ｌ／ｇ〕,严重的低氧血症〔ＰａＯ２ 为（６．５５±０．２３）ｋＰａ（１ ｋＰａ＝ ７．５ ｍ ｍ Ｈｇ）〕。特普他林组ＡＬＣ较油酸致伤组增高６３．７％ ,ＴＬＷ 和ＥＶＬＷ 显著减少〔分别为（３．３９±０．１６）ｍ ｌ／ｇ 和（２．９４±０．１２）ｍ ｌ／ｇ〕。钠转运特异性抑制剂 阿咪洛利或哇巴因能部分抑制特普他林刺激肺泡内液体清除的作用。结论：特普他林通过上调钠主动转运机能,促进肺水肿液的吸收,从而改善换气功能,对急性肺损伤后肺水肿有一定的治疗作用     

吸气压力支持通气在机械通气中应用的临床观察

目的：探讨采用吸气压力支持（ＩＰＳ）通气时压力支持（ＰＳ）水平与潮气量（ＶＴ）、呼吸频率（ｆ）、闭合压（Ｐ０．１）和血气分析（ＢＧＡ）的关系,以及如何选择适宜的ＰＳ水平成功地预测脱机的方法。方法：采用对照研究的方法将３４例机械通气患者按最终是否经ＩＰＳ脱机成功分为２组：脱机成功组２５例,ＡＰＡＣＨＥⅡ记分平均（２５．４±５．４）分;脱机失败组９例,ＡＰＡＣＨＥⅡ记分平均（３０．２±５．２）分。每８小时或改变ＰＳ水平后记录ＶＴ、ｆ、Ｐ０．１、经皮氧饱和度（ＳｐＯ２）,每日查ＢＧＡ。结果：ＩＰＳ脱机成功率７４％（２５／３４）。脱机时ＰＳ＜０．６９ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ）,Ｐ０．１＜０．３９ｋＰａ。机械通气＜１４日者,用ＩＰＳ０．５～２日后结合常规参数指标很容易脱机;超过１４日带机者,用ＩＰＳ３～７日可脱机,脱机指标除常规参数外还应结合Ｐ０．１的动态观察,ＰＳ常需降至０．３９～０．５９ｋＰａ,结合ｆ、Ｐ０．１及ＶＴ调整ＰＳ水平。结论：ＩＰＳ作为患者触发呼吸机的一种辅助通气方式,结合Ｐ０．１监测能提供最佳ＰＳ水平,并能较早地成功预测脱机。     

环磷酰胺联合重组人粒细胞集落刺激因子动员自体外周血干细胞

目的：观察环磷酰胺（ＣＴＸ）联合重组人粒细胞集落刺激因子对自体外周血干细胞（ＡＰＢＳＣ）的动员效果。方法：ＣＴＸ３．７±０．２ｇ／ｍ＾２第１天静滴，白细胞（ＷＢＣ）降至最低点时开始皮下注射ｒｈＧ－ＣＳＦ４．５±０．６μｇ．ｋｇ＾－１．ｄ＾－１，直至采集结束前一天，ＷＢＣ恢复至２．５×１０＾９／Ｌ以上时开始连日采集ＡＰＢＳＣ，采集用ＣＳ３０００ｐｌｕｓ或Ｃｏｂｅ血细胞分离机，当累计采集的单个核细胞（     

反比通气与常规通气治疗犬呼吸窘迫综合征时的呼吸动力学比较

目的：探索反比通气的临床应用价值，观察反比通气对呼吸窘迫综合征时呼吸动力学的影响。方法：应用犬油酸型急性呼吸窘迫综合征（ＡＲＤＳ）模型，Ｓｉｅｍｅｎｓ９００Ｃ呼吸机和ＨＰ１１６５Ａ监护系统，观察反比通气时的气道峰压、气道阻力、平均气道压和动态胸肺顺应性变化。结果：反比通气组的气道峰压和气道阻力显著低于常规通气组（Ｐ均＜０．０１），平均气道压和动态胸肺顺应性显著高于常规通气组（Ｐ均＜０．０１～０．０５）。结论：反比通气在改善ＡＲＤＳ呼吸动力学方面明显优于常规通气，对ＡＲＤＳ的治疗有一定的临床应用价值。     

High-frequency percussive ventilation compared with conventional mechanical ventilation

In seven patients with severe respiratory distress, conventional mechanical ventilation and PEEP were used initially for respiratory support, which was changed to high-frequency percussive ventilation (HFPV) at the same level of airway pressure and FIO2. During both modes of ventilation, patients could breathe spontaneously via a low-threshold demand valve. With HFPV, PaO2 improved significantly (p less than .01) compared with PaO2 during conventional methods. Cardiac output was unaffected by the change to HFPV.     

Comparison of high-frequency jet ventilation with conventional mechanical ventilation in saline-lavaged rabbits

A surfactant-depletion lung-injury model was produced in 37 New Zealand white rabbits by saline lavage. During the next 2 to 3 h, rabbits were ventilated with conventional mechanical ventilation (CMV, group 1), high-frequency jet ventilation (HFJV, group 2), or CMV for 1 h followed by HFJV for 2 h (CMV/HFJV, group 3). Survival until planned termination of the protocol was 56%, 77%, and 63% in groups 1, 2 and 3, respectively. Causes of early demise were usually pneumothorax or metabolic acidosis. There were no statistically significant differences among the groups with respect to survival, incidence of pneumothorax or metabolic acidosis. Arterial oxygenation was more efficient with HFJV (group 2) (P[A-a]O2 = 372 +/- 51 torr [mean +/- SE] at 2 h) than with CMV (group 1) (P[A-a]O2 = 512 +/- 18 torr at 2 h, p less than .01). Furthermore, oxygen gas exchange in 3 of 5 group 3 rabbits improved after institution of HFJV. In contrast to previous findings with high-frequency oscillation (HFO), there were no qualitative histologic differences between lungs ventilated with HFJV vs. CMV. Thus, although HFJV produced more efficient gas exchange in this model, it did not improve pulmonary pathology. HFO may be preferable to HFJV in infant respiratory distress syndrome.     

High-frequency ventilation versus conventional ventilation in dogs with right ventricular dysfunction

A randomized crossover protocol was used to compare conventional mechanical ventilation (CMV) and high-frequency ventilation (HFV) in mongrel dogs experiencing right ventricular dysfunction after right ventriculotomy. When inspired oxygen, pH, PCO2, core temperature, and preload were held constant, cardiac output increased significantly (p less than .05) from 1.16 +/- 0.24 to 1.38 +/- 0.25 L/min and pulmonary vascular resistance decreased significantly (p less than .05) from 734 +/- 257 to 554 +/- 169 dyne X sec/cm5 during HFV relative to CMV. We also noted a significant (p less than .05) increase in mean arterial pressure from 116 +/- 27 to 124 +/- 23 mm Hg and a significant (p less than .05) increase in left ventricular stroke work from 10.2 +/- 3.5 to 12.3 +/- 2.6 g X m during HFV. During the inspiratory phase of CMV there were increases in CVP, pulmonary artery pressure, and systemic arterial pressure, and decreases in pulmonary artery flow which did not occur during HFV. HFV may be preferable to CMV in the presence of right ventricular dysfunction.     

Excess ventilation with oxygen-powered resuscitators

Massive subcutaneous emphysema developed in three patients following ventilation with an oxygen-powered, positive pressure resuscitator used by an urban emergency medical service. A faulty valve regulator was identified as the source of the problem. Following this discovery, an extensive field test of all oxygen-powered resuscitators used by the emergency service was carried out. Sixty resuscitators were tested, 15 of which (25%) were found to be deficient on at least one of the test criteria. It is strongly recommended that all personnel using these devices be trained to recognize equipment malfunction and that periodic performance evaluations be carried out on all such equipment. The results of this field test, and other performance tests done previously, raise questions about the use of positive pressure resuscitators in the emergency setting.     

Proportional-assist ventilation compared with pressure-support ventilation during exercise in volunteers with external thoracic restriction

OBJECTIVES: Proportional-assist ventilation (PAV) is able to unload respiratory muscles in proportion to the subject's inspiratory effort. However, leak-related alterations in the flow signal, effort-induced modifications in respiratory mechanics, or approximate adjustment of PAV could jeopardize such a theory. The aim of this study was to compare noninvasive PAV and pressure-support ventilation (PSV) in healthy volunteers with external thoracic restriction at rest and during exercise. DESIGN: Prospective, crossover, randomized study. SETTING: Investigation unit in a nonteaching hospital. PATIENTS: Seven volunteers with external thoracic restriction. INTERVENTION: After external thoracic restriction to increase elastance (9.00 +/- 1.63 cm H2O/L estimated from the level of elastic assistance), PAV and PSV were compared at rest and during exercise (90 W for 10 mins). MEASUREMENTS AND MAIN RESULTS: Flow, airway pressure, and changes in esophageal pressure were measured, and the tidal volume (Vt) and inspiratory muscle effort indexes were calculated. At rest, all variables were comparable during PSV and PAV. Exercise produced a 200% increased in Vt with no change in the breathing frequency and a 400% increased in inspiratory muscle effort indexes. During exercise, peak inspiratory airway pressure was significantly higher with PAV than with PSV (24 +/- 5 vs. 10 +/- 2 cm H2O, p <.05). The Vt and breathing frequency (23 +/- 4 vs. 24 +/- 3 breaths/min) were similar, but the inspiratory muscle effort indexes were significantly lower with PAV than with PSV. A significant linear correlation was found between changes in esophageal pressure and the peak inspiratory airway pressure during PAV (r =.94, p =.0001), whereas, as expected, it was not the case during PSV (r =.27, p =.34). CONCLUSION: In volunteers with external thoracic restriction mimicking a patient with increased elastic work of breathing, the breathing pattern at rest and during exercise were comparable with PSV and PAV, whereas inspiratory muscle effort was lower with PAV during exercise because of the significant automatic increase in assistance with PAV.     

无创正压通气在慢性阻塞性肺疾病所致严重呼吸衰竭机械通气脱机过程中的应用

目的 探讨无创正压通气在慢性阻塞性肺疾病(COPD)并发呼吸衰竭患者有创机械通气撤机后的应用时机及治疗效果.方法 选择36例COPD患者,随机选取18例行气管插管机械通气并作为实验组,以同步间歇指令通气(SIMV) 压力支持通气(PSV) 呼气末正压(PEEP)方式行机械通气,待肺部感染控制窗出现,拔除气管插管,改为经面罩BIPAP无创通气,逐渐脱机.余18例做为对照组,行常规有创通气,最后以PSV方式至撤机.现察两组病例的呼吸机相关性肺炎(VAP)的发生例数、病死率、机械通气天数、总住院天数、动脉血气分析.结果 实验组住院时间少于对照组,(21.1±1.8)天vs(27.1±1.4)天(P<0.05);机械通气时间为(11.4±0.8)天vs(14.8±2.4)天(P<0.05);呼吸机相关性肺炎发生率为0 vs 5例(P<0.01);死亡例数为1例vs 4倒.实验组撤机前后血气分析比较差异无统计学意义(P>0.05);对照组撤机后pH降低、PaCO2升高(P<0.05).结论 对COPD并发呼吸衰竭患者采用早期有创机械通气,序贯应用无创正压通气可以显著降低VAP发生率,提高撤机成功率,缩短住院时间.     

Complications associated with mechanical ventilation

A constellation of adverse effects and complications may be associated with mechanical ventilation, although in many instances the causal role of the ventilator itself has not been established. Complications occur with greater frequency than is generally appreciated, and tend to be under-reported in the medical literature. Among the potential adverse physiologic effects of positive-pressure ventilation are decreased cardiac output, unintended respiratory alkalosis, increased intracranial pressure, gastric distension, and impairment of hepatic and renal function. Failure of the ventilator to cycle, of safety alarms to function properly, and of inspired gas to be properly heated or humidified are examples of equipment-related complications. Perhaps most feared among medical complications occurring during mechanical ventilation are pneumothorax, bronchopleural fistula, and the development of nosocomial pneumonia; these entities may owe as much to the impairment of host defenses and normal tissue integrity as to the presence of the ventilator per se. Finally, a variety of avoidable "misadventures," due primarily to lapses of understanding and communication among the physicians, nurses, and respiratory care practitioners managing the ventilated patient, can adversely affect comfort, morbidity, and ultimate outcome.     

Differential lung ventilation with HFPPV

A case of a 53 year old lady who developed a unilateral “white lung” of unknown etiology three weeks after injury is described. The clinical picture was suggestive of a pleural or extra-pleural hematoma, and she was operated upon twice. During the second thoracotomy it became evident that the lesion was in the lung parenchyma. The patient was treated with differential lung ventilation with application of a high continuous positive airway pressure, followed by high frequency positive pressure ventilation (HFPPV) of the diseased lung with low frequency continuous positive pressure ventilation of the other lung. This technique proved to be simple and successful.     

Clinical applications of independent lung ventilation with unilateral high-frequency jet ventilation (ILV-UHFJV)

Six patients with unilateral acute lung injury (ALI) were treated with a new form of ventilatory support: independent lung ventilation with unilateral high-frequency jet ventilation (ILV-UHFJV). The first three patients suffered from unilateral ALI complicated by a bronchopleural fistula (BPF); they were at first ventilated with HFJV, but remained unresponsive to treatment, showing a progressive impairment of the ventilation/perfusion ratio with a deterioration in clinical condition. After selective bronchial intubation, ILV-UHFJV was started, ventilating the healty lung with CPPV and the controlateral with HFJV. ILV-UHFJV caused a significant improvement in alveolar gas exchange leading to a rapid fall in Q_s/Q_t; it was also associated with a stable haemodynamic condition throughout the duration of the treatment. Subsequently, three more patients were treated; their respiratory failure was due to a unilateral ALI without BPF, unresponsive to either HFJV or CPPV. Once again, ILV-UHFJV was followed by a dramatic improvement in respiratory function; the haemodynamics remained unchanged and it was also possible to demonstrate a rapid improvement in individual and overall lung function.