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PubMed1978

Lactic acidosis presenting as acute respiratory failure.

Two patients with chronic obstructive pulmonary disease and chronic respiratory failure who developed acute lactic acidosis are described. The initial arterial blood gas values in both patients had the pattern of acute respiratory failure with no metabolic disturbance. It was the calculation of the "anion gap" that provided the clue to the presence of metabolic acidosis, which was then confirmed with the measurement of serum lactate. We emphasize that complete laboratory data and clinical information may be essential for accurate diagnosis and understanding of mixed acid-base disturbances and, hence, for initiation of appropriate treatment.

Acidosis↗

PubMed1976

Significance of arrhythmias in acute respiratory failure.

Arrhythmias are as likely to strike patients with acute respiratory failure as patients with acute myocardial infarction. Both supraventricular and ventricular types were detected in half or more of the patients in two recent studies. Ventricular arrhythmias have a particularly bleak prognosis, since they often deteriorate into ventricular fibrillation or cardiac arrest. The exact causes of these arrhythmias are still a mystery, but metabolic abnormalities associated with respiratory failure are highly suspect. These disturbances can disrupt the transmembrane action potential of cardiac conducting tissue, causing electrophysiologic phenomena known to trigger arrhythmias. Until a specific etiology is confirmed, treatment should focus on identifying and correcting possible metabolic causes. Congestive heart failure--itself a cause of arrhythmias--also should be treated. Cardioversion and antiarrhythmic drugs should be used only in life-threatening situations.

Action Potentials↗

PubMedDate not supplied

Relation between lowered colloid osmotic pressure, respiratory failure, and death.

Plasma colloid osmotic pressure was measured each day in 84 intensive care unit patients. Probit analysis demonstrated a direct relationship between colloid osmotic pressure (COP) and survival. The COP associated with a 50% survival rate was 15.0 torr. COP was higher in survivors than in nonsurvivors without respiratory failure and in patients who recovered from respiratory failure. We conclude that lowered COP is associated with an elevated mortality rate. However, the relationship to death is not explained by the relationship to respiratory failure.

Colloids↗

PubMedDate not supplied

The management of respiratory failure in paediatrics.

Following a discussion on the most frequent causes of respiratory failure in children and the principles of its treatment the author presents methods of preventing the complications of prolonged endotracheal intubation and tracheostomy performed on special indications. Particular attention has been paid to careful nursing and adequate humidification of respiratory gases. Moreover the avoiding of tightly-fitting endotracheal tubes and the method of their fixation -- as established at the author's hospital -- are of basic importance for the maintenance of uncomplicated intubation for even several weeks. In the treatment of respiratory failure the use of CPAP and PEEP is helpful. An exact knowledge of the mechanics of respiration in children and its correct evaluation are of greater significance when using various methods of controlled respiration than a selection of a respirator model.

Child↗

PubMed1978

Pulmonary embolism in respiratory failure.

The occurrence of pulmonary emboli in 617 patients admitted to a respiratory intensive care unit was studied. Pulmonary emboli were found in 18 (27 percent) of 66 autopsies. Half of these pulmonary emboli were not diagnosed before death, despite persistent aggressive attempts to document pulmonary emboli. In this subpopulation of patients with respiratory failure, the usual clinical manifestations of pulmonary emboli (symptoms, signs, chest x-ray film, electrocardiogram, and changes in arterial blood gas levels) frequently are already present, due to the severe underlying pulmonary disease, and any superimposed manifestations of pulmonary emboli are often inapparent. In this group under study, the ventilation/perfusion lung scan correlated poorly with pulmonary angiographic results and with examinations at autopsy; the scan generally was inadequate to rule in or rule out pulmonary emboli. Again, this was due to the distortion of both ventilation and perfusion by the severe underlying pulmonary disease. Currently, pulmonary angiographic studies remain the only reliable technique to confirm or exclude pulmonary emboli in patients with respiratory failure.

Electrocardiography↗

PubMed1978

The variable effect of PEEP in acute respiratory failure associated with multiple trauma.

Both short and longterm effects of positive end-expiratory pressure (PEEP) on oxygenating capacity (OC) were investigated in three groups of patients with acute respiratory failure following multiple trauma (MT). Group A consisted of six patients with "uncomplicated" MT; Group B, eight patients with MT and generalized sepsis; Group C, nine patients with MT and lung contusion. OC was evaluated in terms of PaO2/FIO2 and P(A-a)DO2 on FIO 2 = 1.0. OC was markedly and equally reduced in the three patient groups before use of PEEP. The use of a mean PEEP of 6-7 cm H2O resulted in an initial improvement in mean PaO2/FIO2 of 152.5, 36.1, and 59.2 mm Hg, and an overall improvement of 196.8, 57.5, and 107.0 mm Hg in Groups A, B, and C, respectively. There was a similar improvement in both the initial and the overall effect of PEEP on P(A-a)DO2 in the three groups. The difference in the improvement in OC due to PEEP was statistically significant between Groups A and B. It is concluded that acute respiratory failure following MT includes a wide spectrum of clinical syndromes, and that the improvement in OCT due to PEEP depends on the clinical sydrome that is responsible for the respiratory failure associated with MT.

Acute Disease↗

PubMed1979

The effect of short-term discontinuation of high-level PEEP in patients with acute respiratory failure.

PEEP is the most important therapeutic intervention in the management of acute respiratory failure. Transitory PEEP disconnection to perform clinically relevant maneuvers is often necessary, but its effect upon PaO2 and physiological shunt in patients requiring high-level PEEP is not clear from the literature. Nine adult patients in severe respiratory failure requiring high-level PEEP therapy were studied. The elimination of PEEP decreased the PaO2 and increased the physiological shunt. Maximum values were reached in about 4 min. Restoration of PEEP after 7.4 min in zero and end-expiratory pressure caused an increase in the PaO2 and decrease in the physiological shunt. Baseline values were restored in about 5 min. In 4 patients having endotracheal suction under hand ventilation with 100% oxygen, the continuous PaO2 recording showed an increase in PaO2 during the maneuver. Therefore, necessary manipulations can be accomplished without fear of negating the salutory effects gained by high-level PEEP therapy.

Adult↗

PubMed1978

Symposium on intensive care: 4. Respiratory failure.

Patients requiring respiratory support may have normal lungs but inadequate ventilation, or they may suffer from defective pulmonary gas exchange despite adequate ventilation. In the first group some form of mechanical ventilatory support is called for, either pressure-cycled or volume-cycled, used first with an endotracheal tube and only later with a tracheostomy. Weaning the patient from the apparatus requires special care. In cases of pulmonary insufficiency the use of positive end-expiratory pressure has been a major advance. Hemoglobin concentration, cardiac output and renal function must receive attention. Open lung biopsy is of the greatest value when the diagnosis is open to question. Resort to a membrane oxygenator to provide extracorporeal oxygenation of blood can sustain for a time the patient in whom hypoxia is critical in degree.

Adult↗

PubMed1975

Acute respiratory failure complicating multiple fractures in the absence of fat embolism. A study of pathogenesis and treatment and a preliminary report of catheterization of the right side of the heart.

Eight patients with multiple fractures were all treated for acute respiratory failure. The investigation included catheterization of the right side of the heart, determinations of alveolar-arterial oxygen gradients and studies of serum lipid and coagulation and of water and protein balance. The magnitude of respiratory failure correlated well with the number of fractures, the duration and degree of hypotension, the quantity of fluids and blood administered for resuscitation, the magnitude and duration of positive water balance, and the degree of serum hypoalbuminemia. In three patients, the pulmonary-artery pressures were normal at the onset of respiratory failure. The essential aspects of successful therapy included the early institution of assisted ventilation and the achievement of early negative negative water balance.

Acid-Base Equilibrium↗

PubMed1978

Acid maltase deficiency in adults presenting as respiratory failure.

During the past nine years 10 patients with the adult form of acid maltase deficiency have been observed at the Mayo Clinic. Three of the adults presented with respiratory failure. In all three the respiratory manifestations dominated the clinical picture and the cause of the respiratory failure (muscle weakness) and the underlying myopathy (glycogen storage disease) were initially unsuspected. Careful evaluation of the respiratory function tests, including the maximal static respiratory pressures, electromyographic examination and histochemical and biochemical studies of muscle biopsy specimens eventually led to the correct diagnosis.

Adult↗

PubMed1977

Amyotrophic lateral sclerosis presenting with respiratory failure. Diaphragmatic paralysis and dependence on mechanical ventilation in two patients.

Described are two patients whose initial symptom was acute respiratory failure requiring mechanical ventilation. Initially, the cause of the respiratory failure in each patient was obscure, but diaphragmatic paralysis was subsequently demonstrated fluoroscopically in each case. Further neurologic evaluation then supported the diagnosis of amyotrophic lateral sclerosis. Postmortem examination corroborated this diagnosis.

Aged↗

PubMed1977

Pulmonary hypertension in severe acute respiratory failure.

We repeatedly assessed pulmonary and systemic hemodynamics in 30 patients undergoing therapy for severe acute respiratory failure of diverse causes. Pulmonary-artery hypertension and elevated pulmonar vascular resistance were observed in all patients after correction of systemic hypoxemia. Increasing pulmonary blood flow by isoproterenol infusion or decreasing pulmonary blood flow by partial bypass of the right side of the heart minimally altered pulmonary-artery pressure. Although neither elevated pulmonary vascular resistance nor low cardiac index reliably predicted death, survivors had preogressive decreases of pulmonary vascular resistance with time, whereas nonsurvivors tended to maintain or increase pulmonary vascular resistance. Right ventricular stroke-work index was markedly elevated in all patients. The work load imposed upon the right ventricle by elevation of pulmonary vascular resistance may be a factor limiting survival in severe acute respiratory failure.

Acute Disease↗

PubMed1978

Acute respiratory failure: an approach to diagnosis and management.

Acute respiratory failure can be diagnosed using clinical judgment and simple bedside measurement of physiologic function. Respiratory support is based on the pathophysiology of the disorder. Initial therapy is directed at correcting life-threatening hypercapnia, hypoxia, and acidosis. The final outcome is positively influenced by skillful intensive care and a team approach.

Acute Disease↗

PubMed1977

PAO2-PaO2 relationship for the entire therapeutic range of oxygen in acute respiratory failure.

The PAO2-PaO2 relationship was studied for the entire therapeutic range of oxygen in patients and animals in acute respiratory failure. The method is based on the assumption that the steady state values of PaO2 may be obtained as a mean of the two PaO2 values at an identical F1O2, one obtained 6 min after the F1O2 was raised from a lower level, the other obtained 6 min after the F1O2 was reduced from the higher level. We found that the shunts were large in the low F1O2 range (170 mmHg and below), took a minimum value in the moderate PAO2 range (170 to 300 mmHg), and increased again in the high PAO2 range (300 to 700 mmHg). A similar pattern was observed in the animal experiments, two or more hr following experimentally produced produced aspiration pneumonitis. In contrast, the dogs with bilateral pneumothorax showed a pattern which followed the isoshunt line closely. It was concluded that patients with acute respiratory failure requiring artificial ventilation have two componenents of the pulmonary shunt, one parallel with and the other inversely related with the PAO2. Possible mechanisms for the former were discussed.

Acute Disease↗

PubMed1978

Percutaneous paraquat absorption. An association with cutaneous lesions and respiratory failure.

Striking cutaneous lesions and death owing to respiratory failure occurred in a middle-aged woman eight weeks after initial cutaneous contact with the herbicide paraquat (1,1'dimethyl-4,4'dipyridylium dichloride). While similar changes have been described in animals, to our knowledge, serious morbidity or mortality owing to percutaneous absorption has not been described in man. This case report illustrates the extreme toxicity of this herbicide and demonstrates that lethal quantities of the drug may be absorbed from apparently trivial skin wounds. Stricter precautions, including the mandatory use of protective clothing, should be recommended whenever this material is used.

Accidents↗

PubMed1977

Respiratory failure in childhood status asthmaticus.

Thirteen of 356 children consecutively admitted for treatment of status asthmaticus in a 37-month period experienced 19 episodes of respiratory failure, an incidence of 5.3%. In this retrospective study, all children received similar pharmacologic therapy after admission, and all were treated with nasotracheal intubation and controlled ventilation with a volume-cycled ventilator. Mean duration of mechanical ventilation was 54 hours and mean duration of hospital stay was 7.5 days. Complications occurred in nine of 19 episodes and there was one death not directly related to acute asthma. It is possible that 12 of the 19 episodes of respiratory failure might have been prevented by more prompt or more appropriate treatment of the child with acute asthma.

Acute Disease↗

PubMed1979

Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study.

Nine medical centers collaborated in a prospective randomized study to evaluate prolonged extracorporeal membrane oxygenation (ECMO) as a therapy for severe acute respiratory failure (ARF). Ninety adult patients were selected by common criteria of arterial hypoxemia and treated with either conventional mechanical ventilation (48 patients) or mechanical ventilation supplemented with partial venoarterial bypass (42 patients). Four patients in each group survived. The majority of patients suffered acute bacterial or viral pneumonia (57%). All nine patients with pulmonary embolism and six patients with posttraumatic acute respiratory failure died. The majority of patients died of progressive reduction of transpulmonary gas exchange and decreased compliance due to diffuse pulmonary inflammation, necrosis, and fibrosis. We conclude that ECMO can support respiratory gas exchange but did not increase the probability of long-term survival in patients with severe ARF.

Acute Disease↗

PubMed1976

Respiratory failure and cardiac disturbances in myotonic dystrophy.

Cardiopulmonary abnormalities are frequently encountered in myotonic dystrophy. We present five patients with myotonic dystrophy who entered the intensive care unit in acute respiratory failure. The possible etiologic factors of pulmonary complications are reviewed. The most important is probably aspiration pneumonia. The difficulties in the treatment of the respiratory failure are emphasezed. Myotonia of the chest muscles and diaphragm make artificial ventilation difficult. Recovery is delayed chiefly by swallowing disturbances. General anaesthesia is hazardous. Four patients presented cardiac arrhythmias and/or conduction abnormalities which were transient.

Adolescent↗