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PubMed2005

Pulmonary and extrapulmonary acute respiratory distress syndrome: are they different?

PURPOSE OF REVIEW: Acute respiratory distress syndrome has been considered a morphologic and functional expression of lung injury caused by a variety of insults. Two distinct forms of acute respiratory distress syndrome/acute lung injury are described, because there are differences between pulmonary acute respiratory distress syndrome (direct effects on lung cells) and extrapulmonary acute respiratory distress syndrome (reflecting lung involvement in a more distant systemic inflammatory response). This article will focus on the differences in lung histology and morphology, respiratory mechanics, and response to ventilatory strategies and pharmacologic therapies in pulmonary and extrapulmonary acute respiratory distress syndrome. RECENT FINDINGS: Many researchers recognize that experimental pulmonary and extrapulmonary acute respiratory distress syndrome are not identical. In addition, clinical studies have described the detection of differences radiographically, functionally, and by analysis of the responses to therapeutic interventions (ventilatory strategies, positive end-expiratory pressure, prone position, drugs). However, there are contradictions among the different studies addressing these issues, which could be attributed to the fact that the distinction between pulmonary and extrapulmonary acute respiratory distress syndrome is not always clear and simple. Furthermore, there may be frequent overlapping in pathogenetic mechanisms and morphologic alterations. SUMMARY: The understanding of acute respiratory distress syndrome needs to take into account its origin. If each pathogenetic mechanism were to be considered, clinical management would be more precise, and probably the outcome could include real amelioration.

Animals↗
PubMed1997

Use of percutaneous cardiopulmonary support system with rotary blood pump in graft replacement of the descending thoracic and thoracoabdominal aorta.

Graft replacement of the descending thoracic or thoracoabdominal aorta was successfully performed in 3 patients using percutaneous cardiopulmonary bypass. Femoral inflow and outflow cannulas were inserted percutaneously after induction of anesthesia with the patient in supine position, and low flow normothermic bypass was established before thoracotomy. Next the patient was placed in a right lateral position to create an operating field. With this body position and even an almost prone position, which was sometimes necessary for easy dissection of adhesion of lung to the aneurysmal wall, the bypass flow was easily maintained adequately. The bypass circuit was coated with heparin, and the activated clotting time (ACT) was controlled to be between 150 and 200 s during the entire operating period. Percutaneous insertion of the cannulas avoided local bleeding in the groin, and the low ACT made control of hemorrhage in the operating field easy. For descending aortic surgery, heparin-coated percutaneous cardiopulmonary bypass proved to be a useful adjunctive measure.

Adult↗
PubMedDate not supplied

Comparison of different external beam treatment techniques to deliver high-dose irradiation to local recurrent rectal carcinoma.

AIMS AND BACKGROUND: Treatment of local-regional recurrent rectal carcinoma is a challenging problem, and local control may be dose dependent; doses should probably exceed 60 Gy. Our aim was to verify the possibility to deliver 66 Gy to the target, but less than 35 Gy to the small bowel, comparing different 3D irradiation techniques, in a selected group of patients. METHODS: Five patients with local recurrent rectal carcinoma were selected as representative of different presentations of the disease. Gross tumor volume and clinical target volume were defined [by RS]. Tumors ranged between 182 and 540 cc, and small bowel volumes between 748 and 1050 cc. A three-field technique, coplanar multiple fields, noncoplanar fields and a proton beam were compared using dose volume histograms. A positive result was scored when > or = 90% of the target received the prescribed dose with no more than 5% of the small bowel receiving more than 35 Gy. Doses were escalated in steps of 2 Gy from 60 to 66 Gy. RESULTS: The number of plans fitting the constraints were 7/19, 11/19, 18/19 for doses of 66 Gy, 64 Gy and 62 Gy, respectively. The stage of the tumor did not seem to correlate with the possibility to homogeneously cover the target with the prescribed dose. CONCLUSIONS: Simple coplanar and complex coplanar techniques (up to six fields), positioning the patient in a prone position with dislocation of the bowel, seem to be the best solutions to treat almost all of the patients with doses of 64 Gy. Where higher doses are concerned, it is not possible to suggest a "standard" solution. More personalized techniques have to be tested to define the best option.

Aged↗
PubMed2006

Posterior interhemispheric approach: surgical technique, application to vascular lesions, and benefits of gravity retraction.

OBJECTIVE: To review an experience with the posterior interhemispheric approach applied to vascular lesions in the posterior midline, to examine the effects of patient position and gravity retraction of the occipital lobe, and to identify circumstances requiring increased exposure by sectioning the falx and tentorium. METHODS: During a 6.5-year period, 46 posterior interhemispheric approaches were performed to treat 28 arteriovenous malformations, 10 dural arteriovenous fistulae, seven cavernous malformations, and one posterior cerebral artery aneurysm. Twenty-three patients were positioned prone and 23 patient were positioned laterally. RESULTS: A standard posterior interhemispheric approach was used in 38 patients, and the occipital bitranstentorial/falcine approach was used in seven patients. A contralateral occipital transfalcine approach was used with one thalamic cavernous malformation. All lesions were resected completely and/or obliterated angiographically, with good neurological outcomes in 83% of patients and no operative mortality. Blood loss was lower, operative durations were shorter, postoperative cerebral edema was decreased, and visual outcomes were improved in patients positioned laterally. CONCLUSION: The posterior interhemispheric approach, without additional dural cuts, is appropriate for most vascular lesions in the posterior midline. Gravity retracts the occipital lobes when patients are positioned laterally, enhancing operative exposure and reducing morbidity. Extension of the posterior interhemispheric approach to a transtentorial or transfalcine approach is required for falcotentorial dural arteriovenous fistulae and vein of Galen arteriovenous malformations, but is not usually necessary with cavernous malformations or other arteriovenous malformations.

Adolescent↗
PubMed1981

Exercise effects upon reflex time components in weight lifters and distance runners.

In an effort to identify neuromuscular parameters which differentiate between power-type and endurance-type athletes, an investigation was conducted to determine the effects of an isometric exercise task upon patellar and Achilles fractionated reflex time components in a group of weight lifters and long-distance runners. A reflex hammer was used to deliver a tendon tap stimulus to the patellar tendon (sitting position) and the Achilles tendon (prone position). Under resting conditions, no differences in Achilles reflex components existed between the two subject groups. However, patellar reflex latency was significantly shorter in the weight lifters than in the distance runners. Following knee extensor exercise consisting of three bouts of a 50% MVC holding-time task, the power group manifested a marked lengthening in total reflex time and reflex motor time. In the endurance group, reflex time lengthened after the first bout, but became shorter after the last two bouts. A similar Achilles reflex pattern was seen in both groups after plantar flexor exercise--an initial elongation of the peripheral components of reflex time, followed by a trend towards shorter reflex components in the later bouts. It was suggested that several factors may be competing to produce the bi-directional results observed in reflex time components following isometric exercise.

Achilles Tendon↗
PubMedDate not supplied

Anatomic considerations for sciatic nerve block in the popliteal fossa through the lateral approach.

BACKGROUND AND OBJECTIVES: The disadvantage of the classic posterior approach to block of the sciatic nerve at the knee level (popliteal nerve block [PNB]) is the need to position a patient in the prone position for performance of the block. In this study on cadavers, a lateral approach to the popliteal nerve in the supine position was investigated, and some anatomic considerations of relevance to popliteal nerve block were addressed. METHODS: In 19 cadaver right legs, the lateral approach to PNB was simulated with a needle, introduced in the groove between the biceps femoris and vastus lateralis muscles 7 cm above the knee, at either 30 degrees or 60 degrees relative to the horizontal plane, and 1 mL of dye solution was injected through the needle. After dissection of the popliteal fossa, the position of the solidified bolus of dye in relation to the popliteal nerve was determined. Additionally, the dye was injected into the popliteal nerve sheath, and the spread of the dye and continuity of the sheaths were determined. RESULTS: In 10 legs, the lateral approach was attempted at a 30 degrees angle and in 9 legs at a 60 degrees angle. The solidified injectates at 30 degrees were closely distributed anterolaterally to the nerve, while injectates at 60 degrees tended to be further from the nerve and scattered along its posterolateral aspect (P = .02). The dye injected into the nerve sheaths traveled 5 to 10 cm within the sheath, surrounding both main divisions of the popliteal nerve, the tibial and the common peroneal nerve. CONCLUSION: A lateral approach to the popliteal nerve with insertion of the needle at a 30 degrees angle relative to the horizontal plane results in predictable approximation of the needle tip to the popliteal nerve. The results also suggest the existence of a continuous neural sheath encompassing the popliteal nerve and its main branches. This may have clinical implications similar to those in perivascular neuronal block.

Dissection↗
PubMed2003

Sleep position of low birth weight infants.

OBJECTIVES: To describe sleep positions among low birth weight infants, variations in sleep position according to birth weight, and changes in sleep position over time. To analyze risk factors and influences associated with prone sleep. DESIGN: Prospective cohort study. SETTING: Massachusetts and Ohio, 1995-1998. STUDY PARTICIPANTS: Mothers of 907 low birth weight infants. RESULTS: At 1, 3, and 6 months after hospital discharge, the prevalence of prone sleeping was 15.5%, 26.8%, and 28.3%, respectively. The corresponding rates for supine sleeping were 23.8%, 37.9%, and 50.2% and for side sleeping were 57.3%, 32.4%, and 20.6%. Very low birth weight (VLBW) infants (<1500 g) were most likely to be placed in the prone position. From 1995 through 1998, prone sleeping 1 month after hospital discharge declined among all low birth weight infants from 19.9% to 11.4%; among VLBW infants, the decline in prone sleeping was replaced almost entirely by an increase in side sleeping, whereas in larger low birth weight infants, it was replaced primarily by supine sleeping. Among mothers who placed their infants to sleep in nonprone positions, professional medical advice was cited most frequently as the most influential reason, whereas among mothers of prone-sleeping infants, the infant's preference was cited most frequently. However, mothers of prone-sleeping VLBW infants also frequently cited the influence of medical professionals and nursery practices as most important in the choice of sleeping position. The factors most strongly associated with prone sleeping were single marital status (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.5-6.2), black race (OR: 2.6; 95% CI: 1.5-4.5), birth weight <1500 g (OR: 2.4; 95% CI: 1.3-4.3), and multiparity (OR: 2.1, 95% CI: 1.2-3.5). CONCLUSIONS: Prone sleep decreased among low birth weight infants from 1995 to 1998. However, VLBW infants, who are at very high risk for sudden infant death syndrome, are more likely to sleep prone than larger low birth weight infants.

Birth Weight↗
PubMed2003

Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study.

OBJECTIVE: To examine risk factors for sudden infant death syndrome (SIDS) with the goal of reducing SIDS mortality among blacks, which continues to affect this group at twice the rate of whites. METHODS: We analyzed data from a population-based case-control study of 260 SIDS deaths that occurred in Chicago between 1993 and 1996 and an equal number of matched living controls to determine the association between SIDS and factors in the sleep environment and other variables related to infant care. RESULTS: The racial/ethnic composition of the study groups was 75.0% black; 13.1% Hispanic white; and 11.9% non-Hispanic white. Several factors related to the sleep environment during last sleep were associated with higher risk of SIDS: placement in the prone position (unadjusted odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.7-3.4), soft surface (OR: 5.1; 95% CI: 3.1-8.3), pillow use (OR: 2.5; 95% CI: 1.5-4.2), face and/or head covered with bedding (OR: 2.5; 95% CI: 1.3-4.6), bed sharing overall (OR: 2.7; 95% CI: 1.8-4.2), bed sharing with parent(s) alone (OR: 1.9; 95% CI: 1.2-3.1), and bed sharing in other combinations (OR: 5.4; 95% CI: 2.8-10.2). Pacifier use was associated with decreased risk (unadjusted OR: 0.3; 95% CI: 0.2-0.5), as was breastfeeding either ever (OR: 0.2; 95% CI: 0.1-0.3) or currently (OR: 0.2; 95% CI: 0.1-0.4). In a multivariate model, several factors remained significant: prone sleep position, soft surface, pillow use, bed sharing other than with parent(s) alone, and not using a pacifier. CONCLUSIONS: To lower further the SIDS rate among black and other racial/ethnic groups, prone sleeping, the use of soft bedding and pillows, and some types of bed sharing should be reduced.

Analysis of Variance↗
PubMed2006

A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome.

RATIONALE: Ventilation in the prone position for about 7 h/d in patients with acute respiratory distress syndrome (ARDS), acute lung injury, or acute respiratory failure does not decrease mortality. Whether it is beneficial to administer prone ventilation early, and for longer periods of time, is unknown. METHODS: We enrolled 136 patients within 48 h of tracheal intubation for severe ARDS, 60 randomized to supine and 76 to prone ventilation. Guidelines were established for ventilator settings and weaning. The prone group was targeted to receive continuous prone ventilation treatment for 20 h/d. RESULTS: The intensive care unit mortality was 58% (35/60) in the patients ventilated supine and 43% (33/76) in the patients ventilated prone (p = 0.12). The latter had a higher simplified acute physiology score II at inclusion. Multivariate analysis showed that simplified acute physiology score II at inclusion (odds ratio [OR], 1.07; p < 0.001), number of days elapsed between ARDS diagnosis and inclusion (OR, 2.83; p < 0.001), and randomization to supine position (OR, 2.53; p = 0.03) were independent risk factors for mortality. A total of 718 turning procedures were done, and prone position was applied for a mean of 17 h/d for a mean of 10 d. A total of 28 complications were reported, and most were rapidly reversible. CONCLUSION: Prone ventilation is feasible and safe, and may reduce mortality in patients with severe ARDS when it is initiated early and applied for most of the day.

APACHE↗
PubMed1994

Development of posture in prone and supine positions during the prenatal period in low risk preterm infants.

The development of posture in the prone and supine positions was studied longitudinally in 10 low risk preterm infants between 31 and 39 weeks' postmenstrual age whose subsequent neurological development at 18 months old was normal. The infants were observed from one week after birth until the expected date of delivery. All postures were analysed according to the procedures described by Prechtl et al. There were large intraindividual and interindividual differences in posture in terms of the duration and incidence of the two positions. There was no age specific preferred posture found in either position. The posture duration in the prone position was longer than that in the supine position, but overall flexed and abducted posture were observed more often in the former. Turning of the head to the right side was also observed more often in the prone than in the supine position.

Female↗
PubMed1991

The effect of body posture on exercise- and hyperventilation-induced asthma.

Recent studies have shown that swimming is of relatively low asthmogenicity, even under conditions of high respiratory heat (and/or water) loss (RHL). It has been suggested that the horizontal body position may contribute to swimming's low asthmogenicity. We studied the effects of upright and prone body postures on pulmonary function following exercise (EIA) and after nonexercise hyperventilation (HIA). Twelve asthmatic boys (aged 12 to 16 years) underwent two 8-min exercise sessions of shoulder flexion-extension and two 8-min isocapnic hyperventilation treatments, in a counterbalanced order, either while lying prone or standing upright. All tests were carried out in a climatic chamber at 10 +/- 1 degree C and 31 +/- 2 percent relative humidity. Minute ventilation (VE) was kept constant at a predetermined individual level during all treatments. No differences were observed in pulmonary functions between the prone and upright postures following either exercise (FEV1 = -20.5 +/- 18.7 percent vs -22.2 +/- 18.7 percent, respectively) or hyperventilation (FEV1 = -29.6 +/- 19.0 percent vs -29.7 +/- 20.2 percent). We conclude that body posture on land has no meaningful effect on the severity of bronchoconstriction in asthmatic children; however, in view of some conceivable physiologic benefits of the prone position in water, an interactive effect on swimming-induced asthma (SIA) of body posture and water immersion cannot be ruled out.

Adolescent↗
PubMed2000

Lung recruitment.

It has become increasingly clear that a lung protective ventilatory strategy during adult respiratory distress syndrome/acute lung injury has a positive effect on outcome. Lung recruitment is a major component of this strategy. High-pressure recruitment maneuvers and prone positioning can open the lung; however, once the lung is opened, it must be kept open with appropriate levels of positive end-expiratory pressure. For both of these techniques to be effective, they must be used early in the course of adult respiratory distress syndrome/acute lung injury.

Critical Care↗
PubMedDate not supplied

Effect of religious observance on infants' sleep position in the Jewish population.

OBJECTIVES: To describe the effect of the level of religiousness on infants' sleep position in the Jewish population. METHODS: A longitudinal telephone survey of randomly selected 608 2-month-old Jewish infants repeated at 4 and 6 months. Results were analyzed versus the four levels of Jewish religion observance. RESULTS: A significant correlation was found between the level of religious practice and sleep position (P < or = 0.002). 56.8% (50/88) of ultra-orthodox parents put their babies to sleep in the non-prone position, compared with 79% (411/520) in the other three groups (P < 0.001). Non-prone sleeping decreased when infants grew. Higher parity correlated with the level of religiousness and with prone sleeping in religious families (OR = 1.15, 95% CI 1.00-1.33, P < 0.001). CONCLUSIONS: Jews and especially the ultra-orthodox families comply significantly less with recommendations to avoid prone sleeping. Specific measures may be required in this population that rely more on personal experience and belief than on health care provider advice.

Humans↗
PubMed1989

Child care practices and the sudden infant death syndrome.

Southern New Zealand has one of the highest reported rates of the sudden infant death syndrome (SIDS) in the world. Data were collected on 49 infants who died from SIDS in the Dunedin and Invercargill Health Districts of southern New Zealand. Forty-two of the families were interviewed at home following the loss of their infant. In the week prior to death, 17 infants (40%) had an upper respiratory tract infection, although in 11 of these infants their infection had apparently resolved at least 24 h prior to death. Thirty infants (71%) had their faces down into the bedding or their heads covered with bedding. Thirty-four infants (81%) were found dead in the prone position, whereas 49% of New Zealand infants aged 3 months would be expected to sleep prone. Sleep position and the terminal position of the head in relation to SIDS requires further study.

Humans↗
PubMed2000

Is there significance of the choice of prone versus supine position in the treatment of proximal ureter stones with extracorporeal shock wave lithotripsy?

OBJECTIVE: To determine whether there is a significance of the choice of prone versus supine position in the treatment of proximal ureter stones with extracorporeal shock wave lithothripsy (ESWL). METHODS: Ninety-six patients with proximal ureter stones underwent ESWL. The procedure was performed in the supine position in 48 of them (group 1) and in the prone position in the other 48 patients (group 2). Stone-free rates, repeat ESWL rates, shocks per patient and shocks per session were compared in both groups. RESULTS: The mean session number per patients was 1.64+/-0.75 in group 1 and 1. 33+/-0.59 in group 2 (p = 0.224). The stone-free rates 3 months after ESWL were 88.3% in group 1 and 90.6% in group 2. The difference between the results was statistically insignificant (p<0.05). Therefore, these two parameters were similar in both groups. On the other hand, the number of shocks per session was 4,863.54+/-2, 114.85 in group 1 and 3,704.16+/-1,726.75 in group 2. This difference was statistically significant (p = 0.011). The patients tolerated the supine position better in general. Patients in the prone position experienced discomfort on inspiration and expiration and pain localized to the lumbar vertebrae. CONCLUSION: These results suggest that the supine position decreases the number of shocks per session in the treatment of proximal ureter stones with ESWL and this will be cost-effective.

Humans↗
PubMed2004

Positioning on surgical table.

Positioning on the surgical table is one of the most important steps in any spinal surgical procedure. The "prone position" has traditionally been and remains the most common position used to access the dorsolumbar-sacral spine. Over the years, several authors have focused their attention on the anatomy and pathophysiology of both the vascular system and ventilation in order to reduce the amount of venous bleeding, as well as to prevent other complications and facilitate safe posterior approaches. The present paper reviews the pertinent literature with the aim of highlighting the advantages and disadvantages of various frames and positions currently used in posterior spinal surgery.

Blood Loss, Surgical↗
PubMed1993

[Sudden death syndrome in childhood. Current recommendations for its possible prevention].

The sudden infant death syndrome (SIDS) has a prevalence of 0.31 to 3.5 per 1000 live newborns. It has its peak between two and four months with a greater incidence in the winter season. This syndrome should be diagnosed only after a careful post-mortem examination and a review of the death scene. The babies with SIDS have physiologic differences in their autonomic nervous system when compared with control groups. These babies have a history of excessive room heating and infant bedding. In addition the position most commonly used to put these infants to bed is the prone position. Changes in the way these infants are put to bed, changing from prone to supine position, have led to a significative reduction in SIDS. In order to decrease accidental death by asphyxia, pillows filled with polysterene beads should be avoided.

Autonomic Nervous System↗