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  • 1
    ISSN: 1432-1238
    Keywords: Acute respiratory failure ; Mechanical ventilation ; Nitric oxide ; Inhaled ; Pulmonary artery pressure
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective To evaluate the dose response of inhaled nitric oxide (NO) on gas exchange and central haemodynamics in patients with early acute lung injury (ALI). Design Prospective, multicentre clinical study. Setting General ICUs in university and regional hospitals. Patients 18 patients with early ALI according to specified criteria. Interventions During controlled ventilation an inhalation system was used to deliver NO (1000 ppm in N2) and O2/air to the low pressure fresh gas inlet of a Siemens 900C ventilator. Haemodynamics and pulmonary gas exchange variables were measured at baseline and at stepwise increased inspiratory NO concentrations of 0.1, 0.3, 1, 3, 10, 30 and 100 ppm, each dose being maintained for 15 min. Dose testing was repeated the next day, and the response to prolonged (2 h) NO inhalation at 1 and 10 ppm was also tested. Measurements and results Inhalation of NO produced a significant increase in PaO2 (P〈0.0025). The degree of response, as well as the optimal NO dose varied in individual patients and between different days. Venous admixture (QVA/QT) was reduced (P〈0.02) from 38% (31–46%) to 33% (26–41%). In our patients with early acute lung injury and only a moderate elevation in pulmonary arterial pressure NO inhalation did not reduce mean pulmonary artery pressure significantly, being 27.0 (21–30) mmHg at baseline and 26.0 (21–30) mm Hg at 100 ppm. Conclusions This study shows that improvements in arterial oxygenation in response to inhaled NO may show great inter- as well as intraindividual variability, and that improvements in arterial oxygenation occur without any measurable lowering of the pulmonary artery pressure.
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  • 2
    ISSN: 1432-1238
    Keywords: Key words Acute respiratory failure ; Mechanical ventilation ; Nitric oxide ; Inhaled ; Pulmonary artery pressure
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: To evaluate the dose response of inhaled nitric oxide (NO) on gas exchange and central haemodynamics in patients with early acute lung injury (ALI). Design: Prospective, multicentre clinical study. Setting: General ICUs in university and regional hospitals. Patients: 18 patients with early ALI according to specified criteria. Interventions: During controlled ventilation an inhalation systemwas used to deliver NO (1000 ppm in N2) and O2/air to the low pressurefresh gas inlet of a Siemens 900C ventilator. Haemodynamics and pulmonary gas exchange variables were measured at baseline and at stepwise increased inspiratory NO concentrations of 0.1, 0.3, 1, 3, 10, 30 and 100 ppm, each dose being maintained for 15 min. Dose testing was repeated the next day, and the response to prolonged (2 h) NO inhalation at 1 and 10 ppm was also tested. Measurements and results: Inhalation of NO produced a significant increase in PaO2 (P〈0.0025). The degree of response, as well as the optimal NO dose varied in individual patients and between different days. Venous admixture (QVA/QT)was reduced (P〈0.02) from 38% (31–46%) to 33% (26–41%). In our patients with early acute lung injury and only a moderate elevation in pulmonary arterial pressure NO inhalation did not reduce mean pulmonary artery pressure significantly, being27.0 (21–30) mmHg at baseline and 26.0 (21–30) mm Hg at 100 ppm. Conclusions: This study shows that improvements in arterial oxygenation in response to inhaled NO may show great inter- as well as intraindividual variability, and that improvements in arterial oxygenation occur without any measurable lowering of the pulmonary artery pressure.
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  • 3
    ISSN: 1432-1238
    Keywords: Pulmonary circulation ; Nitric oxide ; Vasodilation ; Hypoxic pulmonary vasoconstriction
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The acute effects of the inhaled gas phase of cigarette smoke on pulmonary (PAP) and systemic (SAP) arterial pressures and on plasma arterial cGMP content were compared with those of inhaling 10, 20 and 80 ppm nitric oxide (NO) in one healthy adult volunteer spontaneously breathing a hypoxic gas mixture. Hypoxia (FIO2 0.12) induced a sustained, stable pulmonary vasoconstriction. Inhaled NO induced a dose-dependent fall in PAP; plasma cGMP rose from 39.4 (hypoxia) to 164 pmol/ml (hypoxia plus 80 ppm NO). Exposure to cigarette smoke induced a rapid, consistent and reversible fall in PAP; plasma cGMP rose from 45.5 (hypoxia) to 138 pmol/ml (hypoxia plus cigarette smoke). Neither NO nor cigarette smoke inhalation induced any change in SAP. These data suggest that exposure to cigarette smoke is able selectively to reverse acute hypoxic vasoconstriction in humans without causing systemic vasodilation, an effect likely mediated through the NO-cGMP pathway.
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  • 4
    ISSN: 1365-2044
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Medicine
    Notes: The addition of 10–20 parts per million nitric oxide to the inspired gas was successful in controlling near fatal pulmonary hypertension after surgical repair of a congenital diaphragmatic hernia in a neonate. A preceding prostacyclin infusion was unable to prevent the failure of pulmonary perfusion. No side effect of nitric oxide therapy was observed, and ventilatory support could be substantially reduced as a result of the treatment. On the basis of the striking and lifesaving effects of nitric oxide therapy demonstrated in this child, we believe that nitric oxide treatment will prove to be a major contribution to the management of postoperative pulmonary hypertensive crises.
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  • 5
    ISSN: 1432-1238
    Keywords: Key words Acute respiratory distress syndrome ; Acute lung injury ; Mortality ; Risk factors ; Multivariate analysis ; Prospective studies ; Respiratory insufficiency ; Positive-pressure respiration
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objectives: Primarily, to determine if respiratory variables, assessed on a daily basis on days 1–6 after ICU admission, were associated with mortality in non-ARDS and ARDS patients with respiratory failure requiring mechanical ventilation. Secondarily, to determine non-respiratory factors associated with mortality in ARDS and non-ARDS patients. Design: Prospective multicentre clinical study. Setting: Seventy-eight intensive care units in Sweden and Iceland. Patients: Five hundred twenty non-ARDS and 95 ARDS patients. Measurements and results: Potentially prognostic factors present at inclusion were tested against 90-day mortality using a Cox regression model. Respiratory variables (PaO2/FIO2, PEEP, mean airway pressure (MAP) and base excess (BE)) were tested against mortality using the model. Primary aim: in non-ARDS a low PaO2/FIO2 on day 1, RR (risk ratio) = 1.17, CI (95 % confidence interval) (1.00; 1.36), day 4, 1.24 (1.02; 1.50), day 5, 1.25 (1.02; 1.53) and a low MAP at baseline, 1.18 (1.00; 1.39), day 2, 1.24 (1.02; 1.52), day 3, 1.33 (1.06; 1.67), day 6, 2.38 (1.11; 5.73) were significantly associated with 90-day death. Secondary aim: in non-ARDS a low age, RR = 0.77 (0.67; 0.89), female gender, 0.85 (0.74; 0.98), and low APS (acute physiologic score), 0.85 (0.73; 0.99), were associated with survival; chronic disease, 1.31 (1.12; 1.52), and non-pulmonary origin to the respiratory failure, 1.27 (1.10; 1.47), with death. In ARDS low age, RR = 0.65 CI (0.46; 0.91), and low APS, 0.65 (0.46; 0.90), were associated with survival. Conclusions: No independent significant association was seen between 90-day mortality and degree of hypoxaemia, PEEP, MAP or BE for the first full week of ICU care in either ARDS or non-ARDS. In a sub-group of non-ARDS a lower PaO2/FIO2 and MAP tended to influence mortality where a significant association was seen for 3 of 7 study days. Age, gender, APS, presence of a chronic disease and a pulmonary/non-pulmonary reason for the respiratory failure were associated with mortality in non-ARDS, while only age and APS showed a similar association in ARDS.
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  • 6
    ISSN: 1432-1238
    Keywords: Acute respiratory failure ; Differential lung ventilation ; Selective PEEP ; Ventilation to perfusion matching
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract A patient with severe, acute respiratory failure (ARF) due to bilateral lung disease has been treated with a new ventilation concept aimed at improving the vertical match of ventilation and perfusion. The patient suffered from severe hypoxemia in spite of artificial ventilation with high PEEP and high inspired oxygen fraction. He was intubated with a double lumen bronchial catheter and placed in the lateral decubital posture, whereafter each lung was ventilated in accordance with its assumed perfusion, and selective PEEP of 10–15 cm H2O to the dependent and 0–5 cm H2O to the non-dependent lung was applied. Differential ventilation with selective PEEP resulted in a substantial improvement in pulmonary gas exchange in two separate periods of 3–4 days. The technique thus proved to be efficient and also clinically feasible in a standard intensive care unit.
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  • 7
    ISSN: 1432-1238
    Keywords: Lung ; Extravascular fluid ; Measurement techniques ; Indicator dilution ; Thermal-dye
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The extent to which extravascular lung water (EVLW) is dependent on cardiac output was analysed in anaesthetized and mechanically ventilated pigs. EVLW was measured by thermal-dye dilution technique, by a fibreoptic thermistor catheter system (system 1), and by a thermistor catheter-external optical cuvette system (system 2). During baseline conditions, at which cardiac output was 3.65 l/min, EVLW was 11.7 and 7.7 ml/kg b. w. with systems 1 and 2 respectively. A reduction of cardiac output to a mean of 1.90 l/min by the addition of halothane to the inspired gas did not significantly affect EVLW with system 1 (−50%) but increased EVLW by 39% (p〈0.05) with system 2. An increase of cardiac output to a mean of 4.78 l/min by intravenous infusion of isoproterenol caused a small increase in EVLW with system 1 (14%;p〈0.05) and a decrease with system 2 (10%;p〈0.05). The dependence on cardiac output was the same whether the catheters were positioned centrally (aortic root) or peripherally (abdominal aorta). With system 1 the CO dependence was due to different time constants in thermistor and optical systems, and with appropriate phasing the dependence could be eliminated. With system 2 a large overestimation of the mean transit time difference between the two indicators was seen when cardiac output was low, resulting in overestimation of EVLW. It is concluded that the dependence of EVLW volume on cardiac output is an artefact due to technical problems in the design of the recording equipment rather than a reflection of pulmonary or vascular effects.
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  • 8
    ISSN: 1432-1238
    Keywords: Fluid filtration ; Lymphatic drainage ; Pulmonary oedema
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract A new model for selective sampling of thoracic lymph flow (TLF) and abdominal lymph flow (TDA) in the dog was assessed to ascertain whether there were extrathoracic contributions of lymph to the TLF. Inflating a right atrial balloon in 4 dogs and a left atrial balloon in 2 dogs indicated good separation between TLF and TDA. Data on total lymph protein and albumin clearance before and after oleic acid induced pulmonary oedema in an additional 5 dogs indicated that TLF and TDA drained two differing regions. Our data demonstrate that this lymph preparation provides a sample of thoracic lymph flow with no major extrathoracic lymph contamination. We also propose an alternative method to test for extrathoracic contributions to thoracic lymph, by the application of positive end-expiratory pressure, thereby replacing right atrial balloon inflation.
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  • 9
    ISSN: 1432-1238
    Keywords: Key words Acute respiratory failure ; Mechanical ventilation ; Nitric oxide ; Inhaled ; Pulmonary artery pressure
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objective: To determine whether inhalation of nitric oxide (INO) can increase the frequency of reversal of acute lung injury (ALI) in nitric oxide (NO) responders. Design: Prospective, open, randomised, multicentre, parallel group phase III trial. Setting: General ICUs in 43 university and regional hospitals in Europe. Patients: Two hundred and sixty-eight adult patients with early ALI. Interventions: NO responders were patients whose PaO2 increased by more than 20 % when receiving 0, 2, 10 and 40 ppm of INO for 10 min within 96 h of study entry. Responders were randomly allocated to conventional treatment with or without INO. INO, 1–40 ppm, was given at the lowest effective dose for up to 30 days or until an end point was reached. The primary end point was reversal of ALI. Clinical outcome parameters and safety were assessed in all patients. Results: Two hundred and sixty-eight patients were recruited, of which 180 were randomised NO responders. Frequency of reversal of ALI was no different in INO patients (61 %) and controls (54 %; p 〉 0.2). Development of severe respiratory failure was lower in the INO (2.2 % ) than controls (10.3 %; p 〈 0.05). The mortality at 30 days was 44 % for INO patients, 40 % for control patients (p 〉 0.2 vs INO) and 45 % in non-responders. Conclusions: Improvement of oxygenation by INO did not increase the frequency of reversal of ALI. Use of inhaled NO in early ALI did not alter mortality although it did reduce the frequency of severe respiratory failure in patients developing severe hypoxaemia.
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