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Reexpansion of a pulmonary atelectasis is often difficult, even after removing possible causes of bronchial obstruction. Chest ultrasounds, inexpensive and readily available at the patient bedside, may offer valuable support to guide recruitment maneuvers. We report the case of a 57-year-old woman that developed a complete collapse of the left lung seven days after undergoing an intestinal resection for perforation. A mucous plug occluding the main bronchus was removed with bronchoscopy, but persistent hypoxemia required mechanical ventilation; 24 hours later, an attempt to wean the patient from the ventilator failed. Chest X-rays revealed the persistence of a partial collapse of the left inferior lobe associated with a pleural effusion. A chest ultrasound confirmed the presence of a lung consolidation and of a modest pleural effusion. Manual reexpansion was then attempted, and ventilatory pressures as well as the duration of forced inspirations were based on real-time ultrasound images. Complete reexpansion was achieved within a few minutes and confirmed by chest X-ray. The patient was weaned from mechanical ventilation on the same day and discharged from ICU three days later.

Flail chest occurs when a series of adjacent ribs are fractured in at least 2 places, anteriorly and posteriorly. This section of the chest wall becomes unstable and it moves inwards during spontaneous inspiration. The physiological impact of a flail chest depends on multiple factors, including the size of the flail segment, the intrathoracic pressure generated during spontaneous ventilation, and the associated damage to the lung and chest wall. Treatment varies with the severity of the physiologic impairment attributable to the flail segment itself. Immediate surgical fixation may decrease morbidity, but conservative treatment with positive pressure ventilation is preferred when multiple injuries to the intrathoracic organs are present.

The pressure-volume curve of the respiratory system is a physiological method used for diagnotic purposes to describe the static mechanical properties of the respiratory system. A renewal of interest in the pressure-volume curve has recently appeared because of experimental evidence regarding the information conveyed by the curve, a better understanding of the pathophysiologic factors influencing its interpretation and the beneficial results of clinical trials based on the use of the pressure-volume curve for ventilatory management of acute respiratory distress syndrome. Thus, adapting ventilatory settings to individual characteristics of the patients in terms of respiratory mechanics may be an extremely important aspect for a better management of the most difficult to ventilate patients with acute lung injury. There is considerable experimental evidence that both the opening-collapse phenomena and the excessive lung stretch may cause damage to the lungs. Therefore tools allowing an individual titration of ventilatory settings taking into account the constraints of the respiratory system seem highly desirable. The pressure-volume curve might be easily achievable at the bedside as a monitoring tool. The low-flow technique using ventilator technology has several potential advantages. It is hopeful to think that in the future the measurement of the P-V curve and the quantification of alveolar recruitment may be easily provided at the bedside and may help for the titration of the ventilatory settings in clinical practice. This review will focus briefly on the physiologic background, technique description, and recent advances concerning the interpretation of the P-V curve in the critically ill patients.

In the patient with homogeneously or inhomogeneously distributed atelectasis, localized primarily in the apices, overdistension of the non-dependent portion of the lung bases, only partially surrounded by the rib cage, is generally observed during mechanical ventilation. This phenomenon is even more pronounced in the neonate and in the infant because their rib cage compliance is almost infinite. In order to protect the lung bases in the event of their overdistension and/or to reexpand the atelectasis of the upper lobes we apply an external resistance, in form of thoracoabdominal binding, to limit the movement of the diaphragm. The degree of the binding's tension is regulated according to the degree of the distension of the lung bases detected on chest x-ray. This restriction was so far applied in 12 children using elastic bandages. We have used the thoraco-abdominal binding with good result in the treatment of atelectasis of the upper lobes, in extensive atelectasis as well as in the treatment of primitive lung bases overdistension, as described in 3 cases reports. We suggest this technique in order to obtain an homogeneous ventilation along the longitudinal axis of the lung. This method does not interfere with prone-supine postural changes, systematically applied in our department, and therefore, the homogeneous ventilation along the vertical axis is also provided.