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The article describes a case of management of postesophagectomy respiratory failure in a 63-year-old man who underwent transthoracic esophagectomy for adenocarcinoma with noninvasive ventilation. His pulmonary function test revealed a forced expiratory volume of 3 liters per second and a forced vital capacity of 3.43 liters as the patient was a former smoker but stopped 5 years before surgery. Blood gas values for the main stages of clinical course in the end of first postoperative day and before paravertebral block second postoperative day.

Objective: The double indicator method is sensitive to alterations in the distribution of pulmonary blood flow. This distribution is influenced by the type of lung injury. The aim of this study was to compare measurements of lung water by the double indicator method with measurements obtained by gravimetry in a direct lung injury model induced by tracheal instillation of hydrochloric acid and in an indirect lung injury model induced by the intravenous injection of oleic acid.Design: Prospective, randomized laboratory study.Setting: Animal research laboratory.Subjects: Forty-two female pigs (28+/-3 kg).Interventions: Pigs were anesthetized and ventilated and were allocated into three groups: control (n = 6), hydrochloric acid (4 mL/kg intratracheally, n = 24), or oleic acid (0.1 mL/kg intravenously, n = 12).Measurements and Main Results: Hydrochloric acid instillation or oleic acid injection resulted in a similar hypoxemia and induced a two- to three-fold increase in extravascular lung water (EVLW) by gravimetry (EVLWG) at 3 hrs compared with controls. In the oleic acid group, there was a significant correlation between EVLWG and EVLW by double indicator method (EVLWDI; r =.88, p <.0001). The bias for EVLWDI - EVLWG measurements was -5.2 mL/kg (95% confidence interval, -5.7 to -4.7 mL/kg) with 95% limits of agreement of -7 to -3.4 mL/kg. In the hydrochloric acid group, there was no significant correlation between EVLWDI and EVLWG values, and the double indicator method failed to detect pulmonary edema in 65% of the animals (EVLWDI <8 mL/kg). The bias was -7.9 mL/kg (95% confidence interval, -9.3 to -6.5 mL/kg) with 95% limits of agreement of -14.4 to -1.4 mL/kg.Conclusions: The double indicator method is useful for evaluation of pulmonary edema in indirect lung injury, as induced by oleic acid, but produces misleading values in direct lung injury, as produced by hydrochloric instillation. [ABSTRACT FROM AUTHOR]

Background: The development of an early-onset pneumonia (EOP), occurring within the first 72 hours after admission, represents a critical event in severe thoracic trauma population. The aim of this study was to determine risk factors associated with the occurrence of this complication in this specific population., Methods: A retrospective review of a prospective implemented trauma registry was conducted during a 4-year period in a Level I trauma center. Over the study period, 223 severely injured patients were admitted with severe thoracic trauma (Injury Severity Score >16 and Thorax Abbreviated Injury Score >2). Multiple logistic regression analysis was used to determine the independent predictors of EOP based on the clinical characteristics and the initial management both in the field and after admission in the trauma center., Results: Independent predictors of EOP were the necessity of intubation and mechanical ventilation in the field (adjusted odds ratio [OR]: 11.8; 95% confidence interval [CI]: 4.3-32.7), a history of aspiration (OR: 28.6; 95% CI: 4.0-203.5), the presence of pulmonary contusion (OR: 7.0; 95% CI: 2.0-23.9), and the occurrence of a hemothorax (OR: 3.2; 95% CI: 1.4-7.6)., Conclusion: These results emphasize the influence of prehospital and early factors in the further occurrence of EOP, which allows the development of early and specific clinical management to prevent it.

Background: In senescent heart, beta-adrenergic response is altered in parallel with beta1- and beta2-adrenoceptor down-regulation. A negative inotropic effect of beta3-adrenoceptor could be involved. In this study, the authors tested the hypothesis that beta3-adrenoceptor plays a role in beta-adrenergic dysfunction in senescent heart., Methods: beta-Adrenergic responses were investigated in vivo (echocardiography-dobutamine, electron paramagnetic resonance) and in vitro (isolated left ventricular papillary muscle, electron paramagnetic resonance) in young adult (3-month-old) and senescent (24-month-old) rats. Nitric oxide synthase (NOS) immunolabeling (confocal microscopy), nitric oxide production (electron paramagnetic resonance) and beta-adrenoceptor Western blots were performed in vitro. Data are mean percentages of baseline +/- SD., Results: An impaired positive inotropic effect (isoproterenol) was confirmed in senescent hearts in vivo (117 +/- 23 vs. 162 +/- 16%; P < 0.05) and in vitro (127 +/- 10 vs. 179 +/- 15%; P < 0.05). In the young adult group, the positive inotropic effect was not significantly modified by the nonselective NOS inhibitor N-nitro-L-arginine methylester (L-NAME; 183 +/- 19%), the selective NOS1 inhibitor vinyl-L-N-5(1-imino-3-butenyl)-L-ornithine (L-VNIO; 172 +/- 13%), or the selective NOS2 inhibitor 1400W (183 +/- 19%). In the senescent group, in parallel with beta3-adrenoceptor up-regulation and increased nitric oxide production, the positive inotropic effect was partially restored by L-NAME (151 +/- 8%; P < 0.05) and L-VNIO (149 +/- 7%; P < 0.05) but not by 1400W (132 +/- 11%; not significant). The positive inotropic effect induced by dibutyryl-cyclic adenosine monophosphate was decreased in the senescent group with the specific beta3-adrenoceptor agonist BRL 37344 (167 +/- 10 vs. 142 +/- 10%; P < 0.05). NOS1 and NOS2 were significantly up-regulated in the senescent rat., Conclusions: In senescent cardiomyopathy, beta3-adrenoceptor overexpression plays an important role in the altered beta-adrenergic response via induction of NOS1-nitric oxide.

Background: In diabetic cardiomyopathy, diastolic dysfunction results in part from sarcoplasmic reticulum abnormalities affecting both phospholamban and sarcoplasmic reticulum Ca2+ uptake (SERCA2a). Consequently, the positive lusitropic effect of beta-adrenoceptors stimulation could be altered, and beta3-adrenoceptor over-expression may play a role, as previously demonstrated with an altered positive inotropic effect. In this study, we tested the hypothesis that the beta-adrenergic positive lusitropic effect is altered in diabetic cardiomyopathy, and that beta3-adrenoceptor over-expression is involved., Methods: beta-adrenergic responses were investigated in vivo (dobutamine-echocardiography) and in vitro (papillary muscle preparation) in healthy and diabetic rats killed 4 (4W) and 12 (12W) wk after IV streptozotocin injection. The effect of beta3-adrenoceptor pathway inhibition by S-cyanopindolol (selective beta3-adrenoceptor antagonist) or by NG-nitro-L-arginine-methyl-ester (nonselective nitric oxide synthase inhibitor) on the lusitropic response to isoproterenol (nonselective beta-adrenoceptors agonist) was studied in vitro. Western blots were performed to quantify the protein expressions of beta1- and beta3-adrenoceptors, phospholamban, and SERCA2a. Data are presented as mean percentages of baseline+/-sd., Results: Despite the increased phospholamban/SERCA2a protein ratio and documented diastolic dysfunction, the positive lusitropic effect of beta-adrenoceptors stimulation was preserved in vivo (dobutamine) and in vitro (isoproterenol) in 4W and 12W diabetic, compared with healthy, rats. The beta3-adrenoceptor was up-regulated whereas beta1-adrenoceptor was down-regulated in 4W and 12W diabetic, compared with healthy, rats. Nevertheless, S-cyanopindolol or NG-nitro-L-arginine-methyl-ester had no lusitropic effect., Conclusions: The positive lusitropic effect of beta-adrenoceptor stimulation was preserved in diabetic cardiomyopathy. beta3-adrenoceptor over-expression does not seem to affect this process.

Objective: The improvement in oxygenation with prone positioning is not persistent when patients with acute respiratory distress syndrome (ARDS) are turned supine. High-frequency oscillatory ventilation (HFOV) aims to maintain an open lung volume by the application of a constant mean airway pressure. The aim of this study was to show that HFOV is able to prevent the impairment in oxygenation when ARDS patients are turned back from the prone to the supine position., Design: Prospective, comparative randomized study., Setting: A medical intensive care unit., Patients: Forty-three ARDS patients with a Pao2/Fio2 ratio <150 at positive end-expiratory pressure > or =5 cm H2O., Interventions: After an optimization period, the patients were assigned to one of three groups: a) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by a 12-hr period of conventional lung-protective mechanical ventilation in the supine position (CV(prone)-CV(supine)); b) conventional lung-protective mechanical ventilation in the supine position (12 hrs) followed by HFOV in the supine position (12 hrs) (CV(supine)-HFOV(supine)); or c) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by HFOV in the supine position (CV(prone)-HFOV(supine) group)., Measurements and Main Results: Pao2/Fio2 ratio was higher at the end of the study period in the CV(prone)-HFOV(supine) group than in the CV(prone)-CV(supine) group (p < .02). Venous admixture at the end of the study period was lower in the CV(prone)-HFOV(supine) group than in the two other groups., Conclusions: HFOV maintained the improvement in oxygenation related to prone positioning when ARDS patients were returned to the supine position.

Objective: To evaluate the effects of neuromuscular blocking agents (NMBAs) on pulmonary and systemic inflammation in patients with acute respiratory distress syndrome ventilated with a lung-protective strategy., Design: Multiple-center, prospective, controlled, and randomized trial., Setting: One medical and two medical-surgical intensive care units., Patients: A total of 36 patients with acute respiratory distress syndrome (Pao2/Fio2 ratio of < or =200 at a positive end-expiratory pressure of > or =5 cm H2O) were included within 48 hrs of acute respiratory distress syndrome onset., Interventions: Patients were randomized to receive conventional therapy plus placebo (n = 18) or conventional therapy plus NMBAs (n = 18) for 48 hrs. Both groups were ventilated with a lung-protective strategy (tidal volume between 4 and 8 mL/kg ideal body weight, plateau pressure of < or =30 cm H2O)., Measurements and Main Results: Bronchoalveolar lavages and blood samples were performed, before randomization and at 48 hrs, to determine the concentrations of tumor necrosis factor-alpha, interleukin (IL)-1beta, IL-6, and IL-8. Pao2/Fio2 ratio was evaluated before randomization and at 24, 48, 72, 96, and 120 hrs. A decrease over time in IL-8 concentrations (p = .034) was observed in the pulmonary compartment of the NMBA group. At 48 hrs after randomization, pulmonary concentrations of IL-1beta (p = .005), IL-6 (p = .038), and IL-8 (p = .017) were lower in the NMBA group as compared with the control group. A decrease over time in IL-6 (p = .05) and IL-8 (p = .003) serum concentrations was observed in the NMBA group. At 48 hrs after randomization, serum concentrations of IL-1beta (p = .037) and IL-6 (p = .041) were lower in the NMBA group as compared with the control group. A sustained improvement in Pao2/Fio2 ratio was observed and was reinforced in the NMBA group (p < .001)., Conclusion: Early use of NMBAs decrease the proinflammatory response associated with acute respiratory distress syndrome and mechanical ventilation.

Objective: To determine whether positive end-expiratory pressure (PEEP) and prone position present a synergistic effect on oxygenation and if the effect of PEEP is related to computed tomography scan lung characteristic., Design: Prospective randomized study., Setting: French medical intensive care unit., Patients: Twenty-five patients with acute respiratory distress syndrome., Interventions: After a computed tomography scan was obtained, measurements were performed in all patients at four different PEEP levels (0, 5, 10, and 15 cm H2O) applied in random order in both supine and prone positions., Measurements and Main Results: Analysis of variance showed that PEEP (p <.001) and prone position (p <.001) improved oxygenation, whereas the type of infiltrates did not influence oxygenation. PEEP and prone position presented an additive effect on oxygenation. Patients presenting diffuse infiltrates exhibited an increase of Pao2/Fio2 related to PEEP whatever the position, whereas patients presenting localized infiltrates did not have improved oxygenation status when PEEP was increased in both positions. Prone position (p <.001) and PEEP (p <.001) reduced the true pulmonary shunt. Analysis of variance showed that prone position (p <.001) and PEEP (p <.001) reduced the true pulmonary shunt. The decrease of the shunt related to PEEP was more pronounced in patients presenting diffuse infiltrates. A lower inflection point was identified in 22 patients (88%) in both supine and prone positions. There was no difference in mean lower inflection point value between the supine and the prone positions (8.8 +/- 2.7 cm H2O vs. 8.4 +/- 3.4 cm H2O, respectively)., Conclusions: PEEP and prone positioning present additive effects. The prone position, not PEEP, improves oxygenation in patients with acute respiratory distress syndrome with localized infiltrates.

Objective: To evaluate long-term survival and functional outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage., Design: Retrospective chart review and prospective follow-up study., Setting: Outpatient follow-up., Patients: Between 1997 and 2000, 120 patients were mechanically ventilated for an intracerebral hemorrhage at our intensive care unit. Sixty-two patients were discharged from hospital (in-hospital mortality = 48%). Sixty patients were evaluated for survival and functional outcome (two were lost to follow-up). Time between discharge and follow-up was > or =1 yr and was a mean of 27 +/- 14 months (range, 12-56)., Interventions: None., Measurements and Main Results: Patients' physicians were first asked about survival, and patients or proxies were interviewed by phone. Barthel Index and modified Rankin Scale scores were collected, and demographic information and general data were reviewed. The estimated life-table survival curve after discharge was 64.6% at 1 yr and 57% at 3 yrs. In the 24 patients who died, the mean time between discharge and death was 5 +/- 6 months. Probability of death after discharge significantly increased if age at admission was >65 yrs (p <.01; odds ratio, 3.5; 95% confidence interval, 1.4-9.1) and if Glasgow Coma Scale score at discharge was <15 (p <.01; odds ratio, 3.9; 95% confidence interval, 1.6-9.5). In the 36 long-term survivors, Barthel Index was 67.5 +/- 15 (median +/- median absolute dispersion) and modified Rankin Scale score was 2.6 +/- 0.5. Fifteen patients (42%) had a slight or no disability (Barthel Index > or =90 and modified Rankin Scale score < or =2), whereas 21 patients (58%) had moderate or severe disability (Barthel Index < or =85 and modified Rankin Scale score >2)., Conclusions: Probability of survival at 3 yrs after mechanical ventilation for an intracerebral hemorrhage was >50%. Age was an important determinant of long-term survival. Forty-two percent of long-term survivors were independent for activities of daily living. Only a few long-term survivors had a very high degree of disability.