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Background: Lung ultrasound experts claim that ‘B line’ artefacts herald pulmonary oedema, but links between early recognition and improved outcome are unconfirmed, particularly for non-expert clinicians. Objective: Assess individual and system impacts of early, non-expert lung ultrasound (LUS) in breathless older patients. Methods: Prospective single-blinded randomised controlled trial of point of care LUS by non-expert clinicians, augmenting ED assessment of patients over 60 years, presenting with dyspnoea. After brief training, clinicians at three hospitals used computer-generated block randomisation envelopes to allocate a convenience sample of consenting presenters to conventional or LUS-augmented management. ED provisional diagnosis was compared to a post-discharge chart audit diagnosis, blinded to ultrasound findings. Secondary outcomes were the length of stay in ED and hospital, costs and discharge destinations. Results: From three sites, 224 controls were compared with 218 interventions. LUS improved diagnostic accuracy, with a small effect size in favour of LUS (risk difference: 6.5%, 95% CI 0.9–12) and a number needed to scan of 16 (95% CI 8–107). With LUS, ED and hospital stay increased non-significantly, while discharge destination trends improved. No harm ensued. Conclusions: Non-expert LUS augmenting dyspnoea workup may improve diagnostic accuracy, but did not significantly alter costs or outcomes in the ED or the hospital. Trial registration: Australia and New Zealand Clinical Trials Registry (ACTRN12613001023741).

Aim High‐altitude pulmonary oedema (HAPE) is a non‐cardiogenic pulmonary oedema that can occur during rapid ascent to a high‐altitude environment. Classically, HAPE has been described as a condition resulting from a combination of pulmonary vasoconstriction and hypertension. Inflammation has been described as important in HAPE, although as a side effect of pulmonary oedema rather than as a causative factor. In this study, we aim to understand the role of hypoxic response in myeloid cells and its involvement in pathogenesis of HAPE. Methods We have generated a conditional deletion in mice of the von Hippel‐Lindau factor (VHL) in myeloid cells to determine the effect of a deregulated hypoxic response in pulmonary oedema. Results The deletion of VHL in pulmonary myeloid cells gave rise to pulmonary oedema, increased pulmonary vascular permeability and reduced performance during exertion. These changes were accompanied by reduced stroke volume in the left ventricle. Conclusion In this model, we show that a deregulated myeloid cell hypoxic response can trigger some of the most important symptoms of HAPE, and thus mice with a deletion of VHL in the myeloid lineage can function as a model of HAPE.

Key content: Hysteroscopy is a common surgical procedure in gynaecology. Fluid distension media is needed to undertake the procedure. The common fluid distension media available are discussed, along with their properties and role in undertaking operative hysteroscopic procedures. Some inherent complications can occur when there is excessive fluid absorption during hysteroscopic procedures. The monitoring of the fluid distension medium used and how to avoid complications is discussed. / Learning objectives: To gain a better understanding of the fluid media are available for hysteroscopic surgery. To understand the risks associated with the use of different distension fluid media. To understand the difference between the various fluid distension media and their effect when excessive absorption occurs. To recognise, manage and prevent complications associated with excessive fluid absorption. To understand the different monitoring systems available during surgery.

Background The northern hairy-nosed wombat (Lasiorhinus krefftii) is critically endangered, with only 200 individuals remaining in the wild. Individuals are rarely available for detailed pathological assessment and identification of disease threats to individuals is critically important to species conservation. Case report Two male northern hairy-nosed wombats, part of the Richard Underwood Nature Refuge population, were presented for necropsy, 5 months apart. They were found to have succumbed to adiaspiromycosis caused by the fungus Emmonsia parva. Pathological presentations were of severe pulmonary oedema and fibrosis, and pleuritis, respectively. Characteristic fungal adiaspores were noted on histopathological examination. The wombats had concurrent variably severe ectoparasite and endoparasite burdens. Conclusion These are the first reported cases of adiaspiromycosis in northern hairy-nosed wombats and the organism was associated with significant pathological changes. The rarity and the logistical challenges of presenting northern hairy-nosed wombats for pathological assessment are a challenge to identifying disease threats in this critically endangered species.

A 4-month-old English bulldog was anaesthetised for investigation and management of chronic urinary incontinence. In the postanaesthetic period, the patient developed respiratory distress, with marked cough and increased inspiratory effort. Diagnostic imaging suggested pulmonary oedema. After excluding all other causes of cardiogenic and non-cardiogenic pulmonary oedema, it was hypothesised that the patient developed postanaesthetic negative pressure pulmonary oedema, suspected to have been exacerbated by tracheal intubation with an oversized endotracheal tube leading to laryngeal swelling and obstruction. The animal was treated with oxygen supplementation, corticosteroids and β-2 adrenergic receptor agonists. The patient recovered from the event and was discharged from the hospital after 48 hours. This article discusses in further details other management options of negative pressure pulmonary oedema. This is the first case report discussing the pathophysiology, critical care and management of postanaesthetic negative pressure pulmonary oedema in a dog.

A two-year-ten-month colt was referred for investigation and surgical treatment of cryptorchidism. Preanaesthetic clinical examination revealed no abnormalities and no relevant history was reported. The patient was anaesthetised with a total intravenous anaesthesia technique, both testicles were identified after induction, and a bilateral open castration was performed in the recovery box. Surgery, anaesthesia and recovery were uneventful. However, in the first hour postrecovery, clinical signs compatible with pulmonary oedema developed. Following arterial blood sampling and airway endoscopy, a low-grade pulmonary oedema was suspected and alleged to have occurred following transient laryngeal spasm. The patient was treated symptomatically and received supportive care. Two days after the surgery, the clinical signs were resolved, and the patient was discharged.

Introduction: In the setting of patients presenting with shortness of breath to an Emergency Department a simple lung ultrasound protocol aimed at detecting pulmonary oedema has been shown to have diagnostic accuracy of 85%. This article reviews data from the original study, in an attempt to determine whether adjusting the protocol and/or interpretive criteria would improve results. Method: A large lung ultrasound project provided the dataset. Inter‐rater and intertest discrepancies were reviewed. Then original stored images and comments were retrospectively analysed using alternate interpretive criteria. Specific variations included changing the number of B‐lines required to define ‘wet lung’ and assessing other pleural line abnormalities. Where they had been acquired cardiac loops were reviewed in addition to the lung images. Results: The 204 original studies available were reviewed. Some disagreement could be attributed to inexperience and unclear definitions. Adjusting the number of B‐lines did not improve diagnostic accuracy. All positive scans, with numerous B‐lines were reviewed using more advanced diagnostic criteria (pleural line abnormalities) and the number of false positives was decreased. In cases where cardiac views were available, their inclusion was beneficial. Conclusion: A simple lung ultrasound protocol to assess for ‘wet lung’ in patients presenting to Emergency Departments provides diagnostic accuracy of around 85% in the hands of relative novices. More advanced interpretation of the same_ultrasound images, and the addition of cardiac views, is likely to further improve diagnostic accuracy.

Summary To evaluate the effect of positive end-expiratory pressure (PEEP) on sound propagation through injured lungs, we injected a multifrequency broad-band sound signal into the airway of eight anesthetized, intubated and mechanically ventilated pigs, while recording transmitted sound at three locations bilaterally on the chest wall. Oleic acid injections effected a severe pulmonary oedema predominately in the dependent lung regions, with an average increase in venous admixture from 19 ± 15 to 59 ± 14% (P

Summary We describe the management of a 62-year-old man who developed severe pain, cramps, paraplegia and pulmonary oedema after the accidental administration of potassium chloride into the subarachnoid space. In addition to supportive treatment, we performed cerebrospinal fluid lavage with saline 0.9%. The patient recovered well without any permanent injury.

We report five patients who presented to an on-site medical team with concurrent haemoptysis and shortness of breath at a recent triathlon event. After initial management in the field, three of the five patients were transported to hospital via ambulance for further management, resulting in patients with haemoptysis and dyspnoea being 17 times more likely to require hospital transport. It is important to consider the differential diagnoses for this presentation, particularly exercise-induced pulmonary oedema.

The use of pleural and lung ultrasound is being performed increasingly by respiratory and critical care clinicians around the world. This article describes how to create cheap and reliable lung and pleural phantoms for teaching. The phantoms described replicate the appearance of normal ventilating lung, pneumothorax (including the contact or lung point), pulmonary oedema, pleural effusion and empyema. The pleural effusion phantom can be used to teach procedural ultrasound (pleurocentesis).

Recurrent pulmonary oedema with no obvious precipitant can prove difficult to treat in patients with preserved left ventricular (LV) systolic function. This report describes the novel use of cardiac resynchronization therapy (CRT) in the prevention of acute pulmonary oedema precipitated by intermittent electrical dyssynchrony in a patient with preserved LV systolic function.

Background and objective: Cough and a reduction in vital capacity have recently been reported following breath-hold dives to depths of 25–75 m. We sought to investigate whether repetitive dives to depths of less than 30 m would elicit similar effects. Methods: Participants in a single-day spearfishing competition were recruited. Subjects performed spirometry before and after the 5-h event. Demographics, medical and diving history, respiratory symptoms and competition diving statistics were collected. Results: Twenty-five subjects (two females), age 33 years (11) (mean (SD)), were studied. During the competition each subject completed 76 (33) dives, to 10 (3) m depth, with each dive lasting 0.9 (0.3) min. Maximum depth was 17 (4) m. No respiratory symptoms were reported. There was no difference in spirometry before and after competition except for FEF25–75%, which increased by 0.16(0.34) L (P

We describe a case of severe falciparum malaria with hyperparasitaemia. Treatment with automated erythrocytapheresis, in conjunction with parenteral artesunate, produced a rapid and sustained fall in parasite burden. Several poor prognostic features were present at admission. Despite the development of a severe headache with abnormal cerebrospinal fluid parameters and transient pulmonary oedema, a complete recovery was observed. Erythrocytapheresis can be considered in selected cases where facilities exist and has theoretical and practical advantages over traditional methods of red cell exchange transfusion. The paucity of systematic or trial evidence convincingly demonstrating a benefit in terms of morbidity or mortality has limited its application. However, the lack of robust trial data should not in itself invalidate considering this therapeutic option in the appropriate context.

Transport of women in preterm labour in Western Australia is conducted in small fixed wing aircraft over distances up to 2,000 km (1,200 miles). In recent years β-sympathomimetic inhibition of uterine activity has been employed to reduce the risk of delivery during transfer. This study reports the outcome of routine use of this therapy in which at times classical contraindications have not been observed. During 1983 and 1984, 99 consecutive maternal aerial transfers for preterm labour using β-sympathomimetic drugs by infusion resulted in only 1 case of pulmonary oedema and 2 of maternal hyperglycaemia. There were no deliveries during the flights. The results of this study suggest β-sympathomimetic inhibition of uterine activity for women in preterm labour is safe and efficacious therapy for long distance aeromedical evacuation in small aircraft.

Summary Pathological studies were made on Red Dane X Sahiwal cattle and buffaloes after inducing acute ruminal acidosis by feeding a single dose of cane sugar molasses, crushed oats or crushed barley grains through a rumen fistula. Gross changes observed in animals that died 96 hours later included exfoliative changes in the rumen mucosa, peritonitis, hepatic necrosis, duodenal and abomasal haemorrhages, pulmonary oedema, necrotic changes in the kidney, degeneration in the myocardium and congestion of the brain and meninges. Animals that died within 24 hours of the experiment showed no significant lesions. Histopathological lesions observed included severe diffuse coagulative necrosis and hyperplasia of the bile duct epithelium in the liver, degenerative changes in the renal tubules, thickening of the interstitial septa in the lungs and haemorrhages in the Virchow-Robin space of the brain. Included in the study was a natural case of rumen acidosis in a Sahiwal cow. The gross and histopathological lesions were largely similar to those observed in the experimental animals. Zusammenfassung Pathologische Veranderungen bei der Pansenazidose bei Rindern und Buffeln Die Versuche wurden an Kreuzungsrindern (Red Dane X Sahiwalrind) und Buffeln ausgefuhrt. Die akute Pansenazidose wurde durch einmalige Verabreichung von Zuckermelasse, gequetschtem Hafer oder gequetschter Gerste mittels Pansenfistel ausgelost. Bei Tieren, die 96 Stunden spater starben, wurden makroskopisch folgende Veranderungen gefunden: Erosionen an der Pansenschleimhaut, Peritonitis, Lebernekrosen, Hamorrhagien im Labmagen und Duodenum, Lungenodem, Nierennekrosen, Myokarddegeneration, Blutstauungen im Gehirn und in den Meningen. Tiere, welche innerhalb 24 Stunden nach dem Beginn des Experiments starben, zeigten keine signifikanten Veranderungen. Histopathologische Veranderungen: Schwere Koagulationsnekrose und Hyperplasie am Gallengangsepithel sowie in der Leber, Degeneration der Nierentubuli, Verdickung der interstitiellen Septen in der Lunge, Hamorrhagien im Virchow-Robin Raum des Gehirnes. Bei einer spontanen Pansenazidose glichen die makroskopischen und mikroskopischen Veranderungen denen bei den experimentell ausgelosten Fallen. Resume Lesions pathologiques lors d'acidose de la panse chez des bovins et des buffles Les essais ont ete faits sur des animaux croises (Red Dane X Sahiwal) et des buffles. L'acidose aigue de la panse fut provoquee par l'administration unique de melasse de sucre, de l'avoine et de l'orge concassee au moyen d'une fistule de la panse. Les lesions macroscopiques suivantes furent constatees sur les animaux qui ont peri apres 96 heures: erosions sur la muqueuse de la panse, peritonite, necrose hepatique, hemorragies dans la caillette et le duodenum, oedeme pulmonaire, necroses renales, degenerescence du myocarde, congestions dans le cerveau et les meninges. Les animaux peris apres 24 heures n'ont pas montre de lesions significatives. Lesions histopathologiques: grave necrose de coagulation et hyperplasie de l'epithelium des canaux biliaires et dans le foie, degenerescence des tubules renaux, epaississement des travees interstitielles dans le poumon, des hemorragies dans l'espace de Virchow-Robin du cerveau. Les lesions macroscopiques et microscopiques sont comparables dans les cas d'acidose de la panse spontanee ou provoquee. Resumen Modificaciones patologicas en la acidosis ruminal en vacunos y bufalos Los ensayos se llevaron a cabo en animales cruzados (Danese roja X Sahiwal) y bufalos. La acidosis ruminal aguda fue desencadenada mediante la administracion simple de melazas de azuca de cana, avena triturada o cebada triturada a traves de la fistula ruminal. En los animales que murieron 96 horas mas tarde se hallaron macroscopicamente las modificaciones siguientes: erosiones en la mucosa ruminal, peritonitis, necrisis hepaticas, hemorragias en el cuajar y duodeno, edema pulmonar, necrosis renales, degeneracion miocardiaca, congestion en el cerebro y en las meninges. Los animales que murieron en el espacio de 24 horas desde el comienzo del experimento no presentaban lesiones significantes. Modificaciones histopatologicas: necrosis coagulativa difusa grave e hiperplasia en el epitelio del conducto biliar y en el higado, degeneracion de los tubulos renales, espesamiento de los septos intersticiales en el pulmon y hemorragias en el espacio de Virchow-Robin del cerebro. En un caso espontanea de acidosis ruminal eran las lesiones macro y microscopicas similares a las de los casos observados en los animales de experiencia.

Summary Introduction: The mechanism of immersion pulmonary oedema occurring in healthy divers is a matter of debate. Among consecutive injured divers admitted to our hyperbaric centre, we analysed prospective data about pulmonary oedema. Method: A total of 22 divers suffering from immersion pulmonary oedema without cardiac disease were included. The occurrence of events was compared to the diving conditions as assessed by diving-computer. Each patient underwent a clinical examination, laboratory tests, thoracic CT scan and echocardiography. Results: The median age was 49 years, with a higher proportion of women, in comparison with the data of the French diving federation. The common feature was the occurrence of respiratory symptoms during the ascent after median dive duration of 29 min with strenuous exercise and/or psychological stress. Most of the dives were deep (37 msw–121 fsw) in cool water (15°C-59°F). The average inspired oxygen partial pressure was 0·99 bar. Progression was rapidly favourable, and the medical check-up after clinical recovery was normal. Conclusion: Immersion, body cooling, hyperoxia, increased hydrostatic pressure and strenuous exercise likely combine to induce pulmonary oedema in patients without cardiac disease. This study underlines new physiopathological tracks related to the frequent occurrence of symptoms noticed in the last part of the ascent and a higher incidence in women.

Epitheliale Natrium Kanale (ENaCs) sind Natrium leitende Ionenkanale, die in der apikalen Membran vieler Epithelien vorkommen. Sie sind der zentrale Faktor zum transepithelialen Transport von Natrium – und damit einhergehend von Wasser. ENaCs tragen zu einer Vielzahl physiologischer Prozesse bei: Regulation des Salz- und Wasserhaushalts, des Blutdrucks oder des Wassergehaltes der Lunge. Auch Erkrankungen wie Bluthochdruck oder Lungenodeme lassen sich auf gestorte Regulationen des ENaC zuruckfuhren. Dieser Artikel beschreibt die Funktion und Physiologie Epithelialer Natrium Kanale, sowie zellulare Mechanismen, die die Aktivitat dieser Ionenkanale bestimmen. Epithelial sodium channels (ENaCs) are sodium-conducting ion channels that are located in the apical membrane of various epithelia. They represent the rate-limiting step for transeptihelial sodium- and thereby water-transport. ENaCs contribute to a variety of physiological processes including the regulation of salt and water homeostasis, blood pressure or the water content of the lung. Further, malfunctions in ENaC regulation contribute to the pathogenesis of diseases like hypertension or pulmonary oedema. This article describes the function and physiology of epithelial sodium channels as well as cellular mechanisms that determine the activity of these ion channels.

A 49 year old man with hypertrophic cardiomyopathy and atrial fibrillation presented with bilateral lower limb ischaemia due to embolism of a left ventricular mural thrombus causing occlusion of the distal aorta and common iliac arteries. The patient developed severe pulmonary oedema. This was thought to be caused by the elevated cardiac after-load imposed by the aortic obstruction. He was successfully treated with continuous positive airway pressure prior to definitive treatment of the obstruction by bilateral aorto-iliac embolectomies.

Venous air embolism was suspected in 3 hospitalised horses on the basis of an inadvertently open jugular venous line. Subsequently the 3 horses developed clinical signs including cardiovascular collapse, cardiac dysrhythmia, pulmonary oedema, behavioural abnormalities and neurological signs consistent with central nervous system injury. Treatment included intranasal oxygen therapy, i.v. fluid administration and anti-inflammatory therapy. Specific therapy aimed at treating air embolism in man is reviewed, with pertinent therapy potentially applicable to horses emphasised.

Objectives: To evaluate clinical results of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) in patients with multivessel disease (MVD), in relation to single or multivessel (MV)-PCI and to patients with single vessel disease (SVD). Methods: Patients treated with PCI in the setting of

TRALI is a life-threatening complication from the transfusion of a blood product. It is characterised by a clinical constellation of signs and symptoms including dyspnoea, cyanosis, hypotension, tachycardia, fever, chills and bilateral non-cardiogenic pulmonary oedema. We will discuss its diagnosis, differential diagnosis, treatment and causative factors. TRALI has been described as a leading cause of transfusion related death. However the incidence of non lethal forms of TRALI is unknown and we will discuss the reasons for this, as well as future directions for the prevention and treatment of this complication.

It is widely known that haemodialysis patients do not readily comply with nutrition guidance. At least 6 months after initiating haemodialysis, the patients' dietary knowledge was tested by use of a questionnaire. The relationship between patient dietary compliance and religion and educational level was studied. Seventy patients were included in the study (33 Christians and 37 Muslims), ages ranging from 24 to 87 years. All patients had received haemodialysis for a period of the time ranging from 6 to 216 months. The questionnaire included questions related to salt, potassium and phosphate. Regarding questions, concerning salt, the Christians answered 85.7 +/- 22.8% correctly whilst the Muslims answered 60.1 +/- 34.6% correctly, a difference which was statistically significant (p=0.0001). However, more Christians arrived at the hospital with pulmonary oedema over a two-year period for emergency haemodialysis than Muslims (p=0.017), whilst there was no difference in the number of patients with residual diuresis between the two groups (p=NS). The difference in the incidence of pulmonary oedema could be attributed to the fact that more Christians had heart failure than Muslims (12/33 vs 6/37, p=0.09). Regarding questions concerning potassium, the Christians answered 74.6 +/- 33.9% correctly whilst the Muslims answered 41.1 +/- 38.5% correctly, a difference that was statistically significant (p=0.0001). However despite this difference, no Muslims attended hospital for emergency haemodialysis related to hyperkalaemia over the two-year period. Finally, regarding questions concerning phosphates, the answers from both group of patients were disappointing. Specifically, Christians answered 49.1 +/- 43% correctly, whilst Muslims answered 19.1 +/- 3.3% of the questions correctly, a difference which was statistically significant (p=0.0001). Patients did not acquire the necessary dietary knowledge but despite insufficient knowledge, they had a low incidence of fluid overload, hyperkalaemia and hyperphosphataemia. The Christians, despite superior knowledge, compared to the Muslims had more episodes of fluid overload.

We have retrospectively audited the use of non-invasive ventilation (NIV) in surgical patients. We analysed the case notes of 38 surgical patients who received NIV over a 9-month period. Twenty-three patients received NIV following emergency surgery, eight after elective surgery, and seven did not have an operation. Co-morbidity was common. The commonest reasons for starting NIV were chest infection, acute respiratory distress syndrome and pulmonary oedema. NIV was often only one aspect of treatment in surgical patients with complex medical problems. With intensive support from the critical care outreach team, NIV can be safely delivered on a surgical ward, and may sometimes prevent intensive care unit admission. Use of NIV on the intensive care unit may obviate the need for tracheal intubation in some patients. In very ill surgical patients with a poor prognosis, NIV was frequently used as the ceiling of respiratory support.

Objective To evaluate the effect on serum electrolyte concentrations of sorbitol–mannitol absorption during hysteroscopic surgery. Design The volume of sorbitol–mannitol retained during hysteroscopic surgery and the difference between the preoperative and the postoperative serum sodium concentrations were measured and analysed for correlation. Setting A university-based hospital. Subjects These were 40 consecutive patients undergoing hysteroscopic resection of submucous fibroid or uterine septum, using a 9-mm continuous flow resectoscope with loop or needle electrode for high-frequency cutting and coagulation and a 4% sorbitol–mannitol solution for uterine irrigation. Results The mean volume of infused sorbitol–mannitol solution was 5435 ± 720 ml (mean ± SEM), with a mean fluid deficit of 718 ± 120 ml. The fall in serum sodium concentration correlated positively with the sorbitol–mannitol deficit (r=0.79, P

We present case reports of five patients with severe forms of mucopolysaccharidoses who developed postobstructive pulmonary oedema during anaesthesia. The difficulties of anaesthesia in these patients and the particular predisposition that these patients exhibit for the development of postobstructive pulmonary oedema is discussed.

A heart murmur was detected in a five-month-old Persian chinchilla cat. The animal was referred to Nihon University Animal Medical Center where radiographic examination revealed an enlarged heart with dilation of pulmonary arteries and veins and pulmonary oedema. Echocardiography revealed partition of the left atrium, with turbulent blood flow within the left atrium. The patient was placed under continuous care at the facility, but died at seven months of age. Postmortem examination revealed that the left atrium was partitioned by a fibromuscular septum, with a 1 mm diameter perforation, consistent with a diagnosis of cor triatriatum sinister.

The Irukandji jelly fish (Carukin ban1esi) is responsible for a significant number of envenomations in northern Australia during the summer. Emergency physicians in these coastal areas frequently manage patients who have been envenomed by this potentially serious marine creature. The jelly fish is small (its bell is u p to 2.Scrn across) but the tentacles may be up to half a metre m length. It is rarely seen before envenomating. The sting usually initially causes localised pain followed by systemic symptoms known as the 'Irukandji syndrome', which include potentially life threatening pulmonary oedema. This article discusses Irukandji envenomation and its treatment, and reviews our experience in treating 30 patients who presented to the Emergency Department of Cairns Base Hospital in December of 1996 having been stung by the Irukandji. Of these cases, 27 (90%) patients developed systemic symptoms (the Irukandji syndrome) and 19 (63cYo) required admission. Twelve (-l0%) patients required more than 1OOmg of titrated, intravenous pethidine to relieve the pain . There were no cases of pulmonary oedema . All patients were discharged home within 2-l hours.

Objective: To describe an effective and inexpensive CPAP-mask apparatus for use in the emergency department. Conclusion: CPAP is an effective tool in the treatment of acute pulmonary oedema in the emergency department. The mask apparatus described is an inexpensive alternative to the commercially produced machines.

Thirteen patients with acute myocardial infarction have been treated during 1968 in a respirator in the intensive care unit at Serafimerlasarettet. Eight of these patients had been transferred from the coronary care unit. The indications for respirator care in the coronary care unit have been frank pulmonary oedema not responding to conventional treatment or marked persistent arterial hypoxia. The usefulness of respirator treatment on these indications is discussed having regard to the fact that none of the patients survived.

1. Unlike in normal rabbits, pulmonary rapidly adapting receptors (RARs) in rabbits with chronic mitral regurgitation (MR) do not respond to small changes in extravascular fluid (EVF) volume in major airways. The present study examined the effect of shrinking the EVF volume in rabbits with chronic MR by infusing hypertonic albumin, to see whether this response of RARs is restored. The effect of raising the left atrial pressure (LAP) acutely above 25 mmHg (to cause pulmonary oedema) on RARs was also investigated. 2. Mean RAR activities in rabbits with MR (n = 6) at initial control, LAP +5 mmHg, LAP +10 mmHg and final control periods were 20.9 +/- 9. 5, 18.8 +/- 11.3, 27.0 +/- 11.2 and 17.2 +/- 9.8 action potentials min-1, respectively (P > 0.05, ANOVA). After infusion of 35 % bovine serum albumin i.v. these values were 9.4 +/- 3.2, 30.6 +/- 14.6, 48. 9 +/- 10.1 and 18.4 +/- 7.3 action potentials min-1, respectively (P < 0.01, ANOVA). In rabbits with chronic MR (n = 7) raising the LAP above 25 mmHg stimulated RARs. 3. EVF content of the airways and lungs was measured in rabbits with MR and in control rabbits, at baseline and after elevation of the LAP by 10 or 25 mmHg for 20 min. In control rabbits the EVF contents in the lower trachea, carina and bronchi at baseline and at LAP +10 mmHg were 52.1 +/- 1.2 and 57.8 +/- 1.7 %, respectively (P < 0.05, Student's t test). In rabbits with MR these values were 58.3 +/- 1.5 and 56.9 +/- 1.9 %, respectively. When the LAP was elevated by 25 mmHg the EVF content increased to 62.4 +/- 1.1 % (P < 0.05, t test compared with baseline and LAP +10 mmHg). 4. We concluded that in rabbits with chronic MR, RARs are unable to respond to acute, small elevations of LAP because there is no concomitant increase in EVF content in the vicinity of these receptors. Furthermore, these receptors can be activated in these animals by elevating the LAP above 25 mmHg or can be made sensitive to acute small elevations of LAP by shrinking the chronically expanded EVF compartment.

A case of unilateral pulmonary oedema following "Mandrax" overdose is presented. The pulmonary oedema is believed to result from hypoxia and increased pulmonary vascular permeability. A multi-factorial pathophysiology including patient posture, may have been responsible for the unusual unilateral distribution of the oedema. This report should serve to increase awareness of this interesting clinical entity.

Diving-related ‘immersion’ pulmonary oedema is very uncommon and probably underreported.1,2 Immersion in thermoneutral water augments cardiac preload and increases pulmonary arterial pressure as blood is redistributed from the periphery to the thoracic cavity. Intrathoracic blood volume may increase by half a litre, resulting in a 30% rise in cardiac output and increases in right atrial pressures of up to 16 mmHg.

The measurement of transthoracic impedance is now possible using new implantable cardioverter-defibrillators. This can be used to monitor fall in impedance associated with increasing pulmonary oedema. We describe a case of a large rapid increase of impedance and dyspnoea related to a pneumothorax.

A 25-year-old woman received oral salazosulfapyridine, 4 g/day, for treatment of ulcerative colitis. At 10 days later, she presented with fever and respiratory symptoms. Based on physical, laboratory and radiological findings, bacterial pneumonia and non-cardiogenic pulmonary oedema was suspected. Salazosulfapyridine was immediately halted and antibiotic therapy started. Two days later, her symptoms and abnormal findings had improved rapidly. Bacteriological studies were negative. Salazosulfapyridine-induced non-cardiogenic pulmonary oedema was diagnosed. Non-cardiogenic pulmonary oedema should be considered as one of several salazosulfapyridine- induced pulmonary diseases in patients who are receiving salazosulfapyridine and who develop respiratory symptoms and an abnormal CXR.