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Objective: To assess the additive effect of inhaled nitric oxide (NO) and intravenous almitrine bismesylate (ALM) on gas exchange., Design: Prospective self-controlled study., Setting: 3 medico-surgical intensive care units., Patients: 17 patients with severe hypoxemia (PaO2/FIO2 ratio: 88 +/- 30 mmHg, venous admixture: 47 +/- 7%) and elevated mean pulmonary artery pressure (MPAP: 30 +/- 5 mmHg) due to adult respiratory distress syndrome (ARDS)., Interventions: 5 conditions were studied: 1) baseline, 2) 5 to 10 ppm of NO during 30 min, 3) discontinuation of NO during 30 min, 4) ALM infusion (0.5 mg/kg) during 30 min, 5) ALM infusion (0.5 mg/kg) during 30 min in combination with 5 to 10 ppm of NO., Measurement and Results: The PaO2/FIO2 ratio rose from 88 +/- 30 to 98 +/- 37 mmHg (NS) with NO alone, and from 92 +/- 25 to 130 +/- 56 mmHg (p < 0.01) with NO + ALM (p < 0.05 vs NO alone). Seven patients were considered as "NO-responders" (rise in PaO2/FIO2 ratio of 10 mmHg or more with NO); in this subgroup the PaO2/FIO2 ratio rose from 87 +/- 30 to 128 +/- 39 mmHg (p < 0.05) with NO alone, and from 93 +/- 20 to 169 +/- 51 mmHg (p < 0.01) with NO + ALM (p < 0.05 versus NO alone). MPAP decreased from 30 +/- 5 to 26 +/- 5 mmHg (p < 0.01) with NO alone, increased slightly from 28 +/- 5 to 31 +/- 5 mmHg (NS) with ALM alone and decreased to 27 +/- 5 mmHg (p < 0.05) with NO + ALM., Conclusions: NO + ALM had additive effects on gas exchange while decreasing MPAP in patients with ARDS. The effects of NO alone were small and non significant, except in a subgroup of 7 patients in whom the combination of both therapies had the more pronounced results.

Eleven patients, with a cervical spine injury and scheduled for elective cervical spine fusion at least 48 h after their initial trauma, were intubated using a new fiberoptic laryngoscope (Bullard). This technique uses either a semi-rigid guide independent of the laryngoscope blade, or a rigid one attached to the blade. The cervical spine was immobilized with either a collar or a halo. General anaesthesia was carried out with thiopentone, fentanyl and vecuronium bromide. Orotracheal intubation was successful at the first attempts in 10 out of the 11 patients. No mobilization of the cervical spine occurred. In the first six patients, the semi-rigid guide was used, and the rigid one in the remaining five. The anaesthetist who carried out the intubations was always the same. Using the rigid guide was easier than the semi-rigid one. This is confirmed by the time required, 44 +/- 22 sec for the rigid guide, and 97 +/- 92 sec for the semi-rigid one. In the patient in whom this technique failed at the first attempt, endotracheal intubation was carried out by the nasal route and controlled by the fiberoptic laryngoscope. This technique enables a rapid and easy orotracheal intubation in trauma patients with an immobilized cervical spine, but careful training is necessary.