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In the present study one of the major problems was classification of patients into groups with or without adult respiratory distress syndrome (ARDS). The pathomorphologic substrate of ARDS is an interstitial edema showing high protein concentrations, which can be measured as extravascular lung water (EVLW). Therefore the primary parameter for determining ARDS and EVLW. Clinical definitions of ARDS as found in the literature are mostly unspecific, simply requiring “respiratory failure” with ventilation. Some definitions require certain values of respiratory parameters in conjunction with low left atrial filling pressures to exclude left pulmonary insufficiency due to left ventricular failure [1]. But these definitions have shown to be too unspecific for the purpose of the present study, which describes the development of an ARDS index to assess ARDS by clinical parameters and validation of ARDS grouping by EVLW.

In order to study the pathomechanisms of the Adult Respiratory Distress Syndrome in an acute animal model, we monitored the alveolar cell pattern and the stimulatory chemiluminescence responses of blood neutrophils and alveolar macrophages in sheep after Escherichia coli endotoxin injection (2 micrograms/kg of body weight). Using appropriate bronchoalveolar lavage techniques, thereby avoiding local inflammation, it was demonstrated that endotoxin injection did not cause any recruitment of neutrophils into the alveoli for a period of up to 24 hours. Following endotoxin injection, blood neutrophils showed a maximal stimulatory response after 5 minutes, and alveolar macrophages after 4 hours. It is concluded that if neutrophils are responsible for initiating the increase in microvascular permeability, then this action must be purely intravascular.

Respiratory failure associated with severe illness and trauma remains a major problem, with an ultimate mortality rate of 5% or greater [16, 18]. Despite intense research efforts the etiology of the adult respiratory distress syndrome (ARDS) and its optimal treatment are not yet fully understood [2, 5, 6, 19].

Extracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.

Fortschritte in der Versorgung von Polytraumatisierten haben zu einer Senkung der Letalitat auf ca. 20% gefuhrt. Haupttodesursache bleibt das Multiorganversagen (MOV), welches in einer Fruhphase nach Unfall durch Schock und Gewebsschaden initiiert und in einer Spatphase durch die posttraumatische Sepsis manifestiert wird. Humorale und cellulare Veranderungen beschleunigen den Capillarschaden und damit das spatere Organversagen. Alle therapeutischen Bemuhungen sollten daher der Minimierung dieser genannten Einflusse dienen. Neben Infusionsund Beatmungstherapie mussen Blutungen und Weichteilschaden fruhzeitig beherrscht und eine fruhe osteosynthetische Versorgung angestrebt werden.

The reticuloendothelial system (RES) and the polymorphonuclear leukocytes (PMNs) are thought to play a major role in defense against sepsis. Disturbances in the function of these two phagocytic systems during a septic event is associated with the development of lung capillary injury. Endotoxemia is said to lead to similar changes. Our study examined the function of the RES and PMNs after bolus injection of endotoxin (2 micrograms/kg BW) in a standardized sheep model. For up to 24 hr after endotoxin, blood samples were drawn and PMN function was followed by chemiluminescence, chemotaxis, and adherence as well as the phagocytosis and killing of bacteria. RES function was determined by the blood clearance of a labeled Tc99 colloid. We found an increase of RES clearance directly after endotoxin. Chemotaxis, phagocytosis, and killing were reduced. Adherence was increased. Chemiluminescence peak maximum (CLPM), representing the metabolic activity of the PMNs, was initially increased but shortly thereafter showed a significant decline (at 1 hr: 0.52 +/- 0.13 X 10(6) cpm with P less than 0.05 compared to baseline). The chemiluminescence peak time (CLPT), a measure of membrane receptor function, was significantly reduced (10.0 +/- 2.2 min with P less than 0.001 compared to baseline). Endotoxin led to a reduction of intracellular PMN functions (phagocytosis, killing, CLPM) within 1 hr. Membrane localized functions (adherence, CLPT) were increased. The changes in PMN function might be the reason for the development of lung capillary injury, in spite of undisturbed RES clearance.

Progress in the therapeutic management of multiple trauma patients has led to a decline in mortality (now 20%). The main cause for death is still the multiple organ failure (MOF), which is initiated in an early phase after trauma by shock and tissue damage, and manifests in a late phase during posttraumatic sepsis. Humoral and cellular changes accelerate the capillary damage, which provokes the failure of the organ systems. For this reason all therapeutic efforts should aim to minimize these influences. Next to infusion and ventilation therapy, early definite reduction of bleeding and tissue damage (debridement) and early osteosynthesis in multiple trauma patients seems reasonable.

Techniken zur bronchoalveolaren Lavage werden zur Charakterisierung von Komponenten des Entzundungs- und Immunsystems im unteren Respirationstrakt bei destruktiven, infektiosen, neoplastischen und interstitiellen Erkrankungen angewandt. Die Untersuchung der BAL-Flussigkeit dient dazu, Zusammensetzung,Konzentrationen und Funktionen loslicher und cellularer BAL-Bestandteile fur diagnostische, prognostische und therapeutische Zwecke zu ermitteln sowie pathogenetische Zusammenhange zu erkennen (1).