经鼻盲探气管插管在抢救呼吸衰竭病人中的应用

目的比较经鼻盲探气管插管和气管切开在抢救呼吸衰竭病人的治疗效果。方法回顾性对比分析同期ICU住院病人采用经鼻盲探气管插管或气管切开建立人工气道后的病情转归,使用呼吸机后血气纠正时间,使用呼吸机时间,留置气管导管时间,平均住院时间及操作并发症。结果经鼻盲探气管插管组拔管率42.9%(9/21例),拔管成功率100%(9/9例);气管切开组拔管率60.7%(17/28例),拔管成功率76.5%(13/17例),两组间比较无显著性差异(P<0.05)。使用呼吸机后血气纠正时间无明显差别,但经鼻盲探气管插管组使用呼吸机时间,留置气管导管时间,平均住院时间均短于气管切开组(P<0.05)。气管切开组操作导致的并发症发生率46.4%(13/28例),而经鼻盲探气管插管组操作导致的并发症发生率23.8%(5/21例),明显少于前者(P<0.01)。结论经鼻盲探气管插管操作简便、实用,能减少并发症,缩短使用呼吸机时间,留置气管导管时间及住院时间,在抢救呼吸衰竭病人中较气管切开术有更好的临床应用价值。     

Postoperative management after thymectomy.

This paper reports a retrospective study of the preoperative and postoperative management of 28 patients who underwent thymectomy between 1956 and 1973. Patients who received postoperative artificial ventilation were compared with the group who did not with respect to sex, age, severity of disease, preoperative vital capacity, and thymic histology. Evidence is presented that postoperative artificial ventilation is required when the preoperative vital capacity with the patient on optimum anticholinesterase treatment is less than 2 litres. Additional features associated with a probable need for artificial ventilation were the presence of a thymoma, bulbar symptoms, especially dysphagia, and age over 50 years. These should be taken into account in any patient whose vital capacity is close to the critical level of 2 litres. When postoperative ventilation was required it was usually necessary for 12 days or more, and tracheostomy should therefore be done at or before thymectomy. Most patients in this series received the same dose of anticholinesterases after operation as before it and no evidence was found of a sudden decrease in requirements for anticholinesterase therapy. Two patients did not, and in them a myasthenic crisis was precipitated. We propose that the preoperative drug regimen can be continued in the immediate postthymectomy period, allowing selection of patients for tracheostomy and artificial ventilation primarily on the basis of the preoperative vital capacity.     

Management of flail chest.

This paper compares the management of two groups of patients with flail chest. The 25 patients in group 1 had a flail chest without other significant injuries or shock, whereas the 57 in group 2 had a flail chest with multiple injuries, shock or both. The group 1 patients were treated with repeated multiple intercostal nerve blocks or high segmental epidural analgesia, oxygen, intensive chest physiotherapy, fluid restriction, furosemide diuretics, methylprednisolone sodium succinate and colloid infusion in an intensive care unit. In addition to these measures, the group 2 patients underwent endotracheal intubation and assisted mechanical ventilation with a volume respirator that provided continuous positive airway pressure and positive end-expiratory pressure. Of the 57 group 2 patients 36 required prolonged ventilation, eventually through a tracheostomy, because of severe head injury, pneumonia, severe facial injury, quadriplegia, pre-existing lung disease or severe sepsis. However, tracheostomy was avoided in the other 21 patients in group 2. There were no deaths in group 1, but 8 (14%) of the patients in group 2 died. These results show that avoidance of tracheostomy and ventilation in selected patients with flail chest is consistent with a low morbidity and mortality.     

Magnetic resonance imaging with pathological correlation in a case of mantle cell lymphoma of the parotid gland: a case report

Introduction

Tetanus rarely occurs in developed countries, but it can result in fatal complications including respiratory failure due to generalized muscle spasms. Magnesium infusion has been used to treat spasticity in tetanus, and its effectiveness is supported by several case reports and a recent randomized controlled trial

Case presentations

Three Caucasian Greek men aged 30, 50 and 77 years old were diagnosed with tetanus and admitted to a general 12-bed intensive care unit in 2006 and 2007 for respiratory failure due to generalized spasticity. Intensive care unit treatment included antibiotics, hydration, enteral nutrition, early tracheostomy and mechanical ventilation. Intravenous magnesium therapy controlled spasticity without the need for additional muscle relaxants. Their medications were continued for up to 26 days, and adjusted as needed to control spasticity. Plasma magnesium levels, which were measured twice a day, remained in the 3 to 4.5 mmol/L range. We did not observe hemodynamic instability, arrhythmias or other complications related to magnesium therapy in these patients. All patients improved, came off mechanical ventilation, and were discharged from the intensive care unit in a stable condition.

Conclusion

In comparison with previous reports, our case series contributes the following meaningful additional information: intravenous magnesium therapy was used on patients already requiring mechanical ventilation and remained effective for up to 26 days (significantly longer than in previous reports) without significant toxicity in two patients. The overall outcome was good in all our patients. However, the optimal dose, optimal duration and maximum safe duration of intravenous magnesium therapy are unknown. Therefore, until more data on the safety and efficacy of magnesium therapy are available, its use should be limited to carefully selected tetanus cases.     

Mandibular distraction osteogenesis in Pierre Robin sequence: application of a new internal single-stage resorbable device

Pierre Robin sequence may result in physiologically significant obstructive apnea in the neonatal and infant period. This may be life threatening and is most often treated by tracheostomy. To avoid tracheostomy or allow for early decannulation in severely affected infants and children, the authors have developed a new class of neonatal and infant mandibular bone distraction devices. These devices require a single operative procedure for placement and no operative removal is necessary. Fifteen infants (aged 7 days to 11 months; mean age, 3 months) and five children (aged 2 to 8 years; mean age, 5.5 years), 10 boys and 10 girls, with severe obstructive apnea and Pierre Robin sequence were treated with the mandibular infant devices over a 24-month period. Tracheostomy was avoided in 14 patients, whereas five of six patients who had previous tracheostomy were decannulated after mandibular distraction. The final tracheostomy status in one patient will be determined after surgery for gastroesophageal reflux. There were no major complications and no structural device failures.     

机械通气患者人工气道管理技术进展

机械通气技术在严重急慢性呼吸衰竭的患者抢救治疗中广泛应用,人工气道管理技术方法在机械通气过程中显示十分重要作用,有效的气道管理技术方法可减少机械通气过程中一些并发症如呼吸机相关性肺炎等。结合临床应用机械通气技术体会,本文主要对人工气道管理技术方法总结分析。     

Artificial ventilation for neurological disease: retrospective analysis 1972-81.

During the 10 year period 1972-81, 39 patients with neurological disorders referred to a respiratory unit required artificial ventilation, seven on two occasions. The decision to undertake ventilation was usually made on clinical grounds because of deteriorating respiratory effort, ineffective cough, or inability to swallow. Arterial blood gas studies were of limited value in assessing the need for ventilation. The most frequent complication was bronchopulmonary infection which occurred in almost every patient, Staphylococcus pyogenes, Pseudomonas pyocyanea, and coliforms being the organisms most commonly isolated. In contrast, serious complications of tracheostomy and pulmonary thromboembolism occurred infrequently. There were 10 deaths among the 39 patients ventilated on 46 occasions; six were directly attributable to the neurological disease itself but four resulted from complications of artificial ventilation.     

气管切开术

气管切开术是一项临床常见的手术操作,偶尔也会在院外实施。手术目的为在颈前气管造口以建立人工气道,使得患者可以自由地通过颈部造口通气,免受窒息的威胁。目前,临床上主要应用于需要进行长期机械通气的患者,特别是重症医学科。随技术和设备的更新换代,临床医生和学者对气管切开术进行了各种尝试,希望能尽可能地降低术中术后并发症。手术向着微创化、多样化发展,手术切口越来越小,手术方法由单一的外科气管切开术,进化出多样的经皮气管切开术、快速反应气管切开术等。不同的手术技巧,其手术的适应症、禁忌症及术中术后出现出血、感染、气肿、声门下狭窄等并发症的发生率也不甚相同。本文重点回顾了气管切开术的历史与现状、颈部解剖生理、适应症、禁忌症和临床常见并发症,并提出对应的预防和解决方法,为临床医生进行手术方案的选择及预防和治疗并发症提供合理新思路,除此之外,我们也基于临床经验提供了一些建议。     

Use of the kinetic treatment table to prevent the pulmonary complications of multiple trauma.

The kinetic treatment table (KTT) has been developed to prevent and treat complications of immobility. Because atelectasis and pneumonia may be related to immobility, we studied the effect of the KTT on the prevention and treatment of pulmonary complications in a prospective randomized study of 30 patients with severe traumatic injuries. All were receiving mechanical ventilation and were randomly assigned to treatment with a KTT or a conventional bed. Both groups received conventional medical-surgical therapy while pulmonary function, chest roentgenograms, and the presence or absence of lung infection were monitored for one week. In the patients who began the study with a clear chest roentgenogram, atelectasis and pneumonia were significantly less frequent in those treated with a KTT (P less than .05). Thus, the KTT can reduce pulmonary complications in selected patients with multiple trauma. The effect of this benefit on overall outcome is uncertain.     

Therapy and prevention of gastric ulcer.

After establishing the benign nature of a gastric ulcer, the treatment is primarily medical. This medical therapy is aimed to alleviate symptoms, to heal the ulcer and to prevent relapses. Based on the history of non-steroidal anti-inflammatory drugs (NSAIDs) and the Helicobacter pylori-status, gastric ulcer patients can be divided into four categories (1) H. pylori positive plus NSAID-use, (2) H. pylori positive without NSAID use, (3) NSAID use with negative H. pylori-status, (4) Negative H. pylori-status and no NSAID use. Patients taking NSAIDs should stop this therapy if possible. Patients with gastric H. pylori infection should be treated by a regimen of a proton pump inhibitor with at least two appropriate antibiotics. This treatment will result in early alleviation of symptoms, rapid healing of the ulcer and prophylaxis of ulcer relapse. In patients with gastric ulcer who cannot stop NSAIDs, maintenance therapy with prostaglandins or potent antisecretory drugs should be considered. The few patients with gastric ulcer who do not take NSAIDs and do not have gastric H. pylori infection should be treated by antisecretory drugs, and they should be carefully followed endoscopically to exclude malignant (carcinoma, lymphoma) or non-peptic (Crohn''s disease) disease. All patients with gastric ulcer should be re-endoscoped to verify complete ulcer healing. Surgery may be considered in gastric ulcer patients with complications, in those with severe dysplasia of the gastric mucosa, and in those who are not able or willing to take the medication.     

Approaches to the treatement of diabetes mellitus: an overview.

Diabetes related complications, if not treated, can be lethal. The basis of diabetes treatment is management of these complications by different approaches with the aim of providing a healthy life to diabetics. This article gives an overview of the various approaches currently in use to control hyperglycemia like pharmacological compounds and natural products. Many natural products have been used in traditional medicine, but only a few of them are discussed here. A combination therapy appears more useful for the treatment of diabetes rather than the use of a single compound.     

Mandibular distraction in neonates: a strategy to avoid tracheostomy

Over the past 5 years, the authors developed an application of mandibular distraction osteogenesis to eliminate existing tracheostomy. That experience led the authors to attempt mandibular distraction osteogenesis in neonates as an alternative before tracheostomy. Success with this approach using supporting objective airway measurements has been reported previously. This report includes six neonates diagnosed with Pierre Robin sequence. Of the six, five neonates ranging in age from 6 to 26 days (mean, 14.5 days) were treated by the authors with mandibular distraction over a 22-month period. The sixth neonate was treated with tracheostomy, because of other airway abnormalities. Findings included retrognathia, glossoptosis, incomplete cleft palate, and airway obstruction in each patient. Birth weights ranged from 2.8 to 3.2 kg. All patients were unable to control their airway during feeding, as evidenced by repeated episodes of choking and obstruction. Resting oxygen saturations were in the 70 to 80 percent range in all patients, with further deterioration during attempted feeding. Bronchoscopy was performed in all patients under anesthesia before distraction. Recurrent near-complete and intermittent complete airway obstruction were present in all patients at the level of the tongue base. There was a consensus by a pediatric intensivist, a pediatric anesthesiologist, and a pediatric otolaryngologist in all cases. Each patient met all criteria requiring ventilation for life support. Tracheostomy would be required if mandibular distraction osteogenesis was not performed, or if it failed. Patients with other airway abnormalities were not considered for treatment. Maxillomandibular disharmony measured at the midline ranged from 8 to 15 mm (mean, 11.2 mm). Active distraction was performed at the rate of 1 to 2 mm a day, with a consolidation period of 4 weeks. Total time of treatment was less than 6 weeks in all cases. All patients were extubated by the completion of active distraction. Distraction distance ranged from 8 to 15 mm (mean, 12.4 mm). All patients were discharged to home on apnea monitors, the use of which was discontinued after 90 days with no further apneic events. Weight gains met or exceeded the average 500 g a month after distraction. Bronchoscopy at the time of distractor removal showed correction of airway obstruction at the tongue base. Radiographs showed bilateral ossification of the distraction sites. Tracheostomy was avoided in all cases selected for treatment by distraction. Patient follow-up range was 9 to 22 months. In selected Pierre Robin sequence patients with tongue base airway obstruction, mandibular distraction osteogenesis can successfully avoid the need for and the associated mortality and morbidity of indwelling tracheostomy.     

Reflex changes in tracheal smooth muscle tone during high-frequency oscillation

We examined the effect of high-frequency oscillatory ventilation (HFOV) on tracheal smooth muscle tension and upper airway resistance in anesthetized dogs. The animals were ventilated via a low tracheostomy by HFOV or conventional intermittent positive pressure ventilation (IPPV) with and without added positive end-expiratory pressure (PEEP). The transverse muscle tension of the trachea above the tracheostomy was measured and found to be lower during HFOV when compared with IPPV or IPPV with PEEP. When both vagi were cooled to 8 degrees C to interrupt afferent traffic from the lungs, there was no longer any difference between the modes of ventilation. In a second series of experiments, the airflow resistance of the upper airway above the tracheostomy was measured (Ruaw). During HFOV, Ruaw was significantly lower than during either IPPV or IPPV with PEEP. We conclude that HFOV induces a relaxation of tracheal smooth muscle and a reduction of upper airway resistance through a vagally mediated mechanism.     

Laryngotracheobronchitis: 2 years' experience with racemic epinephrine.

A relatively new form of treatment of laryngotracheobronchitis, administration of racemic epinephrine by intermittent positive-pressure breathing, was begun in 1973 in the pediatric unit of a large community hospital. A review of 2 years'' experience with this treatment, compared with the experience of the 3 years prior to its introduction, has shown that it has reduced significantly the necessity for tracheostomy, to nearly zero, and the duration of hospital stay. A total of 119 children (33.15% of those admitted) received this treatment, the average number of treatments required being 1.8. There were no important complications of treatment and no deaths.     

Viral infection in hematopoietic stem cell transplantation: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee review on the role of cellular therapy in prevention and treatment

Despite recent advances in the field of HSCT, viral infections remain a frequent causeof morbidity and mortality among HSCT recipients. Adoptive transfer of viral specific T cells has been successfully used both as prophylaxis and treatment of viral infections in immunocompromised HSCT recipients. Increasingly, precise risk stratification of HSCT recipients with infectious complications should incorporate not only pretransplant clinical criteria, but milestones of immune reconstitution as well. These factors can better identify those at highest risk of morbidity and mortality and identify a population of HSCT recipients in whom adoptive therapy with viral specific T cells should be considered for either prophylaxis or second line treatment early after inadequate response to first line antiviral therapy. Broadening these approaches to improve outcomes for transplant recipients in countries with limited resources is a major challenge. While the principles of risk stratification can be applied, early detection of viral reactivation as well as treatment is challenging in regions where commercial PCR assays and antiviral agents are not readily available.     

Metabolic disorders in patients with chronic kidney failure

This review article summarizes the problems of metabolic disorders and nutrition imbalances that often occur in chronic kidney failure (CKF) or following regular dialysis treatment. In this survey, we cover the pathogenesis of these disorders, their clinical consequences, and their association with the most severe complications of chronic kidney failure and dialysis treatment. These complications are primarily atherosclerosis, malnutrition, anemia, hyperparathyroidism, and other serious problems that markedly and negatively affect prognosis and the quality of life of uremic patients. Risk factors for cardiovascular disease are discussed in-depth because cardiovascular disease is the leading cause of death in patients with chronic kidney failure. It is important to pay attention to the development of these complications because early diagnosis and therapy can improve the prognosis for these patients and reduce treatment costs.     

Guillain-Barré syndrome: rehabilitation outcome and recent developments.

Guillain-Barré syndrome is the most common polyneuropathy causing major disability and respiratory failure. Respiratory complications are the main cause of death. Improved respiratory care and new treatment strategies such as plasmaphoresis and immunoglobulin have been shown to improve outcome. We studied the course and outcome of 37 patients with Guillain-Barré syndrome who were admitted to a rehabilitation and respiratory care facility over a 10-year period. There were 21 males and 16 females with a mean age of 62+/-3 years. Fourteen patients developed respiratory failure requiring endotracheal intubation and mechanical ventilation. The mean duration of mechanical ventilation was 38+/-10 days. All patients were successfully liberated from the ventilator. However, 83 percent of the patients were moderately to severely disabled at the time of discharge. Thirteen out of 37 (35 percent) developed long-term disability. None of the patients died over the period of follow-up. These results indicate that early recognition and treatment of respiratory complications in Guillain-Barré syndrome could reduce the morbidity and mortality of this condition.     

儿童术后早期炎性肠梗阻诊治探讨

目的:探讨儿童腹部手术后早期炎性肠梗阻的诊治方法.方法:对17例腹部手术后出现术后早期炎性肠梗阻的患儿采用禁食、胃肠减压、静脉营养支持、中药灌注、抗感染等综合治疗.结果:17例患儿均顺利恢复.炎性梗阻症状消失,院外随访未见不适.结论:采用非手术保守治疗儿童术后早期炎性肠梗阻是安全有效的.     

Craniofacial infection in 10 years of transcranial surgery

Infection following transcranial surgery may be devastating. A review of 170 transcranial operations is presented with a focus on postoperative infection and its relationship to patient age, preoperative microbiology, pattern of operation, length of operation, and the use of antibiotic prophylaxis. The overall postoperative infection rate was 6.5 percent, but the infection rate in adults (23.5 percent) was much higher than in children (2.2 percent). Higher infection rates were found in adults with craniofacial dysostoses undergoing lengthy frontofacial advancements which required tracheostomy airway management. The residual frontal extradural dead space following advancement in adults is a sanctuary to infecting organisms from the respiratory tract--especially Pseudomonas transferred from the tracheostomy site into the upper airway and intracranial dead space by ventilation forces. Operating times for patients who became infected were 2 1/2 hours longer than average operating times for transcranial operations. Preoperative microbiology of the craniofacial region was not a good predictor of subsequent infection. Recommendations include operative intervention at an early age, short preoperative hospital stay, antibiotic prophylaxis to include gram-negative cover, surgical measures to either fill or isolate the dead space, and strict tracheostomy care--preferably with the patient being barrier-nursed.     

慢性阻塞性肺疾病机械通气患者早期肠内营养的疗效观察

目的：评价早期肠内营养（EEN）对慢性阻塞性肺疾病（CORD）机械通气患者的疗效。方法：选择COPD合并呼吸衰竭行机械通气患者60例,分为两组：分别给予相同热量及氮量,EEN组30例,接受早期肠内营养治疗,按照肠内营养优化策略喂养;对照组接受肠内营养联合肠外营养（EN＋PN）30例,接受常规营养治疗。观察两组治疗前后营养指标,机械通气时间、1周平均营养费用、呼吸机相关性肺炎（VAP）发生率。监测治疗前后两组血清总蛋白、前白蛋白和血红蛋白水平及免疫指标T细胞亚群。结果：EEN组病人治疗后一周血清白蛋白水平及免疫指标均明显升高,且均高于对照组治疗后水平（P〈0．05）。机械通气时间、平均营养费用、VAP发生率明显低于对照组（P〈0．05）。结论：优化管理的早期肠内营养治疗费用低,能改善COPD机械通气患者的营养状况、缩短机械通气时间,减少VAP发生率。只要胃肠道有功能,就应尽早实施肠内营养。