Acute Cardiorespiratory Failure Research Articles

Efficiency of Noninvasive Ventilation in Acute Heart Failure

Objective: to evaluate the efficiency of noninvasive supporting ventilation in patients with acute cardiorespiratory failure in the early postoperative period after cardiac surgery under extracorporeal circulation. Methods. Case histories of patients operated on the heart under extracorporeal circulation, who postoperatively developed acute car-diorespiratory failure requiring repeated artificial ventilation (AV), were retrospectively studied. According to the AV mode, the patients were divided into 2 groups. Non-invasive AV was carried out in Group 1 (a study group). In Group 2 (a control group), tracheal intubation and mechanical ventilation were performed when respiratory indices deteriorated. In both groups, anesthesia was maintained without deviating from the clinically accepted protocol. The indications for extubation were routine. Following 24—72 hours after extubation, the health status of patients became worse, as manifested in decreased circulatory performance, requiring that they be switched to AV. Clinical and laboratory findings were used to define indications for AV switching. The conditions for noninvasive ventilation were the close cooperation of a patient with medical personnel, the absence of significant hyperthermia, injury, operation or facial abnormally, which excluded intimate mating. Results. Analysis of gas exchange changes suggests that there are no differences between the groups both just after surgery and within 24 postperfusion hours after extubation. When the condition deteriorated, no differences in oxygen exchange and delivery were observed in the study and control groups. In the control group, PaO2, oxygenation index, and oxygen delivery index were significantly less than those in the study group. Analysis of the duration of assisted ventilation revealed that the study group patients were on a respirator significantly less than the controls. The length of intensive care unit stay also increased greatly in Group 2. All patients with normal gas exchange parameters were transferred to a specialized unit. Complications, such as insignificant skin damages at the site of intimate mask mating, were observed in the study group, while in the control group, ventilator-associated pneumonia was seen in 3 cases. Conclusion. The present study has provided evidence that noninvasive AV may be effective in the occurrence of acute cardiorespiratory failure requiring the correction of gas exchange parameters after surgery under extracorporeal circulation. Key words: noninvasive supporting ventilation, cardiosurgery, extracorporeal circulation.

A fatal case of recurrent amiodarone-induced thyrotoxicosis after percutaneous tracheotomy: a case report

BackgroundAmiodarone is a widely used antiarrythmic drug, which may produce secondary effects on the thyroid. In 14–18% of amiodarone-treated patients, there is overt thyroid dysfunction, usually in the form of amiodarone-induced thyrotoxicosis, which can be difficult to manage with standard medical treatment.Case presentationPresented is the case of a 65-year-old man, under chronic treatment of atrial fibrillation with amiodarone, who was admitted to the Intensive Care Unit with acute cardio-respiratory failure and fever. He was recently hospitalized with respiratory distress, attributed to amiodarone-induced pulmonary fibrosis. Clinical and laboratory investigation revealed thyrotoxicosis due to amiodarone treatment. He was begun on thionamide, prednisone and beta-blockers. After a short term improvement of his clinical status the patient underwent percutaneous tracheotomy due to weaning failure from mechanical ventilation, which led to the development of recurrent thyrotoxicosis, unresponsive to medical treatment. Finally, the patient developed multiple organ failure and died, seven days later.ConclusionWe suggest that percutaneous tracheotomy could precipitate a thyrotoxic crisis, particularly in non-euthyroid patients suffering from concurrent severe illness and should be performed only in parallel with emergency thyroid surgery, when indicated.

Lactate clearance in cardiorespiratory emergency

Early goal directed therapy has been found to improve prognosis in septic patients, if the therapeutic goal is achieved within the first six hours. The aim of our study is to demonstrate that in patients with acute cardiorespiratory failure, rapid (within 2 hours) lactate clearance can help define patients’ prognosis. 67 consecutive patients, admitted to our 16-bed Emergency Medicine ward for acute cardiorespiratory failure (age 75,9 ± 9,8) (APACHE II score 19,0 ± 4,1), were included in the study. Blood lactate concentration was read at admission and after 2, 6 and 24 hours. We evaluated mortality at seven days and the use of orotracheal intubation (patients with negative outcome) vs. discharge or transfer to a non-emergency ward with subsequent discharge (patients with negative outcome). Lactate concentration at admission was 4,6 ± 2,5 mmol/l; lactate clearance (%) at 2 hours was 40,4 ± 32,1 in patients with a positive outcome and –8,3 ± 5,0 in patients with a negative outcome (p < 0,05). Lactate clearance at 2 hours < 25% is correlated to a negative outcome with an 84,2% sensitivity and a 79,2% specificity. The positive predictive value was 61,5% and the negative predictive value was 92,2%. Systematic lactate clearance monitoring can be used in cases of acute cardiorespiratory insufficiency to identify patients with a high risk of negative outcome. In our study, low clearance at two hours was associated with an increase in mortality and/or the need for orotracheal intubation. Conversely, a clearance at two hours of > 25% in most cases confirms the therapeutic strategy undertaken. Serial evaluation of blood lactate concentration may therefore be useful in guiding treatment strategies.

A virologic survey of patients admitted to a critical care unit for acute cardiorespiratory failure

A virologic survey of patients admitted to a critical care unit for acute cardiorespiratory failure

Ventricular unloading with a miniature axial flow pump in combination with extracorporeal membrane oxygenation

ECMO for acute cardiorespiratory failure is an established therapeutic option. Persistent insufficient unloading of the left ventricle (LV) can compromise recovery of ventricular function. We decided to insert a miniature rotary blood pump (Impella) for decompression of the LV. In contrast to previous experience with this new device, where it was generally used for postcardiotomy heart failure or cardiogenic shock and inserted in the operating room or the catheter laboratory, this is the first report describing the potential of this technology in the intensive care unit, in a patient on ECMO and the value of echocardiography guidance. A 13-year-old boy with a history of congenital heart disease was admitted to the ICU with acute cardio-respiratory failure. On day 2 venoarterial ECMO was instituted because of worsening cardiorespiratory insufficiency refractory to conventional treatment. On day 5 a percutaneous rotary blood pump was inserted to decompress the LV. A percutaneous miniature rotary blood pump can be an alternative to decompress a failing LV in the setting of VA-ECMO. Echocardiography can avoid the use of fluoroscopy and the transport to a catheter laboratory to insert the rotary pump.

Contribution of perfusion-related, metabolic and respiratory components to gastric mucosal acidosis in acute cardiorespiratory failure

Local mucosal acidosis in acute circulatory and respiratory failure is influenced by three main components: local perfusion and metabolism (mucosal-arterial pCO2 gradient), systemic metabolic acidosis (arterial bicarbonate), and respiration (arterial pCO2). The aim of this study was to determine the effect of primary resuscitation on these components of gastric mucosal pH in surviving and nonsurviving patients admitted to the ICU.

A virologic survey of patients admitted to a critical care unit for acute cardiorespiratory failure

ObjectiveTo document the prevalence of respiratory virus infections in patients with chronic cardiac or pulmonary disorders admitted to a critical care unit for acute cardiorespiratory failure.Design, setting, patientsThe study took place in a critical care unit during two consecutive winters. All patients admitted to the unit for acute respiratory or cardiac failure were enrolled. A nasal swab was taken for polymerase chain reaction (PCR) detection of influenza virus, respiratory syncytial virus (RSV), metapneumovirus, rhinovirus, and coronavirus.ResultsOne hundred twenty-two patients were enrolled. Their mean age was 69 years; 42% of the patients were female; the new simplified acute physiology score (SAPS II) score on admission was 35.6; 94% of patients had acute respiratory failure, 14% reported “influenza-like” illness before admission, and 11% of patients died in the unit. Twenty-one patients (17%) tested positive for a respiratory virus. The per-1,000 positivity rates were influenza virus 66, RSV 49, rhinovirus 33, metapneumovirus 16, and coronavirus 8. No link was found between virologic results and clinical outcome. A strong link was found between the rate of influenza virus positivity and the incidence of flu-like illness in the community (p=0.017).ConclusionThese results show that respiratory virus infection—particularly influenza virus infection during epidemic periods—is common among patients hospitalized for acute cardiorespiratory failure.

Physiologically Redefining Bronchopulmonary Dysplasia

To the Editor .— I was initially excited after reading the multicenter study published in the November 2004 issue of Pediatrics by Walsh et al, “Impact of a Physiologic Definition on Bronchopulmonary Dysplasia Rates.”1 After more careful thought, I wished to express my concerns about the limitations of the authors' proposed “physiologic definition” of bronchopulmonary dysplasia (BPD) and the potential implications on infant morbidity and mortality. The general pediatrician and the pediatric pulmonologist are the physicians who are most frequently responsible for the follow-up and long-term care of high-risk postneonatal infants who have BPD and respiratory control disorders. After leaving the security of the NICU or “step-down” unit, in which they are closely monitored and observed, they are often discharged to high-risk home environments. Their morbidity and mortality rates, in at least the first year of life, remain high. Some succumb to episodes of acute cardiorespiratory failure, while others may die, suddenly and unexpectedly, in homes or in day care centers in which they may be poorly supervised and/or exposed to stresses such as viral infections or continued tobacco smoke or are left sleeping on unsafe surfaces and positions. I am afraid that limiting the definition of BPD to those infants who can maintain …

A case of adverse reaction potentially related to a microbubble contrast agent for ultrasonography

A growing interest has been raised by microbubble contrast agents for ultrasonographic diagnosis (US) of focal lesions. Controindications are few and rare and, therefore, the method is considered to be safe even when used in patients with severe liver, kidney, heart and lung diseases. We report here the case of a life threatning adverse event observed during the performance of US with contrast agent. Our case regards a 77-year-old female patient, in whom conventional US demonstrated a focal lesion (14 cm × 10 cm) in the liver whose nature was decided to be better defined with the use of a contrast agent (Sono-Vue, Bracco, Italy). About 5 min after the injection of 4.8 ml of Sono-Vue, acute severe dyspnea and a fall of blood pressure until undetectable values occurred. Basic life support manouvres associated to steroid and plasma expander intravenous administration allowed reaching a normalization of cardiac and respiratory functions within 20 min. This case report suggests that Sono-Vue administration and acute cardio-respiratory failure could be directly related, despite the safety of this contrast agent has been assessed in a large series of patients with lung and heart chronic disorders.

Acute cardiorespiratory failure as presenting symptom of chronic lymphocytic leukemia

A patient with acute cardiorespiratory failure caused by hyperleukocytosis due to chronic lymphocytic leukaemia (CLL) is described. Although acute pulmonary failure due to leukostasis is a known and often postmortem finding in patients with acute myelocytic leukaemia (AML) or chronic myelocytic leukaemia (CML) in blastic crises, it is rare in CLL.

Pulmonary embolism: a frequent cause of acute fatality after lung resection.

Between 1975 and 1993, lung resections were performed in 1735 patients because of malignancies, with an early postoperative mortality of 7.2% (125 patients). Early postoperatively acute cardiorespiratory failure was experienced by 32 patients (1.85%), of whom 26 died despite immediate resuscitation measures. In 20/26 patients autopsy was performed revealing central pulmonary embolism as the cause of death in 19 of them. In one patient a rupture of the free posterior left ventricular wall following transmural myocardial infarction was found. Two patients who could be resuscitated successfully were operated on with extracorporeal circulation after pulmonary angiography had been performed to confirm the diagnosis; however they died 2 days later of right heart failure. Of the survivors three cases had myocardial infarctions, one patient had arrhythmias of unknown etiology. Immediate embolectomy with the use of extracorporeal circulation was performed in two patients, only on the ground of suspected pulmonary embolism and without further diagnostic measures. Both patients survived. Of the 23 cases, with proven pulmonary embolism 17 were still under postoperative prophylaxis with heparin. Six patients were already fully mobilized. We conclude that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization. The only successful life-saving measure in the case of central pulmonary embolism is immediate pulmonary embolectomy, if necessary without further diagnostic measures.

Bronchial carcinoids: A review of 60 patients

Sixty patients with a bronchial carcinoid underwent surgical treatment. Preoperative fiberoptic bronchoscopy revealed a characteristic pink, smooth, bleeding tumor in 71.4% of the patients with a typical carcinoid and 16.7% of those with an atypical carcinoid ( p < 0.05) Eight pneumonectomies, seven bilobectomies, 34 lobectomies, three lobectomies with bronchoplasty, six bronchotomies with bronchoplasty, and two segmental resections were performed. All patients entered follow-up, and 47 were followed for more than 5 years. Ten-year survival was 89.6% for patients with a typical carcinoid and 60% for those with an atypical carcinoid. Ten-year survival was 88.1% for patients with carcinoids without lymph node involvement. All patients with lymph node involvement died within 5 years. Overall, 5 of the 8 patients having pneumonectomy died of acute cardiorespiratory failure. We conclude that a limited surgical resection with or without bronchoplasty and systematic lymphadenectomy is the procedure of choice in patients with typical carcinoids. On the other hand, atypical carcinoids are comparable to well-differentiated malignancies of the lung. Whenever possible, pneumonectomy should be avoided in favor of bronchial sleeve resection.

Hypereosinophilic Syndrome with a Rapidly Fatal Course in a Saudi Child

Hypereosinophilic Syndrome with a Rapidly Fatal Course in a Saudi Child

Atrial fibrillation precipitated by acute hypovolaemia.

Six patients with varying degrees of acute cardiorespiratory failure were seen. All patients deteriorated noticeably when rapid atrial fibrillation developed. In all patients intravenous digitalis failed to slow the ventricular response, and in three patients misguided attempts at electrical cardioversion failed. Haemodynamic monitoring showed a normal or low pulmonary artery occlusion pressure in all patients. Controlled expansion of plasma volume was associated with an immediate slowing of the heart rate in all patients, and the heart rate in all patients returned to sinus rhythm within 30 minutes of transfusion. It is suggested that hypovolaemia in critically ill patients may contribute to the development of atrial fibrillation.

Extracorporeal Membrane Oxygenation Experience at the University of Pittsburgh

Between January, 1981, and May, 1985, 33 infants suffering from acute cardiorespiratory failure were treated with extracorporeal membrane oxygenation (ECMO) when all other forms of conventional management had failed. Only the patients with respiratory failure that was thought to be reversible were treated. Prolonged conventional respiratory management (more than five days) was considered a contraindication to ECMO support because of irreversible damage to the lungs caused by the barotrauma associated with conventional ventilation. Eighteen of the 33 patients (54%) survived and were discharged from the hospital. Patients with congenital diaphragmatic hernia had a high incidence of fatal bleeding complications (8 of 14). Good results were obtained in the newborns with persistent fetal circulation and meconium aspiration syndrome. We conclude that ECMO markedly improves the survival of newborns with severe respiratory failure who would have a mortality close to 100% with conventional respiratory management.

Pulmonary Aspiration???Effects of Volume and pH in the Rat

To evaluate the effect of volume of aspirates with different pHs on mortality associated with pulmonary aspiration, hydrochloric acid solutions were injected into the tracheas of 336 Sprague-Dawley rats. The rats were divided randomly into 33 groups, were observed for 96 hr after aspiration, and were not resuscitated. Deaths were divided into two groups: early, less than 30 min after aspiration, and late, greater than 4 hr after aspiration. Late deaths, accounting for 22% of all fatalities, occurred exclusively in animals aspirating solutions with a pH less than 2.5. These late deaths indicated progressive lung damage as opposed to acute cardiorespiratory failure, which early deaths suggested. Low volume pulmonary aspirates (0.3 ml/kg) with extremely low pH (1.0) resulted in a high mortality rate (90%). Conversely, higher volume pulmonary aspirates (1.0-2.0 ml/kg) with a higher pH (greater than or equal to 1.8) resulted in a low mortality rate (14%). These data demonstrate an important interaction between pH and volume of aspirates: even low volumes have a high mortality rate if pH is very low, whereas if gastric fluid is effectively buffered, then much higher volumes than previously thought can be tolerated. This suggests that the routine use of nonparticulate antacids may be indicated in patients at risk from aspiration of stomach contents and should not be withheld because of concern of increasing gastric volume.

Relationship between colloid osmotic pressure and pulmonary artery wedge pressure in patients with acute cardiorespiratory failure : Weil MH, Henning RJ, Morissette M. Michaels S: Am J Med 64: 643–650, 1978

Relationship between colloid osmotic pressure and pulmonary artery wedge pressure in patients with acute cardiorespiratory failure : Weil MH, Henning RJ, Morissette M. Michaels S: Am J Med 64: 643–650, 1978

Relationship between colloid osmotic pressure and pulmonary artery wedge pressure in patients with acute cardiorespiratory failure

Close relationships between progressive respiratory failure, roentgenographic signs of pulmonary opacification and decreases in the difference between colioid osmotic pressure of plasma and the pulmonary artery wedge pressure (colloid-hydrosatic pressure gradient) were demonstrated in 49 critically ill patients with multisystem failure, and especially in patients in shock. The potential Importance of this relationship is underscored by the observation that fatal progression of pulmonary edema was related to a critical reduction in the colloid-hydrostatic pressure gradient to levels of less than 0 mm Hg. More often, reduction in colloid osmotic pressure rather than Increases in left ventricular filling pressure (pulmonary artery wedge pressure) accounted for the decline in colloid-hydrostatic pressure gradient. Routine measurement of colloid osmotic pressure, preferably in conjunction with pulmonary artery wedge pressure, is likely to improve understanding of the mechanisms of acute pulmonary edema.

Acute respiratory failure

Acute cardiorespiratory failure occurred in a patient with advanced bullous emphysema following perfusion photoscintigraphy with radiolabeled macroaggregated albumin. Complications of perfusion photoscintography are rare. However, in patients with advanced pulmonary vascular disease, special precautions may decrease the minimal hazard associated with perfusion photoscintigraphy.

Cor pulmonale due to tumour embolism derived from intrasinusoidal metastatic liver carcinoma.

Two cases of primary breast carcinoma are described, both terminating in acute cardiorespiratory failure due to multiple tumour micro-embolism. In both cases the source of the emboli was extensive metastatic intrasinusoidal carcinomatous infliltration of the liver. The association of these two uncommon conditions has not previously been reported. A brief review of the literature pertaining to diffuse intrasinusoidal metastatic carcinomaof the liver and to carcinomatous pulmonary embolism is included. The latter condition may be commoner and of greater clinical significance than his hitherto been appreciated. Some of the factors which may be responsible for this peculiar type of tumour dissemination are discussed.