Life-threatening Respiratory Failure Research Articles

Benefits and Risks Associated with the R100 High Frequency Oscillatory Ventilator for Patients with Severe Hypoxaemic Respiratory Failure

High frequency oscillatory ventilation has been shown to improve oxygenation of patients with severe respiratory failure. This prospective study examined the potential benefits and risks of the latest generation high frequency oscillatory ventilator (R100, Metran, Saitama, Japan), initiated when the target oxygenation could not be achieved by conventional mechanical ventilation in adult patients with severe hypoxaemic respiratory failure. Thirty-six patients with severe respiratory failure treated with the R100 high frequency oscillatory ventilator were considered. Pneumonia and exacerbation of interstitial pneumonia were the main causes of respiratory failure. The median time on conventional mechanical ventilation or airway pressure release ventilation prior to high frequency oscillatory ventilation was 9.3 hours (interquartile range 4.8 to 25). PaO2/FiO2 at 24 hours after initiation of high frequency oscillatory ventilation was significantly better than the PaO2/FiO2 at baseline (151.2 +/- 61.2 vs. 99.5 +/- 50.0, P = 0.0001). Refractory hypoxaemia within 24 hours was associated with a high risk of mortality (P = 0.0092) and 23 patients (64%), including 11 patients with exacerbation of interstitial pneumonia, died by 30 days. Of the 36 patients included in the study (including one who had developed pneumothorax before high frequency oscillatory ventilation), 12 (33%) developed barotrauma during the course of their intensive care unit stay. In the multivariate analysis, only exacerbation of interstitial pneumonia was a significant risk factor for barotrauma. In summary, the latest generation high frequency oscillatory ventilator could improve oxygenation in adult patients with life-threatening hypoxaemic respiratory failure but the incidence of barotrauma was substantial.

The nursing perspective on monitoring hemodynamics and oxygen transport

Maintenance of adequate systemic oxygen delivery requires careful clinical assessment integrated with hemodynamic measurements and calculations to detect and treat conditions that may compromise oxygen delivery and lead to life-threatening shock, respiratory failure, or cardiac arrest. The bedside nurse constantly performs such assessments and measurements to detect subtle changes and trends in patient condition. The purpose of this editorial is to highlight nursing perspectives about the hemodynamic and oxygen transport monitoring systems summarized in the Pediatric Cardiac Intensive Care Society Evidence- Based Review and Consensus Statement on Monitoring of Hemodynamics and Oxygen Transport Balance. There is no substitute for the observations of a knowledgeable and experienced clinician who understands the patient's condition and potential causes of deterioration and is able to evaluate response to therapy.

An extreme and life-threatening case of recurrent D-lactate encephalopathy

D-lactic acidosis has been reported in patients after a variety of gastrointestinal surgeries, particularly jejunoileal bypass. An insufficient length of small intestine to metabolize ingested carbohydrates leads to an abnormal carbohydrate load in the colon. These carbohydrates are metabolized by colonic anaerobes (especially Lactobacillus species) into the dextrorotary isomer of lactate. Unlike its levorotary counterpart, D-lactate has neurotoxic effects and patients suffering from a significant D-lactate burden may suffer encephalopathic symptoms. These symptoms are usually mild and self-limiting in patients with normal renal function. We present here a case of D-lactic acidosis in a patient with end-stage renal disease who developed recurrent and life-threatening respiratory failure due to severe D-lactic acid encephalopathy. To our knowledge, no previously reported case has been sufficiently severe to necessitate endotracheal intubation and mechanical ventilation. An array of treatments including hemodialysis effected a prompt reversal of sensorium to baseline. We describe the potential treatments for D-lactic acidosis, which can be viewed as a paradigm of substrate, catalyst and pathologic product and review reports of their relative efficacy.

Prognosis of Patients on Extracorporeal Membrane Oxygenation: The Impact of Acute Kidney Injury on Mortality

Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, such as those with life-threatening respiratory failure or postcardiotomy cardiogenic shock. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between prognosis and the Acute Kidney Injury Network (AKIN) scores obtained at pre-ECMO support (AKIN0-hour); and at post-ECMO support 24 hours (AKIN24-hour) and 48 hours (AKIN48-hour). This study reviewed the medical records of 102 critically ill patients on ECMO support at a specialized intensive care unit at a tertiary care university hospital between March 2002 and January 2008. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators. The overall mortality rate was 57.8%. The most common condition requiring ECMO support was cardiogenic shock. Goodness-of-fit was good for AKIN0-hour, AKIN24-hour, and AKIN48-hour criteria. The AKIN0-hour, AKIN24-hour, and AKIN48-hour scoring systems also had excellent areas under the receiver operating characteristic curve (0.804±0.046, 0.811±0.045, and 0.858±0.040, respectively). Furthermore, multiple logistic regression analysis indicated that AKIN48-hour, age, and Glasgow Coma Scale score on the first day of intensive care unit admission were independent risk factors for hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (p<0.05) for AKIN48-hour stage 0 versus AKIN48-hour stages 1, 2, and 3; and AKIN48-hour stage 1 and 2 versus AKIN48-hour stage 3. During ECMO support, the AKIN48-hour scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

Lung Transplantation for Severe Antineutrophilic Cytoplasmic Antibody-Associated Vasculitis

Antineutrophil cytoplasmic antibody–associated vasculitis is a life-threatening disorder for which medical therapy has greatly improved survival. However, there is still significant mortality associated with antineutrophil cytoplasmic antibody–associated vasculitis. Little data exists on the utility of lung transplantation for patients, especially with an acute and severe form of this disease. Herein, we report successful lung transplantation for a patient with life-threatening pulmonary hemorrhage and respiratory failure as a consequence of this pulmonary renal syndrome.

Therapeutic bilateral lung lavage in a child with pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis is a rare condition that can cause life-threatening respiratory failure attributable to excessive alveolar accumulation of surfactant proteins. The standard treatment for removing these secretions is through therapeutic bilateral lung lavage. Descriptions of procedures for performing therapeutic bilateral lung lavage and methods used to evaluate the overall effectiveness of this invasive procedure in children with pulmonary alveolar proteinosis have not been adequately described in the medical literature. We successfully and safely performed therapeutic bilateral lung lavage and obtained lung mechanics measurements in a child with pulmonary alveolar proteinosis. Case report. Operating room within a pediatric hospital. A 13-yr-old boy with pulmonary alveolar proteinosis requiring serial therapeutic bilateral lung lavage for recurrent respiratory distress. The patient presented to the hospital operating room for therapeutic lung lavage after a recent history of progressive dyspnea, respiratory distress, declining lung function measurements, and worsening radiographic abnormalities. We obtained baseline spirometric and respiratory system compliance measurements before and after therapeutic bilateral lung lavage. The left lung was lavaged on the first day and the right lung was lavaged on the third day using selective endobronchial intubation and selective lung ventilation. The procedure was well-tolerated and resulted in the removal of a significant volume of accumulated secretions. After the lavage, the patient demonstrated improvement in respiratory distress, chest radiograph appearance, lung compliance, and spirometric measurements. This case report demonstrates that therapeutic bilateral lung lavage can be performed safely and effectively in a pediatric patient with pulmonary alveolar proteinosis by isolating individual lungs using a dual-lumen endotracheal tube. In this patient, therapeutic bilateral lung lavage was found to have a significant impact on lung function and mechanics after this procedure.

Clinical and physiological features of chronic pulmonary emphysema with paroxysmal dyspnea attacks masquerading as bronchial asthma--improvement of respiratory function after combination therapy of intravenous aminophylline and subcutaneous epinephrine following daily oral administration of prednisolone

Cases of chronic pulmonary emphysema accompanied with paroxysmal dyspnea attacks are often misdiagnosed as bronchial asthma. These patients repeatedly fall into a state of life-threatening respiratory failure. We must make an accurate diagnosis of emphysema to provide care of them. To clarify the possibility of doing this, we investigated the clinical and physiological features (primarily respiratory function) of emphysema. We observed twenty-five patients with chronic pulmonary emphysema and with chronic bronchial asthma, previously confirmed by selective alveolo-bronchogram (SAB); this technique reliably diagnoses emphysema, but often induces dyspnea attacks due to the stimulation resulting from intratracheal and intrabronchial procedures. In eight patients, chronic pulmonary emphysema was accompanied by an attack of paroxysmal wheezing and dyspnea; chronic pulmonary emphysema with wheezing (WPE). In eight other patients, chronic pulmonary emphysema was present without such attacks; usual pulmonary emphysema (UPE). In the final nine patients, chronic bronchial asthma (CBA) was present, while emphysema was ruled out by means of SAB. In all patients, we measured respiratory function before and after the combination therapy of intravenous aminophylline and subcutaneous epinephrine, which followed daily oral administration of prednisolone (PAE-treatment). In the WPE group, significant increases in measurement of various respiratory functions, including VC, RV, RV/TLC%, FVC, FEV1.0, PFR and V75 (p less than .05 excluded in FEV1.0 and PFR were p less than .01), were found after the PAE-treatment, compared with the values revealed before the treatment. In the UPE group, there were few changes PAE-treatment, compared with the values revealed before the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid-Onset Acute Respiratory Distress Syndrome (ARDS) in a Patient Undergoing Metastatic Liver Resection: A Case Report and Review of the Literature

Metastatic liver resection following cytoreductive chemotherapy is an accepted treatment for oligometastatic tumor diseases. Although pulmonary complications are frequently reported in patients undergoing liver surgery including liver transplantation, life-threatening acute respiratory failures in the absence of aspiration, embolism, transfusion-related acute lung injury (TRALI), pulmonary infection, or an obvious source of systemic sepsis are rare. We performed an extensive clinical review of a patient undergoing metastatic liver resection who had a clinical course compatible to an acute respiratory distress syndrome (ARDS) without an obvious cause except for the surgical procedure and multiple preoperative chemotherapies. We hypothesize that either the surgical procedure mediated by cytokines and tumor necrosis factor or possible toxic effects of oxygen applied during general anesthesia were associated with life-threatening respiratory failure in the patient. Discrete and subclinical inflammated alveoli (probably due to multiple preoperative chemotherapies with substances at potential risk for interstitial pneumonitis as well as chest radiation) might therefore be considered as risk factors.

Life‐threatening respiratory failure from H1N1 influenza 09 (human swine influenza)

We present the first six cases of H1N1 influenza 09 (confirmed by a polymerase chain reaction test from nasopharyngeal swabs) in patients requiring admission to intensive care in Australia (in three hospitals in the north-western suburbs of Melbourne). These cases highlight the small but significant risk of life-threatening respiratory failure associated with H1N1 influenza 09 infection.

The use of neuromuscular blockers to facilitate mechanical ventilation in severe asthma

Ensuring adequate oxygenation and ventilation in patients with severe asthma can be challenging. Although no randomized trials have been performed, neuromuscular blockade is a useful adjunct in the care of severe life-threatening asthma with respiratory failure. Neuromuscular blockers can prevent respiratory dysynchrony, help lower peak pressures and allow longer expiratory times to reduce dynamic hyperinflation and its attendant risk of barotraumas and pneumothorax. Patients with severe life-threatening asthma and respiratory failure are often young, male and can be difficult to sedate.

Protective effects of high-molecular weight Polyethylene Glycol (PEG) in human lung endothelial cell barrier regulation: Role of actin cytoskeletal rearrangement

Acute lung injury represents the result of multiple pathways initiated by local or systemic insults and is characterized by profound vascular permeability, pulmonary edema, and life-threatening respiratory failure. Permeability-reducing therapies are of potential clinical utility but are currently unavailable. We hypothesized that polyethylene glycol (PEG) compounds, inert and non-toxic polymers that serve as a surrogate mucin lining in intestinal epithelium, may attenuate agonist-mediated lung endothelial cell (EC) barrier dysfunction. High molecular weight PEG (PEG15-20) produced rapid, dose-dependent increases in transendothelial electrical resistance (TER) in human lung endothelium cultured on gold microelectrodes, reflecting increased paracellular integrity. The maximal effective concentration of 8% PEG induced a sustained 125% increase in TER (40 h), results similar to barrier-enhancing agonists such as sphingosine 1-phosphate (40% increase in TER). Maximal PEG barrier enhancement was achieved at 45–60 min and PEG effectively reversed both thrombin- and LPS-induced EC barrier dysfunction. Consistent with the increase in TER, immunofluorescent studies demonstrated that PEG produced significant cytoskeletal rearrangement with formation of well-defined cortical actin rings and lamellipodia containing the actin-binding proteins, cortactin and MLCK, known participants in cell-matrix and cell-cell junctional adhesion. Finally, PEG challenge induced rapid alterations in levels of MAP kinase and MLC phosphorylation. In summary, PEG joins a number of EC barrier–regulatory agents which rapidly activate barrier-enhancing signal transduction pathways which target the cytoskeleton and provides a potential therapeutic strategy in inflammatory lung injury.

Procalcitonin is a valuable prognostic marker in ARDS caused by community‐acquired pneumonia

ARDS is life-threatening acute respiratory failure, and pneumonia is one of the most common causes of direct ARDS. Procalcitonin (PCT) has been evaluated for its utility in determining the aetiology of community-acquired pneumonia (CAP), choice of antibiotics and prediction of outcome. This study evaluated the role of PCT in predicting the outcome of patients with ARDS caused by severe CAP. This was a prospective observational study conducted from September 2002 to December 2003. The plasma PCT was analysed at baseline, 24 and 72 h after enrolment and measured by ELISA. Of the 22 patients with ARDS caused by CAP and enrolled in the study, 17 (77.3%) were alive 14 days after admission and five (22.7%) had died. The survivors had lower APACHE II scores (22.2 +/- 4.6 vs 30.6 +/- 9.6, P = 0.031), pneumonia severity index (141.9 +/- 2.2 vs 195.6 +/- 23.8, P = 0.005) and lower plasma PCT at baseline (9.83 +/- 3.54 vs 106.70 +/- 67.86, P = 0.004), at 24 h (10.51 +/- 5.39 vs 81.32 +/- 57.68, P = 0.014) and at 72 h (2.03 +/- 0.76 vs 19.57 +/- 6.67, P = 0.005). PCT analysed within 72 h of the onset of ARDS predicted mortality of patients with ARDS caused by severe CAP.

Evaluation of Outcome Scoring Systems for Patients on Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) has been used in critical conditions such as life-threatening respiratory failure or postcardiotomy cardiogenic shock. This investigation compares the predictive value of Acute Physiology, Age and Chronic Health Evaluation IV (APACHE IV), earlier APACHE models, Sequential Organ Failure Assessment (SOFA), and the risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification obtained on the first day of ECMO support for hospital mortality in critically ill patients. We reviewed the medical records of 78 critically ill patients on ECMO support at the specialized intensive care unit in a tertiary care university hospital from March 2002 to October 2005. Demographic, clinical, and laboratory variables and five scoring systems were retrospectively gathered as predicators of survival on ECMO day 1. The overall mortality rate was 60.3%. The most common condition requiring ECMO was cardiogenic shock. Goodness-of-fit was good for APACHE IV but not the APACHE III model. The APACHE IV and APACHE III scoring systems displayed excellent areas under the receiver operating characteristic curve (0.922 +/- 0.030 and 0.907 +/- 0.038, respectively). Furthermore, APACHE IV correlated significantly with APACHE III scores in individual patients (r2 = 0.902; p < 0.001). Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (p < 0.001 for APACHE IV < or = 49% versus APACHE IV > 49%). This study confirms the grave prognosis of critically ill patients receiving ECMO support. The APACHE IV proved to be a reproducible evaluation tool with excellent prognostic abilities in these patients.

Invited commentary

Validation of scoring systems for specific clinical situations is valuable because it may guide decisions regarding the initiation of advanced invasive cardiac or respiratory support in addition to providing early prognostic information for realistic discussions with patients and families. Lin and colleagues [1Lin C.-Y. Tsai F.-C. Tian Y.-C. et al.Evaluation of outcome scoring systems for patients on extracorporeal membrane oxygenation.Ann Thorac Surg. 2007; 84: 1256-1263Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] compare the precision of five scoring systems in predicting hospital mortality in adult patients treated with extracorporeal membrane oxygenation (ECMO): (1) APACHE IV, (2) APACHE III, (3) APACHE II, (4) RIFLE, and (5) SOFA). Cardiogenic shock was the most common indication for the institution of ECMO, although some patients with adult respiratory distress syndrome were also included. The high mortality rate (71%) among the 48 patients treated with ECMO for postcardiotomy cardiogenic shock suggests that alternative modalities of assistance are needed for these patients. Although the data on ventricular assist devices (VADs) as a bridge-to-recovery in chronic heart failure is variable, the favorable cardiac remodeling seen with ventricular unloading may be beneficial and remains to be examined specifically in adults with cardiogenic shock [2Maybaum S. Mancini D. Xydas S. et al.Cardiac improvement during mechanical circulatory support: A prospective multicenter study of the LVAD working group.Circulation. 2007; 115: 2497-2505Crossref PubMed Scopus (323) Google Scholar, 3Birks E.J. Tansley P.D. Hardy J. et al.Left ventricular assist device and drug therapy for the reversal of heart failure.N Engl J Med. 2006; 355: 1873-1884Crossref PubMed Scopus (723) Google Scholar]. With the exception of patients with myocarditis, all groups had high mortality rates and no other diagnosis seems particularly amenable to the use of ECMO for cardiopulmonary support. All of the prognostic scores had good predictive ability. However, the APACHE IV score was the most accurate. At a cutoff of 49%, the APACHE IV score had a positive predictive value of 96% for subsequent hospital mortality, and although the exact number is not given, based on the survival curve it seems that approximately 50% of the patients fell into this high-risk group. As the authors note, McCarthy [4McCarthy J.T. Prognosis of patients with acute renal failure in the intensive-care unit: a tale of two eras.Mayo Clin Proc. 1996; 71: 117-126Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar] has argued that prognostic scores should not be used as arbitrary criteria to withhold potentially lifesaving treatments in the intensive care unit [4McCarthy J.T. Prognosis of patients with acute renal failure in the intensive-care unit: a tale of two eras.Mayo Clin Proc. 1996; 71: 117-126Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar]. However, given the accurate prediction of mortality in these patients and the invasiveness and expense associated with ECMO, we must ask ourselves whether or not these patients benefit from its use. Although perhaps not exclusion criteria on its own, when taken with other factors, based on these data (in approximately 40 patients) an APACHE IV score of less than 49% should be a relative contraindication for the use of ECMO. Whether or not the APACHE IV scores are used to guide decisions regarding device implantation, the data presented by Lin and colleagues [1Lin C.-Y. Tsai F.-C. Tian Y.-C. et al.Evaluation of outcome scoring systems for patients on extracorporeal membrane oxygenation.Ann Thorac Surg. 2007; 84: 1256-1263Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] will be valuable as a guide to discussions with patients and their families and as an indication of which patient populations might benefit from further research into new treatment modalities. Evaluation of Outcome Scoring Systems for Patients on Extracorporeal Membrane OxygenationThe Annals of Thoracic SurgeryVol. 84Issue 4PreviewExtracorporeal membrane oxygenation (ECMO) has been used in critical conditions such as life-threatening respiratory failure or postcardiotomy cardiogenic shock. This investigation compares the predictive value of Acute Physiology, Age and Chronic Health Evaluation IV (APACHE IV), earlier APACHE models, Sequential Organ Failure Assessment (SOFA), and the risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification obtained on the first day of ECMO support for hospital mortality in critically ill patients. Full-Text PDF

Encephalopathy after furosemide use in nephrotic syndrome

An 18-year-old girl with nephrotic syndrome presented with a life-threatening respiratory failure and a severe encephalopathy, shortly after being started on furosemide. The evaluation confirmed furosemide as the sole culprit for the clinical manifestations. This case highlights an unpredictable dose-response relationship of furosemide. The pathophysiological basis, differential diagnosis and clinical implications of the observed findings are discussed.

Venovenous Extracorporeal Life Support After Pulmonary Endarterectomy: Indications, Techniques, and Outcomes

Pulmonary endarterectomy is the accepted therapy for thromboembolic pulmonary hypertension. A recognized complication of this surgery is the postoperative development of reperfusion edema, a potentially fatal cause of respiratory failure. Because reperfusion edema can be a reversible process, temporizing support measures may be life saving. We retrospectively reviewed our experience with venovenous extracorporeal life support (V-V ECLS) from July 1990 to February 2006, in 20 adult patients (mean age 50.5 +/- 14.5 years) presenting with potentially reversible respiratory failure after pulmonary endarterectomy. This subset of patients comprised 1.12% of our total pulmonary endarterectomy experience during that time (1,790 cases). Overall in-hospital survival was 30.0% for patients requiring ECLS support after pulmonary endarterectomy versus 94.2% for patients who underwent pulmonary endarterectomy alone during the same timeframe. V-V ECLS was instituted at a mean of 86.8 hours after surgery. The mean duration of V-V ECLS was 123.4 +/- 71.3 hours. The most common cause of death in ECLS patients after pulmonary endarterectomy was pulmonary hemorrhage. Survival was greater in patients cannulated within 120 hours of surgery (46.2% survival; 6 of 13 patients) compared with those cannulated after 120 hours (0 of 7 patients). Multiple logistic regression identified long duration of mechanical ventilation pre-ECLS and severity of preoperative pulmonary hypertension together as predictors of mortality. A small subset of patients undergoing pulmonary endarterectomy develop temporary life-threatening respiratory failure secondary to severe reperfusion edema. In those patients with satisfactory hemodynamic outcome, V-V ECLS is a therapeutic option when all other conventional strategies have been exhausted.

Pulmonary surfactant in patients with Pneumocystis pneumonia and acquired immunodeficiency syndrome

Pneumocystis pneumonia (PCP) is a severe infection of the immunocompromised host, resulting in diffuse alveolar damage and life-threatening respiratory failure. We analyzed pulmonary surfactant composition and function in bronchoalveolar lavage fluid (BALF) from ventilated and spontaneously breathing HIV-positive patients with PCP. Prospective clinical trial. University hospital intensive care unit. Thirty-four spontaneously breathing (SB-PCP) and 20 ventilated HIV-positive patients with PCP (V-PCP), ten patients with acute respiratory distress syndrome (ARDS), 11 spontaneously breathing patients with bacterial pneumonia (PNEU), and 22 healthy volunteers. None. Total phospholipid in BALF did not differ between any category vs. controls, whereas total protein increased approximately 14-fold in V-PCP and five-fold in SB-PCP compared with controls (p < .001). The relative content of large surfactant aggregates (LA) was reduced in SB-PCP and V-PCP compared with controls (p < .05). The phospholipid and fatty acid profiles showed a significant reduction in the relative content of phosphatidylcholine (PC), phosphatidylglycerol, and palmitic acid in PC in all patient categories compared with controls, with more in V-PCP (p < .001) compared with SB-PCP (p < .05). The neutral lipid-to-phospholipid ratio in LA was three-fold elevated in V-PCP (p < .01 compared with control) but not in SB-PCP. Analysis of neutral lipid classes showed a significant increase in the relative content of triglycerides and a reduction in free fatty acids in V-PCP compared with controls. BALF surfactant protein (SP)-A and SP-D significantly increased in V-PCP and SB-PCP, but not in ARDS and PNEU, compared with controls (p < .05). SP-B and SP-C content in LA remained unchanged in PCP compared with controls but decreased significantly in ARDS and PNEU. The minimum surface tension of LA was impaired (p < .001) in V-PCP more than in SB-PCP and was strongly correlated with the reduction in palmitic acid levels in PC LA (r = -.81). Reductions in phosphatidylglycerol strongly correlated with decreased Pao2/Fio2 values (r = .72). We conclude that severe alterations in surfactant function and composition occur in patients with PCP and are even more pronounced in ventilated patients than in nonventilated patients. Surfactant lipid changes in PCP, but not surfactant protein profiles, closely resemble those found in ARDS.

RIFLE classification is predictive of short-term prognosis in critically ill patients with acute renal failure supported by extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients, such as those with post-cardiotomy cardiogenic shock or life-threatening respiratory failure. Acute renal failure following ECMO support has an extremely elevated mortality rate. This study examined the outcomes of patients treated with ECMO and characterized the association between mortality and RIFLE (risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function and end-stage renal failure) classification. This retrospective study analysed the medical records of 46 critically ill patients-most had post-cardiotomy cardiogenic shock-treated by ECMO. Sixteen patients (34.8%) were treated with both ECMO and continuous renal replacement therapies. The overall mortality rate was 65.2% (30/46). A progressive and significant increase (chi(2) for trend, P < 0.001) was observed for mortality based on RIFLE classification severity. The Hosmer and Lemeshow goodness-of-fit test demonstrated that the RIFLE category has a good fit. By applying the area under the receiver operating characteristic curve (AUROC), the RIFLE classification tool had good discriminative power (AUROC 0.868 +/- 0.068, P < 0.001). Cumulative survival rates at 6 months follow-up following hospital discharge differed significantly (P < 0.05) for non-ARF vs RIFLE-I and RIFLE-F, and RIFLE-R vs RIFLE-F. This investigation confirms that the prognosis for critically ill patients supported by ECMO is grave. The RIFLE category is a simple, reproducible and easily applied evaluation tool with good prognostic capability that might generate objective information for patient families and physicians and supplements the clinical judgment of prognosis.

Acute Eosinophilic Pneumonia

Acute eosinophilic pneumonia is a sudden and severe febrile illness that can result in life-threatening respiratory failure. Because this disease can mimic other diseases causing acute respiratory failure, the diagnosis may be missed or delayed. It is clinically distinguishable from other pulmonary eosinophilic diseases and can be diagnosed with bronchoalveolar lavage. Treatment with corticosteroids results in rapid reversal of respiratory failure and complete recovery, generally without relapse. In some patients, acute eosinophilic pneumonia may be caused by drugs, tobacco smoke, or other inhaled substances; however, in the majority of patients, the condition is idiopathic.

Prolonged ECMO Support for Virus-Induced Cardiorespiratory Failure Early After Cardiac Surgery

Extracorporeal membrane oxygenation (ECMO) after cardiac surgery is a rescue for life-threatening respiratory or circulatory failure. Although ECMO support for short periods (<10 days) represents an effective means of respiratory and cardiac support, treatment for longer periods remains controversial. We describe successful long-term use of ECMO support (48 days) for acquired virus-induced respiratory failure complicated by circulatory collapse following heart surgery.