Acute and sustained effects of early administration of inhaled nitric oxide to children with acute respiratory distress syndrome

OBJECTIVE: To determine the acute and sustained effects of early inhaled nitric oxide on some oxygenation indexes and ventilator settings and to compare inhaled nitric oxide administration and conventional therapy on mortality rate, length of stay in intensive care, and duration of mechanical ventilation in children with acute respiratory distress syndrome. DESIGN: Observational study. SETTING: Pediatric intensive care unit at a university-affiliated hospital. PATIENTS: Children with acute respiratory distress syndrome, aged between 1 month and 12 yrs. INTERVENTIONS: Two groups were studied: an inhaled nitric oxide group (iNOG, n = 18) composed of patients prospectively enrolled from November 2000 to November 2002, and a conventional therapy group (CTG, n = 21) consisting of historical control patients admitted from August 1998 to August 2000. MEASUREMENTS AND MAIN RESULTS: Therapy with inhaled nitric oxide was introduced as early as 1.5 hrs after acute respiratory distress syndrome diagnosis with acute improvements in Pao(2)/Fio(2) ratio (83.7%) and oxygenation index (46.7%). Study groups were of similar ages, gender, primary diagnoses, pediatric risk of mortality score, and mean airway pressure. Pao(2)/Fio(2) ratio was lower (CTG, 116.9 +/- 34.5; iNOG, 62.5 +/- 12.8, p <.0001) and oxygenation index higher (CTG, 15.2 [range, 7.2-32.2]; iNOG, 24.3 [range, 16.3-70.4], p <.0001) in the iNOG. Prolonged treatment was associated with improved oxygenation, so that Fio(2) and peak inspiratory pressure could be quickly and significantly reduced. Mortality rate for inhaled nitric oxide-patients was lower (CTG, ten of 21, 47.6%; iNOG, three of 18, 16.6%, p <.001). There was no difference in intensive care stay (CTG, 10 days [range, 2-49]; iNOG, 12 [range, 6-26], p >.05) or duration of mechanical ventilation (TCG, 9 days [range, 2-47]; iNOG, 10 [range, 4-25], p >.05). CONCLUSIONS: Early treatment with inhaled nitric oxide causes acute and sustained improvement in oxygenation, with earlier reduction of ventilator settings, which might contribute to reduce the mortality rate in children with acute respiratory distress syndrome. Length of stay in intensive care and duration of mechanical ventilation are not changed. Prospective trials of inhaled nitric oxide early in the setting of acute lung injury in children are needed.

Prognostic factors for perioperative pulmonary events among patients undergoing upper abdominal surgery

CONTEXTO E OBJETIVO: Associações significativas entre cirurgia do abdome superior e eventos pulmonares do período perioperatório foram investigadas em pacientes com condições pulmonares pré-operatórias submetidos a anestesia geral. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo cujos dados foram retirados de banco de dados obtidos prospectivamente de forma protocolada, de 1 de janeiro de 1999 a 31 de dezembro de 2004, em hospital universitário terciário. MÉTODOS: Estudados 3107 pacientes com mais de 11 anos, American Society of Anesthesiologists (ASA) I, II, III, com cirurgia de abdome superior sob anestesia geral, enviados à sala de recuperação. Condições pré-operatórias analisadas por regressão logística foram: idade, sexo, estado físico ASA, insuficiência cardíaca congestiva, asma, doença pulmonar obstrutiva crônica, insuficiência respiratória e hábito de fumar. Os resultados estudados, ou variáveis dependentes, incluíram eventos intra- e pós-operatórios: broncoespasmo, hipoxemia, hipercapnia, intubação prolongada e secreção de vias aéreas. RESULTADOS: Dos 3.107 pacientes: 1.540 eram homens, 1.649 mulheres, tinham média de 48 anos, 1088 ASA I, 1402 ASA II, 617 ASA III, com insuficiência cardíaca havia 80, asma, 82, doença pulmonar obstrutiva, 122, insuficiência respiratória, 21, hábito de fumar, 428. Pela regressão logística, sexo feminino (p < 0.001), idade maior que 70 anos (p < 0.01), hábito de fumar (p < 0.001) e doença pulmonar obstrutiva crônica (p < 0.02) influenciaram significativamente o desenvolvimento de eventos pulmonares, principalmente hipoxemia e broncospasmo, em ambos os períodos, mas não nos mesmos pacientes. Asma e insuficiência cardíaca não se associaram com eventos pulmonares na sala de recuperação. CONCLUSÃO: em cirurgia do abdome superior sob anestesia geral, sexo feminino, idade maior que 70 anos, hábito de fumar e doença pulmonar obstrutiva crônica foram fatores de risco independentes para a ocorrência de eventos pulmonares intra- e pós-operatórios.

Paracoccidioidomicose pulmonar agressiva, endotraqueíte estenosante e cor-pulmonale subagudo: descrição de um caso

A paracoccidioidomicose (Pbmicose) atinge os pulmões pela via inalatória, onde se estabelece o complexo primário semelhante ao da tuberculose. A traquéia comprometida pela via tubohemolinfática desenvolveria reação inflamatória em processo granulomatoso levando à obstrução estenosante com asíixia. Acompanhou-se um doente, masculino, 32 anos, branco, natural de Sarutaiá (SP), lavrador, que há 8 meses desenvolveu tosse expectorativa branco-amarelada, diária, sem fatores de melhora ou piora e dispnéia inicial discreta. Há 4 meses, anorexia, fraqueza e astenia. Há 1 mês a dispneia se agravou. Perdeu 15 kg. Tabagista e etilista há 16 anos. Exame físico revelou: PA 10/7 mmHg, FR = 28 bpm, peso 31 kg, hipocratismo digital e hipotrofia muscular Tórax enfisematoso e síndrome obstrutivo aos testes de função pulmonar. Coração: P2 desdobrada e hiperfonética. Hepatesplenomegalia. Desenvolveu cor-pulmonale e insuficiência adrenal à internação, evoluindo após 45 dias para óbito em insuficiência respiratória aguda asfixiante, apesar da terapia antifúngica ter sido completa. A literatura médica revista não mostrou registro de caso semelhante de cor-pulmonale e insuficiência adrenal de evolução subaguda.

Transplante pancreato-duodenal em ratos com microcirurgia. A téchnica e os resultados após 12 anos de experimentação

In this study we present the technical details, adaptations and modifications of the original procedure of pancreaticoduodenal transplantation in rats described by Lee et al. in 1972. We also present the results and technical failures observed in a follow-up of 12 years. From March, 1982 to December, 1994, we performed in the Laboratory of Surgical Technique and Experimental Surgery of Faculty of Medicine, Botucatu - UNESP, Brazil, 665 duodenopancreatectomies in donor rats and 592 surgeries for revascularization of the pancreatic graft in recipient animals. The observed percentage of technical failures in donor rats was 11% due to bleeding and/or vascular complications, irregular flushing of the graft with saline and respiratory insufficiency. In recipients of grafts, we observed a percentage of technical failures of 22,5% due to porto-caval thrombosis, vascular bleeding, pancreatitis and graft ischemia. In both surgeries, the successful results are directly related to the technical performance of the surgeon and the cares in the postoperative period.

Foreign body in the tracheobronchial tree

A 20-year experience with the treatment of 74 patients (83.8% children) for foreign body aspiration is reviewed. The object of this review is to show the clinical manifestations, the radiological findings, the nature and distribution in the bronchial tree, and complications due to longstanding (months or years) foreign bodies in the bronchial tree. The most common foreign bodies found were peanuts (13.5%), corn (13.5%), and beans (13.5%). The most frequent clinical manifestation was choking (67.5%), and the most frequent radiological finding was atelectasis (41.8%). The most serious complication was bronchiectasis needing resection in six patients who had the foreign body retained for years in the bronchial tree. In conclusion, in spite of an obvious foreign body in the tracheobronchial tree many cases are not diagnosed, and a longstanding foreign body in the airway may be responsible for irreversible complications.

Identificação das variáveis associadas à mortalidade de pacientes internados em unidade de terapia intensiva adulto

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Dificuldades na obtenção e caracterização de anticorpos monoclonais murinos anti-proteína F recombinante do vírus (RSV) para diagnóstico laboratorial

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Fatores de predição de mortalidade em pacientes com insuficiência respiratória crônica em uso de oxigenoterapia domiciliar prolongada

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery

BackgroundThis is an update of a Cochrane Review first published in The Cochrane Library 2008, Issue 3.Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry compared to no therapy or physiotherapy, including coughing and deep breathing, on all-cause postoperative pulmonary complications andmortality in adult patients admitted to hospital for upper abdominal surgery.ObjectivesOur primary objective was to assess the effect of incentive spirometry (IS), compared to no such therapy or other therapy, on postoperative pulmonary complications and mortality in adults undergoing upper abdominal surgery.Our secondary objectives were to evaluate the effects of IS, compared to no therapy or other therapy, on other postoperative complications, adverse events, and spirometric parameters.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE, EMBASE, and LILACS (from inception to August 2013). There were no language restrictions. The date of the most recent search was 12 August 2013. The original search was performed in June 2006.Selection criteriaWe included randomized controlled trials (RCTs) of IS in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures.Data collection and analysisTwo authors independently assessed trial quality and extracted data.Main resultsWe included 12 studies with a total of 1834 participants in this updated review. The methodological quality of the included studies was difficult to assess as it was poorly reported, so the predominant classification of bias was 'unclear'; the studies did not report on compliance with the prescribed therapy. We were able to include data from only 1160 patients in the meta-analysis. Four trials (152 patients) compared the effects of IS with no respiratory treatment. We found no statistically significant difference between the participants receiving IS and those who had no respiratory treatment for clinical complications (relative risk (RR) 0.59, 95% confidence interval (CI) 0.30 to 1.18). Two trials (194 patients) IS compared incentive spirometry with deep breathing exercises (DBE). We found no statistically significant differences between the participants receiving IS and those receiving DBE in the meta-analysis for respiratory failure (RR 0.67, 95% CI 0.04 to 10.50). Two trials (946 patients) compared IS with other chest physiotherapy. We found no statistically significant differences between the participants receiving IS compared to those receiving physiotherapy in the risk of developing a pulmonary condition or the type of complication. There was no evidence that IS is effective in the prevention of pulmonary complications.Authors' conclusionsThere is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large RCTs with high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

Cães e gatos: expressão das lesões em intoxicações criminais

Pós-graduação em Medicina Veterinária - FMVZ

Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial

Background: Chronic kidney disease (CKD) is one of the most serious public health problems. The increasing prevalence of CKD in developed and developing countries has led to a global epidemic. The hypothesis proposed is that patients undergoing dialysis would experience a marked negative influence on physiological variables of sleep and autonomic nervous system activity, compromising quality of life.Methods/Design: A prospective, consecutive, double blind, randomized controlled clinical trial is proposed to address the effect of dialysis on sleep, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life in patients with CKD. The measurement protocol will include body weight (kg); height (cm); body mass index calculated as weight/height(2); circumferences (cm) of the neck, waist, and hip; heart and respiratory rates; blood pressures; Mallampati index; tonsil index; heart rate variability; maximum ventilatory pressures; negative expiratory pressure test, and polysomnography (sleep study), as well as the administration of specific questionnaires addressing sleep apnea, excessive daytime sleepiness, depression, anxiety, stress, and quality of life.Discussion: CKD is a major public health problem worldwide, and its incidence has increased in part by the increased life expectancy and increasing number of cases of diabetes mellitus and hypertension. Sleep disorders are common in patients with renal insufficiency. Our hypothesis is that the weather weight gain due to volume overload observed during interdialytic period will influence the degree of collapsibility of the upper airway due to narrowing and predispose to upper airway occlusion during sleep, and to investigate the negative influences of haemodialysis in the physiological variables of sleep, and autonomic nervous system, and respiratory mechanics and thereby compromise the quality of life of patients.

Leukocytes respiratory burst and lysozyme level in pacu (Piaractus mesopotamicus Holmberg, 1887)

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Effect of Aloe vera extract on the improvement of the respiratory activity of leukocytes of matrinxã during the transport stress

This study evaluated the effect of extract of Aloe vera in the transport water of matrinxã (Brycon amazonicus) fish on stress response and leukocyte respiratory activity. Fish was transported for 4 h in water containing Aloe at levels 0; 0.02; 0.2 and 2 mg/L, and sampled before transport 2, 4, 24 and 96 h after for determination of plasma glucose and respiratory activity of leukocytes. An additional in vitro assay was conducted with another fish species, pacu (Piaractus mesopotamicus), to test the respiratory burst of leukocytes exposed to Aloe extract (0.0, phosphate-buffered saline (PBS) only) at 0.1, 0.2, 0.5 and 1 mg/L). Plasma glucose increased after 2 and 4 h of transport and returned to control levels within 24 h, but the addition of Aloe in the transport water did not affect the level of blood glucose. However, at 2 h of transport, Aloe enhanced the respiratory activity of leukocytes in a dose-dependent way. The highest value of respiratory burst activity of leukocytes was observed in the fish transported in water containing Aloe at 2 mg/L. The enhancing effect of the plant extract on the production of oxygen radicals was confirmed in vitro in leukocytes of pacu incubated in Aloe at concentrations 0.1 and 0.2 mg/L. The results suggest that Aloe vera is a modulator of the immune system in fish improving the innate immune response tested.

Effects of leaves of Ipomoea batatas (Convolvulaceae) on nest development and on respiratory metabolism of leaf-cutting ants Atta sexdens L. (Hym., Formicidae)

Laboratory colonies of the leaf-cutting ants Atta sexdens feed daily with leaves of Ipomoea batatas showed ant mortality and a significant decrease in the size of the fungal garden after the second week, with complete depletion of nests after 5 weeks of treatment. The mean oxygen consumption rate of these ants was higher than the control (ants collected from nests feed with leaves of Eucalyptus alba), suggesting a physiological action of the leaves of I. batatas on the ants in addition to the effect of inhibiting the growth of the fungal garden.

Respiratory metabolism of Camponotus rufipes ants: Brood and adults

The respiratory metabolism of immature forms (eggs, larvae, prepupae and pupae) of Camponotus rufipes (Hymenoptera: Formicidae) was studied at 25 degrees C, using a Warburg respirometer. Mean respiratory rates (mu l O gamma mg(-1) live weight.hr(-1)) for eggs, first instars, second instars, third instars, fourth instars, prepupae, and pupae were respectively: 2.53, 5.07, 1.23, 0.32, 0.22, 0.19 and 0.13. Adult workers with body mass between 20 and 30 mg had a mean respiratory rate of 0.43. The high respiratory rate in first instars probably reflects, besides the size influence, the metabolic costs of differentiation that occurs in this phase. (C) 1998 Published by Elsevier B.V.