Prenatal sonographic markers of the outcome in fetuses with bronchopulmonary sequestration.

PURPOSE: To evaluate the prenatal sonographic predictive markers of the outcome in fetuses with bronchopulmonary sequestration (BPS). METHODS: BPS size and diameter of the feeding artery (FA) were measured prenatally and postnatally. Velocity of the FA and the left ventricular-modified myocardial performance index (LV mod-MPI) were also evaluated prenatally. RESULTS: Forty-seven women were included in the study. Mean gestational age, mass size, diameter and velocity of the FA, and LV mod-MPI at prenatal diagnosis were 23.5 ± 2.2 weeks, 3.6 ± 8.3 cm, 2.3 ± 0.6 mm, 46.6 ± 15.4 cm/s, and 0.46 ± 0.06, respectively. Mean mass diameter and FA diameter measured on postnatal CT examinations were 3.8 ± 1.0 cm and 2.3 ± 0.7 mm, respectively. Five patients had respiratory symptoms after birth. Twenty children (43%) underwent or were scheduled to undergo mass excision, and the remaining 27 (57%) were doing well without any intervention. There was no neonatal death. LV mod-MPI at diagnosis, the FA diameter after birth and the serial change in the FA size were significantly associated with postnatal mass excision. CONCLUSION: The FA diameter and LV mod-MPI may be additional markers for predicting whether fetuses with BPS should undergo mass excision in early childhood or conservative care.

Sequential radiologic and functional pulmonary changes in patients with paraquat intoxication.

The sequential changes of paraquat-induced pulmonary damage were studied using high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) in long-term follow-up. Among the cohort of 27 patients who had ingested paraquat, the HRCT findings showed a normal (n = 14) and an abnormal group (n = 13). Increased paraquat ingestion in the abnormal group was associated with more rapid and severe pulmonary changes. Ground-glass opacity on HRCT peaked on day 7 after ingestion. Between 2 weeks and 1 month, consolidation increased and pulmonary fibrosis progressed, and slow improvements were observed for up to six months. Compared with the PFT results obtained at 1 and 6.5 months, FVC, FEV1, and diffusing capacity all improved slightly. Lung changes after paraquat intoxication are functionally and radiologically reversible following treatment.

Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to antiderecruitment strategy, etiological category of diffuse lung injury, and body position of the patient.

OBJECTIVE: To assess how the level of positive end-expiratory pressure (PEEP) (antiderecruitment strategy), etiological category of diffuse lung injury, and body position of the patient modify the effect of the alveolar recruitment maneuver (ARM) in acute respiratory distress syndrome (ARDS). DESIGN: Prospective clinical trial. SETTING: Medical intensive care unit at a tertiary hospital. PATIENTS: Forty-seven patients with early ARDS, including 19 patients from our preliminary study. INTERVENTION: From baseline ventilation at a tidal volume of 8 mL/kg and PEEP of 10 cm H2O, the ARM (a stepwise increase in the level of PEEP up to 30 cm H2O with a concomitant decrease in the magnitude of tidal volume down to 2 mL/kg) was given with (ARM + PEEP, n = 20) or without (ARM only, n = 19) subsequent increase of PEEP to 15 cm H2O. In eight other patients, PEEP was increased to 15 cm H2O without a preceding ARM (PEEP only). MEASUREMENTS AND RESULTS: In all three groups, Pao2 was increased by the respective intervention (all p<.05). In the ARM-only group, Pao2 at 15 mins after intervention was lower than Pao2 immediate after intervention (p =.046). In the ARM + PEEP group, no such decrease in Pao2 was observed, and Pao2 at 15, 30, 45, and 60 mins after intervention was higher than in the ARM-only group (all p<.05). Compared with the PEEP-only group, Pao2 of the ARM + PEEP group was higher immediately after intervention and at the later time points (all p <.05). Compared with patients with ARDS associated with direct lung injury (pulmonary ARDS), patients with ARDS associated with indirect lung injury (extrapulmonary ARDS) showed a greater increase in Pao2 (27 +/- 21% vs. 130 +/- 112%; p=.002) and a greater decrease in radiologic scores (1.0 +/- 2.4 vs. 3.4 +/- 1.5; p=.005) after the ARM. The increase in Pao2 induced by the ARM was greater for patients in the supine position than for patients in the prone position (61 +/- 82% vs. 21 +/- 14%; p=.028). Consequently, Pao immediately after the ARM was similar in the two groups of patients in different positions. CONCLUSIONS: After the ARM, a sufficient level of PEEP is required as an antiderecruitment strategy. Pulmonary ARDS and extrapulmonary ARDS may be different pathophysiologic entities. An effective ARM may obviate the need for the prone position in ARDS at least in terms of oxygenation.