Continuous positive airway pressure vs. pressure support ventilation in acute cardiogenic pulmonary edema: a randomized trial.

BACKGROUND: Both non-invasive continuous positive airway pressure (nCPAP) and non-invasive pressure support ventilation (nPSV) have been shown to be effective treatment for acute cardiogenic pulmonary edema (ACPE). In patients with severe ACPE who are treated with standard medical treatment, the baseline intubation rate is approximately 24%. STUDY OBJECTIVE: This study was conducted to compare the endotracheal intubation (ETI) rate using two techniques, nCPAP vs. nPSV. In addition, mortality rate, improvement in gas exchange, duration of ventilation, and hospital length of stay were also assessed. METHODS: This prospective, multi-center, randomized study enrolled 80 patients with ACPE who were randomized to receive nCPAP or nPSV (40 patients in each group) via an oronasal mask. Inclusion criteria were severe dyspnea, respiratory rate > 30 breaths/min, use of respiratory accessory muscles, or PaO(2)/FiO(2) < 200. RESULTS: ETI was required in 0 (0%) and in 3 (7.5%) patients in the nCPAP group and in the nPSV group, respectively (p = 0.241). No significant difference was observed in in-hospital mortality: 2 (5%) vs. 7 (17.5%) in nCPAP and nPSV groups, respectively (p = 0.154). No difference in hospital length of stay was observed between the two groups, nor was there a difference observed in duration of ventilation, despite a trend for reduced time with nPSV vs. nCPAP (5.91 ± 4.01 vs. 8.46 ± 7.14 h, respectively, p = 0.052). Both nCPAP and nPSV were effective in improving gas exchange, including in the subgroup of hypercapnic patients. CONCLUSIONS: Both methods are effective treatment for patients with ACPE. Non-invasive CPAP should be considered as the first line of treatment because it is easier to use and less expensive than non-invasive PSV.

Decrease in NTproBNP plasma levels indicates clinical improvement of acute decompensated heart failure.

Thirty-seven consecutive patients with acute decompensated heart failure (ADHF) admitted to emergency departments for acute dyspnea were investigated. Ten patients with acute exacerbation of chronic obstructive pulmonary disease and 10 patients with hypertension crisis were also included as controls. For each patient, a plasma amino-terminal pro-B-type natriuretic peptide (NTproBNP) concentration measurement was performed at admission, 4, 12, and 24 hours later, and on the day of discharge. In patients with ADHF, the observation of a progressive reduction to a complete relief of symptoms of heart failure was accompanied by a reduction of 58% of NTproBNP plasma levels on the day of discharge. Amelioration of symptoms was accompanied by improvement of physiologic parameters and New York Heart Association functional class. In the control population (chronic obstructive pulmonary disease and hypertension crisis patients), no significant variation of NTproBNP levels in comparison with those at admission was found at each time point. In conclusion, a plasma profile obtained with sequential measurements indicates that a significant decrease in NTproBNP levels is associated with the clinical improvement of patients with ADHF at the time of discharge.

[Asthma: current therapeutic approach]. / Asma bronchiale: iter terapeutico.

Asthma is a chronic reversible respiratory disease characterized by inflammation and bronchial smooth muscle contraction. The therapeutic approach must improve the acute symptoms, avoid disease exacerbations and prevent the pulmonary functional decay.

[A case of cardiogenic syncope in a drug-addict patient]. / Un caso di sincope di origine cardiogena in paziente farmaco-dipendente.

Torsade de pointes is a polymorphic ventricular tachycardia, associated with prolonged QT interval and characterized by twisting of the mean electrical axis of the QRS complexes around an isoelectric line. The long QT syndrome can be divided into two categories, congenital and acquired. The congenital long QT syndrome may be caused by some gene mutation, whereas the acquired form is usually associated with drugs and electrolyte imbalance. It usually remains asymptomatic or causes presyncope, although it may degenerate into ventricular fibrillation and may cause sudden death. The different presentation depends on the polymorphism that characterizes genotypic and phenotypic expression of proteic channel subunits, and on drug toxicity that provoke subunit dysfunction. The case report presented here is an example of prolonged QT interval syndrome in a patient with cocaine abuse and electrolyte disturbances.

Cardiopulmonary bypass in man: role of the intestine in a self-limiting inflammatory response with demonstrable bacterial translocation.

BACKGROUND: Cardiopulmonary bypass provokes a systemic inflammatory reaction that, in 1% to 2% of all cases, leads to multiorgan disfunction. The aim of this study was to evaluate the possible role of the intestine in the pathogenesis and development of this reaction. METHODS: Eleven selected patients scheduled for elective coronary artery bypass graft surgery were enrolled in a open, prospective clinical study. Gastric tonometry, chromium-labeled test and double sugar intestinal absorption tests, polymerase chain reaction microbial DNA test, and measurement of cytokines and transcriptional factor (nuclear factor kappaB) activation were performed. RESULTS: During the postoperative period, gastric pH remained stable (range,7.2 to 7.3). The partial pressure for carbon dioxide gradient between the gastric mucosa and arterial blood increased significantly (from 1 to 23 mm Hg), peaking in the sixth postoperative hour. Interleukin 6 increased significantly over basal levels, peaking 3 hours after cardiopulmonary bypass (96.3 versus 24 pg/mL). Nuclear factor kappaB never reached levels higher than those observed after lipopolysaccharide stimulation. Escherichia coli translocation was documented in 10 patients: in eight cases from removal of aortic cross-clamps and in two cases from the first postoperative hour. With respect to basal value (6.4%), the urine collection revealed a significant increase in excretion of the radioisotope during the first 24 hours after surgery (39.1%), although there were no significant variations with the double sugar test. CONCLUSIONS: The results obtained showed a correlation between the damage of the gastrointestinal mucosa, subsequent increased permeability, E coli bacteremia, and the activation of a self-limited inflammatory response in the absence of significant macrocirculatory changes and postoperative complications.

[Hibernating and stunned myocardium. Pathogenetic mechanisms during and after myocardial ischemia]. / Miocardio ibernato e stordito. Meccanismi patogenetici durante e dopo ischemia miocardica.

In this paper the Authors consider the concept of stunning/hibernating myocardium, analizing the most recent articles and reviews in literature, until April 2002 (database PubMed). Dysfunctional segments with normal perfusion and normal glucose utilization are considered to be "stunned", and dysfunctional segments with reduced perfusion and preserved glucose utilization are considered to be "hibernated". Together with the two major hypothesis (generation of oxygen-derived free radicals and transient calcium overload) in developing of dysfunctional myocardium after ischaemia, recent studies have demonstrated an important role in down-regulation of beta-adrenergic receptors both in the stunned and in the hibernated segments. Moreover, the increase of negatively inotropic cytokines TNF-alpha and NOS2 has been observed in dysfunctional segments. The number of copies of mRNA has been quantified by reverse transcription-polymerase chain reaction (reverse-PCR).