Characteristics and outcome of traumatic chest injury patients visited a specialized hospital in Addis Ababa, Ethiopia: A one-year retrospective study.

PURPOSE: Injury continues to be an important cause of morbidity and mortality in both developed and developing countries. Globally, it is responsible for approximately 5.8 million deaths per year and 91% of these deaths occur in developing countries. Road traffic collision, suicides and homicides are the leading cause of traumatic deaths. Despite the fact that traumatic chest injury is being responsible for 10% of all trauma-related hospital admissions and 25% of trauma-related deaths across the world including in Ethiopia, only few published studies showed the burden of traumatic chest injury in Ethiopia. So, this study aims at assessing the characteristics and outcome of traumatic chest injury patients visited Tikur Anbesa Specialized Hospital (TASH) over one year period. METHODS: A single center based retrospective study was done. We collected data from patients' records to assess characteristics and outcome of traumatic chest injury at TASH over one year period. All patients diagnosed with traumatic chest injury and received treatment at the hospital from January 1 to December 31, 2016 regardless of its types and severity levels were included in the study. Patients with incomplete medical records for at least 20% of the study variables and without detailed medical history, or patients died before receiving any health care were excluded from the study. The collected data were cleaned and entered into Epidata version 3.1 and exported to SPSS Version 21.0 for analysis. Bivariate and multivariate logistic regression models were used to examine factors associated with outcome of traumatic chest injury patients. RESULTS: A total of 192 chest injury patients were included in the study and about one-fourth of chest injury victims were died during treatment period in TASH. Road traffic collision (RTC) was the leading cause of morbidity and mortality among traumatic chest injury victims. Age of the victims (adjusted odds ratio (AOR) 8.9, 95% confidence interval (CI) 1.51-53.24), time elapsed between the occurrence of traumatic chest injury and admission to health care facilities (AOR 4.6, 95% CI 1.19-18.00), length of stay in hospital (AOR 0.12, 95% CI 0.02-0.58), presence of multiple extra-thoracic injury (AOR 25, 95% CI 4.18-150.02) and development of complications (AOR 23, 95% CI 10-550) were factors associated with death among traumatic chest injury patients in this study. CONCLUSION: RTC contributed for a considerable number of traumatic chest injuries in this study. Old age, delay in delivering the victim to health care facilities, length of stay in hospital, and development of atelectasis and pneumonia were associated with death among traumatic chest injury patients. Road safety interventions, establishment of organized pre-hospital services, and early recognition and prompt management of traumatic chest injury related complications are urgently needed to overcome the underlying problems in the study setting.

Comparative outcomes of inpatients with lung collapse managed by bronchoscopic or conservative means.

Background: Although the incidence and prevalence of atelectatic lung collapse is unknown, such events are common among inpatients, and there are no guidelines for optimally instituting bronchoscopic techniques. The aim of this study was to evaluate the outcomes of patients with complete or near-complete lung collapse managed via interventional flexible fibreoptic bronchoscopy or a conservative approach. Methods: Retrospective analysis of all adult patients admitted to BronxCare Health System between January 2011 and October 2017 with a diagnosis of lung collapse/atelectasis. The primary outcome was radiological resolution. Timing of bronchoscopy relative to radiological resolution and mortality served as secondary outcomes. Results: Of the 177 patients meeting inclusion criteria, 149 (84%) underwent bronchoscopy and 28 (16%) were managed through conservative measures only. A significantly greater number of patients in the bronchoscopy group achieved complete or near-complete resolution on chest X-ray, compared with the conservative group (p=0.007). Timing of bronchoscopy had no impact on the rate of radiological resolution, and mortality in the two groups was similar. New endobronchial malignancies were identified in 21 patients (14%). Conclusions: Our data support the central role of bronchoscopy in instances of complete or near-complete lung collapse, ensuring better radiological outcomes. Judicious use of conservative management is warranted to avoid missing significant pathology. A prime consideration in this setting is obstructive malignancy.

The effects of recruitment maneuver during noninvasive ventilation after coronary bypass grafting: A randomized trial.

OBJECTIVE: Pulmonary impairment is a common complication after coronary artery bypass graft procedure and may be prevented or treated by noninvasive ventilation. Recruitment maneuvers include sustained airway pressure with high levels of positive end-expiratory pressure in patients with hypoxemia, favoring homogeneous pulmonary ventilation and oxygenation. This study aimed to evaluate whether noninvasive ventilation with recruitment maneuver could safely improve oxygenation in patients with atelectasis and hypoxemia who underwent a coronary artery bypass grafting procedure. METHODS: Thirty-four patients admitted to our intensive care unit undergoing mechanical ventilation after surgery, with ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 300 and radiologic atelectasis score ≥2, were included. The control group consisted of 16 randomized patients and the recruitment group consisted of 18 patients. After extubation, noninvasive ventilation was applied for 30 minutes 3 times a day with positive end-expiratory pressure of 8 cm H2O. The recruitment group received recruitment maneuver with positive end-expiratory pressure of 15 cm H2O and 20 cm H2O for 2 minutes each during noninvasive ventilation. We analyzed the arterial oxygen partial pressure in room air, radiologic atelectasis score, hemodynamic stability, and adverse events from extubation until discharge. RESULTS: Arterial oxygen partial pressure increased 12.6% ± 6.8% in the control group and 23.3% ± 8.5% in the recruitment group (P < .001). The radiologic atelectasis score was completely improved for 94.4% of the recruitment group with no adverse events, whereas 87.5% of the control group presented some atelectasis (P < .001). CONCLUSIONS: Noninvasive ventilation with recruitment maneuvers is safe, improves oxygenation, and reduces atelectasis in patients undergoing coronary artery bypass.

Effects of intraoperative PEEP optimization on postoperative pulmonary complications and the inflammatory response: study protocol for a randomized controlled trial.

BACKGROUND: Patients undergoing general anesthesia and mechanical ventilation during major abdominal surgery commonly develop pulmonary atelectasis and/or hyperdistention of the lungs. Recent studies show benefits of lung-protective mechanical ventilation with the use of low tidal volumes, a moderate level of positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers during general anesthesia, even in patients with healthy lungs. The purpose of this clinical trial is to evaluate the effects of intraoperative lung-protective mechanical ventilation, using individualized PEEP values, on postoperative pulmonary complications and the inflammatory response. METHODS/DESIGN: A total number of 40 patients with bladder cancer undergoing open radical cystectomy and urinary diversion (ileal conduit or orthotopic bladder substitute) will be enrolled and randomized into a study (SG) and a control group (CG). Standard lung-protective ventilation with a PEEP of 6 cmH2O will be applied in the CG and an optimal PEEP value determined during a static pulmonary compliance (Cstat)-directed PEEP titration procedure will be used in the SG. Low tidal volumes (6 mL/Kg ideal bodyweight) and a fraction of inspired oxygen of 0.5 will be applied in both groups. After surgery both groups will receive standard postoperative management. Primary endpoints are postoperative pulmonary complications and serum procalcitonin kinetics during and after surgery until the third postoperative day. Secondary and tertiary endpoints will be: organ dysfunction as monitored by the Sequential Organ Failure Assessment Score, in-hospital stay, 28-day and in-hospital mortality. DISCUSSION: This trial will assess the possible benefits or disadvantages of an individualized lung-protective mechanical ventilation strategy during open radical cystectomy and urinary diversion regarding postoperative pulmonary complications and the inflammatory response. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02931409 . Registered on 5 October 2016.

Association Between Expiratory Central Airway Collapse and Respiratory Outcomes Among Smokers.

IMPORTANCE: Central airway collapse greater than 50% of luminal area during exhalation (expiratory central airway collapse [ECAC]) is associated with cigarette smoking and chronic obstructive pulmonary disease (COPD). However, its prevalence and clinical significance are unknown. OBJECTIVE: To determine whether ECAC is associated with respiratory morbidity in smokers independent of underlying lung disease. DESIGN, SETTING, AND PARTICIPANTS: Analysis of paired inspiratory-expiratory computed tomography images from a large multicenter study (COPDGene) of current and former smokers from 21 clinical centers across the United States. Participants were enrolled from January 2008 to June 2011 and followed up longitudinally until October 2014. Images were initially screened using a quantitative method to detect at least a 30% reduction in minor axis tracheal diameter from inspiration to end-expiration. From this sample of screen-positive scans, cross-sectional area of the trachea was measured manually at 3 predetermined levels (aortic arch, carina, and bronchus intermedius) to confirm ECAC (>50% reduction in cross-sectional area). EXPOSURES: Expiratory central airway collapse. MAIN OUTCOMES AND MEASURES: The primary outcome was baseline respiratory quality of life (St George's Respiratory Questionnaire [SGRQ] scale 0 to 100; 100 represents worst health status; minimum clinically important difference [MCID], 4 units). Secondary outcomes were baseline measures of dyspnea (modified Medical Research Council [mMRC] scale 0 to 4; 4 represents worse dyspnea; MCID, 0.7 units), baseline 6-minute walk distance (MCID, 30 m), and exacerbation frequency (events per 100 person-years) on longitudinal follow-up. RESULTS: The study included 8820 participants with and without COPD (mean age, 59.7 [SD, 6.9] years; 4667 [56.7%] men; 4559 [51.7%] active smokers). The prevalence of ECAC was 5% (443 cases). Patients with ECAC compared with those without ECAC had worse SGRQ scores (30.9 vs 26.5 units; P < .001; absolute difference, 4.4 [95% CI, 2.2-6.6]) and mMRC scale scores (median, 2 [interquartile range [IQR], 0-3]) vs 1 [IQR, 0-3]; P < .001]), but no significant difference in 6-minute walk distance (399 vs 417 m; absolute difference, 18 m [95% CI, 6-30]; P = .30), after adjustment for age, sex, race, body mass index, forced expiratory volume in the first second, pack-years of smoking, and emphysema. On follow-up (median, 4.3 [IQR, 3.2-4.9] years), participants with ECAC had increased frequency of total exacerbations (58 vs 35 events per 100 person-years; incidence rate ratio [IRR], 1.49 [95% CI, 1.29-1.72]; P < .001) and severe exacerbations requiring hospitalization (17 vs 10 events per 100 person-years; IRR, 1.83 [95% CI, 1.51-2.21]; P < .001). CONCLUSIONS AND RELEVANCE: In a cross-sectional analysis of current and former smokers, the presence of ECAC was associated with worse respiratory quality of life. Further studies are needed to assess long-term associations with clinical outcomes.

Positive end-expiratory pressure (PEEP) during anaesthesia for prevention of mortality and postoperative pulmonary complications.

BACKGROUND: General anaesthesia causes atelectasis, which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre that increases functional residual capacity (FRC) and prevents collapse of the airways, thereby reducing atelectasis. It is not known whether intraoperative PEEP alters the risks of postoperative mortality and pulmonary complications. This review was originally published in 2010 and was updated in 2013. OBJECTIVES: To assess the benefits and harms of intraoperative PEEP in terms of postoperative mortality and pulmonary outcomes in all adult surgical patients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 10, part of The Cochrane Library, as well as MEDLINE (via Ovid) (1966 to October 2013), EMBASE (via Ovid) (1980 to October 2013), CINAHL (via EBSCOhost) (1982 to October 2013), ISI Web of Science (1945 to October 2013) and LILACS (via BIREME interface) (1982 to October 2010). The original search was performed in January 2010. SELECTION CRITERIA: We included randomized clinical trials assessing the effects of PEEP versus no PEEP during general anaesthesia on postoperative mortality and postoperative respiratory complications in adults, 16 years of age and older. DATA COLLECTION AND ANALYSIS: Two review authors independently selected papers, assessed trial quality and extracted data. We contacted study authors to ask for additional information, when necessary. We calculated the number of additional participants needed (information size) to make reliable conclusions. MAIN RESULTS: This updated review includes two new randomized trials. In total, 10 randomized trials with 432 participants and four comparisons are included in this review. One trial had a low risk of bias. No differences were demonstrated in mortality, with risk ratio (RR) of 0.97 (95% confidence interval (CI) 0.20 to 4.59; P value 0.97; 268 participants, six trials, very low quality of evidence (grading of recommendations assessment, development and evaluation (GRADE)), and in pneumonia, with RR of 0.40 (95% CI 0.11 to 1.39; P value 0.15; 120 participants, three trials, very low quality of evidence (GRADE)). Statistically significant results included the following: The PEEP group had higher arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) on day one postoperatively, with a mean difference of 22.98 (95% CI 4.40 to 41.55; P value 0.02; 80 participants, two trials, very low quality of evidence (GRADE)), and postoperative atelectasis (defined as an area of collapsed lung, quantified by computerized tomography scan) was less in the PEEP group (standard mean difference -1.2, 95% CI -1.78 to -0.79; P value 0.00001; 88 participants, two trials, very low quality of evidence (GRADE)). No adverse events were reported in the three trials that adequately measured these outcomes (barotrauma and cardiac complications). Using information size calculations, we estimated that a further 21,200 participants would have to be randomly assigned to allow a reliable conclusion about PEEP and mortality. AUTHORS' CONCLUSIONS: Evidence is currently insufficient to permit conclusions about whether intraoperative PEEP alters risks of postoperative mortality and respiratory complications among undifferentiated surgical patients.

Efficacy of recruitment maneuver for improving the brain dead marginal lungs to ideal.

BACKGROUND: Because of the shortage of lungs for transplantation, finding the suitable lungs in brain-dead donors is an important issue. Recruitment maneuver is a strategy aimed at re-expanding collapsed and edematous lung tissue. The aim of this study was to assess the efficacy of this maneuver on improving marginal lungs for transplantation. METHODS: From 127 brain-dead potential donor which were evaluated for lung donation in Masih Daneshvari Organ Procurement Unit of Tehran, Iran, 31 (25%) had marginal lungs for transplantation. These donors had normal chest X ray or bilateral infiltration and had PaO2 200-300 mm Hg with FIO2 100%. The recruitment maneuver was performed and arterial blood gas was obtained before and after maneuver. The maneuver lasts for 2 hours with continuous check of O2 saturation and patient's hemodynamic during. Finally, patients with normal bronchoscopy and PaO2/FIO2 >300 mm Hg were considered good candidates for lung transplantation. The frequency (%) and mean ± SD were used for description of variables and the Wilcoxon test was used for comparison between pre- and post-maneuver PaO2 with FIO2 100%. RESULTS: The mean ± SD of PaO2/FIO2 with 100% FIO2 of patients before and after recruitment were 239 ± 62 and 269 ± 91, respectively. Recruitment maneuver could convert 10 marginal lungs (32%) to appropriate ones (PaO2 > 300) and finally 8 lungs were transplanted. CONCLUSIONS: Findings of this study showed that recruitment maneuver could convert inappropriate lungs to appropriate ones in one third of brain-dead patients who had marginal lung condition. So, it is recommended that this maneuver is considered in the assessment protocol of lungs for donation.

Long-term results of lung decortication in patients with trapped lung secondary to coronary artery bypass grafting.

PURPOSE: To evaluate long-term results of decortications in patients with symptomatic restrictive pleurisy and trapped lung after coronary bypass grafting. METHODS: Twenty consecutive patients undergoing lung decortications for trapped lung after coronary bypass grafting were prospectively evaluated. Pulmonary function tests were used as objective criteria, and quality of life was assessed by the Medical Research Council dyspnea scale. A p value <0.05 was considered significant. RESULTS: Twenty patients, 3 women and 17 men, with a median age of 59 years were evaluated. The median time interval between coronary bypass grafting and decortications was 9.3 months. The mean preoperative forced expiratory volume in one second and forced vital capacity were 63.8% ± 7.4% and 50.5% ± 6.6% of the predicted value, respectively, and the improvement rates after decortications were 14.97% ± 6.3% and 17.62% ± 6.38%, respectively. Dyspnea scores improved after decortications (p <0.05). The median follow-up was 25 months. After surgery, 3 patients developed superficial wound infections, and out of 7 patients with prolonged air leaks, 2 underwent re-operation. After surgery, one patient died on day 34 and another, after 3 years. CONCLUSION: Lung decortications, re-expanding the affected lung, ensures symptom remission and improves quality of life of patients with trapped lung after coronary bypass grafting in the long-term.

[Clinical analysis of interventional bronchoscopy for the treatment of malignant obstructive atelectasis].

BACKGROUND: Obstructive atelectasis is frequently accompanied by pulmonary infection and hypoxia. The key to treating this condition is by directly reopening the obstructive airway. The aim of the present study is to explore the safety and efficacy of interventional bronchoscopy for the treatment of malignant obstructive atelectasis. METHODS: A total of 120 cases with pathology-proved malignant obstructive atelectasis were retrospectively analyzed for the treatment of argon plasma coagulation and cryosurgery under bronchoscopy. Patients' age is between 5 and 90 years old. RESULTS: A total of 120 cases had 187 atelectasis originating from 98 lesions with primary airway tumors and 89 with metastases. The most common location of atelectasis was in the upper lobe in the primary group and in the single lung in the metastasis group. Although there was no significant difference in tumor debulging between the two groups, the reopening rate of atelectasis was lower in the primary group than that in the metastasis group. The Karnofsky physical score significantly increased, and shortbreath scale decreased after interventional bronchoscopy. Among the patients, 3/4 had hypoxemia and 3.4% had severe bleeding, which caused the death of 1 patient during a procedure. The mean survival time was 6 months, and the survival rate of 1 year was 27.1%. CONCLUSIONS: Bronchoscopy can rapidly and effectively debulge the airway tumor and reopen the atelectasis.

Decreased respiratory system compliance on the sixth day of mechanical ventilation is a predictor of death in patients with established acute lung injury.

BACKGROUND: Multiple studies have identified single variables or composite scores that help risk stratify patients at the time of acute lung injury (ALI) diagnosis. However, few studies have addressed the important question of how changes in pulmonary physiologic variables might predict mortality in patients during the subacute or chronic phases of ALI. We studied pulmonary physiologic variables, including respiratory system compliance, P/F ratio and oxygenation index, in a cohort of patients with ALI who survived more than 6 days of mechanical ventilation to see if changes in these variables were predictive of death and whether they are informative about the pathophysiology of subacute ALI. METHODS: Ninety-three patients with ALI who were mechanically ventilated for more than 6 days were enrolled in this prospective cohort study. Patients were enrolled at two medical centers in the US, a county hospital and a large academic center. Bivariate analyses were used to identify pulmonary physiologic predictors of death during the first 6 days of mechanical ventilation. Predictors on day 1, day 6 and the changes between day 1 and day 6 were compared in a multivariate logistic regression model. RESULTS: The overall mortality was 35%. In multivariate analysis, the PaO2/FiO2 (OR 2.09, p < 0.04) and respiratory system compliance (OR 3.61, p < 0.01) were predictive of death on the 6th day of acute lung injury. In addition, a decrease in respiratory system compliance between days 1 and days 6 (OR 2.14, p < 0.01) was independently associated with mortality. CONCLUSIONS: A low respiratory system compliance on day 6 or a decrease in the respiratory system compliance between the 1st and 6th day of mechanical ventilation were associated with increased mortality in multivariate analysis of this cohort of patients with ALI. We suggest that decreased respiratory system compliance may identify a subset of patients who have persistent pulmonary edema, atelectasis or the fibroproliferative sequelae of ALI and thus are less likely to survive their hospitalization.

Atelectasis and survival after bronchoscopic lung volume reduction for COPD.

Bronchoscopic therapies to reduce lung volumes in chronic obstructive pulmonary disease are intended to avoid the risks associated with lung volume reduction surgery (LVRS) or to be used in patient groups in whom LVRS is not appropriate. Bronchoscopic lung volume reduction (BLVR) using endobronchial valves to target unilateral lobar occlusion can improve lung function and exercise capacity in patients with emphysema. The benefit is most pronounced in, though not confined to, patients where lobar atelectasis has occurred. Few data exist on their long-term outcome. 19 patients (16 males; mean±sd forced expiratory volume in 1 s 28.4±11.9% predicted) underwent BLVR between July 2002 and February 2004. Radiological atelectasis was observed in five patients. Survival data was available for all patients up to February 2010. None of the patients in whom atelectasis occurred died during follow-up, whereas eight out of 14 in the nonatelectasis group died (Chi-squared p=0.026). There was no significant difference between the groups at baseline in lung function, quality of life, exacerbation rate, exercise capacity (shuttle walk test or cycle ergometry) or computed tomography appearances, although body mass index was significantly higher in the atelectasis group (21.6±2.9 versus 28.4±2.9 kg·m(-2); p<0.001). The data in the present study suggest that atelectasis following BLVR is associated with a survival benefit that is not explained by baseline differences.

Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery.

Over the past decades, major progress in patient selection, surgical techniques and anaesthetic management have largely contributed to improved outcome in lung cancer surgery. The purpose of this study was to identify predictors of post-operative cardiopulmonary morbidity in patients with a forced expiratory volume in 1 s <80% predicted, who underwent cardiopulmonary exercise testing (CPET). In this observational study, 210 consecutive patients with lung cancer underwent CPET with completed data over a 9-yr period (2001-2009). Cardiopulmonary complications occurred in 46 (22%) patients, including four (1.9%) deaths. On logistic regression analysis, peak oxygen uptake (peak V'(O2) and anaesthesia duration were independent risk factors of both cardiovascular and pulmonary complications; age and the extent of lung resection were additional predictors of cardiovascular complications, whereas tidal volume during one-lung ventilation was a predictor of pulmonary complications. Compared with patients with peak V'(O2) >17 mL·kg⁻¹·min⁻¹, those with a peak V'(O2) <10 mL·kg⁻¹·min⁻¹ had a four-fold higher incidence of cardiac and pulmonary morbidity. Our data support the use of pre-operative CPET and the application of an intra-operative protective ventilation strategy. Further studies should evaluate whether pre-operative physical training can improve post-operative outcome.

Prognosis and staging of superficial endobronchial lung cancer: the impact of invasion depth, tumor diameter, and coexistent pneumonitis or atelectasis.

BACKGROUND: There are few reports discussing the surgical pathological characteristics of superficial endobronchial lung cancer (SELC) defined as cancer growth limited to the bronchial wall. Its prognosis and corresponding TNM staging have not been fully clarified. Little is known as to whether T status is impacted by the existence of associated atelectasis or pneumonia (which might be controversial, indicating either T1 or T2), and circumstantial invasion depth. METHODS: Between 1988 and 2007, 81 out of 8817 surgically treated patients met SELC criteria; there was no detectable invasion beyond the bronchial wall. A retrospective review was performed and follow-up information was collected. RESULTS: The overall five-year survival rate of 81 patients was 85.6%; for N0M0 (n = 67), N1M0 (n = 7) and N2M0 (n = 7) patients, they were 89.3%, 75.0% and 60.0%, respectively. Intraluminal tumor size measured from 0.4 to 3.0 cm; obstructive atelectasis or pneumonia was noted in 14 patients. The presence of tumor-associated obstructive atelectasis or pneumonia did not have a significant impact upon prognosis (P = 0.96), nor did the greatest diameter of the tumor (P = 0.70). Histology showed carcinoma in situ (level one) in 13 cases; invasion of the submucosal layer (level two) in 12, involvement of the muscular layer (level three) in 20, invasion into the space between the muscular layer and cartilage (level four) in 21, and bronchial cartilage infiltration in 15 (level five). In cases without lymphnode metastases, five-year survival was 100% for the first three levels and 84.0% and 61.3% for the level four and level five. CONCLUSIONS: Relative to TNM-based prognostic data, superficial endobronchial lung cancer exhibits increased five-year survival rates, and therefore should be placed at the forefront among tumors in the T1 class, regardless of tumor size or the presence of secondary obstructive atelectasis or pneumonia. Lymphnode metastasis is associated with a worse prognosis. Survival is negatively impacted by tumor infiltration depth into the bronchial wall.

Positive end-expiratory pressure (PEEP) during anaesthesia for the prevention of mortality and postoperative pulmonary complications.

BACKGROUND: General anaesthesia causes atelectasis which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre which increases functional residual capacity (FRC) and prevents collapse of the airways thereby reducing atelectasis. It is not known whether intra-operative PEEP alters the risk of postoperative mortality and pulmonary complications. OBJECTIVES: To assess the benefits and harms of intraoperative PEEP, for all adult surgical patients, on postoperative mortality and pulmonary outcomes. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (via Ovid) (1966 to January 2010), EMBASE (via Ovid) (1980 to January 2010), CINAHL (via EBSCOhost) (1982 to January 2010), ISI Web of Science (1945 to January 2010) and LILACS (via BIREME interface) (1982 to January 2010). SELECTION CRITERIA: We included randomized clinical trials that evaluated the effect of PEEP versus no PEEP, during general anaesthesia, on postoperative mortality and postoperative respiratory complications. We included studies irrespective of language and publication status. DATA COLLECTION AND ANALYSIS: Two investigators independently selected papers, extracted data that fulfilled our outcome criteria and assessed the quality of all included trials. We undertook pooled analyses, where appropriate. For our primary outcome (mortality) and two secondary outcomes (respiratory failure and pneumonia), we calculated the number of further patients needed (information size) in order to make reliable conclusions. MAIN RESULTS: We included eight randomized trials with a total of 330 patients. Two trials had a low risk of bias. There was no difference demonstrated for mortality (relative risk (RR) 0.95, 95% CI 0.14 to 6.39). Two statistically significant results were found: the PEEP group had a higher PaO(2)/FiO(2) on day 1 postoperatively (mean difference (MD) 22.98, 95% CI 4.40 to 41.55) and postoperative atelectasis (defined as an area of collapsed lung, quantified by computerized tomography (CT) scan) was less in the PEEP group (SMD -1.2, 95% CI -1.78 to -0.79). There were no adverse events reported in the three trials that adequately measured these outcomes (barotrauma and cardiac complications). Using information size calculations, we estimated that a further 21,200 patients would need to be randomized in order to make a reliable conclusion about PEEP and mortality. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to make conclusions about whether intraoperative PEEP alters the risk of postoperative mortality and respiratory complications among undifferentiated surgical patients.

Atelectasias perioperatorias y maniobras de reclutamiento alveolar / Peri-Operative Atelectasis and Alveolar Recruitment Manoeuvres

Las complicaciones respiratorias postoperatorias constituyen una causa importante de morbimortalidad. Las atelectasias perioperatorias, en concreto, afectan hasta al 90% de los pacientes quirúrgicos y su repercusión puede prolongarse en el tiempo en forma de alteraciones de la mecánica respiratoria, de la circulación pulmonar y de hipoxemia. El colapso alveolar se produce en presencia de ciertos factores predisponentes, fundamentalmente por mecanismos de compresión y absorción. Para prevenir o tratar estas atelectasias, se han propuesto diversas estrategias terapéuticas, como las maniobras de reclutamiento alveolar, cuyo uso se ha popularizado en los últimos años. Su aplicación en pacientes con colapso alveolar, pero sin lesión pulmonar aguda previa relevante, presenta ciertas particularidades, por lo que su empleo no está exento de incertidumbres y complicaciones. Esta revisión describe la frecuencia, la fisiopatología, la relevancia y el tratamiento de las atelectasias perioperatorias, y hace especial incidencia en el tratamiento con maniobras de reclutamiento con el objetivo de proporcionar las bases para un empleo racional y adecuado de éstas(AU)

Respiratory complications are a significant cause of post-operative morbidity and mortality. Peri-operative atelectasis, in particular, affects 90% of surgical patients and its effects can be prolonged, due to changes in respiratory mechanics, pulmonary circulation and hypoxaemia. Alveolar collapse is caused by certain predisposing factors, mainly by compression and absorption mechanisms. To prevent or treat these atelectasis several therapeutic strategies have been proposed, such as alveolar recruitment manoeuvres, which has become popular in the last few years. Its application in patients with alveolar collapse, but without a previous significant acute lung lesion, has some special features, therefore its use is not free of uncertainties and complications. This review describes the frequency, pathophysiology, importance and treatment of peri-operative atelectasis. Special attention is paid to treatment with recruitment manoeuvres, with the purpose of providing a basis for the their rational and appropriate use(AU)

[Respiratory complications of accidental drownings in children]. / Complications respiratoires des noyades accidentelles chez l'enfant.

Accidental drownings are severe and sometimes mortal events in children. Our study aims to better clarify the epidemiology and the respiratory complications of these accidents in our hospital. We led a retrospective study over 10 years concerning the children hospitalized for accidental drowning in our hospital centre. Age at the moment of the accident, sex, history of accident, hospitable care, thoracic imaging and neurological outcome of the children were studied. In total, 83 children were hospitalized (5 years on average, 70% being boys). The drowning especially took place in fresh water (71%), particularly in swimming pools (51.8%). Stages III and IV of drowning concerned 40.9% of the population. The coverage was the following one: admittance in ICU 57.8%, mechanical ventilation 34.9%, oxygen therapy 16.9%, antibiotics 87.9%. A normal chest x-ray was present in 45.7% of the cases. Drowning in fresh water, especially in contaminated fresh water (canal, WC, etc.), induced atelectasis (10.8%), whereas drowning in sea water induced diffuse infiltrates (8.4%). Aspiration pneumonia (33.7%) was present in both cases and a pulmonary oedema (6%) was only noticed during stage IV drowning. The secondary infections were rare (1 case was suspected and another probable). A child presented a secondary acute respiratory distress syndrome (1.2 %). Finally, 7 deaths (8.4%) and 1 case with severe neurological sequelae (1.2%) were noted. Accidental drowning causes important consequences in children. The long-term respiratory outcomes have not been properly studied. Prevention of such accidents is based on parental vigilance during their child's bathe.

The favorable prognostic significance of atelectasis in patients with advanced non-small cell lung cancer: results of a prospective observational study.

PURPOSE: For lung cancer, the TNM staging system included atelectasis (At) as a negative prognostic factor, within the T category. However, according to our clinical experience, we observed the opposite. The aim of the study was to evaluate the influence of At on patient outcome for unresectable stage III and IV non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: We prospectively evaluated the patient survival data, in correlation with the presence, At(+), or absence, At(-), of At. A distinct analysis according to stage was preplanned. Univariate and multivariate analysis were performed to refine the prognostic significance of At. RESULTS: We evaluated 1352 consecutively treated patients, during 1997-2004. Sixty-eight patients (5%) were identified with At, of which 46/592 (8%) were in stage III, and 22/760 (3%) were in stage IV. The survival data were significantly better for patients At(+) vs. At(-); median overall survival (OS): 21 months (95% confidence interval [CI], 12.37-29.63) vs. 10 months (95% CI, 9.25-10.75) (p<0.001), and median progression free survival (PFS):17 months (95% CI, 11.71-22.29) vs. 7 months (95% CI, 6.48-7.52) (p<0.001). The most consistent difference, favoring patients At(+), was noted for patients in stage III, with OS: 24 months (95% CI, 18.65-29.35) vs. 14 months (95% CI, 12.43-15.57) (p<0.001), and PFS: 19 months (95% CI, 12.11-25.89) vs. 8 months (95% CI, 6.89-9.02) (p<0.001). In stage IV, we noted a non-significant trend toward improved survival in patients At(+); OS: 16 months (95% CI, 4.49-27.51) vs. 9 months (95% CI, 8.51-9.49) (p=0.21), and PFS: 8 months (95% CI, 5.80-10.20) vs. 6 months (95% CI, 5.36-6.64) (p=0.12). The multivariate analysis showed that At, stage and ECOG performance status were independent predictors for survival. CONCLUSION: At predicts a better survival in patients with advanced NSCLC. The prognostic value is more stringent for stage III patients. Inclusion of At as a negative prognostic factor in the TNM staging system warrants further evaluation.

Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.

OBJECTIVE: To assess differences in mortality between late-preterm (34-36 weeks) and term (37-41 weeks) infants. STUDY DESIGN: We used US period-linked birth/infant death files for 1995 to 2002 to compare overall and cause-specific early-neonatal, late-neonatal, postneonatal, and infant mortality rates between singleton late-preterm infants and term infants. RESULTS: Significant declines in mortality rates were observed for late-preterm and term infants at all age-at-death categories, except the late-neonatal period. Despite the decline in rates since 1995, infant mortality rates in 2002 were 3 times higher in late-preterm infants than term infants (7.9 versus 2.4 deaths per 1000 live births); early, late, and postneonatal rates were 6, 3, and 2 times higher, respectively. During infancy, late-preterm infants were approximately 4 times more likely than term infants to die of congenital malformations (leading cause), newborn bacterial sepsis, and complications of placenta, cord, and membranes. Early-neonatal cause-specific mortality rates were most disparate, especially deaths caused by atelectasis, maternal complications of pregnancy, and congenital malformations. CONCLUSIONS: Late-preterm infants have higher mortality rates than term infants throughout infancy. Our findings may be used to guide obstetrical and pediatric decision-making.

Lung complications in acute pancreatitis.

CONTEXT: Severe acute pancreatitis has long been known to be a cause of pulmonary dysfunction and multisystem organ failure. OBJECTIVE: We evaluated the spectrum of pulmonary dysfunction in acute pancreatitis. METHODS: Over a period of one year, 60 patients referred to us with a diagnosis of acute pancreatitis on the basis of clinical findings, CT and elevated serum amylase level were studied prospectively. The computed tomography severe index (CTSI) was used to assess the severity of the pancreatitis. Arterial blood gas analysis and chest X-rays were performed in all patients at admission and at intervals, when clinically indicated. RESULTS: The mean age was 42.9+/-15.9 years (range: 18-80 years) and the etiology of the pancreatitis was gallstones in 29 patients, alcohol in 22 patients while no cause could be ascertained in 9. At presentation to our hospital, 48.3% had mild hypoxemia while 18.3% had moderate to severe hypoxemia (PaO2 less than 60 mmHg). The patients who were hypoxemic at presentation had a higher incidence of organ failure during the course of the disease. Pleural effusion at admission was noticed in 50%, atelectasis in 25%, and pulmonary infiltrates in 6.7%. Respiratory failure developed in 48.3% and the mean+/-SD CTSI in these patients was 8.20+/-2.29. Patients with more than 50% necrosis had more pulmonary dysfunction and needed ventilatory support. The development of consolidation during the course of the disease correlated with the occurrence of respiratory failure (P=0.068) but not with mortality (P=0.193). Similarly, the onset of adult respiratory distress syndrome also correlated with respiratory failure (P<0.001) but, unlike consolidation, adult respiratory distress syndrome correlated with mortality (P<0.001). On logistic regression analysis, the development of respiratory failure and other organ dysfunctions were independent risk factors for mortality. CONCLUSION: Our study on patients who were referred to a tertiary care center points out that hypoxemia at presentation predicts a poor outcome which could be due to the high incidence of associated cardiac and renal failure. At presentation, the presence of pleural effusion but not atelectasis and consolidation correlates with the development of respiratory failure and mortality. Among the respiratory complications developing during the course of acute pancreatitis, consolidation and adult respiratory distress syndrome correlate with respiratory failure while adult respiratory distress syndrome alone leads to poor survival.

Bloqueos del neuroeje en cirugía cardíaca / Central neuroaxial blocks in cardiac surgery

El anestésico ideal para la cirugía cardíaca debe ofrecer, además de estabilidad hemodinámica intraoperatoria, una recuperación postanestésica libre de dolor. La utilización de narcóticos en altas dosis se acerca a este ideal. Los bloqueos del neuroeje son una alternativa a los narcóticos en altas dosis. La efectividad de la morfina por vía intratecal o de la analgesia epidural torácica para controlar el dolor postoperatorio está demostrada más allá de toda duda. Esta analgesia es muy necesaria no sólo para confort del paciente sino por una multitud de factores; entre ellos, para disminuir la frecuencia y la severidad de episodios isquémicos postoperatorios así como la cantidad de complicaciones pulmonares y la utilización de drogas vasodilatadoras en el postoperatorio inmediato. El principal problema asociado al uso de morfina por vía intratecal es la depresión respiratoria, que tiene una incidencia de entre el 0.36 y el 1.9 por ciento. Esta depresión está relacionada con la dosis y es fácilmente tratada con naloxona sin abolir el efecto analgésico. Administrar morfina por vía intratecal es técnicamente más fácil y menos costoso, pero la analgesia epidural torácica se puede usar por varios días, no se necesita utilizar opioides, y, al emplearse anestésicos locales, tiene efectos muy beneficiosos sobre la circulación coronaria. La posibilidad de hematoma espinal es cierta y ha impedido la utilización de estos bloqueos, pero ha habido numerosos reportes acerca del uso de morfina por vía intratecal o analgesia epidural torácica involucrando miles de pacientes sin consecuencias adversas. Algunas precauciones son necesarias: agujas ultrafinas, no más de dos intentos para la morfina por vía intratecal y colocación del catéter epidural 20 horas antes de la operación. La utilización de morfina por vía intratecal o analgesia epidural torácica le da grandes beneficios a los pacientes en términos de disminución de complicaciones cardíacas y pulmonares. El riesgo potencial de un hematoma espinal es real, pero probablemente muy sobreestimado, y requiere más estudio.