PURPOSE: For patients with acute respiratory failure due to lung edema or atelectasis, Surplus lung water that is not removed during an initial stay in the Intensive Care Unit (ICU) may be related to early ICU readmission. Therefore, we performed a retrospective study of patient management during the first ICU stay for such patients. MATERIALS AND METHODS: Of 1,835 patients who were admitted to the ICU in the 36 months from January, 2003 to December, 2005, 141 were patients readmitted, and the reason for readmission was lung edema or atelectasis in 21 patients. For these 21 patients, correlations were investigated between body weight gain at the time of initial ICU discharge (weight upon discharge from the ICU ÷ weight when entering the ICU) and the time to ICU readmission, between body weight gain and the P/F ratio at ICU readmission, between the R/E ratio (the period using a respirator (R) ÷ the length of the ICU stay after extubation (E)) and the time to ICU readmission, between the R/E ratio and body weight gain, and between body weight gain until extubation and the time to extubation. RESULTS: A negative linear relationship was found between body weight gain at the time of initial ICU discharge and the time to ICU readmission, and between body weight gain at the time of ICU discharge and the P/F ratio at ICU readmission. If body weight had increased by more than 10% at ICU discharge or the P/F ratio was below 150, readmission to the ICU within three days was likely. Patients with a large R/E ratio, a large body weight gain, and a worsening P/F ratio immediately after ICU discharge were likely to be readmitted soon to the ICU. Loss of body weight during the period of respirator support led to early extubation, since a positive correlation was found between the time to extubation and body weight gain. CONCLUSION: Fluid management failure during the first ICU stay might cause ICU readmission for patients who had lung edema or atelectasis. Therefore, a key to the prevention of ICU readmission is to ensure complete recovery from lung failure before the initial ICU discharge. Strict water management is crucial based on body weight measurement and removal of excess lung water is essential. In addition, an apparent improvement in respiratory state may be due to respiratory support, and such an improvement should be viewed cautiously. Loss of weight at the refilling stage of transfusion prevents ICU readmission and may decrease the length of the ICU stay.
Humans ; Intensive Care Units/*statistics & numerical data ; Patient Readmission/*statistics & numerical data ; Pulmonary Atelectasis/physiopathology/*therapy ; Pulmonary Edema/physiopathology/*therapy ; Retrospective Studies ; Time Factors ; Weight Gain

OBJECTIVETo investigate the effect of oral fluid resuscitation on pulmonary vascular permeability and lung water content in burn dogs during shock stage.

METHODSEighteen male Beagle dogs with catheterization of carotid artery and jugular vein for 24 hours were subjected to 50% TBSA full-thickness burn, then they were divided into non-fluid resuscitation (NR), oral fluid resuscitation (OR), intravenous fluid resuscitation (IR) groups, with 6 dogs in each group. Dogs in OR and IR groups were given glucose-electrolyte solution (GES) by gastric tube or intravenous infusion according to Parkland formula within 24 hours after burn, while those in NR group were not given any treatment. Dogs in each group were then given intravenous fluid for further resuscitation after 24 post burn hours (PBH). Deaths were recorded within 72 hours after burn. Mean arterial pressure (MAP), respiratory rate (RR), PaO2, extravascular lung water index (ELWI) and pulmonary vascular permeability index (PVPI) were determined before burn and at 30 mins and 4, 8, 24, 48, 72 PBH with the aid of PICCO. Dogs were sacrificed to collect lung tissue for determination of water content at 72 PBH or just before death.

RESULTSAll dogs died during 9-22 PBH in NR group, 3 dogs died during 25-47 PBH in OR group, and all dogs survived within 72 PBH in IR groups. Compared with those before burn, RR (44.0 +/- 5.0) times/min, ELWI (10.3 +/- 0.6) mL/kg and PVPI (6.6 +/- 0.6) were markedly increased in NR group at 8 PBH, but PaO2 and MAP were obviously decreased (P < 0.05). In OR group, RR (33.0 +/- 4.0) times/min, ELWI (8.9 +/- 0.3) mL/kg and PVPI (5.7 +/- 0.4) were significantly lower than those of NR group (P < 0.05), but higher than those of IR group [RR (26.0 +/- 3.0) times/min, ELWI (8.2 +/-0.3) mL/kg, PVPI (4.2 +/- 0.4), P < 0.05] at 8 PBH. PaO2 and MAP in OR group were higher than that in NR group (P < 0.05). Lung water content showed no statistically significant difference between OR ang IR groups (P > 0.05), which were lower than that in NR group (P < 0.05).

CONCLUSIONSAlthough the protective effect of oral fluid resuscitation with GES on the lung of burn dog at shock stage was inferior to intravenous fluid, it still can decrease pulmonary vascular permeability, alleviate pulmonary edema, and reduce pulmonary complication compared with no resuscitation with fluids.

Animals ; Burns ; metabolism ; physiopathology ; therapy ; Capillary Permeability ; Dogs ; Extravascular Lung Water ; Fluid Therapy ; adverse effects ; methods ; Lung ; metabolism ; physiopathology ; Male ; Pulmonary Edema ; etiology ; Shock

PURPOSE: Atrial natriuretic peptide (ANP) has a variety of pharmacologic effects, including natriuresis, diuresis, vasodilatation, and suppression of the renin-angiotensin system. A recent study showed that ANP infusion improved hypoxemia and pulmonary hypertension in a lung injury model. On the other hand, the pulse contour cardiac output (PiCCO(TM)) system (Pulsion Medical Systems, Munich, Germany) allows monitoring of the intravascular volume status and may be used to guide volume therapy in severe sepsis and critically ill patients. MATERIALS AND METHODS: We treated 10 pulmonary edema patients without heart disease with human ANP (HANP). The patients were divided into two groups: a group with normal Intrathoracic Blood Volume (ITBV) (900-1100 mL/m2) (n = 6), and a group with abnormal ITBV (n = 4), as measured by the PiCCOtrade mark device; the extravascular lung water (EVLW) and pulmonary vascular permeability index (PVPI) in the two groups were compared. RESULTS: The average patient age was 63.9 +/- 14.4 years. The normal ITBV group showed significant improvement of the EVLW (before, 16.7 +/- 2.7 mL/kg; after, 10.5 +/- 3.6 mL/kg; p = 0.0020) and PVPI (before, 3.2 +/- 0.3; after, 2.1 +/- 0.7; p = 0.0214) after the treatment. The abnormal ITBV group showed no significant improvement of either the EVLW (before, 16.3 +/- 8.9 mL/kg; after, 18.8 +/- 9.6 mL/kg; p = 0.8387) or PVPI (before, 2.3 +/- 0.8; after, 2.7 +/- 1.3; p = 0.2782) after the treatment. In both groups, the EVLW and PVPI were strongly correlated with the chest X-ray findings. CONCLUSION: We conclude that HANP supplementation may improve the EVLW and PVPI in pulmonary edema patients without heart disease with a normal ITBV. The PiCCO(TM) system seems to be a useful device for the management of pulmonary edema.
Aged ; Atrial Natriuretic Factor/administration & dosage/*therapeutic use ; Cardiac Output/*drug effects/*physiology ; Female ; Humans ; Injections, Intravenous ; Male ; Middle Aged ; Monitoring, Physiologic/*instrumentation ; Pulmonary Edema/*drug therapy/*physiopathology

OBJECTIVETo investigate the clinical characteristics and treatment of negative pressure pulmonary edema (NPPE) with upper airway obstruction (UAO) in children.

METHODData of 3 cases with NPPE and UAO in pediatric intensive care unit (PICU) from Mar, 2007 to May, 2013 were analyzed.

RESULT(1) Two cases were male and 1 was female with age respectively 6, 16 and 30 months.One had airway foreign body , 1 laryngitis , and 1 retropharyngeal abscess. The onset of NPPE varied from 5 to 40 minutes following relief of obstruction. (2) NPPE presented with acute respiratory distress with signs of tachypnea, tachycardia, 2 of the 3 with pink frothy pulmonary secretions, progressively decreased oxygen saturation, rales on chest auscultation and wheezing. (3) NPPE chest radiograph showed diffuse interstitial and alveolar infiltrates, images confirmed pulmonary edema. (4) All these patients received these therapeutic measures including mechanical ventilation, retaining high PEEP, diuretics, limiting the fluid input volume to 80-90 ml/ (kg×d) on the basis of circulation stability. The rales on chest auscultation disappeared after 10, 6, 12 hours. The ventilators of 2 patients were removed within 24 hours, in another case it was removed 50 hours later because of secondary infection. All patients were cured and discharged without complication.

CONCLUSIONNPPE progresses very fast, characterized by rapid onset of symptoms of respiratory distress after UAO, with pulmonary edema on chest radiograph. The symptoms resolve rapidly if early support of breath and diuretics are applied properly.

Acute Disease ; Airway Obstruction ; complications ; Child, Preschool ; Diuretics ; therapeutic use ; Female ; Foreign Bodies ; complications ; Humans ; Infant ; Laryngismus ; complications ; Male ; Positive-Pressure Respiration ; Postoperative Complications ; etiology ; physiopathology ; therapy ; Pulmonary Edema ; diagnosis ; etiology ; physiopathology ; therapy ; Radiography, Thoracic ; Retrospective Studies

BACKGROUNDRecent research suggests that beta(2)-adrenergic agonists increase alveolar fluid clearance (AFC) under physiologic and pathologic conditions. It is unknown whether beta(3)-adrenergic agonists also increase AFC under pathologic conditions. The aim of this study was to investigate the effect of beta(3)-adrenergic agonists on AFC following hypoxic lung injury and the mechanisms involved.

METHODSHypoxic rats were exposed to 10% oxygen. BRL-37344 (beta(3)-adrenergic agonist) or CGP-12177 (selective beta(3)-adrenergic agonist) alone or combined with beta receptor antagonists, sodium channel blockers, or Na(+)/K(+)-ATPase blockers were perfused into the alveolar space of rats exposed to 10% oxygen for 48 hours. Total lung water content (TLW) and AFC were measured.

RESULTSAFC did not change for the first 24 hours but then decreased after 48-hour exposure to 10% oxygen. The perfusion of BRL-37344 or CGP-12177 significantly increased AFC in normal and hypoxic rats. The AFC-stimulating effect of CGP-12177 was lowered with amiloride (a Na(+) channel blocker) and ouabain (a Na(+)/K(+)-ATPase inhibitor) by 37% and 49%, respectively. Colchicine significantly inhibited the effect of CGP-12177.

CONCLUSIONSThese findings suggest that beta(3)-adrenergic agonists can increase AFC during hypoxic lung injury in rats and accelerate the amelioration of pulmonary edema.

Adrenergic beta-Agonists ; therapeutic use ; Animals ; Body Fluids ; drug effects ; metabolism ; Ethanolamines ; therapeutic use ; Hypoxia ; physiopathology ; Male ; Propanolamines ; therapeutic use ; Pulmonary Alveoli ; drug effects ; metabolism ; pathology ; Pulmonary Edema ; drug therapy ; etiology ; metabolism ; Rats ; Rats, Wistar

OBJECTIVETo appraise the significance of extravascular lung water index (EVLWI), pulmonary vascular permeability index (PVPI), and intrathoracic blood volume index (ITBVI) in the differential diagnosis of the type of burn-induced pulmonary edema.

METHODSThe clinical data of 38 patients, with severe burn hospitalized in our burn ICU from December 2011 to September 2014 suffering from the complication of pulmonary edema within one week post burn and treated with mechanical ventilation accompanied by pulse contour cardiac output monitoring, were retrospectively analyzed. The patients were divided into lung injury group ( L, n = 17) and hydrostatic group (H, n = 21) according to the diagnosis of pulmonary edema. EVLWI, PVPI, ITBVI, oxygenation index, and lung injury score ( LIS) were compared between two groups, and the correlations among the former four indexes and the correlations between each of the former three indexes and types of pulmonary edema were analyzed. Data were processed with t test, chi-square test, Mann-Whitney U test, Pearson correlation test, and accuracy test [receiver operating characteristic (ROC) curve].

RESULTSThere was no statistically significant difference in EVLWI between group L and group H, respectively (12.9 ± 3.1) and (12.1 ± 2.1) mL/kg, U = 159.5, P > 0.05. The PVPI and LIS of patients in group L were respectively 2.6 ± 0.5 and (2.1 ± 0.6) points, and they were significantly higher than those in group H [1.4 ± 0.3 and (1.0 ± 0.6) points, with U values respectively 4.5 and 36.5, P values below 0.01]. The ITBVI and oxygenation index of patients in group L were respectively (911 197) mL/m2 and (136 ± 69) mmHg (1 mmHg = 0.133 kPa), which were significantly lower than those in group H [(1,305 ± 168) mL/m2 and (212 ± 60) mmHg, with U values respectively 21.5 and 70.5, P values below 0.01]. In group L, there was obviously positive correlation between EVLWI and PVPI, or EVLWI and ITBVI (with r values respectively 0.553 and 0.807, P < 0.05 or P < 0.01), and there was obviously negative correlation between oxygenation index and EVLWI, or oxygenation index and PVPI (with r values respectively -0.674 and -0.817, P values below 0.01). In group H, there was obviously positive correlation between EVLWI and ITBVI (r = 0.751, P < 0.01) but no obvious correlation between EVLWI and PVPI, oxygenation index and EVLWI, or oxygenation index and PVPI (with r values respectively -0.275, 0.197, and 0:062, P values above 0.05). The total area under ROC curve of PVPI value for differentiating the type of pulmonary edema was 0.987 [with 95% confidence interval (CI) 0.962-1.013, P < 0.01], and 1.9 was the cutoff value with sensitivity of 94.1% and specificity of 95.2% . The total area under ROC curve of ITBVI value for differentiating the type of pulmonary edema was 0.940 (with 95% CI 0.860-1.020, P < 0.01), and 1,077. 5 mL/m2 was the cutoff value with sensitivity of 95.2% and specificity of 88.2%.

CONCLUSIONSEVLWI, PVPI, and ITBVI have an important significance in the differential diagnosis of the type of burn-induced pulmonary edema, and they may be helpful in the early diagnosis and management of burn-induced pulmonary edema.

Blood Gas Analysis ; Blood Volume ; Burns ; complications ; Capillary Permeability ; Diagnosis, Differential ; Extravascular Lung Water ; Humans ; Lung ; blood supply ; Lung Injury ; physiopathology ; therapy ; Monitoring, Physiologic ; Pulmonary Edema ; diagnosis ; etiology ; ROC Curve ; Respiration, Artificial ; Retrospective Studies

OBJECTIVETo evaluate the clinical value of the pulse indicator continuous cardiac output (PiCCO) system in patients with severe acute pancreatitis (SAP) complicated with acute respiratory distress syndrome (ARDS).

METHODTwo cases of SAP with ARDS were monitored using PiCCO during comprehensive management in the Pediatric Intensive Care Unit (PICU) of Shengjing Hospital, China Medical University. To guide fluid management, the cardiac index (CI) was measured to assess cardiac function, the global end-diastolic volume index (GEDVI) was used to evaluate cardiac preload, and the extravascular lung water index (EVLWI) was used to evaluate the pulmonary edema.

RESULTCase 1 was diagnosed with type L2 acute lymphoblastic leukemia (intermediate risk) and received the sixth maintenance phases of chemotherapy this time. After a 1-week dosage of chemotherapeutic drugs (pegaspargase and mitoxantrone), he suffered SAP combined with ARDS. Except comprehensive treatment (life supporting, antibiotic, etc.) and applying continuous veno-venous hemodiafiltration (CVVHDF) to remove inflammatory mediators. PiCCO monitor was utilized to guide fluid management. During the early stage of PiCCO monitoring, the patient showed no significant manifestations of pulmonary edema in the bedside chest X-ray (bedside ultrasound showed left pleural effusion), and had an oxygenation index 223 mmHg (1 mmHg = 0.133 kPa), GEDVI 450 ml/m², and ELVWI 7 ml/kg. We increased cardiac output to increase tissue perfusion and dehydration speed of CVVHDF was set at 70 ml/h. Two hours later, GEDVI significantly increased to 600 ml/m² and ELVWI significantly increased to 10 ml/kg, the oxygenation index declined to 155 mmHg, the bedside chest X-ray showed a significant decrease of permeability (right lung) and PEEP was adjusted to 5 cmH₂O (1 cmH₂O = 0.098 kPa), indicating circulating overload. ARDS subsequently occurred, upon which the fluid infusion was halted, the dehydration rate of CVVHDF raised (adjusted to 100-200 ml/h). On day 3 in the PICU, EVLWI dropped to 6 ml/kg, GEDVI dropped to 370 ml/m², and the oxygenation index increased to 180 mmHg. On day 8, the patient was successfully weaned from the ventilator. However, on day 9, the patient reverted to mechanical ventilation due to secondary infection. On day 30, the patient was discharged for voluntarily giving up treatment. Late follow-up results showed that the patient was dead one day after giving up treatment. Case 2 was admitted due to SAP induced by overeating one day before admission. On day 2, the patient showed dyspnea and oxygen saturation decreased to 80%. We applied mechanical ventilation, CVVHDF to remove inflammatory mediators and PiCCO to guide fluid management. According to the initial data of PiCCO, EVLWI was 9 ml/kg, GEDVI was 519 ml/m², the oxygenation index was 298 mmHg, the bedside chest X-ray showed decreased permeability and PEEP was adjusted to 5 cmH₂O, suggesting the existence of ARDS. During treatment, the dehydration speed of CVVHDF was set at 50 ml/h to maintain the balance of fluid input and output. Two hours after PiCCO monitoring, the oxygenation index decreased to 140 mmHg, GEDVI 481 ml/m², EVLWI 9 ml/kg, thus the dehydration speed of CVVHDF was increased (up to 100 ml/h). On day 4 in the PICU, EVLWI was 9 ml/kg, GEDVI was 430 ml/m², oxygenation index was 394 mmHg, and the bedside chest X-ray showed that permeability was higher. On day 5, the patient was transferred from PiCCO. On day 30, the patient recovered and was discharged.

CONCLUSIONPiCCO monitoring can provide real-time surveillance of cardiac function, cardiac preload and afterload, and extravascular lung water in pediatric patients with SAP combined with ARDS. These results are clinically significant for the rescue of critically ill patients with ARDS or shock.

Acute Disease ; Cardiac Output ; physiology ; Child ; China ; Critical Illness ; Extravascular Lung Water ; Fluid Therapy ; Heart ; physiology ; Heart Rate ; Humans ; Lung ; physiology ; Monitoring, Physiologic ; methods ; Pancreatitis ; complications ; physiopathology ; therapy ; Pulmonary Edema ; Respiration, Artificial ; Respiratory Distress Syndrome, Adult ; complications ; physiopathology ; Severity of Illness Index ; Treatment Outcome