Interaction of transferrin saturated with iron with lung surfactant in respiratory failure
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Proteins that decrease the surface activity of surfactant accumulate in epithelial lining fluid in respiratory failure. The aim of this study was to isolate a surfactant inhibitor from the airways of rabbits in acute respiratory failure induced by bronchoalveolar lavage (BAL). This inhibitor was identified as being transferrin (TF). Unlike serum TF, TF recovered in respiratory failure was saturated with iron (Fe(3+)-TF). Fe(3+)-TF decreased the surface activity of normal surfactant in vitro, whereas iron-free TF had no effect. In the presence of H2O2 and a reducing agent, Fe(+3)-TF inactivated the surfactant complex: the surface absorption rate was decreased, immunoreactive surfactant protein A was decreased, and malondialdehyde was formed. The acute effects of Fe(3+)-TF and iron-free TF applied to the airways were studied in animal models. In respiratory failure induced by BAL, Fe(3+)-TF deteriorated respiratory failure, whereas iron-free TF had no effect. In respiratory failure induced by hyperoxia for 48 h, administration of iron-free TF ameliorated the respiratory failure and improved the surface activity in BAL. We propose that Fe(3+)-TF accumulating in epithelial lining fluid during lung damage contributes to surfactant inhibition and promotes the formation of free radicals that inactivate the surfactant system.Objective To assess whether distal bronchoalveolar lavage(DBAL) with plastic tubing allowed recovery of more fluid in comparison with common bronchoalveolar lavage(CBAL), and whether tubing had a favorable impact on operative procedure and complications. Methods A randomized study was performed in the hospital. Patients scheduled for BAL were randomly assigned to DBAL (n = 66) and CBAL (n = 56) group. Results In DBAL group,5.55% more fluid was recovered,9. 19% fewer technical failures,and 7.41% fewer complications were recorded. Conclusions Based on these results, we recommend performing DBAL using plastic tubing to replace CBAL.
Key words:
Bronchoalveolar lavage; Methods; Distal bronchoalveolar lavage; Common bronchoalveolar lavage
Therapeutic irrigation
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Respiratory failure is the most common cause of death in children with neuromuscular disease (NMD). This article provides a conceptual framework for understanding failure of the respiratory pump in these children. Pump failure can be attributed to faulty control of respiration, to mechanical defects, and to respiratory muscle fatigue. In most patients with NMD, respiratory drive is intact. Mechanical defects can be due to either an abnormal pump or an excessive respiratory load on which the pump must operate. In patients with NMD, the weak respiratory muscles cannot generate normal respiratory pressures. Furthermore, inefficient chest wall motion leads to increased work for the respiratory system. Abnormalities of lung and chest wall compliance increase respiratory load. The combination of a weak, inefficient respiratory pump and an abnormally high elastic load can predispose these patients to respiratory muscle fatigue. Respiratory muscle rest with nocturnal assisted ventilation, therefore, provides a rational approach to the treatment of chronic respiratory failure in patients with NMD. Areas of future research that may prove useful in the care of children with respiratory failure due to NMD include: the development of better ways of assessing respiratory muscle fatigue; studies to increase understanding of the role of mechanical ventilation in improving chest wall and respiratory pump function; and studies delineating the role of respiratory muscle training in these patients.
Neuromuscular disease
Respiratory physiology
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Objective To discuss the roles of mechanical ventilation associated with bronchoalveolar lavage when necessary in patients with severe respiratory failure.Methods Thirty-one patients with severe respiratory failure were treated by mechanical ventilation.The patiets with hypoxemia treated by mechanical ventilation after routine 24h,were perform bronchoalveolar lavage by fiberoptic bronchoscopy with saline plus ambroxol hydrochloride and Atrovent,with fluid 150-200ml/d.Results In 31 patients with severe respiratory failure,27 patients were performed bronchoalveolar lavage.The airway pressure descended gradually.The clinical symptoms were improved.The level of PaO_2 was increased,and PaCO_2 was decreased after 24h.Pathogen was definited.All of 27 patients discharged.Conclusion Mechanical ventilation associated with bronchoalveolar lavage is effective measure to treat severe respiratory failure.Bronchoalveolar lavage by fiberoptic bronchoscopy in ICU is safe.
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The purpose of this review is to provide an overview on how interactions between control of breathing, respiratory load, and muscle function may lead to respiratory failure. The mechanisms involved vary according to the underlying pathology, but respiratory failure is most often the result of an imbalance between the muscular pump and the mechanical load placed upon it. Changes in respiratory drive and response to CO<sub>2</sub> seem to be important contributors to the pathophysiology of respiratory failure. Inspiratory muscle dysfunction is also frequent but is not a mandatory prerequisite to respiratory failure since increased load may also be sufficient to precipitate it. It is crucial to recognize these interactions to be able to timeously establish patients on mechanical ventilation and adapt the ventilator settings to their respiratory system physiology.
Pathophysiology
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Pulmonary alveolar proteinosis
Parenchyma
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Data from a drug surveillance programme were analysed to estimate the frequency with which patients with a diagnosis of respiratory failure had been exposed to CNS-depressing drugs. Eleven out of 37 patients with respiratory failure had received such medication. A detailed comparison of these patients and controls admitted to hospital because of respiratory disease who did not develop respiratory failure failed to reveal significant differences in drug usage. This unexpected finding suggests that patients with respiratory disease of equal severity may vary greatly in their tendency to develop carbon dioxide retention following administration of drugs with respiratory depressant properties.
Acute respiratory failure
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Bronchoalveolar lavage (BAL) is a well-established diagnostic tool for the assessment of pulmonary diseases in adults. How BAL contributes to the diagnostic process in childhood lung diseases is less clear. One of the problems in interpreting BAL findings in children is that there are few reference data for BAL fluid constituents in children. This report addresses some of the technical problems of bronchoalveolar lavage in children and summarizes current knowledge on cellular and noncellular bronchoalveolar lavage fluid components in children without lung disease.
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Objective: To take the opportunity of a bronchoalveolar lavage to challenge the transpulmonary thermodilution for detecting the time course of changes in extravascular lung water. Design: Observational study. Setting: Medical ICU. Patients: Mechanically ventilated patients in whom a bronchoalveolar lavage by bronchoscopy was performed. Intervention: Transpulmonary thermodilution before and after bronchoalveolar lavage. Measurements and Main Results: Before and at different times after bronchoalveolar lavage, transpulmonary thermodilution was performed to record the value of indexed extravascular lung water. For each measurement, the values of three thermodilution measurements were averaged at the following steps: before bronchoalveolar lavage, after bronchoalveolar lavage, and 1 hour, 2 hours, 4 hours, and 6 hours after bronchoalveolar lavage. The amount of saline infusion left in the lungs after bronchoalveolar lavage was also recorded. Twenty-five patients with suspicion of pneumonia were included. Twenty-eight bronchoalveolar lavages were finally analyzed. On average, 200 mL (180–200 mL) of saline were injected and 130 mL (100–160 mL) were left in the lungs. Between before and immediately after bronchoalveolar lavage, indexed extravascular lung water significantly increased from 12 ± 4 to 15 ± 5 mL/kg, respectively, representing a 169 ± 166 mL increase in nonindexed extravascular lung water. After bronchoalveolar lavage, the value of indexed extravascular lung water was significantly different from the baseline value until 2 hours after bronchoalveolar lavage and became similar to the baseline value thereafter. Conclusions: Transpulmonary thermodilution enabled to detect small short-term changes of indexed extravascular lung water secondary to bronchoalveolar lavage.
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Objectives: To evaluate the yield of mini-bronchoalveolar lavage compared with that of directed bronchoalveolar lavage in critically ill patients with suspected coronavirus disease 2019–associated pulmonary aspergillosis. Design: A retrospective cohort study. Setting: The ICU of the Amsterdam University Medical Centers. Patients: Patients with confirmed coronavirus disease 2019 screened for coronavirus disease 2019–associated pulmonary aspergillosis. INTERVENTIONS: Mini-bronchoalveolar lavage and/or directed bronchoalveolar lavage. Measurements and Main Results: In total, 76 patients were included, 20 of whom underwent bronchoalveolar lavage, 40 mini-bronchoalveolar lavage, and 16 both mini-bronchoalveolar lavage and bronchoalveolar lavage. The percentage of samples with one or more positive Aspergillus detecting test (galactomannan, culture, polymerase chain reaction) did not differ significantly between bronchoalveolar lavage and mini-bronchoalveolar lavage (16.7% vs 21.4%). However, in mini-bronchoalveolar lavage samples, this was more frequently driven by a positive polymerase chain reaction than in bronchoalveolar lavage samples (17.9% vs 2.8%; p = 0.030). In 81% of patients (13/16) with both mini-bronchoalveolar lavage and bronchoalveolar lavage, the test results were in agreement. In 11 of 12 patients (92%) with first a negative mini-bronchoalveolar lavage, the subsequent bronchoalveolar lavage sample was also negative. Conclusions: We found a similar percentage of positive test results in mini-bronchoalveolar lavage and bronchoalveolar lavage samples in patients with suspected coronavirus disease 2019–associated pulmonary aspergillosis. Our findings indicate that mini-bronchoalveolar lavage could be a useful tool for coronavirus disease 2019–associated pulmonary aspergillosis screening in ICU patients.
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Examination of bronchoalveolar lavage fluid is a method based on obtaining biological material in the from of cells and fluid derived directly from the alveoli of the bronchi. Cytological and biochemical examination of the bronchoalveolar fluid enables to understand pathomechanisms of various interstitial and obstructive pulmonary diseases. Bronchoalveolar lavage (BAL) is a sensitive and safe diagnostic method, which becomes to be widely employed in the pneumonologic++ diagnosis.
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