Won Dong Kim

Mechanistic scheme and effect of "extended sigh" as a recruitment maneuver in patients with acute respiratory distress syndrome: a preliminary study.

Objective To devise a new form of sigh (“extended sigh”) capable of providing a sufficient recruiting pressure × time, and to test it as a recruitment maneuver in patients with acute respiratory distress syndrome. Design Prospective uncontrolled clinical trial. Setting Medical intensive care unit of a university-affiliated hospital. Patients Twenty consecutive patients diagnosed with acute respiratory distress syndrome (18 men, 2 women, age 59 ± 10 yrs). Interventions From baseline settings of tidal volume (Vt) 8 mL/kg and positive end-expiratory pressure (PEEP) 10 cm H2O on volume control mode with the high pressure limit at 40 cm H2O, the Vt-PEEP values were changed to 6–15, 4–20, and 2–25, each step being 30 secs (inflation phase). After Vt-PEEP 2–25, the mode was switched to continuous positive airway pressure of 30 cm H2O for a duration of 30 secs (pause), after which the baseline setting was resumed following the reverse sequence of inflation (deflation phase). This extended sigh was performed twice with 1 min of baseline ventilation between. Measurements and Results Airway pressures and hemodynamic parameters were traced at each step during the extended sigh. Arterial blood gases and physiologic parameters were determined before the extended sigh (pre-extended sigh), at 5 mins after two extended sighs (post-extended sigh), and then every 15 mins for 1 hr. In our average patient, the recruiting pressure × time of the inflation phase was estimated to be 32.8–35.4 cm H2O × 90 secs. Compared with the inflation phase, inspiratory pause pressure of the deflation phase was lower at Vt-PEEP 6–15 (28.9 ± 2.7 cm H2O vs. 27.3 ± 2.8 cm H2O) and 4–20 (31.8 ± 2.9 cm H2O vs. 31.1 ± 2.9 cm H2O; both p < .05). Compared with pre-extended sigh, Pao2 (81.5 ± 15.3 mm Hg vs. 104.8 ± 25.0 mm Hg;p < .001) and static respiratory compliance both increased post-extended sigh (27.9 ± 7.9 mL/cm H2O vs. 30.2 ± 9.7 mL/cm H2O;p = .009). Improvement in these parameters was sustained above pre-extended sigh for the duration of the study. Major hemodynamic or respiratory complications were not noted during the study. Conclusion We present a new form of sigh (i.e., extended sigh) capable of achieving an augmented recruiting pressure × time through a prolonged inflation on a gradually increased end-expiratory pressure. In view of the sustained effect and absence of major complications in our patients, extended sigh could be a useful recruitment maneuver in acute respiratory distress syndrome.

Induced hypothermia as a new approach to lung rest for the acutely injured lung.

Objective:To investigate whether low-frequency ventilation during hypothermia could attenuate lung injury associated with endotoxin and mechanical ventilation. Design:Experimental animal study. Setting:University-affiliated animal laboratory. Subjects:Forty-eight Sprague–Dawley rats. Interventions:Lipopolysaccharide was administered to rats intratracheally to induce acute lung injury. After 1 hr of this treatment, animals were assigned to normothermia-only (NO, rectal temperature 37°C, ventilatory frequency 90/min), normothermia-lung rest (NR, 37°C, 45/min), hypothermia-only (HO, 27°C, 90/min), or hypothermia-lung rest (HR, 27°C, 45/min). After 1 hr of injurious ventilation, the lungs of the rats were removed for bronchoalveolar lavage and histologic examination. Measurements and Main Results:Compared with the normothermia groups (NO, NR), the neutrophil counts (per milliliter) (NO, 7708 ± 5704; NR, 10,479 ± 11,152; HO, 1638 ± 955; HR, 805 ± 591) and interleukin-1&bgr; levels (pg/mL) (1180 ± 439, 1081 ± 652, 620 ± 426, 420 ± 182, respectively) in the bronchoalveolar lavage fluid, the wet-to-dry lung weight ratios (6.0 ± 0.4, 5.7 ± 0.4, 5.6 ± 0.2, 5.2 ± 0.2, respectively), and histologic acute lung injury scores (8.3 ± 2.7, 10.4 ± 3.1, 3.5 ± 2.1, 3.1 ± 2.2, respectively) of the hypothermia groups (HO, HR) were lower (all p < .001). Compared with the HO group, the neutrophil counts and protein content (HO, 1367 ± 490 &mgr;g/mL vs. HR, 831 ± 369 &mgr;g/mL) in the bronchoalveolar lavage fluid, the serum lactate dehydrogenase levels (units/mL) (9.1 ± 3.6 vs. 5.3 ± 1.5), and the wet-to-dry lung weight ratios of the HR group were lower (all p < .05). Conclusions:Reduction of ventilatory frequency in conjunction with hypothermia attenuated many variables of acute lung injury in rats. Use of hypothermia could be exploited as a new approach to lung rest for the ventilatory management of the acutely injured lung.

Long-term effect of bronchial artery embolization in Korean patients with haemoptysis.

Objective and background:  Bronchial artery embolization (BAE) has been regarded as a bridging therapy in the management of massive haemoptysis until a more definite therapy can be pursued. The long‐term effectiveness of BAE and the factors associated with failure to control bleeding in an Asian setting of tuberculosis are unknown and were investigated.

Morphometric effects of the recruitment maneuver on saline-lavaged canine lungs. A computed tomographic analysis.

Background In the face of widespread use of lung-protective, low-volume ventilation in patients with acute lung injury, interest in the recruitment maneuver (RM) is growing. Little is known about lung-morphometric effects of the RM as compared with positive end-expiratory pressure (PEEP) titration (PT) without the RM. Methods RM was defined as a stepwise change in PEEP from baseline to 10, 20, 30, and 20 cm H2O every 30 s, after which PEEP was reset at the lower inflection point + 2 cm H2O. For PT, PEEP was simply increased from baseline to the lower inflection point + 2 cm H2O. Both maneuvers were performed in 10 lung-lavaged dogs. Computed tomography of the lung was performed before and 30 s and 30 min after the maneuver. Results Thirty seconds after the maneuver, the decrease in the amount of nonaerated plus poorly aerated lung was greater and decreases in Hounsfield units in the caudal and dorsal lung regions were greater with the RM than with the PT. The hyper-aerated lung volume after the RM tended to be greater than that after the PT. At 30 s and 30 min after the maneuver, gas plus tissue volume, gas-only volume, and gas–tissue ratio of the lung were greater with the RM than with the PT. At both time points after the maneuver, the coefficient of variation of regional Hounsfield units, an index of regional heterogeneity of aeration, was lower with the RM than with the PT. Conclusions Compared with PT, the RM resulted in a greater lung volume, better aeration of the most dependent lung, and less regional heterogeneity of aeration. However, the RM tended to induce a greater increase in hyperaerated lung volume than did the PT.

Weekly low dose paclitaxel and cisplatin as first-line chemotherapy for advanced non-small cell lung cancer

The efficacy and toxicity of weekly low dose chemotherapy using paclitaxel and cisplatin were evaluated in 22 chemotherapy-naïve patients with non-small cell lung cancer (NSCLC). Paclitaxel (40 mg/m(2) by 1 h infusion) and cisplatin (20 mg/m(2) by 1 h infusion) were administered weekly without interruption. With a median of 16 cycles of weekly chemotherapy, objective response rate was 40.9% (95% confidence interval, 18.6-63.2%). Stable disease and progressive disease categories accounted for 40.9 and 18.2%, respectively. The median response duration was 3 months (1-12 months). Myelosuppression was not noted and non-hematologic toxicities were mild. This study indicates that weekly low dose chemotherapy using paclitaxel and cisplatin could be given safely to the patients with NSCLC and showed a promising response rate.

The Clinical Efficacy of GOCA Scoring System in Patients with Acute Respiratory Distress Syndrome

To explore the following hypotheses: 1) Gas exchange, Organ failure, Cause, Associated disease (GOCA) score, which reflects both general health and the severity of lung injury, would be a better mortality predictor of acute respiratory distress syndrome (ARDS) than acute physiology and chronic health evaluation (APACHE II) or simplified acute physiology score (SAPS II), which are not specific to lung injury, and lung injury score (LIS) that focuses on the lung injury; 2) the performance of APACHE II and SAPS II will be improved when reinforced by LIS, we retrospectively analyzed ARDS patients (N=158) admitted to a medical intensive care unit for five years. The overall mortality of the ARDS patients was 53.2%. Calibrations for all models were good. The area under the curve of (AUC) of LIS (0.622) was significantly less than those of APACHE II (0.743) and SAPS II (0.753). The AUC of GOCA (0.703) was not better than those of APACHE II and SAPS II. The AUCs of APACHE II and SAPS II tended to further increase when reinforced by LIS. In conclusion, GOCA was not superior to APACHE II or SAPS II. The performance of the APACHE II or SAPS II tended to improve when combining a general scoring system with a scoring system that focused on the severity of lung injury.

Hypoxemia and Arrhythmia during Daily Activities and Six-minute Walk Test in Fibrotic Interstitial Lung Diseases

We performed 24-hr monitoring of pulse oximetric saturation (SpO2) with ECG and six-minute walk test (6MWT) in 19 patients with fibrotic interstitial lung diseases (ILD) to investigate; 1) The frequency and severity of hypoxemia and dysrhythmia during daily activities and 6MWT, 2) safety of 6MWT, and 3) the parameters of 6MWT which can replace 24-hr continuous monitoring of SpO2 to predict hypoxemia during daily activities. All patients experienced waking hour hypoxemia, and eight of nineteen patients spent > 10% of waking hours in hypoxemic state. Most patients experienced frequent arrhythmia, mostly atrial premature contractions (APCs) and ventricular premature contractions (VPCs). There were significant correlation between the variables of 6MWT and hypoxemia during daily activities. All of the patients who desaturated below 80% before 300 meters spent more than 10% of waking hour in hypoxemia (P = 0.018). In contrast to waking hour hypoxemia, SpO2 did not drop significantly during sleep except in the patients whose daytime resting SpO2 was already low. In conclusion, patients with fibrotic ILD showed significant period of hypoxemia during daily activities and frequent VPCs and APCs. Six-minute walk test is a useful surrogate marker of waking hour hypoxemia and seems to be safe without continuous monitoring of SpO2.

Poor interpretation of pulmonary function tests in patients with concomitant decreases in FEV1 and FVC

Background and objective:  A new interpretative strategy for pulmonary function tests (PFT) has been proposed by the American Thoracic Society/European Respiratory Society (ATS/ERS) Task Force. To assess the accuracy of this strategy, clinical diagnosis was compared with the PFT interpretation in patients showing concomitant decreases in FEV1 and FVC.

Phase II trial of a novel platinum analog, SKI 2053R, in patients with previously untreated extensive-stage small-cell lung cancer.

A phase II trial of a novel platinum analog, SKI 2053R, was performed in patients with previously untreated extensive-stage disease (ED) small-cell lung cancer (SCLC). SKI 2053R was administered at the dose of 400 mg/m2 every 3 to 4 weeks as a 1-h infusion. After the first cycle, the dose was escalated to 440 mg/m2 based on toxicity. Thirty-eight patients (31 male) were enrolled between June 1995 and August 1997. The median age was 61 years (range, 36-70 years). Six of 37 evaluable patients achieved a partial response (16.2%; 95% confidence interval [CI], 4.4-28.0%). The durations of response were 1.1, 1.5, 1.7, 1.9, 3.4, and 4.6 months. The estimated median survival time was 7.4 months (95% CI, 5.1-9.7 months). Grade 3 or 4 toxicities were not observed. Grade 1 to 2 leukopenia, anemia, and thrombocytopenia were seen in 5 of 68 cycles, 16 of 68, and 2 of 68, respectively. Nonhematologic toxicities included grade 1 to 2 nausea or vomiting (30 of 68 cycles), nephrotoxicity (27 of 68), and hepatotoxicity (13 of 68). SKI 2053R showed a modest antitumor activity with limited toxicities in patients with ED SCLC. Further clinical trials are warranted in SCLC with a higher dose of SKI 2053R.

Concurrent FP (5-fluorouracil, cisplatin) Chemoradiotherapy for Patients with Esophageal Cancer.

PURPOSE The outcomes of a surgical approach for patients with an esophageal carcinoma remain unsatisfactory despite its high complication rates. We conducted a phase II trial, using combined FP (5-fluorouracil and cisplatin) chemotherapy and concurrent radiotherapy, as a definitive therapy for patients with esophageal cancer. MATERIALS AND METHODS Patients with histologically proven esophageal cancer were enrolled onto this study. The treatment consisted of four courses of chemotherapy and six and a half weeks of radiotherapy. The patients received chemotherapy in weeks 1, 5, 12 and 16 (5-fluorouracil 1, 000 mg/m2 on days 1 to 4 and cisplatin 75 mg/m2 on day 1). Radiotherapy was administered at a dose of 59.4 Gy, in five 1.8 Gy fractions a week. RESULTS A total of 22 eligible patients entered the study. Of the 19 evaluable patients, a complete response occurred in 7 (37%), and a partial response in 8 (42%). After a median follow-up of 35 months, the overall survival rate was 32% at three years and the median survival was 11 months. Fourteen (64%) received planned dose of radio-therapy and 13 (59%) received more than three courses of chemotherapy. However, there was no difference in three-year survival rates between the patients that received less than three courses of chemotherapy and those that received three or more courses (31% vs. 32%). The major treatment related toxicity was mucositis, which developed in every patient, with grades III or IV in thirteen (59%) patients. During the treatment, the patients lost, on average, 3.8% of their body weight. The mean hospital stay was 23 days, with a total duration of treatment of 74 days. CONCLUSION S: Concurrent FP chemoradiotherapy was effective as a definitive therapy for patients with esophageal cancer. The major toxicity was mucositis. Although the treatment was relatively feasible, a randomized trial of reduced courses of chemotherapy is warranted.