1/14. Accidental total spinal block: a complication of an epidural test dose.A case is presented of a 36-yr-old parturient who developed a total spinal block after an epidural test dose. After placement of an epidural catheter and confirming negative aspiration for blood or CSF, 3 ml lidocaine 1.5% (45 mg), with 1:200,000 epinephrine (15 micrograms) was injected via the catheter over 30 sec. Within two minutes the patient developed hypotension and extensive sensory and motor block including respiratory paralysis and aphonia. She remained fully conscious and alert and spontaneous respiration recommenced in five minutes. A live healthy infant was delivered by emergency Caesarean section shortly afterwards under general anaesthesia and the mother recovered completely without any untoward sequelae.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
2/14. dyspnea as the predominant manifestation of bilateral phrenic neuropathy.Phrenic neuropathy associated with brachial neuritis has been well described; however, bilateral phrenic neuropathy with minimal or no involvement of the brachial plexus has not. We review the clinical features, as well as the results of radiographic studies, pulmonary function tests, and electrodiagnostic studies, of 3 patients in whom dyspnea was the presenting manifestation of bilateral phrenic neuropathy. All 3 patients had acute-onset dyspnea, which led to consideration of a pulmonary or cardiac etiology. phrenic nerve conduction studies showed bilateral axonal degeneration of the phrenic nerves. Diaphragmatic paralysis should be considered in the differential diagnosis of acute-onset dyspnea. dyspnea increases typically when the patient lies down, and paradoxical respiration may be present. neck, shoulder, or upper limb pain may occur at onset. Inspiratory pressures may be reduced, but a comparison of the forced vital capacity when the patient is standing and supine is more specific for diaphragmatic weakness. phrenic nerve conduction studies and diaphragmatic electromyography may provide evidence of bilateral involvement. Subclinical evidence of brachial plexus involvement may be present. The prognosis for patients with bilateral phrenic neuropathy may be more favorable than reported previously.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
3/14. Selective paralysis of voluntary but not limbically influenced automatic respiration.We describe a patient in whom a discrete infarction of the ventral basis pontis caused a complete loss of voluntary respiration, while automatic respiration remained intact. Respiratory excursions, quantified title volumes, and ventilatory response to carbon dioxide were normal, but the patient could not volitionally modify any respiratory parameters. Emotional stimuli producing laughter, crying, or anxiety appropriately modulated automatic respiration. This case established that pathways subserving limbic modulation of automatic respiration descend in the pontine tegmentum and/or lateral portion of the basis pontis spared by this lesion. Furthermore, descending limbic influences on automatic respiration are anatomically and functionally independent of the voluntary respiratory system.- - - - - - - - - - ranking = 9keywords = respiration (Clic here for more details about this article) |
4/14. respiratory paralysis as a presenting symptom in Japanese encephalitis--a case report.In the literature there are rare reports on Japanese encephalitis (JE) mimicking poliomyelitis or presenting as respiratory paralysis. A case of JE presenting as respiratory paralysis is described. The 22-year-old male was well until five days earlier, when he experienced the acute onset of headache and fever. Four days after onset he developed dysphagia and respiratory difficulty, and a tracheotomy was performed. The following day he lapsed into semicoma and the respiration had to be maintained by an artificial ventilator. He regained consciousness by the 10th day after onset. He became able to comprehend questions and express himself by gestures. But the respiration was still paralytic, and assisted ventilation via a tracheotomy had to be continued. The case was clinically diagnosed as encephalitis. Bulbar poliomyelitis was initially considered due to the clinical features of aseptic meningitis, respiratory paralysis, pharyngeal paralysis with pooling secretions in the pharynx, tachycardia and elevated blood pressure. But poliovirus culture obtained from stool and appropriate serological studies were negative. The diagnosis of encephalitis due to JE virus was confirmed by hemagglutination inhibition test (acute phase HI titer 1:320; convalescent phase HI titer 1.1280).- - - - - - - - - - ranking = 2keywords = respiration (Clic here for more details about this article) |
5/14. Bulbar amyotrophic lateral sclerosis: patterns of progression and clinical management.patients with bulbar amyotrophic lateral sclerosis (ALS) are often referred to the otolaryngologist/head and neck surgeon and speech pathologist for evaluation and management of dysphagia and dysarthria. These patients comprise an unusual group because of the progressive and multi-system nature of their illness. The neuromuscular disabilities associated with bulbar ALS cause a myriad of related symptoms associated with swallowing, speech, and respiration. Although the rate of progression cannot be predicted, a general pattern of progression is noted. Bulbar disease accounts for the majority of the worst symptoms of ALS. The loss of the ability to swallow changes eating from a pleasurable task to a burden of survival. Loss of communication effectively imprisons the patient in a state of isolation. The progressive weakness of respiration, predominantly a spinal rather than bulbar manifestation, is the cause of death for nearly all ALS patients and is also discussed. The general patterns of progression of bulbar ALS are outlined in this paper. The development of symptoms are correlated with specific treatment recommendations to aid the clinician in devising an orderly plan of management for this progressive disease.- - - - - - - - - - ranking = 2keywords = respiration (Clic here for more details about this article) |
6/14. Electrophrenic respiration: report of six cases.The development of electrophrenic respiration has permitted freedom from mechanical ventilation for patients who have irreversible respiratory failure in association with high-cervical spinal cord or brainstem lesions. There are three basic criteria for successful diaphragm pacing: (1) the need for long-term mechanical ventilatory assistance, (2) a functionally intact phrenic nerve-diaphragm axis, and (3) chest wall stability. Inability to achieve satisfactory pacing can be due to malfunction of equipment, instability of the chest wall, or inadequate neuromuscular responsiveness. These features of diaphragm pacing are exemplified in a series of six patients. Three achieved independence from mechanical ventilatory assistance with full-time phrenic pacing. In one patient, only limited electrophrenic respiration was achieved, and in another the method was entirely unsuccessful. Although functioning well, pacing systems were removed from the sixth patient because of infection. diaphragm pacing can be a valuable form of respiratory support for carefully selected patients.- - - - - - - - - - ranking = 6keywords = respiration (Clic here for more details about this article) |
7/14. Intermittent positive pressure ventilation via nasal access in the management of respiratory insufficiency.These are preliminary observations of the introduction of a new technique of noninvasive positive pressure respiratory support for patients with subacute or chronic respiratory failure. Clinical situations where intubation or tracheostomy may have been performed were managed by intermittent positive pressure ventilation via nasal access (NIPPV) with a CPAP mask, or a custom constructed Vel-Foam nose piece. Four patients were managed at home with the use of portable volume ventilators. One patient employed the technique while hospitalized with subacute respiratory failure. Two patients, otherwise dependent on mouth intermittent positive pressure ventilation (MIPPV) 24 hours a day, received necessary dental care with NIPPV support. In a large population with a decade or more follow-up, MIPPV was shown to be an effective noninvasive technique to support respiration in patients with the most severe paralytic respiratory failure. Preliminary observations suggest that NIPPV may compare favorably with MIPPV and deserves more widespread study and application.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
8/14. Brachial neuritis involving the bilateral phrenic nerves.Brachial neuritis with bilateral hemidiaphragmatic paralysis has been reported in two previous cases in the literature. We report a patient who experienced severe right shoulder discomfort three weeks prior to hospital admission which evolved to include both shoulders. Two weeks prior to admission he noticed the onset of discomfort in breathing in the supine position and shortness of breath with minor exertion. The admitting diagnoses were myocardial infarction due to significant ECG changes and idiopathic elevated bilateral hemidiaphragms. The patient had findings significant for tachypnea, dyspnea, decreased breath sounds at the bases bilaterally, impaired motion of the bilateral lung bases on inspiration and paradoxical respirations. Comprehensive medical testing and evaluation revealed bilateral elevated hemidiaphragms and vital capacity 40% of normal. Weakness of the proximal shoulder girdle and bicep musculature bilaterally was noted. electromyography was significant for reduced recruitment pattern in the bilateral shoulder girdle musculature. Nerve conduction studies suggested bilateral phrenic neuropathy. This case is an unusual presentation of brachial neuritis affecting the bilateral shoulder girdle with phrenic nerve involvement. The differential diagnosis of acute shoulder pain associated with respiratory symptomatology should therefore include brachial neuritis.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
9/14. diaphragm pacing in the treatment of ventilatory failure.Thirty years of clinical and technical research have produced a reliable apparatus for diaphragm pacing. This entails electrical stimulation to the phrenic nerve by a remote radio-frequency transmitter. Prerequisites for diaphragm pacing are adequate alveolar gas exchange, an intact phrenic nerve and diaphragm muscle, and a co-operative patient for the prolonged period of rehabilitation. diaphragm pacing has been used in cases of central alveolar hypoventilation and chronic obstructive airway disease, as well as for lesions of the cervical cord. To avoid fatigue and possible irreversible injury to the muscle, the right and left hemidiaphragms are paced alternately. We demonstrate the effectiveness of diaphragm pacing for long-term artificial respiration in a patient with transection of the cord at C3/4. The decisive benefit of diaphragm pacing for the quadriplegic patient is that it renders him free of dependence on a mechanical ventilator with its associated social and psychological impediments.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
10/14. Respiratory variability according to sleep states during mechanical ventilation: a polygraphic study in a baby with bilateral diaphragmatic paralysis.Polygraphic recordings were performed at 1 and 2 months of age in mechanically ventilated baby (25-27 insufflations per min) with bilateral diaphragmatic paralysis. The EEG and the sleep organisation were normal for the given age. The breathing patterns were state dependent. Autonomous breathing movements and phasic inspiratory intercostal EMG were present during both wakefulness and active sleep (AS). In quiet sleep (QS) the respiration was usually passive, completly dependent on the respirator. Small autonomous breathings can occur in some periods of QS, simultaneously with the appearance of numerous skin potential responses. These results are probably related to the differences between the respiratory control in QS and in AS.- - - - - - - - - - ranking = 1keywords = respiration (Clic here for more details about this article) |
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