Cases reported "Chronic Disease"

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11/22. Pulmonary complications in diabetes mellitus.

    diabetes mellitus produces serious complications in several major organ systems. The pulmonary complications, although uncommon and not well recognized, may be life-threatening. We describe a 20-year-old patient with diabetic ketoacidosis in whom pulmonary zygomycosis developed. This condition was complicated by stenosis of the left upper lobe bronchus despite successful treatment of the zygomycosis. Bronchial obstruction has become a well-recognized complication of pulmonary zygomycosis. In addition to infections caused by Zygomycetes, mycobacteria, viruses, and bacteria, the pulmonary complications described in patients with diabetes include pulmonary edema, disordered breathing during sleep, and reductions in elastic recoil of the lungs, diffusing capacity of the lungs for carbon monoxide, and bronchomotor tone. Other reported complications are respiratory alkalosis, cardiorespiratory arrest, pneumothorax, pneumomediastinum, plugging of the airways with mucus, and aspiration pneumonia attributable to diabetic gastroparesis.
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12/22. Management of chronic alveolar hypoventilation with nasal positive pressure breathing.

    Negative pressure ventilation is the most common method of providing assisted ventilation without a tracheostomy. Unfortunately, negative pressure devices have several disadvantages and are not well tolerated by all patients. We present a patient in whom intermittent assisted ventilation was applied successfully by using a nasal mask to provide positive pressure ventilatory support.
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13/22. Lung function in diaphragm pacing.

    electric stimulation of the diaphragm via the phrenic nerve to induce ventilation has recently been used for the long-term management of chronic ventilatory insufficiency. Since 1973 three patients with inadequate alveolar ventilation have been treated with diaphragm pacing at the Toronto Western Hospital. Two, who had quadriplegia due to lesions of the spinal cord in the upper cervical region and a severe restrictive ventilatory defect, were treated with continuous diaphragm pacing. The third patient required assisted nocturnal ventilation because of primary alveolar hypoventilation. All three patients tolerated the diaphragm pacing well, and pulmonary function tests showed satisfactory gas exchange with the patients breathing room air. This form of therapy seems to be a practical clinical method of managing chronic ventilatory failure in patients with lesions of the upper cervical cord or primary alveolar hypoventilation.
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14/22. The maintenance of total ventilatory requirements through a chronic bronchopleural cutaneous fistula.

    In patient with a chronic post-tuberculous bronchopleural cutaneous fistula (BPCF), minute ventilation, dead space, flow rates, arterial blood gas tensions, and oxygen consumption were measured during mouth breathing and after 30 min of steady-state breathing solely through the BPCF. Despite a 390-ml (18%) decrease in dead space when breathing took place through the BPCF, there were no significant changes in minute ventilation or respiratory rate. BPCF breathing was also associated with an increase in airways resistance as reflected by a 300-ml (35%) decrease in the FEV1 and a 16% decrease in the FEV1/FVC ratio. The increased resistance resulted in a 20 ml/min (18%) increase in oxygen consumption. Arterial blood gas tensions remained constant. We conclude that although ventilatory efficiency was not improved, this patient was able to satisfy his total minute ventilatory requirements, for the 30-min period, solely through BPCF breathing.
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15/22. Respiratory dysrhythmia. A new cause of central alveolar hypoventilation.

    An infant developed chronic respiratory failure after aseptic meningoencephalitis at 5 months of age. Neurologic evaluations at 16 and 17 months were normal except for an abnormal pharyngeal stage of swallowing, lower extremity hypotonia, and a mild left hemiparesis. Spontaneous breathing during sleep at 16 months was characterized by alveolar hypoventilation, athetoid truncal movements, and disorganized respiratory muscle activity. At 27 months of age, improvement in sleep-related breathing was accompanied by a change in respiratory pattern characterized by alternating inspiratory and expiratory muscular activation. The findings indicate that disorganized as well as diminished output from the central respiratory pattern generator may result in central alveolar hypoventilation.
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16/22. Chronic ventilatory failure caused by abnormal respiratory pattern generation during sleep.

    A 67-yr-old man presented with a 4-yr history of chronic ventilatory failure in the absence of any restrictive or obstructive ventilatory defect. Detailed neurologic investigations were unremarkable, and the response of minute volume of ventilation to inhaled CO2 was normal. During sleep there was no evidence of upper airway obstruction, and minute volume of ventilation averaged 6.7 L/min, compared with 7.2 L/min during quiet wakefulness. However, sleep was associated with a rapid and shallow pattern of breathing, resulting in high dead space ventilation, inadequate alveolar ventilation, hypoxemia, and hypercapnia. Correction of the abnormal ventilatory pattern during sleep by diaphragmatic pacing abolished all features of chronic respiratory failure. The findings indicate that a disorder of respiratory pattern during sleep can produce chronic ventilatory failure, despite normal respiratory drive.
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17/22. Fatal desquamative interstitial pneumonia in three infants siblings.

    Desquamative interstitial pneumonia occurred in three siblings. cough, difficulty in breathing, cyanosis, and failure to gain weight appeared during the first month of life; progressive hypoxia followed, and the three infants died in respiratory failure before the age of 4 months despite intensive drug and supportive treatment. The radiographic and the histologic appearance of pulmonary changes were similar in all three infants. Chest radiographs yielded normal findings initially, with rapid progression to a ground glass appearance of both lungs. Histologic findings of lung biopsies showed lymphoplasmocytic infiltration and fibrous thickening of the alveolar walls, swelling of alveolar lining cells, and large clumps of macrophages with PAS-positive foamy cytoplasm in the alveolar spaces.
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18/22. Psychogenic cough treated with biofeedback and psychotherapy. A review and case report.

    Psychogenic cough is a barking or honking cough, which is persistent and disruptive to normal activity. The cough may be a debilitating condition that interferes with work and social relationships. Although the frequency of this condition is low, it is not rare. The majority of cases reported involve pediatric or adolescent patients. Surprisingly, there are scant data describing this condition in the adult population and no reports of biofeedback being used to treat this syndrome. We present a case report of an adult patient with psychogenic cough and review the available pediatric and adult literature. A 41-yr-old obese female presented with a complex 7-yr history of intractable, nonproductive, chronic cough. She had been avoiding social activities because of embarrassment by her repeated episodes of coughing. Extensive diagnostic work-up failed to find an organic etiology. Numerous medical and surgical treatments had failed. The patient was treated with a combination of biofeedback-assisted relaxation training, psychotherapy, and physical therapy. review of the literature revealed only one report on adults, in which three of four patients were successfully treated with a combination of speech therapy, relaxation techniques, breathing exercises, and psychotherapy. Our success suggests a possible future use of this treatment protocol for cases of psychogenic cough.
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19/22. Acute effects of intermittent positive pressure breathing in patients with chronic obstructive lung disease.

    The immediate effects of intermittent positive pressure breathing (IPPB) on air were studied in seven patients (age 55-73 years) with advanced chronic obstructive lung disease (COLD) and with chronic respiratory insufficiency. Dynamic lung compliance was reduced by an average of 25% by IPPB, while inspiratory resistance increased by 40%. Distribution of inspired gas, as determined by nitrogen washout, became more even with IPPB. Respiratory frequency was not altered, whereas total ventilation increased by 25% during IPPB and PaCO2 was reduced. Oxygen uptake was reduced by 6%. PaO2 did not change during IPPB but had decreased by an average of 20% 10 minutes after IPPB and then slowly improved; PaCO2 did not change after IPPB. The pressures in the right atrium, pulmonary artery, and in pulmonary wedge position all increased approximately 2 mm Hg (approximately 2 cm H2O) with IPPB, while intrathoracic pressure rose on an average by 5 cm H2O, the transmural pressures thus being lowered during IPPB. The pulmonary vascular resistance was not significantly altered by IPPB, whereas the systemic vascular resistance rose 25%. cardiac output was reduced approximately 20% and venous admixture almost 50%.
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keywords = breathing
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20/22. How to modify a volume-cycled home ventilator to satisfy a child's need for pressure-limiting and continuous positive airway pressure during spontaneous breathing.

    Piston driven volume-cycled home ventilators increase work of breathing in the synchronized intermittent mandatory ventilation mode. A 2-year-old trisomy 21 patient with chronic lung disease due to recurrent aspiration pneumonia required a ventilator rate of 6-8 breaths per minute awake and 15 asleep, with peak pressure of 32 cm H2O and positive end-expiratory pressure (PEEP) of 10 cm H2O. Two circuits were designed to facilitate breathing and respiratory mechanics of his spontaneous breaths on both were compared. A spring valve on the inspiratory line pressure-limited ventilation and at the end of the expiratory line provided PEEP in both systems. The reservoir system had a 2-liter bag on the inspiratory limb of the circuit, and two one-way valves at the patient connector to direct inspiratory and expiratory flow. The continuous positive airway pressure (CPAP) system provided continuous flow with a CPAP device set to deliver a pressure 2 cmH2O higher than the PEEP valve. On the CPAP system, compared to the reservoir system, dynamic compliance was greater [1.52 (0.14 SD) ml/cm H2O/kg vs. 0.39 (0.02), p < 0.001] and resistance less [8.15 (1.26) cm H2O/l/s vs. 45.86 (0.87), p < 0.001] as measured with a PeDS machine. This is an innovative use of a CPAP device.
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