Cases reported "Respiratory Insufficiency"

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1/110. Noninvasive positive-pressure ventilation facilitates tracheal extubation after laryngotracheal reconstruction in children.

    Tracheal extubation after laryngotracheal reconstruction in children may be complicated by postoperative tracheal edema and pulmonary dysfunction. The replacement of a tracheal tube in this situation may exacerbate the existing injury to the tracheal mucosa, complicating subsequent attempts at tracheal extubation. We present two cases where noninvasive positive-pressure ventilation was employed to treat partial airway obstruction and respiratory failure in two children following laryngotracheal reconstruction. Noninvasive positive-pressure ventilation served as a bridge between mechanical ventilation via a tracheal tube and spontaneous breathing, providing airway stenting and ventilatory support while tracheal edema and pulmonary dysfunction were resolved. Under appropriate conditions, noninvasive positive-pressure ventilation may be useful in the management of these patients.
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2/110. Proximal diabetic neuropathy presenting with respiratory weakness.

    A patient is described with proximal diabetic neuropathy presenting with respiratory weakness. A 50 year old man developed progressive shortness of breath over 2 months. He also had weakness of hip flexion. phrenic nerve responses were absent, and spontaneous activity was seen in the intercostal and lumbar paraspinal muscles with long duration neurogenic MUPs and reduced recruitment in the diaphragm. Without treatment, the patient began to improve with resolution of his proximal leg weakness and breathing difficulties. Proximal diabetic neuropathy is another cause of neuromuscular respiratory weakness.
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3/110. Respiratory failure and pulmonary hypertension associated with klippel-feil syndrome.

    A 28-year-old woman with a deformed thorax and kyphoscoliosis associated with klippel-feil syndrome developed respiratory failure with pulmonary hypertension. Pulmonary 133Xe ventilation and 99mTc-MAA perfusion scintigraphies showed maldistributions of lung ventilation and perfusion, and noticeably delayed 133Xe washout from the lungs. Dynamic breathing MR imaging showed poor and/or asynchronous respiratory movements of the chest wall and diaphragm. These findings indicate that the perfusion-ventilation imbalance, the decreased ventilatory turnover, and expiratory flow from the alveolar space partly derived from the impaired respiratory mechanics may be responsible for the respiratory complications in this patient.
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4/110. Bilateral congenital choanal atresia and absence of respiratory distress.

    Bilateral congenital choanal atresia is considered a lethal congenital malformation in an obligatory nasal breathing neonate. Described herein are two cases of bilateral choanal atresia associated with craniofacial anomalies who did not present respiratory distress in the neonatal period. Our first patient had a complete unilateral cleft lip which facilitated oropharyngeal respiration. The second patient presented wory distress in the neonatal period by providing an oropharyngeal airway.
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keywords = respiration, breathing
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5/110. Intemittent obstruction of the upper airway during sleep causing profound hypoxaemia. A neglected mechanism exacerbating chronic respiratory failure.

    An obese patient with a ten year history of respiratory failure presented with insomnia and marked daytime somnolence. Respriatory failure had been attributed to obesity, respiratory centre insensitivity to carbon dioxide, and to diffuse airways obstruction. To investigate the possible role of episodic apnoea with frequent nocturnal arousals, continous recordings were obtained during sleep of arterial oxygen saturation, oesophageal pressure and the motions of the rib-cage and abdomen/diaphragm. Repeated episodes of hypoventilation and profound hypoxaemia were found which were due to intermittent obstruction of the upper airway rather than to cessation of breathing efforts. During the episodes of hypoxaemia, values of arterial O2 tension fell to as low as 24 mmHg. Episodic hypoxaemia was relieved but not abolished, by the use of a collar, designed to hold the mandible forward. Previous reports indicated that recognition of intermittent obstruction of the upper airway during sleep and treatment by a permanent tracheostomy, resulted in a significant long-term imporvement of pulmonary and cardiac function and relief of insomnia and day-time somnolence. When tracheostomy is inadvisable, as in the present patient, it is hoped that similar long-term benefits will result from a supportive collar.
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6/110. pressure support ventilation: reducing the work of breathing during weaning.

    pressure support ventilation decreases the work of breathing by providing the patient with positive airway pressure during the inspiratory phase. The use of this type of ventilatory support is likely to increase over the next few years for patients, especially during the weaning period. By understanding how pressure support ventilation works and what patient parameters need to be monitored, the critical care nurse can help patients decrease respiratory muscle fatigue during weaning and thus decrease the weaning time for these patients.
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keywords = breathing
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7/110. Physical therapy for a patient in acute respiratory failure.

    BACKGROUND AND PURPOSE: The main indications for physical therapy for patients in intensive care units (ICUs) are excessive pulmonary secretions or atelectasis. Timely physical therapy interventions may improve gas exchange and reverse pathological progression, thereby curtailing or avoiding artificial ventilation. The purpose of this case report is to illustrate 24-hour availability of physical therapy for a patient with acute respiratory failure. CASE DESCRIPTION: The patient was a 66-year-old man who was admitted to an ICU for acute respiratory failure. Intensive physical therapy, based on Dean's physiologic treatment hierarchy for treatment of patients with impaired oxygen transport, consisted of upright body positioning, mobilization and exercise, and active cycles of breathing techniques every 2 hours for the first 12 hours he was in the ICU. OUTCOMES: In total, the patient received 11 physical therapy sessions over his 48-hour stay in the ICU (6 sessions on day 1 and 5 sessions on day 2). Arterial oxygenation improved markedly with radiographic resolution of infiltrates, and planned endotracheal intubation and mechanical ventilation were avoided. DISCUSSION: This patient with acute respiratory failure received physical therapy in a timely manner afforded by 24-hour access to physical therapy. The intensive physical therapy might be more cost-effective than if the patient had been managed with intubation and mechanical ventilation. patients in ICUs who have excessive pulmonary secretions or atelectasis may benefit from access to physical therapy 24 hours a day.
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8/110. hypnosis as a diagnostic modality for vocal cord dysfunction.

    vocal cord dysfunction (VCD) is a condition of paradoxical adduction of the vocal cords during the inspiratory phase of the respiratory cycle. VCD often presents as stridorous breathing, which may be misdiagnosed as asthma. The mismanagement of this disorder may result in unnecessary treatment and iatrogenic morbidity. An association with psychogenic factors has been reported, and a higher incidence of anxiety-related illness has been demonstrated in patients with VCD. Definitive diagnosis of VCD is made by visualization of adducted cords during an acute episode using nasopharyngeal fiber-optic laryngoscopy. diagnosis can be problematic, because it may be difficult to reproduce an attack in a controlled setting. To maximize diagnostic yield during laryngoscopy, provocation of symptoms using methacholine, histamine, or exercise challenges have been used. We report a case of an 11-year-old boy, wherein hypnotic suggestion was used as an alternative method to achieve a diagnosis of VCD. The patient was admitted to the pediatric intensive care unit for elective fiber-optic laryngoscopy to confirm a diagnosis of VCD. The patient had a 4-year history of refractory asthma, severe gastroesophageal reflux disease (GERD) for which he had undergone a Nissen fundoplication, and suspected VCD. At 9 years of age the patient began manifesting monthly respiratory distress episodes of a severe character different from those that had been attributed to his asthma. Typically, he awoke from sleep with shortness of breath and difficulty with inhalation. He described a "neck attack" during which he felt as if the walls of his throat were "beating together." The patient was at times noted by his mother to exhibit a "suckling" behavior before onset of his respiratory distress episodes. On 4 occasions the patient became unconscious during an attack and then spontaneously regained consciousness after a few minutes. On these occasions, he was transported by ambulance to the hospital and the severe difficulty with inhalation resolved within a few minutes on treatment with oxygen and bronchodilators. Sometimes he was noted to manifest wheezing for several hours, which was responsive to bronchodilator therapy. Given the severity of the patient's disease, it was imperative to determine whether VCD was a complicating factor. It was proposed that an attempt be made to induce VCD by hypnotic suggestion while the patient underwent a fiberscopic laryngoscopy to establish a definitive diagnosis. The patient and his mother gave written consent for this procedure. He was admitted for observation to the pediatric intensive care unit for the induction attempt. The patient requested that no local anesthesia be applied in his nose before passage of the laryngoscope because he wanted to eat right after the procedure. Therefore, the nasopharyngeal laryngoscope was inserted while he used self-hypnosis as the sole form of anesthesia. He demonstrated no discomfort during its passing. Once the vocal cords were visualized, the patient was instructed to develop an episode of respiratory distress while in a state of hypnosis by recalling a recent "neck attack." His vocal cords then were observed to adduct anteriorly with each inspiration. The patient then was asked to relax his neck. When he did, the vocal cords immediately abducted with inspiration, and he breathed easily. After removal of the laryngoscope, the patient alerted from hypnosis and said he felt well. He reported no recollection of the procedure, thus demonstrating spontaneous amnesia that sometimes is associated with hypnosis. Because the diagnosis of VCD was confirmed, the patient was encouraged to use self-hypnosis and speech therapy techniques to control his symptoms. He also was referred for counseling. To our knowledge this is the first description in the medical literature of the use of hypnotic suggestion for making a diagnosis of VCD. (ABSTRACT TRUNCATED)
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9/110. Cerebral dissection from syringomyelia demonstrated using cine magnetic resonance imaging. Case report.

    A 16-year-old boy presented at the authors' emergency department with a sudden deterioration of respiration. He had been paraparetic for 3 years and had become quadriplegic 2 days previously. Magnetic resonance images revealed a Chiari I malformation and a hydromyelic cavity extending from C-1 to T-11. Rostrally, a small cylindrically shaped lesion extended from the cervicomedullary junction to the left semioval center. The patient made a dramatic neurological recovery following suboccipital craniectomy and upper cervical laminectomies with augmentation duraplasties followed by placement of a syringoperitoneal shunt.
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keywords = respiration
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10/110. Breathing room.

    Appropriate assessment of the respiratory system begins with a good understanding of how this vital system functions. Perform an initial assessment by evaluating the patient's general appearance, patency of the airway and work of breathing. vital signs, including pulse ox measurement, must be gathered early. Evaluation of the respiratory effort should include the inspection, palpation and auscultation. Detection of adventitious breath sounds, such as rhonchi, rales, wheezes and pleural friction rub is obviously important. When you've completed a good assessment and rendered appropriate treatment, both the patient and the EMT can breathe a little easier.
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