• Tuberculosis and Respiratory Diseases
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• 제45권1호
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• pp.153-168
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• 1998

Background: The existing data indicate that obstructive sleep apnea syndrome contributes to the development of cardiovascular dysfunction such as systemic hypertension and cardiac arrhythmias, and the cardiovascular dysfunction has a major effect on high long-term mortality rate in obstructive sleep apnea syndrome patients. To a large extent the various studies have helped to clarify the pathophysiology of obstructive sleep apnea, but many basic questions still remain unanswered. Methods: In this study, the influence of obstructive sleep apnea on systemic blood pressure, cardiac rhythm and urinary catecholamines concentration was evaluated. Over-night polysomnography, 24-hour ambulatory blood pressure and ECG monitoring, and measurement of urinary catecholamines, norepinephrine (UNE) and epinephrine (UEP), during waking and sleep were undertaken in obstructive sleep apnea syndrome patients group (OSAS, n=29) and control group (Control, n=25). Results: 1) In OSAS and Control, UNE and UEP concentrations during sleep were significantly lower than during waking (P<0.01). In UNE concentrations during sleep, OSAS showed higher levels compare to Control (P<0.05). 2) In OSAS, there was a increasing tendency of the number of non-dipper of nocturnal blood pressure compare to Control (P=0.089). 3) In both group (n=54), mean systolic blood pressure during waking and sleep showed significant correlation with polysomnographic data including apnea index (AI), apnea-hypopnea index (AHI), arterial oxygen saturation nadir ($SaO_2$ nadir) and degree of oxygen desaturation (DOD). And UNE concentrations during sleep were correlated with AI, AHI, $SaO_2$ nadir, DOD and mean diastolic blood pressure during sleep. 4) In OSAS with AI>20 (n==14), there was a significant difference of heart rates before, during and after apneic events (P<0.01), and these changes of heart rates were correlated with the duration of apnea (P<0.01). The difference of heart rates between apneic and postapneic period (${\Delta}HR$) was significantly correlated with the difference of arterial oxygen saturation between before and after apneic event (${\Delta}SaO_2$) (r=0.223, P<0.001). 5) There was no significant difference in the incidence of cardiac arrhythmias between OSAS and Control In Control, the incidence of ventricular ectopy during sleep was significantly lower than during waking. But in OSAS, there was no difference between during waking and sleep. Conclusion : These results suggested that recurrent hypoxia and arousals from sleep in patients with obstructive sleep apnea syndrome may increase sympathetic nervous system activity, and recurrent hypoxia and increased sympathetic nervous system activity could contribute to the development of cardiovascular dysfunction including the changes of systemic blood pressure and cardiac function.

• Journal of the Korean Society of Food Science and Nutrition
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• 제34권2호
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• pp.202-208
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• 2005

This study was conducted to examine the food habits, knowledge of nutrition and actual conditions of food ingestion of adolescent middle school students according to questionnaire answers. Questionnaires were completed by 524 students, divided into a healthy group (n=289) and an unhealthy group (n=235) according to clinical signs. Further questions were asked of the two groups in the areas of food habits, knowledge of nutrition and nutritional attitude. The results were as follows: Mean age of all subjects was 14, heights for male and female students were 162.0 em, and 157.2 cm, weights were 53.4 kg, and 49.4, respectively. Heights and weights of male students were greater than those of female students. The body mass index (BMI) for male and female students was 20.3 kg/$m^2$ and 20.0 kg/$m^2$, respectively, and all data were within normal ranges. There were no significant differences in mean age, height, weight, and BMI between the healthy and unhealthy groups. There was no significant difference in body image recognition between the two groups, although the ratio of dissatisfaction with their own body shape was significantly higher in the female unhealthy group (46.1%), than in the female healthy group (33.0%) (p<0.05). In the area of the struggle to control body weight during the previous year, the female unhealthy group (59.4%) was higher than the female healthy group (38.4%) (p<0.01). There was no significant difference in the scores between the two groups in the areas of knowledge of nutrition and the nutritional attitude. Meal frequency and meal patterns were showed that having breakfast less than 4x/week was significantly higher in the female unhealthy group (44.0%), than in the female healthy group (30.7%) (p<0.01). Meal frequency for suppers<4x/week showed that the female unhealthy group (18.8%) was also higher than the female healthy group (10.7%). Therefore, the unhealthy group exhibited a higher pattern of missing both breakfast and supper. The male unhealthy group (16.7%) dined out more frequently than the male healthy group (12.3%) (p<0.01), and female unhealthy group also indulged in snacking significantly more frequently than the female healthy group. The unhealthy group also ate only 1 item for meals more frequently than the healthy group and no significant difference. The conclusion of this study is that adolescent Korean middle school students, who showed a higher incidence of clinical symptoms, representing an unhealthy status, missed breakfast and supper, and dined out and indulged in snacking more frequently. Their quality of breakfast and satisfaction of body image were also lower than the healthy group. These results indicated that there is a high correlation between a Korean adolescent's health status, food habits and body image satisfaction. It is recommended that a more intense program of nutritional education and monitoring be introduce into the current Korean middle-school system in order to optimally support and maximize the health potential of the current population of Korean student.

• Journal of Food Hygiene and Safety
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• 제34권3호
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• pp.227-234
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• 2019

An analytical method was developed for the determination of oxytetracycline in agricultural products using the QuEChERS (Quick, Easy, Cheap, Effective, Rugged and Safe) method by liquid chromatography-tandem mass spectrometry (LC-MS/MS). After the samples were extracted with methanol, the extracts were adjusted to pH 4 by formic acid and sodium chloride was added to remove water. Dispersive solid phase extraction (d-SPE) cleanup was carried out using $MgSO_4$ (anhydrous magnesium sulfate), PSA (primary secondary amine), $C_{18}$ (octadecyl) and GCB (graphitized carbon black). The analytes were quantified and confirmed with LC-MS/MS using ESI (electrospray ionization) in positive ion MRM (multiple reaction monitoring) mode. The matrix-matched calibration curves were constructed using six levels ($0.001{\sim}0.25{\mu}g/mL$) and coefficient of determination ($r^2$) was above 0.99. Recovery results at three concentrations (LOQ, $10{\times}LOQ$, and $50{\times}LOQ$, n=5) were from 80.0 to 108.2% with relative standard deviations (RSDs) less than of 11.4%. For inter-laboratory validation, the average recovery was in the range of 83.5~103.2% and the coefficient of variation (CV) was below 14.1%. All results satisfied the criteria ranges requested in the Codex guidelines (CAC/GL 40-1993, 2003) and the Food Safety Evaluation Department guidelines (2016). The proposed analytical method was accurate, effective and sensitive for oxytetracycline determination in agricultural commodities. This study could be useful for safety management of oxytetracycline residues in agricultural products.

• Journal of the Korean Society of Marine Environment & Safety
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• 제27권7호
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• pp.924-942
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• 2021

The expansion of the Changjiang Diluted Water (CDW) plume during summer is known to be a major factor influencing phytoplankton diversity, community structure, and the regional marine environment of the northern East China Sea (ECS). The discharge of the CDW plume was very high in the summer of 2020, and cruise surveys and stationary monitoring were conducted to understand the dynamics of changes in environmental characteristics and the impact on phytoplankton diversity and community structure. A cruise survey was conducted from August 16 to 17, 2020, using R/V Eardo, and a stay survey at the Ieodo Ocean Research Station (IORS) from August 15 to 21, 2020, to analyze phytoplankton diversity and community structure. The southwestern part of the survey area exhibited low salinity and high chlorophyll a fluorescence under the influence of the CDW plume, whereas the southeastern part of the survey area presented high salinity and low chlorophyll a fluorescence under the influence of the Tsushima Warm Current (TWC). The total chlorophyll a concentrations of surface water samples from 12 sampling stations indicated that nano-phytoplankton (20-3 ㎛) and micro-phytoplankton (> 20 ㎛) were the dominant groups during the survey period. Only stations strongly influenced by the TWC presented approximately 50% of the biomass contributed by pico-phytoplankton (< 3 ㎛). The size distribution of phytoplankton in the surface water samples is related to nutrient supplies, and areas where high nutrient (nitrate) supplies were provided by the CDW plume displayed higher biomass contribution by micro-phytoplankton groups. A total of 45 genera of nano- and micro-phytoplankton groups were classified using morphological analysis. Among them, the dominant taxa were the diatoms Guinardia flaccida and Nitzschia spp. and the dinoflagellates Gonyaulax monacantha, Noctiluca scintillans, Gymnodinium spirale, Heterocapsa spp., Prorocentrum micans, and Tripos furca. The sampling stations affected by the TWC and low in nitrate concentrations presented high concentrations of photosynthetic pico-eukaryotes (PPE) and photosynthetic pico-prokaryotes (PPP). Most sampling stations had phosphate-limited conditions. Higher Synechococcus concentrations were enumerated for the sampling stations influenced by low-nutrient water of the TWC using flow cytometry. The NGS analysis revealed 29 clades of Synechococcus among PPP, and 11 clades displayed a dominance rate of 1% or more at least once in one sample. Clade II was the dominant group in the surface water, whereas various clades (Clades I, IV, etc.) were found to be the next dominant groups in the SCM layers. The Prochlorococcus group, belonging to the PPP, observed in the warm water region, presented a high-light-adapted ecotype and did not appear in the northern part of the survey region. PPE analysis resulted in 163 operational taxonomic units (OTUs), indicating very high diversity. Among them, 11 major taxa showed dominant OTUs with more than 5% in at least one sample, while Amphidinium testudo was the dominant taxon in the surface water in the low-salinity region affected by the CDW plume, and the chlorophyta was dominant in the SCM layer. In the warm water region affected by the TWC, various groups of haptophytes were dominant. Observations from the IORS also presented similar results to the cruise survey results for biomass, size distribution, and diversity of phytoplankton. The results revealed the various dynamic responses of phytoplankton influenced by the CDW plume. By comparing the results from the IORS and research cruise studies, the study confirmed that the IORS is an important observational station to monitor the dynamic impact of the CDW plume. In future research, it is necessary to establish an effective use of IORS in preparation for changes in the ECS summer environment and ecosystem due to climate change.

• Tuberculosis and Respiratory Diseases
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• 제56권5호
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• pp.465-484
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• 2004

Background : Insulin-like growth factor (IGF)-binding protein-3 (IGFBP-3) inhibits the proliferation of non-small cell lung cancer (NSCLC) cells by inducing apoptosis. Methods : In this study, we investigated whether hypermethylation of IGFBP-3 promoter play an important role in the loss of IGFBP-3 expression in NSCLC. We also studied the mechanisms that mediate the silencing of IGFBP-3 expression in the cell lines which have hypermethylated IGFBP-3 promoter. Results : The IGFBP-3 promoter has hypermethylation in 7 of 15 (46.7%) NSCLC cell lines and 16 (69.7%) of 23, 7 (77.8%) of 9, 4 (80%) of 5, 4 (66.7 %) of 6, and 6 (100%) of 6 tumor specimens from patients with stage I, II, IIIA, IIIB, and IV NSCLC, respectively. The methylation status correlated with the level of protein and mRNA in NSCLC cell lines. Expression of IGFBP-3 was restored by the demethylating agent 5'-aza-2'-deoxycytidine (5'-aza-dC) in a subset of NSCLC cell lines. The Sp-1/ Sp-3 binding element in the IGFBP-3 promoter, important for promoter activity, was methylated in the NSCLC cell lines which have reduced IGFBP-3 expression and the methylation of this element suppressed the binding of the Sp-1 transcription factor. A ChIP assay showed that the methylation status of the IGFBP-3 promoter influenced the binding of Sp-1, methyl-CpG binding protein-2 (MeCP2), and histone deacetylase (HDAC) to Sp-1/Sp-3 binding element, which were reversed by by 5'-aza-dC. In vitro methylation of the IGFBP-3 promoter containing the Sp-1/Sp-3 binding element significantly reduced promoter activity, which was further suppressed by the overexpression of MeCP2. This reduction in activity was rescued by 5'-aza-dC. Conclusion : These findings indicate that hypermethylation of the IGFBP-3 promoter is one mechanism by which IGFBP-3 expression is silenced and MeCP2, with recruitment of HDAC, may play a role in silencing of IGFBP-3 expression. The frequency of this abnormality is also associated with advanced stages among the patients with NSCLC, suggesting that IGFBP-3 plays an important role in lung carcinogenesis/progression and that the promoter methylation status of IGFBP-3 may be a marker for early molecular detection and/or for monitoring chemoprevention efforts.

• Journal of the Korean Society of Food Science and Nutrition
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• 제42권3호
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• pp.464-477
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• 2013

There is a great need to develop a training program proven to change behavior and improve knowledge. The purpose of this study was to evaluate employee hygiene knowledge, hygiene practice, and cleanliness, before and after HACCP system implementation at one small-size restaurant. The efficiency of the system was analyzed using time-temperature control after implementation of u-HACCP$^{(R)}$. The employee hygiene knowledge and practices showed a significant improvement (p<0.05) after HACCP system implementation. In non-heating processes, such as seasoned lettuce, controlling the sanitation of the cooking facility and the chlorination of raw ingredients were identified as the significant CCP. Sanitizing was an important CCP because total bacteria were reduced 2~4 log CFU/g after implementation of HACCP. In bean sprouts, microbial levels decreased from 4.20 logCFU/g to 3.26 logCFU/g. There were significant correlations between hygiene knowledge, practice, and microbiological contamination. First, personnel hygiene had a significant correlation with 'total food hygiene knowledge' scores (p<0.05). Second, total food hygiene practice scores had a significant correlation (p<0.05) with improved microbiological qualities of lettuce salad. Third, concerning the assessment of microbiological quality after 1 month, there were significant (p<0.05) improvements in times of heating, and the washing and division process. On the other hand, after 2 months, microbiological was maintained, although only two categories (division process and kitchen floor) were improved. This study also investigated time-temperature control by using ubiquitous sensor networks (USN) consisting of an ubi reader (CCP thermometer), an ubi manager (tablet PC), and application software (HACCP monitoring system). The result of the temperature control before and after USN showed better thermal management (accuracy, efficiency, consistency of time control). Based on the results, strict time-temperature control could be an effective method to prevent foodborne illness.

• The Journal of Engineering Geology
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• 제28권2호
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• pp.217-246
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• 2018

During the selection and characterization of target formations in the Small-scale Offshore $CO_2$ Storage Demonstration Project in the Pohang Basin, we have carefully investigated the possibility of induced earthquakes and leakage of $CO_2$ during the injection, and have designed the storage processes to minimize these effects. However, people in Pohang city have a great concern on $CO_2$-injection-intrigued seismicity, since they have greatly suffered from the 5.4 magnitude earthquake on Nov. 15, 2017. The research team of the project performed an extensive self-investigation on the safety issues, especially on the possible $CO_2$ leakage from the target formation and induced earthquakes. The target formation is 10 km apart from the epicenter of the Pohang earthquake and the depth is also quite shallow, only 750 to 800 m from the sea bottom. The project performed a pilot injection in the target formation from Jan. 12 to Mar. 12, 2017, which implies that there are no direct correlation of the Pohang earthquake on Nov. 15, 2017. In addition, the $CO_2$ injection of the storage project does not fracture rock formations, instead, the supercritical $CO_2$ fluid replaces formation water in the pore space gradually. The self-investigation results show that there is almost no chance for the injection to induce significant earthquakes unless injection lasts for a very long time to build a very high pore pressure, which can be easily monitored. The amount of injected $CO_2$ in the project was around 100 metric-tonne that is irrelevant to the Pohang earthquake. The investigation result on long-term safety also shows that the induced earthquakes or the reactivation of existing faults can be prevented successfully when the injection pressure is controlled not to demage cap-rock formation nor exceed Coulomb stresses of existing faults. The project has been performing extensive studies on critical stress for fracturing neighboring formations, reactivation stress of existing faults, well-completion processes to minimize possible leakage, transport/leakage monitoring of injected $CO_2$, and operation procedures for ensuring the storage safety. These extensive studies showed that there will be little chance in $CO_2$ leakage that affects human life. In conclusion, the Small-scale Offshore $CO_2$ Storage Demonstration Project in the Pohang Basin would not cause any induced earthquakes nor signifiant $CO_2$ leakage that people can sense. The research team will give every effort to secure the safety of the storage site.

• Radiation Oncology Journal
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• 제28권3호
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• pp.155-165
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• 2010

Purpose: In order to evaluate the positional uncertainty of internal organs during radiation therapy for treatment of liver cancer, we measured differences in inter- and intra-fractional variation of the tumor position and tidal amplitude using 4-dimentional computed radiograph (DCT) images and gated orthogonal setup kilovolt (KV) images taken on every treatment using the on board imaging (OBI) and real time position management (RPM) system. Materials and Methods: Twenty consecutive patients who underwent 3-dimensional (3D) conformal radiation therapy for treatment of liver cancer participated in this study. All patients received a 4DCT simulation with an RT16 scanner and an RPM system. Lipiodol, which was updated near the target volume after transarterial chemoembolization or diaphragm was chosen as a surrogate for the evaluation of the position difference of internal organs. Two reference orthogonal (anterior and lateral) digital reconstructed radiograph (DRR) images were generated using CT image sets of 0% and 50% into the respiratory phases. The maximum tidal amplitude of the surrogate was measured from 3D conformal treatment planning. After setting the patient up with laser markings on the skin, orthogonal gated setup images at 50% into the respiratory phase were acquired at each treatment session with OBI and registered on reference DRR images by setting each beam center. Online inter-fractional variation was determined with the surrogate. After adjusting the patient setup error, orthogonal setup images at 0% and 50% into the respiratory phases were obtained and tidal amplitude of the surrogate was measured. Measured tidal amplitude was compared with data from 4DCT. For evaluation of intra-fractional variation, an orthogonal gated setup image at 50% into the respiratory phase was promptly acquired after treatment and compared with the same image taken just before treatment. In addition, a statistical analysis for the quantitative evaluation was performed. Results: Medians of inter-fractional variation for twenty patients were 0.00 cm (range, -0.50 to 0.90 cm), 0.00 cm (range, -2.40 to 1.60 cm), and 0.00 cm (range, -1.10 to 0.50 cm) in the X (transaxial), Y (superior-inferior), and Z (anterior-posterior) directions, respectively. Significant inter-fractional variations over 0.5 cm were observed in four patients. Min addition, the median tidal amplitude differences between 4DCTs and the gated orthogonal setup images were -0.05 cm (range, -0.83 to 0.60 cm), -0.15 cm (range, -2.58 to 1.18 cm), and -0.02 cm (range, -1.37 to 0.59 cm) in the X, Y, and Z directions, respectively. Large differences of over 1 cm were detected in 3 patients in the Y direction, while differences of more than 0.5 but less than 1 cm were observed in 5 patients in Y and Z directions. Median intra-fractional variation was 0.00 cm (range, -0.30 to 0.40 cm), -0.03 cm (range, -1.14 to 0.50 cm), 0.05 cm (range, -0.30 to 0.50 cm) in the X, Y, and Z directions, respectively. Significant intra-fractional variation of over 1 cm was observed in 2 patients in Y direction. Conclusion: Gated setup images provided a clear image quality for the detection of organ motion without a motion artifact. Significant intra- and inter-fractional variation and tidal amplitude differences between 4DCT and gated setup images were detected in some patients during the radiation treatment period, and therefore, should be considered when setting up the target margin. Monitoring of positional uncertainty and its adaptive feedback system can enhance the accuracy of treatments.

• Tuberculosis and Respiratory Diseases
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• 제44권3호
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• pp.592-600
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• 1997

Background : The level of imposed work of breathing (WOB) is important for patient-ventilator synchrony and during weaning from mechanical ventilation. Triggering methods and the sensitivity of demand system are important determining factors of the imposed WOB. Flow triggering method is available on several modern ventilator and is believed to impose less work to a patient-triggered breath than pressure triggering method. We intended to compare the level of imposed WOB on two different methods of triggering and also at different levels of sensitivities on each triggering method (0.7 L/min vs 2.0 L/min on flow triggering ; $-1\;cmH_2O$ vs $-2cm\;H_2O$ on pressure triggering). Methods : The subjects were 12 patients ($64.8{\pm}4.2\;yrs$) on mechanical ventilation and were stable in respiratory pattern on CPAP $3\;cmH_2O$. Four different triggering sensitivities were applied at random order. For determination of imposed WOB, tracheal end pressure was measured through the monitoring lumen of Hi-Lo Jet tracheal tube (Mallincrodt, New York, USA) using pneumotachograph/pressure transducer (CP-100 pulmonary monitor, Bicore, Irvine, CA, USA). Other data of respiratory mechanics were also obtained by CP-100 pulmonary monitor. Results : The imposed WOB was decreased by 37.5% during 0.7 L/min on flow triggering compared to $-2\;cmH_2O$ on pressure triggering and also decreased by 14% during $-1\;cmH_2O$ compared to $-2\;cmH_2O$ on pressure triggering (p < 0.05 in each). The PTP(Pressure Time Product) was also decreased significantly during 0.7 L/min on flow triggering and $-1\;cmH_2O$ on pressure triggering compared to $-2\;cmH_2O$ on pressure triggering (p < 0.05 in each). The proportions of imposed WOB in total WOB were ranged from 37% to 85% and no significant changes among different methods and sensitivities. The physiologic WOB showed no significant changes among different triggering methods and sensitivities. Conclusion : To reduce the imposed WOB, flow triggering with sensitivity of 0.7 L/min would be better method than pressure triggering with sensitivity of $-2\;cm\;H_2O$.

• Tuberculosis and Respiratory Diseases
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• 제43권2호
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• pp.201-209
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• 1996

Background : Auto-PEEP which develops when expiratory lung emptying is not finished until the beginning of next inspiration is frequently found in patients on mechanical ventilation. Its presence imposes increased risk of barotrauma and hypotension, as well as increased work of breathing (WOB) by adding inspiratory threshold load and/or adversely affecting to inspiratory trigger sensitivity. The aim of this study is to evaluate the relationship of auto-PEEP with WOB and to evaluate the effect of PEEP applied by ventilator (external PEEP) on WOB in patients with auto-PEEP. Method : 15 patients, who required mechanical ventilation for management of acute respiratory failure, were studied. First, the differences in WOB and other indices of respiratory mechanics were examined between 7 patients with auto-PEEP and 8 patients without auto-PEEP. Then, we applied the 3 cm $H_2O$ of external PEEP to patients with auto-PEEP and evaluated its effects on lung mechanics as well as WOB. Indices of respiratory mechanics including tidal volume ($V_T$), repiratory rate, minute ventilation ($V_E$), peak inspiratory flow rate (PIFR), peak expiratory flow rate (PEFR), peak inspiratory pressure (PIP), $T_I/T_{TOT}$, auto-PEEP, dynamic compliance of lung (Cdyn), expiratory airway resistance (RAWe), mean airway resistance (RAWm), $p_{0.1}$, work of breathing performed by patient (WOB), and pressure-time product (PTP) were obtained by CP-100 Pulmonary Monitor (Bicore, USA). The values were expressed as mean $\pm$ SEM (standard error of mean). Results : 1) Comparison of WOB and other indices of respiratory mechanics in patients with and without auto-PEEP : There was significant increase in WOB ($l.71{\pm}0.24$ vs $0.50{\pm}0.19\;J/L$, p=0.007), PTP ($317{\pm}70$ vs $98{\pm}36\;cm$ $H_2O{\cdot}sec/min$, p=0.023), RAWe ($35.6{\pm}5.7$ vs $18.2{\pm}2.3\;cm$ H2O/L/sec, p=0.023), RAWm ($28.8{\pm}2.5$ vs $11.9{\pm}2.0cm$ H2O/L/sec, p=0.001) and $P_{0.1}$ ($6.2{\pm}1.0$ vs 2.9+0.6 cm H2O, p=0.021) in patients with auto-PEEP compared to patients without auto-PEEP. The differences of other indices including $V_T$, PEFR, $V_E$ and $T_I/T_{TOT}$ showed no significance. 2) Effect of 3 cm $H_2O$ external PEEP on respiratory mechanics in patients with auto-PEEP : When 3 cm $H_2O$ of external PEEP was applied, there were significant decrease in WOB ($1.71{\pm}0.24$ vs $1.20{\pm}0.21\;J/L$, p=0.021) and PTP ($317{\pm}70$ vs $231{\pm}55\;cm$ $H_2O{\cdot}sec/min$, p=0.038). RAWm showed a tendency to decrease ($28.8{\pm}2.5$ vs $23.9{\pm}2.1\;cm$ $H_2O$, p=0.051). But PIP was increased with application of 3 cm $H_2O$ of external PEEP ($16{\pm}2$ vs $22{\pm}3\;cm$ $H_2O$, p=0.008). $V_T$, $V_E$, PEFR, $T_I/T_{TOT}$ and Cdyn did not change significantly. Conclusion : The presence of auto-PEEP in mechanically ventilated patients was accompanied with increased WOB performed by patient, and this WOB was decreased by 3 cm $H_2O$ of externally applied PEEP. But, with 3 cm $H_2O$ of external PEEP, increased PIP was noted, implying the importance of close monitoring of the airway pressure during application of external PEEP.