• Journal of Chest Surgery
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• v.29 no.7
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• pp.777-779
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• 1996

Recently we operated on two cases of PDA in premature infant. In both cases, indomethacin therapy had failed to close the PDA. The extremely small baby(body weight 540gm) died 28hrs postoperatively by unexpe ted intrathoracic bleeding probably due to coagulopathy related to septic condition and thrombocytopenia. The clinical course of the second case(body weight 1395gm) was complicated by ileal perforation sec- ondary to necrotizing enterocolitis. The baby underwent segmental resection of ileum with ileostomy on the 8th hospital day. On the 34th hospital day surgical closure of the PDA was done and the ile'ostomy was repaired simultaneously. Ventilator weaning was possible on the postoperative 6th day. The baby discharged on the postoperative 33th day with the body weight of 2050gm.

• Clinical and Experimental Pediatrics
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• v.48 no.4
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• pp.401-405
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• 2005

Purpose : The use of mechanically-assisted ventilators at home reduces morbidity and improves the quality of life in children with chronic respiratory failure. But in Korea there is no clinical data of children with home mechanical ventilation. We investigated ventilator types, duration, the causes of failure or death, and the cost needed for care. Methods : We retrospectively analyzed the medical records of 21 children who were admitted and who applied for home mechanical ventilation at the Pediatric Intensive Care Unit in Asan Medical Center. Phone interviews took place after discharge. and interviewed by phone after discharge. Results : The median age was 31 months; the median duration with ventilator was 25 months. Underlying diseases were 16 neuromuscular diseases, one metabolic disease and four chronic respiratory diseases. The types of ventilator were pressure and volume type(16 and five patients, respectively). The frequency of ventilation failure was once per 19 months. Weaning could be performed in three cases. Frequencies of admission after receiving ventilators were 1.7 times per year; the most common cause was pneumonia. Nine patients(43%) died; four of them died because of endotracheal tube obstruction. The costs for medical care were about 1,110,000 won per month. Conclusion : There is an increment in the numbers of individuals who need mechanical ventilation support. The most common cause of death was endotracheal tube obstruction. The most important problem for the patients was medical cost. There needs to be more interest in patients with ventilator and social welfare systems to support their families need to be prepared.

• Tuberculosis and Respiratory Diseases
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• v.42 no.5
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• pp.723-730
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• 1995

Background: Noninvasive ventilation has been used extensively for the treatment of patients with neuromuscular weakness or restrictive chest wall disorders complicated by hypoventilatory respiratory failure. Recently, noninvasive positive pressure ventilation has been used in patients with alveolar hypoventilation, chronic obstructive pulmonary disease(COPD), and adult respiratory distress syndrome. Sanders and Kern reported treatment of obstructive sleep apnea with a modification of the standard nasal CPAP device to deliver seperate inspiratory positive airway pressure(IPAP) and expiratory positive airway pressure(EPAP). Bi-level positive airway pressure(BiPAP) unlike nasal CPAP, the unit delivers a different pressure during inspiration from that during expiration. The device is similar to the positive pressure ventilator or pressure support ventilation. Method and purpose: Bi-level positive airway pressure(BiPAP) system(Respironics, USA) was applied to seven patients with acute respiratory failure and three patients on conventional mechanical ventilation. Results: 1) Two of three patients after extubation were successfully achieved weaning from conventional mechanical ventilation by the use of BiPAP ventilation with nasal mask. Five of seven patients with acute respiratory failure successfully recovered without use of conventional mechanical ventilation. 2) $PaO_2$ 1hour after BiPAP ventilation in acute respiratory failure patients significantly improved more than baseline values(p<0.01). $PaCO_2$ 1hour after BiPAP ventilation in acute respiratory failure patients did not change significantly more than baseline values. Conclusion: Nasal mask BiPAP ventilation can be one of the possible alternatives of conventional mechanical ventilation in acute respiratory failure and supportive method for weaning from mechanical ventilation.

• Journal of Yeungnam Medical Science
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• v.32 no.2
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• pp.98-101
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• 2015

Bronchiolitis obliterans (BO), which is associated with graft-versus-host disease after allogenic hematopoietic stem cell transplantation, is a major obstacle to survival after bone marrow transplantation due to its gradual progress, eventually leading to respiratory failure. Pumpless extracorporeal interventional lung assist (iLA) is effective in treatment of reversible hypercapnic respiratory failure. In this paper, we present a 23-year-old female patient who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) for acute lymphocytic leukemia. After 6 months, she complained of shortness of breath and was diagnosed with BO. Five months later, she developed an upper respiratory tract infection that worsened her BO and caused life-threatening hypercapnia. Since mechanical ventilation failed to eliminate $CO_2$ effectively, iLA was applied as rescue therapy. Her hypercapnia and respiratory acidosis showed significant improvement within a few hours, and she was successfully weaned off iLA after 12 days. This is the first case report of iLA application for temporarily aggravated hypercapnia of PBSCT-associated BO followed by successful weaning. This rescue therapy should be considered in ventilator-refractory reversible hypercapnia in BO patients.

• Journal of Chest Surgery
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• v.54 no.1
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• pp.17-24
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• 2021

Background: Although extracorporeal membrane oxygenation (ECMO) is generally performed percutaneously, the technology is deployed under sedation and necessitates endotracheal intubation. However, in some patients, the use of venoarterial (VA) ECMO without intubation may be beneficial. Herein, we describe our experiences with VA ECMO performed without prior endotracheal intubation. Methods: A total of 783 patients treated with VA ECMO at a single center between January 2013 and July 2018 were reviewed retrospectively. We included patients who underwent successful VA ECMO implementation without prior endotracheal intubation, and excluded those who were younger than 18 years, had ongoing cardiopulmonary resuscitation status, and had poor quality of the vessels needed for percutaneous cannulation. The primary study outcome was in-hospital survival. Results: In total, 50 patients were included in this study, 94% of whom showed cardiogenic shock. The mean age of the study participants was 56.3±14.5 years. The median VA ECMO support time was 7 days (range, 2-13 days). Twenty-one patients (42%) did not receive ventilator care during the VA ECMO support period, while 29 patients (58%) progressed to intubation after VA ECMO implementation. The rates of survival at discharge and weaning success were 82% (n=41) and 92% (n=46), respectively, and 80% (n=40) of patients presented good Glasgow-Pittsburgh Cerebral Performance Categories scores at discharge. Conclusion: Even in patients with cardiogenic shock, percutaneous VA ECMO can be introduced safely without prior endotracheal intubation by an experienced care team. The application of nonintubated VA ECMO might be a feasible strategy in selected cases.

• Clinical and Experimental Pediatrics
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• v.48 no.7
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• pp.737-744
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• 2005

Purpose : Infants and children with cardiovascular diseases often present with respiratory symptoms. However, missed or delayed evaluation for potential airway problem may complicate overall prognosis. The aim of this study is to determine the clinical characteristics of these patients and explore the cause of airway problem. Methods : We reviewed the medical records of 64 patients(M : F=33:31, mean age : $6.3{\pm}7.5$ months) whose airway problems were proven by computed tomography or bronchoscopy in perioperative periods at the Asan Medical Center from January 1997 to June 2004. Patients were divided into two groups based on the duration of ventilator care : ${\leq}7$ days(group 1 : 23 cases, M : F=10 : 13) and >7 days(group 2 : 41 cases, M : F=23 : 18). Results : The patients in group 2 significantly developed more post-operative respiratory symptoms than group 1(P<0.001) and had more airway problems including extrinsic obstruction, intrinsic anomaly, and combined problem than group 1 although not significantly different(P=0.082). Among underlying diseases, the most common diseases were vascular anomaly(26.2 percent) and aortic arch anomaly(26.2 percent) in group 1 and pulmonary atresia with ventricular septal defect(22.4 percent) in group 2. The most frequent respiratory symptoms were recurrent wheezing pre-operatively and failure of ventilator weaning post-operatively. The major types of airway anomaly were tracheomalacia and tracheal stenosis(in each case 18.2 percent). Nineteen patients with persistent airway problems underwent aortopexy or other vascular correction. Of the 19 patients, 13(68.4 percent) were improved, but 2 failed in weaning ventilator and 4 died of non-airway problems. Conclusion : Early evaluation and treatment for potential airway problems may affect natural or surgical prognosis in patients with cardiovascular diseases presenting with respiratory symptoms.

• Tuberculosis and Respiratory Diseases
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• v.44 no.3
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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 $-2\;cm\;H_2O$.

• Journal of Chest Surgery
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• v.18 no.2
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• pp.182-192
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• 1985

[here are so many reports that pulsatile blood flow provides physiologic organ perfusions during cardiopulmonary bypass. So, we compared the recent 30 cases undergoing cardiac surgery by Cobe-Stckert pulsatile roller pump with another 30 cases by Polystan nonpulsatile roller pump. Pulsatile flow was applied during aortic-cross clamping period when synchronized to internal EKG simulator, and perfusion mode was changed to continuous nonpulsatile flow after declamping of aorta. Age, sex, weight, and disease entities were comparable and operative techniques were similar between two groups. 1. There were no differences in average ACC time, ECC time, and Operation time. 2. Postoperative artificial respiration time was 6hrs 30mins in nonpulsatile group and 4hrs 48mins in pulsatile group, and detubation time after ventilator weaning was 2hrs 44mins in nonpulsatile group and 1hrs 43mins in pulsatile group. 3. Average pulse pressure was 8mmHg in nonpulsatile group and 55mmHg in pulsatile group, and a mean arterial pressure was 66.0mmHg in nonpulsatile group and 60.7mmHg in pulsatile group. 4. Mean urine-output during ACC;ECC period was 9.717.3;9.913.2ml/kg/hr in nonpulsatile group and 14.215.0;15.817.5 in pulsatile group [p<0, 05], and thereafter progressive decrease of differences in urine output between two groups until POD 2, and lesser amounts of diuretics was needed in pulsatile group during same postoperative period. Serum BUN/Cr level showed no specific difference and urine concentration power was well preserved in both groups. 5. Plasma proteins and other Enzymes showed no differences between two groups, but serum GOT/GPT level was higher in nonpulsatile group till POD 2. 6. Serum Electrolytes showed no differences between two groups. 7. WBC, RBC, Platelet counts, Hgb and Hct were not different and Coagulogram was well preserved in both groups. 8. Plasma free Hgb level was 7.09mg% in pulsatile group compared with 3.48mg% in pulsatile group on POD 1 but was normalized on POD 2. Gross hemoglobinuria after ECC was noted in 6 cases [20%] of pulsatile group and 4 cases [13%] of nonpulsatile group. 9. In both groups, most patients were included in NYHA class III to IV [28 cases;93% in nonpulsatile group, 22 cases;73% in pulsatile group] preoperatively, and well improved to class I to 11[22 cases; 73% in nonpulsatile group, 30 cases; 100% in pulsatile group] postoperatively. There were 7 operative mortalities in nonpulsatile group only, which were 5 cases of TOF with hepatic failure, 1 case of multiple VSDs with low out-put syndrome, and 1 case of mitral valvular heart disease with cardiomyopathy. We concluded that the new, commercially available Cobe-Stckert pulsatile roller pump device was safe, simple, and reliable.

• Clinical and Experimental Pediatrics
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• v.45 no.10
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• pp.1204-1212
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• 2002

Purpose : Early surfactant therapy with either gentle ventilation, high-frequency ventilation or aggressive weaning of mechanical ventilation are principles for the treatment of respiratory distress syndrome(RDS). We studied to determine the accessibility of noninvasive nasal continuous positive airway pressure(CPAP) rather than mechanical ventilation by invasive intubation after early surfactant therapy. Methods : The study group consisted of 14 infants who were born and diagnosed with moderate respiratory distress syndrome and received early surfactant therapy with nasal CPAP of PEEP 5-6 cm $H_2O$ within two hours after birth in the Fatima neonatal intensive care unit for two years from January 1999 to August 2001. The control group consisted of 15 infants who were diagnosed with the disease and could be weaned from mechanical ventilator within five days after birth during the same period. Results : The characteristics, the severity of clinical symptoms and laboratory findings in the two groups at birth showed no significant difference. Neither did the interim analysis of laboratory data in two groups. Of 14 infants in the study group who received nasal CPAP after early surfactant therapy, only two infants showed weaning failure with this therapy. In the response cases, duration of CPAP was five days and mean airway pressure was $5.4{\pm}0.5cm$ $H_2O$. Two had the complication of CPAP with abdominal distension. Final complications and outcomes in the two groups showed no signifcant difference(P>0.05). Conclusion : The clinical courses in the two groups showed no significant difference. Therefore, we suggest that early surfactant therapy with noninvasive nasal CPAP is a simple and safe method rather than aggressive weaning after invasive mechanical ventilation in moderate respiratory distress syndrome.

• Tuberculosis and Respiratory Diseases
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• v.54 no.4
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• pp.429-438
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• 2003

Background : The mortality from acute respiratory distress syndrome(ARDS) is >40-50%. Although some prospective trials have failed to demonstrate a survival benefit of steroids in the early stages of ARDS, there are some reports showing some success with steroids in the later stages. This study observed the changes in the physiologic parameters with time in late ARDS patients who were treated with steroids. Methods : The medical charts of 28 intensive care unit patients(male:female=24:4; mean age 64 years), who had been diagnosed with refractory late ARDS ($PaO_2/FIO_2$ <200) and were treated with corticosteroids from December 1999 to July 2002, were retrospectively reviewed. The patients were divided into two groups: the weaned group(n=14), which included the patients who had been successfully weaned from a ventilator after corticosteroid therapy, and the failed group(n=14), which included the patients who had failed weaning. The physiologic parameters included the $PaO_2/FIO_2$ ratio, the positive end-expiratory pressure(PEEP) level, the $PaCO_2$, compliance, the sequential organ failure assessment(SOFA) score, the acute physiologic and the chronic health evaluation(APACHE) II score, and the Murray Lung Injury Score(LIS) in the two groups were compared from the day of mechanical ventilation(Dmv) to 7 days after the corticosteroid therapy. Results : There was no significant difference in the clinical characteristics and the physiologic parameters between the two groups prior to the corticosteroid therapy except for the SOFA score at Dmv(weaned group : $6.6{\pm}2.5$ vs failed group : $8.8{\pm}2.9$, p=0.047). However, within 7 days after corticosteroid therapy, there was significant improvement in the $PaO_2/FIO_2$ ratio, the PEEP level, the $PaCO_2$, the SOFA score, the APACHE II score, and the LIS of the weaned group compared to the failed group. Conclusions : During corticosteroid therapy in late ARDS, the continuation of corticosteroid therapy should be determined carefully in patients who do not show improvement in their physiologic parameters by day 7.