Background: Inhaled Nitric oxide (INO) decreases pulmonary artery pressures and improves oxygenation in patients with ARDS. Aim: To evaluate the dose response to 1-20 parts per million (ppm) INO in ARDS, by noting changes in oxygenation, pulmonary artery systolic pressures (PASP) and to determine optimum dose. Methodology and Design: Prospective study. Setting: 10 bed general intensive care unit. Patients: 13 consecutive patients with ARDS. Interventions: INO was given between 1-20 ppm with 15 minutes at each concentration via an insufflator from a high pressure source, to the inspiratory limb of the ventilator. Study had ascending and descending phase. Results and Conclusions: The optimum dose of INO to improve oxygenation was between 3 and 10 ppm. PaO2 improvement was independent of pulmonary haemodynamic changes. The pulmonary haemodynamic changes needed higher INO initially. Once stabilized, INO could be brought down to concentrations at which maximum improvement in PaO2 occurred. The ′responders′ had lesser duration of pre INO ventilation and lower PaO2/FiO2.

Background and Aims: Patients with respiratory failure requiring assisted ventilation form a large diagnostic group among critically ill patients. The outcome of patients with acute respiratory failure (ARF) as compared to those with acute on chronic respiratory failure (ACRF), may be different. The present study was designed to evaluate the clinical and acid base profile at presentation, hospital course and outcome in patients with ARF and ACRF requiring ventilatory support and to define factors that influence the outcome of these two groups of patients. Materials and Methods: Fifty patients with respiratory failure {ACRF (n=27) and ARF (n=23)} who required invasive mechanical ventilation, were included in a prospective fashion. Clinical data including APACHE II score, blood gas analysis and renal and liver functions were recorded at presentation and for the next three days. Survival to hospital discharge was the primary outcome measure. Various parameters were compared between ARF and ACRF, as well as between survivors and non-survivors to define predictors of mortality. Results: Patients with ARF were significantly younger (41.5 versus 64.4 years, P < 0.001), but all other baseline parameters including APACHE II score were similar for the two groups. During the hospital course, mean blood urea and serum creatinine became significantly higher in patients with ARF (P < 0.001). Mortality was significantly higher for patients with ARF (74% versus 48%, P =0.009). For the whole study group, APACHE II score and serum creatinine, 48 hrs after admission, were independent predictors of mortality. Conclusions: Although patients with ARF and ACRF may appear equally ill at presentation, mortality is higher for patients with ARF. A higher incidence of complications such as development of non-pulmonary organ failure during the hospital course in patients with ARF, seems to be responsible for this increased mortality.

Background and Aims: To identify predictors of need of mechanical ventilation (MV) and that of reintubation, after a planned extubation, among the patients with exacerbation of chronic obstructive pulmonary disease. Materials and Methods: Prospectively collected data of 82 patients with exacerbation of COPD over a one-year period were reviewed. Clinical and demographic profile, APACHE II score, blood gas parameters and serum biochemistry, recorded at the time of admission, were compared between patients who required MV and those who did not. Parameters were also compared between the groups formed on the basis of requirement of reintubation. Results: Sixty-nine patients (84.1%) required invasive MV. Independent predictors of need of MV were pH< 7.26 (adjusted OR, 95% CI) (4.9, 1.1-21.3; P =0.03) and SA < 3.5 g/dL (6.3, 1.4-27.7; P =0.01). Reintubation was required in 8 patients out of 45, who were extubated (17.8%). PaCO2 rise 12 hours after extubation (1.25, 1.0-1.5; P =0.01) and APACHE II score (1.33, 1.0-1.7; P =0.03) were independent predictors for need of reintubation. A cut off level of 7.2 mmHg for PaCO2 rise had sensitivity of 100% and specificity of 84%, for need of reintubation. Conclusions: Presence of acidemia and hypoalbuminemia at admission are predictors of need of MV, whereas APACHE II score at baseline and PaCO2 rise in the initial 12 hours after extubation, predict need of reintubation.

Prompt and skilful resuscitation during cardiac arrest can make a significant difference between life and death. There have been important advances in the science of resuscitation and various international resuscitation committees have formulated evidence-based recommendations for the performance of basic life support. The revised guidelines published in the year 2005 have been designed to simplify cardiopulmonary resuscitation. In this article, we have summarized basic life support guidelines for adult victims.

Pulmonary embolism (PE) is a common, treatable, highly lethal emergency, which despite advances in diagnostic testing, remains an under diagnosed killer. The mortality rate of diagnosed and treated pulmonary embolism ranges from 3-8%, but increases to about 30% in untreated pulmonary embolism. PE is a part of the spectrum of venousthromboembolic disease and most pulmonary emboli have their origin from clots in the iliac, deep femoral, or popliteal veins. Nonspecific clinical signs and symptoms with low sensitivity and specificity of routine tests such as arterial blood gas, chest roentgenogram and electrocardiogram make the diagnosis of PE very challenging for the clinician. Pulmonary angiography is the gold standard diagnostic test, but this technique is invasive, expensive, not readily available and labor intensive. Diagnostic strategies have revolved around establishing clinical probabilities based on predictive models, then ruling in or ruling out the diagnosis of PE with various tests. The aim of this article was to review the literature and present an evidence- based medicine approach to diagnosis of pulmonary embolism.

We report a 60-year-old woman who was admitted to our hospital with high-grade fever and dyspnea. Laboratory findings showed pancytopenia and examination of aspirated bone marrow showed mature histiocytes with marked hemophagocytosis. The patient′s condition continued to deteriorate despite adequate antibiotic coverage. Her respiratory condition worsened, so she was transferred to the ICU and ventilated. Transbroncheal biopsy was performed, which showed caseating granuloma suggesting pulmonary TB. Eight weeks later, bone marrow culture in Lowenstein media confirmed the presence of mycobacterium tuberculosis susceptible to INH, Rifampcine, pyrasinamide, ethambutol and streptomycin. Though anti-tuberculous therapy was started, she died after 28 days of hospitalization.

A 28-year-old male died following massive hemoptysis at Nizam′s Institute of Medical Sciences, Hyderabad. He presented with recurrent hemoptysis and hematuria. The lungs showed alveolar hemorrhages with hemosiderin laden macrophages. Kidneys showed focal proliferative glomerulonephritis with crescents. Direct immunoflouresence of the kidney showed linear deposition of IgG and granular deposits of C3.