P181EFFECTS OF ACUTE ANEMIA ON OXYGEN CONSUMPTIONAFTER MAJOR TRAUMAP. Mavrocordatos , R. Chiolero , J-P Revelly , C. Cayeux, J-J Llvio

Introduction: Major trauma Induces important blood losses, which often requireblood transfusions. The administration of blood products is associated withsignificant risks. Although lower hemoglobin (Hb) levels are presentlyrecommended', It has been shown that in severe acute anemia (Hb<80gf)mortality Is related to Hb level In patients following major surgery2. There areyet no clear data on Hb critical level in traumatized patients during the acutestage, In whom 02 demand Is increased and the ability to extract 02 may beimpaired.We prospectively studied severely traumatized patients with mild to severeanemia during the acute stage of trauma in order to evaluate the relationshipbetween V02 and Hb level.Methods: After Informed consent and Intitutional Review Board approval, westudied 17 patients within the 48-hour period following trauma. Included werethe patients with an Injury Severity Score of over 16 and multiple fractures.Excluded were the patients with cerebral or thoracic injuries or requiringmechanical ventilation. All patients were resting in bed under room air and hadreceived no nutritional support. V02 was measured during 40 minutes byindirect calorimetry (Deltatrac®) using the canopy mode. Arterial blood wascollected during the study. Hb level was determined by photometry (Coulter®)and Hb 02 saturation was assessed using a CO-oxymeter (Ciba-Corning®).For statistical analysis, least square linear regression and one-tail unpaired t-test were used as required, p<0.05 was considered statistically significant.Re3utts;The 17 patients studied (15 males and 2 females) were between 19and 49 yrs old, (30 ± 10yrs; mean ± SD). Hb level ranged from 52 to 102 g/I(80.2 ± 17.29/I; mean ± SD). V02 and Resting Energy Expenditure rangedfrom 95.7% to 141.4% of normal reference values (Fleisch).V02 was significantly higher in patients with }Ib levels>80g/I (8 patients) ascompared to patients with Hb levels<80g/l (9 patients). Indexed mean valueswere respectively: 172 ± 11 ml/m2/min; 154 ± 20 ml/m2/min (p=0.02).However, no correlation was found between V02 and Hb level (p=0.20) norbetween V02 and arterial oxygen saturation (p=0.63).Conclusion : Anemia was clinically well tolerated in these traumatized patientswith no previous disease. However, Hb level did directly influence the bodyV02 since the patients with Hb levels below 80 g/I had reduced V02. Furtherstudies are necessary to evaluate the clinical relevance of this relativedecrease in V02.References: 1.,JAMA 260: 2700-2703, 1988, 2.Lancet 1:727-729, 1988.

Department of Anesthesiology, CHUV, 1011 Lausanne, Switzerland.

Acute/Chronic respiratory failure11P183SHORT AND LONG-TERM OUTCOME PROSPECTIVE STUDY OFMECHANICALLY VENTILATED PATIENTS WITH ACUTE RESPIRATORYFAILURE COMPLICATING CHRONIC RESPIRATORY INSUFFICIENCYH. Georges*, N. Gueteau*, 0. Leroy*, C. Santre*,C. Beuscart*, H. Medaoui**. C. Lemaire***. G. Beaucaire*

To assess prognosis of chronic respiratory insufficiency(CRI) patients admitted to an Intensive Care Unit (ICU)for an acute respiratory failure (ARF) leading tomechanical ventilation (MV), we studied retrospectively154 patients (sex ratio M/F 2.85, mean age 67.4±10.4years, PaOZ at rest 61.4±9.2 mmHg, PaCo2 at rest 45.1±7.5 mmHg). admitted from January to December 1990 in 3ICUs. CRF included COPD (74), restrictive lung disease(33), mixed pathology (29) and silicosis (18).On admission in ICU the mean SAPS was 13.5±4. The durationof MV was 13.7±14.3 days. Death occurred in 46 cases. Thepoor prognosis factors, in a monovariate analysis, aresummarized in the table :Factor Alive (108) dead (46) X2 test

Male sex (n-114) 75 39 0.05PaCo2 at rest 46.4± 7.9 43.2± 6.2 0.05FEV1 33.4±14.3 42.2±15.4 0.03FVC 52.7±15.2 62.2±16.4 0.03

SAPS 12.2±3.1 16.7± 6.6 0.0001

Silicosis (n-18) 7 11 0.02

MV duration (d) ],2± 11.2 17.7± 19.5 0.04Because of the too small size of the studied population,multivariate analysis could not be performed.After ICU discharge, 20 patients died. The main poor prog-nosis factor was a non self governing state (p<0.005).After hospital discharge, 24 patients died during.the yearof follow-up. The good prognosis factors were pulmonolo-gist survey (p<0.05) and Pa02 at rest over 60 mmHg(p<0.05)

*Intensive Care and Infectious Diseases Unit. Tourcoing**Intensive Care Unit. Hepital B - Lille. *** IntensiveCare Unit. Roubaix. Lille University Medical School 59208TOURCOING - FRANCE.

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P1 R2THORACIC TRAUMA AND SELECTIVE DIGESTIVE DECONTAMINATIONB.Bui-Xuan,Godard, C.Guillaume, J.M.Vedrinne, P.Bachmann, B.Allaouchiche,

M.E.Reverdy.

Reduction of pulmonary infections by selective digestive decontamination(S.D.D.) was proved to be effective in our ICU by previous studies. Since 1988we used S.D.D. for all patients admitted in the ICU and mechanically ventiled.Does SDD reduce prevalence of pulmonary contusion superinfections?METHOD 84 consecutive ICU patients intubated and ventilated for traumaticlung contusion were studied. When lung contusion superinfection wassuspected, systematic Wimberley's brushing was performed.Among these patients, 42 benefited from SDD (Tobramycine 70mg, Colistin120mg, Amphotericin 500 mg four times daily), 42 did not have SDD dr receivedplacebo.RESULTS:

SDD+ SDD- p I SDD+ SDD- pn=42 n=42 n=42 n=42

SAPS 14.1± 12.8± ns stay/d 24.3±19 27.4±21 ns5.3 3.8

AGE 35.9±18 35.1±15 ns intuba/d 19.1±18 20±17 ns

SEX m/f ' 33/9 32/10 ns death 3 2 ns

Contus 2.38± 2.57±1 ns lungInf. 7 19 p<0.010.9 lobe

Pa02/ 32.1±15, 35.9±14 ns delay/d 10±7 9.6±7 nsFi02

COMMENTS : two groups are similar with respect to age, sex, number ofpulmonary lobes damaged, PaO2/FiO2 ratio.The lack of efficiency of S.D.D. with regard to ICU-stay and intubation durationor mortality confirm other studies on S.D.D. and would obviously mean thatpulmonary contusion superinfections with correct treatment don't affect theseparameters.CONCLUSION : In this study SDD reduced incidence of pulmonary contusionsuperinfections but don't affect the evolution of ICU patients.

Service de reanimation -Pavillon G- Höpital Edouard Herriot - Place d'Arsonval69437 LYON Cedex 03 - FRANCE.

P184

LOW-TE(M WGIOICAL VENTILATION, CLINICAL ASPECTSI. Cabezas, H. Romp, E. Salazar, M. NarväezThe mechanical ventilatory support is one of the procedures moreoften used in Critical Care Medicine. Nevertheless, it increasesthe morbidity for patients already critically ill adding life-threatening coaplications. It having been established that Long-Term Mechanical Ventilation (L1MV) means the use of mechanicalventilation for longer than 48 hours, we studied the issue in ourIntensive Care Unit (ICU).Fifty-four (54) patients were prospectively followed in an eight-month period. They were divided into two groups according to thelength of mechanical ventilation.Group I (less than 48 hrs.)=39 patients, and group 2 (more than-48 hrs.)=15 patients. We looked at their age, sex, mortality rate,length of stay, number of organ failures (Na O.F.) and APACHEscore. A significant difference was found in the length of staynumber of organ failures and mortality rate of the two groupsas is shown below:

Group I (Cl ) Group 2 (G2 ) __ICU days (x) 4 10.9 < 0.0001No O:F. 2 5 < 0.0001Mort.rate(%) 12.8 60 < 0.0001

The analysis of our data showed that Cl included 18 (46%) andG2 4(26%) post-operative patients.

The requirement of LIMV increased morbidity and mortality inour patients and the group whose patients were admitted for non-surgical reasons was the one with the highest risk of needingLTMV.

National Police Hospital, Intensive Care Unit. Mariana de Jesus1607, Quito, ECUADOR

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P185MULTICHANNEL ENDOTRACHEAL TUBE : A WAY TOLIMIT BAROTRAUMAD. PINQUIER, G. BOUSSIGNAC, D. PAVLOVIC, M.AUBIER, F.BEAUFILS

High peak airway pressures and tidal volumes are required to achieve adequate gasby changes in the neonatal respiratory distress syndrome (NRDS) and may beresponsible of severe pulmonary barotrauma. Limitation of these deleteriousefects with a new endotracheal tube was studied regarding gas exchanges,breathing rate (BR), peak respiratory pressure (PIP) and tidal volume (VT). Themodified tube (PORGES, France) is a standard tube with 8 capillaries moldedinto its wall and ending 1cm above the distal tip of the tube, without any changein internal and external diameters. This tube can be. used either as a classical tube(CT) or as a multichannel tube (McT) with injection of gas mixture at 2 to 3bars through the capillaries. This method allows pressurization of the airway tractbetween 0 to 40 cm d'H20 by an entrainment effect, the proximal tip being freeat atmospheric pressure (TAEMA, FRANCE).Twelve healthy anesthetized rabbits were tracheotomised and intubated with themodified tube. After muscle relaxation with pancuromium (150 mg/kg/min IV),each animal was ventilated in a ctrolled mode (CV) either with the tube connectedto a controlled-pressure ventilator (Infant-star) in a conventional use (CT) or withnjection of 2.2 bars air through the capillaries (McTI). First, the driving pressurein CT was determined for a PaCO2 of 40±5 mmHg and was compared with McTfor the same pressure. In a second time, driving pressure was ajusted in MeTmode to obtain a normal PaCO2 level (McT2). Statistics mere performed withpaired Student's t-test, P<0.05 being considered as significant.Results are summarized in the table :.

CT MITI McT2Pa02 (mmHg) 94±17 105±14 83±1PaCO2 mmH 41±4 31±3* 40±3VT ml 25±10 18±7 10±3°BR/min 40 40 40V/min I/min 0,99±0.4 0.7±0.28* 0.41±0.12°PMax 21±2 21±2 12±2°P.E.P.cm 5 5 5p<U.U1 Mcl I vs CT. "p<O.UI McT2 vs CT

McT provides adequate gas exchanges in healthy rabbits during CV, with a feverdegree of barotrauma, by decreasing either tidal volume and peak inspiratorypressure. This result suggests the possibility to provide a better management ofNRDS. A study on a surfactant depletion model in rabbits is actually in progressto evaluate this problem.Unite INSERM 226, Faculte X. Bichat, Paris -15G 12 , I'..,'vxc Nr5JRi HU'_i"i)

Pediatric intensive care unit,R.DEBRE Hospital.

P186MULTICHANNEL ENDOTRACHEAL TUBE : A WAY TO IMPROVE THEWEANING FROM MECHANICAL VENTILATION.D. PINQUIER, G. BOUSSIGNAC, D. PAVLOVIC, M. AUBIER, F. BEAUFILS.

Weaning procedures from mechanical ventilation are often limited byendotracheal tube resistance coupled with respiratory muscles weakness,especially in neonates. This study was performed to evaluate the use of amodified endotracheal tube during spontaneous breathing, regarding gasexchanges, breathing rate (BR), tidal volume (VT), and minute-ventilation (V).The modified tube (PORGES, FRANCE) is a standard tube with 8 capillariesmolded into its wall and ending 1cm above the distal tip of the tube, withoutany change in internal and external diameters. This tube can be used either as aclassical tube (CT) or as a multichannel tube (McT) with injection of gasmixture at 2 to 3 Bars through the capillaries. This method allows dynamicpressurization of the airway tract between 0 to 40 cm d'H20 by a entrainmenteffect, the proximal tip being free at atmospheric pressure (TAEMA, FRANCE).Twelve healthy tracheotomised rabbits were allowed to breath spontanouslythrough the modified tube either connected to a pressure-controlled ventilator(Infant-star) (CT) or with continuous injection of 2.2 bars air through thecapillaries (McT), the proximal tip of the tube being at atmospheric pressure.Both ventilatory modes were used in each animal in a random order. A 5 cmH2O PEEP measured with a thin intratracheal catheter was obtained in bothventilatory modes. Statistics were performed with paired Student's t-test, p<0.05being considered as significant.Results are summarized in the table:

CT McTPa02 (mmHg) 73±12 87±10 <001PaCO2 (mmHg) 43±7 36±5 <0,01VTm1 8.2±1.3 7.2±1.3 <001BR /min 51±8 45±5 <0,01V 1/min 0.41±0.11 0.27±0.07 «0,01PEEP (cm H2O 5 5

Creation of a dynamic PEEP with the multichannel tube during spontaneousbreathing supports adequate gaz exchanges with a tower respiratory work bydecreasing either respiratory rate and tidal volume. This method may be usefullin the weaning procedures, with early respiratory muscles reeducation, as well asin the prevention of pulmonary atehxtasim after thoraco-abbominal surgery.INSERM U 226, Facultd X. Bichat, Paris, t 6 r u-x. N- N r. r<c U n , o •5 c sPediatric intensive care unit ,R.DEBRE Hospital.

P187IMPERATIVE HOME MECHANICAL VENTILATION INDUCHENNE DE BOULOGNE MUSCULAR DYSTROPHY.PRELIMINARY RESULTS OF A PROSPECTIVEMULTICENTRIC CLINICAL STUDY.Groupe multicentrique stir l'6valuation de la ventilation m6canique Is domiciledans la DMDB. Coordination : J.C. Raphael 1 , F. Bouvet 1 ,Methodology : S. Chevret 2 , Cl. Chastang 2 .

The present multicentric prospective study was curried to evaluate 3 techniquesof home mechanical ventilation (HMV) in patient with Duchenne de Boulognemuscular dystrophy (DBMD) ventilation when such assistance is imperative :mechanical ventilation by nasal way (NMV), by tracheostomy (VT), or byexternal means (VEM). The need of HMV was defined in stable patients bythe presence of at. least one of the six following criteria : VC < 20% ofexpected, PaCO2 > 45 mmHg, Pa02 < 60 mmHg, at least two episodes ofacute respiratory distress needing endotracheal ventilation, patient ventilatedduring an episode of acute respiratory distress still respiratory dependent, andtracheostomized patient whatever the cause. From June 1987 to June 1990 58patients were included : 32 NMV, 15 VT, II VEM. Results : the maincharacteristics of the patients at baseline are displayed in table I.

NMV (n =32) VT (n =15) VEM (n =11)Age (years) mean 19 21 19Pa02* (mmHg) 76 49 59PaCO2* (mmHg) 46 65 50VC (ml) 735 571 846Pa02** (mmHg) 93 90 81PaCO2** (mmHg) 39 33 41* : Without mechanical ventilation. ** : Under mechanical ventilation.

Patients in the VT group had initially a more severe respiratory handicap thanthe others, as shown by the mean value of vital capacity (lower in the VTgroup), age (patients in the VT group were older), and gazomctryabnormalities. Four patients in the NMV group and one patient in the VEMgroup were tracheostomized. The mortality rate was higher in the NMV group(n = 10, 31%) than in the VT and VEM groups (n = 3, 2% in each group).Conclusions : these preliminary results must obviously be confirmed on alarge sample size, they suggest great caution in the use of NMV amongpatient with DBMD.

1)Reanimation Mddicale - Hbpital Raymond Poincarf - 92380 Garches.2) DBIM - H6pital Saint-Louis - 75010 Paris (France).

P188PREVENTIVE HOME MECHANICAL VENTILATION VIANASAL MASK IN DUCHENNE DE BOULOGNE MUSCULARDYSTROPHY.Groupe multicentrique sur l'8valuation de la ventilation mdcanique 8 domiciledans la DMDB. Coordination : J.C. Raphael 1 , F. Bouvet 1 ,Methodology : S. Chevret 2 , Cl. Chastang 2.

The aim of this multicentric prospective randomized clinical trial was toevaluate the nocturnal nasal mechanical ventilation (NMV) at home in patientwith Duchenne de Boulogne muscular dystrophy (DBMD), who do not fulfilany criterion of imperative ventilation : (vital capacity > 20% of expected,Pa02 > 60 mmHg, PaCO2 < 45 mmHg without mechanical ventilation).From October 1986 to July 1991, 70 patients were included: 35 in the controlgroup, 35 in the NMV. Results : the main characteristics of the patients atthe time of randomization are displayed in table I.

Age VC Pa02 PaCO2(years) (ml) (mmHg) (mmHg)

Control group(n= 35) 15±4 1335±352 86±10 38±4Ventilated group (n = 35) 16±3 1334 ± 398 88±10 39±3

In the ventilated group, ventilation was initially performed using a large tidalvolume (17 ± 9 ml/kg) , a low frequency (16 ± 2/min) and during 7 ± 3hours per day. 10 patients died, 2 in the control group and 8 in the ventilatedgroup, (test logrank, p = 0.04). Analysis of vital capacity shows that adecrease of more than 20%, as compared to the initial value, was observed in25 patients (15 control group, 10 NMV). However, 2 patients in the controlgroup were ventilated, 4 in the NMV were not effectively ventilated. Tofurther examine these results, we decided to perform the same analysisconsidering the treatment effectively used instead of the treatment allocated bythe randomization procedure. Among the 37 patients who were not effectivelyventilated, 4 deaths occured, as compared to 6 deaths among the 33 ventilatedpatients. The'decrease of VC more than 20% is noted in 25 patients, 15 in thecontrol group, 10 in the effectively ventilated group (test logrank, p = 0.8).Conclusions : Preventive NMV is a technique that puts contrains on thepatient, is difficult to supervise in the home. It procures no benefit in termesof mortality or in variation of VC. It must not be recommended for DMDB.

1)Reanimation Mddicale - Höpital Raymond Poincard - 92380 Garches.2) DBIM - Hbpital Saint-Louis - 75010 Paris (France).

S165

P189BEHAVIOUR OF VENTILATORS (V) DURINGTRACQ EAL SUCI'IONNING (TS)R.Boiteau.T.Lherm.F.Mercier,F.Chamieh , D.Perrin ,

A.Teneillon

It is recommended to succion hypoxemic patientswithout disconnecting them from V.This closedsuction may induce a thoracic depression and afunctionnel residual capacity decrease exceptwhen aspired gas come from V.Depressiongenerated inside the V circuit induces aresponse which depends on the ventilatory modeand the V model.To analyse this••response.5 Vwere tested during controlled ventilation:CESARwithout compansation(C").CESAR with servo-controlled to zero pressure compensation(CS).SERVO90OB(S).ERICA(E),ADVENT(A).BENNET7200B(B)on a lung test, and in 7 patients during TS(TSdepression=-300 cm H20.TS dura.tion=l2 s.TScathetersize=CH14).In these conditions.151 /mn of gas were suctionned.With the lungtest(Vt=0.521.V=8.31/mn).pressures became lowerthan-50 cmH2O for CW,S and B. which moaned 'thatthere were an undercompensation by V.In thepatients(Vt=0.561,V=8.91/mn) tracheal andoeso.phageal pressures. inspiratory cicuitpressure, flow and volumes were measured.ExceptCW,there is no significant diff(3rences forpressures.flows and volumes between thedifferent V. Nethertheless.compensation wassmooth for CS,E,A and with jolts for S andB.inducing important variations of trachealpressures(about 30 cm H2O)These datas are in favour of a constant flow

servocontrolled to pressure compensation asused in CESAR V.

Hopital Louise Michel ,Evey France

P190PROSPECTIVE EVALUATION OF SELF-EXTUBATIONSIN AN INTENSIVE CARE UNIT. T. Vassal, NG. D. Anh,JM. Gabillet, B. Guidet, F. Staikowsky, G. Offenstadt, P. Amstutz.

Oral or nasotracheal intubation is routinely used in intensive care units.It is a simple and effective technique but can give rise to a variety ofcomplications: Among these, self-extubation has rarely been evaluated.The aim of our study was to determine the frequency and gravity of thistype of incident.Patients and methodes : We prospectively studied all the patientsintubated in our intensive care over a period of eight months. Thepatients were divided in two groups: self-extubated (SE) and the others(NSE). The SE group was sub-divided into two groups : deliberateself-extubation (DSE) was defined as patients who removed the tubedeliberately while there was no tube occlusion or other mechanicalproblem, accidental self-extubation (ASE) was defined as extubationoccuring during nursing, movement or coughing.Age, sex, simplified severity score, glasgow score, etiology andduration of mechanical ventilation were recorded for all patients, usinga real time database (4th Dimension, Macintosh computer). Moreover aspecial questionnaire filled in by the attending physician at the time ofthe extubation, was used to establish the circumstances of the accident:time of the incident (nursing team), agitation prior to the accident,sedation, gastric tube status, need for reintubation or tracheotomoy,and outcome. When reintubation was necessary, the cause, route andcatheter diameter were recorded.Results : Twenty-four of the 197 patients included presented a total of27 extubations (12 %). Twenty-one incidents were deliberate and sixaccidental. The only differences between the cases and the rest of thepopulation were a higher mean age (67 vs 59 years) and a largerproportion of chronic respiratory failure (66 % vs 35 %). Reintubationwas necessary in 20 cases (74 %) within 30 minutes in 16 cases. Themain indication for reintubation was acute respiratory distress (90 %).Reintubation was associated with one death.Conclusion : Self-extubation is a frequent and serious complicationof mechanical ventilation. -Deliberate self-extubation, the most frequenttype of incident could possibly be reduced by better sedation of agitatedpatients and accidental self-extubation by better training of the nursingstaff.ICU, Saint Antoine hospital, 75571 Paris cedex 12, France.

P191

PROSPECTIVE STUDY FROM TRACHEAL STENOSIS IN INTENSIVECARE UNIT VENTILATED PATIENTS, TRDU6HT TLI AND TTI.C. Truchero, J. Moya•, A. Diaz-Prieto.

During 16 months all ICU ventilated patients with translaryngeal(TLI) andtranstracheal(TTI) intubation, were prospective observed, in order to detecttracheal stenosis and other sequelae. Endoscopic follow up pre and postdecannulation and respiratory functional tests, as well as tomographic studieswere extended. to 1.5 years after ICU discharge.The number of patients was 48: Eleven (22.9%) presented stenosis. Eight ofthem were dlägwsUcated as -precocius stenosis" (PS), In predecannulationendoscopy; and three'late stenosls"(LS) were detected between 2 and 6 weeksafter decannulatlan time.According to the degree of obstruction, we observed seven severe Stenoeiswith lumen reduction of 409 or more, and clinical symtomatology. four lightstenosis with less than 20% of lumen reduction without clinical symtomatologybut with signs lcative alteration of flow/volume loops.Depending on their level: 4 laryngo-subglottal, 4 ostial, and 3 infraostial.Our most significative results, with statistical significance were:I. A PS appeared mainly In young patients. 30.7 years old against 46.6 yearsold not slowed patients (p<0.05).2. The PS were not direct related to TLI time. Appeared In patients who hadundergone TU periods average of 18.5 days, v.s. 25.9 days of not stenosedpatients (p<0,05).3.Slack or respiratory Infection during TTI. were the factors related withhigher incidence of stenosis (PS and LS)

Departments of Intensive Care and Thorax Chirurgie, University HospitalBeIMNtge, Feixa Llarga s.n., 08907 L'Hospitalet Barcelona. Spain,

P192ULTRASTRUCTURE AND MUCOCILIARY CLEARANCEOF THE BRONCHIAL RESPIRATORY EPITHELIUM ININTUBATED PATIENTSF. Konrad, R. Schiener, J. Kilian, M. Georgieff

In patients with acquired pulmonary diseases ultrastructural changes ofthe respiratory epithelium are described in the literature and it is assu-med that these alterations in turn lead to a deterioration of efficient cili-ary cleansing. There are no data in the literature about the ultrastructu-re and function of the respiratory epithelium in intubated patients. Wetherefore investigated whether in these patients a reduced bronchialclearance is caused by a loss of cilia or ultrastructural abnormalities ofcilia. 29 intubated patients of a surgical intensive care unit were stu-died in a convenience sample trial. The study was approved by theEthics Committee of the University of Ulm. Appropriate informed con-sent was obtained from the patients respectively their relatives.Bronchial transport velocity (BTV) was measured with a radioactivetracer technique in both main bronchi. Afterwards two biopsy sampleswere taken from the bronchi for scanning (SEM) and transmission(TEM) electromnicroscopic investigations.SEM: Patients with normal or slight impaired BTV (group 1; n = 14;BTV: 8.5 (3.8 - 11.5) mm/min; median with range) had statistically si-gificant more cilia on the luminal surface than patients with markedlydepressed BTV(p < 0.05) (group 2; n = 15; BTV: 0(0-2.1)). The BTVcorrelated with the number of cilia on the luminal surface (r = 0.46;p = 0.02). TEM: in group 1 6.5 % of cilia were defect vs 9.3 % ingroup 2; these differences were not statistically significant. There wasalso no significant correlation between the BTV and the frequency ofdefect cilia (r = 0.44; p = 0.07).Thus an impaired mucociliary transport in intubated patients is associa-ted with a loss of cilia which might be one important factor in the pa-thogenesis of a decreased mucus transport whereas ultrastructural ab-normalities of cilia are less relevant. Since in these cases the motor ofthe mucociliary apparatus is impaired, an improvement by drugs maybe difficult to be measured and could explain controversial results onthe effect of drugs on mucociliary transport.Department of Anesthesiology, University of Ulm, Steinhövelstr. 9,7900 Ulm, FRG

Si 66

P193COMPLICATIONS OF LONG—TERM MECHANICAL VENTILATION IN

NEUROLOGICAL AND NEUROSURGICAL INTENSIVE CARE UNIT.F.Salord, V.Cayrel, A.Peloux, S.Tixier, R.Cb.acornac,

We have been conducting a prospective study since January.1992. The aims of

the study are- evaluation of the frequency and main factors of complications of

mechanical ventilation (MV) in 100 consecutive adults ('15 y-o) under MV for

more them 48 hours- evaluation of the modified preventive measures in the following

50 patients.Methods : the parameters daily recorded are : size, type of articifiat

airways and gastric tube, ventilation mode, max. inspiratory pressure, 02

inspired fraction, peep, blood gases, cytologic count, chest Xray,

temperature, organ failures, treatments, bodyweight, osmotality.

The complications daily recorded are : problems at intubation or

tracheostomy, airleak, artificial airway-related complication (obstruction,

biting, balloon leak, selectivity, self-extubation, nose or tip

necrosis...), ventilator dysfunction, atelectasis, acute sinusitis or

pneumonia, other nosocomiat infections, o'Gilvie syndrom, problems at

extubation (immediate and in the following 24 hours).

Preliminary results (n=100) : age= 51±15 ; sex-ratio= female 49

SAPS= 9±4 ; MV duration= 14±10 d ; ICU stay= 17111 d ; reasons for MV=neurological 80%, respiratory distress 10%, infections 6%, cardiac

insufficiency 4%.Complications of intubation : 6%, tracheostomy : 0, extubation : 9%,

Airleak : 6%. Tube-related complication : 22,5% (biting= 1/3, self-extuba-

tion= 1/6, balloon leak= 1/6, necrosis= 1/3) ; no patient died from

intubation or extubation problem nor tube-related complication. O'Gitvie

syndrom : 4%. Ventilator dysfunction : 6% (1/230 NV day). Atelectasis :

28,5% (mean delay.: 3,5 d). Nosocomial iPfection : 57% : pneumonia (35% mean

delay 6 d, following an atelectasis : 40%, associated with sinusitis 50%) ;

sinusitis (30%, mean delay 6,5 d, nasal tube : 80%) ; urinary tract

infection (31%) ; septicemia (9%, meningitis (18%), other (10%).

Eighteen patients died under mechanical ventilation, 82 were discharged from

ICU after weaning. These results lead us to modifie preventive measures

(humidification, physiotherapy, nasal decontamination...) in order to

disminish the rate of pneumonia and sinusitis, and of atelectasis.

ICU. I löpital P.Werthcimer 59 bd Peel 69003 Lyon - Prance

P194QUALITY OF LIFE OF OLDER PEOPLE WITH CHRONIC RESPIRATORY INSUFFICIENCYAND HOME VENTILATION

A. Durocher, A.M Durocher, C. hires, L. Behr, F. Saulnier, L. Gruez,

F. Boileau, Ph Dewailly

Quality of life of 53 old patients (mean age : 71 ! 5 years), with

chronic respiratory insufficiency treated by home ventilation for 3,6

years, was studied be use of two self - administered questionnaires :

the Nottingham Health Profide (NHP) and the Perceived Quality of Well

Being (PQWB). Home ventilation was realized 12 hours per day by

tracheostomy (n=32) or nasal mask (n-21).

Respiratory effects of home ventilation are well observed : there is a

significant increase of Pa02 and a significant decrease of PaCO2 as

well in controlled ventilation as in spontaneous ventilation. The

number and the length of hospital stays for acute respiratory failure

are significantly decreased with home ventilation.

There is a slight decrease in quality of life of these patients. The

mean value of NHP is 225/660 (b(t theoretical value : 0/600) ; the

mean value of PQWB is 650/1100 (best theoretical value : 1100/1100).

Two domains of NHP are chiefly disturbed : energy and physical

mobility. 'The nfain disturbed subscales of PQWB are health, leisure,

community and work.

There is no relationship between score of quality of life assessment

and the daily duration or the total duration of home ventilation.

There is no relationship between quality of life and results of

arterial blood gas before and after home ventilation.

To conclude efficiency and utility (in term of quality of life) of

home ventilation are good in older people. Patients are more impaired

on body movement and'social interaction, two domains which could be

improved by use of home care facilities and patients'associations.

Laboratoire d'Evaluation Medicale - Faculth de Medecine

1 place de Verdun - 59045 Lille (France)

CSPA - CHU 59000 Lille (France)

AVAD - 59000 Lille (France)

P195IMPAIRMENT OF MUCUS TRANSPORT IN THE LUNG ANDPULMONARY COMPLICATIONS IN INTUBATED PATIENTSF. Konrad, H. Wiedeck, M. Georgieff

Impairment of mucus transport is considered significant to the postope-rative development of retention of secretions and nosocomial pneumo-nia in intensive care patients, but the association has never been de-monstrated in humans. We therefore prospectively studied the bronchi-al transport velocity (BTV) in 66 intubated patients of a surgical inten-sive care unit in a convenience sample trial. BTV was measured with asmall volume (0.05 - 0.08 ml) of albumin micorspheres labeled withtechnetium-99m, which was deposited on the dorsal surface at the lo-wer end of the right and left main bronchus via a catheter placed in theinner channel of a fibre-optic bronchoscope. The movement of the mi-crospheres towards the trachea was visualized and recorded using ascintillation camera. After BTV was determined, all patients were exa-mined daily over 4 days to record postoperative pulmonary complica-tions (nosocomial pneumonia; retention of secretion with the need ofbronchoscopic suctioning). The study was approved by the EthicsCommitee of the University of Ulm. Appropriate informed consentwas obtained from the subjects respectively their relatives.BTV (mm/min) was 4.1 (0 - 12,3) (median with range) in the left mainbronchus, 5.3 (0 - 16.0) in the right (statistically not significant). 18 pa-tients developed 25 pulmonary complications (11 x pneumonia; 14 xretention of secretion). Post-operative pulmonary complications wereassociated with impaired BTV (Table!). 13 out of 15 patients with nomucus transport suffered from pulmonary complications and 5 subjectswith measurable BTV (p < 0.05; x2-test).Table 1:BTV (mm/min): median with range

left bronchus right bronchusPts. with complications (n = 18) 0(0-6.0) 0 (0 - 4.8)Pts. without complications (n = 48) 8.2 (0 - 12) 8.7 (0 - 16.0)Thus, in intubated patients impaired ciliary function and mucus trans-port are associated with and implicated in pulmonary complications.Department of Anesthesiology, University -of Ulm, Steinhövelstr. 9,7900 Ulm, FRG

P196IMPROVEMENT OF PERFORMANCES OF AN HYGROPHOBICHEAT AND MOISTURE EXCHANGER (HME).R. Boiteau, A. Tenaillon, T. Lherm, F. Chamieh,D. Perrin-Gachadoat.Hygrophobic HME provide better bact rio ogicaand viral filtration than hygroscopic HME, butthey are less efficient in matter of heat andmoisture exchanges.One airm of HME research is to improve heat andmoisture performances of hygrophobic membranes.PALL proposes a new HME to replace BB 2215 HME.The performances of this new HME (NP) and BB2215 (P) were randomly compared for 12ventilated patients in stable conditions. Eachdevice was tested with low volume (V=7.7 1/mn,VT 0,48 1) and high volume (V=12 1/mn, VT=0,801) ventilation. Temperature (T) was measured byHexacon modified temperature probes respectivelyin insufflation line, in expiration and at 20 cminside the tracheal tube. In the same points,moisture was calculated according topsychrometric method (comparison between wet anddry T). The table shows mean values for T (°C)and moisture (mg/1) delivered to the patient(TI, MI), for tracheal T (Tx) and for lost waterper day (W, g/24 h).

LOW VOLUME HIGH VOLUMEP NP P NP

TI oC 25.3+0.9 .26.4+0.5 25.2 26.5MI nig/l 20 +1.8 23.4+1.8 17.6 22.2W g/24h 75 55 204 149Tt oC 31.6 32.4 33 33.2

n conclusion, it is possible to Improve heatanu moisture performances of hygrophobicmembranes -. New Pall HME should advantageouslyreplace BB 2215.Höpital Louise Michel d'Evry, France

P197OROTRACHBAL (OTI) VS NASOTRACHEAL (NTI) INTUBATION : INFLUENCE ON PERFORMANCES OF HEAT ANDMOISTURE EXCHANGERS (ID(E)R. Boiteau, T. Lherm', F. Chamieh; E. Valente,A. Tenaillon, D. Perrin-Gachadoat

HME may be routinely used in long term mechani-cally ventilated patients. Their performances areconditionned by the exsufflated gas temperatures.In orotracheal intubation,as the part of tube outof the patient is longer than in nasotracheal intubation, the gas temperature is lower ; conse-quently the HME performances might be altered.On the same day, the performances of 5 HME 552215(PALL), NEW BB2215 (NPALL), HYGROBAK (DAR), EDITHFLEX (ENGSTROM), FILTRAFLUX (VYGON), were random-ly.compared for 12 patients : 7 OTI, 5 NTI, for 2levels of ventilation:low volume(V= 7.21 Vt=0.481and high volume (V=111 Vt=Q.721). Temperature wasmeasured and moisture was calculated (psychrome-tric method) in insufflation line,expiration line .at tracheal tube intrance with a special deviceparting I and S and at 20 cm inside the trachealtube. For low volume regimen, the table shows cooples of mean values (IOT/INT).for T (T,°C) and M(M, mg/1) delivered to the patient by HME and fortracheal T (t,°C).

PALL NPALL DAR ENGS VYGT 25.1/25.7 26.2/26.7 27.2/27.2 27..2./27 27..6/28M 19.3/20.9 22.5/24.6 22.6/24.7 23.8/24.5 26.1/27t 32.4/33.8 32.7/33.9 32.8/33.7 32.9/34.1 33.5/34

In conclusion : HME performances are significan-tly better in NTI patients than in OTI patientspatients in term of moisture and temperature. Orotracheal tubes should be systematically cut.

Hopital Louise Michel Evry France.

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P198SYNCHRONIZATION OF A MECHANICAL VENTILATOR WITHAN X-RAY MOBIL UNIT IN INTENSIVE CARE. R.Boiteau, A. Tenaillon, T. Lherm, H. Hmouda, A.Fatrane, L. Fakhfakh, N. Bloch*, B. Rousset*.

Pulmonary X-Rays quality depends for a largepart on' patient apnea and inspiration level. Formechanically ventilated patients, bedsidepulmonary X-Rays are often bad especially because1) insufflation is limited to mechanical tidalvolume (Vt), 2) there is no apnea during therealization of the X-Rays. To improve theseconditions, a CESAR, ventilator (TAEMA-CFPO) andan X-Rays mobil unit (CGR) have been synchronizedto obtain the X-Rays during an insufflationplateau (1.1 S) of a sigh (Vt x 1.5). The purposeof the study was to compare X-Rays quality withnormal versus automatic technique. 27 patientshave had a pulmonary X-Rays with each method at10 min interval in the same position and with thesame settings of the mobil unit. The 54 X-Rayswere numbered at random without anyidentification sign of the patients. They wereindependently analysed by an intensivistpractitioner and a radiologist not in charge ofthe patients, according to a preset evaluationscale. The results showed that whatever themethod, many X- Ray remained bad. Howeverpulmonary inflation evaluated by the distancefrom diaphragm to first rib is significantlybetter with synchronized method as well as X-Raysdarkness. Intensive care practitioner andradiologist have modified their diagnosisrespectively in 67 % and 37 % of cases with thesynchronized method but both practioners werecoherent only in -30 % of the cases.Synchronization between a ventilator and an X-Raymobil unit is able to improve bedside pulmonaryX-Rays of mechanically ventilated patients.Höpital Evry, * TAEMA-CFPO.

P199ACUTE ßlSPIRATORY FAILURE IN CFMC o utUCIZVE PUIMXJARY DLBASERI L3 WEANING AND BASE E=.JH Boix •, J Marin, A Arnau, M Tejeda, D Olivares, E Servers.

In patients with COPD and ARF who need mechanical ventilation,weaning could be effective even when it is not carried out with the pre-established weaning parameters.One of the unsolved problem in the weazw,g from mechanical vantilation iswhether to utilize a technique of ventilatory cmtiruity, such as INN, ora 02 in I have not yielded conclusive results. It mist be pinted out, hoe-ever, taht such studies have been performed with postoperative cardiac pa-tients and the cmclusicns draan fron than might not be applicable to pa-tients %ho are recovering fron respiratory failure.

To determine whether westing f4<m mechanical ventilation should becarried out with a oontiraxs technique, sinchr nized intermittent mandatoryventilation (SIMV), an with a disccntirtas technique ((2 in T) in patientswith comic obstructive pilmmary disease ((OPD) recovering from acuterespimt ry failure (AFE), as well as to determine the predictive value ofcontrol blood gases analysis.

Prospective study in 16 patients with.(LPD and ABE : 10 with acutebronchitis, 3 with left ventricular failure, 2 with pneunmia an 1 withno identified cause.

Three stages were delimited : 1) assist/cattrol mode ventilation(A/W1V) vs SINV, 2) return to a resting period with the basal A/CW for 2haus, 3) A/CW vs 02 in T.

There was in both situations (1 and 3) an increase in Pa(X2 (p().001)with a subsequient decrease in pH (p(0.001). Mien weaning was tolerated wellwith both todinices, there was a significant decrease in pH the to the in-crease in Pa002; BE remained stable. When weaning was tolerated badly, the-re was a significant decrease in pH, greater in SIMV, with similar in..rea-ses in PaCO2, but with significantly different reductirns in base excess(BE).Concleiers : Ehen to pH retails within narmalit the to a high BE, weaningis usually tolerated well in both modalites. A noderate metabolic alkalosisprevious to weaning might contribute to its pregasis.

Intensive Care Unit. Hospital Grp Via,G.V. Tarne Mmteblanco n2 43

12006r Castellon. Spain

P200WEANING FROM MECHANICAL VENTILATION WITH A COMPtITER-CONTROLLED VENTILATION SYSTEM. A CLINICAL STUDY IN ICUPATIENTSM. Dambrosio, M. Dojat, D. Touchard, A. Harf, F. Lemaire, L. Brothard

Weaning is a stressful and time-consuming procedure because iterativeexaminations and adjustments are necessary. We developped a computer-controlled expert system (ES) with the aim of adjusting the ventilator settingswith regards to the needs of the patient, to continuously perform a weaningprocedure and to provide a decision for extubation. A personal computerconnected to a Veolar ventilator and Ombeda capnometer, sampled in real timeend-tidal CO2, RR (main variable) and VT and set via a feedback-loop the levelof pressure support (PS). A zone of respiratory comfort was defined (RRbetween 12 and 28 breaths/min, VT above a minimal value and PCO2 below aminimal value) allowing the ES to perform the weaning strategy. Going out thiszone of comfort induced changes in the PS level.The aim of this study was 1) to search for a relation between the initial PS leveldecided by the ES and physiological data of the patients and 2) to assess whetherthe duration of weaning was predictible from initial data. 13 patients wereventilated with the ES at the time where weaning was envisaged, withoutcardiovascular and/or neurological dysfunction. 4 of them were COPD. 10patients could be weaned in 5.6 t 5.1 days (range 1-15). 3 patients failed to beweaned, mainly for cardiovascular failure or development of multiple organdysfunction. We analysed data of the first day of weaning on the ES. Mean PS onthe first day was significantly correlated with PaO 2/Fi02 (r = 0.67) and with RR(r = 0.74 p < 0.02). The % of time spent out of the zone of comfort (% OC)was correlated with temperature (r = 0.82, p < 0.01) and with mean PS level (r= 0.75 p <0.02). Multiple linear regression with a step wise prgcedure showedin the 10 weaned patients that weaning duration was explained (t` = 0.98) by themean value of heart rate, % OC, severity score (SAPS), blood pressure, mean PSand P02/FIO2 on the first day.

Conclusion : Decision-making of the ES, although based on limited simplerespiratory parameters was tightly correlated with indices of global severity andhealth status of the patients. Weaning duration was predictible and multifactorial.

Reanimation M6dicale, INSERM U296, Höpital Henri Mondor, Creteil 94,France

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P201AN EASY, FAST AND ECONOMIC METHOD FOR THEDIAGNOSIS OF THE TRACHEO-ESOPHAGEAL FISTULA (T-EF)

C. Tormo, V. Lopez, V. Parra. R. Calvo. V. Lacueva, J.L.Marava11Intensive Care Unit. Sagunto's Hospital S.V.S., Valencia,

INTRODUCTION The present issue shows an easy,fast, economic and safe method for the precocious.

diagnostic of the T-EF.

METHODS : On three critical patients subjected toa prolonged mechanical ventilation, the existenceof communication between the air way and thedigestive way was suspected, since there wasgreat amount of gas obtained by the nasogastriccatheter.Performing the precocious diagnostic of

the T-EF after holding for 30 minutes time amechanical ventilation with 100% oxygen, 2gasometries were taken, one arterial and the other

from the gastric juice, P02 were assessed with theauto-analyzer ABL-30 . The data are present as

mean 3 SD ,using student's paired t-test forstatistical analysis and linear regresion todetermine the degree of correlation between pairsof measured variables.

RESULTS : 6 Arterial gasometries were performedon the 3 patients that were analized, with a pa02

of x= 333.40 ± 133.80 and 6'from gastric juice,with a P02 of x= 341.40 ± 136.66 (p = N.S.) with

positive correlation between arteria-gastricjuice r= .8363 (p < .05).

CONCLUSIONS : 1- The presence of T-EF in criti-cal patients subjected to prolonged mechanicalventilation is frequent. 2- The fast diagnosticof such can be made through double gasometrie(arteria-gastric juice) that showed P02 similar.

between them, whilst the 02 should be almost

undetectable in the gastric juice.

P203EFFECT OF MECHANICAL VENTILATION ON RIGHT VENTRICULAR(RV) VOLUMES AND EJECTION FRACTION, MEASURED BY THERMO-DILUTION.AJ Schneider', Groeneveld ABJ 2 , Thijs LG 2 , Wesdorp RIC'.

OBJECTIVES. To quantify the modulation of thermodilution measure-ments of RV end-diastolic volume (RVEDV), RV end-systolic volume(RVESV) and RV ejection fraction (RVEF) by the ventilatory cycle.PATIENTS. Eleven patients adequately resuscitated from septic shockwere studied. All patients were ventilated at a rate of 12-24 breathsper minute, an inspiration/pause/expiratory ratio of 25%/10%/65%.and PEEP of 5 cmH 3O.MEASUREMENTS. RVEDV, RVESV and RVEF were measured with aREF pulmonary artery catheter. Injection of cooled 5 ml dextrose 5%was automatically performed by a phase controller, connected to theventilator, and a pneumatically driven syringe. The moment ofinjection in the ventilatory cycle was determined by a signal given bythe controller. Two series of measurement sets, at every 10% of thecycle, i.e. a total of 22 measurements, were done in each patient. Themean and coefficient of variation of RV parameters were calculated.RESULTS. Measured at the same moment in the ventilatory cycle, theerror for RVEF was 7.5%, for RVEDV 9.4% and for RVESV 12.5%.The coefficient of variation for the RVEF was 13 t 5%, for theRVEDV 15 t 7% and for RVESV 26 ± 14 %. The moment of modula-tion of RV parameters in the ventilatory cycle was unpredictable.CONCLUSION. 1. 'every parameter of the RV varied substantaillyduring mechanical ventilation RVESV > RVEDV > RVEF 2. it wasimpossible to predict these variations in each individual 3. RVEFshowed the least measurement error and also the least influence ofventilation.

Opt Surgery' and Dpt Int Medicine 2 . Free University Hospital PO BOX7057 1007 MB Amsterdam. The Netherlands

P202INFLUENCE OP THE HEAT AND MOISTURE EXCHANGING FILTERS(HMEF) VERSUS HEATED HUMIDIFIERS ON THE WORK LOAD OFICU NURSES AND THERAPI.S'I'SA. Carneiro, B. Huet, F. Lemaire, L. Brdchard, C. Brun-Buisson

As a part of a prospective randomized study we compared the influence of theuse of a HMEF (Hygrostar DAR) or a classical heated humidifier (Fisher-Paykell, MR 600) on the work load of nurses and therapists, and thecomplications of the two techniques. 15 patients intubated in the ICU, withoutpneumonia and with prolonged need of MV, were randomly assigned to HMEF(n = 7) for a mean duration of study of 9 days (3 to 22) or to Fisher-Paykell fora mean duration of 17 days (4 to 22 days). In the Fisher-Paykell group, ventilatorcircuits and humidifying chambers were changed every 48/72 hours, while filterswere changed every day without any change of the ventilator circuits. The timespent by nurses and therapists for care of the ventilator equipment was recorded,and related complications were noted.

Results : In the Fisher-Paykell group, the mean time spent for changing thecircuits amounted to 10.2 minutes per patient per day (1 h 12 min per patient perweek). The time for cleaning and sterilizing the circuits reached 11.3 minutes perpatient per day (1 h 19 min per patient per week).. Due to the time required forcomplete sterilization, three complete circuits were needed per patient in thisgroup. In the HMEF group, the mean time spent to change filters was 2 minutesper patient per day (14 minutes per week) without any additional workload. Fivetechnical problems occurred, always with the heated humidifiers (failure of theheater base, tubing inversion, inadequate temperature regulation). On sixoccasions, emergency tracheal extubation and reintubation were necessary forendotracheal tube occlusion : 5/6 times in the Fisher-Paykell group. Lastly themaintenance equipment cost was of 30.9 ECU per patient per week (39.4 USdollars) for Fisher-Paykell and 31.5 ECU (40 US dollars) for the IiMEF. Weconclude that the workload imposed on nurses and therapists by the use of heatedhumidifiers is considerably higher than using a HMEF.

Reanimation Medicale, Höpital Henri Mondor, Creteil 94, France

P204PROGNOSIS OF PNEUMOCYSTIS CARINII PNEUMONIA (PCP)REQUIERING MECHANICAL VENTILATION (MV) IN AIDSPATIENTS - F. Staikowsky *, B. Lafon **, B. Guidet *, M. Denis **, J.M.Gabillet *, T. Vassal *, C. Mayaud **, G. Offenstadt *

Mortality rate of HIV patients requiring MV for acute respiratory failure (ARF) se-cöndary to PCP is still a matter of discussion. For some, death 'rate could be in the50 % range while for others the prognosis is very bad with almost 100 % death rate.The aim of this study is to analyse retrospectively, between january 1987 and de-cember 1992, the outcome of such patients.Patients: we studied 33 patients, 29 men and 4 women (age 38,6 t 9,9 years, 21homosexuals, 8 intravenous drug users, 3 transfusions related, 1 heterosexual) HIVinfected since 19,7 ± 21,6 months. It was the first PCP episode for all but 2, anddiagnosis was made from BAL (n = 32) or lung biopsy (n = 1). Only 3 patients hadprimary prophylaxis for PCP (TMP-SMX n = 2, Pentamidine n = 1). PCP was thefirst manifestation of AIDS for 7 patients. Duration of symptoms prior to treatmentwas 19,6 f 11,3 days. At admission, laboratory data were : Pa02 = 40,7 ± 7,8mmHg on room air, serum LDH 1172 ± 792 UI/I, T4 count 60,2 ± 671mml. MVwas always required for ARF which was never induced by bronchoscopy. Intervalbetween treatment and MV was 8.1 ± 6,5 days and the anteriority of MV was 11,4± 9,9 days.Methods: According to the duration and to the type of treatment before MV. thepatients were classified into 3 groups : group I (n = 10) TMP-SMX (20-100 mg/kg)IV and methylprednisolone (MP *) for less than 5 days before MV; group I1 (n = 4)treatmdnt with TMP-SMX Z 5 days and MP < 5 days; group III (n = 19): TMP-SMX and MP institued more than 5 days before MV. (* MP: 240 mg/d once a dayfrom dt to d3, then 120 mg/d from d4 to d6, and 60 mg/j until d9).Results: Despite MV, TMP-SMX and MP, death secondary to PCP-related ARF,occured in 82 % of patients 20,0 ± 4,8 days after the beginning of treatment and11,4+ 9,9 days after the beginning of MV. Six patients survived, 5 in group I and1 in group III. No prognosis factor has been isolated between survivals and non-sur-vivals except for the interval between treatment and MV (2,8 ± 5,5 vs 9,3 ± 6,1days, p < 0,02) and for the evolution of seropositivity (3.2 ± 7,3 vs 23,4± 22,1months, p <0,03).Conclusion: MV instituted early in the course of PCP-related ARF has a 50 %mortality rate, while after 5 days of TMP SMX and high dose IV steroids, it's reachalmost 100 %

Saint-Antoine * and Tenon ** hospitals, 75012 Paris.

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P205IS NITRIC OXIDE INHALATION BENEFICIAL TO THE

ASTHMATIC PATIENT?M. Högman, H.Hedenström, C.Frostell, H.Arnberg, G.Hedenstierna.

Constriction of human tracheal strips was inhibited by Nitric Oxide(NO). in a tissue bath (Belvisi et al 1991). We wanted to learn whetherNO inhalation, compared to a ß 2-agonist (Salbutamol 2.5 mg), couldimprove the airway conductance (sGAW) in obstructive patients. Weexamined two groups of patients, chronic bronchitis (n =6) andasthmatics .(n =6). The patients inhaled 80 ppm NO during 10 minbefore .p2-agonist nebulization. Measurements of 5GAW in a body-plethysmograph were obtained before, after NO inhalation and after ß 2

agonist nebulization. The results of sGAW (L•kPa t •s) were:

Group Baseline 10 min NO 112-agonist

chronicbronchitis 0.68±0.20 0.49±0.11 0.74±0.20

asthmatics 0.40±0.08 0.57±0.15 1.12±0.17'

Mean ± SEM * p<0.05 ** p<0.001

Inhalation of 80 ppm NO or a p3 2-agonist did not affect sGaw in thepatients with chronic bronchitis. In the group of asthmatics, we founda moderate increase in sGAW of border-line significance (t-test, onetailed) on NO inhalation. A more significant increase in sGAW wasfound on b2-agonist nebulization.

We conclude that 10 min inhalation of 80 ppm NO has a weakbronchodilatory effect in patients with reversible airway obstruction,but seems to be less potent than b2-agonist nebulization.

Department of Clinical Physiology, University Hospital, S-751 85Uppsala, SWEDEN.

P206EFFECT OF -INHALED NITRIC OXIDE ON PULMONARYHEMODYNAMICS AFTER ACUTE LUNG INJURY, J-A. Romand,MR. ,Pinsky, L. Firestone, JR. Lancaster Jr, H. Zar.

Introduction : Pulmonary hypertension (PHTN) often accompanies acute lunginjury (ALI). Nitric oxide (NO), an endothelium-derived relaxating factor, modulatessystemic vascular resistance during septic shock, resting pulmonary artery pressure(Ppa) and the hypoxic pulmonary vasoconstriction response. Inhaling NO duringhypoxia decreases Ppa. To test whether NO inhalation reverses PHTN in ALI, wecompared the hemodynamic response of NO-inhalation during normoxia FiO2=0.5and 30 min. after ALI induced by oleic acid (0.lml/kg/IV) and propranolol (0.15mg/kg, IV). Methods: with Institutional Animal Care and Use Committeepermission, 6 ventilated-pentobarbital anesthetized dogs were studied. Arterial (Pa),Ppa and cardiac output (CO,by aortic flow probe) were measured. Dogs wereventilated to maintain normocarbia and with 7.5 cm H2O of PEEP. End tidal CO2was monitored. The effect of 5 min. exposures to 0, 17, 28, 47 and 0 ppm of NOwere recorded during normoxia and ALI (FiO2=0.5). Inspired NO concentrations wasmeasured by chemiluminescence, and blood nitrosyl-hemoglobin (NO-Hb) wasmeasured by ESR spectroscopy. ANOVA for repeat measurements was used. Dataexpressed as mean ± SD. Results : PaO2 decreased from a baseline of 247 ± 50 mmHg to 52 ± 26 during ALI. 28 ppm NO inhalation produced no hemodynamicresponse by 5 min at any level of NO. End-tidal CO 2 remained constant followingexposure to NO, and methemoglobin levels remained <1.1 % and NO -Hb wasunmeasurable. Hemodynamic data obtained with and without exposure to 28 ppmNO values are presented in Table. Pulmonary vascular resistance (PVR) increasedduring ALI, but was unchanged by NO inhalation .T&&I :Conditions Control ALINO(ppm) 0 47 0 47Ppa mean 25.4±8.1 25.2±8.8 28.3±9.7 28.8±10.3PVR 445±161 435±174 663±394* 741±469*CO(1/min) 2.6±0.4 2.6±0.4 2.2±0.5 2.1±0.5Pa 99±28 99±23 75±17 76±20Pressures in mm Hg, PVR dyn*sec*cm -5; * = P < 0.05 compared to control

Discussion : Nitric oxide inhalation has no direct effects on systemichemodynamics. Furthermore it does not alter pulmonary vasomotor tone duringnormoxic condition or after ALI-induced hypoxemia.

Department of Anesthesiology and CCM, University of Pittsburgh, Pittsburgh, PA15261.

P207

ECCO2R-LFPPV DOES IMPROVE ARTERIAL OXYGENATIONIN PATIENTS WITH ARDS IN WHOM MECHANICALVENTILATION (MV) FAILED.F.Brunet, M.Belghith, J.P. Mira, J.J.Lanore, B.Renaud, F.Pochard,J.F.Vaxelaire, I.Hamy, A.Armaganidis, J.Dall'ava, J.F.Dhainaut.Severe hypoxemia during ARDS can be source of multiorgan dysfunctionand death, especially when respiratory function is supported using highpressures-volumes ventilation (Bone, Chest, 1992,101, 320-26): Westudied the efficacy of ECCO2R-LFPPV on gas exchange, in 23 patientswith ARDS (Murray score> 2.5), who did not respond to MV (ECMO criteria,group B of European study). The cause of ARDS was infectious (9pts),gastric inhalation (7pts), trauma (2pts), tat embolism (2pts) amnioticembolism, drowning and vasculitis. They had on admission, SAPS =15, OSF=2, and prior to ECCO2R-LFPPV a duration of MV: 9d. Comparaison wasmade, using Wifcoxon test, between averaged values of PaO2/FiO2 andPaCO2, In MV and in ECCO2R-LFPPV in all pts and then same test wasused to compare survivors and non-.

All patients Survivors Non Survivors(n=23) (n=12) (n=11)

Pa02,Fi02 MV 84±30 84 ± 35 84±26E0002R 272±128 356±113 180±64•••'

p=0.0001 p=0.002 p=0.003

PCO2 MV 56±20ECCOQR

55±15 58±2641±7 42±6 41 ±8p=0.0001 p=0.005 p=0.004

Paw MV 26±4 25±4 28±5ECCtR 1913 18±2 20±4

p=0.0001 p=0.002 p=0.008

(**) : comparaison survivors vs non-survivors; p=0.0033

In all patients. ECCO2R-LFPPV increased arterial content in oxygen,decreased airway pressures (mean and peak) and normalized PaCO2.Comparaison between survivors and non- only revealed two factorssignificantly ditferents: increase in arterial oxygen content was greater andduration of MV prior to ECCO2R (71 6 vs 12±9, p= 0.05) was shorter insurvivors.Service de Reanimation medicale. Cochin University. Paris. F

P208

CUMULATIVE DOSE-RESPONSE RELATIONSHIP FOR SALBUTAMOLDELIVERED BY METERED DOSE INHALER IN MECHANICALLYVENTILATED PATIENTS WITH SEVERE AIRFLOW OBSTRUCTION.P. Navalesi, F. Maltais. A. Gursahanev. P. Hemmdez. M. Sovili. S. Gottfried.Bronchodilators are tradionally administered using an updraft nebuliser inhospitalized COPD patients. The use of a metered dose inhaler (MDI) offers anumber of practical advantages, including reduced cost and ease of administration.However, the optimal dosage and magnitude of bronchodilation achieved inmechanically ventilated patients has not been well characterized. The present studyexamined the cumulative dose-response relationship of salbutamol administered byMDI (with spacer) during controlled mechanical ventilation in 6 sedated, paralyzedpatients with an acute exacerbation of severe COPD (FEVI = 0.74L ± 0.21).Tracheal pressure, flow, and volume were measured at baseline and after theadministration of 4, 8, 12, 16 and 20 puffs (100 mcg/puff) of salbutamol over a 60-minute period. Blood pressure (BP) i heart rate (HR), and serum K+ were alsomonitored. During the last minute of each experimental condition, respiratoryresistance (Rrs) and elastance (Ers) were determined from the equation of motionusing multiple linear regression analysis. In addition, end-expiratory occlusions wereperformed in order to measure intrinsic PEEP (PEEPi). Results (mean ± SEM) aresummarized below. There was a significant initial reduction in Rrs after 4 puffsfollowed by a more gradual decrease in Rrs which appeared to plateau at 12 puffs.There was a similar but quantitatively smaller improvement in Ers. PEEPi decreasedsignificantly after 4 puffs with no further change thereafter, presumably due to theoffsetting effects of Rrs and Ers on lung volume. There were no significant changesin BP, HR, and K+. These results indicate that a higher than recommended dosagemay be required to achieve maximal bronchodilatation using an MDI in mechanicallyventilated COPD patients. In addition, a cumulative dose-response curve may beutilized to determine optimal dosage in individual patients, which appeared to be 12-16 puffs in this setting.Dose Resistance Elastance PEEPi0 17.8±0.1, 34.2 ± 0.3 10.1 ± 0.14 16.4±.0.1* 33.5 ± 0.3 8.9 ± 0.1*8 16.110.2* 32.6 ± 0.4* 9.0±0.1*12 15.9 f 0.2# 32.9 f 0.4* 9.1 t 0.2*16 15.6 1 0.1# 32.3 ± 0.3* 9.1 1 0.1*20 15.9 1 0.1# 32.0 ± 0.4* 8.8 f 0.2** = p < 0.05 compared to 0 puffs; # = p < 0.05 compared to 0 and 4 puffs.

Dept of Medicine; Meakins-Christie Labs, McGill Univ, Montreal, QC, Canada

S170

P209MANAGEMENT OF ACUTE ASTHMA IN PREGNANCYL.Gregorakos, C.Katsanos, V.Malessios, J.Nicolopoulos,L.Tsaldari, M.Kountouri.

Although the incidence of severe asthma during pregnancy islow (0.4%01.3%), its effect on the mother and fetus can bedisastrous. The purpose of our study was to present our ex-perience which .gained the last 5 years (1986-1990) from.ho-spitalization of 11 pregnant women (13-39 weeks"gestation)with severe asthma in our ICU.Their ages ranges from 19 to40 years (mean 31 years). All patients gave a previous hi-story of asthma and have experienced a severe acute asthmaattack, before admitted to the ICU, that did not respondto the usual outpatient treatment.On physical examination,all patients (100%) were dyspneic, diaphoretic and had in-spiratory and expiratory wheezes in both lung fields.7(63.6%) patients had pulse (>100 beats/min) without ECG - sabnormalities,11(100%) respiration >30breaths/min,3(27.2%)temperature >38°C, 9(81.8%) elevated WBC (>12.800/mm 3 ), 11(100%) had abnormal arterial blood gases (P02<65mmHg,PCO2<34mmHg, PH>7.48 on room air). No chest radiographs wereperformed to all of them. 11(100%) demonstrated at spirome-try, shortly after admission, a severe obstructive ventila-tory defect that was relieved by bronchodilators. All pa-tients were treated successfuly with subcutaneous epine-phrine 0.3-0.5ml of a 1:1000 solution given every 15 to 20minutes,IV aminophylline, hydrocortisone, ampicillin,oxy-gen by venturi mask and nebulized salmutamol. No adverseeffects were noted. The mean duration of stay was 11,2 days(4,6 in ICU).All patients had no further asthma attacksduring pregnancy after discharge.In conclusion, severe asthma in our pregnant women wasunexpectedly good. Pregnant asthmatic patients should bereceived appropriate attention, optimal treatment and closefollow-up of asthma in the final weeks before deliveryuntil the desired therapeutic effects are obtained.

Hospital for the diseases of the Chest, Athens-Greece152 Messogeion Avenue

P210DOES AFFECT C.A.V.HENOFILTRATION RESPIRATORY FUNCTION 7

MT Martin, FJ Santos, S Iribarren, A Fernandez,G Diaa-Reganon, Ch Martinez

To determine the effect of CAVH on pulmonary gas exchangeand its capacity to clear plasma urea and creatinine, wecarried out a retrospective study on 25 patients (17m/Sf)between February 90 and March 92 in our Trauma ICU. Theindications for CAVH-were: 7 Oliguric Acute Renal Failure(ARF) (28%); 7 Non Oliguric ARF (28%); 8 ARDS (32%) andother diagnoses in 3 (12%). All patiens were on mechanicalventilation, inotropics and nutritional support. 18 ofthem died (72%) and 7 survived. In 6 cases CAVHemodiafiltration was needed to control uremia.To assess gas exchange we calculated AaDO, at thebeginning, at 24 hours and at. the end of CAVH. Urea andcreatinine were measured at the beginning and at the endof CAVH.

RESULTS: The variation is given in % respect the initialvalue of the parameter elected, and the sign + or -according to its increase or decrease.

AaDO BEGINNING 24 HOURS END

TOTAL 374,9 266,1(-30,1%) 203,5 ( -46%)Non Surv. 385,8 302 (-22%) 228 ( -41%)Survivors 347 174 ( -50%) 140,7 (-60%)

BEGINNING ENDUREA 93,04 (mg/dl) 121,4 (+30%)GREAT. 2,61 (mg/dl) 2,95 ( +13%)

We conclude that CAVH has been useful to improve gasexchange. The elevation in uremia is already described incritical patients with ARF, CAVH'and hyperalimentation .

Trauma ICU.University Hospital Marques de ValdecillaAvda. Valdecilla s/n. 39007 Santander. Spain.

P211ISOLATED ULTRAFILTRATION OF BLOC INTHERAPY OF PATIENTS WITH POSTINFAWrIONPULMONARYIAYu. Sirenko, 0. Sychev, M Shchupak, L. Babiv

We treated 23 pts with postinfarction relap-sing pulmonary oedema (P0). All pts received the:ordinary, therapy (i.v. nitrates, diuretics, mor-phine, ect) and continual dobutamine -infusion - :(DI). In additional the isolated ultrafiltratior:of blood (IUF) was performed. Its velocity wa600-1200 ml/h. The hemodynamics patterns (echo--cardiography and right heart catheterization),blood gases, acid-basic status were determinedbefore, right away and one day after IUF. Avera-ge moved off 1,8+0,3 1 of the fluid. Symptoms ofthe PO were abolished in all pts. We noted thefavorable changes of hemodynamic indices: cent-ral venous pressure, pulmonary wedge pressure andvolumes of left ventricule diminished, while thecardiac 'output not changed and EF increased(30,3+2,4 vs 41,5+3,0 7., p< 0,05), blood pressu-re not changed, and the patterns of blood gasesimproved. This changes observed one day afterIUF in 68% pts. Hospital mortality was redusedto 47%. ;We suggest., that the combined IUF and DIcarries not risks for pts with deep circulatorydisorders and should be wide apply as a reservein post i nfarct i on F'0.

Department of Intensive Care, Institute ofCardiology, 5, Narodnogo Opolcheniya st,252151, Kiyev, UKRAINA

P212IM'RAVrnIE »1Ia E TD IS AT PAlaSCimIAL ATRIAL FIBRfl ATIai IN 07PDPATIENTS WITH ACUTE IRATCRY FAIIdJsi. J. Murk, F. Ruoz, J. Blaxpier, M. Sim6, A. Herrejä,, C. N, E. Qiiner.

Parczyael atrial fibrillation (PAF) occurs fregse t]y in chrmic obs-tnntive lug disease (07P)) patients with acute respiratory failureAl*). Treatment is difficult the to its nultifactxrial etiology. Thepurpose of this study ras to asses the efficacy of intravenous aniodarv,ne in arse patien s.In all our 00PD patients with AFF, when RAF 's detected, we obtainedblood samples for ga jneb'ic and biochemical determinations, includingteofiline levels. Then a initial 300 og bolus dose of aniodervs gi-vaifollowed by inflsion of 300 ng for 8 h zs and äb0 for 24 hats.T2wtment was considered succesfwi if onion to sins rtyrthn wasachieved.Thirteen patients (tan nen, three wrnasi) entered the sbx. They were onavar years old (fie 6)-80 ). AlF' global in 6, but only 5 re-(paired medical ventilation. Ijypoceula ras present in six cases, hy-per epnia in twelve with acidania in fora, I se'calienia in three andhyporalienia in only are patient. The plasma teofiline levels variedfran 7.9 to 19.1 mcg/ml (nea, 14.2); two patients had cone trationslower than 10 mcgJml, in nine it ras superior to 14 mcg/ml. Five pa-tients were reoeivirg concomitant beta-e€ nist &'i s, Mole we re tacirgthgcdn.Twelve patients responded to intravenous anicthraae therapy. Conversionto sins ti Uin corral in seven (5's) in the first how, in two in thethird har, in other two in the tenth hour and in another as patientin the 24th har.The.strily support the concept that PAF in AFB' of COPD patients are dueto several factors; in none of our cases it seers related to t xcic le-vels of teofiline. Our results serest that anio,fsme intravenous isuseful for treatment of PAF in this kind of pstieats.

Servicio de Medicina Into Siva y cardiokgia. Hospital Clinico Ihive<si-tario de Valencia. Espäia.

P213

P214BRONCHODILATOR EFFECTS AND SAFETY OF TWODOSFS OF NEBULIZED EPINEPHRINE IN STABLEASTHMATIC PATIENTS. S. NOUIRA; S. ELATROUS,• A. BCHIR;M. JAAFOUR.f; F. ABROUG; S. BOUCHOUHA.

Because of their rapid onset of action and . significant bronchodilatoreffect, beta-adtetiergic agents have become the drugs of choice in. theinitial treatment of acute asthma. Nebulized Epinephrine at dosages of1 to 3 mg has been show effective in acute asthma. Its predominantpulmonary metabolism would permit the safe use of higher doses andan enhanced bronchodilator effect might be expected.. The goal of ourstudy is to assess the bronchodilator effect and safety of 5mg nebulizedEpinephrine. Eleven stable asthmatic patients(mean age 30±15 years)were randomly assigned to receive either 2 or 5mg Epinephrinenebulized during 15mn in a crossover manner at 24 hours interval.Standard treatment was maintained except for beta-2 agonist• whichwere suspended eight hours before the trial. The following data werecollected at baseline, every 15minutes during the first hour and eachhour until the return to baseline: FEVI, cardiac rythm, respiratoryfrequency and arterial pressure. Serum potassium was measured atbaseline and 60minutes.Both Epinephrine doses produced significant bronchodilator effect thatwas higher with 5mg than with 2mg( FEV1 increase: 19% of predictedvalues vs 10%; p< 0.05). The time of onset of the bronchodilatoreffect (15mn) and its duration(12omn) were similar. No significantchanges were seen in the other variables.Conclusion : 5mg nebulized Epinephrine is safe and has more potentbronchodilator effect than 2mg: A trial of this dosage in the treatmentof acute asthma is justified.

Service de Reanimation Polyvalence. CHU F.BOURGUIBA.MONASTIR. 5019 TUNISIA.

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P215HWA 138- A NEW XANTHINE DERIVATIVE- PREVENTSINJURY TO ISOLATED PERFUSED RABBIT LUNG INDUCEDBY SEPSIS-LIKE PLASMA:S. Bahrami, Y. Yu, H. Redl, G. Schlag.The important role of endotoxin in the clinical manifestation ofseptic shock and related acute lung injury is well known. Xanthinederivatives were found to exert beneficial effects in sepsis models. Inthe present study we exposed an isolated perfused rabbit lung (IPRL)to a sepsis-like plasma (SPL) and investigated the beneficial effect ofHWA 138 (Hoechst A.G., Wiesbaden), a new xanthine derivative,against sepsis' related lung injury. Heparinized human blood wascentrifuged (25(1 G, 10 min.). The heparin plasma was decanted andheat treated to inactivate the complement. The cells were washedand resuspended in the decomplemented serum followed by anincubation with or without endotoxin (100 ng LPS/ml) at 37 °C fortwo hours to harvest SPL or control plasma (CPL). SPL, CPL, orLPS was introduced to the IPRL and weight change, vascularresistance, and airway pressure were computed. Whereas, endotoxinitself (up to 10 µg/ ml) did not induce any changes, the SPL, whichcontains LPS induced mediators, led to the development of lungedema indicated by significantly elevated lung weight (5.4±1.9 withSPL vs 1.1±1.3 g/hr with CPL) and pulmonary artery pressure(PAP = 19,lf 10.7 with SPL vs 6.5±1.9 mmHg with CPL).Application of 1IWA 138 (200 ng/ml) to IPRL 30 minutes prior toSPL prevented the SPL-induced lung injury (weight gain = 1.3±.8g/hr, PAP = 4.3±1.5 mmHg) . From our data we suggest that thelung injury is a secondary response to the LPS-induced mediatorsrather than a direct LPS effect. HWA 138 might be a useful agent inthe treatment of sepsis related lung injury.

Ludwig Boltamann Inst. f. Exp. a. Clin. Traumatology,Donaueschingenstr. 13, 1200 Vienna, Austria

P216DOXOPHYLLINE INDUCES BRONCHODILATION IN ARDSPATIENTSG. Conti, A. Cogliati, D. Dell'Utri, A. l'erretti, It. Traversa, L. Di Chisra, P.Marino.

Only recently, it has been showed that ARDS patients have both decreased

Cstat and increased Raw,mas, but litlle informations are available about

the evaluation of the effects of bronchodilntors upon the Raw in ARDS. The

aim of this study was to evaluate the effects of doxophylline upon the

resistitive properties of the respiratory system in 7 ARDS patients (5M,2N)

mechanically ventilated in control mode at constant inspiratory flow with

PEEP=S cmII2O. We analysed, with the flow interruption technique, the

following variabks:Cstat,Cdyn.PIP Raw,max Raw,min and Draw; all

measurements were performed in basal con-ditions, after 15' and after 30'

following the adnti istration of doxophylline (200 mg iv.). In detail

Raw,max averaged 17*3,7 cmIIZO/l/sec and was severely increased. The

interest of Raw,max was due to as increase is "ohmic" and pulmonary

viscoelastic resistances. The administration of doxophylline did not induce

significant modifications ofCstat, Draw and PEEPi values; conversely, PIP

and Rnw,mla decreases significantly and Cdyu significantly increase (PIP

from 36,0*5,5 cmH20 to 34,1±7,1 cmBEO; Raw,min from 7,1±1,6 to

4,111,1 cmJIZO/I/sec; Cdyn from from 17,0.t3,7 to 19,85,9 ml/cmA2O).

The major result of our study is that doxophyllise administration produce

broachodilation in ARDS patients. This means that the increase in Raw,min

observed during .ARDS is in large part functional and reversible.

Institute of Anesthesia and Intensive Care, University "La Sapienza" of

Rome, Italy

S172

P217REDUCTION OF VENTILATION INHOMOGENEITY WITHKETANSERIN IN PIGS WITH ARDSJ.Kesecioglu, J.C.Pompe*, I.Giiltuna*, C.Ince*,W.Erdmann, H.A.Bruining*.

Ketanserin is reported in some studies to improve oxygenationand this is related either to the redistribution of perfusion towell ventilated lung units or to improved ventilation to nor-mally perfused lungs due to decreased bronchoconstriction Inthis study the effect of ketanserin on ventilation inhomogene-ity, functional residual capacity (FR.C) and oxygenation in apig model with surfactant depleted lungs, produced by lunglavage, were investigated. Six pigs (20.7±1.1 kg) were venti-lated with volume controlled ventilation with 4 cm H 2 O PEEP,10 ml/kg Vt, 12/min frequency and inspiratory/expiratory ra-tio of 1:2. Values obtained before lung lavage with 30 ml/kgsaline (BL), after lung lavage (AL) and after ketanserin (0.2mg/kg, IV bolus) administration were recorded.The ventilation inhomogeneity was measured using mass-spectrometry. A multiple breath indicator gas washout testwas performed by the use of an insoluble gas, sulphurhexa-fluoride. The volumes regression index was 0.33±0.08 BL and1,12±0.17 AL. Lung lavage produced a significantly higher ven-tilation inhomogeneity (p<0.001). This was improved signifi-cantly after ketanserin administration (0.71±0.09) (p<0.01).PaO 2 values were 539±48 mmHg BL and 75±11 mmHg AL.The AL values were significantly improved with ketanserin ad-ministration (104±36 mmHg) (p<0.05). An increase of FRC wasobserved due to ketanserin effect (BL = 545±75, AL = 320±55,ketanserin = 393±81 ml). Ketanserin improved ventilation in-homogeneity and hypoxia produced by the ARDS model usedin our study probably due to a bronchodilation in the distalairways.

Departments of Anesthesiology and Surgery*, University Hos-pital Rotterdam, Dr. Molewaterplein 40, 3015GD Rotterdam,NL.

P219FHARMACOKINETIC OF MIDAZOLAM IN ELDERLY PATIENTS WITHCHRONIC OBSTRUCTIVE PULMONARY DISEASE (C.O.PD.) AND ACUTERESPIRATORY FAILURE REQUIRING MECHANICAL VENTILATION (M.V.)T. Boulain, Y. Furet",P.F. Dequin, A. Legras, D. Perrotin.

MIDAZOLAM (MDZ) Is often used for sedation in the intensive care unitHowever pharmacoklnetic of MDZ in elderly patients with C.O.P.D. is poorlyinvestigated. Nine patients, over 65 years old (76 s 10). requiring M.V. (SAPS13 ± 3) were sedated for 48 hours by MDZ infusion (0.08 mg kg -1h-)thenadapted according Ramsay score). The aim was to keep the patient atsedation level 3. Blood samples were collected from induction of sedation tothe 6th day. Clinical examination (Ramsay score) was performed at the sametime. Midazolam was determined in plasma by gas-liquid chromatography withelectron capture detection. After ending of the infusion of midazolam, 6 bloodsamples were taken at H12, H24, H36, H48, H72 and H96. Pharmacokineticparameters of midazdam were computed and analysed by a SIPHAR -system,according to one-compartment model.Clinical results : the recovery of consciousness (.c 6 hours in 7 patients and Yt2hours in two patients) wase held to be acceptable with regard to duration ofM.V. (9,6 ± 1,8 days).Pharmacokinetic results: mean elimination half-life (t1/2 ß) was 10 hrs (0.5;21,8). Mean volume of distribution at steady-state (Vdss) was 4 I kg-1 (0.2.8,7). Mean elimination plasmatic clearance was 18,41 h-1 (10,2; 38,7) Thepatients with optimal sedation (Ramsay 3) showed midazolam concentration inthe range of 50 to 410 ng ml-1. Pharmacokinetic study of midazolam revealedwide interpatient variability, as described previously in intensive care unitT1/2 ß was increased, compared with same age population data, except for 3patients. Vdss was increased in six patients. However elimination clearancewas mostly in the reference range, or slightly reduced. All the patients hadhypoalbuminemia (27 * 3 g/l). We found a relation between hypoalbumineniaand increase of Vdss, but without statistical significance, according to thesmall population studied. Midazolam is highly bounded to albumin (95-98 %)and a large decrease of albuminemia, as observed here, may explain increaseof Vdss and therefore prolongation of t1/2 0, while elimination clearance is notaffected or slightly reduced, leading to decreased elimination of midazolam insuch subjects.

Services de Reanimation MCdicale et de Pharmacologie et de ToxicologicCliniques", 37044 TOURS, FRANCE.

P218IVD1LED NITRIC OXIDE (R0) 19 PCI401ARY EMROLISMJ. CASTADED.I, J. ILAOCi1, C. ,ILDICOA.

The purpose of this study was to determine the effects of 10inhalation on pulmonary heaodioa.ics in a canine aodel of pulmonaryembolism (P.F.)011101 5: Two groups of adult mongrel dogs were studied: Group 1(control)= 6 dogs, Group 2 (90 inhalation)= 1 dogs. P. B. ras inducedby the Fisher's method'. Both groups were anesthesized, mechanicallyventilated (FIO7=0.11) and instrumented before induction of embolism.10 inhalation (80 ppa) in group 2 was started 15 nie. prior to P.B.and kept constant through the experiment. ID inhaled concentration wasanalyzed by cheniluaiuisceoce technique. In each group systemic,pulmonary (PAP) and central venous pressures were continuouslyrecorded. Cardiac output and arterial 202 (Pa02 ) were measured before,15, 30 and 45 min. after P.E. Data were analyzed with A90VA, andreported as mean 1 SD and statistical significance was considered if p<0.05.

RSULTS: There were no significant differences between groups for PAP,pulmonary vascular resistance (PER) and 250 7 .

MEAN PAP (aids)

BEFORE PE AFTER PE1' 15 30' 45'

G 1 15.3i5.1 51.3!4 31.614 2816 24.5!662 15.512.4 69,1!14 30.416 21±5 24.3!4

PVR 1D19/SEC/C9=51

BEFORE Pf AFTER Pf15' 30' 45'

G 1 3871268 9691338 1661394 71214'00G 2 354!113 934±445 1161292 680001

Pa02 auD

BEFORE PE - Al TER Pt15' 30' 45'

G 1 15.6!12 58.3±12 65.9!15 68.2±14G 2 76.8!:1 64.0111 69!6.5 12.6±8CONCLUSION: to our crime andel, 40 inhalation (80 ppa ) does notmodify neither pulanoary hesodinamics nor oxygenation.BIBL16GRAPHY: 1 Fisher et al. Anesthesioloty, 54: 204-9. 1981.

DEPT. OF SURGERY,'Ai.1FSTIES1.4 AND CRITICAL GARE. FACULTY OF MEDICINE.R.A401 Y CAJAL S.O. VALLADOLID. SP.ill.