• 대한신경집중치료학회지
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• 제11권2호
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• pp.63-70
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• 2018

Management of mechanical ventilation is essential for patients with neuro-critical illnesses who may also have impairment of airways, lungs, respiratory muscles, and respiratory drive. However, balancing the approach to mechanical ventilation in the intensive care unit (ICU) with the need to prevent additional lung and brain injury, is challenging to intensivists. Lung protective ventilation strategies should be modified and applied to neuro-critically ill patients to maintain normocapnia and proper positive end expiratory pressure in the setting of neurological closed monitoring. Understanding the various parameters and graphic waveforms of the mechanical ventilator can provide information about the respiratory target, including appropriate tidal volume, airway pressure, and synchrony between patient and ventilator, especially in patients with neurological dysfunction due to irregularity of spontaneous respiration. Several types of asynchrony occur during mechanical ventilation, including trigger, flow, and termination asynchrony. This review aims to present the basic interpretation of mechanical ventilator waveforms and utilization of waveforms in various clinical situations in the neuro-ICU.

• Tuberculosis and Respiratory Diseases
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• 제60권4호
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• pp.451-463
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• 2006

연구배경: 활성산소종은 기계환기로 인한 폐손상 (ventilator-induced lung injury, VILI)에서 주요한 역할을 한다. Poly (ADP-ribose) polymerase-1 (PARP1)은 DNA 손상 감시 기능을 하는 단백질로서, DNA 파열을 신호하고 복구에 관여한다. 그러나 활성산소종에 의한 것과 같은 심한 유전자 손상을 받게 되면, 과활성화되어 ${\beta}$-nicotinamide adenine dinucleotide ($NAD^+$)의 결핍을 통한 세포의 사멸을 초래하여, 염증 반응을 일으킨다. 본 연구에서는 VILI의 기전에 있어서 PARP1의 역할 및 그 억제제의 효과를 고찰하고자 하였다. 방법: 48마리의 수컷 C57BL/6 생쥐를 겉보기 수술군 (Sham군), 폐보호적 환기군(lung protective ventilation group, LPV군), 기계환기기로 인한 폐손상군 (ventilator-induced lung injury group, VILI군) 및 PARP1 억제제인 PJ34 전처치 후 기계환기로 인한 폐손상군 (PJ34+VILI군)으로 나누어 실험하였다. LPV군에 대한 기계환기는 $PIP\;15cmH_2O$ + $PEEP\;3cmH_2O$ + RR 90/min. 조건으로, VILI 및 PJ34+VILI군에 대해서는 $PIP\;40cmH_2O$ + $PEEP\;0cmH_2O$ + RR 90/min.의 조건으로 2시간 동안 시행하였다. PJ34+VILI군에서 PARP1 억제제로는, PJ34 20 mg/Kg을 기계환기 2시간 전에 복강 내로 주사하였다. VILI의 정도는 습건중량비 및 급성폐손상 지수로 측정하였고, PARP1의 활성은 biotinylated NAD를 이용한 면역조직화학적 방법을 이용하였다. 또한 기관지폐포세척액 (bronchoalveolar lavage fluid, BALF) 내에서 myeloperoxidase (MPO) 활성 및 tumor necrosis factor-${\alpha}$ ($TNF-{\alpha}$), interleukin-$1{\beta}$ ($IL-1{\beta}$), IL-6 등의 염증성 시토카인의 농도를 측정하였다. 결과: PJ34+VILI군에서 VILI군과 비교하여, PJ34 전처치로 인하여 폐손상의 정도가 현저히 감소하였다 (p<0.05). 5개의 고배율 시야에서 관찰한 PARP1의 활성을 보이는 세포의 수는 VILI군에서 유의하게 증가하였고, PJ34+VILI군에서 현저히 감소하였다 (p=0.001). BALF 내에서 측정한 MPO 활성 및 $TNF-{\alpha}$, $IL-1{\beta}$, IL-6의 농도 역시 PJ34+VILI군에서 의미 있게 감소하였다 (p<0.05). 결론: VILI의 기전에 있어서 PARP1의 과활성이 주요한 역할을 하고, PARP1 억제제가 MPO 활성 및 염증성 시토카인의 감소와 함께 VILI의 발생을 억제한다.

• Tuberculosis and Respiratory Diseases
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• 제53권6호
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• pp.619-634
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• 2002

배 경 : Matrix metalloproteinase(MMPs), 특히 주로 염증세포에서 분비되는 MMP-9은 여러 가지 급성폐손상 모델 및 급성호흡곤란증후군 환자에서 증가하고, 최근에는 주기적인 물리적 스트레스가 폐포대식세포 및 결체조직세포에서 MMP-9의 생성 및 활성을 증가시키는 것으로 보고된 바 있다. 따라서 본 연구에서는 기계환기로 인한 백서의 급성폐손상에서 MMP-9의 발현 및 MMP 억제제(MMPI)의 효과에 대해서 연구하고자 하였다. 방 법 : Sprague-Dawley 백서를 적은 일호흡량(tidal volume, $V_T$)과 적절한 호기말양압(positive end-expiratory pressure, PEEP)을 적용한 LVT군과 많은 일호흡량과 PEEP을 적용하지 않은 HVT군 및 동일한 조건에서 MMPI를 투여한 HVT+MMPI의 세 군으로 나누어 실험하였다. MMPI로는 CMT-3(chemically modified tetracycline-3)를 기계환기 3일 전부터 구강으로 투약하였다. 폐손상의 정도는 습건중량비와 급성 폐손상지수로 측정하였고, MMP-9의 발현은 면역조직화학염색으로 고찰하였다. 결 과 : 습건중량비, 급성 폐손상지수 및 MMP-9의 발현이 HVT 군에서 다른 두군에 비하여 유의하게 높았고(p<0.05), HVT+MMP군에서 HVT군에 비하여 폐손상의 정도 및 MMP-9의 발현이 현저하게 낮았다(p<0.05). 결과적으로 MMPI의 투여가 MMP-9의 발현을 저하시킴으로써 기계환기로 인한 폐손상의 정도를 유의하게 감소시키는 것으로 관찰되었다 결 론 : 많은 일호흡량과 PEEP을 적용치 않은 기계환기는 폐조직에서 MMP-9의 발현을 유의하게 증가시켜 폐손상을 유발하고, MMPI는 MMP-9의 작용을 억제함으로써 기계환기로 인한 폐손상의 정도를 유의하게 감소시키는 것으로 판단된다.

• Journal of Chest Surgery
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• 제55권4호
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• pp.325-331
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• 2022

Postoperative critical care management for lung transplant recipients in the intensive care unit (ICU) has expanded in recent years due to its complexity and impact on clinical outcomes. The practical aspects of post-transplant critical care management, especially regarding ventilation and hemodynamic management during the early postoperative period in the ICU, are discussed in this brief review. Monitoring in the ICU provides information on the patient's clinical status, diagnostic assessment of complications, and future management plans since lung transplantation involves unique pathophysiological conditions and risk factors for complications. After lung transplantation, the grafts should be appropriately ventilated with lung protective strategies to prevent ventilator-induced lung injury, as well as to promote graft function and maintain adequate gas exchange. Hypotension and varying degrees of pulmonary edema are common in the immediate postoperative lung transplantation setting. Ventricular dysfunction in lung transplant recipients should also be considered. Therefore, adequate volume and hemodynamic management with vasoactive agents based on their physiological effects and patient response are critical in the early postoperative lung transplantation period. Integrated management provided by a professional multidisciplinary team is essential for the critical care management of lung transplant recipients in the ICU.

• Tuberculosis and Respiratory Diseases
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• 제50권5호
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• pp.540-548
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• 2001

Backgrounds : Because ventilator-induced lung injury is partly dependent on the intensity of vascular flow, we hypothesized that hypothermia may attenuate the degree of such an injury through a reduced cardiac output. Methods : Twenty-seven male Sprague-Dawley rats were randomly assigned to normothermia ($37{\pm}1^{\circ}C$)-injurious ventilation (NT-V) group (n=10), hypothermia ($27{\pm}1^{\circ}C$)-injurious ventilation (HT-V) group (n=10), or nonventilated control group (n=7). The two thermal groups were subjected to injurious mechanical ventilation for 20 min with peak airway pressure 30 cm $H_2O$ at zero positive end-expiratory pressure, which was translated to tidal volume $54{\pm}6\;ml$ in the NT-V group and $53{\pm}4\;ml$ in the HT-V group (p>0.05). Results : Pressure-volume (P-V) curve after the injurious ventilation was almost identical to the baseline P-V curve in the HT-V group, whereas it was shifted rightward in the NT-V group. On gross inspection, the lungs of the HT-V group appeared smaller in size, and showed less hemorrhage especially at the dependent regions, than the lungs of the NT-V group. [Wet lung weight (g)/body weight (kg)] ($1.6{\pm}0.1$ vs $2.4{\pm}1.2$ ; p=0.014) and [wet lung weight/dry lung weight] ($5.0{\pm}0.1$ vs $6.1{\pm}0.8$ ; p=0.046) of the HT-V group were both lower than those of the NT-V group, while not different from those of the control group($1.4{\pm}0.4$, $4.8{\pm}0.4$, respectively). Protein concentration of the BAL fluid of the HT-V group was lower than that of the NT-V group($1,374{\pm}726\;ug/ml$ vs $3,471{\pm}1,985\;ug/ml$;p=0.003). Lactic dehydrogenase level of the BAL fluid of the HT-V group was lower than that of the NT-V group ($0.18{\pm}0.10\;unit/ml$ vs $0.43{\pm}0.22\;unit/ml$;p=0.046). Conclusions : Hypothermia attenuated pulmonary hemorrhage, permeability pulmonary edema, and alveolar cellular injuries associated with injurious mechanical ventilation, and preserved normal P-V characteristics of the lung in rats.

• Clinical and Experimental Pediatrics
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• 제59권10호
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• pp.389-394
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• 2016

The incidence of bronchopulmonary dysplasia (BPD) has not decreased over the last decade. The most important way to decrease BPD is by weaning the patient from the ventilator as soon as possible in order to reduce ventilator-induced lung injury that underlies BPD, and by using a noninvasive ventilator (NIV). Use of a heated, humidified, high flow nasal cannula (HHHFNC), which is the most recently introduced NIV mode for respiratory support in preterm infants, is rapidly increasing in many neonatal intensive care units due to the technical ease of use without sealing, and the attending physician's preference compared to other NIV modes. A number of studies have shown that nasal breakdown and neonatal complications were lower when using a HHHFNC than when using nasal continuous positive airway pressure (nCPAP), or nasal intermittent positive pressure ventilation. The rates of extubation failure during respiratory support were not different between patients who used HHHFNC and nCPAP. However, data from the use of HHHFNC as the initial respiratory support "after birth", particularly in extremely preterm infants, are lacking. Although the HHHFNC is efficacious and safe, large randomized controlled trials are needed before the HHHFNC can be considered an NIV standard, particularly for extremely preterm infants.

• Tuberculosis and Respiratory Diseases
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• 제67권5호
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• pp.402-408
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• 2009

Background: Pre-B-cell colony enhancing factor (PBEF) has been suggested as a novel biomarker in sepsis and acute lung injury. We measured the PBEF in bronchoalveolar lavage (BAL) fluid of acute critically ill patients with lung infiltrates in order to evaluate the clinical utility of measuring PBEF in BAL fluid. Methods: BAL fluid was collected by bronchoscope from 185 adult patients with lung infiltrates. An enzyme-linked immunosorbent assay was then performed on the collected fluids to measure the PBEF. Results: Mean patient age was 59.9 ${\pm}$14.5 years and 63.8% of patients were males. The mean concentration of PBEF in BAL fluid was 17.5 ${\pm}$88.3 ng/mL, and patients with more than 9 ng/mL of PBEF concentration (n=26, 14.1%) had higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores on the BAL exam day. However, there were no significant differences in clinical characteristics between survivors and non-survivors. In patients with leukocytosis (n=93) seen on the BAL exam day, the linear regression analysis revealed a significant, positive relationship between PBEF and APACHE II ($r^2$=0.06), SOFA score ($r^2$=0.08), Clinical Pulmonary Infection Score ($r^2$=0.05), and plateau pressure in patients on ventilators ($r^2$=0.07) (p<0.05, respectively). In addition, multivariate regression analysis with PBEF as a dependent variable showed that the plateau pressure ($r^2$=0.177, p<0.05) was correlated positively with PBEF. Conclusion: The PBEF level in the BAL fluid may be a useful, new biomarker for predicting the severity of illness and ventilator-induced lung injury in critically ill patients with lung infiltates and leukocytosis.

• Tuberculosis and Respiratory Diseases
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• 제77권1호
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• pp.6-12
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• 2014

Severe sepsis is the most common cause of death among critically ill patients in non-coronary intensive care units. In 2002, the guideline titled "Surviving Sepsis Campaign" was published by American and European Critical Care Medicine to decrease the mortality of severe sepsis and septic shock patients, which has been the basis of the treatment for those patients. After the first revised guidelines were published on 2008, the most current version was published in 2013 based on the updated literature of until fall 2012. Other important revised guidelines in critical care field such as 'Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit' were revised in 2013. This article will review the revised guidelines and several additional interesting published papers of until March 2014, including the part of ventilator-induced lung injury and the preventive strategies.

• Tuberculosis and Respiratory Diseases
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• 제70권1호
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• pp.36-42
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• 2011

Background: Adaptive support ventilation (ASV), an automated closed-loop ventilation mode, adapts to the mechanical characteristics of the respiratory system by continuous measurement and adjustment of the respiratory parameters. The adequacy of ASV was evaluated in the patients with acute lung injury (ALI). Methods: A total of 36 patients (19 normal lungs and 17 ALIs) were enrolled. The patients' breathing patterns and respiratory mechanics parameters were recorded under the passive ventilation using the ASV mode. Results: The ALI patients showed lower tidal volumes and higher respiratory rates (RR) compared to patients with normal lungs ($7.1{\pm}0.9$ mL/kg vs. $8.6{\pm}1.3$ mL/kg IBW; $19.7{\pm}4.8$ b/min vs. $14.6{\pm}4.6$ b/min; p<0.05, respectively). The expiratory time constant (RCe) was lower in ALI patients than in those with normal lungs, and the expiratory time/RCe was maintained above 3 in both groups. In all patients, RR was correlated with RCe and peak inspiratory flow ($r_s$=-0.40; $r_s$=0.43; p<0.05, respectively). In ALI patients, significant correlations were found between RR and RCe ($r_s$=-0.76, p<0.01), peak inspiratory flow and RR ($r_s$=-0.53, p<0.05), and RCe and peak inspiratory flow ($r_s$=-0.53, p<0.05). Conclusion: ASV was found to operate adequately according to the respiratory mechanical characteristics in the ALI patients. Discrepancies with the ARDS Network recommendations, such as a somewhat higher tidal volume, have yet to be addressed in further studies.

• Journal of Trauma and Injury
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• 제27권4호
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• pp.229-232
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• 2014

A 55 year-old man hit a vehicle while riding a bicycle. He was diagnosed as left hemopneumothorax, multiple rib fracture, cerebral hemorrhage, and skull fracture. Initially he suffered from hypoxia requiring 100% oxygen with a mechanical ventilator. Finally he became hypotensive. Venovenous extracorporeal membrane oxygenation (ECMO) was initiated to support patient's gas exchange. Because hypotension and left ventricular dysfuction persisted, we converted the mode of support to veno-arterio-venous ECMO. Over four days of intensive care, we could wean off ECMO. The patient went to rehabilitation facility after 45 days of hospitalization. Although trauma and bleeding are considered as relative contraindication of ECMO, careful decision making and management may enable us to use ECMO for trauma-related refractory heart and/or lung failure.