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Background: Recruitment manoeuvres are widely used in clinical practice to open the lung and prevent lung injury by derecruitment, although the evidence is still discussed. In this study two different recruitment manoeuvres were compared to no recruitment manoeuvres (control) in ventilated sheep with acute respiratory distress syndrome (ARDS), induced by lung lavage., Methods: We performed a prospective, randomised study in 26 ventilated sheep with ARDS, to evaluate the effect of two different recruitment manoeuvres on gas exchange, blood pressure and lung injury. The two different recruitment manoeuvres, the high pressure recruitment manoeuvre (HPRM), with high peak pressure, and the smooth and moderate recruitment manoeuvre (SMRM), with lower peak pressure, were compared to controls (no recruitment) after disconnection. Oxygenation index and ventilation efficacy index were calculated to evaluate gas exchange. Lung injury was assessed by inflammatory response in broncho-alveolar lavage fluid (BALF) and blood and histology of the lung., Results: Oxygenation index improved significantly after both recruitment manoeuvres compared with controls, but no significant difference was found between the recruitment manoeuvres. Blood pressure decreased after HPRM but not after SMRM. HPRM induced a higher number of total cells and more neutrophils in the BALF. In the histology of the lung, mean alveolar size was increased in the dorsocranial region of the lung of SMRM compared to controls., Conclusion: Recruitment manoeuvres improved oxygenation, but SMRM was superior, with respect to hemodynamics and pulmonary inflammation, in ventilated sheep suffering from ARDS induced by lung lavage.

Objective: To assess the safety of non-bronchoscopic bronchoalveolar lavage (NB-BAL) in critically ill mechanically ventilated children., Setting: Paediatric intensive care unit in a tertiary children's hospital., Methods: The data from 60 consecutive critically ill mechanically ventilated children who underwent NB-BAL was reviewed from November 1997 to December 1999. PRISM score prior to NB-BAL, observations at the time of NB-BAL and arterial blood gases, oxygenation index (OI), ventilator settings, haemodynamic variables and temperature taken at 1 h before, and 1 and 6 h after NB-BAL, were retrieved from the archived computerised database., Results: Median age was 7 months (IQR 2.8-43 months) and median weight was 5.5 kg (IQR 4-14 kg). Four (7%) patients exhibited significant immediate complications, requiring escalation of respiratory or haemodynamic support. Forty-two (70%) patients had complete data for calculation of OI; there was no significant change in median OI at 1 and 6 h after NB-BAL. However 5 (12%) of these patients experienced an increase in OI of between 10 and 45 at 1 h post NB-BAL, which returned to baseline at 6 h post NB-BAL. Complications did not correlate with any of the available variables: baseline OI, PRISM score or with deterioration at the time of the procedure, although it was observed that four out of the six patients with baseline OIs of greater than 20 experienced complications., Conclusion: Non-bronchoscopic bronchoalveolar lavage in critically ill mechanically ventilated neonates and children is generally a well-tolerated procedure, but for some patients, in whom it was not possible to elucidate predictive factors, complications developed. All patients, particularly those with OIs of greater than 20, require careful monitoring during and after the procedure.

Objective: To assess the effect of bronchoalveolar lavage (BAL) volume on arterial oxygenation in critically ill patients with pneumonia., Design: Randomized clinical comparison., Setting: Six-bed respiratory intensive care unit of a 850-bed tertiary care university hospital., Patients: Thirty-seven intubated and mechanically ventilated patients with clinical suspicion of pneumonia., Interventions: Bronchoscopically guided protected specimen brush (PSB) followed by either a "high volume" BAL (n = 16, protected catheter, mean volume: 131 +/- 14 ml) or a "low volume" BAL (n = 21, protected double-plugged catheter, 40 ml volume for all patients)., Measurements: Arterial oxygen tension/fractional inspired oxygen (PaO2/FIO2) and mean arterial pressure (MAP) before and up to 24 h after the intervention. Bacterial growth in quantitative cultures. Analysis of variance for repeated measurements with inter-subject factors., Results: All patients showed a lower PaO2/FIO2 ratio and higher MAP after the diagnostic procedure, without differences between the study arms (p = 0.608 and p = 0.967, respectively). Patients with significant bacterial growth (p = 0.014) and patients without preemptive antibiotic (p = 0.042) therapy showed a more profound and longer decrease in arterial oxygenation after the diagnostic procedure., Conclusions: A decrease in the PaO2/FIO2 ratio was observed in all patients after a combined diagnostic procedure, independent of the BAL volume used. A significant bacterial burden recovered from the alveoli and no preemptive antibiotic therapy were associated with a larger and longer-lasting decrease in arterial oxygenation.

Unilateral flooding of the lung after intubation with a double-lumen tube enables intraoperative sonography of the lung tissue. The flooding restricts the pulmonary blood stream of the flooded lung in a relevant degree and thus reduces the right-to-left shunt volume. The deficient perfusion of the lung tissue during the flooded phase might cause capillary permeability disorders and secondary oedema development. This can be determined by examination of extravascular lung water (EVLW) after draining and reventilation of the flooded lung. Although one-time unilateral lung flooding must be distinguished from bronchopulmonary lavage, it is interesting to study the effects of flooding on the surfactant system. The wet-to-dry ratio of the lung tissues of 13 female pigs was ascertained at different times following one-lung flooding (1 to 11 weeks). A trend towards an increased wet-to-dry ratio in the previously flooded lung was found only in the tissue samples taken 1 h after reventilation. After only 24 h, the two lungs no longer differed in their wet-to-dry ratio. In six pigs, the phospholipid content of the drained flooding liquid was determined. It was shown that the surfactant loss caused by flooding was maximally 47% of the calculated surfactant pool of the respective lung.

We report on an unusual, albeit potentially severe, complication of the performance of a pleural lavage with streptokinase in two patients demonstrating parapneumonic pleural effusion. During the time they underwent repeated pleural lavages with saline and streptokinase, they suddenly demonstrated focal neurological signs. As a result of early diagnosis and emergency hyperbaric oxygenation, both patients recovered without delayed sequelae. Air embolism is a potentially severe complication which can occur during pleural lavage. Whether streptokinase increases the risk of opening a latent vascular breach cannot be definitely established, but clinicians should be aware of this risk. In this context, the onset of acute focal neurological signs should suggest the possibility of air embolism and lead to the transfer of the patient close to a hyperbaric facility within a few hours.

Objective: We prospectively assessed the impact of bronchoalveolar lavage (BAL) on respiratory mechanics in critically ill, mechanically ventilated patients., Study Design: Mechanically ventilated patients underwent BAL of one lung segment using 5 x 20 ml of sterile, physiologic saline with a temperature of 25-28 degrees C. The fractional inspired oxygen was increased to 1.0, but ventilator settings were otherwise left unchanged. Static pulmonary compliance, pulmonary resistance, alveolar ventilation, and serial dead space were measured 60 min and 2 min before and 8, 60, and 180 min after BAL to assess the consequences of the procedure. In addition, blood gases [partial pressure of carbon dioxide in arterial blood (PaCO2) and arterial oxygen tension (PaO2)], hemodynamic variables (heart rate, systolic and diastolic blood pressure), and body temperature were recorded at the same time points., Setting: Intensive care unit of a university hospital., Patients: 18 consecutive critically ill, mechanically ventilated patients., Results: Pulmonary compliance decreased by 23% (p < 0.05) and pulmonary resistance increased by 22% (p < 0.05) shortly after BAL. The changes in pulmonary compliance and resistance were more than 30% in one third of the patient population. One hour after the procedure, PaO2 was significantly lower and PaCO2 significantly higher than before the procedure. Three hours after the procedure, pulmonary resistance returned to pre-BAL values but compliance remained 10% below baseline values (p < 0.05)., Conclusion: BAL in mechanically ventilated patients is associated with deterioration of pulmonary mechanics and function.