Table of Content

15 June 2011, Volume 2 Issue 2

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Editorial

Further recommendations for trauma training of Indian medical officers and medical students

Robert J Douglas, Tonia M Mezzini, G Anand Kumar, Andrew JA Giles

2011, 2(2):  85-87. 

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Review Article

Sepsis and immune response

Xing-hai Chen, Yong-jie Yin, Jing-xiao Zhang

2011, 2(2):  88-92.  doi:10.5847/wjem.j.1920-8642.2011.02.002

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BACKGROUND: Sepsis and secondary multiple organ failure in critically ill patients are the major cause of death, but the pathogenesis of sepsis is not clear, especially the dysfunction of the immune system. In this paper, we review the response and regulation of the immune system and the functions of a variety of inflammatory mediators in sepsis.
DATA SOURCES: Studies were identified by searching MEDLINE and PubMed for articles using the keywords "sepsis", "immune response", and "inflammatory mediator" up to October 2010. Additional papers were identified by a manual search of the references from the key articles.
RESULTS: This systematic review was conducted of: 1) the immune response; 2) immune regulation; 3) inflammatory mediators; 4) high-mobility group box 1 protein; 5) the complement system; and 6) the autonomic nervous system. There are no therapeutic approaches available for sepsis that target inflammatory response; the mortality of sepsis has not been significantly reduced.
CONCLUSIONS: Sepsis is complex and dynamic, and it has a group of heterogeneous syndromes. Since different patients with sepsis have different etiology, susceptibility, and responses, treatment should be prescribed individually.

Original Articles

Influence of tissue pressure on central venous pressure/peripheral venous pressure correlation: An experimental report

Martyn G Harvey, Grant Cave

2011, 2(2):  93-98. 

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BACKGROUND: Peripheral venous pressure (PVP) has been shown to correlate with central venous pressure (CVP) in a number of reports. Few studies, however, have explored the relationship between tissue pressure (TP) and PVP/CVP correlation.
METHODS: PVP and CVP were simultaneously recorded in a bench-top model of the venous circulation of the upper limb and in a single human volunteer after undergoing graded manipulation of tissue pressure surrounding the intervening venous conduit. Measures of correlation were determined below and above a point wherein absolute CVP exceeded TP.
RESULTS: Greater correlation was observed between PVP and CVP when CVP exceeded TP in both models. Linear regression slope was 0.975 (95% CI: 0.959-0.990); r² 0.998 above tissue pressure 10 cmH₂O vs. 0.393 (95% CI: 0.360-0.426); and r² 0.972 below 10 cmH₂O at a flow rate of 2000 mL/h in the in vitro model. Linear regression slope was 0.839 (95% CI: 0.754-0.925); r² 0.933 above tissue pressure 10 mmHg vs. slope 0.238 (95% CI: -0.052-0.528); and r²0.276 in the en vivo model.
CONCLUSION: PVP more accurately reflects CVP when absolute CVP values exceed tissue pressure.

An evaluation of compliance and performance following the introduction of the Inter-Facility Transport Triage Guideline

Venus WS Siu, Y Pau, PY Lok, Larry LY Lee, Simon YH Tang, Jimmy TS Chan

2011, 2(2):  99-103. 

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BACKGROUND: In Hong Kong, the reorganization of healthcare frame work for better utilization of resources has led to an increase in the frequency of inter-facility transport in recent years. An Inter-Facility Transport Triage Guideline (IFTTG) was introduced and evaluated on its compliance and performance. This study aimed to evaluate the compliance to the IFTTG and performance of inter-facility transport after the IFTTG was implemented.
METHODS: The patients who required emergency IFT with accompanying personnel in two consecutive periods (pre-implementation period: January 1, 2006 to April 30, 2006; post-implementation period: May 1, 2006 to August 31, 2006) were included. The compliance to pre-transport triage and transport team configuration was evaluated by a review panel with eight performance indicators identified. The performance indicators were compared individually and as an overall score.
RESULTS: Sixty-eight (26 in the pre-implementation period and 42 in the post-implementation period) IFTs were reviewed. There was demonstrable improvement on compliance to the IFTTG. The appropriateness of pre-transport triage increased from 34.6% to 54.8% whereas appropriateness of transport team configuration rose significantly from 73.1% to 92.9% (P<0.05). Staff performance on individual IFT performance indicator was satisfactory in both periods and the means of overall score on performance indicators were 7.12 and 7.29 respectively. The most improved performance indicator was the appropriateness of transport team configuration.
CONCLUSIONS: The compliance and performance with the newly implemented IFTTG were satisfactory. However, staff comment and satisfaction with the use of the new guideline should be collected so as to achieve continuous quality improvement.

Association of MMP-9 gene polymorphisms with acute coronary syndrome in the Uygur population of China

Lei Wang, Yi-tong Ma, Xiang Xie, Yi-ning Yang, Zhen-yan Fu, Fen Liu, Xiao-mei Li, Bang-dang Chen

2011, 2(2):  104-110. 

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BACKGROUND: Matrix metalloproteinase-9 (MMP-9) plays a pivotal role in early atherosclerosis, vascular remodeling and development of atherosclerotic lesion. The potentially functional MMP-9 gene polymorphism may contribute to the susceptibility of acute coronary syndrome (ACS). This study aimed to investigate the association between two single nucleotide polymorphisms (-1562C>T, R279Q) of the MMP-9 gene in patients with ACS in the Uygur population of China.
METHODS: This case-control study was composed of 361 ACS patients and 432 control subjects, who had undergone coronary angiography. Among the ACS patients, 162 (44.9%) had single-vessel disease, 145 (40.2%) had two-vessel disease, and 54 (14.9%) had three-vessel disease. The genotypes of the two selected SNPs were determined by the method of polymerase chain reaction and restriction fragment length polymorphism (RFLP-PCR). The relationship between the polymorphism of the MMP-9 gene and the severity of coronary arterial stenosis was analyzed.
RESULTS: Analysis of the two SNPs showed that the frequency of CT and TT genotypes in patients with ACS was significantly higher than that in the control group (ACS vs. controls; CT+TT: 25.5% vs. 15.8%, P=0.001). And the -1562 gene allele (C/T) was significantly associated with acute coronary syndrome (ACS vs. controls; C allele: 85.7% vs. 91.5%, T allele: 14.3% vs. 8.5%, P<0.001). But the frequencies of CT+TT and CC genotypes were not statistically different among ACS patients with one, two and three or more significantly diseased vessels (P=0.55). The R279Q polymorphism site with regard to the association with ACS was not significant (P>0.05). The presence of CT or TT genotypes, assuming codominant effect of the T allele, was independently associated with increased risk of coronary artery disease when adjustment was made for age, body mass index, smoking, hypertension and diabetes mellitus [odds ratio=1.737 (95% confidence interval, 1.337-2.257), P=0.018].
CONCLUSIONS: MMP-9-1562C>T polymorphism is associated with the susceptibility to ACS in the Uygur population of China. However, this mutation apparently is not related to the severity of coronary arterial stenosis. Another SNP (R279Q) polymorphism of MMP-9 is not significantly associated with the risk of ACS.

Clinical and pathologic characteristics of pancreatic necrosis in critically ill children

Yi-min Zhu, Fang Liu, Xiao-yu Zhou, Xi-rong Gao, Zhi-yue Xu, Yu-kai Du

2011, 2(2):  111-116. 

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BACKGROUND: Pancreatic damage in critically ill patients is associated with the progressive failure of multiple organs, but little is known about its clinical characteristics. At present, no guidelines are available for the diagnosis and management of pancreatic damage. This study was undertaken to analyze the clinical and pathologic characteristics of pancreatic necrosis in critically ill children, and to find some biological markers of pancreatic damage or pancreatic necrosis.
METHODS: We retrospectively reviewed the clinical data, laboratory results, and autopsy findings of 25 children, who were admitted to Hunan Children’s Hospital, China from 2003 to 2009, and died of multiple organ failure. The autopsy revealed pancreatic necrosis in 5 children, in whom sectional or gross autopsy was performed.
RESULTS: The 5 children had acute onset and a fever. Two children had abdominal pain and 2 had abdominal bulging, flatulence and gastrointestinal bleeding. Four children had abnormal liver function, characterized by decreased albumin and 3 children had elevated level of C-reactive protein (CRP). B-ultrasonography revealed abnormal acoustic image of the pancreas in all children, and autopsy confirmed pancreatic necrosis, which may be associated with the damage of the adrenal gland, liver, lung, heart, spleen, kidney, intestine, thymus, mediastinal and mesenteric lymph nodes and other organs. Children 1 and 2 died of acute hemorrhagic necrotizing pancreatitis (AHNP); children 3-5 died of multiple organ dysfunction syndrome (MODS) due to pancreatic necrosis.
CONCLUSION: Pancreatic damage or pancreatic necrosis in critically ill children is characterized by acute onset, severity, short course, multiple organ damage or failure. It may be asymptomatic in early stage, and easy to be ignored.

Distribution and antibiotic resistance of pathogens isolated from ventilator-associated pneumonia patients in pediatric intensive care unit

Xiao-fang Cai, Ji-min Sun, Lian-sheng Bao, Wen-bin Li

2011, 2(2):  117-121. 

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BACKGROUND: With mechanical ventilation widely used in intensive care unit, the ventilator associated pneumonia (VAP) has become a common and serious complication in critically ill patients. Compared with adults, the incidence of VAP and the mortality are higher in children in pediatric intensive care unit (PICU) because of immune deficiency, severe basic diseases, and increased use of artificial airway or mechanical ventilation. Hence it is of significance to study the epidemiology and changes of antibacterial susceptibility in order to reduce the incidence and mortality of VAP in children.
METHODS: From January 2008 to June 2010, 2758 children were treated in PICU of Wuhan Children’s Hospital. Among them, 171 received mechanical ventilation over 48 hours in PICU, and 46 developed VAP. The distribution and drug-resistance pattern of the pathogenic bacteria isolated from lower respiratory tract aspirations were analyzed.
RESULTS: A total of 119 pathogenic microbial strains were isolated. Gram-negative bacilli (G^-) were the most (65.55%), followed by fungi (21.01%) and gram-positive cocci (G⁺, 13.45%). Among them, the most common pathogens were Acinetobacter baummannii, Escherichia coli, Klebsiella pneumoniae, candida albicans and coagulase-negative staphylococci. Antibiotic susceptibility tests indicated that the multiple drug-resistances of G^- and G⁺ to antibiotics were serious. Most of G^- was sensitive to ciprofloxacin, amikacin, imipenem, meropenem, cefoperazone-sulbactam and piperacillin-tazobactam. The susceptibility of G⁺ to vancomycin, teicoplanin and linezolid were 100%. Fungi were almost sensitive to all the antifungal agents. The primary pathogens of VAP were G^-, and their multiple drug-resistances were serious.
CONCLUSION: In clinical practice we should choose the most sensitive drug for VAP according to pathogenic test.

Expression patterns of plasma von Willebrand factor and serum interleukin-8 in patients with early-stage severe pulmonary contusion

Jin-xian Qian, Shi-qi Lu, Yi-ming Zhao, Jun-hao Lu

2011, 2(2):  122-126. 

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BACKGROUND: von Willebrand factor (vWF) is only released from endothelial cells and platelets and is an in vivo and in vitro marker of endothelial injury in septic patients with acute lung injury (ALI). Interleukin-8 (IL-8), as a proinflammatory mediator causing recruitment of inflammatory cells, induces an increase in oxidant stress mediators and makes it as a key parameter for localized inflammation. However, it has not been well established whether the level of serum IL-8 is associated with the severity of lung injury and whether it is a prognosis marker for severe lung contusion. This study was to investigate the expression of plasma vWF and IL-8 and their association with the severity and outcomes of severe pulmonary contusion.
METHODS: A total of 63 patients were divided into a severe pulmonary contusion with acute respiratory distress syndrome (ARDS) group and a non-ARDS group, or a survivor group and a non-survivor group, or an injury severity score (ISS) <20 group and an ISS ≥20 group. Another 20 healthy volunteers served as controls. The levels of plasma vWF and serum IL-8 were measured by enzyme-linked immunosorbent assay (ELISA) at 1, 3, 5 and 7 days after injury. The expression patterns of the plasma vWF and serum IL-8 were compared between different groups.
RESULTS: The concentrations of plasma vWF and serum IL-8 were significantly increased in all severe pulmonary contusion patients at all time points in comparison with the control group. The concentrations of plasma vWF in patients with ARDS increased during the whole study period, but vWF in patients with non-ARDS increased gradually until day 5 and then decreased at day 7. The concentration of serum IL-8 showed a similar expression pattern in both groups, but the expression increased more significantly in the ARDS group than in the non-ARDS group. Interestingly, both plasma vWF and serum IL-8 levels steadily increased in the non-survivor group. Furthermore, the level of plasma vWF was higher in the ISS≥20 group than in the ISS<20 group. The level of serum IL-8 in the ISS≥20 group was consistently high, while that in the ISS<20 group peaked at day 3 and decreased at day 5. In addition, the level of plasma vWF was positively correlated with platelet count, but negatively correlated with oxygen index. The level of serum IL-8 was positively correlated with white blood cell count and ISS score, and inversely correlated with oxygen index.
CONCLUSION: The elevated levels of plasma vWF and serum IL-8 in severe pulmonary contusion patients reflect the severity of pulmonary injury and patients outcomes, suggesting that the plasma vWF and serum IL-8 are sensitive markers for clinical evaluation of the severity of pulmonary injury and predication of patient prognosis.

Effects of high-volume hemofiltration on alveolar-arterial oxygen exchange in patients with refractory septic shock

Hong-sheng Ren, Shi-xue Gao, Chun-ting Wang, Yu-feng Chu, Jin-jiao Jiang, Ji-cheng Zhang, Mei Meng, Guo-qian Qi, Min Ding

2011, 2(2):  127-131. 

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BACKGROUND: High-volume hemofiltration (HVHF) is technically possible in severe acute pancreatitis (SAP) patients complicated with multiple organ dysfunction syndrome (MODS). Continuous HVHF is expected to become a beneficial adjunct therapy for SAP complicated with MODS. In this study, we aimed to explore the effects of fluid resuscitation and HVHF on alveolar- arterial oxygen exchange, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in patients with refractory septic shock.
METHODS: A total of 89 refractory septic shock patients, who were admitted to ICU, the Provincial Hospital affiliated to Shandong University from August 2006 to December 2009, were enrolled in this retrospective study. The patients were randomly divided into two groups: fluid resuscitation (group A, n=41), and fluid resuscitation plus high-volume hemofiltration (group B, n=48). The levels of O₂ content of central venous blood (C_cvO₂), arterial oxygen content (C_aO₂), alveolar-arterial oxygen pressure difference P_(A-a)DO₂, ratio of arterial oxygen pressure/alveolar oxygen pressure (P_aO₂/P_AO₂), respiratory index (RI) and oxygenation index (OI) were determined. The oxygen exchange levels of the two groups were examined based on the arterial blood gas analysis at different times (0, 24, 72 hours and 7 days of treatment) in the two groups. The APACHE II score was calculated before and after 7-day treatment in the two groups.
RESULTS: The levels of C_cvO₂, C_aO₂ on day 7 in group A were significantly lower than those in group B (C_cvO₂: 0.60±0.24 vs. 0.72±0.28, P<0.05; CaO₂: 0.84±0.43 vs. 0.94±0.46, P<0.05). The level of oxygen extraction rate (O₂ER) in group A on the 7th day was significantly higher than that in group B ( 28.7±2.4 vs. 21.7±3.4, P<0.01). The levels of P_(A-a)DO₂ and RI in group B on the 7th day were significantly lower than those in group A. The levels of P_aO₂/P_AO₂ and OI in group B on 7th day were significantly higher than those in group A (P<0.05 or P<0.01). The APACHE II score in the two groups reduced gradually after 7-day treatment, and the APACHE II score on the 7th day in group B was significantly lower than that in group A (8.2±3.8 vs. 17.2±6.8, P<0.01).
CONCLUSION: HVHF combined with fluid resuscitation can improve alveolar- arterial-oxygen exchange, decrease the APACHE II score in patients with refractory septic shock, and thus it increases the survival rate of patients.

Visfatin levels in patients with severe pneumonia

Xie Juan, Yi-ming Lu, Jin-dong Shi, Xing-qi Deng, Wei Long

2011, 2(2):  132-136. 

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BACKGROUND: As a cytokine highly expressed in internal organs, visfatin could be used as a biomarker of systemic inflammation response for chronic obstructive pulmonary diseases, but few studies have reported the use of visfatin in severe pneumonia. The present study was undertaken to determine the plasma levels of visfatin in patients with severe pneumonia.
METHODS: A total of 70 patients, including 40 patients with severe pneumonia (group A) and 30 patients with non severe pneumonia (group B) who had been admitted to the ICU from June 2009 to June 2010, were enrolled in this prospective study. And another 30 healthy physical examinees served as healthy controls (group C). Patients were excluded if they suffered from severe diseases of the heart, brain and kidney, cancers, autoimmune diseases, or received special treatment in the latest month. The plasma levels of visfatin, IL-6, IL-8 and TNF-α were measured by ELISA, while the level of CRP was determined by immuneturbidimetry, and the routine blood test was performed. Blood gas analysis and Acute Physiology and Chronic Health Evaluation II (APACHE II) were performed in patients with pneumonia. Comparisons between the groups were conducted by Student's t test, ANOVA or nonparametric test. Correlation analysis was carried out by Pearson's correlation test or Spearman's rank-order correlation test.
RESULTS: The plasma level of visfatin in group A was significantly higher than that in groups B and C (P<0.001), and the level of visfatin in group B was significantly higher than that in group C (P<0.001). The plasma level of visfatin was positively correlated with CRP, TNF-α, APACHE II and PMN% in patients with severe pneumonia (r_ho=0.653, r=0.554, r=0.558, r=0.484, respectively, P<0.05 for all), while it was negatively correlated with PaO₂ and PaO₂/FiO₂ (r_ho=-0.422, r=-0.543, respectively, P<0.05 for all).
CONCLUSION: Visfatin may be involved in the systematic inflammation response in patients with severe pneumonia as a pro-inflammatory cytokine, and it is valuable in assessing the severity of pneumonia..

Risk factors for carotid artery distensibility in middle-aged and elderly hemodialysis patients

Hong-qi Ren, Guo-fang Chen, Qing Cai, Yan Li, Shu-jing Han, Ling Li

2011, 2(2):  137-140. 

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BACKGROUND: Carotid intima media thickness (CIMT) and stiffness are taken as useful surrogate markers of atherosclerosis. In China, the number of elderly patients undergoing hemodialysis has increased year by year, with the increase of dialysis-related cardiovascular events. This study was undertaken to examine carotid stiffness in elderly hemodialysis patients by the ultrasound techniques in order to find out the possible risk factors.
METHODS: From January 2006 to February 2010, a total of 87 patients (41 males and 46 females) treated with routine hemodialysis at the 97th Hospital of People's Liberation Army were enrolled in this study. The distensibility coefficient (DC) of the carotid artery was detected by Doppler ultrasonic diagnosis apparatus (Philips HBI5000, frequency 12 MHz) for evaluation of arterial stiffness. Serum albumin, total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), triglyceride (TG), glucose, creatinine, calcium, phosphorus, and intact parathyroid hormone (iPTH) were examined with standard methods. The liner correlation and multiple stepwise regression analysis were used to find correlations between them.
RESULTS: In this study, the systolic blood pressure was 153.33±25.98 mmHg, DBP 84.22± 10.39 mmHg, TC 4.39±1.05 mmol/L, TG 1.36±0.72 mmol/L, LDL 2.47±0.77 mmol/L, Cr 889.82± 207.38 μmol/L, Glu 5.36±1.87 mmol/L, Ca I 2.00±2.19±0.21 mmol/L, and DC 13.39±5.32×10^-3/kPa. DC was associated with age (r =-0.459, P<0.001), SBP (r =-0.527, P<0.001), and serum calcium (r =-0.273, P=0.011). The multiple stepwise regression analysis showed that SBP, age, increased serum calcium level, and diabetes were independent risk factors for decreasing DC.
CONCLUSION: Systolic blood pressure, age, increased serum calcium level and diabetes in elderly hemodialysis patients are independent risk factors for increased carotid arterial stiffness.

Original Article

Effect of post recruitment maneuver ventilation by different tidal volume on lung vascular endothelial diastole function in rats with acute lung injury

Jian-qiang Wang, Chun Pan, Lin Liu, Liang Jin, Yi Yang, Hai-bo Qiu

2011, 2(2):  141-148. 

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BACKGROUND: This study aimed to observe the effect of recruitment maneuver (RM) and post-RM ventilation at different tidal volume on lung vascular diastole endothelial function in rats with acute lung injury (ALI).
METHODS: A ALI rat model was produced by intravenous infusion of lipopolysaccharide (6 mg/kg). Twenty-five rats were randomly divided into five groups: control group (n=5), ALI group (n=5), low tidal volume group (LV group, VT 6 mL/kg, n=5), sustained inflation (SI) with low tidal volume group (SI+LV group, VT 6 mL/kg, n=5), and SI with moderate tidal volume group (SI+MV group, VT 12 mL/kg, n=5). RM was performed with SI, airway pressure 30 cmH₂O for 30 seconds, and positive end-expiratory pressure (PEEP) was set to 5 cmH₂O. Lung tissue was taken after 5 hours of mechanical ventilation. Mean arterial blood pressure (MAP) was monitored during the experiment. Endothelin-1 (ET-1), endothelial nitricoxide synthase (eNOS), Ach-induced endothelium-dependent relaxation response of isolated pulmonary artery rings were determined at 5 hours.
RESULTS: LPS increased ET-1 level, decreased the expression of eNOS in lung tissue, impaired the Ach-induced endothelium-dependent relaxation response in the pulmonary artery, without obvious effect on systemic hemodynamics. SI+LV significantly reduced LPS-induced elevation of ET-1 level, increased the expression of eNOS, significantly improved endothelial dysfunction, and improved the dysfunction of endothelium-dependent relaxation in the pulmonary artery.
CONCLUSIONS: RM with a high or low tidal volume ventilation could improve the lung vascular endothelial function of rats with acute lung injury, and RM with low tidal volume ventilation could lower significantly the injury of lung vascular endothelial diastole function in rats with acute lung injury.

Original Articles

Saturated hydrogen saline protects rats from acute lung injury induced by paraquat

Hui-li Zhang, Yuan-fei Liu, Xu-rui Luo, Wei-hua Tan, Liang Huang

2011, 2(2):  149-153. 

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BACKGROUND: Paraquat (PQ) intoxication causes lung oxidative stress damage. Saturated hydrogen saline, a newly explored antioxidant, has been documented to play a powerful antioxidant role in preventing oxidative stress damage. This study aimed to investigate the protective effects and the possible mechanisms of intoxication on rats with acute lung injury (ALI) caused by paraquat poisoning.
METHODS: Thirty PQ poisoned rats were randomly divided into a PQ intoxication group (intoxication group), a saturated hydrogen saline intervention group (intervention group), and a control group, with 10 rats in each group. The first two groups accepted an intragastric administration of PQ at a dose of 50 mg/kg for every single rat, and the control group was fed with a same volume of normal saline. Five mL/kg of saturated hydrogen saline was given to the intervention group three times a day by peritoneal injection for three days after intoxication. Arterial blood gas was detected on the third day. The rats were executed and their lungs were taken for measurement of wet dry weight ratio, homogenate malondialdehyde (MDA), and 8-hydroxy-2'-deoxyguanosine (8-OhdG). Histological changes of the lungs were also observed.
RESULTS: Compared with the control group, the intoxication group had more serious hypoxemia, greater wet/dry weight ratio, higher MDA level, higher expression of 8-OhdG and more severe lung damage (P<0.01 or P<0.05). However, after intervention with saturated hydrogen saline, poisoned animals turned to have lighter hypoxemia, smaller wet/dry weight ratio, lower MDA level, lower expression of 8-OhdG, and milder lung damage (P<0.01 or P<0.05).
CONCLUSIONS: Saturated hydrogen saline is effective in preventing acute lung injury caused by PQ. Possibly, it can neutralize toxic oxygen radicals selectively and alleviate the oxidative stress injury induced by PQ.

Case Report

Early tracheotomy for acute severe asthma

Huan Huang, Xin-hui Xu, Yi Chen, Li-xiong Lu, Chang-qing Zhu

2011, 2(2):  154-156. 

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BACKGROUND: Few studies have reported the effects of early tracheotomy in acute severe asthmatic patients. We report two patients with acute severe asthma who were successfully treated with early tracheotomy.
METHODS: The two patients with acute severe asthma were retrospectively reviewed. They had been treated at the Department of Emergency and Critical Care, Renji Hospital, Shanghai Jiaotong University School of Medicine.
RESULTS: They developed progressively hypercapnia and severe acidosis, and were not improved after conventional therapies. Early tracheotomy after mechanical ventilation decreased airway resistance and work of breathing, and corrected hypercapnia and acidosis. Adequate gas exchange was maintained after tracheotomy. The two patients were subsequently weaned from mechanical ventilation and discharged.
CONCLUSION: Early tracheotomy could be a valuable approach in certain patients with severe asthma.