This study was designed to use volumetric capnography to evaluate the breathing pattern and ventilation inhomogeneities in patients with chronic sputum production and bronchiectasis and to correlate the phase 3 slope of the capnographic curve to spirometric measurements. Twenty-four patients with cystic fibrosis (CF) and 21 patients with noncystic fibrosis idiopathic bronchiectasis (BC) were serially enrolled. The diagnosis of cystic fibrosis was based on the finding of at least two abnormal sweat chloride concentrations (iontophoresis sweat test). The diagnosis of bronchiectasis was made when the patient had a complaint of chronic sputum production and compatible findings at high-resolution computed tomography (HRCT) scan of the thorax. Spirometric tests and volumetric capnography were performed. The 114 subjects of the control group for capnographic variables were nonsmoker volunteers, who had no respiratory symptoms whatsoever and no past or present history of lung disease. Compared with controls, patients in CF group had lower SpO(2) (P < 0.0001), higher respiratory rates (RR) (P < 0.0001), smaller expiratory volumes normalized for weight (V(E)/kg) (P < 0.028), smaller expiratory times (Te) (P < 0.0001), and greater phase 3 Slopes normalized for tidal volume (P3Slp/V(E)) (P < 0.0001). Compared with controls, patients in the BC group had lower SpO(2) (P < 0.0001), higher RR (P < 0.004), smaller V(E)/kg (P < 0.04), smaller Te (P < 0.007), greater P3Slp/V(E) (P < 0.0001), and smaller VCO(2) (P < 0.0002). The pooled data from the two patient groups compared with controls showed that the patients had lower SpO(2) (P < 0.0001), higher RR (P < 0.0001), smaller V(E)/kg (P < 0.05), smaller Te (P < 0.0001), greater P3Slp/V(E) (P < 0.0001), and smaller VCO(2) (P < 0.0003). All of the capnographic and spirometric variables evaluated showed no significant differences between CF and BC patients. Spirometric data in this study reveals that the patients had obstructive defects with concomitant low vital capacities and both groups had very similar abnormalities. The capnographic variables in the patient group suggest a restrictive respiratory pattern (greater respiratory rates, smaller expiratory times and expiratory volumes, normal peak expiratory flows). Both groups of patients showed increased phase III slopes compared with controls, which probably indicates the presence of diffuse disease of small airways in both conditions leading to inhomogeneities of ventilation.

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The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54%) were diagnosed as having VAP and 17 (46%) as not having the condition. Quantitative culture of BAL effluent showed 90% sensitivity (18/20), 94.1% specificity (16/17), 94.7% positive predictive value and 88.8% negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1% of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1% (16/17), and a cut-off point of 50% of BAL neutrophils showed a sensitivity of 90% (19/20).In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP. Correspondence

Whether the gut alterations seen during sepsis are caused by microcirculatory hypoxia or disturbances in cellular metabolic pathways associated with mitochondrial respiration remains controversial. We hypothesized that hypoperfusion or hypoxia and local production of nitric oxide might play an important role in the development of gut mucosal injury during endotoxic shock and investigated their roles by using differing levels of fluid resuscitation and occlusion of the superior mesenteric artery (SMA). Anesthetized New Zealand rabbits were allocated to group I (sham, n = 8); group II [low-dose endotoxin (LPS, Escherichia coli-055:B5, 150 microg/kg)/fluid resuscitation (12 ml x kg(-1) x h(-1)); n = 8]; group III [high-dose LPS (1 mg/kg)/fluid resuscitation (12 ml x kg(-1) x h(-1)); n = 8]; group IV [high-dose LPS (1 mg/kg)/hypovolemia (4 ml x kg-1 x h(-1) fluids); n = 8]; and group V [SMA ligation/fluid resuscitation (12 ml x kg(-1) x h(-1)); n = 4]. Luminal gut lactate concentrations and PCO2 gap increased in groups IV and V (P < 0.05), reflecting alterations in gut perfusion. Interestingly, significant histological alterations were observed in all LPS groups but not in group V. Blood and luminal gut nitrate/nitrite concentrations increased only in group IV. The mechanism of gut injury in endotoxic shock seems unrelated to hypoxia and release of nitric oxide. Gut dysfunction may occur as a result of so-called "cytopathic hypoxia."

RESUMO -O b j e t i v o:Estudar a influência das manobras de fisioterapia respiratória na pressão intracraniana (PIC) dos pacientes com trauma craniencefálico grave. Método: Trinta e cinco pacientes com trauma craniencefálico grave foram incluídos no estudo, sendo divididos em três grupos: com PIC < 10, 11-20 e 21-30 mmHg. As variáveis monitorizadas foram: PIC e pressão arterial média. A pressão de perfusão cerebral foi calculada pela diferença de pressão arterial média e PIC. Resultados: A manobra de aspiração traqueal causou aumento de PIC em todos os grupos. A pressão arterial média não teve alterações e a pressão de perfusão cerebral diminuiu pouco, porém mantendo valores normais. Conclusão: As manobras de fisioterapia respiratória podem ser usadas com segurança em pacientes com traumatismo craniencefálico grave, com PIC abaixo de 30 mmHg.Certo cuidado deve ser tomado durante a aspiração traqueal.PALAVRAS-CHAVE: traumatismo craniencefálico, fisioterapia respiratória, pressão intracraniana, pressão de perfusão cerebral.Influence of the respiratory physioterapy on intracranial pre s s u re in severe head trauma patients ABSTRACT -O b j e c t i v e:To evaluate influence of the respiratory physiotherapy on intracranial pressure (ICP) in patients with severe head trauma. M e t h o d: Thirty five patients with severe head trauma were included in the study.The patients were divided into three groups: ICP 0-10, 11-20 and 21-30 mmHg. The following variables were measured: ICP and mean arterial pressure. Cerebral perfusion pressure was calculated as the difference between mean arterial and intracranial pressure. R e s u l t s: Endotracheal aspiration increased ICP in all patients. The mean arterial pressure didn't change and cerebral perfusion pressure decreased, but remaning normal value. Conclusion: Respiratory physiotherapy maneuvers can be safely applied in patients with severe head trauma with ICP below 30 mmHg. More attention should be taken during endotracheal aspiration .KEY WORDS: head injury, respiratory physioterapy, intracranial pressure, cerebral perfusion pressure.Os pacientes com traumatismo craniencefálico (TCE) grave, com escala de coma de Glasgow igual ou menor que 8, são geralmente submetidos à monitorização da pressão intracraniana (PIC), e da pressão arterial média (PAM) e tratados de acordo c o m um protocolo rígido de assistência, que inclui sedação, elevação de cabeceira do leito, ventilação mecânica otimizada, fisioterapia respiratória e motora, entre outras 1 , 2 . A aplicação das manobras cinéticas de fisioterapia respiratória promove aumento momentâneo da pressão intratorácica, diminuindo o retorno venoso cerebral e elevando a PIC nesses p acientes [3][4][5][6] .Sabe-se que as alterações da PIC influenciam diretamente a pressão de perfusão cerebral (PPC), que é calculada como diferença entre a PAM e a PIC. Portanto, aumentos da PIC poderiam acarretar diminuição da PPC, se não houver aumento conco-