BackgroundLung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography.MethodsAfter induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar.ResultsInduction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO2/FiO2): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO2): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO2 at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO2/FiO2 at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d.ConclusionsProne position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.

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This case reports highlights of the feeding problems in MarshallSmith syndrome and the weaning from a tube in a 5-year-old patient. The patient, Maya, showed the typical signs of this rare disease. The diagnosis of Marshall-Smith syndrome was made at the age of 2½ years. Because of respiratory problems and a high risk of aspiration, Maya got a percutaneous endoscopic gastrostomy (PEG) tube at the age of 5 months. After stabilization of her respiratory situation, Maya was able to eat from a strictly medical point of view. Maya was admitted to the authors' ward dependent on a PEG tube, but her parents wanted her to be weaned from the tube. In contrast to other patients with Marshall-Smith syndrome, Maya's typical respiratory problems stabilized, and on the basis of the little experience published in the literature, Maya seems to have a relatively good life expectancy. After careful analysis of her medical state, Maya was integrated into the specialized tube-weaning program. Tube weaning was successful, and after 3 weeks of treatment, Maya was able to gain weight by exclusive and selfregulated oral intake. In conclusion, this case report shows that weaning a child with Marshall-Smith syndrome from a feeding tube is possible and gives these children the chance to gain weight by oral intake, as any healthy child does. The reachable eating skills depend on the grade of disability. In the authors' clinical experience, weaning from a tube shows a positive effect on psychomotor development and reduces the mortality rate and the rate of complications associated with tube feeding itself.