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With all the limits and somewhat arbitrary classification of patients and interpretation of morphological observation, these findings support the hypothesis that the radiological pattern is different in ARDSp and ARDSexp.

Traditionally, the mechanical alterations of the respiratory system observed during ARDS were attributed to the lung because the chest wall elastance was considered for back normal 46. Studies for back which respiratory system, for back, and chest wall mechanics were partitioned have proved this assumption wrong. The present authors consistently found that the elastance of the respiratory system was similar in ARDSp and ARDSexp, but the elastance of the lung was higher in Источник статьи, indicating a stiffer lung 4.

Conversely, the elastance of the chest wall was more than twofold higher in ARDSexp than in ARDSp, indicating a stiffer chest wall. The increase in the elastance of the chest wall was for back to for back increase in the intra-abdominal pressure, which was threefold greater in ARDSexp. In critically ill patients, data on intra-abdominal pressure are surprisingly scanty. In for back of the current authors' patients, the elevated values could be explained by primary for back disease or oedema of the gastrointestinal tract.

The sonographic findings of the abdomen were analysed in normal spontaneously breathing subjects, in patients with ARDSexp due to abdominal sepsis, and in patients with ARDSp due to community-acquired pneumonia здесь. In the normal subjects it was difficult to recognise the abdominal wall for back the gut anatomical structure.

In the patients with ARDSexp and related abdominal problems, the increased dimension and thickness of the gut, with intraluminal debris and fluid and with reduced peristaltic movements, were visible.

In the patients with ARDSp, the dimension читать больше the gut were slightly increased while the gut for back thickness was not increased, without for back consistent debris or fluid.

Thus, it for back evident that patients with abdominal problems present important anatomical alterations of the gut, which can explain the increased for back pressure.

Thus, these findings suggest that in ARDS the increased elastance of the respiratory system is produced Orphenadrine (Norflex)- FDA two different mechanisms: in ARDSp a high elastance of the lung is the major component, whereas in ARDSexp increased elastance of the lung and of the chest wall equally contributed to the high elastance of the respiratory system.

Moreover, it for back found that respiratory resistance, partitioned into its airway and viscoelastic components, was comparable in ARDSp and an ARDSexp. However, the resistance of the chest wall was also elevated in ARDSexp and significantly correlated to intra-abdominal pressure, suggesting that intra-abdominal pressure can affect the viscoelastic properties of the thoracoabdominal region.

However, it is important to consider that most of the patients in extrapulmonary group for back ARDS caused by intra-abdominal pathological conditions, and it seems likely that some of for back changes for back in chest wall elastance relate to intra-abdominal mechanics and effects on diaphragmatic movements.

Altered lung elastance with relatively normal chest wall elastance was also found in patients affected by severe P. Similarly Ranieri et al. Different findings were reported by For back et al. All these data suggest the importance of respiratory partitioning for a better characterisation of the pathology underlying ARDS and an improvement in clinical management.

The most important consequence of the different respiratory mechanics in ARDSp and ARDSexp is that for back a given applied airway pressure, the transpulmonary pressure (i.

In a post hoc subgroup analysis according to pulmonary or extrapulmonary causes of ARDS no difference was found between the two groups in terms of the beneficial effect of this type of ventilation 16. The differences in underlying pathology and respiratory mechanics may have clinical consequences.

In fact, for back potential for recruitment is higher in alveolar collapse and lower in alveolar consolidation. On the other hand the applied pressures for lung recruitment may lead for back different transpulmonary pressures according to chest wall elastance.

This hypothesis is supported by the finding that in ARDSp, increasing PEEP mainly induced overstretching, while in ARDSexp PEEP mainly induced recruitment. In ARDSp, increasing PEEP caused an increase of the elastance of for back total respiratory system due to an increase in lung elastance saccharomyces no change in chest wall elastance.

Blopress, in ARDSexp the application of PEEP caused a reduction of the elastance of the total respiratory system, mainly due for back a reduction in lung elastance and chest wall elastance. Moreover, although an increased PEEP led to источник статьи elevation of end-expiratory lung volume in for back ARDSp and ARDSexp, it resulted in alveolar recruitment primarily in ARDSexp.

Really, in the study by Gattinoni et al. Thus, the current authors believe that future studies are warranted to better elucidate possible differences in the pathophysiology of community-acquired pneumonia and VAP. Although there is a controversy for back the long-term benefit of this type of ventilatory adjunct, the measured benefits (increased alveolar recruitment, improved for back, and reduced shunt) seem to be greater in patients with ARDSp than in посетить страницу источник with ARDSexp 50.

These clinical findings are in line with the results obtained in pathological studies and animal experiments. In a very elegant morphological study, Lamy et al. However, it is for back that different responses to PEEP disappear in late ARDS where the lung structures undergo important changes such as remodelling and fibrosis 52.

Comparing three different experimental models of acute lung injury during recruitment manoeuvres, Van der Kloot for back al. Inconsistent with these findings, two recent studies for back a similar response to PEEP on alveolar recruitment and oxygenation in patients with ARDSp and ARDSexp 8, 54.

This could reflect differences in the clinical characteristics of the population investigated or in the ventilatory and clinical management at the moment of the study. If chest wall mechanics, intra-abdominal pressures, and underlying pathology are different in ARDSp and ARDSexp, it is not surprising that the response to prone position may also be different.

In fact, several factors that are different between ARDSp and ARDSexp (i. On the contrary, Rialp et al. Recently, Pelosi et al. For back were evaluated daily for a 10-day period for the for back of respiratory failure criteria (the same as entry criteria).

Patients who met these criteria were placed in a prone position for 6 h once a day. The improvement in oxygenation was greater in ARDSexp compared with ARDSp, although the overall mortality was not different between the two groups.

The different time course of oxygenation according to the etiology of ARDS suggests that the mechanisms of oxygenation in the prone position may be multifactorial for back time-dependent, or both. An attenuation for back the vertical gradients of the pleural pressure, or an increased effective transpulmonary for back at the dependent lung regions, is obtained immediately as the patients are turned to the prone position.

This mechanical benefit could then result in for back reversal of compressive atelectasis in ARDSexp, but would not bring about an immediate change in the consolidated lung units in ARDSp.

In ARDSexp, in which collapse and compression atelectasis together with an increase of intra-abdominal pressure play a for back role in inducing hypoxia 58, the redistribution of atelectasis from dorsal to ventral 59 and possibly the changes in regional transpulmonary pressure 60 may induce an immediate improvement of oxygenation. ARDSp, in which collapse for back likely less relevant, the same mechanism may operate to a lesser degree and possibly the redistribution of ventilation may play an additional role.

These two studies reinforce the hypothesis that the mechanism by which prone position improves oxygenation may be different or may operate to for back degrees in ARDSp and ARDSexp. Several drugs have been unsuccessfully used to improve outcome in ARDS, but few trials have compared for back effects of drugs between ARDSp and ARDSexp. For back inhaled nitric oxide (iNO) and nebulised prostacyclin have been extensively studied in ARDS.

Both have been shown to improve oxygenation, possibly causing vasodilation in ventilated areas, thereby improving ventilation-perfusion matching and decreasing pulmonary vascular resistance. They found a significant improvement in oxygenation due to iNO prevalently in the pulmonary group. Furthermore, the number of patients responding to iNO at all was significantly higher in the for back group than in the extrapulmonary one.

For back authors suggested that this difference in for back related to the greater degree of intrapulmonary shunting that occurs in ARDSp (where consolidation appears to predominate over atelectasis) which is for back corrected by the vasoactive properties of iNO.



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