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Partial pulmonary resection in early childhood is well tolerated. Although long-term outcome has been described in several follow-up studies, almost no information is available on postoperative lung perfusion. We studied 14 patients 3 to 20 years (mean, 11.6 years) after they underwent partial pulmonary resection at 1 week to 30 months of age (mean, 6.8 months). We examined development, pulmonary function, endurance, radiographs and ventilation-perfusion scans. We used predicted pulmonary function test values, which were corrected for the relative amount of lung removed and called predicted-corrected values. We hypothesized that the remaining lung would have altered ventilation-perfusion characteristics. We found no abnormalities in the patients' physical development. Most children had abnormal regional ventilation, but normal equilibration occurred; five patients had gas retention; all had decreased perfusion to the area of resection; nine patients showed ventilation-perfusion mismatch characterized by dead-space ventilation. Lung volumes were within the predicted range in 12 patients. Residual volume and functional residual capacity were larger than predicted-corrected values in most patients but residual volume in relation to total lung capacity was at or below normal in 6 of 11 and did not correlate with the amount of lung removed. Most patients had prolonged expiratory flows. We conclude that lung resection in early childhood leads to good functional recovery. However, decreased expiratory flows, regional ventilation abnormalities, and decreased perfusion suggest dysplastic parenchyma and vascular bed in the area of resection.

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Airway pressure and air flow were measured at the endotracheal tube in 13 children on a variety of ventilators. These signals were stored for analysis on a computer. Further data sets were obtained after 24 hours or following major interventions. Air flow rate was integrated to give volume. Pulmonary resistance and elastance were obtained by multiple linear regression. Pressure-volume, pressure-flow and flow-volume loops were plotted. "Closed" pressure-volume and pressure-flow loops (by subtraction of the resistive or elastic pressure components, respectively) were also displayed, giving compliance and resistance loops. The loops from the initial data set were taken as the baseline, and loops from later data sets were superimposed to provide visual comparisons. Change in clinical status was reflected by the change in slope of compliance and resistance loops. A 30% change in compliance or resistance was easily observed. There was minimal interference with patient care. This pilot study demonstrates that changes in respiratory mechanics can be displayed safely and easily in ventilated patients using resistance and compliance loops. Further work is necessary to confirm the usefulness of real time of these displays.

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A 4,907-mile medical air transport recently took place between Vancouver, Canada, and London, England. The patient was a 6-year-old boy with multiple pleural, pulmonary, and pericardial hemangiomata who required heart-lung transplant. Because his respiratory function was so poor (including oxygen-induced hypercarbia and sleep-induced hypoxia), a Lear 35 was used. The aircraft made a low altitude flight possible, allowing adjustment of cabin pressure to overcome the child's sensitivity to any significant reduction in partial pressure and to minimize his need for supplemental oxygen. Clinical observation and monitoring using oximetry and transcutaneous blood gas measurements were carried out en route to warn of excessive altitude effects. Sequential increases in altitude were made once oxygenation had stabilized at each cabin pressure. Cabin pressure was not allowed to rise above 3,700 ft to ensure an oxygen saturation level of at least 80%. The transport was accomplished successfully with no requirement for intervention. This approach to in-flight management has applications for other aero-medical transports.

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Pleuropulmonary disease in childhood onset SLE is common. It may be insidious or present as a life threatening event. North American Indian children in our population appear to be at high risk for severe lung disease. Pulmonary symptoms are present in the majority of children at some time during their disease course and pulmonary function studies are abnormal in the majority of patients. The pulmonary manifestations and frequency of occurrence in childhood appear to be similar to that described in adult onset SLE. Although pulmonary function studies do not correlate well with pulmonary symptoms, these studies provide objective quantification of the type and severity of the functional lesion. Serial tests may be helpful in monitoring disease activity in childhood SLE.

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Two infants presented with fever and signs of brainstem dysfunction, including impaired consciousness, miosis, absence of oculocephalic responses, respiratory depression and a very peculiar tremor of the tongue and floor of the mouth. They were found to have methadone poisoning caused by accidental contamination of prescribed antibiotics in the same pharmacy, which was a dispensing centre for a methadone maintenance program. They recovered with supportive treatment only.

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How important is the ventilator circuit and the humidification system? What problems are created by relatively high compliance circuits? Is circuit volume "steal" important when the level of water in the humidifier changes? What is the state of the art for pediatric ventilators?

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The recommendations set forth here are based partly on empirical clinical data and partly on physiologic principles. Because both sources of information are incomplete, some of the advice offered will doubtless prove incorrect. The techniques must be individualized, and this requires first a good understanding of the pathophysiology involved and then a process of manipulation of variables with careful monitoring of their effect by appropriate "dependent variables." Optimal ventilator management is possible only with a good working relationship among physician, nurse, and respiratory technologist.

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The past 20 years have seen striking changes in ventilators for use in infants and children. Early in this period, we relied on traditional machines and techniques that were largely borrowed from adult medicine. The availability of second-generation machines brought better understanding of pulmonary physiology, particularly as it relates to oxygen transport. Today, third-generation ventilators very different from the others have forced abandonment of dogma concerning the manner in which molecules of gas enter and leave the lung. Their full impact cannot yet be judged, but they have shown great clinical promise and no doubt will change further our understanding of pulmonary physiology.

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