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Acute respiratory distress syndrome (ARDS) is associated with high mortality rates . The aim of treatment and ventilation is to improve oxygenation. Prone positioning improves oxygenation in patients with ARDS by shifting blood flow to undamaged or better ventilated regions of the lung. Critical care nurses follow the current guidelines with respect to prone positioning, which are mostly based on the medical aspects of the treatment. Prone positioning challenges nursing care of these patients. The research question that emerges is: Which nursing interventions during prone positioning will benefit the patient and reduce or eliminate complications? The purpose of this research is to do a systematic review in order to: Explore the evidence in support of the beneficial nursing interventions during prone positioning of ventilated patients and to develop evidence-based nursing guidelines with regard to the nursing process. The research design can be described as an exploratory, descriptive and retrospective systematic review. The population consisted of experimental study designs, as well as comparative, non-randomised and observational studies on nursing interventions during the prone positioning process. Selected studies included a population of adult or paediatric subjects who were ventilated and turned into the prone position, and the search strategy was restricted to articles published or translated into English. Studies that included animals or neonates were excluded from this review. The data collection process involved the systematic extraction of relevant data onto standardised data abstraction forms and the assessment of the methodological quality of each study. Data were summarised into evidence tables and data from randomised controlled trials were used for meta-analysis. There were thirteen randomised controlled trials, of which only seven could be included for quantitative analysis. Forty five clinical trials involving prone positioning were identified, with a total population of 2 148 patients. Outcomes that were measured, included oxygenation outcomes, responder and non-responder groups, haemodynamic outcomes, complications in the prone position, mortality, the length of sta y in the intensive care units and the total number of ventilated days. Prone positioning showed significant increases in the PaO2 and PaO2 / FiO2 ratio. The effect of the outcomes compared against the different ventilation, sedation, nutrition and positioning protocols had inconclusive results. Haemodynamic variables had insignificant increases in the prone position. Pulmonary artery wedge pressure (PAWP) however, did show a significant increase in the prone position. Complications related to prone positioning were insignificantly less than expected. Patients treated in the prone position were ventilated for an insignificantly shorter period of time, but had a longer ICU stay, although the results were also insignificant. The mortality of patients in the selected trials was 33.5%. Evidence gained from the selected studies could be used to develop nursing guidelines, despite inconclusive results related to some of the measured outcomes. / Dr. Elzabé Nel

Respiratory distress syndrome is the major cause of mortality in premature babies. Increasing numbers of neonates are now surviving the disease due to advances in techniques used in neonatal intensive care units. Mechanical ventilation is an essential part of the treatment for respiratory distress syndrome and is an area in which improvements and modifications are constantly being made. In the early 1980's a new infant ventilator was introduced involving ventilation by a distal jet. As yet, the mechanisms by which the distal jet ventilator enhances gas exchange are unknown. Original experiments are carried out to record the attenuation and speeds of the pressure wave produced by the distal jet ventilator. The observed changes in wave shape and the high wave speed imply that the ventilator produces waves operating within an acoustic regime. An understanding of the gas exchange mechanisms active in shock assisted ventilation is initiated by a comprehensive investigation of the transport properties of acoustic waves. The advection and diffusion that result from a linear concentration gradient in an acoustic flow are analysed, from the Eulerian and Lagrangian viewpoints. The Eulerian investigation shows that the total flux of tracer through a given pipe can be optimized by choosing the frequency appropriately. The Lagrangian transport is increased as both frequency and radius increase. For all values of parameters, Lagrangian streaming is observed, with a steady net flow in the pipe core away from the tube entrance and an opposing net flow near the tube walls.

This study was undertaken primarily to investigate the plasma protein system in infants with IRDS, as compared with healthy premature infants, as it had previously been reported that the plasma protein concentration in affected infants was abnormally low. It was attempted further to establish biochemical and/or immunological criteria for diagnosis of the disease and to discover reasons for the low IgG concentrations and raised α-fetoprotein concentrations found in the sera of these infants. Maternal serum proteins were also studied during pregnancy and at and after delivery of the infant. Interrelationships between α-fetoprotein, Human Growth Hormone and other proteins, in immunochemical systems were investigated. In summary, the main conclusions reached were as follows: (i) The total serum-protein concentration in affected infants is much reduced, as compared with healthy premature infants of the same gestational age. (ii) In IRDS infants, the relative and absolute concentration, of IgG is extremely low, whereas concentrations of other immune globulins, as far as could be determined, are within normal limits. (iii) Mothers of affected infants have significantly lower concentrations both of serum IgG and of IgM, than mothers of healthy premature infants. These changes in the serum-proteins are present throughout pregnancy. By six weeks post-partum, the IgG level has returned to normal, but the IgM level remains low. Concentrations of IgA and total serum-protein are normal at all times. (iv) Examination of oedema fluid, urine, faeces and amniotic fluid for γ-globulin content, has excluded the possibility that IgG is being lost from the circulation by these routes. (v) IRDS infants have, in their serum, agglutinins of the IgM type directed against the intact maternal IgG molecule. Similar agglutinins are present in a minority of healthy premature infants. Both IRDS and healthy infants have agglutinins against IgG fragments, in approximately 50% of cases. Agglutinin titres against these are similar in the two groups, but the incidence of agglutinins against Bence Jones protein type Lis raised in IRDS. (vi) Affected infants have an elevated serum concentration of α-fetoprotein, which disappears from the serum during the: first week of post-natal life. (vii) The majority of pregnant women examined have been observed to have serum agglutinins directed against α-fetoprotein. These cross-react with albumin prepared from sera of healthy adult males α-fetoprotein has been found in the serum of many pregnant women, especially during the second trimester. (viii) Immunological interrelationships between α-fetoprotein human serum albumin, Human Growth Hormone and human IgG have been demonstrated. (ix) Infants suffering from Rh-isoimmunization exhibit a serum- protein pattern similar to that seen in IRDS. Biochemical and immunological criteria for the diagnosis of IRDS have thus been established. The data to be presented indicate the presence of an immunological factor in the aetiology of the disease.

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This study was designed to follow up a chance observation in patients with an admission white blood cell (WBC) count showing an absolute lymphocytosis and relative neutropenia that changed to a lymphopenia and neutrophilia within 24 hours. As 15 of the 20 patients were admitted following trauma, we examined this association further by reviewing charts of 69 patients who had sustained stab wounds to the chest and abdomen. A prospective study involving 40 patients in the Intensive Care Unit was also undertaken because of the related hypothesis that the Adult Respiratory Distress Syndrome (ARDS) is associated with sequestration of complement activated polymorphonuclear leukocytes (PMN) by the lung. These studies show that trauma is frequently associated with a lymphocytosis and relative neutropenia. In cases where ARDS did develop, the onset of respiratory failure was associated with a profound fall in the circulating PMN count. To test the hypothesis that these leukocyte changes were due to catecholamine release and sequestration of PMN within the pulmonary micro-vasculature, we studied the effects of epinephrine infusion, lowered cardiac output and complement activation on WBC uptake and release from the dog lung. The data show that pulmonary blood flow has a marked effect on the uptake and release of WBC by the lung but has no effect on differential counts. Epinephrine infusion increases circulating WBC counts but also does not alter differential counts. In contrast, activation of the complement cascade alters differential values by causing preferential sequestration of PMN. We conclude that trauma is frequently associated with a lymphocytosis and relative neutropenia and speculate that this phenomenon is due to a combination of catecholamine release and sequestration of PMN within pulmonary and systemic microvasculatures. The findings that a profound fall in PMN counts occurs prior to the onset of ARDS and after activation of the complement pathway with cobra venom factor support the hypothesis that complement activated PMN play a role in the pathogenesis of ARDS. These data also suggest that prospective leukocyte counts may be a useful predictor with respect to determining which patients will develop this syndrome. / Medicine, Faculty of / Pathology and Laboratory Medicine, Department of / Graduate

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Class of 2012 Abstract / Specific Aims: The objective of this study is to evaluate and compare clinical outcomes and economic impact involved with the use of beractant (B) compared to poractant (P) for the treatment of respiratory distress syndrome (RDS) in premature neonates admitted to a neonatal intensive care unit. Methods: Patients were included if they were less than 35 weeks gestational age at birth, survived at least 48 hours, and admitted to the neonatal intensive care unit and treated with P or B for RDS. The primary outcome of this study is the change in the fraction of inspired oxygen (FiO2) over the first 48 hours after surfactant administration. Secondary outcomes were the change in oxygen saturation, time spent on mechanical ventilation and continuous positive airway pressure (CPAP), complication occurrence and mortality of the neonates. Main Results: There were a total of 40 neonates whose charts were reviewed (n= 13 and n=27 in the P and B groups respectively). The mean gestational age of the neonates were 29.2+/-2.9 and 28.8+/-2.9 weeks in the P and B groups respectively. The FiO2 was found to not be lower between the P and B groups (35.5+/-22.2 and 42.4+/-24.2, respectively; p=0.379), as well as the O2 saturation (94.6+/-4.6 and 92.3+/-6.1; p=0.194). Significance was also not found for the other clinical or economic outcomes assessed in this study. Conclusions: There was not a significant difference between poractant and beractant in FiO2, O2 saturation, or in the other clinical outcomes evaluated in this study.