Bleeding in the tracheobronchial tree in intubated patients on an intensive care unit is a potentially life-threatening incident. The antecedent state of disease and frequent respiratory failure require immediate and effective therapeutic measures to avoid further respiratory and cardiocirculatory depression. We present our bronchoscopic management of endobronchial bleeding. Cardiorespiratory function must be maintained by modification of the mechanical ventilation and drug therapy owing to the patient's condition. Seven consecutive patients with acute endobronchial bleeding were treated with fiberoptic bronchoscopy and instillation of cold epinephrine-saline solution (1:10,000-100,000) during the period of July 1997 to December 1997. Control of bleeding was achieved after 1 to 20 (mean +/- SEM: 5.86 +/- 0.93) bronchoscopic interventions during a period of 0.5 hours to 10 days. One control bronchoscopy was performed additionally in every patient. Cardiocirculatory instability was observed in five patients. Six patients survived; one patient died of uncontrolled bleeding caused by severe pulmonary aspergillosis. Fiberoptic endobronchial epinephrine instillation is an effective therapy for life-threatening hemoptysis in critically ill patients. Widespread use of flexible bronchoscopy makes this procedure immediately applicable in critical situations. Intubated and mechanically ventilated patients with life-threatening hemoptysis especially benefit from this rapidly feasible procedure.
The devetopment of megacolon in adutts is attributed to malformations of the entefic nervous system apart from mechanic, metabolic, endocrinologic, pharmacologic, neurologic, infectious of systemic causes. Hirschsprung's disease is considered to represent the most acknowledged forro of intestinal innervation disorders underlying the formation of megacolon. In order to evaluate this association, morphologic alterations of the enteric nervous system were examined in patients (age: 19 to 67 years) with megacolon. From the resected colonŸ segments conventional serial sections and whole-mount preparations were obtained and submitted to immunohistochemical procedures for Protein Gene Product 9.5 asa neuronal marker aIlowing the 2-dimensional assessment of the architecture of the intramural nervous ptexus tayers. Whereas complete aganglionosis was diagnosed in only 25% of the cases examined, thus resembling classic Hirschsprung's disease, the remaining colonic segments showed other forms of intestinal neuronal malformations: 1. Hypoganglionosis of varying severity, 2. intestinal neuronal dysplasia characterised by submucosal giant ganglia and concomitant hypertrophy of nerve fibers, 3. heterotopic ganglia located ectopically within the longitudinal muscle layer as well as within the lamina propria mucosae. In contrast to conventional histologic sections, whole-mount preparations allowed a more subtle assessment of the morphologic alterations of intramural nervous plexus from the normal to the pathologic area and, therefore, a more precise diagnostic classification of intestinal innervation disorders. Ir could be shown that neurogenic megacolon in adults is not onty caused by agangtionosis but also by non-agangtionic innervation disorders. The findings implicate that in adotescent and adult patients suffering from intestinal motility disorders anda concomitant development of megacolon hypoganglionic conditions and intestinal neuronal dysplasia have to be taken into consideration in regards to the diagnostic and therapeutic approach.
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