We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.

Saprophytic infestation with Aspergillus was observed in pathologic specimens of primary squamous cell lung carcinoma. In one case, the fungus grew in cystic scarred parenchyma and bronchi distal to an obstructing carcinoma of a segment bronchus. In the other, fungi colonized the inner surface of a peripheral cavitary carcinoma. Neither patient had roentgenographic evidence of aspergilloma and neither experienced severe pulmonary hemorrhage or other complications attributable to the presence of fungus. Although both specimens showed colonizing growth within the abnormal air spaces, in neither had the colonies detached to form a separate intracavitary fungus ball. These patients, and eight patients with similar lesions reported in the literature, demonstrate that Aspergillus colonization of a lung neoplasm frequently lacks one or both of the features characteristic of post-inflammatory intracavitary aspergilloma, a loose fungus ball and antifungal serum antibodies. No patient, to date, has developed massive hemorrhage as a complication of this lesion.

Conventional ventilatory support of patients with the adult respiratory distress syndrome (ARDS) consists of volume-cycled ventilation with applied positive end-expiratory pressure (PEEP). Unfortunately, recent evidence suggests that this strategy, as currently implemented, may perpetuate lung damage by overinflating and injuring distensible alveolar tissues. An alternative strategy--termed inverse ratio ventilation (IRV)--extends the inspiratory time, and, in concept, maintains or improves gas exchange at lower levels of PEEP and peak distending pressures. There are two methods to administer IRV: (1) volume-cycled ventilation with an end-inspiratory pause, or with a slow or decelerating inspiratory flow rate; or (2) pressure-controlled ventilation applied with a long inspiratory time. There are several real or theoretical problems common to both forms of IRV: excessive gas-trapping; adverse hemodynamic effects; and the need for sedation in most patients. Although there are many anecdotal reports of IRV, there are no controlled studies that compare outcome in ARDS patients treated with IRV as opposed to conventional ventilation. Nonetheless, clinicians are using IRV with increasing frequency. In the absence of well-designed clinical trials, we present interim guidelines for a ventilatory strategy in patients with ARDS based on the literature and our own clinical experience.

The effect of two different circuit leaks on the measurement of maximal static inspiratory and expiratory pressures at the mouth (Pimax, Pemax) was assessed in 70 patients with respiratory disease. Patients were divided into three groups with similar anthropometric and spirometric characteristics. The first group (30 patients) had their Pmax measured with a leak of 2.0 mm internal diameter (ID) and 37 mm length (as proposed by T. Ringqvist) and repeated with a second leak of 1.0 mm ID and 15 mm length (as recommended by J. L. Clausen). The two measurements were done in random order. Measurements for the other two groups (20 patients each) were taken with one or another, the two leaks randomly alternated with no leak. Pimax measurements obtained with Ringqvist's leak were 17 percent (p less than 0.005) lower than those with Clausen's leak and 22 percent (p less than 0.005) lower than those with no leak. Pemax measurements performed with Ringqvist's leak in place were 11 percent (p less than 0.005) lower than those with Clausen's leak and 11 percent (p less than 0.005) lower than those obtained with no leak. The comparison between Clausen's leak and no leak showed no statistically significant difference. We conclude that whenever the effect of pressure generated in the mouth is to be avoided in the measurement of respiratory Pmax, a leak of the size proposed by Ringqvist is to be preferred.

Late recurrent Candida endocarditis (LRCE) developed on a prosthetic mitral valve 22 months after treatment for primary native mitral valve endocarditis. The LRCE was difficult to diagnose; results of two dimensional echocardiography and repeated blood cultures were negative. Only transesophageal echocardiography revealed a vegetation and only lysis centrifugation blood cultures demonstrated candidemia. Postmortem examination revealed a large Candida vegetation on the prosthetic valve and Candida in the mitral valve ring. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that LRCE, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.

A 50-year-old man with pulmonary fibrosis and COPD presented with worsening cough, dyspnea, chest pain, and hypoxemia of no readily apparent etiology, approximately four weeks after insertion of a transtracheal oxygen therapy catheter. Despite vigorous bronchial hygiene therapy, the patient died. Autopsy revealed obstruction of the trachea by a large mucous ball. We point out the nonspecificity of physical and radiologic findings associated with this condition and suggest that serial flow-volume loop analysis or earlier use of fiberoptic bronchoscopy might have been of assistance in premortem diagnosis of the mucous plug.

The adverse effects of prolonged immobility are due primarily to gravitational effects on blood flow and ventilation, impairment of the normal mucociliary escalator and possibly an increase in extravascular lung water. However, CLRT theoretically should reverse these abnormalities. The sequence of events that culminate in LRTI or pneumonia is unclear; however, low tidal volumes, increased extravascular lung water and the accumulation of bronchopulmonary secretions may lead to atelectasis, a well-known precursor of pneumonia. Three prospective, randomized studies evaluating patients with acute head trauma, orthopedic injuries requiring traction and blunt chest trauma all showed a decreased incidence of LRTI or pneumonia with CLRT compared with those treated in a conventional bed and turned every 2 h by the nursing staff. In general, the methodology was sound with early randomization, use of precise criteria to define LRTI and pneumonia and appropriate observation. The fourth study performed in a medical ICU with a heterogeneous group of patients did not show a difference in incidence of nosocomial pneumonia between treatment in CLRT and a conventional bed, but did show a decreased length of ICU stay for patients with pneumonia treated with CLRT. It appears that if CLRT is to be effective, it needs to be instituted early in the patient's illness. The length of time that CLRT should be utilized is unknown; however, intuitively, as long as the patient is at risk, the therapy should be continued. It is also unclear whether CLRT should be started at full rotation immediately or begun at lesser degrees of rotation and advanced serially over several hours. Another unknown is the minimum time that CLRT should be administered per day. In the studies discussed, most patients were rotated for 10 to 16 h/day. The minimum degree of rotation necessary for an effect is also unknown; in the studies cited, rotations from 40 degrees to 62 degrees in each direction were used. Based on the current data, the early use of CLRT in comatose or otherwise immobile patients decreases the incidence of LRTI including pneumonia over the first 7 to 14 days of ICU care. The prevention of pneumonia and more rapid transfer from the ICU should offset the additional expense of a specialized bed. The data suggest that a multicenter study with accrual of a large number of patients to evaluate this form of therapy in a prospective, randomized study is necessary. If the hypothesis that CLRT decreases the incidence of nosocomial pneumonia in the ICU is proven, the impact on critical care in the 90s would be substantial.

The most common pulmonary complication of EVS is pleural effusion. The most clinically significant pulmonary complication of EVS is delayed perforation with formation of esophagopleural or esophagobronchial fistula. Pneumonia, empyema, pulmonary infarction, and atelectasis can also occur. Endoscopic variceal sclerotherapy probably does not cause ARDS, but that issue remains unsettled. Transient relative pulmonary hypertension during EVS is probably of no clinical significance, but caution is urged when sclerosing varices in a patient with borderline right heart function.