C. Kor-Shach. University of Saint Mary.
The aim was to study the socio- demographic characteristics and the influence of culture and beliefs on the pattern of decision-making and health care utilization discount finasteride amex hair loss in men ministry. The study indicated that allopathic health services are many times more available and also more utilized by the community irrespective of its location buy on line finasteride hair loss 1 year after childbirth. The disease morbidity was relatively low in rural area of the Southern Shan State (probably due to healthy environment and less stressful working conditions) and majority of the population that suffered from minor ailments seemed to be successfully taken care of, with available health care facilities, whether it may be allopathic or traditional. The likelihood of conflicts with culture and current healing practices is discussed. Investigation of acute toxicity, anti inflammatory activity& some chemical constituents of Kanzaw [Madhuca lobbii (C. Kanzaw seed oil from Tanintharyi Division of Myanmar has been popularly used as a folk medicine for the treatment of inflammation, rheumatism, tumor and different type of cancers. The reported distribution of this plant species was not found in any other parts of the world. Two seeds oil samples extracted by means of Traditional method and solvent (pet-ether, 60-80ºC) extraction method were used for chemical and pharmacological investigation and yields of oils based on the dried kernals were found to be 39% and 48% respectively. In the present work, the acute toxicity effect of Kanzaw oil obtained from traditional method was assessed on mice and it showed no toxic symptoms and mortality in mice up to an oral maximal permissible dose (60g/kg) of Kanzaw oil. Anti-inflammatory activity of Kanzaw oil was evaluated on carrageenin-induced paw edema in rats and it was found that the reduction of paw edema with an oral dose (45g/kg) of Kanzaw oil was comparable to that of standard drug aspirin (300mg/kg). The observation of these two compounds (Lupeol and Campesterol) in the seed oil of Kanzaw [Madhuca lobbii (C. The in vitro model also employed a shorter duration of incubation period of two days with daily renewal of the bathing solution which is suitable for the screening of such indigenous herbal agents. A concentration of 40 to 80mg/ml pineapple significantly killed the test worm during the experimental period of two days. As a prerequisite test for its clinical application and in vivo model using pigs had been done and found satisfactory. The anthelmintic action of fresh pineapple consumed was due to its bromelain content. The mechanism of action of bromelain is due to its proteolytic digestion of the worm’s cuticle. At its edible form and amount, the pineapple possesses sufficient anthelmintic activity even though it was partially destroyed on its passage to the stomach. The required anthelmintic effect was suggestive to be achieved by consuming a quarter to the whole fruit of medium size depending on the age of the subjects. Investigation of anthelmintic and bioactivities and some organic constituents of Balanites aegyptiaca Linn. The investigation of anthelmintic activity of two isolated compounds β-sitosterol and diosgenin was also carried out. Therefore, it could be inferred that β-sitosterol and diosgenin have anthelmintic potency and diosgenin possessed slightly better activity. Investigation of antibacterial activity of three traditional medicine formulations. Three traditional medicine formulations which are widely used by local people were investigated for antibacterial activity using 14 species of bacteria. The bacteria include one specie each of Escherichia coli, Klebsiella pneumoniae, Streptococcus pyogenes and Vibrio cholerae; two species each of Proteus, Salmonella and Staphylococcus and 4 species of Shigellae. The formulations were Ah-bein-nyin, Heleikda-sonna and Nandwin-nganzay which contain herbs and chemicals and have been used as antipyretic or in the treatment of urinary disorders, gastrointestinal disorders and cardiovascular disorders. Fifty percent alcoholic extract of these drugs were found to possess some antibacterial activity on certain bacteria. Moreover, extracts from 7 plants namely, Saxifraga ligulata (Wall) (Nat-hsay-gamone), Capparis sepiaria (Sugaut-net), Holoptelea integrifolia (Pyauk-seik), Zizyphus oenoplia (Baung-bet), Hygrophila spinosa (Su-padaung), Mitragyna parviflora (Htain-they) and unidentified sp. It was observed that Saxifraga ligulata, Capparis sepiaria and Zizyphus oenoplia showed antibacterial activity on some bacteria. Investigation of antimicrobial activities of some organic constituents from Cyperus scariasus R. The aim of this study is to screen in vitro and in vivo antimicrobial activity and some bioactive phytoconstituents from activity guided plant extracts of Cyperus scariosus R. These have been studied on preliminarily in vitro screening of antibacterial activity by agar disc diffusion method. Therefore, among four plants tested, the two antibacterial activities guided plants C. In vitro screening of antibacterial activity by agar well diffusion method, all of the extracts of C. Exhibited the most significant antibacterial activity when compred with activities of extracts of both plants. Activity guided extracts of both plants were separated by column chromatographic method. Investigation of antimicrobial, antidiarrhoeal & antioxidant activities of Sabalin (Cymbopogon flexsuosus) Stapf. This versatile herb will grow in almost any tropical or subtropical climate as long as it gets adequate water and nutrition. In this research, the antimicrobial, antidiarrhoeal and antioxidant activities were investigated. According to the phytochemical investigation, chemical constituent’s flavonoids, alkaloids, phenolic compound, tannins, carbohydrate, glycoside, steroids and reducing sugar) were found in the leaves of Sabalin. Then the citral was isolated from essential oil (70% yields) by using column chromatographic technique using silica gel G. Investigation of bioactive phytoconstituents and the biological activities of some Myanmar traditional medicinal plants. These are the whole plants of Phyllanthus niruri (Taung-zee-phyu), the whole plants of Elephantopus scaber (Taw-mon-lar or Sin-chay) leaves of Eclipta alba (Kyeik-hman) and flowers of Butea monosperma (Pauk-pwint). Fifteen compounds were isolated and identified from the whole plants of Phyllanthus niruri. Among these one was a new flavone sulfonic acid named niruri flavone (8) together with hypophyllanthin (1). Ten compounds were isolated and identified from the whole plants of Elephantopus scaber. Among these two new sesquiterpene lactones named 17, 19-dihydrodeoxyelephantopin (18). Seventeen compounds were isolated and identified from the flowers of Butea monosperma. In the biological activities, primary) screening was carried out for the antitumour activity of 21 compounds (compound 1-9 from P. From these tests, as we are getting not only the cellular toxicity but also the selectivity, results will allow us to evaluate the potential medical value of the metabolites. Antiviral activity of four plant extracts and the pure compounds wedelolactone (44) (isolated from E. The antioxident activity of fourteen pure compounds namely isoquercetin (2), gallic acid (3), brevifolin carboxylic acid (4), methyl brevifolin carboxylate (5), niruri flavone (8) and quercetin-3-0-β-D-glucopyranosyl-(1→4)-α- rhamnopyranoside (9) from P.
Examples of these types of toxins include endotoxins buy finasteride 5 mg on line hair loss xeloda, exotoxins order finasteride 1mg fast delivery hair loss in men jeans, toxic amines, toxic derivatives of bile, and various carcinogenic substances. Gut-derived microbial toxins have been implicated in a wide variety of diseases, including liver diseases, Crohn’s disease, ulcerative colitis, thyroid disease, psoriasis, lupus erythematosus, pancreatitis, allergies, asthma, and immune disorders. In addition to toxic substances being produced by microorganisms, antibodies formed against microbial antigens can cross-react with the body’s own tissues, thereby causing autoimmune diseases. Diseases that have been linked to cross-reacting antibodies include rheumatoid arthritis, myasthenia gravis, diabetes, and autoimmune thyroiditis. To reduce the absorption of toxic substances, we recommended a diet rich in ﬁber, particularly soluble ﬁber, such as that found in vegetables, guar gum, pectin, and oat bran. Fiber has an ability to bind to toxins within the gut and promote their excretion. The immune system as well as the liver is responsible for dealing with the toxic substances that are absorbed from the gut. Breakdown Products of Protein Metabolism The kidneys are largely responsible for the elimination of toxic waste products of protein breakdown (ammonia, urea, etc. You can support this important function by drinking adequate amounts of water and avoiding excessive protein intake. Diagnosis of Toxicity In addition to directly measuring toxin levels in the blood or urine, or by biopsy of fat, there are a number of special laboratory techniques useful in assessing how well we detoxify the chemicals we are exposed to. Clearance tests measure the levels of caffeine, acetaminophen, benzoic acid, and other compounds after ingestion of a speciﬁed amount. Other tests for liver function (serum bilirubin and liver enzymes) are also important but are less sensitive. Genetic testing is a newer option that can determine which detoxiﬁcation enzymes are not optimal. Perhaps the best way to help determine if your liver is functioning up to par is to look over the following list. If any factor applies to you, we recommend following the guidelines for improving liver function given below: • More than 20 pounds overweight • Diabetes • Presence of gallstones • History of heavy alcohol use • Psoriasis • Natural and synthetic steroid hormone use Anabolic steroids Estrogens Oral contraceptives • High exposure to certain chemicals or drugs: Cleaning solvents Pesticides Antibiotics Diuretics Nonsteroidal anti-inflammatory drugs Thyroid hormone • History of viral hepatitis Naturopathic physicians use a number of special laboratory techniques to determine the presence of microbial compounds, including tests for the presence of abnormal microbial concentrations and disease-causing organisms (stool culture); microbial by-products (urinary indican test); and endotoxins (erythrocyte sedimentation rate is a rough estimator). The determination of the presence of high levels of breakdown products of protein metabolism and kidney function involves both blood and urine measurement of these compounds. How the Body’s Detoxification System Works The body eliminates toxins either by directly neutralizing them or by excreting them in the urine or feces (and to a lesser degree through the hair, lungs, and skin). Toxins that the body is unable to eliminate build up in the tissues, typically in our fat stores. The Liver The liver is a complex organ that plays a key role in most metabolic processes, especially detoxiﬁcation. The liver is constantly bombarded with toxic chemicals, both those produced internally and those coming from the environment. The metabolic processes that make our bodies run normally produce a wide range of toxins for which the liver has evolved efﬁcient neutralizing mechanisms. However, the level and type of internally produced toxins increase greatly when metabolic processes go awry, typically as a result of nutritional deficiencies. Yet even those eating unprocessed organic foods need an effective detoxiﬁcation system, because even organically grown foods contain naturally occurring toxic constituents. It ﬁlters the blood to remove large toxins, synthesizes and secretes bile full of cholesterol and other fat-soluble toxins, and enzymatically disassembles unwanted chemicals. The liver also plays a critical role in the excretion of metal toxins such as mercury. The Liver’s Detoxification Pathways Proper functioning of the liver’s detoxiﬁcation systems is especially important for the prevention of cancer. Up to 90% of all cancers are thought to be due to the effects of environmental carcinogens, such as those in cigarette smoke, food, water, and air, combined with deﬁciencies of the nutrients the body needs for proper functioning of the detoxiﬁcation and immune systems. Our exposure to environmental carcinogens varies widely, as does the efﬁciency of our detoxiﬁcation enzymes. High levels of exposure to carcinogens coupled with sluggish detoxiﬁcation enzymes signiﬁcantly increase our susceptibility to cancer. The link between our detoxiﬁcation system’s effectiveness and our susceptibility to environmental toxins, such as carcinogens, is exempliﬁed in a study of chemical plant workers in Turin, Italy, who had an unusually high rate of bladder cancer. When the liver detoxiﬁcation enzyme activity of all the workers was tested, those with the poorest detoxiﬁcation system were the ones who developed bladder cancer. Fortunately, the detoxiﬁcation efﬁciency of the liver can be improved with dietary measures, special nutrients, and herbs. Ultimately, your best protection from cancer is to avoid carcinogens and make sure your detoxification system is working well in order to eliminate those you can’t avoid. Filtration of toxins is absolutely critical for the blood that is coming from the intestines, because it is loaded with bacteria, endotoxins (toxins released when bacteria die and are broken down), antigen-antibody complexes (large molecules produced when the immune system latches on to an invader to neutralize it), and various other toxic substances. When working properly, the liver clear 99% of the bacteria and other toxins from the blood before it is allowed to reenter the general circulation. The Bile The liver’s second detoxiﬁcation process involves the synthesis and secretion of bile. Each day the liver manufactures approximately one quart of bile, which serves as a carrier in which many toxic substances are effectively eliminated from the body. Sent to the intestines, the bile and its toxic load are absorbed by ﬁber and excreted. However, a diet low in ﬁber means these toxins are not bound in the feces very well and are reabsorbed. Even worse, bacteria in the intestine often modify these toxins so that they become even more damaging. The liver normally clears through the bile about 1% of the body load of mercury every day. However, 99% of what is excreted in the bile is often reabsorbed, due to insufﬁcient dietary ﬁber intake. Besides eliminating unwanted toxins, the bile emulsiﬁes fats and fat- soluble vitamins, improving their absorption in the intestine. Phase I Detoxification The liver’s third role in detoxiﬁcation involves a two-step enzymatic process for the neutralization of unwanted chemical compounds. These include not only drugs, pesticides, and toxins from the gut but also normal body chemicals such as hormones and inﬂammatory chemicals (such as histamine) that would become toxic if allowed to build up. Phase I detoxiﬁcation of most chemical toxins involves a group of enzymes that collectively have been named cytochrome P450. Each enzyme works best in detoxifying certain types of chemicals, but with considerable overlap in activity among the enzymes. In other words, some may metabolize the same chemicals, but with differing levels of efficiency. The activity of the various cytochrome P450 enzymes varies signiﬁcantly from one individual to another based on genetics, the individual’s level of exposure to chemical toxins, and nutritional status. Since the activity of cytochrome P450 varies so much, so does an individual’s risk for various diseases.
The maintenance phase vascular necrosis and granulomatous changes in the of therapy will include a less toxic cytotoxic agent larger vessels of involved tissues of the respiratory and low dose corticosteroid therapy buy discount finasteride 1mg hair loss in men models. Often insidious at onset discount finasteride 1mg without a prescription hair loss yeast infection, disease activity is seg- That changed dramatically after uncontrolled studies mental and can occur at the bifurcation of vessels in showed remarkable improvement in survival with use any organ. Later uncontrolled trials the entire vessel wall, possibly resulting in aneurysms showed even better outcomes with the combination of or vascular occlusion. Erythematous mide (2 mg kg−1 daily) have been used, and there was and painful nodules in the extremities are character- anecdotal evidence that oral therapy is more effective istic, but livedo reticularis, purpura, and gangrene . Finally, myocardial infarction may Patients with severe renal dysfunction also appear to be recognized, usually after the patient succumbs. As have better outcomes when several courses of thera- with most idiopathic vasculitides, there is no diagnos- peutic plasma exchange are used . Possible laboratory findings patient will be treated with cyclophosphamide for 6 include elevated erythrocyte sedimentation rate, ele- months with the dose adjusted to prevent neutropenia vated serum immunoglobulin concentrations, and, not (a particular problem in patients with renal failure). Those patients who require prolonged ther- A systemic illness characterized by the presence of either a apy to retain remission may benefit from a switch to biopsy showing small and mid-size artery necrotising vasculitis a less toxic agent, such as azothiaprine. Therapeutic plasma exchange has not shown to nodules, other vasculitic lesions) be effective when added to steroids alone or steroids › Myalgia or muscle tenderness plus cyclophosphamide in at least two controlled trials › Systemic hypertension, relative to childhood normative data [32, 33], although there was a trend for improved sur- › Mononeuropathy or polyneuropathy vival in both studies, and the sample size may have › Abnormal urine analysis and/or impaired renal functionb resulted in a type 2 error. Therefore, in a critically ill patient, we still would consider therapeutic plasma › Testicular pain or tenderness exchange at least in the acute phase of the illness. Several reports have shown a positive outcome of therapy with tumor necrosis factor-alpha a Should include conventional angiography if magnetic resonance blockade in patients with chronic disease that failed angiography is negative b to remit with steroid and cytotoxic therapy, includ- Glomerular filtration rate of less than 50% normal for age ing one pediatric patient . Five-year survival at any level [39, 51], and it may be limited to only the untreated is only 13%, but treatment has improved this descending thoracic or abdominal aorta in a minority rate to 80% [24, 26]. In the later stages, the pulmonary artery one half of patients, and addition of a cytoxic agent can also be affected. Therefore, mononuclear infiltrates in all layers, with more general recommendations are to use corticosteroid involved sections containing granulomas with giant therapy initially only for patients with mild disease cells and central necrosis . For lead to narrowing of the branch orifices (accounting children, we recommend 2mg kg−1 day−1 of steroids for the past name of pulseless disease). Treatment of moderately severe disease with tutional symptoms and body aches for weeks to months solid organ involvement should also include either before more significant symptoms occur. Frequently, oral or pulse cyclophosphamide (the latter probably these will include visual disturbance (Takayasu retin- being less toxic but also less convenient), using stand- opathy), focal neurologic deficits, claudication, and ard immunosuppressant dosing (oral 2mg−1 kg−1 day−1 intestinal angina. Of note, with a maximum of 100mg daily or 500–1,000mg blood pressure readings are often lower in the upper m−2 intravenously every month) , titrating dosing extremities compared with the lower extremities to response and keeping absolute neutrophil counts (termed reverse coarctation) because of occlusion of Chapter 17 Vasculitis 243 4. Patients therapies for proliferative lupus nephritis: mycophenolate who survive the first few years could only do so with mofetil, azathioprine and intravenous cyclophosphamide. Dillon M, Ozen S (2006) A new international classification ity of complications at diagnosis, age at onset, and of childhood vasculitis. There is no consensus for following synchronization of plasmapheresis with sub- sequent pulse cyclophosphamide. Surgical intervention or stent placement is nec- Lupus Plasmapheresis Study Group: rationale and updated essary in patients with renovascular hypertension or interim report. Haematopoietic stem cell gene therapy to treat autoimmune Medicine (Baltimore) 52:535–61 disease. Chin Med J (Engl) cell antibodies mediate enhanced leukocyte adhesion 115:705–9 to cytokine-activated endothelial cells through a novel 39. Circulation of good-prognosis polyarteritis nodosa and Churg-Strauss 90:1855–60 syndrome: comparison of steroids and oral or pulse cyclo- 41. Glicklich D, Acharya A (1998) Mycophenolate mofetil Care Med 173:180–187 therapy for lupus nephritis refractory to intravenous cyclo- 44. Am J Kidney Dis 32:318–22 granulomatosis: long-term follow-up of patients treated 29. Arthritis Rheum 42:2666–2673 phosphamide in the treatment of generalized Wegener’s 46. Am J riority of steroids plus plasma exchange to steroids alone Med 67:941–7 in the treatment of polyarteritis nodosa and Churg-Strauss 48. Hellmich B, Lamprecht P, Gross W (2006) Advances in the Heart J 93:94–103 therapy of Wegener’s granulomatosis. Ann Intern vasculitis and renal involvement: A prospective, randomized Med 116:488–98 study. Arthritis Rheum 58:308–17 yarteritis: presence of anti-endothelial cell antibodies and 55. Clin Lupus Erytmatosus, Anaphylactoid Purpura and Vasculitis Exp Immunol 85:14–9 Syndromes. Arthritis Rheum 54:2970–82 pilot trial comparing cyclosporine and azathioprine for 75. Niaudet P, Habib R (1998) Methylprednisolone pulse ther- Ann Intern Med 75:165–71 apy in the treatment of severe forms of Schonlein- Henoch 77. Pediatr Nephrol 12:238–43 renal prognosis of Henoch-Schönlein Purpura in an unse- 61. The Wegener’s Granulomatosis Etanercept Trial Research therapy on rapidly progressive type of Henoch-Schonlein G (2005) Etanercept plus standard therapy for Wegener’s nephritis. Takayasu’s arteritis: correlations of their titers and isotype Scand J Rheumatol 33:423–7 distributions with disease activity. Robbins S, Cotran R, Kumar V, Inflammation - The with special reference to renal involvement. Two months posttransplant, graft dysfunction developed and was found to be caused by obstruction of the transplant ure- more definitive intervention, the ureteral stent was ter at the level of the bladder anastomosis. A ureteral removed during the cystoscopy, and the patient was stent was placed, graft function stabilized (serum cre- monitored closely for recurrence of graft dysfunction, atinine 0. With this support, the patient stabilized and general categorization according to transplant status eventually recovered, including his graft function, and introduced above. Under may affect the patient’s transplant candidacy signifi- all of these circumstances, renal dysfunction can occur, cantly, either by presenting a potential contraindication typically requiring complex management tailored to the to the desired nonrenal transplantation or by establishing specific needs of the individual patient. Some patients with renal dysfunction prior to non- highly multidisciplinary fashion, usually codirected by renal organ transplantation may be expected to recover a combination of intensivists, pediatric subspecialists, kidney function after nonrenal transplantation, likely and transplant surgeons and their teams. Such decisions young recipients of a preemptive transplant from a and plans are examples for the aforementioned complex living adult donor, this complication also appears to multidisciplinary, individualized, and communicative be driven by dramatic decreases in serum osmolality management approach for these patients and require associated with rapid clearance of uremic toxins from thorough consideration of medical prognosis, quality of the circulation when renal graft function is excellent life implications, and other, e. Even in older and bigger recipients, the frequency and volume of urine output measurements and replace- 18. Recovery of tubular abilities to concentrate the urine and reabsorb sodium usually takes several days, over which urine output replacement is gradu- 18. Of critical importance is the realization that the hourly urine output may actu- Table 18. Generally, circumstances, particularly when an adult allograft immunosuppressive therapy is in constant evolution is placed into an infant. This creates a tremendous to achieve the best possible antirejection prophylaxis Table 18. In this context, it has become Hypertension frequently occurs or worsens in the quite clear that immunosuppressive protocols cannot immediate posttransplant setting for several reasons, be administered in a one size fits all fashion: First-time including liberal fluid management (see above) and Caucasian recipients of a living donor kidney who have treatment with high doses of corticosteroids.
Pa- tients in the intervention group had more ventilator-free days buy discount finasteride on-line hair loss after gastric sleeve, with a mean difference after correcting for baseline variables of 4 purchase finasteride with american express hair loss in men what is the function. Another approach to manage sedation in order to improve overall outcomes of me- chanically ventilated patients is the establishment of patient-targeted sedation protocols. Several trials have evaluated the effect of using these protocols/algorithms, some of which are nurse driven [54–57], showing a bene¿t in weaning outcomes. Therefore, we include a few words about the process of weaning in these special groups. These ¿ndings were con¿rmed in a study conducted by De Jonghe and colleagues  in a prospective cohort of 95 patients. Nevertheless, controversy has been raised around the threshold of mental status actually required for successful weaning. The absence of adequate mental status actually prolongs mechanical ventilation among this population. Several studies have assessed whether a systematic approach to weaning in these patients is better than using physician judgment alone. In the intervention group, a systematic approach to weaning and extubation was used, whereas in the control group, physician’s judgment only was consid- ered. Other features that must be considered when weaning these patients are the role of performing an early tracheotomy, and carefully assessing adequate cough and secretion amount. Several studies have demonstrated the importance of evaluating cough strength, amount of secretions and mental status to successfully wean a patient [30, 64]. In some of these patients, weaning from mechanical ventilation is particularly dif¿cult . Do the risk factors for extubation failure differ from those in a pooled mixed population? Is weaning different in patients with chronic hypercapnia compared with normocapnic patients? Should the same oxygenation threshold be used to assess readiness to start weaning among patients with chronic hypoxia? Several studies that try to solve these issues have been reviewed here; nevertheless, further evidence is necessary to answer many of these questions, and studies performed solely involving these subgroup of pa- tients would probably be useful for this purpose. Esteban et al (2002) Characteristics and outcomes in adult patients receiving me- chanical ventilation: a 28-day international study. Esteban et al (1994) Modes of mechanical ventilation and weaning: a national sur- vey of Spanish hospitals; the Spanish Lung Failure Collaborative Group. Brochard L, Rauss A, Benito S et al (1994) Comparison of three methods of gradual withdrawal from ventilator support during weaning from mechanical ventilation. Saura P, Blanch L, Mestre J et al (1996) Clinical consequences of the implementa- tion of a weaning protocol. Esteban A, Alía I, Gordo F et al (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. Ezingeard E, Diconne E, Guyomarc’h S et al (2006) Weaning from mechanical ventilation with pressure support in patients failing a T-tube trial of spontaneous breathing. Task Force by the American College of Chest Physicians; American Association for Respiratory Care and the American College of Critical Care Medicine (2001). Salam A, Tilluckdharry L, Amoateng-Adjepong Y,et al (2004) Neurologic status, cough, secretions and extubation outcomes. Nava S, Ambrosino N, Clini E et al (1998) Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmo- nary disease. Girault C, Daudenthun I, Chevron V et al (1999) Noninvasive ventilation as a sys- tematic extubation and weaning technique in acute-on-chronic respiratory failure. Ferrer M, Esquinas A, Arancibia F et al (2003) Noninvasive ventilation during persistent weaning failure. Research Group in Mechanical Ventilation Weaning (2008) Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized controlled trial. Nava S, Gregoretti C, Fanfulla F et al (2005) Noninvasive ventilation to prevent re- spiratory failure after extubation in high-risk patients. Ferrer M, Sellarés J, Valencia M et al (2009) Non-invasive ventilation after extuba- tion in hypercapnic patients with chronic respiratory disorders: randomised con- trolled trial. Esteban care (Awakening and Breathing Controlled trial): a randomized controlled trial. Strøm T, Martinussen T, Toft P (2008) A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial. De Jonghe B, Bastuji-Garin S, Fangio P et al (2005) Sedation algorithm in critically ill patients without acute brain injury. Arias-Rivera S, Sánchez-Sánchez MdelM, Santos-Díaz R et al (2008) Effect of a nursing-implemented sedation protocol on weaning outcome. Van den Berghe G, Schoonheydt K, Becx P et al (2005) Insulin therapy protects the central and peripheral nervous system of intensive care patients. Khamiees M, Raju P, DeGirolamo A et al (2001) Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. The most common trigger is infection of the lower respiratory tract as pneumonia, followed by sepsis and bronchiolitis . The dynamic interaction between inÀammation, coagulation, restoration of water transport and cell function need to be rebalanced and surfactant production restarted . Clearance of pulmonary oedema Àuid and transcapillary water transport is crucial, and apoptosis should be rebalanced, providing the clearance of inÀammatory cells . Infants and small children present peculiar features compared with larger children and adults: smaller airways with increased resistance, less rigid chest walls and lower functional residual capacity leading to a higher risk of respiratory failure and more rapid development of sustained hypoxia. Personal skill in intubating paediatric airways and use of appropriately sized equipment and endotracheal tubes are important factors. Cuffed endotracheal tubes can be used safely in infants and young children, and may even be optimal to ensure adequate positive end-expiratory pressure delivery in the face of low pulmonary compliance . Although mechanical ventilatory support is life- saving, low lung compliance and high ventilatory pressures can lead to ventilator-induced lung injury caused by alveolar overdistention (volutrauma), repeated alveolar collapse and reexpansion (atelectrauma) and oxygen toxicity . Barotrauma is characterised by the fact 7 Ventilatory Strategies in Acute Lung Injury 79 that mechanical forces (high-pressure inÀation) during arti¿cial inÀation cause pressure- related ‘‘shear forces’’ on inhomogeneous (partly aerated and partly consolidated) lung tissues . On microscopy, lungs show disruption of the alveolar capillary sheets with air leaks. Atelectrauma is de¿ned as repetitive opening and closing of alveolar units dur- ing mechanical ventilation, with alveolar–capillary stress failure. Volutrauma comes when large tidal volumes (Vt) cause disruption of alveolar–capillary sheets, pulmonary oedema, increased alveolar–capillary permeability, alveolar–capillary stress failure and structural abnormalities on electron microscopy [15, 16]. Additionally, mechani- cal stretch activates many signal transduction pathways (e. However, the exact relationship between pro- and anti-inÀammatory mediators and their balance are still under debate: they might differ in children and may occur in healthy as well as in preinjured lungs (e. Finally, these proinÀammatory mediators may spill over from the pulmonary compartment to the systemic circulation and trigger a generalised inÀam- matory response in major organs, leading to multiorgan failure and death . Furthermore, overdistention should be prevented and high-pressure ventilation avoided. Many clinical case series have shown that oxygenation improved in children when placed in the prone position [36–46].