Bronchial asthma has now been recognized as an inflammatory disease of the airway. Anti-inflammatory therapy with inhaled corticosteroid is now prevalent worldwide. This review covers the recent advances in our knowledge about the pathogenesis of airway inflammation and the guidline for the management of asthma in Japan.

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Apoptosis is an unique morphologic pattern of cell death characterized by chromatin condensation and nuclear fragmentation. This programed cell death is induced by a wide variety of agents including tumor necrosis factor-α (TNF-α), Fas/Apo-1 and cytokines. However, the molecular mechanisms of the apoptotic signaling have not yet be defined. The sphingomyelin (SM) cycle, with regulated conversion of SM to ceramide by sphingomyelinase, has been extensively studied as a key pathway to induce apoptosis. On the other hand, PI 3 kinase is considered to exert a preventive action on apoptosis. We will describe the involvement of membrane lipid signaling, especially the phospholipase system in apoptosis.

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Although calcium ions play a critical role in myocardial contractile performance and impulse formation, retrospective and prospective studies in the cardiac arrest setting have not demonstrated benefit from the use of calcium. In addtion, there is a considerable theoretical reason to believe that heigh levels induced by calcium administration may be detrimental. However, there have been few studies that investigated the variations of the levels of calcium during cardiac arrest. We recently demonstrated that ionized hypocalcemia occurs during out-of-hospital cardiac arrest and cardiopulmonary resuscitation (CPR) . The main mechanism of ionized hypocalcemia during CPR may be intracellular influx of ionized calcium due to ischemia and reperfusion. Complexing by bicarbonate is another mechanism. Although ionized calcium levels decrease during resuscitation from cardiac arrest, the mechanisms of ionized hypocalcemia and the detrimental effects of calcium administration suggest that calcium should not be employed during cardiac arrest and CPR except special situations, such as calcium channel blocker toxicity and hyperkalemia.

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Transesophageal echography (TEE) has been widely applied as a routine monitor in operating rooms. We describe how TEE has been used in the management of critically ill patients. TEE is useful for the diagnosis of right atrial thrombus, dependent lung disease and pleural effusion. This monitor can be applied to evaluate how cardiac massage work during resuscitation. It is useful for the insertion of catheter including intraaortic balloon.

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Systemic sympathetic nerve activity increases during occlusion of coronary artery in patients with acute myocardial infarction. NA is released from sympathetic nerve endings by exocytotic release and non-exocytotic release. Exocytotic release is inhibited by stimulating presynaptic α₂-adrenoceptors and is enhanced by stimulating presynaptic β-adrenoceptors. Cardiac sympathetic nerve activity increases and ventricular fibrillation threshold decreases during ischemia via the stimulation of β-adrenoceptors. Stimulation of β-adrenoceptors by dobutamine is effective in the treatment of stunning. Stimulation of α_1b-adrenoceptors by NA plays an important role in the mechanism of ischemic preconditioning.

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Lung injury may result in the development of acute respiratory distress syndrome (ARDS) . The pathogenetic mechanism of ARDS was investigated by measuring changes in chemical mediators in the alveoli and plasma of patients with lung injury. Bronchoalveolar lavage fluid (BALF) was collected for 3 days and blood for 5 days, and polymorphonuclear leukocyte (PMN) elastase, endo-thelin, interleukin (IL) -2, IL-8, and C-reaction protein (CRP) were measured in both BALF and plasma. In addition, arterial blood gases, and liver and kidney functions were measured. The endothelin level in plasma increased immediately after an episode of lung injury, and decreased after 6 hours. The values of PMN elastase in plasma and IL-8 in plasma and BALF were highest on the 2 nd day after lung injury, while those of PMN elastase and IL-2 in BALF were highest on the 3 rd day. CRP in plasma increased to a maximum on the 5 th day. The values of PMN elastase, IL-2 and IL-8 in BALF were several orders of magnitude higher than those in plasma. These changes suggested that endothelin was released immediately into the blood after lung injury, inducing the migration of white blood cells to the lung, while chemical mediators such as IL-8 and PMN elastase were released more slowly into the lung, resulting in prolonged inflammation in the lung. Therefore, inhalation of a protease inhibitor may be an effective therapy for ARDS due to lung injury.

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The aim of this study is to assess the difficulty of bag and mask ventilation for inexpert. Thirteen healthy adult patients who was scheduled for oral surgery was par-ticipated for this study. During anesthesia induction till endotracheal intubation, inhalation anesthesia with muscle relaxant was performed under semi-closed anesthetic circle. Then, at first, dental anesthesiologist as expert performed manual controlled ventilation with bag and mask for five minutes, and next five minutes, we suddenly requested that bag and mask ventilation to ambient dental surgeon as inexpert in the operating room. SPO₂ was observed during ventilation.
All thirteen expert does not decrease the patients' SPO₂. But, five of thirteen inexpert were suspended to continue the ventilation due to severe reduction of patients' SPO₂. For other inexpert, SPO₂ decreased gradually due to inappropriate airway securing and mask fitting. The inexperts who was expected to continue the safely ventilation was very few.
Inexperts who participated in this research was working in operating room and looking mask ventilation frequently during anesthesia. Therefore, appropriate ventilation was not expected for inexpert who has not seen the mask ventilation. Furthermore, real resuscitation must be more difficult by various factor. In conclusion, it is difficult for inexpert to perform the appropriate mask ventilation, and it need something to solve.

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Music therapy with saxophone and piano playing associated with up-and-down rhythmic movement on the trampoline proved effective to improve brain and autonomic nervous system function in a patient with disturbance of conciousness three years after stroke. The effect of so-called music/exercise therapy was medically evaluated and examined by measuring changes in EEG action potentials of the right and left hemisheres of the brain every 10 seconds and sympathetic nervous activity (LF/HF ratio) as determined every minute by the analysis of heart rate variability and quantifying 1/f fluctuation as an indicator of comfortableness.
This patient showed different responses to music playing as determined by EEG action potentials centered around a-waves. Music playing exerted a sedative effect on the non-stroke right side hemishere of the brain and a stimulating effect on the stroked left side hemisphere with quick-tempo. The up-and-down rhythms on the trampoline, on the other hand, gave a stimulating effect on the right side hemisphere and a sedative effect on the left side hemisphere. Furthermore, these responses became different when music playing was combined with trampoline movement. In either case, however, music playing and/or trampoline movement was associated with 1/f fluctuation, indicating that the patient was in a comfortable mood. The repetition of this therapy led to increasingly active changes in sympathetic nervous activity little by little. These findings demonstrated that the music/exercise therapy was effective in activating brain and autonomic nervous functions in cerebral disorder.

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This report describes a case of Guillain-Barré syndrome accompanied by cervical disc hernia. A 75-yr-old man became unconscious in the public bath and was transferred to the hospital by the ambulance car. He has had a mild whiplash injury by a traffic accident two days before this episode. On the next day of admission, his consciousness recovered but right hemiparesis and speech disturbance remained. On the second day after admission, left hemiparesis appeared and the motor disturbance of the limbs was more dominant than the sensory disturbance. Biochemical findings revealed albuminocytologic dissociation in the cerebrospinal fluid. He was diagnosed as Guillain-Barré syndrome, and plasmapheresis was done. Two months later the symptoms of Guillain-Barré syndrome disappear-ed gradually, but the sensory disturbance still remained. The sensory disturbance was considered to be due to cervical disc hernia, and the cervical laminoplasty was performed and the neurological disturbance had been gradually subsided.

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We were unexpectedly confronted with a sign of paroxysmal ventricular tachycardia (VT) intraoperatively in a patient who had been smoking heavily.
A 48-year-old male heavy smoker, who had no past history, was scheduled for maxillofacial reconstructive surgery with a forearm flap. Preoperative examinations revealed no findings of dysrhythmias or electrolyte defi-ciencies. Anesthesia was induced with thiamylal and suxamethonium following precurarization for endotracheal intubation, followed by maintenance with nitrous oxide and low-dose isoflurane in oxygen. Muscle relaxation was maintained with vecuronium or pancuronium as needed. Dopamine and prostaglandin E₁ were administered continuously by intravenous infusion. Just during preparation for the angiorrhaphy in the cervical region, the cardiac rhythm changed from nomal sinus to PVC short run, followed by VT. Immediate bolus injection of lidocaine successfully restored sinus rhythm, which was accompanied by a marked ST-segment depression. Subsequently, the ST level reverted to baseline progressively after the prompt infusion of intravenous nitroglycerin and diltiazem. The patient remained hemodynamically stable throughout the remainder of the procedure. The postoperative course was uneventful without any dysrhythmias.
This case suggests that smoking may be regarded as the serious background etiology responsible for latent myocar-dial ischemia. The cardiac risk factor, therefore, can be estimated likely to bring on VT or coronary artery spasm especially in case that intraoperative intrinsic catecholamine and anesthesia relating agents interact to coronary vasoconstriction.

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Alveolar re-epithelialization is necessary in the repair of damaged alveolar epithelium after lung injury. Alveolar type II cells are stem cells for alveolar epithelium. We have demonstrated that keratinocyte growth factor (KGF) is a potent proliferation and differentiation factor for rat alveolar type II cells. We hypothesized that KGF would prevent bleomycin-induced fibrosis. Double intratracheal injection of KGF at 48 h before and 24 h after bleomycin instillation prevented the loss of body weight and reduction of total lung capacity due to bleomycin, and markedly attenuated the protein accumulation and mRNA expression of collagen types I and III in the lungs of bleomycin treated rats. KGF may play an important role in repairing the damaged epithelium after injury, and directed delivery of KGF to the lungs may provide a new therapeutic strategy to restore the alveolar epithelium after injury.

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A new two rescuer CPR by Komeda, an emergency medical technician, was introduced. One rescuer maintains patient's airway patent and holds the mask of a selfinflating bag to the face air-tight by using the rescuer's both hands. The other rescuer performs artificial respiration by squeezing the bag intermittently after each series of sternal compression. It is advantageous for a patient on a running ambulance car or a patient with a difficult airway. A new manual sternal compressor with air was developed for a patient being transported on a litter. Rationals of modified ACD-pump, maneuvers of manual sternal compression, modified Heimlich's maneuver were discussed. The re-adoption of either one of the two methods of manual artificial respiration by Silverster or Ivy was suggested for patients with contagious diseases, such as AIDS and viral hepatitis. The author recommended Ivy method.

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