A patients with congenital tracheal stenosis (CTS) require long-term mechanical ventilation, and have many difficult airway problems, such as tracheal bleeding, granulomatous formation, etc. The ultimate aim is succeed in extubation against the challenges of respiratory complications. We have managed six pediatric CTS patients in our Intensive Care Unit during the past six years. A postoperative 3-stage management period has been used in these cases.
In the first stage, patients are paralyzed and sedated using benzodiazepines and neuromuscular blocking agents to stabilize tracheal anastomosis until 10 days after operation. This is to prevent postoperative tracheal bleeding due to insufficient sedation and neuromuscular blockade in these period.
In the second stage, for patient stability, we have preferred the administration of isoflurane and morphine instead of neuromuscular blocking agents. Aggressive pulmonary physical therapy, and diagnostic and therapeutic bronchoscopies have also been performed as needed.
In the third stage, weaning from mechanical ventilation is performed. For the prevention of excessive respiratory effort, we have administered a variety of sedative drugs, such as midazolam, promethazine. Further research, however, is required to improve management procedures after the extubation.

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Inhalation of Welpas^(R) (80% ethyl alcohol and 0.2% benzalkonium chloride) occurred in a 72-year-old male who had undergone left pneumonectomy. He inhaled a small quantity of Welpas^(R) with an ultranebulizer five days after total gastrectomy.
He experienced chest pain the following day and four days later his temperature rose to over 38°C. Seven days later, he had respiratory failure necessitating mechanical ventilation. Chest radiophotography showed reticular shadow in most of the lung. We tried to wean the patient from mechanical ventilation and extubated the endotracheal tube but failed because PaO₂ dropped rapidly to dangerous level. The patient died of multiple organ failure a month later.
We tried to show that Welpas^(R) can cause interstitial pneumonia in rats by injecting Welpas^(R) into their trachea. Benzalkonium chloride induced pulmonary fibrosis in the rat after 5 days. This fact supports our hypothesis of Welpus induced interstitial pneumonia in case use report.

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We reported on a six-month old boy who needed long-term mechanical ventilation for respiratory failure caused by lipoid pneumonia. Pressure support ventilation was employed as intermittent positive pressure ventilation failed to improve his respiratory state. Although his respiratory index improved from 7 to 3, we were unable to wean him from the ventilator using synchronized intermittent mandatory ventilation on 3 occasions over 4 months. The use of a T-piece without a ventilator was employed initially for a very short time, and the duration was gradually prolonged. The weaning period was 7 months. Enteral nutrition was used as sepsis was observed twice from total parenteral nutrition. His body weight increased from 4.5kg to 6.2kg. He was weaned from mechanical ventilation and the tracheal tube extubated after 354 days.
Mechanical ventilation with pressure support ventilation, weaning by T-piece without a ventilator, and enteral nutrition were useful for long-term mechanical ventilation in an infant with lipoid pneumonia.

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We presented a case of acute respiratory failure with decreased serum cholinesterase caused by an anticholinesterase agent (distigmine bromide).
A 70-year-old man had been taking distigmine bromide for prostatic hypertrophy. He underwent coronary artery bypass grafting for unstable angina. Dyspnea, diarrhea and bradycardia were noticed on the 5th postoperative day. Blood gas analysis showed marked respiratory acidosis (facemask; O₂ 5l·min^-1, pH7.186, PaCO₂ 86.4mmHg, PaO₂ 97.6mmHg and BE 12.6mml·l^-1). The clinical features were similar to acute organophosphate poisoning. We diagnosed these symptoms as a cholinergic crisis from distigmine bromide poisoning as serum cholinesterase decreased to 91 (normal range: 3000-6500) IU·l^-1. The clinical symptoms improved after stopping the administration of distigmine bromide.
This case shows us that we should be aware of the possibility of acute respiratory failure due to cholinergic crisis in patients taking distigmine bromide.

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An unconscious 75-year-old man in state of shock was admitted to our ICU. He had undergone a resection of a brain tumor two months previously. Acute pulmonary thromboembolism was diagnosed based on the following: hypoxia, increased pulmonary arterial pressure, right bundle branch block on electrocardiography, and perfusion defect on pulmonary perfusion scintigram. In spite of mechanical ventilation and intravenous administration of nasaruplase and low-molecular-weight heparin, his pulmonary oxygenation did not improve and inhalation therapy with nitric oxide (NO; 5ppm) was started. The PaO₂/F_IO₂ ratio (P/F) increased from 164 to 194 after NO inhalation, but decreased to about 90 by 30 minutes after the cessation of NO inhalation. Mean pulmonary arterial pressure and pulmonary vascular resistance decreased during NO inhalation. These results suggest that inhaled NO was effective for the improvement of pulmonary oxygenation and pulmonary hypertension in a patient with acute massive pulmonary thromboembolism.

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A case of neuroleptic malignant syndrome with a high elevation of serum myoglobin was successfully treated by wash-out therapy.
A 34-year-old man developed neuroleptic malignant syndrome after an intramuscular injection of fluphenazine. The laboratory examination showed remarkable increases in serum myoglobin and creatine phosphokinase (CPK) (maximum values: 15×10⁴ng·ml^-1, 49.7×10⁴IU·l^-1, respectively). Continuous infusions of mannitol and furosemide, and volume expansion were carried out to increase urinary flow. Urinary output increased up to 13 liters per day, and serum myoglobin, and CPK decreased dramatically.
This case suggested that wash-out therapy was effective in preventing acute renal failure which is often seen in neuroleptic malignant syndrome accompanying a remarkable increase in serum myoglobin.

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A case of ascending cholangitis with sepsis where a combination of flurbiprofen axetil and dobutamine improved tissue oxygen metabolism is reported. A 23-year-old man was admitted to our hospital with a diagnosis of ascending cholangitis. He had a history of hepatic porto-enterostomy for biliary atresia at 90 days after birth. The patient fell into respiratory failure with sepsis one day after admission and was transfered to our ICU. Mechanical ventilation via tracheal tube was performed. Hemodynamic values including an elevated heart rate (128min^-1) and cardiac index (7.8l·min^-1·m^-2) indicated a hyperdynamic state, but oxygen uptake decreased with a lowered oxygen extraction ratio (13%) and elevated mixed venous oxygen saturation (89.3%). Severe lactic acidosis (lactate 9.8mg·dl^-1) occurred, indicating that oxygen debt induced hypoxic tissue injury. Flurbiprofen axetil (2mg·hr^-1) was administered to inhibit systemic inflammatory response and decrease cellular oxygen demand. As body temperature decreased from 38.2°C to 37.4°C, systolic arterial pressure, cardiac index and oxygen delivery index declined from 130mmHg, 7.8l· min^-1·m^-2, and 1, 226ml·min^-1·m^-2 to 80mmHg, 5.7l·min^-1·m^-2, and 744ml·min^-1·m^-2, respectively. Body temperature, systolic arterial pressure, cardiac index and oxygen delivery index reached adequate levels of 37.4°C, 100mmHg, 6.1l·min^-1·m^-2, and 7, 180ml·min^-1·m^-2, respectively after combined administration of flurbiprofen axetil at a reduced dose of 1.5mg·hr^-1, and dobutamine at a dose of 2μg·kg^-1·min^-1. Mixed venous oxygen saturation decreased to 85.4% and the oxygen extraction ratio increased to 18%. Lactate was reduced to 2.3mg·dl^-1.
These findings demonstrated improvement of tissue oxygen metabolism. It may be useful to keep a supranormal level of oxygen delivery and to reduce cellular oxygen demand adequately by nonsteroidal anti-inflammatory drugs for the treatment of severe sepsis with oxygen debt.

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