Mediastinal histoplasmosis causing massive hematemesis.

spontaneous breathing as soon as possible 2 and lowpressure suction of the chest tubes after operation are critical.2, 3 Some ventilatory support is necessary, however, when a patient continues to have hypoventilation after operation. Pressure-controlled ventilation rather than volume-controlled ventilation has been recommended for such patients because it can deliver high inspired gas flows in the presence of airway leaks. 3 Although NPV is generally less effective than PPV, 1 it places less stress on the airway. Even if a peak inspiratory pressure inside the cuirass respirator is highly negative, a fraction of the pressure is transmitted to pleural pressure in patients with chronic obstructive pulmonary disease during cuirass ventilation. 4 Marino and Pitchumoni 4 showed that esophageal pressure decreased from -5 .4 cm H20 during spontaneous breathing to -7 .3 cm H20 during inspiratory cycle of NPV while an inspiratory peak pressure of 4 0 cm H20 inside the cuirass worked on the chest. In contrast, during PPV a high positive peak pressure is transmitted to the airway and lung. NPV may therefore be less likely than PPV to induce barotrauma in patients with fragile stapling lines of the lung, Indeed, the decrease in Pco2 in our patient may have been rather slow compared with PPV; however, NPV successfully led him to stable spontaneous breathing without increasing air leakage. Although our patient died, we believe that NPV with the cuirass respirator could be an appropriate ventilatory support for the patient with hypercarbia after operation for emphysema when the lung is adequately inflated.