Risk Factors for Isoniazid Hepatotoxicity in Children With Latent TB and TB: Difference From Adults

In an interesting article in CHEST (November 2007), Talmor and colleagues 1 demonstrate that recruitment maneuvers are well tolerated in ARDS, with no major hemodynamic or immunologic evidence of deterioration within the fi rst hour of a recruitment maneuver. However, certain aspects of this study are not clear from the article. In this study, eight out of the 26 patients had intraabdominal pathologic results wherein the pressures applied during the study may not be appropriate, because higher airway pressures are required to generate an equivalent transpulmonary pressure in the patient with increased intraabdominal pressure. 2 The use of bladder pressure measurements may help in determining the intraabdominal pressure and may help in this regard. Furthermore, stratifying the results into abdominal and extraabdominal categories may alter the results. Gattinoni et al 3 showed that patients with extrapulmonary ARDS (ARDSexp) have a greater response rate to recruitment maneuvers than those with pulmonary ARDS (ARDSp). Thus, patients with pneumonia may have a limited amount of recruitable lung tissue, and the higher pressure may overinfl ate normal lung rather than aerating the consolidated tissue. So, further separating the results into ARDSp and ARDSexp may lead to greater insight in the study. A series by Gattinoni et al 4 found that patients with ARDSp had a higher percentage of recruitable lung than patients with ARDSexp when using CT scanning of the whole lung to quantify recruitment. Thus, CT scanning should ideally be performed when evaluating the effects of recruitment maneuvers. Finally, two (7.69%) out of 26 patients in this study did show a hemodynamic compromise and early termination of the recruitment maneuver, which defi nitely puts a question mark on the safety of this maneuver in critically ill patients with ARDS.