Airway pressure release ventilation was introduced to clinical practice about two decades ago as an alternative mode for mechanical ventilation; however, it had not gained popularity until recently as an effective safe alternative for difficult-to-oxygenate patients with acute lung injury/ acute respiratory distress syndrome This review will cover the definition and mechanism of airway pressure release ventilation, its advantages, indications, and guidance.
Critical care; mechanical ventilation; respiratory failure
Despite the fact that miliary tuberculosis is frequently seen, associated pneumothorax developing during antitubercular chemotherapy for miliary tuberculosis is rare. Pneumothorax is potentially life threatening in association with miliary tuberculosis; and its symptoms may be masked by those of miliary tuberculosis, leading to avoidable delay in the diagnosis of pneumothorax. Here we describe a 24-year-old female patient developing recurrent pneumothorax while on antitubercular chemotherapy for miliary tuberculosis.
Computed tomogram features; miliary tuberculosis; nonimmunocompromised patient; recurrent pneumothorax
Pneumothorax due to mycetoma is extremely rare and has been described only in patients undergoing intensive cytotoxic therapy for hematologic malignancies. A non-immunocompromised subject presenting with pneumothorax due to rupture of the mycetoma into the pleural cavity is being described here.
Invasive fungal infection; mycetoma; pneumothorax
Pulmonary tumor thromoembolism is well described in literature especially in patients known to have cancer. We are presenting this report of a patient presenting with Acute Cor-pulmonale secondary to Occult Gastric carcinoma causing pulmonary tumor embolism. This is an unusual presentation of occult neoplasm.
Occult carcinoma; tumor thromboembolism
The goal of this study was to investigate the short-term outcomes in patients older than 60 years with isolated rib fractures and admitted to emergency hospital.
MATERIALS AND METHODS:
This study included patients who were 60 years old or more and sustained blunt chest injury and had isolated rib fractures. The following data were obtained from the medical records: age, gender, number of fracture ribs, side of fracture ribs, mechanism and nature of injury, preexisting medical conditions, complications, admission to intensive care unit (ICU), need for mechanical ventilation, length of ICU and hospital stay and mortality.
For the study, 39 patients who were 60 years old or more and admitted to the hospital because of isolated rib fractures were enrolled. There were 28 males (71.7%) and 11 females (28.3%) with mean age of (66.84 ± 4.7) years. No correlation was found between comorbidities and hospital outcomes except in those who were diabetic (P-value = 0.005) and those with chronic lung disease (P-value = 0.006). Pulmonary complications were the most frequent complications encountered in those patients. Pulmonary complications were: lung contusion in 8 patients (20.5%) and pulmonary infection in 6 patients (15.8%).
Elderly patients sustaining blunt chest trauma had significant morbidity and potential for mortality.
Blunt chest trauma; elderly; rib fractures
Pneumonia is a serious complication of varicella infection in adults. This study investigates the clinical characteristics in 19 patients admitted to our hospital with diagnosis of Varicella pneumonia.
MATERIALS AND METHODS:
A retrospective chart review study was performed in adult patients admitted with diagnosis of Varicella pneumonia over 13 years (1992–2005). The study documented the clinical characteristics, laboratory investigations, hospital course, complications, treatment received and the outcomes.
Nineteen patients were identified with a mean age of 41 (±15.4). All were males except two. Eleven patients (58%) were smokers. Eleven patients (58%) had direct contact with persons with chickenpox infection. One patient had underlying chronic pulmonary disease (sarcoidosis). Sixteen patients (84%) were admitted to the intensive care unit due to respiratory failure; eight of them required mechanical ventilation. The mean duration of ICU stay was 4.4 days. All patients were treated with acyclovir and IV antibiotics. Three patients received IV steroid. There was one death.
Patients with Varicella pneumonia are at high risk for respiratory failure and the need for mechanical ventilation. However, early implementation of supportive therapy seems to positively influence the recovery rate and outcome.
Outcome; pneumonia; varicella
BACKGROUND AND OBJECTIVES:
Genetic studies suggest that the sickle cell mutation has arisen on at least four separate occasions in Africa and as a fifth independent mutation in the Eastern Province of Saudi Arabia or India. The pathophysiology of sickle cell disease (SCD) is essentially similar in these different areas although the frequency and severity of complications may vary between areas. The aim of this study was to evaluate the prevalence and outcome of acute chest syndrome (ACS) in SCD patients from Eastern province of Saudi Arabia in comparison with patients with African haplotypes.
MATERIALS AND METHODS:
This was a retrospective study involving 317 SCD patients who were two years or older, admitted to King Fahad Hospital Hofuf between January-May 2003 for different etiologies. Twenty six patients presented with different causes of ACS; 11 patients presented with different pathologies other than ACS, but had past history of ACS; 280 patients presented with different pathologies and never presented with ACS. Clinical features, CBC, Hb-electrophoresis, G6PD activity, cultures, chest X-ray, arterial oxygen saturation, blood transfusion rates and outcome were studied. Univariate and multiple regression analysis were carried out to evaluate influence on ACS. Comparison between SCD patients with ACS from this study and from Eastern province of Saudi Arabia to patients with African haplotypes were carried out, using data reported in the literature.
During the period of this study, 37 patients with new or previous episodes of ACS were studied (accounting for 11.67% of admitted SCD patients). Most of the patients with ACS had only one episode, but five patients (13.51%) had had episodes or more. One patient died giving an in-hospital mortality rate of 1/26 (3.85%). Comparison of recurrence of ACS and mortality between SCD patients in Eastern province of Saudi Arabia to that of patients with African haplotype showed that recurrence is significantly lower (P<0.025) in patients from Eastern province compared to patients with African haplotype, mortality also is lower but not statistically significant.
Acute chest syndrome in SCD patients in Eastern province of Saudi Arabia is relatively uncommon, but causes significant morbidity and mortality. Its prevalence and recurrence is low if compared to that of patients with African haplotypes.
Acute chest syndrome; sickle cell disease
Smear-negative tuberculosis occurs more frequently in human immunodeficiency virus (HIV)-infected patients than in non-HIV-infected patients. Besides, there are substantial numbers of patients who cannot produce sputum, making the diagnosis of pulmonary tuberculosis (PTB) difficult.
To evaluate the relative yield of pre- and post-bronchoscopy sputum and bronchoalveolar lavage (BAL) in ‘sputum smear’-negative, HIV-positive patients.
A tertiary care referral hospital in Addis Ababa.
MATERIALS AND METHODS:
Acid-fast stain (AFS) using the concentration technique was done on 85 pre-bronchoscopy sputum and 120 BAL samples. Direct AFS was done on all BAL and 117 post-bronchoscopy sputum samples. Culture for Mycobacterium tuberculosis (MTB) was done for all sputa and BAL.
MTB was isolated from 26 (21.7%), 23 (19.7%) and 13 (15.3%) of BAL, post- and pre-bronchoscopy sputum cultures respectively. AFS on pre-bronchoscopy sputum using concentration technique and direct AFS on BAL together detected 11 (41%) of the 27 culture-positive cases. In patients who could produce sputum, the sensitivity of pre-bronchoscopy sputum culture (13/85, 15.3%) was comparable to BAL (12/85, 14%) and post-bronchoscopy sputum (12/85, 14%). In patients who could not produce sputum, however, both BAL (12/35, 40%) and post-bronchoscopy sputum (12/32, 31.4%) detected significantly more patients than those who could produce sputum (P=0.002, P=0.028 respectively).
In HIV-infected patients, AFS by concentration method on pre-bronchoscopy sputum and direct AFS on BAL in patients who cannot produce sputum are the preferred methods of making a rapid diagnosis. BAL culture seems to add little value in patients who can produce sputum; therefore, bronchoscopy should be deferred under such circumstances.
Acid-fast stain; bronchoalveolar lavage; concentration technique; M. tuberculosis; post-bronchoscopy; pre-bronchoscopy
Esophageal Doppler monitoring (EDM) is utilized in numerous clinical settings. This study examines the relationship between pulmonary artery catheter (PAC) and EDM-derived hemodynamic parameters, concentrating on gender- and age-related EDM measurement biases.
MATERIALS AND METHODS:
Prospective study of EDM use in ventilated surgical ICU patients. Parameters examined included demographics, diagnosis, resuscitation endpoints, cardiac output (CO) and stroke volume from both devices, number of personnel and time needed to place equipment, time to data acquisition, duration of use, complications of placement.
Fifteen patients (11 men, 4 women, mean age 47 years) were included. Most common diagnoses included trauma (7/15) and sepsis (4/15). Insertion time and time to data acquisition were shorter for EDM than for PAC (P<0.001). The EDM required an average of 1.1 persons to place (2.4 for PAC, P=0.002). Mean EDM utilization time was 12.4 h. There was a fair CO correlation between EDM and PAC (r = 0.647, P<0.001). Overall, the EDM underestimated CO relative to PAC (bias -1.42 ± 2.08, 95% CI: -5.58-2.74), with more underestimation in women (mean bias difference of -1.16, P<0.001). No significant age-related measurement bias differences between PAC and EDM were noted. Significant reductions in lactate and norepinephrine requirement were noted following EDM monitoring periods.
This study found that the EDM significantly underestimated cardiac output in women when compared to PAC. Clinicians should be aware of this measurement bias when making therapeutic decision based on EDM data. Significant reductions in lactate and norepinephrine requirement during EDM monitoring periods support the clinical usefulness of EDM technology.
Critically ill patients; esophageal echo-Doppler; measurement bias; ventilated patients
The aim of this study was to evaluate asthma control after the introduction of a leukotriene modifier (Montelukast), in addition to the current controller asthma therapies, in patients with inadequately controlled mild-to-moderate persistent asthma. Asthma control and patient perception were assessed prior to, and 4 weeks after, the introduction of Montelukast, and the pre-introduction and post-introduction results were compared.
Materials and Methods:
A cross-sectional, observational study collected information on 1,490 eligible adult asthmatic patients in Saudi Arabia. The eligibility criteria included patients aged 15 years or more with symptomatic mild-to-moderate persistent asthma despite treatment with inhaled corticosteroids with or without long-acting beta agonist; also, the patient should attend the initial visit and follow-up visits after at least 4 weeks.
Of the 1,490 eligible patients, 79.5% received inhaled corticosteroids alone, and the remaining 20.5% received combination of inhaled corticosteroids and long-acting bronchodilator. Despite the treatment with daily controller medications, asthma symptoms persisted in more than two-thirds of the study population. Upon adding Montelukast, more than 80% of patients reported improvement in symptoms, which was consistent in all patients irrespective of corticosteroid type or dose (stratum) or the addition of long-acting β2-agonist. At the follow-up visit, 92.2% of patients reported that they felt better on Montelukast.
Leukotriene modifier Montelukast has significant additive benefits in the management of patients who suffer from mild-to-moderate asthma and who are inadequately controlled on inhaled corticosteroids therapy with or without long-acting bronchodilator.
New information is available on pleural diseases. The authors selected articles to make recommendations on diagnostic and treatment aspects of pleural diseases.
MATERIALS AND METHODS:
Eleven articles published in the English language between 2004 and 2007 were chosen. The basis of selection of the articles was the impact on daily practice, change in prior thinking of a disease process or specific treatment modality, as well as proper design and execution of the study. 5-amino-laevulinic acid with fluorescent light combined with white light may allow further diagnostic yield in undiagnosed pleural disease. FDG-PET may allow prognostication of patients with pleural tumors. Utilizing ultrasound by trained Emergency Department physicians is a rapid and effective technique to evaluate non-traumatic pleural effusions in symptomatic patients. Serum osteopontin levels may distinguish patients exposed to asbestos with benign disease from those with pleural mesothelioma. Administration of streptokinase in patients with empyema does not need for surgical drainage, length of hospital stay, or mortality as compared to conventional treatment with chest tube drainage and intravenous antibiotics. Silver nitrate may be an alternative agent to talc for producing pleurodesis. Routine use of graded talc (50% particles greater than 25 microns) is recommended to reduce the morbidity associated with talc pleurodesis. Study design does not permit us to conclude that aspiration of spontaneous pneumothorax is as effective as chest tube drainage. Pleural catheter may prove to be an important palliative modality in treating debilitated patients or patients with trapped lung who show symptomatic improvement with drainage; however, at the present time, these catheters cannot be considered a first line treatment option for patients with malignant pleural effusion. One of the studies reviewed showed no significant difference in tract metastasis in patients with malignant mesothelioma undergoing an invasive pleural procedure with or without irradiation to the procedure site. However, the design of the trial does not allow us to make this conclusion at the present time.
Pleural; empyema; effusions; mesothelioma; ultrasound; pleurodesis; pneumothorax; thoracoscopy
A 7-year-old male presented with history of low-grade fever, epigastric pain and dysphagia. Ultrasound of abdomen and thorax revealed presence of paraesophageal lymphadenopathy. ‘Barium swallow’ and computerized tomography scan thorax with oral contrast suggested a provisional diagnosis of paraesophageal diverticulum. Esophagoscopy was normal. Endoscopic ultrasonography with biopsy confirmed tuberculosis. The patient was started on four-drug antitubercular treatment.
Mediastinal tuberculous lymphadenopathy traction diverticulum
An 18-year-old male presented with 4 weeks' history of productive cough and fever that had started 1 day after alleged ingestion of a plastic whistle. Multiple courses of antibiotics had proved ineffective. Crepitation and a localized wheeze on right chest were observed on clinical examination. Chest radiograph showed a right-sided pneumonitis. Bronchoscopy revealed a grayish-black foreign body in the right bronchial tree, which was retrieved and found to be the ‘lost whistle.’ The patient improved dramatically following the procedure.
Bronchus; foreign body; plastic
We report a case of an adult male who presented with recurrent massive hemorrhagic pleural effusion with a mediastinal cyst due to an unusual complication of pancreatic pseudocyst-like pancreaticopleural fistula and a mediastinal pseudocyst. The clinical presentation was misleading since the patient presented with predominantly respiratory complaints. High index of suspicion of pancreatic etiology in recurrent massive hemorrhagic pleural effusion may lead to the diagnosis.
Acute pancreatitis; mediastinal pseudocyst; pancreaticopleural fistula
Extrapulmonary tuberculosis (EPTB) still constitutes an important clinical problem. We aimed to evaluate the incidence and features of extrapulmonary tuberculosis.
MATERIALS AND METHODS:
We retrospectively evaluated 14,266 tuberculosis patients diagnosed between January 1999 and December 2003 in a tertiary care hospital in Istanbul. As many as 2,435 patients (17.1%) with EPTB were evaluated for the incidence and features.
Of the 14,266 patients, 4,154 were female (29%) and 10,112 were male (71%) and were aged between 14 and 86 years with a mean age of 35 ± 14 years. As many as 660 (17.9%) patients were diagnosed as EPTB in 1999, 568 (17.8%) in 2000, 357 (13.7%) in 2001, 462 (22%) in 2002 and 388 (14.5%) in 2003. EPTB presented most commonly as pleurisy (66%), followed by lymphadenitis (23%). Lymphadenitis and pleurisy were more commonly observed among female TB patients (60%) and among male TB patients (59%) respectively. EPTB showed a significant female predilection (26.8%) compared to male patients (13.1%). Multi-organ involvement was observed in 37 (1.5%) patients (two organs in 33 and three organs in 4). As many as 197 (8%) EPTB cases had pulmonary tuberculosis simultaneously.
EPTB still constitutes an important clinical problem. The rates of EPTB have remained constant despite the decline in pulmonary tuberculosis cases. In the current study, we present our experience of the incidence and features of EPTB patients without HIV infection. In this study, EPTB cases constituted one-fifth of all tuberculosis cases presented to our center in the study period.
Extrapulmonary tuberculosis; gender; incidence; tuberculosis
This study evaluates changes in pulmonary functions before and after mitral valve replacement (MVR).
MATERIALS AND METHODS:
Twenty-five patients with rheumatic mitral lesions who had undergone MVR were divided into three groups, based on New York Heart Association (NYHA) class. They were evaluated for changes in pulmonary functions, preoperatively and postoperatively at 1 week, 1 month and 3 months to find any improvements after MVR.
Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow rates were universally found to be decreased preoperatively. Total lung capacity (TLC) and diffusion capacity (DLCO) were significantly reduced preoperatively in NYHA Class III and IV. The pulmonary functions further declined at 1 week after surgery. Except for FVC in NYHA Class IV (32.3% improvement, P < 0.05), the changes were statistically insignificant.
Pulmonary functions deteriorate immediately after surgery and then recover gradually over a period of 3 months. However, they remain below the predicted values.
Mitral valve replacement; pulmonary function test
Hydrogen peroxide (H2O2) that is mainly generated by neutrophils and eosinophils in asthma is known to be damaging to the airway and to contribute to airway inflammation. The purpose of the present study was to determine the contribution and the role of lactoperoxidase in scavenging airway hydrogen peroxide, in order to propose a therapeutic approach for asthma. The study was an open clinical trial. Twenty-five nonsmoking asthmatic patients were included in the study. Of them, 16 patients (64%) were male and 9 (36%) were female, with age ranging from 29 to 48 years (45.13 ± 4.6). Of the 25 patients included in the study, only 16 patients completed the study; and they were eligible for analyses. Exhaled breath condensate was collected from all patients at the time of entering the study; and 2, 4 and 8 weeks later. All patients received dapson as a lactoperoxidase inhibitor at a dose of 50 mg daily for 8 weeks. The study was conducted during the period from January 2006 to end of October 2006. H2O2 concentration was determined by an enzymatic assay. Determination of exhaled breath condensate for hydrogen peroxide concentration after 8 weeks of dapson usage indicated an increase (1.05 ± 0.36 μM; 95% CI, 0.89-1.21) as compared to that at baseline (P < 0.0001), 2 weeks (P < 0.001) and 4 weeks (P > 0.05). The increase in hydrogen peroxide concentration in exhaled breath condensate after inhibition of lactoperoxidase by dapson advocates a potential role for lactoperoxidase in scavenging of hydrogen peroxide in asthmatic airway.
Asthma; lactoperoxidase; pathogenesis
Spirometry measures the mechanical function of lungs, chest wall and respiratory muscles by assessing the total volume of air exhaled from total lung capacity to residual volume. Spirometry and peak flow measurements have usually been carried out on separate equipments using different expiratory maneuvers.
The present study was carried out to determine whether there is a significant difference between peak expiratory flow (PEF) derived from a short sharp exhalation (PEF maneuver) and that derived from a full forced vital capacity (FVC) maneuver in healthy volunteers.
A medical college and tertiary level hospital.
MATERIALS AND METHODS:
The present study was carried out during the period from January 2006 to July 2006. The study included 80 healthy volunteers with no coexisting illnesses, who were in the 15-45 years age group and belonging to either sex. They were asked to perform two sets of PEF and FVC maneuvers using the same turbine spirometer; the order was randomly assigned.
The difference between PEF obtained from a peak flow maneuver (PEFPF) and that obtained from a forced vital capacity maneuver (PEFVC) in healthy volunteers was analyzed separately for males and females, as well as for both groups combined, and statistical significance of its correlations with study data parameters was analyzed.
The difference between PEF obtained from a peak flow maneuver (PEFPF) and that obtained from a forced vital capacity maneuver (PEFVC) was statistically significant (P < 0.001) in males and in females separately and also for both groups combined. PEFPF (517.25 ± 83.22 liters/min) was significantly greater than PEFVC (511.09 ± 83.54 liters/min), as found on combined group mean analysis. However, the difference was small (6.16 + 7.09 liters/min).
FVC maneuver can be used over spirometers to detect the PEF; and on follow-up subsequently, the same maneuver should be used to derive PEF. If we are using a peak flow maneuver subsequently, corrections are required to compensate for the difference due to the different maneuver.
Forced vital capacity maneuver; healthy volunteers; peak expiratory flow maneuver; peak expiratory flow rate; turbine spirometer
18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a useful technique to characterize the solitary pulmonary nodule, diagnose primary lung cancer, carry out mediastinal and extrathoracic staging, plan radiotherapy, therapeutic response assessment and detect recurrence. PET may help to determine the ideal site for tissue diagnosis as well as predict prognosis. Combined PET and computed tomography (PET / CT) has the best of both worlds of metabolic and anatomic imaging and may provide optimal disease assessment.
Lung cancer; positron emission tomography (PET); PET/computed tomography; tumor staging; therapy response
A 21-year-old primigravida, at 32 weeks of gestation, presented with acute onset of respiratory failure and circulatory shock. Chest imaging showed findings suggestive of ruptured hydatid cyst, which was confirmed by histology post-thoracotomy. Tissue cultures from the removed cyst grew Mycobacterium tuberculosis also. She was successfully managed in the intensive care unit and was then discharged home on antituberculosis medications in addition to albendazole after prolonged hospitalization and a need for chest tube for bronchopleural fistula. Acute respiratory failure and anaphylactic shock secondary to ruptured pulmonary hydatid cyst and superimposed pulmonary tuberculosis in a pregnant lady should be considered in patients living in endemic areas.
Critical illness; pregnancy; pulmonary hydatid; tuberculosis