Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33192115
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Hyperammonemia is the pathological accumulation of ammonia in the blood, which can occur in many different clinical settings. Most commonly in adults, hyperammonemia occurs secondary to hepatic dysfunction; however, it i...Hyperammonemia is the pathological accumulation of ammonia in the blood, which can occur in many different clinical settings. Most commonly in adults, hyperammonemia occurs secondary to hepatic dysfunction; however, it is also known to be associated with other pathologies, surgeries, and medications. Although less common, hyperammonemia has been described as a rare, but consistent complication of solid organ transplantation. Lung transplantation is increasingly recognized as a unique risk factor for the development of this condition, which can pose grave health risks-including long-term neurological sequelae and even death. Recent clinical findings have suggested that patients receiving lung transplantations may experience postoperative hyperammonemia at rates as high as 4.1%. A wide array of etiologies has been attributed to this condition. A growing number of case studies and investigations suggest disseminated opportunistic infection with Ureaplasma or Mycoplasma species may drive this metabolic disturbance in lung transplant recipients. Regardless of the etiology, hyperammonemia presents a severe clinical problem with reported mortality rates as high as 75%. Typical treatment regimens are multimodal and focus on 3 main avenues of management: (1) the reduction of impact on the brain through the use of neuroprotective medications and decreasing cerebral edema, (2) augmentation of mechanisms for the elimination of ammonia from the blood via hemodialysis, and (3) the diminishment of processes producing predominantly using antibiotics. The aim of this review is to detail the pathophysiology of hyperammonemia in the setting of orthotopic lung transplantation and discuss methods of identifying and managing patients with this condition.
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33173369
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The COVID-19 pandemic has presented challenges in symptomology identification, diagnosis, management and follow-up in common respiratory diseases, and in particular asthma. Research is rapidly ongoing to try and understa...The COVID-19 pandemic has presented challenges in symptomology identification, diagnosis, management and follow-up in common respiratory diseases, and in particular asthma. Research is rapidly ongoing to try and understand how the SARS-CoV-2 virus affects individuals with asthma, as well as, how underlying asthma affects Covid-19 risk, symptomology and prognosis. In light of this unique medical challenge, clinicians are faced with case-by-case based decisions to implement or continue current asthma therapy. This review will discuss the current literature regarding asthma and COVID-19 based on best available evidence at this time (See box 1).
Edriss H, Yang S, Juarez E
… +4 more, Crane J, Lear M, Sanchez A, Nugent K
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33117037
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BACKGROUND: Pressures measured during mechanical ventilation provide important information about the respiratory system mechanics and can help predict outcomes. METHODS: The electronic medical records of patients hospita...BACKGROUND: Pressures measured during mechanical ventilation provide important information about the respiratory system mechanics and can help predict outcomes. METHODS: The electronic medical records of patients hospitalized between 2010 and 2016 with sepsis who required mechanical ventilation were reviewed to collect demographic information, clinical information, management requirements, and outcomes, such as mortality, ICU length of stay, and hospital length of stay. Mechanical ventilation pressures were recorded on the second full day of hospitalization. RESULTS: This study included 312 adult patients. The mean age is 59.1 ± 16.3 years; 57.4% were men. The mean BMI was 29.3 ± 10.7. Some patients had pulmonary infections (46.2%), and some patients had extrapulmonary infections (34.9%). The overall mortality was 42.6%. In a multi-variable model that included age, gender, number of comorbidities, APACHE 2 score, and PaO/FiO ratio, peak pressure, plateau pressure, driving pressure, and PEEP all predicted mortality when entered into the model separately. There was an increase in peak pressure, plateau pressure, and driving pressure across BMI categories ranging from underweight to obese. CONCLUSIONS: This study demonstrates that ventilator pressure measurements made early during the management of patients with acute respiratory failure requiring mechanical ventilation provide prognostic information regarding outcomes, including mortality. Patients with high mechanical ventilator pressures during the early course of their acute respiratory failure require more attention to identify reversible disease processes when possible. In addition, increased BMIs are associated with increased ventilator pressures, and this increases the complexity of the clinical evaluation in the management of obese patients.
Ossei PPS, Owusu IK, Owusu-Asubonteng G
… +3 more, Ankobea-Kokroe F, Ayibor WG, Niako N
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33117036
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BACKGROUND: There is a dearth of publications on the prevalence of venous thromboembolism in Ghana. Knowledge of the prevalence of venous thromboembolism, which is often undetected clinically, will help save lives as app...BACKGROUND: There is a dearth of publications on the prevalence of venous thromboembolism in Ghana. Knowledge of the prevalence of venous thromboembolism, which is often undetected clinically, will help save lives as appropriate interventions can be made as well as provide a general clue to clinicians on detecting venous thromboembolism and pulmonary embolism. METHODS: The study employs a retrospective design with data extracted from the Autopsy Daybook of the Pathology unit, Komfo Anokye Teaching Hospital, 2009 to 2016. Data on patients' demographics were retrieved to establish diagnoses and age and gender distribution. Analysis was made of pulmonary embolism and deep vein thrombosis as a cause of death recorded on death certificates using the criteria of the International Classification of Diseases, version 10. RESULTS: A total of 150 cases of deep vein thrombosis and/or pulmonary embolism were available for the study period and the results showed an average age of 45.3 years with a standard deviation of 19.96. The ages ranged between 3 years and 96 years with the age group 31 to 40 years being the modal age group. Males recorded the highest number of cases with 92 (59.35%) compared to females with 63 (40.65%). Respiratory disorders, of which pneumonia is the most prevalent, are the leading clinical condition that is often misdiagnosed in place of pulmonary thromboembolism. CONCLUSION: VTE is a major health problem especially among the elderly, but unfortunately the clinical diagnosis is usually missed by clinicians hence the need to maintain a high suspicion index.
Aueyingsak S, Khrisanapant W, Kukongviriyapun U
… +4 more, Pasurivong O, Ratanawatkul P, Wanitpongpan C, Pussadhamma B
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33117035
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BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiopulmonary exercise testing (CPET) are useful for severity assessment in patients with pulmonary hypertension (PH). Correlations between these tes...BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiopulmonary exercise testing (CPET) are useful for severity assessment in patients with pulmonary hypertension (PH). Correlations between these tests in pre-capillary PH patients is less well studied. METHODS: We studied 23 patients with pre-capillary PH: 8 with idiopathic pulmonary arterial hypertension (IPAH), 6 with systemic sclerosis-associated PAH (SSc-PAH), and 9 with chronic thromboembolic pulmonary hypertension (CTEPH). Clinical evaluation, NT-proBNP levels, six-minute walking test (6MWT), spirometry, and CPET were evaluated on the same day. Correlation between NT-proBNP levels and CPET parameters were investigated. RESULTS: In all patients, NT-proBNP levels were significantly correlated with peak oxygen uptake (VO) ( = -0.47), peak oxygen pulse ( = -0.43), peak cardiac output (CO) ( = -0.57), peak end-tidal partial pressure of carbon dioxide (PCO) ( = -0.74), ventilatory equivalent to carbon dioxide (VE/VCO) at anaerobic threshold (AT) ( = 0.73), and VE/VCO slope ( = 0.64). Significant correlations between NT-proBNP levels and peak PCO and VE/VCO were found in IPAH and CTEPH subgroups, and a significant correlation between NT-proBNP levels and VO at AT was found in the CTEPH subgroup. No significant correlation was found in the SSc-PAH subgroup. CONCLUSION: NT-proBNP levels were significantly correlated with CPET parameters in patients with IPAH and CTEPH subgroups, but not in SSc-PAH subgroup. A further study with larger population is required to confirm these preliminary findings.
Fernández-Trujillo L, Bolaños JE, Álvarez C
… +5 more, Giraldo J, Velásquez M, Zúñiga-Restrepo V, Pérez B, Sua LF
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33110350
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Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal neoplasms that originate from mesenchymal growth in the pleura, tend to be single tumors, usually have an indolent course and show nonspecific symptoms. S...Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal neoplasms that originate from mesenchymal growth in the pleura, tend to be single tumors, usually have an indolent course and show nonspecific symptoms. SFTP can be often diagnosed from an incidental finding of a single mass in the thorax and should be confirmed by biopsy and immunohistochemistry. A minority of cases may present Doege-Potter syndrome (DPS, episodes of refractory hypoglycemia) associated with production of insulin-like growth factor 2 (IGF-2). Both SFTP and DPS are rare occurrences with less than 2000 cases reported worldwide. The curative treatment is tumor resection. Two cases of patients with DPS caused by SFTP are presented below.
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 33100832
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BACKGROUND: Acute pulmonary embolism (PE) is the third most fatal cardiovascular disease. PE is frequently misdiagnosed due to its clinical presentation's heterogeneity and the inexistence of biomarkers for its immediate...BACKGROUND: Acute pulmonary embolism (PE) is the third most fatal cardiovascular disease. PE is frequently misdiagnosed due to its clinical presentation's heterogeneity and the inexistence of biomarkers for its immediate diagnosis. Mean platelet volume (MPV) has shown a potential role as a biomarker in acute PE. In this analysis, we aimed to systematically compare the MPV in patients with and without definite diagnosis of PE, in emergency departments. METHODS: Embase, PubMed and Medline were searched for relevant publications, in English. The main inclusion criteria were studies which compared MPV in patients with acute PEA versus a control group. RESULTS: Thirteen studies consisting of a total number of 2428 participants were included. Of the participants included, 1316 were patients with confirmed acute PE, and 1112 were assigned to the control group. MPV was significantly higher in patients with acute PE than in controls (RR: 0.84, 95% CI: 0.76 - 0.92; < .00001). There was a significant heterogeneity in the data. CONCLUSIONS: This analysis showed higher MPV to be associated with acute PE immediate diagnosis. These data show promise for the use of MPV as a readily available biomarker for the diagnosis of acute PE at the emergency department.
Boregowda U, Gandhi D, Jain N
… +2 more, Khanna K, Gupta N
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 35173507
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IMPORTANCE: Coronavirus 2019 pandemic (COVID 19) is caused by the Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) virus. The pandemic is affecting the livelihood of millions of people all over the world. At...IMPORTANCE: Coronavirus 2019 pandemic (COVID 19) is caused by the Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) virus. The pandemic is affecting the livelihood of millions of people all over the world. At the time of preparing this report, the pandemic has affected 1 827 284 patients, with 113 031 deaths in 185 countries as per Johns Hopkins University. With no proven treatment for the disease, prevention of the disease in the community and healthcare setting is need of the hour. OBJECTIVE: To perform a comprehensive literature search for preventive measures and experimental treatment options. In this review, we have focused our discussion on the risk of disease transmission, supportive treatment, and possible treatment options based on available evidence. EVIDENCE REVIEW: We performed a literature search on google scholar, PubMed, and society guidelines for literature related to COVID 19 and previous coronavirus pandemics. We included data review articles, observational studies, and controlled trials to synthesize the treatment options for COVID 19. FINDINGS: In this article, we have extensively reviewed and discussed recommendations from various world organizations for the public and healthcare workers. We have also discussed currently available experimental treatments since there is no proven treatment for COVID 19. The best method of dealing with the current outbreak is to reduce the community spread and thus "flatten the curve." Although Hydroxychloroquine, Remdesivir, Lopinavir/Ritonavir, and Azithromycin have been tried, passive immunity through convalescent serum and vaccine is still at an experimental stage. Patients with severe COVID 19 infections could be considered for this experimental treatment through various national randomized control trials, which may eventually lead to an evidence-based treatment strategy. CONCLUSIONS AND RELEVANCE: Awareness of currently available experimental treatment among healthcare providers and exploration of possible treatment options through evidence is need of the hour. We have discussed the most recently available literature and evidence behind experimental treatment in this article.
Pranata R, Supriyadi R, Huang I
… +5 more, Permana H, Lim MA, Yonas E, Soetedjo NNM, Lukito AA
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32994700
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OBJECTIVE: The aim of the study was to evaluate the association between chronic kidney disease (CKD) and new onset renal replacement therapy (RRT) with the outcome of Coronavirus Disease 2019 (COVID-19) in patients. METH...OBJECTIVE: The aim of the study was to evaluate the association between chronic kidney disease (CKD) and new onset renal replacement therapy (RRT) with the outcome of Coronavirus Disease 2019 (COVID-19) in patients. METHODOLOGY: A systematic literature search from several databases was performed on studies that assessed CKD, use of RRT, and the outcome of COVID-19. The composite of poor outcome consisted of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care, and use of mechanical ventilator. RESULTS: Nineteen studies with a total of 7216 patients were included. CKD was associated with increased composite poor outcome (RR 2.63 [1.33, 5.17], = .03; = 51%, = .01) and its subgroup, consisting of mortality (RR 3.47 [1.36, 8.86], = .009; = 14%, = .32) and severe COVID-19 (RR 2.89 [0.98, 8.46], = .05; = 57%, = .04). RRT was associated with increased composite poor outcome (RR 18.04 [4.44, 73.25], < .001; = 87%, < .001), including mortality (RR 26.02 [5.01, 135.13], < .001; = 60%, = .06), severe COVID-19 (RR 12.95 [1.93, 86.82], = .008; = 81%, < .001), intensive care (IC) (RR 14.22 [1.76, 114.62], < .01; = 0%, < .98), and use of mechanical ventilator (RR 34.39 [4.63, 255.51], < .0005). CONCLUSION: CKD and new-onset RRT were associated with poor outcome in patients with COVID-19.
Akoluk A, Mazahir U, Douedi S
… +7 more, Aziz A, Obagi A, Kiss D, Flynn D, Costanzo E, Simsir SA, Saybolt MD
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32952405
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BACKGROUND: Novel coronavirus 2019 (COVID-19) has been the focus of the medical world since being declared a pandemic in March 2020. While the pathogenesis and heterogeneity of COVID-19 manifestations is still not fully...BACKGROUND: Novel coronavirus 2019 (COVID-19) has been the focus of the medical world since being declared a pandemic in March 2020. While the pathogenesis and heterogeneity of COVID-19 manifestations is still not fully understood, viral evasion of cellular immune responses and inflammatory dysregulation are believed to play essential roles in disease progression and severity. CASE PRESENTATION: We present the first case of a patient with COVID-19 with massive pulmonary embolism treated successfully with systemic thrombolysis, VA-ECLS, and bail out catheter directed thrombolysis. He was discharged from the hospital after an eventful hospital course on therapeutic anticoagulation with warfarin. CONCLUSIONS: We present the first case of a patient with COVID-19 with massive pulmonary embolism (PE) treated successfully with systemic thrombolysis, VA-ECLS and bail out catheter directed thrombolysis. In our experience catheter directed thrombolysis comes with an acceptable bleeding risk despite use of mechanical circulatory support, particularly with meticulous attention to vascular access and dose response monitoring.
White S, Sakon C, Fitzgerald L
… +3 more, Kam C, McDade E, Wong A
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32595284
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BACKGROUND: Vancomycin is commonly used to treat acute cystic fibrosis (CF) exacerbations associated with methicillin-resistant (MRSA). Multiple studies have demonstrated pharmacokinetic differences of antimicrobials in...BACKGROUND: Vancomycin is commonly used to treat acute cystic fibrosis (CF) exacerbations associated with methicillin-resistant (MRSA). Multiple studies have demonstrated pharmacokinetic differences of antimicrobials in the CF population. Very little data exist regarding pharmacokinetics postlung transplant, but 2 studies have noted changes in tobramycin pharmacokinetics. No such studies exist evaluating vancomycin in CF patients postlung transplant. METHODS: A retrospective cohort review of CF patients who underwent lung transplantation and received vancomycin pre- and posttransplant was conducted. CF patients who underwent transplant between 2007 and 2016 at 4 medical centers throughout the United States were included. The primary endpoint was the change in elimination rate constant. The secondary endpoints were subgroup analyses of patients grouped by age, time posttransplant, and number of nephrotoxic medications. RESULTS: A total of 25 patients were included, of which just under half were pediatric. Patients were significantly older and heavier posttransplant and had higher serum creatinine and number of nephrotoxic medications. The change in elimination rate constant from pre- to posttransplant was -0.50 hr which was statistically significant ( < .001). This significant decrease was consistent among all subgroups of patients evaluated with the exception of pediatric patients. CONCLUSION: Vancomycin pharmacokinetics are significantly altered in CF patients in the posttransplant setting as evidenced by a decrease in elimination rate constant. This decrease may be related to a decrease in renal clearance and higher numbers of nephrotoxic medications posttransplant. Regardless, pretransplant vancomycin regimens may not predict appropriate posttransplant regimens.
Pervaiz S, Homsy S, Narula N
… +2 more, Ngu S, Elsayegh D
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32595283
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Bevacizumab is a vascular endothelial growth factor-directed humanized monoclonal antibody used to treat many types of cancer and some eye diseases. Due to inhibition of angiogenesis, many adverse reactions such as bowel...Bevacizumab is a vascular endothelial growth factor-directed humanized monoclonal antibody used to treat many types of cancer and some eye diseases. Due to inhibition of angiogenesis, many adverse reactions such as bowel necrosis, nasal septal perforation, and renal thrombotic microangiopathy have been described. However, its association with interstitial pneumonitis is scarcely reported in the literature. We report a case of a 79-year-old woman with metastatic colon cancer who presented with cough and dyspnea on exertion the day after initiation of bevacizumab. She was found to have bilateral airspace opacities on imaging. Infectious and cardiogenic etiologies of dyspnea were ruled out. Due to the temporal relationship with the initiation of chemotherapy, she was suspected to have developed bevacizumab-induced interstitial pneumonitis. She improved rapidly with high-dose steroids. Follow-up imaging showed resolution of infiltrates. This is the first reported case in the literature that directly links bevacizumab to interstitial pneumonitis.
Cheema TJ, Young M, Rabold E
… +3 more, Barbieri AN, Baldwin N, Steen VD
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32214863
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Systemic sclerosis-associated interstitial lung disease is challenging to diagnose and treat. Patients and physicians can perceive the disease differently and have different views on its management. Communication issues...Systemic sclerosis-associated interstitial lung disease is challenging to diagnose and treat. Patients and physicians can perceive the disease differently and have different views on its management. Communication issues between them can lead to suboptimal disease management. Despite a clear need for improvement in the speed and accuracy of the diagnostic workup, the heterogeneity of clinical symptoms renders the process long and challenging. When considering treatment options, physicians may be more focused on the evidence supporting a particular treatment or on a patient's pulmonary function test results, as opposed to the realities of the patient's difficulties with symptoms or the psychosocial effects of systemic sclerosis-associated interstitial lung disease. Disease management plans should be determined by the patient's own preferences and goals as well as the objective clinical situation. Health care providers must consider their patients as partners on a journey in which treatment decisions are reached jointly. This review will focus on the perspectives of physicians and patients in relation to the diagnosis and management of systemic sclerosis-associated interstitial lung disease. Similarities and differences in these perspectives will be identified, and strategies for achieving optimal disease management will be proposed.
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32076372
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OBJECTIVE: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies. DATA SOURCE: Published ran...OBJECTIVE: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies. DATA SOURCE: Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials. DATA SUMMARY: Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients. CONCLUSION: Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.
Alvarado Sánchez JI, Caicedo Ruiz JD, Diaztagle Fernández JJ
… +2 more, Ospina-Tascón GA, Cruz Martínez LE
Clin Med Insights Circ Respir Pulm Med
· 2020 · PMID 32047358
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INTRODUCTION: Pulse pressure variation (PPV) has been shown to be useful to predict fluid responsiveness in patients ventilated at tidal volume (Vt) >8 mL kg. Nevertheless, most conditions in critical care force to use l...INTRODUCTION: Pulse pressure variation (PPV) has been shown to be useful to predict fluid responsiveness in patients ventilated at tidal volume (Vt) >8 mL kg. Nevertheless, most conditions in critical care force to use lower Vt. Thus, we sought to evaluate the operative performance of PPV when a Vt ⩽8 mL kg is used during mechanical ventilation support. METHODS: We searched PubMed and Embase databases for articles evaluating the operative performance of PPV as a predictor of fluid responsiveness in critical care and perioperative adult patients ventilated with tidal volume ⩽8 mL kg without respiratory effort and arrhythmias, between January 1990 and January 2019. We included cohort and cross-sectional studies. Two authors performed an Independently selection using predefined terms of search. The fitted data of sensitivity, specificity, and area under the curve (AUC) were assessed by bivariate and hierarchical analyses. RESULTS: We retrieved 19 trials with a total of 777 patients and a total of 935 fluid challenges. The fitted sensitivity of PPV to predict fluid responsiveness during mechanical ventilation at Vt ⩽8 mL kg was 0.65 (95% confidence interval [CI]: 0.57-0.73), the specificity was 0.79 (95% CI: 0.73-0.84), and the AUC was 0.75. The diagnostic odds ratio was 5.5 (95% CI: 3.08-10.01, < .001) by the random-effects model. CONCLUSIONS: Pulse pressure variation shows a fair operative performance as a predictor of fluid responsiveness in critical care and perioperative patients ventilated with a tidal volume ⩽8 mL kg without respiratory effort and arrhythmias.
Assanangkornchai N, Vichitkunakorn P, Bhurayanontachai R
Clin Med Insights Circ Respir Pulm Med
· 2019 · PMID 31700253
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Extracorporeal membrane oxygenation (ECMO) is a treatment option considered for acute respiratory distress syndrome (ARDS) patients who are refractory to conventional treatments. However, treatment with ECMO has not show...Extracorporeal membrane oxygenation (ECMO) is a treatment option considered for acute respiratory distress syndrome (ARDS) patients who are refractory to conventional treatments. However, treatment with ECMO has not shown significant reduction of mortality which may be due to inappropriate selection criteria. Thus, we aim to evaluate the treatment outcomes of patients treated with ECMO in our center and determine an optimal cutoff level of the Respiratory ECMO Survival Prediction (RESP) score for case selection. This was a retrospective case-control study conducted at Songklanagarind Hospital, Thailand, from January 2014 to August 2018. ECMO patients were randomly matched to a control group of patients with severe ARDS within the same time period. There were 19 cases diagnosed with ARDS and treated with ECMO and 57 controls with ARDS. The patients in both groups had an average APACHE II score of 30.2 (SD = 4.7) and mainly had bacterial pneumonia. The in-hospital mortality was not significantly different between the cases and controls (68.4% vs 63.2%, respectively); however, the ECMO cases had a significantly longer length of intensive care unit stay and cost of hospitalization. Active malignancy, male gender, PaO/FiO ratio, and hypotension needing vasopressors were the risk factors for mortality. The RESP score did not discriminate between the survivors and nonsurvivors. Thus, more patient is needed to construct a better selection criterion.
Fernández-Trujillo L, Tapia L, Vallejo M
… +3 more, Aguirre M, Lores J, Sua LF
Clin Med Insights Circ Respir Pulm Med
· 2019 · PMID 31516313
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Lung carcinoma currently represents 1 of the leading causes of death from cancer worldwide and regionally. The molecular identification of sensitive mutations of targeted treatment have changed the strategies of pharmaco...Lung carcinoma currently represents 1 of the leading causes of death from cancer worldwide and regionally. The molecular identification of sensitive mutations of targeted treatment have changed the strategies of pharmacologic management in non-small cell lung carcinoma. However, mechanisms of resistance have been described, among them the change of histological type to small cell carcinoma. We present the case of a 46-year-old male patient, non-smoker, with a clinical history of a mass in the upper lobe of the right lung and an initial histological diagnosis of adenosquamous carcinoma of the lung, with the presence of mutations for epidermal growth factor receptor (EGFR) in exons 20 (S768I) and 21 (L858R). He received treatment with tyrosine kinase inhibitor (Erlotinib) with good clinical and radiological response. However, 1 year after the start of the medication, he consulted for a progressive onset of constitutional symptoms and respiratory symptoms, with radiographic worsening and new biopsy with a diagnosis of adenosquamous carcinoma with the adenocarcinoma component transformed to small cell carcinoma, with persistence of EGFR mutation. We describe the clinical, radiological, and laboratory characteristics as well as the outcome of this case. To conclude, among the mechanisms of resistance described to the treatment with tyrosine kinase inhibitors in patients with carcinomas with mutated EGFR, the transformation to small cell carcinoma besides being infrequent is particular, requiring a different diagnostic and therapeutic approach.
Clin Med Insights Circ Respir Pulm Med
· 2019 · PMID 31516312
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Small-bore pleural drainage device insertion has become a first-line therapy for the treatment of pleural effusions (PLEFF) in the intensive care unit; however, no data are available regarding the performance of resident...Small-bore pleural drainage device insertion has become a first-line therapy for the treatment of pleural effusions (PLEFF) in the intensive care unit; however, no data are available regarding the performance of resident doctors in the execution of this procedure. Our aim was to assess the prevalence of complications related to ultrasound-guided percutaneous small-bore pleural drain insertion by resident doctors. In this single-center observational study, the primary outcome was the occurrence of complications. Secondary outcomes studied were as follows: estimation of PLEFF size by ultrasound and postprocedure changes in PaO/FiO ratio. In all, 87 pleural drains were inserted in 88 attempts. Of these, 16 were positioned by the senior intensivist following a failed attempt by the resident, giving a total of 71 successful placements performed by residents. In 13 cases (14.8%), difficulties were encountered in advancing the catheter over the guidewire. In 16 cases (18.4%), the drain was positioned by a senior intensivist after a failed attempt by a resident. In 8 cases (9.2%), the final chest X-ray revealed a kink in the catheter. A pneumothorax was identified in 21.8% of cases with a mean size (±SD) of just 10 mm (±6; maximum size: 20 mm). The mean size of PLEFF was 57.4 mm (±19.9), corresponding to 1148 mL (±430) according to Balik's formula. Ultrasound-guided placement of a small-bore pleural drain by resident doctors is a safe procedure, although it is associated with a rather high incidence of irrelevant pneumothoraces.
Furukawa H, Oka S, Shimada K
… +4 more, Hashimoto A, Komiya A, Matsui T, Tohma S
Clin Med Insights Circ Respir Pulm Med
· 2019 · PMID 31391785
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OBJECTIVE: Acute-onset diffuse interstitial lung disease (AoDILD) includes acute exacerbation of interstitial lung disease (ILD), drug-induced ILD, and pneumonia in collagen diseases patients. As AoDILD causes a poor pr...OBJECTIVE: Acute-onset diffuse interstitial lung disease (AoDILD) includes acute exacerbation of interstitial lung disease (ILD), drug-induced ILD, and pneumonia in collagen diseases patients. As AoDILD causes a poor prognosis in collagen disease patients, the pathogenesis of AoDILD should be investigated. Exome sequencing studies revealed that rare variants were detected to be causative in some diseases. Recently reported upregulated genes in acute exacerbation of idiopathic pulmonary fibrosis could provide candidate genes for restricted exome analysis of AoDILD in collagen disease. Here, we investigated rare variants in the coding and boundary regions of these candidate genes in AoDILD. METHODS: Deleterious rare variants in the coding and boundary regions of the candidate genes were analyzed by exome sequencing and the deleterious rare allele frequencies in AoDILD were compared with those of controls. RESULTS: A significant association was detected for deleterious rare alleles in ( = .0044, = .0399, odds ratio [OR] = 10.05, 95% confidence interval [CI] = 3.01-33.55). A deleterious rare allele frequency in the 9 candidate genes ( = .0011, OR = 7.17, 95% CI = 2.80-18.33) was also increased in AoDILD in multigene panel analysis. The Krebs von den Lungen-6 (KL-6) levels in AoDILD patients with deleterious rare alleles were tended to be lower than those without ( = .0168, = .1509). CONCLUSIONS: The deleterious rare alleles in were associated with AoDILD. In addition, the deleterious rare allele frequency in the 9 candidate genes was also increased in AoDILD. The deleterious rare alleles might contribute to the pathogenesis of AoDILD.