Myasthenia gravis and acute respiratory muscle paralysis following wasp sting.

A 34-year-old lady presented with generalised weakness of body, indistinguishable from myasthenia gravis within 24 hours of a wasp sting. Respiratory muscle paralysis leading to respiratory failure developed and mechanical ventilatory support was required. The patient made an uneventful recovery.

Portopulmonary hypertension in a patient of autoimmune hepatitis.

A 35-year-old women presented with breathlessness and features suggestive of pulmonary hypertension. Further investigations revealed that she had autoimmune hepatitis and both portal and pulmonary hypertension. Pertinent literature is reviewed.

A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension.

OBJECTIVES: Hepatopulmonary syndrome consists of a triad of hepatic dysfunction and/or portal hypertension, intrapulmonary vascular dilatations and hypoxemia. A study of hepatopulmonary syndrome among patients of cirrhosis of liver and portal hypertension was undertaken. METHODS: Thirty patients participated in this study. The diagnosis of cirrhosis of liver was confirmed by liver biopsy. Arterial blood gas analysis, pulmonary function tests, two-dimensional transthoracic air contrast echocardiography were undertaken in all the patients. Those patients in whom contrast echocardiogram showed intrapulmonary vascular dilatations were classified as the positive group while others were labelled as the negative group. RESULTS: Ten patients (33.33%) had a positive contrast echocardiogram; five (16.67%) of them were found to have PaO2<70 mmHg and were qualified for the diagnosis of hepatopulmonary syndrome (HPS); and other five (16.67%) with PaO2>70 mmHg were diagnosed as intrapulmonary dilatations syndrome (IPVDS). Five patients of HPS revealed significant P(A-a)O2 gradient and intrapulmonary shunts of moderate severity computed by a/A ratio. Cyanosis (p=0.001), clubbing (p=0.009) and orthodeoxia (p=0.0024) were significantly commoner in the five patients of hepatopulmonary syndrome. Presence of spider naevi was significantly related with the presence of intrapulmonary vascular dilatations. CONCLUSIONS: The study results showed presence of hepatopulmonary syndrome and intrapulmonary vascular dilatation syndrome among patients of portal hypertension. The presence of cyanosis, clubbing and orthodeoxia were found to be suggestive indicators of hepatopulmonary syndrome. Even though not very specific, spider naevi were found to be a useful clinical indicator for the presence of intrapulmonary vascular dilatations.

Evaluation of ventilator-associated lower respiratory tract infection and tracheobronchial aspiration of gastrointestinal contents.

STUDY OBJECTIVE: Ventilator-associated lower respiratory tract infection (LRTI) in a set up of respiratory intensive care unit was evaluated. Also the incidence of tracheobronchial aspiration of gastrointestinal contents was explored among these patients. DESIGN: Twenty eight patients admitted in the respiratory intensive care unit of referral teaching hospital were studied. All patients were evaluated for tracheobronchial aspiration of gastrointestinal contents in the initial 48 hours of initiating mechanical ventilation using methylene blue as marker and glucostix reagent strip. Protected endotracheal aspirate was secured after 48 hours of beginning of mechanical ventilation and was submitted for microbiological assay. RESULTS: Of the 28 mechanically ventilated patients, 82% were found to have developed LRTI. Aerobic gram-negative bacilli accounted for 79% of the infections, Klesiella responsible for 39% while Pseudomonas and Escherichia accounted for 18% each. The remaining 4% were caused by Acinetobacter. Gram-positive cocci were responsible for 21% of infection with Staphylococcus and enterococci 14% and 7% respectively. Tracheobronchial aspiration of GI contents was found to be present in 72% of the patients which was significantly correlated with the incidence of LRTI (p=0.014). Significant association was also found between the incidence of LRTI and mortality (p=0.05). CONCLUSION: The incidence of gastrointestinal aspiration was found to be high and correlation with LRTI was significant. Both glucostix reagent strip and methylene blue were observed to have same positivity rate.

Bronchial stenosis after blunt chest trauma.

A young boy who sustained blunt chest trauma 24 months back, presented with repeated chest infections. His chest skiagram revealed right hemithorax opaque and CT scan of thorax showed collapse of right lung. Fiberoptic bronchoscopy helped to diagnose the post-traumatic stenosis of right main bronchus. Laser resection was utilized to restore the patency.

Vocal cord dysfunction masquerading as bronchial asthma.

Vocal cord dysfunction (VCD) is a relatively rare condition that may mimic asthma or upper airway obstruction. In contrast to initial reports, recent work emphasizes that patients with VCD often may have both asthma and VCD concurrently. VCD presents a formidable diagnostic challenge. Spirometry often gives variable results. The diagnosis is confirmed at direct laryngoscopy by observing abnormal vocal cord movements without other pathologic processes. Therapy of VCD involves removal of unnecessary medications, efforts to minimize vocal cord irritation, and aggressive speech therapy. In selected cases, anxiolytic medications and psychiatric consultation may be beneficial.

Efficacy of noninvasive nasal mechanical ventilation in acute respiratory failure: monitored by breathing patterns.

OBJECTIVES: Till a decade back, the mainstay delivery of mechanical ventilation to patients with acute respiratory failure was through the endotracheal tube. To obviate the various complications of endotracheal intubation, noninvasive mechanical ventilation (NIMV) techniques were devised which could be used outside the confines of an ICU setting, and have been employed by several workers to achieve a high success rate. METHODS: Twenty patients of acute respiratory failure (ARF) were treated with NIMV. The latter was delivered by assist control mode of ventilator and nasal CPAP mask. Improvement of the illness was monitored by serial ABG analysis and breathing pattern parameters over one week. RESULTS: The application of NIMV was successful in reversing the illness in 17 patients (85%) and the other three patients had to be intubated. The pH rose from 7.267 +/- 0.087 at presentation to 7.411 +/- 0.032 (p < 0.00005), the PaCO2 dropped from 85.17 +/- 13.48 mmHg to 46.27 +/- 3.79 mmHg (p < 0.00005). The PaO2 improved from 52.36 +/- 11.14 mmHg to 63.60 +/- 7.55 mmHg (p < 0.005) on the seventh day. The respiratory rate (RR) decreased from 30.07 +/- 6.10 breaths/min to 22.05 +/- 4.05 breaths/min (p < 0.00005), the %RC (percent rib cage) also showed a significant reduction in rib cage contraction from 61.7 +/- 10.17 to 42.76 +/- 10.66 (p < 0.00005). A marked improvement during the initial four hours of application of NIMV was observed in all the 17 patients. CONCLUSIONS: It was concluded that NIMV resulted in marked improvement in both the breathing pattern and blood gas parameters in patients of ARF; and PaCO2, pH, RR, %RC served as the best indicators of improvement. NIMV was observed to be most useful in those patients who had CO2 retention.

Sleep apnea syndrome among patients with hypothyroidism.

OBJECTIVE: There is an association of sleep apnea among patients with untreated hypothyroidism. Thyroxine therapy is considered to reduce AHI (apnea-hypopnea index) significantly. A study of 20 successive hypothyroid patients was undertaken to investigate the occurrence of sleep apneas, and response to thyroxine therapy after achieving euthyroid state. METHODS: Sleep studies were conducted in 20 consecutive hypothyroid patients at our sleep centre while they were hypothyroid. All were restudied during euthyroid state subsequent to three months of thyroxine therapy. RESULTS: Nine (45%) of untreated 20 patients had obstructive sleep apnea syndrome (OSAS). Restudy of them during euthyroid state showed complete recovery in six, partial improvement in two and no change in one. Besides them, three other patients developed sleep apnea syndrome of central origin after euthyroid state was achieved. Central respiratory drive improved in 17 patients, while it was reduced among three of nine patients with OSAS who did not show recovery. CONCLUSION: Our experience suggests that there is high incidence of sleep apnea among hypothyroid patients. Thyroxine treatment could achieve disappearance of these apneas in majority of them. Few hypothyroids may develop sleep apnea despite the achievement of euthyroid state. Central respiratory drive probably plays an insignificant role in the pathogenesis of sleep apnea among hypothyroids.

Obstructive sleep apnea syndrome: evaluation of subcritical continuous positive airway pressure.

Twenty eight of 48 patients diagnosed of obstructive sleep apnea syndrome over a six month duration opted for CPAP therapy. Half of them were given critical CPAP (Group A) and other half were prescribed subcritical level of CPAP (Group B). Re-evaluation after 3 months revealed that side effects like headache and feeling of inconvenience were more in Group A, though beneficial effects were same in both groups. It is concluded that subcritical level of CPAP should be adopted to treat patients of obstructive sleep apnea syndrome.

Study of oxygen saturation, breathing pattern and arrhythmias in patients of interstitial lung disease during sleep.

Twenty patients of interstitial lung disease (ILD) and same number of healthy adults were selected to monitor arterial hemoglobin oxygen saturation (SaO2) breathing pattern and arrhythmias during sleep. The maximum fall in SaO2 during sleep was 13.1% (10-16%) in ILD patients as compared to 4.8% (3-6%) in controls and the difference was significant (p < 0.005). The ILD patients spent 16.9% of mean total sleep time (TST) below 85% SaO2 and 0.7% of mean TST below 80% SaO2 whereas none of the healthy subjects had SaO2 below 90% during sleep. These patients had more disturbed sleep than controls. Abnormally high breathing frequency demonstrated by ILD patients while awake, was not altered during sleep. Both tidal volume (VT) and minute ventilation (Vmin) decreased by 6.6% and 11.5%, respectively in ILD patients during sleep though it was not significant (p > 0.25) statistically. The respiratory drive was declined during sleep in ILD patients. The percent of tidal volume contributed by rib cage (% RC) lessened during sleep in all the subjects. The ratio of the total excursion of the rib cage and abdomen during inspiration without considering the direction of movement, divided by tidal volume (TCD/VT) revealed asynchronous breathing in ILD patients during sleep. Arrhythmias were found in 6 (30%) of ILD patients and 4 (20%) of control subjects. Observed apnea-hypopnea did not qualify for sleep apnea syndrome in any case.

Faulty use of metered dose inhalers by physicians.

A questionnaire regarding use of metered dose inhalers (MDI) was administered to 38 physicians, 9 faculty members and 29 residents. Fifty-five percent of faculty members answered at least three or more of the seven steps of inhalation technique correctly as compared with 86% of residents, this was statistically significant (p value < 0.01). All the participants used to prescribe MDI to their patients. 80% of them responded that they followed package insert instructions to educate their patients. It was concluded that doctors involved with MDI use, should learn and become familiar with proper recommendation for its optimal aerosol delivery.

Assessment of upper airway obstruction by pulmonary function testing.

Twenty-five cases of upper airway obstruction (UAO) of different diseases and ten normal healthy controls were studied by deriving parameters from raw data on Gould System-21 Pulmonary Work station. All the obstructive lesions were confirmed under direct visualisation by fibreoptic bronchoscopy or indirect laryngoscopy. It was observed that FEF 50%/FIF 50% ratio above 1 was the best diagnostic indicator for fixed and variable extrathoracic UAO (p < 0.02). FEV1/PEFR was altered significantly (p < 0.001) and value above 10 ml/Litre/min was the second best parameter to recognise UAO. FEV1 0.5 < or = 1.5 (p < 0.001) and FIF 50% < 100 Lit/min were also suggestive of UAO. Flow volume loop remained the most sensitive method to detect UAO but only 15 patients could construct it. These altered parameters returned to normal after the surgical removal of obstruction which was possible in three cases.

Re-expansion pulmonary edema and hypotension.

A case with diagnosis of non-Hodgkin's lymphoma and superior vena cava obstruction on chemotherapy, presented with respiratory distress and massive pleural effusion of right hemithorax. On removal of 3.5 litres of fluid, he developed pulmonary edema of the same side and hypotension.

Recurrent pneumothorax.

A young man with spontaneous pneumothorax who suffered from fourth recurrence, is being reported. He was treated by surgical pleural abrasion.

Massive pleural effusion, pseudocysts and pancreatico-pleural fistula with asymptomatic pancreatic disease.

A case of chronic pancreatitis with multiple pseudocysts of the pancreas and a pancreatico-pleural fistula causing massive left sided pleural effusion is reported, being a rare and an unusual cause of pleural effusion. This case illustrates the importance of pleural fluid amylase estimation in the diagnosis and the role of endoscopic retrograde cholangio pancreatography to elucidate the pathogenesis of such an effusion. The role of medical management is also emphasized.