Multidrug-resistant tuberculosis: response to treatment.

OBJECTIVE: We investigated clinical response and mortality rates in 18 HIV- negative patients with multidrug-resistant tuberculosis. METHOD: We obtained detailed data from our hospital on patients with multidrug - resistant tuberculosis defined as tuberculosis resistant at least to isoniazid and rifampicin. Therapeutic responses were evaluated by both microbiologic and clinical data. RESULTS: From January 1985 to December 1990, 18 HIV-negative patients were identified and treated. One patient committed suicide 1 week after receiving antituberculous drugs. Of the 17 patients, 10 (58.8%) had clinical response as well as microbiologic response, 6 (35.3%) were persisters during 24 months of follow-up, and 1 (5.8%) died after 30 months of treatment. The median follow-up for the patients was 87 weeks (range, 24 to 212). For those who responded well, there was no relapse.

Adult respiratory distress syndrome in Thai medical patients.

Adult respiratory distress syndrome (ARDS) has been a well recognized severe form of acute respiratory failure of multiple causes, which is characterized by intractable hypoxemia and an extremely high mortality rate. Forty-six cases of ARDS admitted to the Department of Medicine, Ramathibodi Hospital during a 39 months period were studied prospectively to explore the etiologic risk, positive end-expiratory pressure (PEEP) profiles, complications and outcome of treatment. There were 19 females and 27 males with the mean age of 40 years. Risks of ARDS included intra- and extra-pulmonary disease conditions and also tropical diseases such as malaria and leptospirosis. At the time of diagnosis, patients in this group were extremely hypoxic with a mean arterial/alveolar oxygen tension (PaO2/PAO2) of 0.125 +/- 0.04. After the application of appropriate PEEP, the mean PaO2/PAO2 ratios increased significantly in both survivor and non-survivor groups (0.277 and 0.199). The levels of PEEP used were below 16 and 11 cmH2O in 93.46% and 67.38% of cases, respectively. Complications of PEEP which included barotrauma and hypotension were found in 11 cases (23.9%) with a very high mortality rate (81.8%). There were 28 deaths of patients in this study, giving an overall 60.8% group mortality rate. Despite the similarities in most clinical profiles, the survivors, when compared to the non-survivors, showed a greater extent of improved oxygenation in response to the application of PEEP, with fewer PEEP complications. The present study would, hopefully, provide the Thai clinicians with valuable informations in the management of ARDS.

The severity of disease measurements among Thai medical intensive care unit patients.

Since the diversity of diseases and complexities of treatment keeps on increasing, a precision of evaluation system that shows a strong and stable relationship to outcomes is needed. The APACHE II severity of disease classification system is an example that proved to be valid for large numbers of patients in different countries. Data from 334 Thai medical ICU patients were collected prospectively in order to validate the APACHE II system, and compare the findings with previous reports. Despite some differences in disease categories, the results showed close relation between APACHE II scores and the hospital mortality rate. The predictive power for death was strong with a specificity of 95% and correct prediction of 83% at the risk level of 0.5. The actual to predicted death ratio, an indicator of hospital performance, in this studied group was 1.17 and was close to the findings of most centers in USA. By providing a measure of severity of disease, APACHE II classification system can provide Thai researchers with a useful tool for clinical researches and improving the treatment of critically ill patients.

A home-made IMV-CPAP system for difficult to wean patients.

A continuous, high flow gas was incorporated into the conventional intermittent mandatory ventilation (IMV) circuit attached to the pressure or volume cycled ventilator which had no built-in IMV mode. These created a continuous flow IMV-CPAP system. During the spontaneous breathing period, the gas flow was high enough to raise a 5-6 cm H2O CPAP level and cause minimal airway pressure fluctuation, an indicator of reduced breathing work. Sixteen patients who were unable to tolerate T-piece weaning were weaned successfully by this IMV-CPAP system. They were medical and surgical patients with prolonged ventilatory support (10-62 days). The respiratory mechanics prior to weaning were relatively marginal. Tidal volume, minute volume and respiratory rate were 260.71 +/- 104 cc, 9.71 +/- 3.54 LPM and 30.29 +/- 5.31/minute respectively. During the weaning course arterial pCO2 retained gradually to their steady states in chronic CO2 retaining patients. This resulted in very minimal fluctuations in arterial pH. All patients were weaned successfully with the average weaning duration of 14.19 days.

Nosocomial pneumonias in Thailand.

In order to compare the etiology, clinical manifestations, and prognosis of patients acquiring nosocomial pneumonia, we studied and compared sixty normal hosts who acquired nosocomial pneumonia during Jan 1, 1989-Dec 31, 1991 (group I) with seventy-two immunocompromised patients with nosocomial pneumonia who were admitted during 1984-1992 (group II). Both groups were similar in some patterns, eg gram-negative bacilli were common (80%, 50%), the chest roentgenogram showed initial localized lesions (74%, 72%), and there was a high mortality rate (46.7%, 54.2%). The differing findings were that the first group acquired pneumonia more often during the first 7 days after admission, transbronchial aspiration was believed to be the route of entry and most of the patients had productive coughs. Blood cultures rarely yielded the organisms (7%). The second group had pneumonia at a mean of 32 days after admission, hematogenous spread to the lungs was common and blood cultures more often yielded the etiologic organisms (41.7%).

Preoperative pulmonary evaluation: which parameters determine the surgical outcome.

In order to find out the correlation between preoperative pulmonary and nonpulmonary variables and the outcome of surgery, one hundred and five cases who had preoperative pulmonary evaluation were included in the study. Of 105 cases, 88 cases underwent surgery. The majority of the cases were old (62.5 +/- 9.63 yrs), with no chest symptoms and signs. The spirometric values in most cases were normal. Most of them were smokers, with the diagnosis of carcinoma of esophagus and underwent thoracoabdominal surgery. Postoperative pulmonary complication was found in 58 cases and mortality was encountered in 12 cases. FEV1, FEF 25-75 per cent and PFEF 25-75 per cent could discriminate survival from death. Duration of surgery (DS) and age factors could predict post-operative pulmonary complication. Only DS could predict prolonged hospital stay, when PFEF 25-75 per cent was coupled with DS, it could predict survival. It was concluded that multiple factors other than spirometric values were responsible for the surgical outcome. They should be taken into consideration for preoperative pulmonary evaluation.

The course of clinical COPD in Thailand.

Spirometry and outcome of 96 cases who were clinically diagnosed as having COPD were studied. Ninety-two cases had significant airway obstruction. Of these 92 cases, initial bronchodilator responses were evaluated in 73 cases. Twenty-six cases were responders (CRAO), while 47 cases were nonresponders (COPD). The average median survival of the whole group was 4 years and 5-year survival was 30 per cent. The annual change in FEV1 in both COPD and CRAO group were fluctuating, with a tendency to decrease in the former and increase in the latter. Spirometric parameters were found to be different between the survivors and nonsurvivors, these included initial PFEV1, PFVC, PFEF 25-75 per cent and postbronchodilator FEV1 and FEF 25-75 per cent. Inspite of the differences, an initial response to bronchodilator could not predict a better outcome for CRAO as compared to COPD. It was concluded that most clinical COPD who had progressive symptoms had significant airway obstruction and shorter survival. Due to fluctuating FEV1 during the course, the initial spirometry and degree of bronchodilator response were not accurate enough to predict subsequent outcome. Long-term follow-up on spirometry and response to bronchodilator should be individually evaluated.

Nosocomial pneumonias-a comparison among normal and compromised hosts in Thailand.

In order to compare the etiology, clinical manifestation, and prognosis of patients acquiring nosocomial pneumonia, we studied and compared twenty normal hosts who acquired nosocomial pneumonia from Jan 1, 1989 to Dec 31, 1989 (group 1) with fifty-four immunocompromised patients with nosocomial pneumonia who were admitted between 1984 and 1990 (group 2). Both groups were similar in some patterns such as: gram-negative bacilli were common (75%, 60%), the chest roentgenogram showed initial localized lesions (75%, 73%), there was a history of prolonged hospitalization (27, 33 days) and a high mortality rate (60%, 50%). The differing findings were that the first group acquired pneumonia more often during the first 7 days after admission; transbronchial aspiration was believed to be the route of entry and most of the patients had productive cough. Blood cultures rarely yielded the organisms (5%). The second group had pneumonia at a mean of 33 days after admission, hematogenous spread to the lungs was common and blood cultures yielded the etiologic organisms more often (40.7%).

The compromised host and pulmonary infiltration: a prospective study.

If immediate sputum examination does not result in a diagnosis, broad spectrum antibiotics should be administered while awaiting cultures. Three days later, if the patient deteriorates and has a negative hemoculture, bronchoalveolar lavage should be done before open lung biopsy or antifungal drugs are considered. We have demonstrated that rational empiric therapy in immunosuppressed patients with pneumonia is beneficial. Diagnostic tests must be performed so that treatment can be modified later when the etiological agent has been identified.

Final diagnosis of "suspicious for malignancy" from bronchial washing cytology.

Our study showed that patients whose first bronchial washing cytology was reported "suspicious for malignancy" had 82 per cent positive predictive value for malignancy. Repeat bronchoscopy should be offered to those with a visible endobronchial mass, and transthoracic needle aspiration should be performed in patients with peripheral lesions.

The effects of inhaled ipratropium bromide, fenoterol and their combination in COPD patients.

A double-blind, cross over, placebo controlled study was conducted to compare the response of lung function to metered doses inhaler of ipratropium bromide (IB, 40 micrograms, fenoterol hydrobromide (F), 100 micrograms, and a combination of the two (IBF). The drugs were administered on 4 consecutive days to 16 stable chronic airway obstructive patients (COPD), all of whom had shown minimal improvement after inhaling sympathomimetic drugs. Lung function response was measured for six hours after administration. All active medications caused greater improvement of FEV1 and FVC than the placebo did and none caused cardiovascular side effects. Improvement of FEV1 and FVC after IBF therapy was significantly better than after F at 1 hour and lasted up to six hour, whereas IBF was better than IB only after the third hour onwards. In addition, additive effects on FEV1 and FVC were seen in this period. IB caused greater response in FEV1 and FVC than F at both first and fifth hour. IB and IBF showed a rapid onset of action and had greater duration of action than F.

Use of bronchoalveolar lavage to diagnose pulmonary infiltrates in immunocompromised hosts.

Bronchoalveolar lavage is a simple and safe technique that aids in making the diagnosis of pulmonary infiltrates in immunosuppressed patients. The procedure can be done even in thrombocytopenic patients and those requiring ventilatory support.