Prognostic Value of Respiratory Variation in Right Atrial Pressure in Patients With Precapillary Pulmonary Hypertension.

BACKGROUND: Precapillary pulmonary hypertension is characterized by elevated mean pulmonary artery pressure from increased pulmonary vascular resistance. Lack of respiratory variation in right atrial pressure can be viewed as a surrogate for severe pulmonary hypertension and inability of the right ventricle to tolerate preload augmentation during inspiration. RESEARCH QUESTION: Is the lack of respiratory variation in right atrial pressure predictive of right ventricular dysfunction and worse clinical outcomes in precapillary pulmonary hypertension? STUDY DESIGN AND METHODS: We retrospectively reviewed right atrial pressure tracings of patients with precapillary pulmonary hypertension who underwent right heart catheterization. Patients with respiratory variation in right atrial pressure (end expiratory-end inspiratory) ≤ 2 mm Hg were considered to have effectively no meaningful variation in right atrial pressure. RESULTS: Lack of respiratory variation in right atrial pressure was associated with lower cardiac index by indirect Fick (2.34 ± 0.09 vs 2.76 ± 0.1 L/min/m2; P = .001), lower pulmonary artery saturation (60% ± 1.02% vs 64% ± 1.15%; P = .007), higher pulmonary vascular resistance (8.9 ± 0.44 vs 6.1 ± 0.49 Wood units, P < .0001), right ventricular dysfunction on echocardiography (87.3% vs 38.8%; P < .0001), higher pro brain natriuretic peptide (2,163 ± 2,997 vs 633 ± 402 ng/mL; P < .0001), and more hospitalizations within 1 year for right ventricular failure (65.4% vs 29.6%; P < .0001). There was also a trend toward higher mortality at 1 year in patients with no respiratory variation in right atrial pressure (25.4% vs 11.1%; P = .06). INTERPRETATION: Lack of respiratory variation in right atrial pressure is associated with poor clinical outcomes, adverse hemodynamic parameters, and right ventricular dysfunction in patients with precapillary pulmonary hypertension. Larger studies are needed to further evaluate its utility in prognosis and potential risk stratification in patients with precapillary pulmonary hypertension.

The Diagnostic Yield, Safety, and Impact of Flexible Bronchoscopy in Non-HIV Immunocompromised Critically Ill Patients in the Intensive Care Unit.

BACKGROUND: Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests. OBJECTIVE: To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU). METHODS: A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL. RESULTS: FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases. CONCLUSION: FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.

Disorders of the Chest Wall: Clinical Manifestations.

Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.

Hypoxic hepatitis - its biochemical profile, causes and risk factors of mortality in critically-ill patients: A cohort study of 565 patients.

PURPOSE: A retrospective analysis of critically-ill patients with hypoxic hepatitis (HH) to characterize the biochemical profile and to identify predictors of mortality using the Medical Information Mart for Intensive Care III database. METHODS: HH was defined as a rapid increase in AST/ALT≥800IU/L after exclusion of other causes. We investigated the correlation between various clinical and laboratory parameters and mortality rates using regression models. RESULTS: Among 38,645 ICU-patients, 565 (1.46%) were diagnosed with HH; 57.9% were males; median age was 63years. The unique biochemical profile of HH was confirmed; lactate dehydrogenase (LDH) was higher than both ALT and AST; AST>ALT for the first 2days then the ratio is reversed until recovery. All-cause hospital mortality was 44.1%. All-cause hospital mortality was 44.1%. On multivariate analysis, older age, higher SAPS-II, higher INR, higher bilirubin, higher LDH, acute kidney injury (AKI), and the need for vasopressors were independently associated with mortality. CONCLUSION: Older age, higher SAPS-II, LDH, INR and bilirubin levels, concomitant AKI and the need for vasopressors were all factors associated with increased mortality. The diagnosis of HH was an important harbinger of mortality in this population, which appears to be driven mainly by the severity of the underlying conditions.

Right in Front of Our Eyes: Evolution of Streptococcal Toxic Shock Syndrome with Ischemic Optic Neuropathy.

INTRODUCTION: Toxic shock syndrome occurs from dysregulation of host inflammatory responses. Toxin- producing strains of Group A streptococcus cause TSS. Ischemic optic neuropathy rarely complicates septic shock. We present a rare case of streptococcal pharyngitis complicated by septic arthritis and TSS with reversible blindness due to non-arteritic ischemic optic neuropathy. CASE: A 28-year-old man drove to our ED with exudative pharyngitis. A rapid streptococcal test was positive. While awaiting oral penicillin he became hypotensive refractory to IV fluids and developed knee effusion. The patient noted progressive dimming of his vision. Arthrocentesis yielded GAS. ICU course was complicated by ARDS but after 2 weeks the patient was weaned off vasopressors and the ventilator. He regained his vision and had no neurological sequelae. The patient's GAS isolate was M protein gene (emm) type 1 and T type 1. He was followed in the IM clinic for 9 months post discharge with complete resolution of symptoms. CONCLUSION: The rapidity of the development of shock is attributed to streptococcal exotoxins acting as superantigens. GAS type M1 is commonly associated with severe shock in TSS. The severe shock was the likely cause of his ischemic optic neuropathy. Early recognition and aggressive management of TSS are crucial to clinical outcome. [Full article available at http://rimed.org/rimedicaljournal-2016-12.asp].

Evidence for the vitamin D hypothesis: The NHANES III extended mortality follow-up.

BACKGROUND AND AIMS: Emerging evidence suggests that low levels of vitamin D may be an important risk factor for multiple chronic diseases and mortality, but the evidence is mixed. Vitamin D levels are associated with sun exposure, diet, and metabolic status. One potential explanation for the lack of consistent findings amongst various studies is that low vitamin levels may be associated with poor diets or other risk factors that we were not adequately controlled for in different analyses. METHODS: Prospective analysis of adults over the age of 35 in NHANES III data (1988-1994) with 20 year mortality follow-up. Sequential Cox proportional hazard models quartiles of 25OH vitamin D adjusted for age, season, geography, sociodemographic (SD), CVD risk factors (CVD) and nutritional factors (NF) were performed. RESULTS: Gender, race, diabetes, anti-hypertensive meds, income, taking vitamin D supplements, physical activity, alcohol consumption, region, body mass index, blood pressure, creatinine, albumin, CRP, thyroxine, iron, RBC folate, vitamin A, E, alpha-carotene, and lycopene were all associated with different quartiles of vitamin D and as well as CHD and all-cause mortality and thus are important potential confounders of this relationship. Adjusting for the confounding factors, higher levels of vitamin D demonstrate an inverse relationship with all-cause mortality, but only the top quartile of vitamin D shows an inverse relationship with CHD mortality. CONCLUSIONS: The highest quartile compared to the lowest quartile of 25OH vitamin D levels is inversely associated with CHD and all-cause mortality adjusting for multiple confounders. Whether supplementation of individuals with low vitamin D will result in similar benefits will require a randomized clinical trial.

Fluid Choice Matters in Critically-ill Patients with Acute Pancreatitis: Lactated Ringer's vs. Isotonic Saline.

OBJECTIVES: To investigate the effect of different crystal- loid solutions on clinical outcomes in critically-ill patients with acute pancreatitis (AP). METHODS: We conducted a retrospective study of patients with AP admitted to the ICU using the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. We investigated the effect of fluid type; lactated ringer's (LR) vs. isotonic saline (IS) on hospital mortality rates, and ICU length of stay (LOS). RESULTS: Hospital mortality of the 198 included patients was 12%. For fluid type, 32.9% were resuscitated with LR vs. 67.1% with IS. Hospital mortality was lower in the LR group (5.8%) vs. 14.9% for IS group, odds ratio of 3.10 [P=0.041]. This effect was still observed after adjusting for confounders. However, ICU LOS was longer in LR compared to IS group; 6.2±6.9 vs. 4.2±4.49 days respectively [P= 0.020]. CONCLUSION: The type of fluid used for resuscitation in AP may affect the outcome. LR may have survival benefit over IS in critically-ill patients with AP. [Full article available at http://rimed.org/rimedicaljournal-2016-10.asp].

Diffuse Alveolar Hemorrhage Secondary to Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Predictors of Respiratory Failure and Clinical Outcomes.

OBJECTIVE: To identify predictors of respiratory failure and to evaluate the therapeutic efficacy of plasma exchange (PE) and of rituximab versus cyclophosphamide in a cohort of patients with diffuse alveolar hemorrhage (DAH) secondary to antineutrophil cytoplasmic antibody-associated vasculitis (AAV) with or without respiratory failure. METHODS: We performed a single-center historical cohort study of all consecutive patients with AAV-associated DAH who were evaluated over a 16-year period. Logistic regression models were developed to examine the predictive role of the baseline clinical characteristics for the development of respiratory failure, and for the effect of PE and remission induction therapy on the main outcome (complete remission at 6 months). RESULTS: Seventy-three patients with DAH were identified, and 34 of them experienced respiratory failure. The degree of hypoxemia upon initial presentation, a higher percentage of neutrophils in the bronchoalveolar lavage fluid cell count, and higher C-reactive protein levels were independently associated with the development of respiratory failure. PE was not associated with achieving complete remission at 6 months, with an odds ratio (OR) of 0.49 (95% confidence interval [95% CI] 0.12-1.95) (P = 0.32). Rituximab treatment was independently associated with achieving complete remission at 6 months (OR 6.45 [95% CI 1.78-29], P = 0.003). CONCLUSION: Our findings indicate that the most important predictor of respiratory failure in patients with DAH secondary to AAV is the degree of hypoxemia upon presentation. No clear benefit of the addition of PE to standard remission induction therapy was demonstrated. Complete remission by 6 months was achieved at a higher rate with rituximab than with cyclophosphamide in patients with DAH secondary to AAV, including those needing mechanical ventilation.

Takotsubo Cardiomyopathy: A New Perspective in Asthma.

Takotsubo cardiomyopathy (TCM) is an entity of reversible cardiomyopathy known for its association with physical or emotional stress and may mimic myocardial infarction. We report an exceedingly rare case of albuterol-induced TCM with moderate asthma exacerbation. An interesting association that may help in understanding the etiology of TCM in the asthmatic population. Although the prognosis of TCM is excellent, it is crucial to recognize beta agonists as a potential stressor.

Decision support tool for differential diagnosis of Acute Respiratory Distress Syndrome (ARDS) vs Cardiogenic Pulmonary Edema (CPE): a prospective validation and meta-analysis.

INTRODUCTION: We recently presented a prediction score providing decision support with the often-challenging early differential diagnosis of acute lung injury (ALI) vs cardiogenic pulmonary edema (CPE). To facilitate clinical adoption, our objective was to prospectively validate its performance in an independent cohort. METHODS: Over 9 months, adult patients consecutively admitted to any intensive care unit of a tertiary-care center developing acute pulmonary edema were identified in real-time using validated electronic surveillance. For eligible patients, predictors were abstracted from medical records within 48 hours of the alert. Post-hoc expert review blinded to the prediction score established gold standard diagnosis. RESULTS: Of 1,516 patients identified by electronic surveillance, data were abstracted for 249 patients (93% within 48 hours of disease onset), of which expert review (kappa 0.93) classified 72 as ALI, 73 as CPE and excluded 104 as "other". With an area under the curve (AUC) of 0.81 (95% confidence interval = 0.73 to 0.88) the prediction score showed similar discrimination as in prior cohorts (development AUC = 0.81, P = 0.91; retrospective validation AUC = 0.80, P = 0.92). Hosmer-Lemeshow test was significant (P = 0.01), but across eight previously defined score ranges probabilities of ALI vs CPE were the same as in the development cohort (P = 0.60). Results were the same when comparing acute respiratory distress syndrome (ARDS, Berlin definition) vs CPE. CONCLUSION: The clinical prediction score reliably differentiates ARDS/ALI vs CPE. Pooled results provide precise estimates of the score's performance which can be used to screen patient populations or to assess the probability of ALI/ARDS vs CPE in specific patients. The score may thus facilitate early inclusion into research studies and expedite prompt treatment.

Focal tracheal stenosis due to intramural hematoma following endobronchial ultrasound-guided transbronchial needle aspiration.

Tracheal obstruction can present insidiously or be acute and life threatening. This condition can occur acutely, as in cases of infection or foreign body aspiration, whereas posttraumatic tracheal stenosis or obstruction due to intraluminal tumor growth typically evolves more gradually. Tracheal stenosis secondary to intramural hematoma is exceedingly rare. We report a case of intramural tracheal hematoma causing obstruction following endobronchial ultrasound-guided transbronchial needle aspiration in a 69-year-old woman.

Chronic pulmonary aspergillosis complicating bronchial atresia.

Bronchial atresia is a rare pulmonary developmental anomaly characterized by the presence of a focal obliteration of a segmental or lobar bronchial lumen. The lung distal to the atretic bronchus is typically emphysematous along with the presence of mucus filled ectatic bronchi (mucoceles). BA is usually asymptomatic but pulmonary infections can rarely develop in the emphysematous lung distal to the atretic bronchus. We present a unique case of chronic pulmonary aspergillosis (CPA) in a patient with BA with no evidence of immune dysfunction. The patient was treated initially with voriconazole and subsequently underwent surgical excision of the involved area. On follow-up, she has done extremely well with no evidence for recurrence. In summary, we describe the first case of chronic pulmonary aspergillosis in an immunocompetent patient with bronchial atresia.

The "forgotten zone": acquired disorders of the trachea in adults.

The upper airway is generally defined as the air passage segment that extends between the naso- or oropharynx and the carina. The longest segment of the upper airway-the trachea-begins at the inferior portion of the larynx and extends to the branch point of the main carina. The trachea has the potential to be a "forgotten zone" in differential diagnoses, as pathological processes involving this portion may not receive prominent clinical consideration in disorders presenting with respiratory symptoms and signs. Unlike the oropharynx, this anatomical area is beyond visualization on routine inspection; unlike the mediastinum and lung fields, it is a potential "blind spot" on initial, plain radiographic examination of the chest. Nonetheless, the adult trachea is affected by a number of primary disorders and is also a target organ of a variety of systemic diseases. This review will focus on both primary and systemic diseases involving the adult trachea with specific attention to their clinical manifestations and diagnostic hallmarks.