Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center.

A performance improvement project was instituted at our facility to standardize pediatric inpatient asthma care by instituting an asthma clinical pathway (ACP). Formal asthma education and standardized postdischarge follow-up plans for all asthma inpatients were initiated. Patients treated by following the ACP were compared against historically similar patients from the previous 4 years. Differences in hospital length-of-stay (LOS) for patients treated on the ACP were compared to historical LOS. Adherence to The Joint Commission's home management plan of care metric, CAC-3, was also compared. There was a 25% lower hospital LOS in the ACP group compared to historical control group, 45.8 hours versus 60.9 hours (p < 0.002). CAC-3 adherence significantly increased from 48% to 89% (p < 0.001) after initiating formal asthma education. The implementation of a pediatric asthma inpatient performance improvement project was associated with a significant decrease in hospital LOS, when compared to historic controls. It also led to a significant improvement in adherence with The Joint Commission's CAC-3 measures.

Delayed presentation: negative pressure pulmonary hemorrhage.

Negative pressure pulmonary hemorrhage (NPPH) is a rare, life-threatening complication that develops after an acute upper airway obstruction. A 26 year old, healthy African-American man with no underlying lung disease developed negative pressure pulmonary edema and subsequently NPPH during recovery from general anesthesia for elective spine surgery. Diagnostic bronchoscopy confirmed an alveolar source of the bleeding. Clinical improvement was quick with supportive care in the medical intensive care unit.

Bronchoscopic view of a tuberculosis cavity with actinomyces.

Coexistence of pulmonary actinomycosis with tuberculosis has rarely been reported. The presence of Actinomyces in sputum and bronchoalveolar lavage is inadequate for diagnosis, as it may represent mere colonization. Traditionally, excisional biopsy is considered to be the gold standard for histologic diagnosis. There are multiple case reports in which the diagnosis of pulmonary actinomycosis was based on bronchial biopsy and Wang needle aspiration. We describe an incidental finding of a bronchial communication with passage of a flexible bronchoscope into the tuberculosis cavity. The images reveal a 5-cm cavity with a whitish, stone-like structure noticed to move back and forth with respiration. Colonies of Actinomyces were seen on transbronchial brushing cytology. Bronchoalveolar lavage cultures were negative. To our knowledge such a detailed pictorial description of a tuberculosis cavity with Actinomyces has not been reported in the past.

Bronchoscopic view of pulmonary blastomycosis.

Blastomycosis is a chronic fungal infection often diagnosed in the south-central and midwestern United States. Lungs are primarily involved, with lymphatic or hematogenous spread to other organs. Bronchoscopy is considered when the noninvasive tests fail to establish the diagnosis. We describe bronchoscopic finding of blastomycosis involving the upper and lower respiratory tract. Inhaled steroids may have suppressed cellular immunity, allowing fungus to grow in the submucosa with histology significant for extensive eosinophilic infiltration. To our knowledge, such a detailed pictorial description of pulmonary blastomycosis with a cobblestone appearance of the tracheobronchial mucosa has not been reported in the past.

Acute splenic rupture in an adult with homozygous sickle cell anemia treated with chronic transfusions.

Splenic rupture is a very rare event in adult homozygous sickle cell patients. The authors describe a 19-year-old patient with homozygous sickle cell disease who experienced an acute splenic rupture crisis requiring emergent splenectomy. He had been receiving chronic blood transfusions regularly for 7 years secondary to a previous stroke. It is possible that these transfusions contributed to regeneration of splenic red pulp, which allowed a crisis to occur at an advanced age.