Extracorporeal Membrane Oxygenation in Severe Acute Eosinophilic Pneumonia.

Acute Eosinophilic Pneumonia (AEP) is a potentially fatal cause of hypoxemic respiratory failure characterized by fever, diffuse bilateral pulmonary infiltrates, and pulmonary eosinophilia. Shown to be associated with a number of environmental exposures and lifestyle choices, AEP has a good prognosis when diagnosed early and treated with corticosteroids. In this clinical case report, we detail the presentation, evaluation, diagnosis, and management of a 40-year old male who presented to the emergency department with dyspnea, chills, and diaphoresis. He had a history of pulmonary embolism 8 years prior but was otherwise healthy, though he had re-started smoking cigarettes a week prior to presentation. Initial chest CT scan revealed widespread mixed groundglass and solid airspace opacities; over the next 12 hours, he rapidly decompensated and after not responding to other invasive mechanical ventilation, was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO). Bronchoalveolar lavage later revealed pulmonary eosinophilia, and after an infectious workup was negative, a diagnosis of AEP was reached and the patient was started on corticosteroids. To our knowledge, this is one of few published cases of AEP requiring V-V ECMO for clinical stabilization, highlighting the utility of this treatment modality in severe disease.

Intravenous vitamin C as adjunctive therapy for enterovirus/rhinovirus induced acute respiratory distress syndrome.

We report a case of virus-induced acute respiratory distress syndrome (ARDS) treated with parenteral vitamin C in a patient testing positive for enterovirus/rhinovirus on viral screening. This report outlines the first use of high dose intravenous vitamin C as an interventional therapy for ARDS, resulting from enterovirus/rhinovirus respiratory infection. From very significant preclinical research performed at Virginia Commonwealth University with vitamin C and with the very positive results of a previously performed phase I safety trial infusing high dose vitamin C intravenously into patients with severe sepsis, we reasoned that infusing identical dosing to a patient with ARDS from viral infection would be therapeutic. We report here the case of a 20-year-old, previously healthy, female who contracted respiratory enterovirus/rhinovirus infection that led to acute lung injury and rapidly to ARDS. She contracted the infection in central Italy while on an 8-d spring break from college. During a return flight to the United States, she developed increasing dyspnea and hypoxemia that rapidly developed into acute lung injury that led to ARDS. When support with mechanical ventilation failed, extracorporeal membrane oxygenation (ECMO) was initiated. Twelve hours following ECMO initiation, high dose intravenous vitamin C was begun. The patient's recovery was rapid. ECMO and mechanical ventilation were discontinued by day-7 and the patient recovered with no long-term ARDS sequelae. Infusing high dose intravenous vitamin C into this patient with virus-induced ARDS was associated with rapid resolution of lung injury with no evidence of post-ARDS fibroproliferative sequelae. Intravenous vitamin C as a treatment for ARDS may open a new era of therapy for ARDS from many causes.

A protocol-driven approach to early extubation after heart surgery.

OBJECTIVE: We assessed the effectiveness of standardized protocols in decreasing postoperative mechanical ventilation time to <6 hours. METHODS: In 2061 patients undergoing coronary bypass, the proportion extubated in <6 hours was calculated for 3 sequential time periods. During period 1 patients were weaned per baseline practices; during period 2, per a protocol developed by a multidisciplinary committee; and during period 3, as in period 2 but with paralytic reversal and extubation performed at lower body temperatures and an extubation reminder sheet prominently displayed. We used a χ(2) test to examine differences in ventilation times among the 3 time periods and logistic regression modeling to control for independent risk factors for prolonged ventilation. As measures of patient safety, we examined rates of reintubation and rates of patient shivering following paralytic reversal. RESULTS: Twelve percent of patients were extubated in <6 hours during period 1, 24% during period 2 (P < .01), and 38% during period 3 (P < .01 compared with both periods 1 and 2). After controlling for 12 risk factors, patients were more likely to be extubated in <6 hours during period 2 (odds ratio, 2.39; 95% confidence interval, 1.84-3.10) and period 3 (odds ratio, 5.05; 95% confidence interval, 3.65-6.99) than during period 1. There was no difference in reintubation rates across periods, and the rate of patient shivering did not increase with paralytic reversal at lower body temperature. CONCLUSIONS: The standardized protocols outlined in this article dramatically improved early extubation performance.