The polymorphisms of C-reactive protein gene modify the association between central obesity and lung function in taiwan asthmatics.

High-sensitivity C-reactive protein (hs-CRP) concentrations and obesity are proposed to have a significant relationship with impairment of lung function, but little has been reported to date on the association between CRP gene and lung function. We studied the association of three tagSNPs (tag single nucleotide polymorphisms) of CRP gene and their interactions with central obesity on lung function. A total of 384 asthmatic adults and 384 controls who were 1:1 matched by sex and age were recruited for this study. Three tagSNPs polymorphisms for CRP rs1417938, rs1800947 and rs1205 were selected from HapMap data and genotyping by using TaqMan allelic discrimination assay. A questionnaire interview, body composition and pulmonary function tests were performed. CRP single nucleotide polymorphisms (SNPs) did not increase the risk of asthma, but CRP rs1205 CC genotype significantly decreased the predictive value of forced vital capacity (FVC) in the asthma group (adjusted mean change = -7.54%, 95% CI = -13.82 to -1.25%). Waist-to-hip ratio, not body mass index, also decreased the predictive value of FVC in asthmatics. The subjects with central obesity who carried CRP SNPs have a significant reduction effect in lung function. The current results suggest that central obesity may play a major role in lung function, and these effects were modified significantly by the polymorphisms for CRP gene.

Ventilator-associated pneumonia with circuit changes every 2 days versus every week.

BACKGROUND: Frequent ventilator circuit changes are expensive and sometimes unnecessary. Following the worldwide trend to lengthen the intervals for ventilator circuit change from 2 days to 1 week, this study aims to assure that low rate of ventilator-associated pneumonia (VAP) can be maintained with cost containment. METHODS: Ventilator circuits were routinely changed every 7 days in the study period for 2 years and every 2 days during the historical control period of another 2 years. Pediatric patients (age less than 15 years) were not included. Nosocomial pneumonia was diagnosed by the criteria of the Centers of Disease Control and Prevention (CDC) of the United States (US). VAP was identified by combining and comparing 2 databases from the Respiratory Therapy Department and the Infection Control Unit of our hospital. RESULTS: In the study group, 225 episodes of pneumonias were observed in 7,068 patients and 87,338 ventilator days. The rate of VAP was 2.58 per 1,000 ventilator days. There were 174 episodes of pneumonia in 6,213 patients and 65,467 ventilator days of the control group. The rate of VAP was 2.66 per 1,000 ventilator days. The difference between both groups was not significant (p = 0.803). Yet, the cost curbed was around 80,000 US dollars per year. CONCLUSIONS: Extending ventilator circuit change interval from 2 days to 7 days do not increase the risk for VAP, but the cost savings for labor and supply are substantial.

Comparison of bilevel positive airway pressure and volume ventilation via nasal or facial masks in patients with severe, stable COPD.

BACKGROUND: In the past decade, noninvasive positive pressure ventilation (NIPPV) has been successfully used in chronic obstructive pulmonary disease (COPD) with acute exacerbation. Nonetheless, its effect in stable COPD remains controversial. Theoretically, differences in the mode of ventilation such as pressure versus volume preset, or interfaces such as nasal versus full facial mask could have an impact on the efficacy of NIPPV. Few published studies have focused on this topic. METHODS: In this crossover study, bilevel positive airway pressure (BiPAP) for pressure preset ventilation or PLV-100 as a home-care volume preset ventilator was used via a nasal or facial mask in 12 patients with stable hypercapnic COPD. The four types (2 ventilators and 2 masks) of NIPPV were used for 20 minutes each, with a randomized sequence. The patient breathed spontaneously for 10 minutes before and between each type of NIPPV as a baseline for comparison. RESULTS: Respiratory rate, tidal volume, pulse rate, Borg scale and phase angle were all significantly improved during BiPAP ventilation via either a nasal or facial mask (p < 0.05 for all). Suppression of inspiratory muscle activity was obvious, although not statistically significant. In contrast, inspiratory muscle activity, phase angle and respiratory rate increased and tidal volume decreased significantly during PLV-100 ventilation with either nasal or facial masks (p < 0.05 for all). Peak expiratory flow rate and maximum inspiratory and expiratory mouth pressures remained unchanged after each type of NIPPV. CONCLUSIONS: For patients with stable hypercapnic COPD, short-term use of BiPAP via either a nasal or facial mask markedly rests the inspiratory muscles, improves the respiratory pattern and reduces the sense of dyspnea for patients. In contrast, short-term use of PLV-100 via either a nasal or facial mask worsens the above parameters.

Hyperbaric oxygen as an adjunctive treatment for descending necrotizing mediastinitis: a case report.

Descending necrotizing mediastinitis is a rare but serious complication of oropharyngeal and deep neck infection which spreads down to the mediastinum via the cervical-facial planes. Its mortality rate remains high even with aggressive surgical drainage and appropriate antibiotics. Here, a case of descending necrotizing mediastinitis secondary to peritonsillar abscess is reported. It was successfully treated with hyperbaric oxygen and antibiotics followed by surgical drainage. Based on this report, hyperbaric oxygen therapy might be of great value as an adjunctive management to control this fatal infection.

Chylothorax: a complication of internal jugular vein catheterization.

Thoracic duct injury is a potential problem from central venous catheter insertion that has rarely been reported. A case in which a left chylothorax developed 2 days after internal jugular vein catheterization is presented here. This complication was managed successfully by continuous drainage of the pleural space, oral administration of a low-fat, high-carbohydrate and high-protein diet, and application of positive end-expiratory pressure. The etiology, pathogenesis, clinical presentation and recommended management of such iatrogenic chylothorax are discussed on the basis of this clinical report and of a review of the literature.

Postextubation laryngeal edema in adults. Risk factor evaluation and prevention by hydrocortisone.

OBJECTIVE: To evaluate the risk factors for postextubation laryngeal stridor and its prevention by hydrocortisone in adult patients. DESIGN: Prospective, randomized, double-blind, placebo controlled study. SETTING: Medical and surgical ICU of a tertiary teaching hospital. PATIENTS: 77 consecutive patients of both sexes, who had undergone tracheal intubation for more than 24 h and fulfilled the weaning criteria, were eligible for the study. Patients were excluded if they were less than 15 years of age, had a disease or the surgery of the throat, or had been extubated during the current hospitalization. INTERVENTION: The control group received placebo (normal saline 3 cc) and the experimental group received hydrocortisone 100 mg by intravenous infusion 60 min before extubation. MAIN OUTCOME MEASURES: Patients were observed 24 h after extubation for symptoms or signs of laryngeal edema or stridor: prolonged inspiration with accessory usage of respiratory muscles or crowing sound with inspiration or reintubation. RESULTS: The overall incidence of postextubation stridor was 22% (17/77). Only one patient (1%), who belonged to the control group, needed reintubation. 39% of female patients and 17% of male patients developed stridor. The relative risk of females developing this complication was 2.29. 7/39 of the hydrocortisone group and 10/38 of patients in the control group developed postextubation stridor. CONCLUSIONS: Hydrocortisone did not significantly reduce the incidence of postextubation laryngeal edema or stridor. From the risk factors evaluated, we were unable to demonstrate a statistical correlation between postextubation stidor and the duration of the intubation, the patient's age, the internal diameter of the endotracheal tube, or the route of intubation. However, female patients were more likely to develop this complication.

Short-term effects of nasal pressure support ventilation in acute exacerbation of hypercapnic COPD.

BACKGROUND: If nasal pressure support ventilation (NPSV) can be used at the early stage of acute exacerbation of severe COPD, profound ventilatory failure may be prevented without the complication from delayed intubation. To our knowledge, no study has focused on this group of patients. METHODS: In this prospective study, BiPAP was used with three stages of settings each for 30 min as follows: pressure support (PS) 10 cmH2O without PEEP (stage 1), PS 10 & PEEP 5 cmH2O (stage 2), and PS 17 & PEEP 5 cmH2O (stage 3). Data of spontaneous breathing before and after NPSV each for 10 min were also recorded as baselines. RESULTS: One of our 10 male patients dropped out due to intolerance of the mask, who was intubated immediately. Data of the other nine patients showed that integrated diaphragmatic EMG, respiratory rate, end-tidal CO2, VT/Ti, and VE reduced significantly when compared between baselines and stage 3 values (p = 0.0121, 0.0026, 0.0005, 0.0116, 0.0111 respectively). VT and SaO2 increased significantly (p = 0.0265 & 0.0019). The above parameters showed no significant difference between stage 1 and 2. Maximum inspiratory and expiratory mouth pressure remained unchanged after NPSV. No obvious complication was noted. CONCLUSIONS: For patients with acute exacerbations of sever COPD, early and short-term use of NPSV at higher level of PS can significantly suppress inspiratory muscle activities and respiratory drive, and improve VE, respiratory rate, gas exchange and thoracoabdominal asynchrony. Respiratory muscle strength changes little. The addition of 5 cmH2O of PEEP to 10 cmH2O of PS has no obvious effect.

Urinary PCO2 for hemodynamically unstable patients.

BACKGROUND: Gastric intramural pH (pHi) derived from gastric PCO2 has been successfully used to assess splanchnic ischemia for patients with unstable hemodynamics, but with some limitations. Urinary bladder, also an easily accessible hollow viscus, should provide as a useful route for the same purpose. However, no study has used urinary PCO2 to evaluate the adequacy of perfusion in critically ill patients. METHODS: Fifty patients admitted to intensive care unit were included and divided into hemodynamically stable and unstable groups. Several parameters such as arterial pressure, dopamine dosage, heart rate, serum lactate, arterial blood gas, urinary PCO2, and concentrations of Na, K and Cl in urine were measured. Patients with some other renal or pre-renal conditions that might affect urinary PCO2 were excluded. RESULTS: Urinary PCO2 was markedly higher (78.6 +/- 9.9 vs. 43.1 +/- 1.7 mmHg, p < 0.0001) in unstable group. Serum anion gap level, dopamine dosage and heart rate were significantly higher and PaO2/FiO2 ratio as well as mean arterial pressure was lower in unstable group. Serum lactate, arterial pH and other parameters failed to distinguish between groups. Dopamine dosage significantly correlated with urinary PCO2 (r = 0.5357, p = 0.0149) in unstable group. CONCLUSIONS: With careful selection of patients, urinary PCO2 can effectively differentiate hemodynamically unstable patients from stable ones. It also correlates significantly with dopamine dosage in patients with unstable hemodynamics.

Rapid differentiation of pathogenesis in patients with pulmonary edema by protein measurement with refractometer.

BACKGROUND: No study has focused on using refractometer to rapidly determine total protein ratio of edema fluid to blood concentration (TPe/TPb) and, to differentiate hydrostatic pulmonary edema (HPE) from adult respiratory distress syndrome (ARDS). METHODS: The reliability of refractometer was evaluated by correlating the protein concentration measured by refractometer with that by sequential multiple autoanalyzer (SMA) in 91 blood samples. In intensive care unit, thirteen patients with florid pulmonary edema were included. All had an unequivocal diagnosis of either HPE or ARDS. Edema fluid and blood were collected simultaneously for the measurement of protein concentration by refractometer. RESULTS: Protein concentration measured by refractometer correlated excellently with that by sequential multiple autoanalyzer (r = 0.991, p < 0.00001). In 7 patients with ARDS, the mean TPe/TPb was 0.75 +/- 0.13. In contrast, in 6 patients with HPE, the mean TPe/TPb was 0.36 +/- 0.14. The difference between groups was significant (p < 0.005). An inverse correlation between TPe/TPb and wedge pressure was also significant (r = -0.814, p < 0.001). CONCLUSIONS: Using refractometer to determine protein ratio of edema fluid to blood concentration can rapidly and effectively distinguish ARDS from HPE in patients with florid pulmonary edema. TPe/TPb correlates inversely with wedge pressure in these patients.

Characteristics of the ventilatory load with different ventilatory training devices.

BACKGROUND: The characteristics of the load on the ventilatory muscles during breathing with different ventilatory muscle training devices have not been quantified, which may profoundly affect the nature of the training stimulus and the clinical outcome of the ventilatory muscle training. METHODS: In four normal males, we continuously measured mouth pressure, esophageal pressure, tidal volume, breathing frequency (fb), minute ventilation (VE), inspiratory time, duty cycle, tension time index (TTI), and total respiratory work (WTOT) during 10 seconds' maximum ventilatory maneuvers. Maximum breathing was performed at 3 fb's (20, 60 and 88 breaths/min) with each of 3 different inspiratory loading devices: 1) Isocapnic hyperpnea (H) with an orifice of 2 (H2) and 1 (H1) cm; 2) Resistive breathing through a Pflex using 3 orifices of diameter 0.54 cm (P1), 0.40 cm (P3) and 0.22 cm (P5); 3) A threshold loading device (T) set at 10 (T10) and 25% (T25) of the previously measured maximum inspiratory mouth pressure. RESULTS: Pflex could provide higher TTI and lower VE, compared with the other 2 devices, at the breathing frequencies of 60 and 88 breaths/min (p < 0.05). Pflex with smaller orifices (P3 and P5) could exaggerate this difference (p < 0.01). WTOT increased significantly as fb increased from 20 to 88 with H1, H2, T10, T25 and P1 (p < 0.02), but not with P3 and P5. VE showed a better correlation with WTOT than TTI did (p < 0.001, r = 0.863 vs p > 0.1, r = -0.365). CONCLUSIONS: High flow, high WTOT and low tension loads were provided by H2, H1, T10 and T25 devices whereas low flow, low WTOT and high tension loads were provided by P5 and P3. P1 provided intermediate flow and tension load.

Comparison of BiPAP nasal ventilation and ventilation via iron lung in severe stable COPD.

The effects of noninvasive ventilators on COPD remain controversial because of their obscure mechanisms. A randomized crossover study, using iron lung and positive pressure nasal ventilation (BiPAP) each for 40 min, was performed in 11 stable patients with severe COPD. Throughout the study, we monitored surface EMGdi, EMGst, ECG, SaO2, ETCO2, and the movements of RC and AB. Afterwards the data were replayed to calculate VT, RR, PR, VT/TI, iEMG, and phase angle. No statistically significant improvement was found in view of the above parameters. However, the percentage of iEMGst change after 40-min BiPAP ventilation, compared with the baseline, was much more significant in patients with FEV1 below 0.55 L than those with FEV1 above 0.55 L (n = 4:7, delta iEMGst -62.93 percent +/- 23.27 percent vs 32.45 percent +/- 42.79 percent, p = 0.0056). delta iEMGst correlated significantly with FEV1 during BiPAP ventilation (p < 0.05, r = 0.59). We conclude that the iEMGst during short-term BiPAP ventilation correlates with the severity of the disease.

[Efficacy of disodium cromolyn in adult chronic asthma].

Disodium cromolyn is effective in preventing asthma, but its steroid sparing effect remains controversial. In this prospective cross-over study, we used two different brands of disodium cromolyn, Intal and Ticromil, each for 4 weeks on 7 adult patients with chronic asthma. The dosage was 20 mg qid via a special inhaler. The whole course of the study was 12 weeks for each patient, including 2 run-in weeks and 2 wash-out weeks. Patients were followed up by the same physician at outpatient clinics every 2 weeks to measure FEV1, FVC, peak expiratory flow rate (PEFR), and reversibility after bronchodilator. The physician also assessed the severity of the patients' symptoms via a special score system. Patients recorded symptom severity and frequency of medications at home on daily diary cards. Patients also measured PEFR twice a day. At the end of the treatment, FEV1 was improved more in Intal group; daily prednisolone dosage was markedly reduced in Ticromil group; PEFR was improved in both group; but neither symptom severity nor airway reversibility was significantly changed. When two groups were calculated as a whole, PEFR increased significantly from 294 +/- 20 l/min to 342 +/- 19 l/min (p = 0.0225). The daily prednisolone dosage reduced from 5.87 +/- 0.91 mg to 3.91 +/- 0.60 mg in the 3rd week and to 4.05 +/- 0.63 mg in the 4th week. The differences between these 2 dosages and the baseline dosage were statistically significant (both p < 0.05). Side effects were minimal in all patients. We concluded that after the use of disodium cromolyn for 4 weeks, PEFR was markedly improved and daily prednisolone dosage was also significantly reduced.

[Incidence of pulmonary aspiration with different kinds of artificial airways].

A patient with an artificial airway in place, pulmonary aspiration is a serious complication. A prospective study was conducted to investigate the incidence of pulmonary aspiration in patients with all kinds of modern artificial airways with high-volume low-pressure cuffs. In ICU and NSCU (neurosurgery care unit), 40 patients with a tracheostomy or endotracheal tube were included. Before study, cuff pressure was checked and remained at 25 cmH2 O if possible. Then, 0.2 ml of 1% methylene blue was applied on the tongue of each patient every 4 hours. Routine tube care was performed including frequent suction at least once an hour. Any evidence of the blue dye-marker obtained on suctioning was considered positive. The duration of study was 24 hours. Among these 40 patients, the procedure was performed in 50 episodes because some of the patients were evaluated with different kinds of artificial airways. Thirty episodes were evaluated with endotracheal tube, including 7 oral and 23 nasotracheal tubes. No episode of aspiration could be found (0/30). With tracheostomy tubes, 5 of 20 episodes showed positive result (5/20). The difference of incidence between these 2 groups was statistically significant (p less than 0.01). Some possible contributing factors were evaluated between positive and negative episodes, including age, sex, respiration rate, different brands of tracheostomy tubes, modes of ventilation, PEEP level, cuff pressure, nasogastric tubes, coma scale, posture, and ratio of tube and tracheal diameters in tracheostomy group.(ABSTRACT TRUNCATED AT 250 WORDS)