Pulmonary sarcoidosis and the acute respiratory distress syndrome (ARDS).

A 50 year old man presented with 3 weeks of exertional dyspnoea. His chest radiograph on admission revealed diffuse bilateral interstitial infiltrates. He did not respond to antibiotics but subsequently improved on high dose corticosteroids. Bronchoscopic examination with transbronchial biopsy specimens revealed the presence of non-necrotising granulomas. This case demonstrates an unusual clinical presentation of life threatening pulmonary sarcoidosis characterised by the development of acute respiratory distress syndrome (ARDS) with acute respiratory failure.

Post-extubation stridor: risk factors and outcome.

Post-extubation stridor is a potential complication of endotracheal intubation. The incidence, risk factors, and outcome in adult patient populations are poorly defined. It was our clinical impression that the occurrence of post-extubation stridor in our medical intensive care unit was more frequent than generally reported. We therefore monitored all intubated patients to determine the incidence of post-extubation stridor and to identify any predisposing factors. All adult patients requiring endotracheal intubation and medical intensive care admission were prospectively observed over a 5-month period in a university-affiliated medical intensive care unit. Sixty-seven patients requiring intubation and medical intensive care admission were evaluated. Twenty-two patients were excluded from analysis because no extubation was attempted. The remaining 45 patients were divided into two groups: 8 with and 37 without post-extubation stridor. Of the parameters analyzed, cuff pressure, treatment with corticosteroids at the time of extubation, and the presence of a primary neurologic process necessitating intubation differed significantly between groups. Six of the 8 patients who developed post-extubation stridor required reintubation. Four of these patients were subsequently successfully extubated, one required tracheostomy, and one patient died after a 2-week deteriorating clinical course. The incidence of significant stridor in our population was 17.8%. Medical management was successful in the majority of patients with post-extubation stridor. Routine tracheostomy following a single episode of post-extubation stridor is not indicated. Further investigation regarding risk factors and a placebo-controlled trial evaluating the efficacy of systemic corticosteroids before extubation in individuals at risk for developing post-extubation stridor are needed.

Tuberculosis update: will good news become bad news?

Recent efforts to reestablish control of tuberculosis have resulted in some success. However, deaths from tuberculosis continue to increase worldwide. Molecular techniques have dominated investigators' efforts to improve diagnostic methods and therapeutic options. Unfortunately, no significant advances in the development of new drugs have occurred. Ongoing attempts to develop more effective vaccines hold some preliminary promise, but delineation of the protective antigens on Mycobacterium tuberculosis and the development of a vaccine for use in humans is considered decades away from clinical use. The lack of political commitment worldwide and the potential loss of support nationally remain major obstacles to the establishment of effective and long-lasting tuberculosis control.

Tuberculosis reemerges: the captain remains aboard.

The resurgence of tuberculosis and the emergence of multidrug resistant tuberculosis have led to renewed interest in this ancient disease. Advances in the field of molecular biology have increased our understanding of the epidemiology and transmission of infection. This has had a particular impact on the documentation of, and the subsequent development of guidelines to prevent, the nosocomial transmission of tuberculosis. Molecular techniques have dominated the efforts of investigators to improve diagnostic methods and therapeutic options. Recent information regarding the mechanism of developing protective immunity to tuberculosis may lead to the development of more effective vaccines and a role for immunotherapy in treatment. National and international organizations have formulated guidelines for the diagnosis and treatment of disease and infection. The development of a global response to the problem of tuberculosis in order to ensure the establishment of long-lasting control is needed.

Survival following mechanical ventilation for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome: a different perspective.

PURPOSE: Pulmonary infection is a frequent cause of morbidity and mortality in patients with acquired immunodeficiency syndrome (AIDS), and Pneumocystis carinii pneumonia (PCP) is the predominant infection in these patients. In those patients who experience progression to respiratory failure from PCP, the reported mortality rate has been between 87% to 100%. This, in addition to the ultimately fatal outcome of patients with AIDS, has led many physicians to question the advisability of instituting mechanical support for respiratory failure in the setting of PCP. It had been our impression that the outcome of patients on our service was not as poor as was generally reported. We therefore undertook a retrospective analysis of our clinical experience. PATIENTS AND METHODS: We reviewed the clinical course of patients admitted to our service between December 1984 and June 1988 who required intubation and mechanical ventilation for PCP or presumed PCP. RESULTS: Thirty-three cases were identified with 18 survivors (54.5%) and 15 non-survivors (45.5%). Twenty-five of the 33 patients were intubated for their first episode of PCP, with 16 survivors (64%), whereas the remaining eight patients were intubated for their second episode of PCP, with two survivors (25%). We were not able to identify any parameters that predicted survival, although the serum lactate dehydrogenase level was useful in following the response to treatment. CONCLUSION: It is our belief that there is a reasonable chance of survival for patients requiring mechanical ventilation for PCP. We question the wisdom of avoiding intubation and mechanical ventilation altogether in patients with PCP due to the presumption of fatality in this clinical situation.