Pleural Uptake Patterns in F18Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) Scans Improve the Identification of Malignant Pleural Effusions

BACKGROUND

The confirmation of malignant pleural effusions (MPE) requires an invasive procedure. Diagnosis can be difficult and may require repeated thoracentesis or biopsies. F18Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) can characterize the extent of malignant involvement in areas of increased uptake. Patterns of uptake in the pleura may be sufficient to obviate the need for further invasive procedures.

METHODS

This is a retrospective review of patients with confirmed malignancy and suspected MPE. Patients who underwent diagnostic thoracentesis with cytology and contemporaneous FDG-PET were identified for analysis. Some underwent confirmatory pleural biopsy. The uptake pattern on FDG-PET underwent blinded review and was categorized based on the pattern of uptake.

RESULTS

One hundred consecutive patients with confirmed malignancy, suspected MPE and corresponding FDG-PET scans were reviewed. MPE was confirmed in 70 patients with positive pleural fluid cytology or tissue pathology. Of the remaining patients, 15 had negative cytopathology, 14 had atypical cells and 1 had reactive cells. Positive uptake on FDG-PET was noted in 76 patients. The concordance of malignant histology and positive FDG-PET occurred in 58 of 76 patients (76%). Combining histologically confirmed MPE with atypical cytology, positive pleural FDG-PET uptake had a positive predictive value of 91% for MPE. An encasement pattern had a 100% PPV for malignancy.

CONCLUSION

Positive FDG-PET pleural uptake represents an excellent method to identify MPE, especially in patients with an encasement pattern. This may eliminate the need for additional invasive procedures in some patients, even when initial pleural cytology is negative.

Design and methods of a randomized trial testing "Advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE)"

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbid diseases among aging people with HIV (PWH) and is often mismanaged. To address this gap, we are conducting the study, "Advancing care for COPD in people living with HIV by Implementing Evidence-based management through proactive E-consults (ACHIEVE)." This intervention optimizes COPD management by promoting effective, evidence-based care and de-implementing inappropriate therapies for COPD in PWH receiving care at Veteran Affairs (VA) medical centers. Study pulmonologists are proactively supporting ID providers managing a population of PWH who have COPD, offering real-time evidence-based recommendations tailored to each patient. We are leveraging VA clinical and informatics infrastructures to communicate recommendations between the study team and clinical providers through the electronic health record (EHR) as an E-consult. If effective, ACHIEVE could serve as a model of effective, efficient COPD management among PWH receiving care in VA. This paper outlines the rationale and methodology of the ACHIEVE trial, one of a series of studies funded by the National Heart, Lung, and Blood Institute (NHLBI) within the ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (PRECluDE) consortium to study chronic disease comorbidities in HIV populations.

CD4+ cell count and outcomes among HIV-infected compared with uninfected medical ICU survivors in a national cohort

BACKGROUND

People with HIV (PWH) with access to antiretroviral therapy (ART) experience excess morbidity and mortality compared with uninfected patients, particularly those with persistent viremia and without CD4+ cell recovery. We compared outcomes for medical intensive care unit (MICU) survivors with unsuppressed (>500 copies/ml) and suppressed (≤500 copies/ml) HIV-1 RNA and HIV-uninfected survivors, adjusting for CD4+ cell count.

SETTING

We studied 4537 PWH [unsuppressed = 38%; suppressed = 62%; 72% Veterans Affairs-based (VA) and 10 531 (64% VA) uninfected Veterans who survived MICU admission after entering the Veterans Aging Cohort Study (VACS) between fiscal years 2001 and 2015.

METHODS

Primary outcomes were all-cause 30-day and 6-month readmission and mortality, adjusted for demographics, CD4+ cell category (≥350 (reference); 200-349; 50-199; <50), comorbidity and prior healthcare utilization using proportional hazards models. We also adjusted for severity of illness using discharge VACS Index (VI) 2.0 among VA-based survivors.

RESULTS

In adjusted models, CD4+ categories <350 cells/μl were associated with increased risk for both outcomes up to 6 months, and risk increased with lower CD4+ categories (e.g. 6-month mortality CD4+ 200-349 hazard ratio [HR] = 1.35 [1.12-1.63]; CD4+ <50 HR = 2.14 [1.72-2.66]); unsuppressed status was not associated with outcomes. After adjusting for VI in models stratified by HIV, VI quintiles were strongly associated with both outcomes at both time points.

CONCLUSION

PWH who survive MICU admissions are at increased risk for worse outcomes compared with uninfected, especially those without CD4+ cell recovery. Severity of illness at discharge is the strongest predictor for outcomes regardless of HIV status. Strategies including intensive case management for HIV-specific and general organ dysfunction may improve outcomes for MICU survivors.

The Natural History of a Patient With COVID-19 Pneumonia and Silent Hypoxemia

A patient who declined all interventions, including oxygen, and recovered highlights the importance of treating the individual instead of clinical markers and provides a time course for recovery from pneumonia and severe hypoxemia.

Community-Acquired Pneumonia and Risk of Cardiovascular Events in People Living With HIV

Background Hospitalization with community-acquired pneumonia (CAP) is associated with an increased risk of cardiovascular disease (CVD) events in patients uninfected with HIV. We evaluated whether people living with HIV (PLWH) have a higher risk of CVD or mortality than individuals uninfected with HIV following hospitalization with CAP. Methods and Results We analyzed data from the Veterans Aging Cohort Study on US veterans admitted with their first episode of CAP from April 2003 through December 2014. We used Cox regression analyses to determine whether HIV status was associated with incident CVD events and mortality from date of admission through 30 days after discharge (30-day mortality), adjusting for known CVD risk factors. We included 4384 patients (67% [n=2951] PLWH). PLWH admitted with CAP were younger, had less severe CAP, and had fewer CVD risk factors than patients with CAP who were uninfected with HIV. In multivariable-adjusted analyses, CVD risk was similar in PLWH compared with HIV-uninfected (hazard ratio [HR], 0.89; 95% CI, 0.70-1.12), but HIV infection was associated with higher mortality risk (HR, 1.49; 95% CI, 1.16-1.90). In models stratified by HIV status, CAP severity was significantly associated with incident CVD and 30-day mortality in PLWH and patients uninfected with HIV. Conclusions In this study, the risk of CVD events during or after hospitalization for CAP was similar in PLWH and patients uninfected with HIV, after adjusting for known CVD risk factors and CAP severity. HIV infection, however, was associated with increased 30-day mortality after CAP hospitalization in multivariable-adjusted models. PLWH should be included in future studies evaluating mechanisms and prevention of CVD events after CAP.

Corticosteroids in the Management of Severe Coccidioidomycosis

BACKGROUND

There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids.

METHODS

We present a case report of 2 patients with persistent and progressive coccidioidomycosis who demonstrated a dramatic response to adjunctive corticosteroid therapy.

RESULTS

Both patients had Coccidioides immitis cultured from respiratory samples. One was a 69-year-old man who had been treated with combination fluconazole and liposomal amphotericin for over 6 weeks, with persistent fever and pneumonia. The other was a 61-year-old man treated with fluconazole and then amphotericin for 3 weeks, with progression to acute respiratory distress syndrome and shock. Both received short courses of intravenous methylprednisolone and recovered to be discharged home.

CONCLUSIONS

As opposed to associated hypersensitivity, corticosteroid treatment in these cases was directed at modulating the ongoing destructive effects of unchecked inflammation. Rapid improvement was noted in both cases and raises the possibility that the addition of systemic corticosteroids may hasten recovery in patients with severe coccidioidomycosis.

Electric Field-Induced Release and Measurement Liquid Biopsy for Noninvasive Early Lung Cancer Assessment

Previously, we detected circulating tumor DNA that contained two EGFR mutations (p.L858R and exon19 del) in plasma of patients with late-stage non-small-cell lung carcinoma (NSCLC) using the electric field-induced release and measurement (EFIRM) platform. Our aim was to determine whether EFIRM technology can detect these mutations in patients with early-stage NSCLC. Prospectively, 248 patients with radiographically determined pulmonary nodules were recruited. Plasma was collected before biopsy and histologic examination of the nodule. Inclusion criteria were histologic diagnosis of benign nodule (control) and stage I or II adenocarcinoma harboring either p.L858R or exon19 delEGFR mutations. Plasma samples were available from 44 patients: 23 with biopsy-proven benign pulmonary nodules and 21 with stage I or II adenocarcinoma (12 p.L858R and 9 exon19 delEGFR variants). Samples were analyzed for the EGFR mutations using the EFIRM platform. Assay sensitivity was 92% for p.L858R (11 of 12 samples positive) and 77% for exon19 del (7 of 9 samples positive). Specificity was 91% with two false-positive results in 23 patients with EGFR-positive nodules and 95% for the entire 44-patient series. Concordance was 100% with identical mutations discovered in plasma and nodule biopsy. The EFIRM platform is able to noninvasively detect two EGFR mutations in individuals with early-stage NSCLC.

Tension hydropneumothorax as the initial presentation of Boerhaave syndrome

Boerhaave syndrome, a rare yet frequently fatal diagnosis, is characterized by the spontaneous transmural rupture of the esophagus. The classic presentation of Boerhaave syndrome is characterized by Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema. However, Boerhaave syndrome rarely presents with all the features of Mackler's triad; instead, the common presentation of Boerhaave syndrome includes chest or epigastric pain, severe retching and vomiting, dyspnea, and shock. These symptoms are typically misdiagnosed as cardiogenic in origin. Due to its atypical presentation, rarity, and mimicry of emergent conditions, diagnosis of Boerhaave syndrome is often delayed, resulting in a high mortality rate at the time of diagnosis and with a subsequent exponential increase in mortality if treatment is delayed by greater than 48 hours. Here, we report two atypical presentations of Boerhaave syndrome presenting as tension hydropneumothorax and review ten previously reported cases of Boerhaave syndrome presenting as tension hydropneumothorax. This review serves to raise clinician awareness about the expansive and elusive ways by which esophageal perforation may present, and thereby facilitate timely and potentially life-saving diagnosis.

Accuracy of electronic health record data for the diagnosis of chronic obstructive pulmonary disease in persons living with HIV and uninfected persons

PURPOSE

No prior studies have addressed the performance of electronic health record (EHR) data to diagnose chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWH), in whom COPD could be more likely to be underdiagnosed or misdiagnosed, given the higher frequency of respiratory symptoms and smoking compared with HIV-uninfected (uninfected) persons.

METHODS

We determined whether EHR data could improve accuracy of ICD-9 codes to define COPD when compared with spirometry in PLWH vs uninfected, and quantified level of discrimination using the area under the receiver-operating curve (AUC). The development cohort consisted of 350 participants who completed research spirometry in the Examinations of HIV Associated Lung Emphysema (EXHALE) study, a pulmonary substudy of the Veterans Aging Cohort Study. Results were externally validated in 294 PLWH who performed spirometry for clinical indications from the University of Washington (UW) site of the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

RESULTS

ICD-9 codes performed similarly by HIV status, but alone were poor at discriminating cases from non-cases of COPD when compared with spirometry (AUC 0.633 in EXHALE; 0.651 in the UW cohort). However, algorithms that combined ICD-9 codes with other clinical variables available in the EHR-age, smoking, and COPD inhalers-improved discrimination and performed similarly in EXHALE (AUC 0.771) and UW (AUC 0.734).

CONCLUSIONS

These data support that EHR data in combination with ICD-9 codes have moderately good accuracy to identify COPD when spirometry data are not available, and perform similarly in PLWH and uninfected individuals.

Long-Term Experience With a Mandatory Clinical Decision Rule and Mandatory d-Dimer in the Evaluation of Suspected Pulmonary Embolism

PURPOSE

This study evaluated the long-term effectiveness of mandatory assignment of both a clinical decision rule (CDR) and highly sensitive d-dimer in the evaluation of patients with suspected pulmonary embolism (PE).

MATERIALS AND METHODS

Institutional guidelines with a CDR and highly sensitive d-dimer were embedded in an order entry menu with mandatory assignment of key components before ordering a CT pulmonary angiogram (CTPA). Data were retrospectively extracted from the electronic health record.

RESULTS

This was a retrospective review of 1,003 CTPA studies (905 patients, 845 male and 60 female patients, age 63.7 ± 13.5 years). CTPAs were positive for PE in 170 studies (17%), representing an average yield of 15% (year [average]; 2007 [15%], 2008 [18%], 2009 [15%], 2010 [15%], 2011 [17%], 2012 [15%], 2013 [23%]). The increased yield represented efforts of mandatory order entry assignments, educational sessions, and clinical champions. Different d-dimer thresholds with or without age adjustments in combination with the CDR identified about 10% of patients who may have been managed without CTPA.

CONCLUSION

Mandatory assignment of a CDR and highly sensitive d-dimer clinical decision pathway can be successfully incorporated into an order entry menu and produce a sustained increase in CTPA yield of patients with suspected PE.

Non-invasive early detection of malignant pulmonary nodules by FISH-based sputum test

BACKGROUND

Early detection decreases lung cancer mortality. The Target-FISH Lung Cancer Detection (LCD) Test is a non-invasive test designed to detect chromosomal changes (deletion or amplification) via Fluorescence in situ Hybridization (FISH) in sputum specimens from persons suspected of having lung cancer. We evaluated the performance of the LCD test in patients with highly suspicious pulmonary nodules who were scheduled for a biopsy procedure.

METHODS

Induced sputum was collected from patients who were scheduled for biopsy of a solitary pulmonary nodule (0.8-3 cm) in one of 6 tertiary medical centers in the US and Israel. The lung cancer detection (LCD) Test combined sputum cytology and Target-FISH analysis on the same target cells and the results were compared to the pathology. Participants with non-surgical negative biopsy results were followed for 2 years to determine their final diagnosis.

RESULTS

Of the 173 participants who were evaluated, 112 were available for analysis. Overall, the LCD test had a sensitivity of 85.5% (95% CI, 76.1-92.3), specificity of 69% (95% CI, 49.2-84.7) and an accuracy of 81.3% (95% CI, 72.8-88). The positive and negative predictive values (PPV, NPV) were 88.8% and 62.5%, respectively. The LCD test was positive in 9 of 11 lung cancer patients who had an initial negative biopsy.

CONCLUSIONS

In a cohort of patients with highly suspicious lung nodules, the LCD test is a non-invasive option with good sensitivity and a high positive predictive value. A positive LCD test reinforces the need to aggressively pursue a definitive diagnosis of suspicious nodules.

Cerebral Artery Gas Embolism Following Navigational Bronchoscopy

INTRODUCTION

Cerebral artery gas embolism (CAGE) is a rare but serious adverse event with potentially devastating neurologic sequelae. Bronchoscopy is a frequently performed procedure but with only a few reported cases of CAGE.

METHODS

We report the first documented case of CAGE associated with electromagnetic navigational bronchoscopy.

RESULTS

A 61-year-old man with a left lower lobe nodule underwent electromagnetic navigational bronchoscopy. The target lesion underwent transbronchial biopsy, brushing and an end-procedure lavage. Following the procedure, he developed seizures, evidence of hypoxic injury and cerebral edema, and air emboli were seen on computed tomography imaging. He then underwent treatment with hyperbaric oxygen with a full and complete neurologic recovery. Review of other cases reported in the literature suggests improved neurologic outcomes with hyperbaric oxygen treatment.

CONCLUSIONS

Biopsy techniques performed during bronchoscopy and electromagnetic navigational bronchoscopy can result in CAGE. Comparison with other reported cases suggests improved neurologic outcomes in those treated with hyperbaric oxygen. Prompt recognition of this complication and timely treatment with hyperbaric oxygen are the cornerstones to recovery.

A Low Peripheral Blood CD4/CD8 Ratio Is Associated with Pulmonary Emphysema in HIV

Objectives

The prevalence of emphysema is higher among HIV-infected (HIV+) individuals compared to HIV-uninfected persons. While greater tobacco use contributes, HIV-related effects on immunity likely confer additional risk. Low peripheral blood CD4+ to CD8+ T-lymphocyte (CD4/CD8) ratio may reflect chronic inflammation in HIV and may be a marker of chronic lung disease in this population. Therefore, we sought to determine whether the CD4/CD8 ratio was associated with chronic obstructive pulmonary disease (COPD), particularly the emphysema subtype, in a cohort of HIV+ subjects.

Methods

We performed a cross-sectional analysis of 190 HIV+ subjects enrolled in the Examinations of HIV Associated Lung Emphysema (EXHALE) study. Subjects underwent baseline laboratory assessments, pulmonary function testing and chest computed tomography (CT) analyzed for emphysema severity and distribution. We determined the association between CD4/CD8 ratio and emphysema, and the association between CD4/CD8 ratio and pulmonary function markers of COPD.

Results

Mild or greater emphysema (>10% lung involvement) was present in 31% of subjects. Low CD4/CD8 ratio was associated with >10% emphysema in multivariable models, adjusting for risk factors including smoking, current and nadir CD4 count and HIV RNA level. Those with CD4/CD8 ratio <0.4 had 6.3 (1.1–39) times the odds of >10% emphysema compared to those with a ratio >1.0 in fully adjusted models. A low CD4/CD8 ratio was also associated with reduced diffusion capacity (DLCO).

Conclusions

A low CD4/CD8 ratio was associated with emphysema and low DLCO in HIV+ subjects, independent of other risk factors and clinical markers of HIV. The CD4/CD8 ratio may be a useful, clinically available, marker for risk of emphysema in HIV+ subjects in the antiretroviral therapy (ART) era.

Thrombolytic Therapy for Massive Pulmonary Embolism in a Patient With a Known Intracranial Tumor

The objective was to describe and review the use of thrombolytic therapy in a patient with an intracranial tumor and massive pulmonary embolism. This is the first reported case of a patient with a known glioblastoma multiforme and massive pulmonary embolism who was successfully treated with alteplase. Pulmonary embolism was demonstrated by a ventilation-perfusion scan and transthoracic echocardiogram with repeat studies demonstrating resolution of the thromboembolism and reperfusion of pulmonary vasculature. A review of the literature revealed that the incidence of intracranial hemorrhage with thrombolysis is <3% and compares favorably with the much higher mortality rate of 25% to ≥50% in patients with hemodynamically unstable pulmonary emboli. The benefit of thrombolysis may outweigh the risks of intracranial hemorrhage in these patients, and careful consideration for its use in these patients is warranted.

The Role of Noninvasive Ventilation in the Hospital and Outpatient Management of Chronic Obstructive Pulmonary Disease

Positive pressure noninvasive ventilation (NIV) has become widely accepted in the treatment of both hospitalized and outpatient subjects with chronic obstructive pulmonary disease (COPD). The support has evolved over the past two decades to be part of first-line management in acute exacerbations of COPD and is also instrumental in discontinuing mechanical ventilation in COPD patients with acute respiratory failure. It is also suitable for treatment of COPD with other associated conditions including pneumonia, following lung resectional surgery, with concomitant obstructive sleep apnea and as part of end-of-life care. Short-term application can also facilitate some endoscopic procedures that may otherwise require endotracheal intubation. Outpatient use of NIV in COPD has garnered much attention, but the support has not been as robust as with NIV in hospitalized patients. However, an approach with higher pressures with a goal of significant reduction in daytime PaCO2 may be an effective strategy. NIV can also facilitate exercise training in pulmonary rehabilitation. A portable device which can augment tidal volume during ambulation and other activities of daily living may further expand the use of NIV in COPD patients.

Angiotensin-converting Enzyme Inhibitor Angioedema Requiring Admission to an Intensive Care Unit

OBJECTIVE

The purpose of this study was to review consecutive cases of angiotensin-converting enzyme (ACE) inhibitor angioedema admitted to an intensive care unit.

METHODS

Fifty subjects with ACE-inhibitor angioedema admitted from 1998-2011 were reviewed.

RESULTS

All 50 subjects were men, 62.8 ± 8.4 years of age, 76% African Americans. Fifteen (30%) required ventilatory support and 2 (4%) required tracheostomy. Over half (56%) had taken ACE inhibitors for over a year. Logistic regression identified dyspnea and tongue involvement with the need for ventilatory support (P < .01). Hypercapnia (PaCO2 = 45.2 ± 6.7; P = 0.046) also identified patients needing ventilatory support.

CONCLUSIONS

Ventilatory support was provided for about one-third of those with ACE inhibitor-associated angioedema. Angioedema can occur even after extended use. Dyspnea and tongue involvement identified patients requiring ventilatory support.

Increased risk of radiographic emphysema in HIV is associated with elevated soluble CD14 and nadir CD4

BACKGROUND

The association between HIV and emphysema remains incompletely understood. We sought to determine whether HIV is an independent risk factor for emphysema severity and whether markers of HIV severity and systemic biomarkers of inflammation (IL-6), altered coagulation (D-dimer), and immune activation (soluble CD14) are associated with emphysema.

METHODS

We performed a cross-sectional analysis of 114 participants with HIV infection and 89 participants without HIV infection in the Examinations of HIV-Associated Lung Emphysema (EXHALE) study. Participants underwent chest CT imaging with blinded semiquantitative interpretation of emphysema severity, distribution, and type. We generated multivariable logistic regression models to determine the risk of HIV for radiographic emphysema, defined as > 10% lung involvement. Similar analyses examined associations of plasma biomarkers, HIV RNA, and recent and nadir CD4 cell counts with emphysema among participants with HIV infection.

RESULTS

Participants with HIV infection had greater radiographic emphysema severity with increased lower lung zone and diffuse involvement. HIV was associated with significantly increased risk for > 10% emphysema in analyses adjusted for cigarette smoking pack-years (OR, 2.24; 95% CI, 1.12-4.48). In multivariable analyses restricted to participants with HIV infection, nadir CD4 < 200 cells/μL (OR, 2.98; 95% CI, 1.14-7.81), and high soluble CD14 level (upper 25th percentile) (OR, 2.55; 95% CI, 1.04-6.22) were associated with increased risk of > 10% emphysema. IL-6 and D-dimer were not associated with emphysema in HIV.

CONCLUSIONS

HIV is an independent risk factor for radiographic emphysema. Emphysema severity was significantly greater among participants with HIV infection. Among those with HIV, nadir CD4 < 200 cells/μL and elevated soluble CD14 level were associated with emphysema, highlighting potential mechanisms linking HIV with emphysema.

Overview and assessment of risk factors for pulmonary embolism

Pulmonary embolism is one of the most common undiagnosed conditions affecting hospitalized patients. There are a plethora of risk factors for venous thromboembolism and pulmonary emboli. These factors are grouped under the broad triad of hypercoagulability, stasis and injury to provide a framework for understanding. Important risk factors include inherited thrombophilia, age, malignancy and estrogens. These risk factors are reviewed in detail and several risk assessment models are reviewed. These risk assessment models help identify those at risk for disease and therefore candidates for thromboprophylaxis. Diagnosis can be difficult and is aided by clinical decision rules that incorporate clinical scores that define the likelihood of pulmonary embolism. These are important considerations, not only for diagnostic purposes, but also to minimize excessive use of imaging, which increases exposure to and risks associated with radiation. A healthy index of suspicion is often the key to diagnosis.

Real-time telehealth for COPD self-management using Skype™

The utility of real-time interactive voice and video telehealth for teaching pursed-lips breathing (PLB) in chronic obstructive pulmonary disease (COPD) is unknown. This was a pilot study to determine its feasibility and efficacy on the key variables of social support and dyspnea. A randomized control study design with repeated measures (baseline, 4 and 12 weeks) was used. All participants in the control and intervention groups received PLB instruction at baseline, but only the intervention group received one weekly PLB reinforcement session for 4 weeks via home computer and Skype™ software. Outcome measures were Medical Outcomes Study Social Support Survey and dyspnea assessment (visual analogue scales for intensity and distress, modified Borg after six-minute walk distance, and Shortness of Breath Questionnaire for activity-associated dyspnea). A total of 22 participants with COPD (mean FEV(1)% predicted = 56) were randomized; 16 (9 telehealth, 7 control) completed the protocol. Intent-to-treat analysis at week 4, but not week 12, demonstrated significantly improved total social support (P = 0.02) and emotional/informational subscale (P = 0.03) scores. Dyspnea intensity decreased (P = 0.08) for the intervention group with a minimal clinical important difference of 10.4 units. Analysis of only participants who completed the protocol demonstrated a significant decrease in dyspnea intensity (P = < 0.01) for the intervention group at both week 4 and 12. Real-time telehealth is a feasible, innovative approach for PLB instruction in the home with outcomes of improved social support and decreased dyspnea.

Noninvasive ventilation in adults with acute respiratory distress: a primer for the clinician

Noninvasive ventilation (NIV) has become an integral part of critical care management. Despite > 2 decades of experience, it is relatively underused, with general utilization reported as a little over 10% in a recent international survey. Lack of training, knowledge, equipment, and experience with NIV may account for its slow adoption. Patient selection, staff training and experience, and prompt recognition of ineffective NIV are important components to successful application of NIV. Noninvasive ventilation does have a learning curve that may be steep for some institutions but must be mastered if the procedure is to become a successful institutional component of care. Patients with acute respiratory failure due to chronic obstructive pulmonary disease or congestive heart failure are ideal candidates for NIV, and optimal efficacy in associated conditions is often linked to these 2 conditions. Technical issues and written guidelines are addressed, including details of an adequate trial of therapy as well as criteria for intubation. Attention to these elements should increase the success rate of NIV, which in turn should increase its general use.

Regression of recurrent respiratory papillomatosis with celecoxib and erlotinib combination therapy

Recurrent respiratory papillomatosis (RRP) can be difficult to manage. Symptoms are related to recurrent tracheobronchial papillomas and are usually treated with bronchoscopic removal. Other modalities are added when the papilloma burden becomes too great or recurrence is too frequent, but with limited efficacy. We report a patient with progressive RRP that had become refractory to available therapy. Because papillomas overexpress epidermal growth factor receptor, along with increased expression of cyclooxygenase-2 and prostaglandin E2, it was reasoned that a combination therapy of erlotinib and celecoxib would be effective in controlling papilloma growth. After institutional approval and informed patient consent, this combination was initiated. There was a striking improvement in the number and appearance of respiratory tract papillomas, with elimination of the need for repeated papilloma removal. Pretreatment and posttreatment images document this response, and the improvement has now been maintained for nearly 2 years with effective therapy.

Noninvasive ventilation for acute respiratory failure: a national survey of Veterans Affairs hospitals

BACKGROUND

The utilization of noninvasive ventilation (NIV) in the Veterans Affairs health-care system is not well characterized. A survey of physicians and respiratory therapists was conducted to better understand its use.

METHODS

Three hospitals in each of 21 Veterans Affairs networks were selected based on severity of patient mix, level of staffing and workload. A request was sent via e-mail to Veterans Affairs respiratory therapists and critical care physicians at these hospitals to complete a 41-question survey using an Internet-based survey site.

RESULTS

A total of 192/882 (22%) responses were received from a survey of about half (63/128) of the Veterans Affairs intensive care units (ICUs). Previous experience and training in NIV was limited. NIV is reported to be widely available and applied in both monitored (ICU, step-down, emergency department) and unmonitored (ward) settings. NIV was identified as a first-line option for COPD and CHF, but perceived use was less. Sixty-four percent of respiratory therapists felt NIV was used <50% of the time when indicated, compared to 29% of physicians (P<.001). Reported NIV use varied, with 45% treating 0-4 patients a month and 23% with >10 patients a month. Larger ICUs reported more frequent use of NIV (>10 patients a month) than smaller ICUs (P=.02). Written guidelines were noted by 65%, but only 27% had titration guidelines. The perceived efficacy of NIV was low, with a success rate of >50% noted by only 29% of respondents.

CONCLUSIONS

The perception of NIV use in the Veterans Affairs hospitals varies significantly. This survey revealed a wide range of training and experience, location of use, presence of written guidelines, and methods of delivery. Notable perceptual differences exist between respiratory therapists and physicians. Underutilization of NIV and low rates of perceived efficacy are major findings.

Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction

PURPOSE

Breathing pattern retraining is frequently used for exertional dyspnea relief in adults with moderate to severe chronic obstructive pulmonary disease. However, there is contradictory evidence to support its use. The study objective was to compare 2 programs of prolonging expiratory time (pursed-lips breathing and expiratory muscle training) on dyspnea and functional performance.

METHODS

A randomized, controlled design was used for the pilot study. Subjects recruited from the outpatient pulmonary clinic of a university-affiliated Veteran Affairs healthcare center were randomized to: 1) pursed-lips breathing, 2) expiratory muscle training, or 3) control. Changes over time in dyspnea [modified Borg after 6-minute walk distance (6MWD) and Shortness of Breath Questionnaire] and functional performance (Human Activity Profile and physical function scale of Short Form 36-item Health Survey) were assessed with a multilevel modeling procedure. Weekly laboratory visits for training were accompanied by structured verbal, written, and audiovisual instruction.

RESULTS

Forty subjects with chronic obstructive pulmonary disease [age = 65 +/- 9 (mean +/- standard deviation) years, forced expiratory volume 1 second/forced vital capacity % = 46 +/- 10, forced expiratory volume 1 second % predicted = 39 +/- 13, body mass index = 26 +/- 6 kg/m, inspiratory muscle strength = 69 +/- 22 cm H2O, and expiratory muscle strength (PEmax) = 102 +/- 29 cm H2O] were enrolled. No significant Group x Time difference was present for PEmax (P = .93). Significant reductions for the modified Borg scale after 6MWD (P = .05) and physical function (P = .02) from baseline to 12 weeks were only present for pursed-lips breathing.

CONCLUSION

Pursed-lips breathing provided sustained improvement in exertional dyspnea and physical function.

Intensive insulin therapy in critical care: a review of 12 protocols

OBJECTIVE

To review performance characteristics of 12 insulin infusion protocols.

RESEARCH DESIGN AND METHODS

We systematically identify and compare 12 protocols and then apply the protocols to generate insulin recommendations in the management of a patient with hyperglycemia. The main focus involves a comparison of insulin doses and patterns of insulin administration.

RESULTS

There is great variability in protocols. Areas of variation include differences in initiation and titration of insulin, use of bolus dosing, requirements for calculation in adjustment of the insulin infusion, and method of insulin protocol adjustments. Insulin recommendations for a sample patient are calculated to highlight differences between protocols, including the patterns and ranges of insulin dose recommended (range 27-115 units [mean +/- SD 66.7 +/- 27.9]), amount recommended for glucose readings >200 mg/dl, and adjustments nearing target glucose.

CONCLUSIONS

The lack of consensus in the delivery of intravenous insulin infusions is reflected in the wide variability of practice noted in this survey. This mandates close attention to the choice of a protocol. One protocol may not suffice for all patients.

Idiopathic Pulmonary Fibrosis: Evaluation with Positron Emission Tomography

BACKGROUND

The pathogenesis of interstitial lung disease remains under investigation, but may be related to increased inflammatory or cellular activity. This activity may be detectable with physiologic imaging.

OBJECTIVES

We investigated the role of physiologic imaging using (18)F-2-fluoro-2-deoxy-D-glucose ((18)FDG)-positron emission tomography (PET) scans in idiopathic pulmonary fibrosis (IPF).

METHODS

Seven male patients with histologically confirmed IPF underwent (18)FDG-PET scans. Scans were analyzed qualitatively and interpreted as positive or negative. Patients also underwent pulmonary function tests and computed tomography (CT) scans.

RESULTS

The average total lung capacity was 71 +/- 22% predicted (mean +/- SD) and diffusing capacity for carbon monoxide was 44 +/- 14% predicted. All had changes consistent with IPF on chest CT and 2 patients had ground glass attenuation. Six of seven patients (86%) had a positive (18)FDG-PET scan. Changes in the (18)FDG-PET scan were seen in 1 patient corresponding to changes in clinical status.

CONCLUSIONS

Our findings suggest that (18)FDG-PET scans may be helpful in the evaluation of IPF. Increased activity suggests active disease and changes in response to therapy.

Impact of clinical guidelines in the management of severe hospital-acquired pneumonia

STUDY OBJECTIVES

To asses the impact of locally developed antimicrobial treatment guidelines in the initial empiric treatment of ICU patients with severe hospital-acquired pneumonia (HAP).

DESIGN

Observational cohort study with pre-guideline and post-guideline data collection.

PATIENTS

A total of 48 pre-guideline patients with 56 episodes of severe HAP defined by the National Nosocomial Infections Surveillance (NNIS) compared with 58 guideline-treated (GUIDE) patients with 61 episodes of severe HAP.

RESULTS

The two groups were similar in terms of mean (+/- SD) age (NNIS group, 67.7 +/- 9.6 years; GUIDE group, 68.0 +/- 11.5 years) and simplified acute physiology score (NNIS group, 12.9 +/- 3.9; GUIDE group, 12.6 +/- 3.1) at the HAP diagnosis, and the proportion of the most frequent isolates (ie, Pseudomonas and methicillin-resistant Staphylococcus aureus). There was wide variation in initial antibiotic use in NNIS-treated patients, with cefotaxime, ceftazidime, and piperacillin being the most common agents compared with all of the GUIDE patients who received an imipenem-cilastin-based regimen. Vancomycin use was similar in both groups. The GUIDE patients had a higher percentage of adequately treated patients (81% vs 46%, respectively; p < 0.01) with a lower mortality rate at 14 days (8% vs 23%, respectively; p = 0.03). A lower mortality rate was also noted at the end of 30 days and the end of hospitalization but was not statistically significant. Appropriate imipenem use (as defined by the guidelines) occurred in 74% of the cases, and there was no increase in the number of imipenem-resistant organisms isolated during the course of the study.

CONCLUSIONS

These guidelines represent a successful implementation of a "deescalation" approach, because the recommended empiric therapy with broad-spectrum antibiotics was switched to therapy with narrower spectrum agents after 3 days. Based on our experience, this approach improves the adequacy of antibiotic treatment, with improvement in short-term survival and without increasing the emergence of resistant organisms.

Pulmonary hypertension in men with thyrotoxicosis

Thyrotoxicosis has a myriad of respiratory symptoms including dyspnea. Pulmonary hypertension may contribute to the respiratory symptoms of thyrotoxicosis, but is often unrecognized. We describe 3 male patients with thyrotoxicosis and associated pulmonary hypertension. Case reports of an additional 15 patients are also reviewed. In patients with thyrotoxicosis and pulmonary hypertension, treatment of thyrotoxicosis alone is associated with improvement in pulmonary hypertension. Previous reports have consisted of mostly female patients, but we report 3 men. When all cases are considered, the typical patient is female (10/14 = 71%), middle-aged (48 years), with mean pulmonary artery systolic pressures improving from 56 to 32 mm Hg with treatment. Autoantibodies were detected in 10/14 (71%) patients. The response to treatment (medical or surgical) of thyrotoxicosis supports the hypothesis that hyperthyroidism is either a cause of pulmonary hypertension, or a factor that may unmask pulmonary hypertension. Recognition is important since treatment and response are very different compared to other patients with pulmonary hypertension. This association may not be readily considered in men, since most reports have been of women.

Comparison of breathing patterns during exercise in patients with obstructive and restrictive ventilatory abnormalities

Patients with obstructive and restrictive ventilatory abnormalities suffer from exercise intolerance and dyspnea. Breathing pattern components (volume, flow, and timing) during incremental exercise may provide further insight in the role played by dynamic hyperinflation in the genesis of dyspnea. This study analyzed the breathing patterns of patients with obstructive and restrictive ventilatory abnormalities during incremental exercise. It also explored breathing pattern components with dyspnea at maximum oxygen uptake (VO2 max). Twenty patients, thirteen obstructive patients (forced expiratory volume 38% +/- 13% predicted, forced expiratory volume in 1 s/forced vital capacity ratio 39 +/- 8%), and seven restrictive patients (forced vital capacity 55 +/- 16% predicted, forced expiratory volume in 1 s/forced vital capacity ratio 84% +/- 11%) performed symptom-limited incremental exercise tests on a cycle ergometer with breath-by-breath determination of ventilation and gas exchange parameters. Breathing patterns were analyzed at baseline, 20, 40, 60, 80, and 100 percent of VO2 max. Dyspnea was measured at end-exercise with a 100 mm visual analogue scale. The timing ratio of inspiratory to expiratory time (T(I)/T(E)) and the flow ratio of inspiratory flow to expiratory flow ratio (V(I)/V(E)) were different (p < 0.008) between obstructive and restrictive patients at all exercise intensity levels. The timing components of expiratory time (T(E)) and inspiratory time to total time (T(I)T(TOT)) were significantly different (p < 0.008) at baseline and maximum exercise. Dyspnea scores were not significantly different. For obstructive patients, correlations were noted between T(I)/T(E), V(I)/V(E), T(I)T(TOT) and dyspnea (p < 0.05). Breathing pattern-timing components, specifically T(I)/T(E), in patients with obstructive and restrictive ventilatory abnormalities during exercise provided further insight into the pathophysiology of the two conditions and the contribution of dynamic hyperinflation to dyspnea.

Nonpharmacologic adjuncts to training during pulmonary rehabilitation: the role of supplemental oxygen and noninvasive ventilation

Exercise training is the cornerstone of pulmonary rehabilitation. However, patients may not be able to exercise at a level that produces a training effect because of limitations related to their underlying lung disease. Adjuncts during exercise training may increase their exercise capacity and increase the benefit of pulmonary rehabilitation. The pathophysiology of exercise associated limitation is reviewed, as well as the role of supplemental oxygen and noninvasive ventilatory support as nonpharmacologic adjuncts to training. While most studies demonstrate benefit during exercise, the evidence of an added benefit during pulmonary rehabilitation is mixed. Work is needed to better define the benefits and appropriate patient populations. The subgroups that may derive the most benefit from these adjuncts are those with oxygen desaturation during exercise and those with severe chronic obstructive pulmonary disease (defined as a forced expiratory volume in 1 s (FEV1) < 1.0 L). Nocturnal noninvasive ventilation during pulmonary rehabilitation seems to be an effective adjunct and merits further study.

Fatal large-volume mouthwash ingestion in an adult: a review and the possible role of phenolic compound toxicity

OBJECTIVE

To describe a case of fatal mouthwash ingestion and review possible sources of toxicity.

DESIGN

Case report.

SETTING

Veterans Administration Medical Center.

PATIENT

Single patient with massive mouthwash ingestion.

MAIN RESULTS

This patient was a 45-year-old man who developed cardiovascular collapse and multiorgan system failure following a massive ingestion of mouthwash (almost 3 liters). His presentation was remarkable for a profound anion-gap metabolic acidosis and a significant osmolar gap. No other co-ingestants were identified, and he expired despite full supportive care including dialysis and mechanical ventilation. An autopsy failed to identify any other cause of death. Nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the reported toxic range of these ingredients.

CONCLUSIONS

When ingested in large quantities, the phenolic compounds in mouthwash may contribute to a severe anion-gap metabolic acidosis and osmolar gap, multiorgan system failure, and death. These compounds, in addition to alcohol, may account for the adverse effects associated with massive mouthwash ingestion.

Variations in the measurement of weaning parameters: a survey of respiratory therapists

OBJECTIVES

Respiratory therapists differ in the methods used to obtain weaning parameters. A questionnaire survey was conducted to better characterize those differences.

DESIGN

A questionnaire survey was conducted among respiratory therapists from nine hospitals in the Los Angeles area. The four-page, 32-question instrument was self-administered and anonymous. Responses were tabulated for analysis.

SETTING

Respondents from nine hospitals, three hospitals with residency training programs and six community hospitals without training programs in the Los Angeles area.

PARTICIPANTS

One hundred two respiratory therapists.

RESULTS

There was no universally acknowledged group of weaning parameters, although four parameters were named by > 90%. There was wide variation in methods used to obtaining weaning parameters. Almost all (91%) obtained measurements with the patients breathing their current fraction of inspired oxygen, but there was great variability in the ventilator mode used to collect these parameters (T-tube, continuous positive airway pressure, pressure support), with an equally wide range of pressures added to each mode (0 to 10 cm H(2)O). There was great variation in the time (< 1 to > 15 min) before recording weaning parameters. Measurement of parameters was done either with bedside instruments or read from the ventilator display. The maximal inspiratory pressure had great variation in the duration of airway occlusion (< 1 to 20 s), with the most frequent time frame being 2 to 4 s. Differences were noted between therapists from the same hospital as well as between hospitals.

CONCLUSIONS

There is great variation among respiratory therapists when obtaining weaning parameters. This calls for further standardization of the measurement of weaning parameters.