Structured Evaluation and Management of Patients with COPD in an Accredited Program

Background

Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition.

Methods

We compared the impact of care received by patients with COPD at Joint Commission-accredited, disease-specific clinics and primary care clinics at an academic health care systemfrom April 2014 to March 2018. Patients with COPD ≥ 40 years old with ≥ 2 outpatient visits 30 days apart were identified. Baseline demographics, disease-specific performance measures, and health care utilization were compared between groups. Propensity matching was conducted and time to the first emergency department (ED) visit and hospitalization was performed using Cox regression analysis.

Results

Of 4646 unique patients with COPD, 1114 were treated at disease-specific clinics and 3532 at primary care clinics. The entire group was predominantly female (58.8 %), non-Hispanic White (74.2 %) with a mean age of 65.4 ± 11.4 years consisting of current (47.6 %) or former smokers (38.4 %). In the disease-specific group, performance measures were performed more frequently, and lower rates of ED visits (hazard ratio [HR]=0.31, 95% confidence interval [CI] 0.18-0.54) and hospitalizations (HR 0.41, 95% CI 0.21-0.79) noted in comparison to the primary care group.

Conclusions

In this observational study, the implementation of achronic disease management program through accredited disease-specific clinics for patients with COPD was associated with reduced all-cause ED visits and hospitalizations.

Corticosteroids and Outcomes in Solid Organ Transplant Recipients Infected With Severe Acute Respiratory Syndrome Coronavirus 2

Objective

To examine outcomes in organ transplant and nontransplant patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the initial 22 months of the pandemic.

Patients and Methods

We used Optum electronic health records to compare outcomes between an adult transplant group and a propensity-matched nontransplant group that tested positive for SARS-CoV-2 from February 1, 2020, to December 15, 2021. Baseline characteristics, hospitalization, intensive care unit admission, mechanical ventilation, renal replacement therapy, inpatient, and 90-day mortality were compared between the transplant and nontransplant groups and among specific transplant recipients. Cox proportional analysis was used to examine hospitalization and mortality by organ transplant, medical therapy, sex, and the period of the pandemic.

Results

We identified 876,959 patients with SARS-CoV-2 infection, of whom 3548 were organ transplant recipients. The transplant recipients had a higher risk of hospitalization (30.6% vs 25%, respectively; P<.001), greater use of mechanical ventilation (7.8% vs 5.6%, respectively; P<.001), and increased inpatient mortality (6.7% vs 4.7%, respectively; P<.001) compared with the nontransplant patients. The initiation of mechanical ventilation was significantly more frequent in the transplant group. After adjustment for baseline characteristics and comorbidities, the transplant group had a higher risk of hospitalization (odds ratio, 1.38; 95% confidence interval, 1.19-1.59), without a difference in mortality. In the transplant group, lung transplant recipients had the highest inpatient mortality (11.6%).

Conclusion

Among patients with SARS-CoV-2 infection, the transplant recipients were at a higher risk of hospitalization and inpatient mortality; however, mortality was mainly driven by advanced age and comorbidities rather than by transplant status or immunosuppressive medications. Lung transplant recipients had the greatest inpatient and 90-day mortality.

Liver transplant recipient with respiratory failure due to pulmonary fibrosis related to telomere disease requiring lung transplantation

Short telomere syndrome (STS) is characterized as multiorgan dysfunction presenting with unexplained cytopenias, cryptogenic cirrhosis and pulmonary fibrosis. We present a liver transplant recipient that gradually developed hypoxic respiratory failure attributed to idiopathic pulmonary fibrosis associated telomere disease that culminated in a successful single lung transplantation.

HRCT Diagnosis of Pleuroparenchymal fibroelastosis: Report of two cases

Pleuroparenchymal fibroelastosis (PPFE) is a rare idiopathic interstitial pneumonia that is often underdiagnosed on computed tomography scans. The disease process involves a combination of fibrosis involving the visceral pleura and fibroelastic changes within the subpleural lung parenchyma. Although definitive diagnosis is based on pathological evaluation, this is often not feasible and pattern recognition on CT as "definite PPFE" or "consistent with PPFE" is important given that sub group of patients will undergo rapid progression with clinical deterioration.

Trends and Factors Associated with Nebulized Therapy Prescription in Older Adults with Chronic Obstructive Pulmonary Disease from 2008 to 2015

Background: Medical management of patients with chronic obstructive pulmonary disease (COPD) includes nebulized therapy as an option for inhalational drug delivery. A broad variety of short- and long-acting bronchodilators and inhaled corticosteroids in the nebulized form are available. Despite this, limited information exists on the pattern and predictors of nebulized prescription. We examined the trend and factors associated with prescription of nebulized therapy among Medicare beneficiaries with COPD. Methods: A retrospective cross-sectional study of 5% Medicare beneficiaries with COPD (n = 66,032) who were enrolled in parts A, B, and D and received nebulized prescription from 2008 to 2015 was conducted. This sample has shown to be representative of the entire fee-for-service Medicare population. The primary outcome was a prescription of nebulized medications. Reliever nebulized medications included short-acting beta agonist (SABA), short-acting muscarinic agents (SAMAs), and a combination of SABA and SAMA, while maintenance nebulized medications included long-acting beta agonists, long-acting muscarinic agents, and corticosteroid solutions as well as combinations of these agents. The secondary outcome was prescription of other inhaler respiratory medications not administered with a nebulizer. Results: Overall, 38.9% patients were prescribed nebulized medication and their prescription significantly declined from 42.4% in 2008 to 35.1% in 2015, majority of which was related to decreased prescriptions of nebulized relievers. Factors associated with the prescription of nebulized medications include female gender (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.02-1.09), dual eligibility or low-income subsidy beneficiaries (OR = 1.49; CI = 1.44-1.53), hospitalization for COPD in the previous year (OR = 1.29; CI = 1.25-1.34), home oxygen therapy (OR = 2.29; CI = 2.23-2.36), pulmonary specialist visit (OR = 1.24; CI = 1.20-1.27), and moderate (OR = 1.61; CI = 1.57-1.65) or high (OR = 1.52; CI = 1.46-1.59) severity of COPD. Conclusion: Between 2008 and 2015, prescriptions for nebulized therapy for COPD declined among Medicare beneficiaries, probably related to increase in use of maintenance non-nebulized medications.

Discordant bilateral bronchoalveolar lavage findings in a patient with acute eosinophilic pneumonia associated with counterfeit tetrahydrocannabinol oil vaping

Vaping has emerged as a popular alternative form of inhalation of nicotine and marihuana derivates (including Tetrahydrocannabinol, THC) in part due to the avoidance of combustion byproducts. Unfortunately, THC oil (especially that produced by unregulated individuals) may contain dilutants such as propylene glycol, vitamin E, and flavoring ingredients that can lead to adverse respiratory effects. Acute eosinophilic pneumonia (AEP) has been described in association with e-cigarette and vaping associated lung injury (EVALI) but the majority of bronchoalveolar lavage (BAL) samples reported in the literature do not show eosinophils as the predominant cell lineage. Only two other cases of AEP have been published, and here we present the first case reported in the literature of a patient with EVALI with AEP pattern associated with counterfeit tetrahydrocannabinol (THC) oil vaping and discordant bilateral BAL cell count differential.

Spirometry Measurement of Peak Inspiratory Flow Identifies Suboptimal Use of Dry Powder Inhalers in Ambulatory Patients with COPD

Objectives

Determine the prevalence of suboptimal peak inspiratory flow rate (PIFR) and associated patient characteristics and compare PIFR measurements obtained with spirometry and In-Check DIAL^® device in ambulatory patients with COPD.

Methods

Patients underwent PIFR measurement with In-Check DIAL^® device and pulmonary function testing with calibrated equipment. Group characteristics and lung function were compared for patients with suboptimal (≤ 60 L/min) and optimal (> 60 L/min) PIFR. Receiver operating curve analysis determined the best maximal forced inspiratory flow (FIF max) value in identifying optimal PIFR by gender and height.

Results

From July 1, 2016 to January 31, 2018, a total of 303 patients with chronic obstructive pulmonary disease (COPD) had PIFR and pulmonary function measurements. Group mean age was 65.5 ± 11.3 years with equal gender distribution. Suboptimal PIFR was observed in 61 (20.1%) patients. A significant correlation was observed between PIFR and FIF max, inspiratory capacity and residual volume (RV) to total lung capacity (TLC) ratio. In the suboptimal PIFR group, mean FIF max measured by spirometry was significantly less compared with the optimal PIFR group; 178.5 ± 56.9 L/min and 263.4 ± 89.9 L/min, respectively (p<0.0001). Receiver operator curve analysis of FIF max to identify an optimal PIFR yielded an area under the curve of 0.79. Males < 65 inches had a suboptimal PIFR in 16.7 % of the male cohort, while females < 65 inches had a suboptimal PIFR in 27.4 % of the women.

Conclusions

Suboptimal PIFR was present in 1 in 5 stable patients with COPD and was more frequent in short statured females. Spirometry determined FIF max was associated with PIFR based on gender and height.

Validation of claims-based algorithms for pulmonary arterial hypertension

Administrative claims studies do not adequately distinguish pulmonary arterial hypertension (PAH) from other forms of pulmonary hypertension (PH). Our aim is to develop and validate a set of algorithms using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and electronic medical records (EMR), to identify patients with PAH. From January 2012 to August 2015, the EMRs of patients with ICD-9-CM codes for PH with an outpatient visit at the University of Texas Medical Branch were reviewed. Patients were divided into PAH or non-PAH groups according to EMR encounter diagnosis. Patient demographics, echocardiography, right heart catheterization (RHC) results, and PAH-specific therapies were assessed. RHC measurements were reviewed to categorize cases as hemodynamically determined PAH or not PAH. Weighted sensitivity, specificity, and positive and negative predictive values were calculated for the developed algorithms. A logistic regression analysis was conducted to determine how well the algorithms performed. External validation was performed at the University of Virginia Health System. The cohort for the development algorithms consisted of 683 patients with PH, PAH group (n = 191) and non-PAH group (n = 492). A hemodynamic diagnosis of PAH determined by RHC was recorded in the PAH (26%) and non-PAH (3%) groups. The positive predictive value for the algorithm that included ICD-9-CM and PAH-specific medications was 66.9% and sensitivity was 28.2% with a c-statistic of 0.66. The positive predictive value for the EMR-based algorithm that included ICD-9-CM, EMR encounter diagnosis, echocardiography, RHC, and PAH-specific medication was 69.4% and a c-statistic of 0.87. A validation cohort of 177 patients with PH examined from August 2015 to August 2016 using EMR-based algorithms yielded a similar positive predictive value of 62.5%. In conclusion, claims-based algorithms that included ICD-9-CM codes, EMR encounter diagnosis, echocardiography, RHC, and PAH-specific medications better-identified patients with PAH than ICD-9-CM codes alone.

Post-transplant native pneumonectomy for interstitial fibrosis and small cell lung cancer

Lung transplantation is a definitive treatment for select patients with end-stage pulmonary disease. Following transplantation, the reported rate of lung cancer is between 1-9% and is associated with a variety of risk factors, including smoking history and chronic immunosuppression. The majority of post-transplant lung cancer reported in the literature is histologically classified as non-small cell lung carcinoma (NSCLC). We report a unique case of early stage small cell lung carcinoma (SCLC) identified in the native lung following single lung transplantation.

Pulmonary arterial hypertension associated with interferon therapy: a population-based study

Background: Isolated cases of pulmonary arterial hypertension (PAH) with interferon α or β therapy have been reported, but no population-based estimates of the incidence of the disease after interferon exposure are available. The aim of this study was to determine the incidence of PAH after initiation of interferon therapy, using a large commercial insurance database. Methods: Using National Drug Codes (NDCs) and Healthcare Common Procedure Coding System (HCPCS) codes, we utilized the Clinformatics™ Data Mart (CDM) database to identify subjects between 20 and 65 years old who received α or β interferon therapy between April 2001 and December 2012. Patients were followed from one year prior to the first medication claim for interferon to the first diagnosis of pulmonary hypertension using ICD-9-CM codes 416.0 and 416.8, or disenrollment. In those subjects diagnosed with pulmonary hypertension, a prescription for PAH-specific medications was used as a surrogate endpoint. Results: We identified 20,113 subjects who received interferon therapy during the study period. The median follow-up was 20 months. Pulmonary hypertension occurred in 71 subjects, and PAH-specific medications were prescribed to 7 of these subjects. Conclusion: Although our analysis showed that the development of PAH is a rare event with

Pulmonary arterial hypertension associated with interferon therapy: a population-based study

BACKGROUND

Isolated cases of pulmonary arterial hypertension (PAH) with interferon α or β therapy have been reported, but no population-based estimates of the incidence of the disease after interferon exposure are available. The aim of this study was to determine the incidence of PAH after initiation of interferon therapy, using a large commercial insurance database.

METHODS

Using National Drug Codes (NDCs) and Healthcare Common Procedure Coding System (HCPCS) codes, we utilized the Clinformatics™ Data Mart (CDM) database to identify subjects between 20 and 65 years old who received α or β interferon therapy between April 2001 and December 2012. Patients were followed from one year prior to the first medication claim for interferon to the first diagnosis of pulmonary hypertension using ICD-9-CM codes 416.0 and 416.8, or disenrollment. In those subjects diagnosed with pulmonary hypertension, a prescription for PAH-specific medications was used as a surrogate endpoint.

RESULTS

We identified 20,113 subjects who received interferon therapy during the study period. The median follow-up was 20 months. Pulmonary hypertension occurred in 71 subjects, and PAH-specific medications were prescribed to 7 of these subjects.

CONCLUSION

Although our analysis showed that the development of PAH is a rare event with interferon therapy, the risk of developing the disease is several fold higher than that for the general population.

Incidence of right heart catheterization in patients initiated on pulmonary arterial hypertension therapies: A population-based study

BACKGROUND

Pulmonary hypertension represents a heterogeneous collection of conditions classified into 5 groups according to pathology, pathophysiology and response to treatment. Right heart catheterization is required to classify patients and before initiation of specific therapy for treatment of pulmonary arterial hypertension. The aim of this study was to determine performance of right heart catheterization in patients prescribed pulmonary arterial hypertension (PAH)-specific medications.

METHODS

A retrospective review of administrative claims was performed using the Clinformatics Data Mart database. Individuals with an encounter diagnosis of pulmonary hypertension were identified by ICD-9 codes. An initial encounter diagnosis was defined as continuous enrollment for 12 months without a previous ICD-9 diagnosis of pulmonary hypertension. These individuals were followed for 15 months after initial encounter diagnosis. Individuals prescribed PAH-specific medications were assessed for characteristics, comorbidities and performance of echocardiography and right heart catheterization.

RESULTS

From 2002 to 2011, 15,772 patients had an outpatient visit with a diagnosis of pulmonary hypertension. From the initial group, 969 (6.1%) patients were prescribed PAH-specific medications within 1 year of encounter diagnosis. Oral PAH-specific medications were prescribed to 94.2% of patients. In patients prescribed PAH-specific medications, 91% had an echocardiogram within 1 year of encounter diagnosis. Cardiac catheterization was performed in 407 patients (42%) within 3 months of initial prescription and in 583 patients (60.2%) during the entire study period.

CONCLUSION

Performance of right heart catheterization was low in this population-based study of patients with an ICD-9 diagnosis code of pulmonary hypertension and taking PAH-specific medications.

Successful treatment of aortic root abscess in a patient with pulmonary arterial hypertension

Continuous prostanoid infusion is an established treatment for pulmonary arterial hypertension that has led to improvements in symptoms, exercise tolerance, and survival. Patients with pulmonary arterial hypertension (PAH) who develop sepsis frequently experience clinical and hemodynamic deterioration associated with poor outcomes. Successful management of sepsis involves identification of the source of infection, early antimicrobial administration, judicious fluid resuscitation, and continuation of specific PAH therapies. We describe successful management of a patient with idiopathic PAH receiving chronic intravenous prostacyclin therapy who developed an aortic root abscess due to Clostridium perfringens requiring emergent aortic root repair. Management involved imaging studies, removal of potential sources with administration of intravenous antibiotics, and cautious fluid administration with hemodynamic monitoring. A multidisciplinary group led by a PAH specialist worked cohesively before, during, and after surgical intervention and achieved a successful outcome.

ARDS in pregnancy

Acute respiratory distress syndrome (ARDS) is an uncommon condition in pregnant patients. The causes of ARDS are associated with obstetric causes such as amniotic fluid embolism, preeclampsia, septic abortion, and retained products of conception or nonobstetric causes that include sepsis, aspiration pneumonitis, influenza pneumonia, blood transfusions, and trauma. An essential component in management of ARDS involves good communication between the obstetrics team and critical care specialist and a fundamental understanding of mechanical ventilatory support. Medical therapies such as nitric oxide and corticosteroids play a complimentary role. Extracorporeal life support is beneficial in the management of the parturient with severe ARDS.

Burn injury associated with home oxygen use in patients with chronic obstructive pulmonary disease

OBJECTIVES

To quantify the risk of burn injury associated with home oxygen use and to examine the risk factors associated with the development of this injury.

PATIENTS AND METHODS

We used a nested case-control and a retrospective cohort design to study enrollment and claims data from a national sample of Medicare beneficiaries 66 years and older with a diagnosis of chronic obstructive pulmonary disease (COPD) from January 1, 2001, through December 31, 2010. The primary outcome was burn injury in patients with COPD prescribed home oxygen.

RESULTS

In the nested case-control method, patients with burn injury were twice (odds ratio, 2.43; 95% CI, 1.57-3.78) as likely to be prescribed oxygen in the preceding 90 days compared with those without burn injury. In the retrospective cohort study, the absolute risk of burn injury in patients prescribed oxygen therapy was 2.98 per 1000 patients compared with 1.69 per 1000 patients not prescribed oxygen during a 22-month period. The excess risk of a burn injury associated with oxygen was 0.704 per 1000 patients per year, and the number needed to harm was 1421. In multivariable analysis, factors associated with burn injury included male sex, low socioeconomic status, oxygen therapy use, and the presence of 3 or more comorbidities.

CONCLUSION

The benefits of oxygen therapy in patients with COPD outweigh the modest risk of burn injury associated with home oxygen use. However, with the increasing number of patients being prescribed oxygen, health care professionals must educate and counsel patients regarding the potential risk of burn injury.

Chronic pulmonary artery dissection associated with pulmonary arterial hypertension

Abstract Pulmonary artery dissection is a complication associated with pulmonary arterial hypertension. This complication is described as acute in onset and is frequently fatal without intervention. We describe a patient with idiopathic pulmonary arterial hypertension and chest pain found to have an unsuspected chronic pulmonary artery dissection on postmortem examination. Chronic pulmonary artery dissection should be considered in patients with chest pain and worsening dyspnea, as the frequency this condition may be underestimated.

Management of pulmonary arterial hypertension during pregnancy: a retrospective, multicenter experience

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare disease with a predilection for young women that is associated with right ventricular failure and premature death. PAH can complicate pregnancy with hemodynamic instability or sudden death during parturition and postpartum. Our aim was to examine the impact of PAH on pregnancy outcomes in the modern era.

METHODS

We conducted a retrospective evaluation of pregnant patients with PAH managed between 1999 and 2009 at five US medical centers. Patient demographics, medical therapies, hemodynamic measurements, manner of delivery, anesthetic administration, and outcomes were assessed.

RESULTS

Among 18 patients with PAH, 12 continued pregnancy and six underwent pregnancy termination. Right ventricular systolic pressure in patients managed to parturition was 82 ± 5 mm Hg and in patients with pregnancy termination was 90 ± 16 mm Hg. Six patients underwent pregnancy termination at mean gestational age of 13 ± 1.0 weeks with no maternal deaths or complications. Twelve patients elected to continue their pregnancy and were hospitalized at 29 ± 1.4 weeks. PAH-specific therapy was administered to nine (75%) at time of delivery consisting of sildenafil, IV prostanoids, or combination therapy. All parturients underwent Cesarean section at 34 weeks with one in-hospital death and one additional death 2 months postpartum for maternal mortality of 16.7%.

CONCLUSIONS

Compared with earlier reports, maternal morbidity and mortality among pregnant women with PAH was reduced, yet maternal complications remain significant and patients should continue to be counseled to avoid pregnancy.

Cough reflex in lung transplant recipients

Lung transplantation has become the standard of care for particular individuals with advanced lung disease. However, this surgical procedure involves interruption of the lower vagal nerve fibers which leads to loss of the protective cough reflex. Injury of the neural pathways involved with the sensory limb of the cough reflex is associated with an increased risk of complications involving the allograft. While loss of the cough reflex was once considered permanent, recent evidence indicates functional and structural restoration is a time-dependent process that occurs 6-12 months after lung transplantation. The implication that the cough reflex may be reestablished in lung transplant recipients provides insight into the dynamic response to airway neural injury that may lead to improvements in allograft tissue repair.

Coccidioidomycosis pneumonia in a nonendemic area associated with infliximab

Tumor necrosis factor (TNF) inhibitors, such as infliximab, are highly effective in the management of rheumatoid arthritis; however, these agents are associated with an increased risk of infectious complications. Individuals developing coccidiomycosis pneumonia frequently acquire this while residing in endemic regions. We present a patient with rheumatoid arthritis treated with infliximab who developed acute respiratory distress syndrome (ARDS) from coccidiomycosis pneumonia while residing in a non-endemic region near the Texas-Louisiana border and was successfully treated with antifungal therapy. The source for coccidiomycosis was suspected to be from inhalation of pulverized rock dust imported from Arizona. Patients treated with TNF inhibitors may acquire coccidiomycosis infection through fomite dust exposure.

Outcomes of morbidly obese patients requiring mechanical ventilation for acute respiratory failure*

OBJECTIVE

To examine the outcomes of morbidly obese patients with acute respiratory failure treated with mechanical ventilation.

DESIGN

Retrospective study.

SETTING

A 14-bed medical intensive care unit in an 800-bed university-based hospital.

PATIENTS

A total of 50 morbidly obese subjects with acute respiratory failure requiring ventilatory assistance.

INTERVENTIONS

None.

MEASUREMENTS

Arterial blood gas measurements, intubation rate, days of mechanical ventilation, intensive care unit length of stay, hospital length of stay, and mortality.

RESULTS

From January 1997 to December 2004, 50 morbidly obese patients with acute respiratory failure were treated with mechanical ventilation. Invasive mechanical ventilation was implemented in 17 patients with a mean body mass index of 53.2 +/- 12.2 kg/m2. A total of 33 patients were treated with noninvasive ventilation (NIV), of which 21 avoided intubation (NIV success) and 12 required intubation (NIV failure). Mean body mass index for the NIV success group was significantly less than for the NIV failure group (46.9 +/- 8.9 and 62.5 +/- 16.1 kg/m2, respectively, p = .001). Acute Physiology and Chronic Health Evaluation II scores were similar for patients treated with invasive and noninvasive ventilation. Significant improvements in pH and Paco2 were noted for the invasive mechanical ventilation and NIV success groups. No improvements in gas exchange were noted in the NIV failure group. Of patients treated with NIV, 36% required intubation. Hospital mortality for the invasive ventilation and NIV failure groups was increased.

CONCLUSION

The type of ventilatory assistance may influence clinical outcomes in morbidly obese patients with acute respiratory failure.

Fatal Reactive Hemophagocytosis Related to Disseminated Histoplasmosis with Endocarditis: An Unusual Case Diagnosed at Autopsy

Reactive hemophagocytic syndrome (RHS) is an uncommon life-threatening disorder. It is believed to be caused by widespread non-neoplastic proliferation and inappropriate activation of mature macrophages, resulting in excessive cytokine activation which leads to hematophagocytosis by cells of the macrophage-monocyte lineage and multiorgan dysfunction. RHS may be associated with infections caused by bacterial, viral and fungal organisms as well as lymphoproliferative disorders, nonhematopoietic malignancies, autoimmune diseases and some therapeutic drugs. Immunosuppression is a frequent underlying condition in RHS. The following case presentation describes a patient with a history of chronic hepatitis C, cryoglobulinemia, renal failure and Staphylococcus aureus perinephric abscess and bacteremia, who, at autopsy, was found to have disseminated histoplasmosis with fungal endocarditis and RHS.

Disseminated Acanthamoebiasis after Lung Transplantation

Protozoan infections in organ transplant recipients are rare. We report a fatal case of disseminated acanthamoebiasis in a bilateral lung transplant recipient that presented with cutaneous lesions, respiratory failure, and seizures. Acanthamoeba infection may be identified in transplant recipients with exposure to water who develop non-healing cutaneous ulcers with granulomatous inflammation. Cutaneous lesions are the initial manifestation of infection and a harbinger of dissemination. Early institution of combination anti-microbial therapy is therefore necessary for effective treatment and prevention of lethal spread to the central nervous system.

Inhaled bronchodilator administration during mechanical ventilation

Inhaled bronchodilators are routinely administered to mechanically ventilated patients to relieve dyspnea and reverse bronchoconstriction. A lower percentage of the nominal dose reaches the lower respiratory tract in a mechanically ventilated patient than in a nonintubated subject, but attention to device selection, administration technique, dosing, and patient-ventilator interface can increase lower-respiratory-tract deposition in a mechanically ventilated patient. Assessing the airway response to bronchodilator by measuring airway resistance and intrinsic positive end-expiratory pressure helps guide dosing and timing of drug delivery. Selecting the optimal aerosol-generating device for a mechanically ventilated patient requires consideration of the ease, reliability, efficacy, safety, and cost of administration. With careful attention to administration technique, bronchodilator via metered-dose inhaler or nebulizer can be safe and effective with mechanically ventilated patients.

Squamous cell lung cancer simulating an acute myocardial infarction

Lung cancer involvement of the heart is silent, carries a poor prognosis, and is most commonly identified at autopsy. A patient with lung cancer presented with symptoms and ECG findings suggestive of an acute coronary syndrome. Persistent symptoms and normal creatine phosphokinase (CPK) levels led to use of MRI and radionuclide scintigraphy to diagnose neoplastic infiltration of the myocardium. Palliative care was established with significant symptom relief. Assessment for cardiac metastases should be considered in patients with advanced lung cancer presenting with chest pain, new ECG findings, and normal CPK levels.

Perioperative care of the lung transplant patient

Improvements in the perioperative management of lung transplant recipients have produced a 90% survival in the first 30 days following surgery. Detailed attention to donor organ procurement and preservation of the allograft are important in ensuring an early successful outcome. Early antibacterial administration based on donor or pretransplant cultures and antiviral therapy in CMV-negative recipients assist in avoiding early infectious complications. Development of hypoxemia or hemodynamic instability in the perioperative period requires a rapid, systematic evaluation with attention to mechanical, immunologic, or infectious causes. Nonpulmonary complications are not infrequent in lung transplant recipients.

Inhalation therapy during mechanical ventilation

An increasing number of pharmacologic agents, including bronchodilators, prostaglandin, proteins, surfactant, mucolytics, and antibiotics are administered to mechanically ventilated patients by the inhalation route. To achieve a therapeutic effect, adequate amounts of an inhaled agent must be delivered to the desired site of action. The delivery of inhaled drugs to the lower respiratory tract of mechanically ventilated patients is complicated by deposition of the aerosol particles in the ventilator circuit and endotracheal tube, and the factors governing pulmonary deposition in mechanically ventilated patients are different from those in ambulatory patients. Meticulous adherence to several steps in the technique of aerosol administration is necessary for successful aerosol therapy in mechanically ventilated patients. With a proper technique of administration, an increasing number of inhaled drugs may be administered safely, conveniently, and effectively to mechanically ventilated patients.

Pregnancy and primary pulmonary hypertension : successful outcome with epoprostenol therapy

Primary pulmonary hypertension (PPH) associated with pregnancy carries a high maternal mortality rate. Short-term epoprostenol infusion has been demonstrated to improve the hemodynamic profile in patients with PPH. We report a successful maternal-fetal outcome with epoprostenol therapy during pregnancy, cesarean section, and postpartum in a patient with PPH. Epoprostenol therapy did not produce any physical or developmental abnormalities in the fetus. A favorable maternal-fetal outcome may occur with a multidisciplinary approach.

Bronchodilator therapy with metered-dose inhaler and spacer versus nebulizer in mechanically ventilated patients: comparison of magnitude and duration of response

OBJECTIVE

Four-hour comparison of the bronchodilator response of albuterol administered via metered-dose inhaler (MDI) with spacer versus small-volume nebulizer (SVN) to mechanically ventilated patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Prospective randomized clinical trial.

SETTING

Medical intensive care unit in a university hospital.

PATIENTS

Thirteen mechanically ventilated COPD patients.

INTERVENTION

Albuterol administration of 4 puffs (0.4 mg) or 10 puffs (1.0 mg) via MDI with spacer or 2.5 mg via SVN to mechanically ventilated patients in order to assess the bronchodilator response over 4 hours.

MEASUREMENTS AND RESULTS

Mechanically ventilated patients were enrolled in a randomized crossover study wherein one group received 4 puffs (0.4 mg) or 2.5 mg of albuterol and another group received 10 puffs (1.0 mg) or 2.5 mg of albuterol on separate days. Respiratory mechanics measurements were obtained over 4 hours. Total airway resistance declined by 14.4 +/- 3.8% after 4 MDI puffs, 18.3 +/- 1.8% after 10 MDI puffs, or 13.7 +/- 2.6% after 2.5 mg via SVN, compared to baseline (p < 0.01). After albuterol delivery, airway resistance remained improved for 90-120 minutes (p < 0.05) and returned to baseline by 4 hours with all treatments.

CONCLUSION

The airway response to albuterol administration via MDI and SVN to mechanically ventilated patients was similar in magnitude and duration, returning to baseline by 240 minutes. In stable, mechanically ventilated COPD patients, albuterol may be administered via MDI with spacer or via SVN every 4 hours.

Pathogenesis and management of respiratory insufficiency following pulmonary resection

The underlying principle of the surgical treatment of non-small-cell lung cancer (NSCLC) is complete removal of the local/regional disease within the thorax. Pulmonary resection should be as conservative as possible without compromising the adequacy of tumor removal. A multitude of factors influence the incidence and severity of complications following pulmonary resection including the pre-operative physical and psychological status of the patient, the pathologic process requiring resection, the physiologic impact of the procedure, and the addition of pre-operative or postoperative adjuvant therapy. The insidious onset of interstitial changes on chest X-ray (CXR) 1 to 2 days after pulmonary resection forewarns of respiratory distress; however, the pathophysiology of adult respiratory distress syndrome (ARDS) with progression to respiratory failure requiring mechanical ventilation and advanced critical care often unfolds. Management of patients with severe respiratory failure remains primarily supportive. "Good critical care" is the mainstay of therapy: this includes gentle mechanical ventilation to avoid ventilator-induced barotrauma and over-extension of remaining functional alveoli, diuresis, infection identification and management, and nutritional support. New therapeutic strategies that may impact on outcomes in the adult population include pressure-limited ventilation (permissive hypercapnia), inverse ratio ventilation, high-frequency jet ventilation, high-frequency oscillatory ventilation, intratracheal pulmonary ventilation, and prone position ventilation. In addition, alternative therapies such as partial liquid ventilation, inhaled nitric oxide, and extracorporeal techniques including extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO(2)R), intravascular oxygenation (IVOX), and arteriovenous carbon dioxide removal (AVCO(2)R), provide additional modalities. A component of some or all of these strategies is finding a role in clinical practice.

Serum albuterol levels in mechanically ventilated patients and healthy subjects after metered-dose inhaler administration

In mechanically ventilated patients, systemic blood levels of inhaled drugs reflect absorption from the lower respiratory tract alone since, unlike nonintubated patients, oropharyngeal and gastrointestinal absorption cannot occur. To determine the efficiency of aerosol administration by a metered-dose inhaler (MDI), we measured serum albuterol levels after administration by a MDI and spacer to nine mechanically ventilated patients (10 puffs) and to 10 healthy subjects (six puffs). Serum albuterol levels (+/- SEM) quantitated by high-performance liquid chromatography and electrochemical detection were: 0.09 +/- 0.04 mg/ml/puff at baseline, 0.66 +/- 0.10 at 5 min, 0.98 +/- 0.10 at 10 min, 0.56 +/- 0.08 at 15 min, and 0.37 +/- 0.03 at 30 min in mechanically ventilated patients versus zero at baseline, 0.89 +/- 0.12 at 5 min, 1.27 +/- 0.13 at 10 min, 0.84 +/- 0.09 at 15 min, and 0.53 +/- 0.07 at 30 min in control subjects (p > or = 0.07 at 5, 10, and 30 min; p < or = 0.05 at baseline and at 15 min). Area under the curve (AUC0-30) in the mechanically ventilated patients was 16.8 +/- 1.4 versus 23.4 +/- 1.9 ng/ml/puff x min in control subjects (p = 0.014). In summary, administration of albuterol with a MDI achieved a profile of serum levels in mechanically ventilated patients similar to that in healthy control subjects, but the peak serum level and systemic bioavailability (AUC0-30) were lower in the patients. In conclusion, serum levels reliably assess lower respiratory tract deposition of albuterol, and show that MDIs are more efficient for aerosol delivery in mechanically ventilated patients than was previously reported in studies using radiolabeled aerosols.

Aerosol delivery from a metered-dose inhaler during mechanical ventilation. An in vitro model

Successful bronchodilator therapy with a metered-dose inhaler (MDI) in intubated, mechanically ventilated patients requires adequate delivery of aerosol to the lower respiratory tract. We determined the effect of ventilator mode, inspiratory flow pattern, humidity, and spontaneous respiratory effort on albuterol delivery in a model of the trachea and bronchi. The model was ventilated through an endotracheal tube during controlled mechanical ventilation (CMV), assist control (AC), pressure support (PS), and continuous positive airway pressure (CPAP), separately with a dry and humidified ventilator circuit. Delivery of albuterol administered by a MDI and spacer on filter placed at the ends of the bronchi was measured by spectrophotometry (246 nm). Under dry conditions and with a frequency of 10 breaths/min, albuterol delivery with CMV (VT, 800 ml; 30.3 +/- 3.4%), AC (VT, 800 ml; 31.9 +/- 1.3%), PS 10 cm H2O (VT, 700 ml; 28.8 +/- 4.5%), or PS 20 cm H2O (VT, 800 ml; 30.9 +/- 1.8%) was lower than that observed with simulated spontaneous breaths with CPAP (VT, 800 ml; 39.2 +/- 1.4%) (p < 0.01 for all modes). Delivery was greater under dry (28.8 to 39%) than under humidified conditions (15.9 to 20.2%) (p < 0.005 in all modes). Albuterol delivery showed a linear correlation with both inspiratory time and duty cycle (r > 0.91). Lower respiratory tract delivery of aerosol from a MDI varied from 4.9 to 39.2%. We conclude that in addition to other known factors such as dose, type of spacer, and its position the technique of administering MDIs in mechanically ventilated patients markedly influences lower respiratory tract aerosol delivery.

Dose-response to bronchodilator delivered by metered-dose inhaler in ventilator-supported patients

In nonintubated patients, metered-dose inhalers (MDIs) are accepted as the most convenient, efficient, and cost effective method of administering inhaled bronchodilators. Recent studies have demonstrated the efficacy of MDIs in ventilator-supported patients; however, the optimal dose of a bronchodilator from a MDI is unknown. We determined the response to increasing doses of albuterol administered by a MDI and cylindrical spacer to 12 mechanically ventilated patients with chronic obstructive pulmonary disease (COPD). Four, eight, and 16 puffs of albuterol were given at 15-min intervals. Rapid airway occlusion were performed before and at 5-min intervals after albuterol for 80 min. Respiratory mechanics were also measured for 60 min in another group of seven patients with COPD who received four puffs of albuterol. Significant decrease in airways resistance occurred after administration of albuterol (p < 0.001). The decrease in airway resistance with four puffs of albuterol was comparable to that observed with cumulative doses of 12 puffs (p = 0.12) and 28 puffs (p = 0.25). Heart rate increased significantly (p < 0.01) after a cumulative dose of 28 puffs. The decrease in airway resistance was sustained for 60 min in the group that received only four puffs of albuterol (p < 0.003). In conclusion, four puffs of albuterol given by a MDI and spacer provided the best combination of bronchodilator effect and safety in stable mechanically ventilated patients with COPD.

Probiotics: nonantigenic tissue fractions in cancer control

The effects of probiotics, nonantigenic fractions of normal and malignant cells on tumors, and of similar fractions of normal cells on bacteria and viruses are discussed. The effects are considered in relation to tumor growth and development. In a control group of mice given subcutaneous inoculations only of viable dbrB tumor cells in DBA/1 mice, 100% developed tumors. In a group receiving subcutaneous and intravenous injections of tumor cells and given the tumor fractions, 20% developed lung tumors and 53% developed subcutaneous tumors. In an experiment in which mice received only intravenous injections of viable tumor cells and the tumor fractions, 100% of the controls died with no deaths occurring in the treated group. It is concluded that nonantigenic cellular fractions (probiotics) effective in inducing resistance to some bacterial and viral diseases are effective in inducing resistance to tumors in an inbred strain of mice.