[Intermediate-high risk pulmonary embolism: identification and treatment]

Patients with intermediate-high risk pulmonary embolism have a different mix of clinical symptoms. Optimal treatment of patients with intermediate high-risk pulmonary embolism is necessary to prevent short-term mortality. According to the current guidelines, the use of standard coagulation is the treatment of choice in hemodynamic stable patients with intermediate-high risk pulmonary embolism. Systemic thrombolytic therapy is recommended in patients with intermediate-high risk pulmonary embolism who circulatory deteriorate or who did not respond appropriately to standard anticoagulation. Catheter-guided thrombolysis is reserved for patients with intermediate-high risk pulmonary embolism who have a contraindication for systemic thrombolysis or did not respond to systemic thrombolysis. The timing and choice for the right treatment are significant treatment dilemmas. The development of pulmonary embolism response teams helps in the decision-making in patients with intermediate high-risk pulmonary embolism.

Effects of Community-based Exercise Prehabilitation for Patients Scheduled for Colorectal Surgery With High Risk for Postoperative Complications: Results of a Randomized Clinical Trial

OBJECTIVE

To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in high-risk patients scheduled for elective colorectal resection for (pre)malignancy.

SUMMARY BACKGROUND DATA

Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications.

METHODS

This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold <11 mL/kg/min at the baseline cardiopulmonary exercise test was the final inclusion criterion. Inclusion was based on a power analysis. Patients in the prehabilitation group participated in a personalized 3-week (3 sessions per week, nine sessions in total) supervised exercise program given in community physical therapy practices before colorectal resection. Patients in the reference group received usual care. The primary outcome was the number of patients with one or more complications within 30 days of surgery, graded according to the Clavien-Dindo classification. Data were analyzed on an intention-to-treat basis.

RESULTS

Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024).

CONCLUSIONS

Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.

Retrospective validation of a new volumetric capnography parameter for the exclusion of pulmonary embolism at the emergency department

Volumetric capnography might be used to exclude pulmonary embolism (PE) without the need for computed tomography pulmonary angiography. In a pilot study, a new parameter (CapNoPE) combining the amount of carbon dioxide exhaled per breath (carbon dioxide production (V_CO2)), the slope of phase 3 of the volumetric capnogram (slope 3) and respiratory rate (RR) showed promising diagnostic accuracy (where CapNoPE=(V_CO2×slope 3)/RR).

To retrospectively validate CapNoPE for the exclusion of PE, the volumetric capnograms of 205 subjects (68 with PE) were analysed, based on a large multicentre dataset of volumetric capnograms from subjects with suspected PE at the emergency department. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and diagnostic accuracy of the in-pilot established threshold (1.90 Pa·min) were calculated. CapNoPE was 1.56±0.97 Pa·min in subjects with PE versus 2.51±1.67 Pa·min in those without PE (p<0.001). The AUC of the ROC curve was 0.714 (95% CI 0.64–0.79). For the cut-off of ≥1.90 Pa·min, sensitivity was 64.7%, specificity was 59.9%, the negative predictive value was 77.4% and the positive predictive value was 44.4%.

The CapNoPE parameter is decreased in patients with PE but its diagnostic accuracy seems too low to use in clinical practice.

Retrospective validation in a large multicentre dataset shows that a novel volumetric capnography derived parameter (CapNoPE) is decreased in patients with PE but its diagnostic accuracy seems too low to use in clinical practicehttp://ow.ly/Ogpg30m0HuU

Reproducibility of hypercapnic ventilatory response measurements with steady-state and rebreathing methods

In this study, the hypercapnic ventilatory response (HCVR) was measured, defined as the ventilation response to carbon dioxide tension (P_CO2). We investigated which method, rebreathing or steady-state, is most suitable for measurement of the HCVR in healthy subjects, primarily based on reproducibility. Secondary outcome parameters were subject experience and duration.

20 healthy adults performed a rebreathing and steady-state HCVR measurement on two separate days. Subject experience was assessed using numeric rating scales (NRS). The intraclass correlation coefficient (ICCs) of the sensitivity to carbon dioxide above the ventilatory recruitment threshold and the projected apnoea threshold were calculated to determine the reproducibility of both methods.

The ICCs of sensitivity were 0.89 (rebreathing) and 0.56 (steady-state). The ICCs of the projected apnoea threshold were 0.84 (rebreathing) and 0.25 (steady-state). The steady-state measurement was preferred by 16 out of 20 subjects; the differences in NRS scores were small.

The hypercapnic ventilatory response measured using the rebreathing setup provided reproducible results, while the steady-state method did not. This may be explained by high variability in end-tidal P_CO2. Differences in subject experience between the methods are small.

The hypercapnic ventilatory response measured by a rebreathing setup is reproducible, as opposed to a steady-state setuphttp://ow.ly/yGDg30hStIB

[Aspiration pneumonitis after fire-eating: fire-eater's lung]

On the emergency department we saw two men aged 19 and 26 with symptoms of lipoid pneumonitis (fire-eater's lung) following aspiration of petroleum during fire-eating. They were both admitted to hospital and treated with amoxicillin and clavulanic acid. Both patients were clinically recovered within a few days. Following aspiration of petroleum there is often a period of latency from 8-24 hours before the symptoms occur; it is recommended that patients should be admitted for observation. Known symptoms are coughing, shortness of breath, thoracic pain, fever, tachypnoea and sometimes haemoptysis. Apart from chest radiographs and laboratory values, taking into account the specific history, unless complications are expected additional diagnostic tests are often considered unnecessary. Treatment is symptomatic: administration of oxygen, pain relief, bronchodilation and potentially antibiotics if a bacterial superinfection is suspected. Clinical recovery is usually quick. Temporary restrictive disorders of lung function and reduced diffusion capacity have been described. Recovery of lung function and radiological recovery are seen within weeks to months. Mortality is less than 1%.