Roentgenographic mimics of pneumonia in the critical care unit

Clinicians are confronted with a complex challenge when a patient is admitted to a critical care unit (CCU) with a significant chest roentgenography (CXR) abnormality. The etiology of a new infiltrate seen on CXR in a patient already in the CCU is more difficult to establish, but is of equal concern.

Aspiration pneumonia. Strategies for early recognition and prevention

Aspiration is the result of dysfunction during the oral, pharyngeal, or esophageal stage of deglutition. Depending on the type of aspirate, the resultant lung injury may include chemical or bacterial inflammation or obstruction of the airways. Tools for evaluation include roentgenography, upper GI tract studies, bronchoscopy, and esophageal pH studies. Medical management is primarily supportive. Because aspiration pneumonia has a high morbidity rate, prevention involving early recognition and modification of predisposing factors whenever possible is critical for improving outcomes.

Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.

Submandibular tissue obstruction of tracheostomy tube: reversal with "chin sling"

We report on a 55-year-old woman with a tracheostomy who had unexplained respiratory failure from acute nocturnal shortness of death. During the second day of admission, the patient noticed that her "second chin" folded over the tracheostomy on neck flexion, occluding her artificial way. The patient jury-rigged a strap to retain the submental tissue from occluding the opening of the tracheostomy tube. She was subsequently free from obstructive symptoms with good oxygen saturation even with neck flexion. She was consequently discharged with a presumptive diagnosis of acute upper airway obstruction. We believe that this unusual complication of the tracheostomy tube may be more common than appreciated. Accordingly, patients with a tracheostomy should be evaluated through a full range of body and neck positions. Increases in body fat and tissue relaxation should be suspected as possible causes occlusion of tracheostomy tubes. The application of a "chin sling" can reverse this unusual upper airway obstruction until definitive correction by surgical lipectomy is performed.

Radiographic mimics of pneumonia. Pulmonary disorders to consider in differential diagnosis

Pinpointing the source of roentgenographic lung abnormalities can be challenging because many noninfectious pulmonary disorders mimic pneumonia. The authors of this article discuss the most common radiographic presentations of lung disorders that may be mistaken for pneumonia, including focal and diffuse infiltrates, nodules, cavities, and pleural effusion. They also outline the role of thorough history taking and examination in prompt and accurate diagnosis of pulmonary disorders.

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.

Using advance directives effectively in the intensive care unit. Terminating care in the presence--or absence--of directives

When a patient is admitted to the ICU, determine whether the person has decisional capacity and whether an advance directive exists. If so, discuss treatment options and the directive with the patient--as well as with family members and appointed surrogates; clarify the patient's wishes. If no directive has been drawn up, encourage the patient to do so. If a patient lacks decisional capacity but has a directive, determine whether it applies to the current situation. If it does, follow its instructions. If no directive exists or if it does not apply, consult with family members to determine the patient's wishes, and ascertain whether these substitute judgments meet state laws.

How to determine decisional capacity in critically ill patients. Presume the patient can make decisions unless proven otherwise

Decisional capacity includes ability to comprehend information, to make an informed choice, and to communicate that choice; it is specific to the decision at hand. Presume a patient has decisional capacity; an evaluation of incapacity must be justified. Administer a standardized mental status test to help assess alertness, attention, memory, and reasoning ability. A patient scoring below 10 on the Folstein Mini-Mental State Examination (maximum score, 30) probably does not have decisional capacity; one scoring from 10 to 15 probably can designate a proxy but not make complex health care decisions. Obtain psychiatric consultations for a patient who exhibits psychological barriers to decision making.

Thoracentesis in clinical practice

Thoracentesis is a commonly performed procedure indicated for diagnostic and therapeutic purposes. Removal of pleural fluid should be performed by experienced operators and, when attempted by physicians-in-training, close supervision by credentialed individuals is necessary. Diagnostic thoracentesis is most valuable in separating exudates from transudates. Analysis of the exudative fluid has the highest yield when infection and malignancy is likely. Pneumothorax is the most common major complication and can be minimized by the use of small-gauge needles (no. 21 or no. 22) when a small amount of fluid is removed (35 to 50 ml). Patients who may pose difficulties (e.g., those receiving ventilator support) appear to have no greater morbidity with thoracentesis than those patients not ventilator dependent. Ultrasound may be of value to decrease morbidity when small or loculated volumes of fluid are present. Therapeutic thoracentesis offers relief of symptoms of dyspnea, but caution is particularly needed because large needles and large volumes of fluid removed may increase morbidity.

Postural changes in pleural fluid constituents

Measurement of pleural fluid constituents (pH, PCO2, protein, lactic dehydrogenase [LDH], glucose, red blood cells [RBC], and white blood cells [WBC]) are of value in the diagnosis of pleural effusions and in the separation of exudates from transudates. The position of the patient (sitting or lying) prior to thoracentesis may result in differences in the measurement of these constituents. We found significant postural changes (p < 0.05) in the measurement of pH, protein, LDH, and RBCs in all exudative effusions (n = 12) in the upright sitting position compared with the supine position. No postural changes were noted in the transudative effusions (n = 6). The location of basal pleural tumors and the molecular weight of certain constituents may explain this postural sedimentary effect. Repeated thoracentesis after 30 min in the sitting position may result in exudative values when borderline transudates are found in a patient previously in a supine position.

The benefit of lateral radiographs in an intensive care unit

The portable anteroposterior (AP) radiograph (CXR) is an essential component of clinical management in the intensive care unit (ICU). In view of the immobility of patients, and overlying tubes, wires, and catheters, lateral (LAT) CXRs are infrequently ordered. We constructed a portable acrylic (Plexiglas) CXR cassette holder and were able to obtain reproducible quality LAT CXRs in the ICU. Of the 72 simultaneously obtained AP and LAT CXRs, 60 were technically acceptable for interpretation. We found an 11 percent incidence of either unexpected conditions or we were able to improve on the AP CXR interpretation. Lateral CXRs should be obtained routinely in the ICU in select patients.

Pneumothorax after thoracentesis in chronic obstructive pulmonary disease

OBJECTIVE

To determine whether the frequency of pneumothorax is increased after thoracentesis in chronic obstructive pulmonary disease patients.

DESIGN

Prospective.

SETTING

Northeastern community hospital.

PATIENTS

One-hundred-six patients underwent multiple thoracentesis; 36 patients had co-existent chronic obstructive pulmonary disease (mean age, 68.2 years). Chronic obstructive pulmonary disease was identified by radiologic findings consistent with chronic obstructive pulmonary disease and as forced expiratory volume in one second less than 70% of predicted.

OUTCOME MEASURES

Identification of pneumothorax on chest roentgenogram after thoracentesis.

INTERVENTION

Patients had diagnostic or therapeutic thoracentesis with follow-up chest radiography within 2 hours, or sooner if clinically indicated.

RESULTS

Patients with chronic obstructive pulmonary disease had a higher incidence of pneumothorax (15 of 36 patients; 41.7%) than those patients without underlying chronic obstructive pulmonary disease (13 of 70 patients; 18.5%; p = 0.005). The frequency of pneumothorax was no different according to who performed the procedure (house staff or pulmonologist), whether it was for diagnostic or therapeutic reasons, and whether a small (< 500 ml) or large (> 500 ml) amount of fluid is removed.

CONCLUSION

Pneumothorax may frequently occur in patients with chronic obstructive pulmonary disease undergoing thoracentesis. The reason may be related to the altered architecture of the lung parenchyma and the change in mechanical forces in chronic obstructive pulmonary disease. Sonography-guided thoracentesis may offer a safer means of performing thoracentesis in patients with chronic obstructive pulmonary disease.

Aspiration pneumonia. A threat when deglutition is compromised

Aspiration results from abnormal structure or from dysfunction during the oral, pharyngeal, or esophageal stage of deglutition. Chemically induced inflammation of the lungs and obstruction of the airways may ensue. Feeding and swallowing problems may occur at any age, but they are particularly prevalent in the elderly, and the morbidity and mortality that result from impaired oral intake are now recognized as a major geriatric problem. Aspiration pneumonitis and/or pneumonia has a high morbidity and mortality rate. Medical management is mainly aimed at supportive care with the hope of resolution over time. Complications demand aggressive measures. Prevention of aspiration is apt to be more rewarding than treatment of consequences. All predisposing factors should be carefully assessed by the physician and modified whenever possible.

Increased muscle enzyme activity after yoga breathing during an exacerbation of asthma

The case is reported of a yoga practitioner who, during an exacerbation of asthma, developed a substantial increase in serum muscle enzymes. This was related to his yoga breathing exercises, which he used to enhance the delivery of aerosolised bronchodilators. As his condition improved and the use of these yoga manoeuvres diminished, the muscle enzyme levels fell to normal.