Reversal of sleep apnea in uremia by dialysis.

Obstructive sleep apnea (OSA) is a common syndrome occurring in 1% to 4% of the population. While obesity is the most common predisposition to OSA, metabolic disorders have been associated with this syndrome. We describe a patient who presented with severe OSA while in an advanced untreated uremic state, which resolved following intensive dialysis. We speculate that the sleep disturbances, which are common in uremia, may be accounted for in some patients by OSA and may resolve with specific therapy for advanced renal failure.

Nonresolving pneumonia in steroid-treated patients with obstructive lung disease.

PURPOSE: To review autopsy-proven cases of opportunistic pneumonia and determine how many of these patients had received corticosteroid therapy for obstructive lung disease in order to define whether this therapy was the major risk factor predisposing to infection. PATIENTS AND METHODS: All autopsies performed at Winthrop-University Hospital over a 5-year period were reviewed, and 30 cases of opportunistic pneumonia were identified. In eight of 30 cases, corticosteroid therapy for chronic obstructive pulmonary disease (COPD) was the only identifiable risk factor for opportunistic infection. The other 22 patients had other well-defined risk factors for infection. Chart review of the eight patients with COPD was undertaken to define the clinical features of their infections. RESULTS: All eight patients had a progressive multilobar pneumonia that failed to resolve, either clinically or radiographically, despite the use of multiple broad-spectrum antibiotics. In four cases, the infection was community-acquired, while in the other four cases, it was nosocomial in origin. Despite the presence of a nonresolving pneumonia, opportunistic infection was generally not considered as a diagnostic possibility, with only one case being correctly diagnosed antemortem. Autopsy examination documented Aspergillus species as being responsible for six episodes of pneumonia, Candida albicans accounting for one episode, and cytomegalovirus accounting for one episode. CONCLUSION: Based on this experience, it is clear that corticosteroid therapy of COPD can lead to opportunistic pulmonary infection, in or out of the hospital. This diagnosis should be considered when patients receiving this therapy develop a pneumonia that fails to respond to broad-spectrum antibiotics.

Procainamide-induced lupus lung disease characterized by neutrophil alveolitis.

Bronchoalveolar lavage demonstrated a flux of neutrophils into the lung of a patient with procainamide-induced lupus pulmonary disease. Serial lavage studies have shown persistent low-grade alveolitis despite the absence of clinical, serologic, and radiographic evidence of disease activity.

Tension ball valve mucus plug in asthma.

This report describes a patient with status asthmaticus and respiratory failure in whom profound hypoxemia developed during mechanical ventilation. During the hypoxemic episode, breath sounds were absent over the left lung, and chest radiography revealed a hyperlucent left hemithorax with tension shift of the mediastinum to the right. The presence of lung markings in the left lung on radiography eliminated the possibility of tension pneumothorax and led to the diagnosis of tension mediastinal shift secondary to a ball valve obstruction by a central mucus plug. Bronchoscopic lung lavage removed the mucus plug, thereby correcting the hypoxemia. Recognition of this previously undescribed acute complication of mechanical ventilation in status asthmaticus is essential so that confusion with tension pneumothorax is avoided and appropriate therapy instituted.

Sleep in normal late pregnancy.

Twelve women in their third trimester of pregnancy and 10 age-matched nonpregnant controls underwent complete polysomnography for one night in the laboratory. Seven of the original women returned for a second study 3-5 months postpartum. During late pregnancy, women showed increased wake after sleep onset (WASO) and a lower sleep efficiency in comparison with the control group. The percentage of rapid eye movement (REM) sleep was significantly decreased and the percentage of stage 1 significantly increased compared to the nonpregnant group. At 3-5 months postpartum, a significant reduction in WASO and increased sleep efficiency were noted. However, only a slight increase was noted in REM sleep during the postpartum period compared to the prepartum period. The most frequent sleep complaints in the pregnant group were restless sleep, low back pain, leg cramps and frightening dreams. In summary, in accordance with their complaints, women in their third trimester demonstrated polysomnographic patterns of sleep maintenance insomnia.

Lung volume reduction surgery: answering the crucial questions.

Emphysema and other forms of COPD are not only common, but also have a poor prognosis. Mortality with severe COPD may be as high as 60% at 5 years and is associated with a significant degree of disability and cost to the health-care system. Building on Dr. Otto Brantigan's experience in the 1950s, when multiple-wedge resections of emphysematous lung were performed to decrease lung volume, thereby improving airflow and reducing hyperinflation, recent investigators, utilizing improved surgical and anesthetic technique, have redeveloped a surgical approach to the treatment of emphysema. The operations used to treat emphysema include excision of large bullae (bullectomy) and resection of diffusely emphysematous lung and are variously known as lung volume reduction surgery (LVRS), pneumectomy, and reduction pneumoplasty. These operations aim for a 20 to 30% reduction in lung volume and may be performed by stapler or laser resection, or both. The mechanisms of benefit have been attributed to enhanced elastic recoil, correction of ventilation perfusion mismatch, improved efficiency of respiratory musculature, and improved right ventricular filling. Questions that remain to be answered include duration of benefits, safety, and cost of LVRS. The National Heart, Lung, and Blood Institute and the Health Care Financing Administration have responded to the demand for more access to and information about LVRS by organizing both a national registry and controlled clinical trial of these procedures over a 7-year period. This multicenter trial intends to enroll patients with end-stage emphysema to compare methods of bilateral LVRS to maximal medical therapy.

Delayed onset adult respiratory distress syndrome in babesiosis.

Reported herein is a second case of a patient who developed adult respiratory distress syndrome secondary to babesiosis. The features of acute lung injury after babesiosis will be described.

Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter.

STUDY OBJECTIVE: Patients with symptomatic malignant pleural effusion are usually treated with large-bore chest tube placement and pleurodesis requiring > or = 3 days of hospitalization. We sought to demonstrate the feasibility of ambulatory drainage and sclerosis using a small-bore pigtail catheter in patients with malignant pleural effusions. We reasoned that this approach would improve symptoms and quality of life at a reduced cost. METHODS: A 14F pigtail catheter was percutaneously inserted into the pleural space and connected to a closed gravity-drainage bag system. The patients were instructed in the use of the drainage system and discharged to return for sclerosis with 4 g of talc after the drainage was < 100 mL/24 h. Patients were graded for dyspnea and performances status using the Eastern Cooperative Oncology Group score (ECOG) and baseline and transitional dyspnea index score (BDI-TDI) before tube placement and again at 30 days. Radiographic response was graded as total response, partial response, or failure. Telephone follow-up was initiated when the patient could not return for evaluation. RESULTS: Ten ambulatory women, ages 41 to 79 years, were enrolled. The chest tube was left in place from 1 to 10 days, draining a mean of 2,956 mL (1,685 to 6,050 mL). Only two patients were unable to undergo sclerosis owing to catheter dislodgment and minimal drainage. Six reported symptomatic improvement at 30 days confirmed by TDI and ECOG scores in four of six. One with a prior history of a lobectomy was found to have a chylous pleural effusion and experienced a hydropneumothorax, for which sclerosis was unsuccessful. One died in hospital on day 26 after sclerosis despite radiographic resolution. Of the four patients who had improved dyspnea and functional status by TDI and EGOG scores, radiographic response was complete in three and partial in one. Two of the six were not able to return for follow-up because of weakness but reported improvement by telephone inquiry. CONCLUSION: Ambulatory sclerosis of malignant effusion using a small-bore catheter is a feasible alternative to inpatient sclerosis with a large-bore chest tube, especially in patients with strong preferences for outpatient care.

Neutrophil-endothelial cell interaction in critical illness.

Sepsis syndrome frequently results in endothelial injury in many organ systems. To evaluate neutrophil-pulmonary endothelial cell interaction in the sepsis syndrome, we studied 39 critically ill patients prospectively and 20 normal volunteers. Thirteen patients with sepsis (mean age, 71.4 years), 14 patients in an intensive care unit control group (mean age 65.4 years), and 12 patients admitted with acute myocardial infarction (mean age, 66.8 years) were evaluated. Blood samples were drawn from septic patients within 24 hours and from ICU and MI patients within 72 hours of admission. All sepsis patients were culture positive, 6 of 13 from the blood. Both renal failure and ARDS developed in 54 percent of septic patients. 51Cr-labelled neutrophils were prepared and added to bovine pulmonary endothelial cell monolayers with and without added phorbol myristate acetate. Endothelial cells with adherent PMA and nonadherent PMN's, were harvested and radioactivity in each fraction measured with a gamma scintillation counter. Baseline and maximally stimulated (PMA, 3.0 ng/ml) neutrophil adherence to endothelial cells were similar in all patients groups. However, in septic patients, PMA-stimulated PMN adherence was reduced at lower doses, most significantly in those who developed ARDS within 24 to 48 hours of admission (p less than 0.05). Seventy-one percent of patients who developed ARDS had reduced stimulated adherence (PMA 1.0 ng/ml) compared to 22 percent of critically ill patients who did not. We conclude that diminished adherence of neutrophils to endothelium in response to low-level PMA stimulation is significantly more common in patients with sepsis who develop ARDS. Our findings suggest that PMN-endothelial cell interaction is altered by the time sepsis is clinically recognized but before the development of ARDS. We speculate that the observed reduction in adherence of the PMN to endothelial cells may be a consequence of down-regulation by mediators generated in the inflammatory response to sepsis and/or the need for active participation of septic endothelium in this interaction.

Non-cardiogenic pulmonary edema after pericardial drainage for cardiac tamponade.

We report a patient who developed adult respiratory distress syndrome following relief of pericardial tamponade. Because of increasing recognition of pulmonary edema in this situation, we recommend gradual removal of pericardial fluid with hemodynamic monitoring to limit the massive fluid shifts which appear to herald this dire complication.

Patterns and routes of tracheobronchial colonization in mechanically ventilated patients. The role of nutritional status in colonization of the lower airway by Pseudomonas species.

Tracheobronchial colonization by Gram-negative bacteria is common in mechanically ventilated patients. Pseudomonas sp are commonly isolated from the lower airways. We hypothesized that Pseudomonas sp would preferentially colonize the lower airway and would be more common in patients with poor nutritional status. We serially collected 75 pairs of upper and lower respiratory tract cultures from 14 patients treated with mechanical ventilation for at least one week, examined patterns of airway colonization and routes of bacterial entry for Pseudomonas sp and other enteric Gram-negative bacteria (EGNB), and related these findings to host-associated factors, including nutritional status. Pseudomonas sp were the most common species isolates taken from the lower airway, found in nine of 14 patients and in 41.3 percent of all cultures. In contrast to other EGNB, Pseudomonas sp were found significantly (p less than or equal to 0.05) more often in the tracheobronchial tree (31 of 75 cultures) than in the oropharynx (18 of 75 cultures). Primary colonization of the lower airway by Pseudomonas sp was found in four patients, while other EGNB never followed this pattern when subjects were studied with cultures taken every third day. A host-related factor related to lower airway colonization by Pseudomonas species was poor nutritional status, assessed by a multifactorial index (p less than or equal to 0.01). We conclude that in mechanically ventilated patients, Pseudomonas sp colonize the lower airway in a different pattern and by a different route from those of other EGNB. The findings that Pseudomonas sp preferentially colonize the tracheobronchial tree may be important for the design of strategies to prevent airway colonization. The recognition that poor nutritional status, a potentially modifiable host-related factor, favors lower airway growth of Pseudomonas sp suggests one direction for future infection-control efforts.

COPD and endobronchial polyposis associated with hypogammaglobulinemia. Are proteolytic enzymes involved?

The present report describes a patient who had severe obstructive lung disease in association with acquired hypogammaglobulinemia. Evidence obtained by bronchoalveolar lavage is presented that suggests that his lung disease resulted from both a marked increase in elastase load and a reduction in protease inhibitor function.

Utility of fiberoptic bronchoscopy in nonresolving pneumonia.

Although fiberoptic bronchoscopy (FOB) has been traditionally used to evaluate nonresolving pneumonia, its efficacy is unknown. We, therefore, reviewed FOB in 35 consecutive patients who had (1) a roentgenographic infiltrate, (2) cough, (3) either temperature greater than 38.1 degrees C, leukocytosis, sputum production, (4) symptoms present for at least ten days, and antibiotic therapy for at least one week. Known lung cancer and AIDS were excluded. Fiberoptic bronchoscopy was diagnostic in 86 percent (12/14) in whom a specific cause was found. No patient had endobronchial cancer. Two patients with nondiagnostic FOB and persistent systemic symptoms had open lung biopsy specimens showing Wegener's granulomatosis and bronchiolitis obliterans with organizing pneumonia (BOOP). Twenty-one patients with nondiagnostic FOB had no final diagnoses other than community-acquired pneumonia. We conclude that FOB is extremely useful in finding a specific diagnosis for a nonresolving pneumonia when a specific diagnosis can be made. Fiberoptic bronchoscopy was most likely to yield a specific diagnosis in nonsmoking patients with multilobar infiltrates of long duration and could have been avoided in older, smoking, or otherwise compromised patients with lobar or segmental infiltrates with no decrease in diagnostic yield in our series.

The risk factors, incidence, and prognosis of ARDS following septicemia.

Adult respiratory distress syndrome (ARDS) is frequently associated with septicemia. However, the incidence, risk factors, and prognosis are poorly defined. Therefore, during a nine-month period, 116 consecutive patients with septicemia were analyzed. ARDS occurred in 21 of 116 (18 percent) of septicemic patients. Shock preceded all cases of ARDS but occurred in only 15 percent of patients without ARDS (p less than 0.001). Thrombocytopenia was more frequent (62 percent vs 16 percent, p less than 0.001). Age, sex, compromised host status, type of septicemia, temperature, and white blood cell count were not significantly different between the two groups. It is concluded that ARDS frequently complicates all forms of septicemia. It is usually preceded by shock and thrombocytopenia and significantly worsens the prognosis.

Cardiopulmonary effects of acute thallium poisoning.

Gastrointestinal distress and alopecia are the most commonly reported symptoms of acute thallium intoxication; however, cardiac and pulmonary disease may dominate the acute stages of the disease. We report four cases which illustrate the importance of cardiac and respiratory disease in this syndrome.

Benefits of a multidisciplinary pulmonary rehabilitation program. Improvements are independent of lung function.

We evaluated the conditions of 33 patients who completed an outpatient pulmonary rehabilitation program to determine what types of improvements occurred, and whether these changes were related to the baseline degree of ventilatory impairment, to determine whether rehabilitation was beneficial to patients, regardless of the degree of underlying lung dysfunction. Endurance measurements, including sustained submaximal performance on a cycle ergometer and the 12-minute walk distance (1,349 +/- 625 feet to 1,700 +/- 670 feet) increased significantly (p less than 0.01), as did multiple educational and subjective parameters. Maximal exercise performance on a graded cycle test improved very little, with a decline in the ventilatory equivalent for oxygen consumption (VE/VO2) being the only significant change (48.2 +/- 28.3 L/ml to 36.6 +/- 8.7 L/ml). Of the observed changes, only one endurance measurement, the sustained submaximal exercise performance, correlated with FEV1 (r = 0.5, p less than 0.01), but only if it was expressed as an absolute number (liters) and not as percent predicted. Lung function did not correlate with changes in the 12-minute walk distance, in maximal exercise performance on the cycle ergometer or with changes in educational and subjective parameters. We conclude that because the magnitude of change in both physiologic and psychologic parameters was not directly related to lung function, the benefits of rehabilitation can extend to all patients with chronic lung disease, regardless of the severity of preexisting pulmonary dysfunction.

Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine.

An American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference was held in Northbrook in August 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic parameters by which a patient may be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods when dealing with septic patients was recommended as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended. The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.

Platelet-specific alpha-granule proteins and thrombospondin in bronchoalveolar lavage in the adult respiratory distress syndrome.

Levels of platelet-specific alpha-granule proteins, PF, BTG, and TSP were measured in BAL fluids of patients with the ARDS, ILD, and normal healthy subjects, comprising two separate cohorts. In both groups BAL showed elevated levels of BTG and thrombospondin in ARDS patients. Low levels of PF4 were found in BAL and did not differ between ARDS and control patients. The BTG:PF4 ratio was 2:1 or greater in BAL of ARDS patients and of control subjects with other lung diseases, suggesting in vivo release. In ARDS patients, the ratio of TSP to BTG exceeded that usually found in plasma. In ARDS patients in group 2, BAL levels of TSP, BTG, and total protein correlated strongly with the composite injury scores that were used to quantitate their degree of lung injury. Elevated levels of platelet-derived proteins, which modulate chemotaxis of inflammatory cells and promote connective tissue reorganization, occur in the alveolar compartment of ARDS and ILD patients but are usually undetectable in BAL of healthy control subjects. Levels in these patients in BAL fluid are nonspecific indices of the severity of lung injury in patients with ARDS.

Clostridium difficile infection as a cause of severe sepsis.

Although colitis is often seen in critically all patients who have received multiple broad-spectrum antibiotics, there are no reports describing severe sepsis as a result of Clostridium difficile infection. We describe three cases of severe sepsis with local intestinal Clostridium difficile infection as the only identifiable etiology. The mechanism of severe sepsis may be a derangement of the gastrointestinal barrier function. This could result in absorption of microbes or endotoxin or activation of inflammatory cascades in the submucosa of the intestine or liver.

Pneumonia in the elderly. Special diagnostic and therapeutic considerations.

Clinical and radiologic signs and symptoms of gram-negative infections are often muted or obscured by a concurrent disease, and therefore, are not reliable for predicting the infecting organisms. Thus, initial therapy is nearly always empiric and based on the clinician's judgment that a patient's pneumonia is likely to be caused by particular pathogens. The choice of an appropriate regimen requires careful consideration of the extent and severity of coexisting illness and debilitation, the severity of the pneumonia, and the level of care required.