ACE inhibitor-induced angioedema in elderly African American females requiring tracheostomy.

Angioedema is a well-demarcated localized edema involving the deeper layers of the skin, subcutaneous tissue, mucosa, and submucosa. It is a well-recognized side effect of angiotensin-converting enzyme (ACE) inhibitor therapy. Prolonged angioedema is rare. In most cases, the angioedema is self-limited and responds to cessation of ACE inhibitor therapy. ACE inhibitor-related angioedema occurs more commonly in African American patients and tends to be particularly severe in elderly African American women. We report 2 cases of extremely severe angioedema of prolonged duration that required tracheostomy to stabilize the airway.

Superior vena cava syndrome caused by embolisation of liquid Onyx.

Superior vena cava syndrome (SVCS) is usually caused by a malignancy or the presence of an intravascular device in a central vein. A 74-year-old male with a history of a superior vena cava (SVC) stent underwent embolisation of a brain arterio-venous malformation through the right meningeal artery with liquid Onyx. Two weeks later he presented with acute respiratory failure, upper airway obstruction, plethora, varices of the chest wall and stridor. He was intubated and placed on mechanical ventilatory support. Chest imaging revealed a linear structure in the SVC, extending to the right atrium. Interventional radiology removed the material, which was determined to be liquid Onyx. Venous pressures of the right internal jugular vein decreased after removal of the material. The symptoms resolved and patient was successfully extubated. This is the first reported case of SVCS caused by liquid Onyx.

Chest tube drainage of transudative pleural effusions hastens liberation from mechanical ventilation.

BACKGROUND: Pleural effusions occur frequently in patients requiring mechanical ventilatory support. Treatment of the precipitating cause and resolution of the pleural effusion may take considerable time. We retrospectively studied the effect of chest tube drainage of transudative pleural effusions on the liberation of patients from mechanical ventilatory support. METHODS: Patients in the medical ICU (MICU) at Maimonides Medical Center between January 1, 2009, and October 31, 2009, requiring mechanical ventilatory support with a transudative pleural effusion, were studied retrospectively. They were divided into two groups: standard care and standard care plus chest tube drainage. Chest tubes were placed under ultrasound guidance by trained intensivists. Duration of mechanical ventilatory support was the primary end point. Secondary end points included measures of oxygenation, amount of fluid drained, and complications associated with the chest tube. RESULTS: A total of 168 patients were studied; 88 were treated with standard care and 80 underwent chest tube drainage. Total duration of mechanical ventilatory support was significantly shorter for patients who had chest tube drainage: 3.8±0.5 days vs 6.5±1.1 days for the standard group (P=.03). No differences in oxygenation were noted between the two groups. The average amount of fluid drained was 1,220 mL. No significant complications were caused by chest tube drainage. CONCLUSIONS: Chest tube drainage of transudative pleural effusions resulted in more rapid liberation from mechanical ventilatory support. It is a very safe procedure when performed under ultrasound guidance by experienced personnel. TRIAL REGISTRY: ClinicalTrials.gov; Identifier: NCT0114285; URL: www.clinicaltrials.gov.