Acute respiratory compromise resulting from tracheal mucous impaction secondary to a transtracheal oxygen catheter.

Transtracheal oxygen catheters are being increasingly used because of savings in oxygen usage and patient preference. The complications of the catheter are believed to be minor and easily managed. Inspissated mucous collections that form at the tip of the SCOOP 1 (Transtracheal Systems, Denver, Colorado) catheter have been reported but are usually easily expectorated by the patient. This report describes a patient who had development of acute respiratory compromise from crusted mucoid impaction of the trachea secondary to transtracheal catheter use. General anesthesia and rigid bronchoscopy were required for removal of the obstructing impaction. Unexplained worsening of respiratory symptoms in patients with transtracheal oxygen catheters should be addressed by prompt stripping of the catheter.

The serum-effusion albumin gradient in the evaluation of pleural effusions.

The objective of the study was to compare the serum-effusion albumin gradient (serum albumin level minus pleural effusion albumin level) to Light's traditional criteria (pleural fluid/serum total protein ratio greater than 0.5, pleural fluid/serum LDH ratio greater than 0.6, and pleural fluid LDH greater than 200 U/L) for identifying exudative pleural effusions. The design included prospective measurement of the serum-effusion albumin gradient and Light's criteria in patients with pleural effusions in an inpatient ward in a military teaching hospital. Fifty-nine consecutive patients with pleural effusions who were undergoing diagnostic or therapeutic thoracentesis in whom the etiology of the effusion could be determined were studied. Serum and pleural effusion fluid chemistries were measured in order to determine both the serum-effusion albumin gradient and Light's criteria. Using an albumin gradient of 1.2 g/dl or less to indicate exudates and greater than 1.2 g/dl to indicate transudates, 57 of the 59 patients (41 exudates; 18 transudates) were correctly classified. Two patients with malignant effusions were misclassified as having transudates. Although Light's criteria correctly identified all of the exudates, five patients with congestive heart failure were misclassified as exudates. Four of these patients had had previous diuretic therapy, and all had a clinical response to further diuretic therapy. We conclude that although Light's criteria for exudates are very sensitive, an albumin gradient of 1.2 g/dl or less tends to be more specific, especially in cases of chronic congestive heart failure.

Delayed pleuropulmonary complications following coronary artery revascularization with the internal mammary artery.

We have seen four cases of delayed postoperative pleuro-pulmonary complications associated with use of the internal mammary artery (IMA) conduit. In each case the left IMA was used as a bypass conduit to the left anterior descending (LAD) coronary artery. In two of the instances the complications were life-threatening to the patients. Each patient was left with symptomatic residual roentgenographic changes. The IMA is becoming the graft of choice for coronary artery revascularization. The potential for delayed pleuropulmonary complications associated with use of this graft is not well recognized.