The impact of surgical learning curve on short-term outcomes after bilateral lung transplantation: results from a multidisciplinary surgical team.

OBJECTIVES: The aim of this study was to examine the impact of surgical learning curve on short-term clinical outcomes of patients after bilateral lung transplantation (LTx) performed by a surgical multidisciplinary team (MDT). METHODS: Forty-two patients underwent double LTx from December 2016 to October 2021. All procedures were performed by a surgical MDT in a newly established LTx program. The time required for bronchial, left atrial cuff and pulmonary artery anastomoses was the main end point to assess surgical proficiency. The associations between the surgeon's experience and procedural duration were examined by linear regression analysis. We employed the simple moving average technique to generate learning curves and evaluated short-term outcomes before and after achieving surgical proficiency. RESULTS: Both total operating time and total anastomosis time were inversely associated with the surgeon's experience. On analysing the learning curve for bronchial, left atrial cuff and pulmonary artery anastomoses using moving averages, the inflection points occurred at 20, 15 and 10 cases, respectively. To assess the learning curve effect, the study cohort was divided into early (cases 1-20) and late (cases 21-42) groups. Short-term outcomes-including intensive care unit stay, in-hospital stay and severe complications-were significantly more favourable in the late group. Furthermore, there was a notable tendency for patients in the late group to experience a decreased duration of mechanical ventilation along with reduced instances of grade 3 primary graft dysfunction. CONCLUSIONS: A surgical MDT can perform double LTx safely after 20 procedures.

Increased Production of Interleukin-10 and Tumor Necrosis Factor-Alpha in Stimulated Peripheral Blood Mononuclear Cells after Inhibition of S100A12.

Sepsis may induce immunosuppression and result in death. S100A12 can bind to the receptor for advanced glycation end-products (RAGE) and Toll-like receptor (TLR)4 following induction of various inflammatory responses. It is unclear whether S100A12 significantly influences the immune system, which may be associated with sepsis-related mortality. We measured plasma S100A12 levels and cytokine responses (mean ± standard error mean) of lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs) after S100A12 inhibition in healthy controls and patients with sepsis on days one and seven. Day one plasma soluble RAGE (sRAGE) and S100A12 levels in patients with sepsis were significantly higher than those in controls (2481.3 ± 295.0 vs. 1273.0 ± 108.2 pg/mL, p < 0.001; 530.3 ± 18.2 vs. 310.1 ± 28.1 pg/mL, p < 0.001, respectively). Day seven plasma S100A12 levels in non-survivors were significantly higher than those in survivors (593.1 ± 12.7 vs. 499.3 ± 23.8 pg/mL, p = 0.002, respectively). In survivors, plasma sRAGE levels were significantly decreased after 6 days (2297.3 ± 320.3 vs. 1530.1 ± 219.1 pg/mL, p = 0.009, respectively), but not in non-survivors. Inhibiting S100A12 increased the production of tumor necrosis factor (TNF)-α and interleukin (IL)-10 in stimulated PBMCs for both controls and patients. Therefore, S100A12 plays an important role in sepsis pathogenesis. S100A12 may competitively bind to TLR4 and RAGE, resulting in decreased IL-10 and TNF-α production.

Effects of Curcuma longa L., Eucommia ulmoides Oliv. and Gynostemma pentaphyllum (Thunb.) Makino on Cytokine Production in Stimulated Peripheral Blood Mononuclear Cells in Patients with Tuberculosis.

BACKGROUND: Tuberculosis (TB) infection triggers the innate and adaptive immune responses. Eucommia ulmoides Oliv., Gynostemma pentaphyllum (Thunb.) Makino, and Curcuma longa L. extracts exhibit various immunomodulatory effects. OBJECTIVE: This study aimed to determine the effects of 3 extracts used in Traditional Chinese Medicine (TCM) on cytokine production in peripheral blood mononuclear cells (PBMCs) obtained from patients with TB. DESIGN: The research team performed an in vitro study with self controls. SETTING: The study took place at the Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Taiwan. PARTICIPANTS: 18 patients diagnosed with pulmonary TB were enrolled in the study. INTERVENTION: Purified protein derivative (PPD)-stimulated PBMCs were cultured for 48 h in the presence and absence of 0.05 or 0.1 mg/mL of herbal extracts. OUTCOME MEASURES: Cytokine levels of interferon (IFN)-γ, interleukin (IL)-10, IL-12, tumor necrosis factor (TNF)-α and transforming growth factor (TGF)-ß1 in the culture supernatant were measured. RESULTS: C longa L., E ulmoides Oliv. and G pentaphyllum (Thunb.) Makino extracts decreased IFN-γ production in PPD-stimulated PBMCs. C longa L. extract did not exhibit a marked and consistent effect on the production of IL-10, IL-12, TNF-α and TGF-ß1. E ulmoides Oliv. extract increased the production of IL-10, TNF-α and TGF-ß1. G pentaphyllum (Thunb.) Makino extract increased the production of IL-10, IL-12, TNF-α and TGF-ß1. CONCLUSION: These results show that G pentaphyllum (Thunb.) Makino might enhance cell immunity since it increased the production of IL-12 and TNF-α with dose effect.

Outcomes of severe H1N1 pneumoniae: A retrospective study at intensive care units.

BACKGROUND: The incidence of acute respiratory distress syndrome (ARDS) and the mortality rate of H1N1 influenza pneumonia are unclear. The aim of this study is to investigate the clinical features and outcomes of adult patients admitted to intensive care units (ICUs) with H1N1 pneumonia related ARDS. METHODS: This retrospective study included patients with confirmed H1N1 influenza pneumonia admitted to the ICUs of a medical center between July 2009 and May 2014. We investigated the patients' characteristics, clinical presentations, illness severities, and outcomes. RESULTS: Sixty-six patients were confirmed to have H1N1 influenza pneumonia requiring mechanical ventilation. Fifty-four of those patients (82%) developed ARDS, while their hospital mortality rate was 33% (22/66). There were no significant differences in the ICU and hospital mortality rates of the ARDS and non-ARDS patients. Among the ARDS patients, there were higher rates of solid malignant disease (22.8% vs. 2.8%, p = 0.038) and sepsis (66.7% vs. 33.3%, p = 0.020) and a higher mean tidal volume (8.9 ± 1.8 vs. 7.8 ± 1.9 ml/kg, p = 0.032) in the non-survivors than the survivors. Logistic regression analysis revealed that a high tidal volume (odds ratio = 1.448, 95 % CI = 1.033-2.030; p = 0.032) and sequential organ failure assessment (SOFA) score (odds ratio = 1.233, 95% CI = 1.029-1.478; p = 0.023) were the risk factors of hospital mortality. CONCLUSION: For H1N1 influenza pneumonia patients admitted to ICUs with mechanical ventilation, there is a high probability of developing ARDS with a modest mortality rate. For patients with ARDS due to H1N1 influenza pneumonia, the tidal volume and SOFA score are the predictors of hospital mortality.

Ethyl pyruvate attenuates ventilation-induced diaphragm dysfunction through high-mobility group box-1 in a murine endotoxaemia model.

Mechanical ventilation (MV) can save the lives of patients with sepsis. However, MV in both animal and human studies has resulted in ventilator-induced diaphragm dysfunction (VIDD). Sepsis may promote skeletal muscle atrophy in critically ill patients. Elevated high-mobility group box-1 (HMGB1) levels are associated with patients requiring long-term MV. Ethyl pyruvate (EP) has been demonstrated to lengthen survival in patients with severe sepsis. We hypothesized that the administration of HMGB1 inhibitor EP or anti-HMGB1 antibody could attenuate sepsis-exacerbated VIDD by repressing HMGB1 signalling. Male C57BL/6 mice with or without endotoxaemia were exposed to MV (10 mL/kg) for 8 hours after administrating either 100 mg/kg of EP or 100 mg/kg of anti-HMGB1 antibody. Mice exposed to MV with endotoxaemia experienced augmented VIDD, as indicated by elevated proteolytic, apoptotic and autophagic parameters. Additionally, disarrayed myofibrils and disrupted mitochondrial ultrastructures, as well as increased HMGB1 mRNA and protein expression, and plasminogen activator inhibitor-1 protein, oxidative stress, autophagosomes and myonuclear apoptosis were also observed. However, MV suppressed mitochondrial cytochrome C and diaphragm contractility in mice with endotoxaemia (P < 0.05). These deleterious effects were alleviated by pharmacologic inhibition with EP or anti-HMGB1 antibody (P < 0.05). Our data suggest that EP attenuates endotoxin-enhanced VIDD by inhibiting HMGB1 signalling pathway.

Elevated Serum Markers of Acute Kidney Injury in Patients With Obstructive Sleep Apnea.

STUDY OBJECTIVES: Previous research revealed a positive correlation between endothelial cell injury (indicated by albuminuria) and obstructive sleep apnea (OSA). However, little else has been revealed about acute kidney injury (AKI) in patients with OSA. METHODS: This prospective study recruited consecutive patients undergoing overnight polysomnography for evaluation of sleep apnea. Patients in whom any major disease or recent infection had been previously diagnosed were excluded. Ultimately, data from 75 patients with apnea-hypopnea indices of 5 or more were analyzed. Baseline values for the urinary albumin-creatinine ratio (UACR), serum levels for three markers of AKI (cystatin C, neutrophil gelatinase-associated lipocalin [NGAL], interleukin-18 [IL-18]), and polysomnography data were recorded and analyzed. Patients then were followed for 6 months of continuous positive airway pressure (CPAP) treatment. RESULTS: At baseline, UACRs were greater in patients with more severe OSA (P = .005, r = .329). All three serum markers of AKI (cystatin C, NGAL, and IL-18) studied were positively correlated with OSA severity, and two (cystatin C and IL-18) were positively correlated with the frequency of oxygen desaturation during sleep. However, none of the AKI markers had positive correlations with UACR. After 6 months of CPAP treatment, UACR and IL-18 were decreased significantly in patients with good adherence. CONCLUSIONS: Albuminuria and levels of three serum markers of AKI (cystatin C, NGAL, IL-18) were positively correlated with OSA severity, and good adherence with CPAP treatment decreased albuminuria and interleukin-18 levels. These results may provide additional tools for assessing early renal injury in patients with OSA.

First tidal volume greater than 8 mL/kg is associated with increased mortality in complicated influenza infection with acute respiratory distress syndrome.

BACKGROUNDS: Severe influenza infection causes substantial morbidity and mortality worldwide and remains an important threat to global health. This study addressed factors related to treatment outcomes in subjects of complicated influenza infection with acute respiratory distress syndrome (ARDS) during the Taiwan epidemic in the Spring of 2016. METHODS: This is a retrospective study conducted by Taiwan Severe Influenza Research Consortium (TSIRC), including eight tertiary referral medical centers. Patients with virology-proven influenza infection admitted to intensive care unit (ICU) between January and March 2016 were included for analysis. RESULTS: We identified 263 patients with complicated influenza infection who fulfilled ARDS criteria; the mean age was 59.8 ± 14.6 (years), and 66.1% (166/263) were male. Type A influenza (77.9%, 205/263) virus was the main pathogen during this epidemic. The 30-day mortality rate was 23.2% (61/263). The mean tidal volume (VT) in the first three days after intubation was greater than 8 mL/kg of predicted body weight (PBW). Patients whose first measured VT was >8 mL/kg PBW had an increased 30-day mortality (p = 0.04, log-rank test). In a multivariate Cox proportional hazard regression model, an increase of 1 mL/kg PBW of first VT was associated with 26.1% increase in 30-day mortality (adjusted hazard ratio 1.261, 95% confidence interval [CI] 1.072-1.484, p < 0.01). CONCLUSION: First tidal volume, shortly after intubation, greater than 8 mL/kg PBW is an independent risk factor for mortality in complicated influenza infection with ARDS. Timely recognition of ARDS with strict adherence to protective ventilation strategy of lowering VT may be important in reducing mortality.

Mesalazine-related lung disease in a patient with ulcerative colitis: A case report.

RATIONALE: Mesalazine is widely used to treat inflammatory bowel disease (IBD). However, discriminating between pulmonary manifestations of IBD and drug-related lung disease remains a challenge. There were few case reports of mesalazine-related organizing pneumonia so far. PATIENT CONCERNS: A 75-year-old female was diagnosed with ulcerative colitis and took mesalazine over a period of 2 years and 8 months. She presented with progressive shortness of breath for 3 days and visited our emergency department. Chest radiography showed increased bilateral infiltrates. During hospitalization her clinical condition deteriorated, and she was transferred to our intensive care unit under noninvasive ventilator support. DIAGNOSIS: Computed tomography (CT) scan showed diffuse peribronchial and subpleural consolidations in bilateral lungs. Possible etiologies of interstitial lung disease were surveyed, including various infectious diseases and connective tissue diseases. Transbronchial lung biopsy showed characteristic features of organizing pneumonia. INTERVENTIONS: Under the consideration of mesalazine-related lung disease, mesalazine was discontinued early in disease course and steroid therapy was given. OUTCOMES: The patient was discharged from hospital with improved clinical symptoms and radiographic images. LESSONS: Although this patient suffered a life-threatening adverse event, prompt diagnosis with proper management can result in a favorable outcome.

Feasibility of Radial Endobronchial Ultrasound-Guided Bronchoscopic Cryobiopsy without Fluoroscopy for Lung Parenchymal Lesions.

Background: Cryobiopsy is used to biopsy peripheral lung lesions through flexible bronchoscopy with fluoroscopic guidance. However, fluoroscopy is not available at some institutions. This study evaluated the feasibility of radial endobronchial ultrasound-guided bronchoscopic cryobiopsy without fluoroscopy. Methods: This retrospective study was conducted at Chang Gung Memorial Hospital, Linkou branch, in Taiwan. This study enrolled patients who received bronchoscopy examinations with cryotechnology between July 2014 and June 2016. The data were collected through medical chart review. Results: During the study period, 101 patients underwent bronchoscopy examinations with cryotechnology. Ninety patients with endobronchial tumors were excluded from this study. Eleven patients who underwent radial endobronchial ultrasound-guided bronchoscopic cryobiopsy for lung parenchymal lesions were enrolled into this study. The mean age was 61.1 ± 13.8 years. Five patients were men, and the other six were women. The number of cryobiopsies ranged from 1 to 3. In the histological biopsies, the mean specimen diameter was 0.53 ± 0.23 cm, and the mean biopsy area was 0.20 ± 0.19 cm2. Nine of 11 patients had pathological diagnoses. No complications, including pneumothorax, respiratory failure, or major bleeding, were recorded after the procedure. Conclusions: Endobronchial ultrasound is used to ensure biopsy location, and endobronchial ultrasound-guided cryobiopsy is a feasible technique to biopsy peripheral lung lesions in selected cases at institutions without fluoroscopy equipment. This study provided some rationale for further studies examining the impact of fluoroscopy.

Survival predictor in patients with acute respiratory distress syndrome and diffuse alveolar damage undergoing open lung biopsy.

BACKGROUND: Diffuse alveolar damage (DAD) is a typical pathological finding of open lung biopsies in patients with acute respiratory distress syndrome (ARDS). Patients with ARDS and DAD have been reported to have a poorer prognosis than those without DAD. The aim of this study was to investigate the survival predictors in patients with ARDS and DAD. METHODS: We retrospectively reviewed all ARDS patients who underwent an open lung biopsy which showed evidence of DAD from January 2006 to June 2015 at Chang Gung Memorial Hospital. Clinical data including baseline characteristics, medication, and survival outcomes were analyzed. RESULTS: A total of 64 ARDS patients with DAD were eligible for analysis and divided into known etiology (n = 17, 26.6%) and unknown etiology groups (n = 47, 73.4%). There was no significant difference in hospital mortality rate between the two groups (71.9% vs. 70.6%, p = 0.890). Univariate logistic regression analysis revealed that sequential organ failure assessment (SOFA) score at the time of a diagnosis of ARDS, and SOFA score, PaO2/FiO2 ratio, and positive end expiratory pressure level when the biopsy was performed were associated with hospital mortality. Multivariate analysis showed that the SOFA score on the day of the biopsy was an independent predictor of hospital mortality (odds ratio 1.413, 95% confidence interval 1.127-1.772; p = 0.03). There were no significant differences in the use, dose, duration and timing from ARDS to glucocorticoid therapy between the survivors and nonsurvivors. CONCLUSION: For selected ARDS patients who underwent an open lung biopsy with pathological DAD, SOFA score was an independent predictor of hospital mortality.

Invasive fungal tracheobronchitis in mechanically ventilated critically ill patients: underlying conditions, diagnosis, and outcomes.

BACKGROUND: Invasive fungal tracheobronchitis (IFT) is a severe form of pulmonary fungal infection that is not limited to immunocompromised patients. Although respiratory failure is a crucial predictor of death, information regarding IFT in critically ill patients is limited. METHODS: In this retrospective, multicenter, observational study, we enrolled adults diagnosed as having IFT who had been admitted to the intensive care unit between January 2007 and December 2015. Their demographics, clinical imaging data, bronchoscopic and histopathological findings, and outcomes were recorded. RESULTS: This study included 31 patients who had been diagnosed as having IFT, comprising 24 men and 7 women with a mean age of 64.7 ± 13.7 years. All patients developed respiratory failure and received mechanical ventilation before diagnosis. Eighteen (58.1%) patients had diabetes mellitus, and 12 (38.7%) had chronic lung disease. Four (12.9%) patients had hematologic disease, and none of the patients had neutropenia. Twenty-five (80.6%) patients were diagnosed as having proven IFT, and the remaining patients had probable IFT. Aspergillus spp. (61.3%) were the most common pathogenic species, followed by Mucorales (25.8%) and Candida spp. (6.5%). The diagnoses in six (19.4%) patients were confirmed only through bronchial biopsy and histopathological examination, whereas their cultures of bronchoalveolar lavage fluid were negative for fungi. The overall in-hospital mortality rate was 93.5%. CONCLUSIONS: IFT in critically ill patients results in a high mortality rate. Diabetes mellitus is the most prevalent underlying disease, followed by chronic lung disease. In addition to Aspergillus spp., Mucorales is another crucial pathogenic species. Bronchial lesion biopsy is the key diagnostic strategy.

Molecular evolution and the global reemergence of enterovirus D68 by genome-wide analysis.

Human enterovirus D68 (EV-D68) was first reported in the United States in 1962; thereafter, a few cases were reported from 1970 to 2005, but 2 outbreaks occurred in the Philippines (2008) and the United States (2014). However, little is known regarding the molecular evolution of this globally reemerging virus due to a lack of whole-genome sequences and analyses. Here, all publically available sequences including 147 full and 1248 partial genomes from GenBank were collected and compared at the clade and subclade level; 11 whole genomes isolated in Taiwan (TW) in 2014 were also added to the database. Phylogenetic trees were constructed to identify a new subclade, B3, and represent clade circulations among strains. Nucleotide sequence identities of the VP1 gene were 94% to 95% based on a comparison of subclade B3 to B1 and B2 and 87% to 91% when comparing A, C, and D. The patterns of clade circulation need to be clarified to improve global monitoring of EV-D68, even though this virus showed lower diversity among clades compared with the common enterovirus EV-71. Notably, severe cases isolated from Taiwan and China in 2014 were found in subclade B3. One severe case from Taiwan occurred in a female patient with underlying angioimmunoblastic T-cell lymphoma, from whom a bronchoalveolar lavage specimen was obtained. Although host factors play a key role in disease severity, we cannot exclude the possibility that EV-D68 may trigger clinical symptoms or death. To further investigate the genetic diversity of EV-D68, we reported 34 amino acid (aa) polymorphisms identified by comparing subclade B3 to B1 and B2. Clade D strains had a 1-aa deletion and a 2-aa insertion in the VP1 gene, and 1 of our TW/2014 strains had a shorter deletion in the 5' untranslated region than a previously reported deletion. In summary, a new subclade, genetic indels, and polymorphisms in global strains were discovered elucidating evolutionary and epidemiological trends of EV-D68, and 11 genomes were added to the database. Virus variants may contribute to disease severity and clinical manifestations, and further studies are needed to investigate the associations between genetic diversity and clinical outcomes.

Comparison of community-acquired, hospital-acquired, and intensive care unit-acquired acute respiratory distress syndrome: a prospective observational cohort study.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is a syndrome characterized by diffuse pulmonary edema and severe hypoxemia that usually occurs after an injury such as sepsis, aspiration and pneumonia. Little is known about the relation between the setting where the syndrome developed and outcomes in ARDS patients. METHODS: This is a 1-year prospective observational study conducted at a tertiary referred hospital. ARDS was defined by the Berlin criteria. Community-acquired ARDS, hospital-acquired ARDS and intensive care unit (ICU)-acquired ARDS were defined as ARDS occurring within 48 hours of hospital or ICU admission, more than 48 hours after hospital admission and ICU admission. The primary and secondary outcomes were short- and long- term mortality rates and ventilator-free and ICU-free days. RESULTS: Of the 3002 patients screened, 296 patients had a diagnosis of ARDS, including 70 (23.7 %) with community-acquired ARDS, 83 (28 %) with hospital-acquired ARDS, and 143 (48.3 %) with ICU-acquired ARDS. The overall ICU mortality rate was not significantly different in mild, moderate and severe ARDS (50 %, 50 % and 56 %, p = 0.25). The baseline characteristics were similar other than lower rate of liver disease and metastatic malignancy in community-acquired ARDS than in hospital-acquired and ICU-acquired ARDS. A multiple logistic regression analysis indicated that age, sequential organ function assessment score and community-acquired ARDS were independently associated with hospital mortality. For community-acquired, hospital-acquired and ICU-acquired ARDS, ICU mortality rates were 37 % 61 % and 52 %; hospital mortality rates were 49 %, 74 % and 68 %. The ICU and hospital mortality rates of community-acquired ARDS were significantly lower than hospital-acquired and ICU-acquired ARDS (p = 0.001 and p = 0.001). The number of ventilator-free days was significantly lower in ICU-acquired ARDS than in community-acquired and hospital-acquired ARDS (11 ± 9, 16 ± 9, and 14 ± 10 days, p = 0.001). The number of ICU-free days was significantly higher in community-acquired ARDS than in hospital-acquired and ICU-acquired ARDS (8 ± 10, 4 ± 8, and 3 ± 6 days, p = 0.001). CONCLUSIONS: Community-acquired ARDS have lower short- and long-term mortality rates than hospital-acquired or ICU-acquired ARDS.

Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy.

INTRODUCTION: Diffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS), however, the presence of DAD in the clinical criteria of ARDS patients by Berlin definition is little known. This study is designed to investigate the role of DAD in ARDS patients who underwent open lung biopsy. METHODS: We retrospectively reviewed all ARDS patients who met the Berlin definition and underwent open lung biopsy from January 1999 to January 2014 in a referred medical center. DAD is characterized by hyaline membrane formation, lung edema, inflammation, hemorrhage and alveolar epithelial cell injury. Clinical data including baseline characteristics, severity of ARDS, clinical and pathological diagnoses, and survival outcomes were analyzed. RESULTS: A total of 1838 patients with ARDS were identified and open lung biopsies were performed on 101 patients (5.5 %) during the study period. Of these 101 patients, the severity of ARDS on diagnosis was mild of 16.8 %, moderate of 56.5 % and severe of 26.7 %. The hospital mortality rate was not significant difference between the three groups (64.7 % vs 61.4 % vs 55.6 %, p = 0.81). Of the 101 clinical ARDS patients with open lung biopsies, 56.4 % (57/101) patients had DAD according to biopsy results. The proportion of DAD were 76.5 % (13/17) in mild, 56.1 % (32/57) in moderate and 44.4 % (12/27) in severe ARDS and there is no significant difference between the three groups (p = 0.113). Pathological findings of DAD patients had a higher hospital mortality rate than non-DAD patients (71.9 % vs 45.5 %, p = 0.007). Pathological findings of DAD (odds ratio: 3.554, 95 % CI, 1.385-9.12; p = 0.008) and Sequential Organ Failure Assessment score on the biopsy day (odds ratio: 1.424, 95 % CI, 1.187-1.707; p<0.001) were significantly and independently associated with hospital mortality. The baseline demographics and clinical characteristics were not significantly different between DAD and non-DAD patients. CONCLUSIONS: The correlation of pathological findings of DAD and ARDS diagnosed by Berlin definition is modest. A pathological finding of DAD in ARDS patients is associated with hospital mortality and there are no clinical characteristics that could identify DAD patients before open lung biopsy.

Immediate and Long-term Neurocognitive Outcome in Patients with Obstructive Sleep Apnea Syndrome After Continuous Positive Airway Pressure Treatment.

Neurocognitive dysfunction is a major clinical consequence in patients with obstructive sleep apnea syndrome (OSAS). The effects of continuous positive airway pressure (CPAP) treatment, as the gold standard of treatment in OSAS, on this major complication are controversial. The duration and compliance of CPAP are thought to be important factors but evidence is lacking. This study is designed to evaluate the effects of immediate (one night), long-term (3 months) influence and the compliances of CPAP treatment on the neurocognitive function in OSAS patients. We enrolled newly diagnosed severe OSAS patients. Neurocognitive function test battery, CANTAB (Cambridge Neuropsychological Test Automated Battery), was performed before, one night and 3 months of CPAP treatment. Patients with CPAP compliance rate ≥ 70 % and < 50 % were grouped into good and poor adherence subjects, respectively. Fourteen patients were enrolled in final analyses. Six of them were in poor compliant group. Improvements in attention domain were found in all subjects after one-night treatment and maintained till three-month follow-up. Additional improvements in some attention performances and visual memory performances were gained only after three-month treatment. Significant changes of decision-making and response control function were found between good and poor compliance groups after three-month treatment. CPAP can improve some neurocognitive function at the very first day used. Longer treatment of CPAP can additionally improve some other neurocognitive functions. Compliance of CPAP has influence on the recovery of neurocognitive functions in patients with severe OSAS.

Survival predictors in acute respiratory distress syndrome with extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) can be used as a salvage therapy, but the effectiveness is controversial. The aim of this study was to investigate the predictors of mortality and the influence of organ dysfunction scores in severe acute respiratory distress syndrome (ARDS) patients treated with ECMO. METHODS: The records of adult severe ARDS patients receiving ECMO support from May 2006 to December 2011 at Chang Gung Memorial Hospital were retrospectively analyzed. RESULTS: The records of 65 patients with severe ARDS who received venovenous ECMO were analyzed. The hospital survival rate was 47.7%. Survivors were younger than nonsurvivors (41.4 ± 15.4 versus 54.1 ± 16.9 years, respectively; p = 0.002) and had shorter duration of mechanical ventilation before ECMO (52.7 ± 51.1 versus 112.1 ± 101.0 hours, respectively; p = 0.01). Before ECMO, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Multiple Organ Dysfunction scores were significantly lower for survivors than for nonsurvivors. Mortality rate increased with rising predictive score. During 7 days of ECMO use, organ dysfunction scores were significantly lower for survivors than nonsurvivors. CONCLUSIONS: Severe ARDS patients who are younger, have shorter duration of mechanical ventilation, and lower organ dysfunction scores before ECMO initiation have more favorable survival outcome. Early application of ECMO, especially if predictive score is below 2, may improve survival. Organ dysfunction scores before and during ECMO support are correlated with survival.

The impact of aerosolized mucolytic agents on the airflow resistance of bacterial filters used in mechanical ventilation.

BACKGROUND/PURPOSE: In order to reduce the contamination in the ventilator, bacterial filters were placed on the expiratory limb of a ventilator circuit. Aerosolized mucolytic agents may increase the resistance of the ventilator. The goal of this study is to determine the impact of aerosolized mucolytic agents on the pressure change during mechanical ventilation. METHODS: A lung model was investigated with mucolytic inhaled agents of 10% acetylcysteine and 2% hypertonic saline. The agents were administered using a jet nebulizer every 45 minutes for 15 minutes. The pressure drop was measured after nebulization. The end point was referred to the 45(th) dose or obstruction of the filter. Furthermore, the pressure drop after steam autoclaving was also measured. RESULTS: The maximum pressure was significantly higher with 10% acetylcysteine than with 2% sodium chloride (39.32 ± 7.22 cmH2O vs. 3.53 ± 0.90 cmH2O, p < 0.001). With acetylcysteine filters, the pressure drop over 4 cmH2O occurred earlier and had a good relationship between the degree of pressure drop and doses. The acetylcysteine group yielded a significant difference in the pressure drop compared to the newly autoclaved and the end point of inhalation (p = 0.043). CONCLUSION: This study demonstrated the aerosolized mucolytic agents could increase the pressure drop of the bacterial filters during mechanical ventilation. The pressure drop of the bacterial filters was higher with 10% acetylcysteine. It is critical to continuously monitor the expiration resistance, auto-positive end-expiratory pressure, and ventilator output waveform when aerosolized 10% acetylcysteine was used in mechanical ventilation patients.

The utility of surgical lung biopsy in cancer patients with acute respiratory distress syndrome.

BACKGROUND: This retrospective study evaluated the utility and safety of surgical lung biopsy (SLB) in cancer patients with acute respiratory distress syndrome (ARDS). METHODS: All cases of critically ill patients with cancer and diagnosed with ARDS who underwent SLB in a tertiary care hospital from January 2002 to July 2009 were reviewed. Clinical data including patient baseline characteristics, surgical complications, pathological findings, treatment alterations, and survival outcomes were retrospectively collected and analyzed. RESULTS: A total of 16 critically ill patients with cancer diagnosed with ARDS who underwent SLB were enrolled. The meantime from ARDS onset to SLB was 3.0 ± 1.5 days. All SLB specimens offered a pathological diagnosis, and specific diagnoses were made in 9 of 16 patients. Biopsy findings resulted in a change in therapy in 11 of 16 patients. Overall, the SLB surgical complication rate was 19% (3/16). SLB did not directly cause the observed operative mortality. The ICU mortality rate was 38% (6/16). Patients who switched therapies after SLB had a trend toward decreased mortality than patients without a change in therapy (27% versus 60%; P = 0.299). CONCLUSIONS: In selected critically ill cancer patients with ARDS, SLB had a high diagnostic yield rate and an acceptable surgical complication rate.

Risk factors and possible mechanisms of superior vena cava intravenous port malfunction.

OBJECTIVE: To identify the risk factors leading to catheter malfunction. BACKGROUND: Reliable venous access is crucial for cancer patients. Malfunction of intravenous ports may lead to discontinuation of treatment and repeated interventions. We retrospectively reviewed the independent risk factors for catheter malfunction among patients receiving intravenous port implantations. METHODS: A total of 1508 procedures were included from the calendar year 2006, and clinical data and chest plain films were analyzed. The patients were followed-up until June 30, 2010. For patients still alive, the last outpatient follow-up date was considered as the end point. For the remaining patients, the date of death or discharge against advice was considered as the end points. The risk factors for catheter malfunction were then evaluated. RESULTS: The intervention-free periods of the malfunction group and nonmalfunction group were 317 and 413 days, respectively. Statistical analyses showed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P = 0.001). A logistic model also confirmed that the Nut-Catheter Angle was the only risk factor for catheter malfunction (P < 0.001). Valve tip catheters were not advantageous with regard to catheter malfunction prevention as compared to open tip catheters. CONCLUSIONS: A smaller Nut-Catheter Angle had a greater risk for catheter malfunction. Catheter impingement caused by inadequate pocket creation and port implantation lead to compromised catheter lumen and difficulty flushing. The possibility of retained blood and medications increased thin thrombotic biofilm formation and medication precipitation. Catheter malfunctions can be avoided by using proper surgical techniques and adequate maintenance.

Invasive fungal infection among hematopoietic stem cell transplantation patients with mechanical ventilation in the intensive care unit.

BACKGROUND: Invasive fungal infection (IFI) is associated with high morbidity and high mortality in hematopoietic stem cell transplantation (HSCT) patients. The purpose of this study was to assess the characteristics and outcomes of HSCT patients with IFIs who are undergoing MV at a single institution in Taiwan. METHODS: We performed an observational retrospective analysis of IFIs in HSCT patients undergoing mechanical ventilation (MV) in an intensive care unit (ICU) from the year 2000 to 2009. The characteristics of these HSCT patients and risk factors related to IFIs were evaluated. The status of discharge, length of ICU stay, date of death and cause of death were also recorded. RESULTS: There were 326 HSCT patients at the Linkou Chang-Gung Memorial Hospital (Taipei, Taiwan) during the study period. Sixty of these patients (18%) were transferred to the ICU and placed on mechanical ventilators. A total of 20 of these 60 patients (33%) had IFIs. Multivariate analysis indicated that independent risk factors for IFI were admission to an ICU more than 40 days after HSCT, graft versus host disease (GVHD), and high dose corticosteroid (p < 0.01 for all). The overall ICU mortality rate was 88% (53 of 60 patients), and was not significantly different for patients with IFIs (85%) and those without IFIs (90%, p = 0.676). CONCLUSION: There was a high incidence of IFIs in HSCT patients requiring MV in the ICU in our study cohort. The independent risk factors for IFI are ICU admission more than 40 days after HSCT, GVHD, and use of high-dose corticosteroid.