Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score.

PURPOSE: Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS: In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS: Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION: Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study.

BACKGROUND: Overuse of arterial blood gas (ABG) determinations leads to increased costs, inefficient use of staff work hours, and patient discomfort and blood loss. We developed guidelines to optimize ABG use in the ICU. METHODS: ABG use guidelines were implemented in all adult ICUs in our institution: three medical, two trauma-surgery, one cardiovascular, and one neurosurgical ICU. Although relying on pulse oximetry, we encouraged the use of ABG determination after an acute respiratory event or for a rational clinical concern and discouraged obtaining ABG measurements for routine surveillance, after planned changes of positive end-expiratory pressure or Fio2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected. ABG measurements and global ICU metrics were collected before (year 2014) and after (year 2015) the intervention. RESULTS: We saw a reduction of 821.5 ± 257.4 ABG determinations per month (41.5%), or approximately one ABG determination per patient per mechanical ventilation (MV) day for each month (43.1%), after introducing the guidelines (P < .001). This represented 49 L of saved blood, a reduction of $39,432 in the costs of ICU care, and 1,643 staff work hours freed for other tasks. Appropriately indicated tests rose to 83.4% from a baseline 67.5% (P = .002). Less than 5% of inappropriately indicated ABG determinations changed patient management in the postintervention period. There were no significant differences in MV days, severity of illness, or ICU mortality between the two periods. CONCLUSIONS: The large scale implementation of guidelines for ABG use reduced the number of inappropriately ordered ABG determinations over seven different multidisciplinary ICUs, without negatively impacting patient care.

Follicular Lymphoma Diagnosed With Medical Thoracoscopy.

Non-Hodgkin lymphomas may present with a recurrent pleural effusion, usually with involvement of other thoracic or extrathoracic sites. Lymphomas typically presenting with pleural disease include primary effusion lymphoma and pyothorax-associated lymphoma. We describe an unusual case of recurrent pleural effusion secondary to follicular lymphoma with no other known extrathoracic involvement at the time of diagnosis.

Pulmonary function and flow-volume loop patterns in patients with tracheobronchomalacia.

BACKGROUND: Patterns of pulmonary function tests (PFTs) and flow-volume loops among patients with clinically important tracheobronchomalacia (TBM) are not well described. Small studies suggest 4 main flow-volume loop morphologies: low maximum forced expiratory flow, biphasic expiratory curve, flow oscillations, and notching. We studied common PFT and flow-volume loop patterns among the largest prospective series of patients to date, undergoing clinical evaluation for symptomatic moderate to severe TBM. METHODS: We conducted a retrospective analysis of prospectively collected data from patients who were referred to our Chest Disease Center from January 2002 to December 2008, with respiratory symptoms that were attributed primarily to TBM. The PFT results of 90 subjects with symptomatic moderate to severe TBM were evaluated. RESULTS: By PFTs, 40 (44.4%) subjects had an obstructive ventilatory defect, 16 (17.8%) had a definite or highly likely restrictive ventilatory defect, 15 (16.7%) had a mixed defect, and 19 (21.1%) were within normal limits. Among 76 subjects with available flow-volume loops, the most frequent finding was low maximum forced expiratory flow, in 62 (81.6%) subjects, followed by biphasic morphology (15, 19.7%), notched expiratory loop (7, 9.2%), and expiratory oscillations (2, 2.6%). The balance of 13 subjects (17.1%) had no distinctive flow-volume loop abnormality. CONCLUSION: PFTs and flow-volume loops are normal in a substantial number of patients with moderate to severe TBM, and should not be used to decide whether TBM is present or clinically important.