Two Methods of Setting Positive End-expiratory Pressure in Acute Lung Injury: An Experimental Computed Tomography Volumetric Study

This study was conducted to observe effects of two methods of setting positive endexpiratory pressure (PEEP) based on the pressure-volume (PV) curve. After lung injury was induced by oleic acid in six mongrel adult dogs, the inflation PV curve was traced and the lower inflection point (LIP) was measured. The 'PEEP(INF)' was defined as LIP+2 cmH2O. After recruitment maneuver to move the lung physiology to the deflation limb of PV curve, decremental PEEP was applied. The lowest level of PEEP that did not result in a significant drop in PaO2 was defined as the 'PEEP(DEF)'. Arterial blood gases, lung mechanics, hemodynamics, and lung volumes (measured on computed tomography during end-expiratory pause) were measured at PEEP of 0 cmH2O, PEEP(INF) and PEEP(DEF) sequentially. The median PEEP(INF) was 13.4 cm H2O (interquartile range, 12.5-14.3) and median PEEP(DEF) was 12.0 cm H2O (10.0-16.5) (p=0.813). PEEP(DEF) was associated with significantly higher PaO2 and lung volumes, and significantly lower shunt fraction and cardiac index when compared to PEEP(INF) (p<0.05). Setting the PEEP based on the deflation limb of the PV curve was useful in improving oxygenation and lung volumes in a canine lung injury model.

A Case of Acute Respiratory Distress Syndrome Induced by Injection of Silicone Fluid for Colpoplasty / 결핵및호흡기질환

Acute respiratory distress syndrome after silicone fluid injection is uncommon. Reasons that organic silicone is inactive in the human body and has low surface tension and is not affected by physical factors such as time or temperature make this material to be widely used as a medical product. However, lately some of its side effects have been noted and also cause respiratory problems in rare occasions. The mechanism is not clear but silicone injection cause one to cough, produce hemoptysis, fever, pleuritic chest pain, and dyspnea, and may even lead to acute respiratory failure. In other countries, these side effects were reported from 1970s and several cases started to appear in Korea from 1990s. We report a 58 years-old female who recovered from acute respiratory distress syndrome after injection of silicone fluid into vaginal wall by a conservative therapy.

Physiologic Changes During Bronchoscopy in Mechanically Ventilated Patients / 결핵

BACKGROUND: Bronchoscopy in patients on mechanical ventilation is being performed much more frequently. However, there is little data on the changes in physiologic parameters and no established mechanical ventilation protocol during bronchoscopy. A decreasing or the removal of positive end-expiratory pressure (PEEP) during bronchoscopy may precipitate severe hypoxemia and/or derecruitment. METHODS: Our standardized mechanical ventilation protocol, without changing the PEEP level, was used during bronchoscopy. The physiological parameters were measured during the bronchoscopic procedure. RESULTS: During bronchoscopy, respiratory acidosis, elevation of peak pressure, elevation of heart rate and auto-PEEP were developed, but were reversible changes. Procedure-related gross barotraumas or other severe complications did not developed. CONCLUSION: No serious complications developed during bronchoscopy under our standardized mechanical ventilation protocol when the PEEP level remained unchanged. The procedure time should be kept to a minimum to decrease the exposure time to undesirable physiological changes.

A Case of Anticonvulsant Hypersensitivity Syndrome with Subcarinal Lymph node Enlargement and Eosinophilic Pneumonia Induced by Carbamazepine / 결핵및호흡기질환

Anticonvulsant hypersensitivity syndrome (AHS) is an uncommon, but potentially fatal and mutilsystemic disorder that occurs after exposure to the arene oxide-producing anticonvulsants-carbamzepine, phenobarbital and phenytoin. The multisystemic reactions include fever, skin eruptions, lymphadenopathy, hematologic abnormality and hepatitis. The diagnosis of AHS is made by history of drug exposure and clinical course. No specific treatments are proved as benefit except discontinuing the offending drug and trying the steroids in some severe cases. We report a case of carbamazepine induced anticonvulsant hypersensitivity syndrome characterized by skin rash, eosinophilia, subcarinal lymphadenopathy and eosinophilic pneumonia. The patient was resolved completely after only discontinuing carbamazepine.

The Changes of Physiologic Parameters with Time in Steroid treated-Late Acute Respiratory Distress Syndrome Patients / 결핵

BACKGROUND: The mortality from acute respiratory distress syndrome(ARDS) is > 40-50%. Although some prospective trials have failed to demonstrate a survival benefit of steroids in the early stages of ARDS, there are some reports showing some success with steroids in the later stages. This study observed the changes in the physiologic parameters with time in late ARDS patients who were treated with steroids. METHODS: The medical charts of 28 intensive care unit patients(male:female=24:4; mean age 64 years), who had been diagnosed with refractory late ARDS (PaO2/FIO2 < 200) and were treated with corticosteroids from December 1999 to July 2002, were retrospectively reviewed. The patients were divided into two groups: the weaned group(n=14), which included the patients who had been successfully weaned from a ventilator after corticosteroid therapy, and the failed group(n=14), which included the patients who had failed weaning. The physiologic parameters included the PaO2/FIO2 ratio, the positive end-expiratory pressure(PEEP) level, the PaCO2, compliance, the sequential organ failure assessment(SOFA) score, the acute physiologic and the chronic health evaluation(APACHE) II score, and the Murray Lung Injury Score(LIS) in the two groups were compared from the day of mechanical ventilation(Dmv) to 7 days after the corticosteroid therapy. RESULTS: There was no significant difference in the clinical characteristics and the physiologic parameters between the two groups prior to the corticosteroid therapy except for the SOFA score at Dmv(weaned group : 6.6+/-2.5 vs failed group : 8.8+/-2.9, p=0.047) . However, within 7 days after corticosteroid therapy, there was significant improvement in the PaO2/FIO2 ratio, the PEEP level, the PaCO2, the SOFA score, the APACHE II score, and the LIS of the weaned group compared to the failed group. CONCLUSIONS: During corticosteroid therapy in late ARDS, the continuation of corticosteroid therapy should be determined carefully in patients who do not show improvement in their physiologic parameters by day 7.

Clinical and Radiographic Characteristics of 12 Patients with Mycobacterium abscessus Pulmonary Disease / 결핵

BACKGROUND: Mycobacterium abscessus is the most common respiratory pathogen in rapidly growing mycobacteria and is resistant to all of the first-line antituberculosis drugs. This report describes the clinical and radiographic characteristics in patients with pulmonary disease caused by M. abscessus. MATERIALS AND METHODS: Twelve patients with pulmonary disease caused by M. abscessus who fulfilled the 1997 American Thoracic Society diagnostic criteria for a nontuberculous mycobacterial pulmonary infection were observed over a five-and-a-half year period. The clinical characteristics and chest radiographic findings were analyzed, retrospectively. RESULTS: The patients were predominantly female(11/12, 92%) and nonsmokers(12/12, 100%). Coughing (10/12, 83%), sputum(10/12, 83%) and hemoptysis(10/12, 83%) were the common symptoms and they had prolonged periods from the onset of symptoms to the diagnosis of their disease(median 6.5 years). Eleven (92%) patients had a previous history of being treated for pulmonary tuberculosis. The sputum specimens were acid-fast bacilli smear-positive in all patients. All patients were administered antituberculosis drugs. Six (50%) patients were treated with second-line antituberculosis drugs on account of persistent smear-positive sputum specimens. The chest radiographs showed that reticulonodular opacities(11/12, 92%) were the most common pattern of abnormality, followed by cavitary lesions(5/12, 42%). The computed tomography findings suggested bronchiolitis from the centrilobular nodules with a tree-in-bud appearances(9/10, 90%) and bronchiectasis (9/10, 90%) were the most common, followed by well-defined nodules smaller than 10-mm in diameter(7/10, 70%). CONCLUSIONS: M. abscessus pulmonary disease should be recognized as a cause of chronic mycobacterial lung disease, and respiratory isolates should be assessed carefully.

Clinical Characteristics of the Patients with Mycobacterium avium Complex Pulmonary Disease / 결핵

BACKGROUND: Mycobacterium avium complex(MAC) is the most common respiratory pathogen in nontuberculous mycobacterial pulmonary disease. This study described the clinical characteristics of the patients with pulmonary disease caused by MAC. MATERIALS AND METHODS: The clinical characteristics of 24 patients with pulmonary disease caused by the MAC, who fulfilled the 1997 American Thoracic Society diagnostic criteria for nontuberculous mycobacterial pulmonary disease, were retrospectively analyzed. RESULTS: Fourteen patients(58%) were male and the median age at diagnosis was 61 years(range 46-75). Of the 24 patients, 16(67%) had a M. intracellulare infection, 7(29%) had a M. avium infection and one patient was not identified. Coughing(92%) and sputum(88%) were most frequently observed symptoms. The sputum smear for acid-fast bacilli was positive in 17(71%) patients. Fourteen(58%) patients had the upper lobe cavitary form and 10(42%) patients had the nodular bronchiectatic form. In a comparison between the patients with the upper lobe cavitary form and those with the nodular bronchiectatic form, significant differences were found according to sex(male 86% vs. 20%, p=0.003), smoking history(79% vs. 10%, p=0.008), the presence of an underlying disease(64% vs. 20%, p=0.036), the pulmonary function(% forced vital capacity, median 71% vs. 88%, p=0.022; % forced expiratory volume in one second, median 69% vs. 89%, p=0.051) and bilateral disease at chest radiography(29% vs. 90%, p=0.005). The time from the onset of symptoms to diagnosis was longer in those with the nodular bronchiectatic form(median 72 months, range 8-132) than those with the upper lobe cavitary form(median 22 months, range 6-60) CONCLUSIONS: MAC pulmonary disease occurs in two distinct populations with two distinct clinical presentations. For a correct diagnosis of MAC pulmonary disease, knowledge of the diverse clinical and radiological findings is essential.

Diagnosis of sick sinus syndrome with intravenous adenosine injection

BACKGROUND: The most widely utilized indexes of sinus node dysfunction are the sinus node recovery time (SNRT) and the corrected sinus node recovery time (CSNRT), which generally require catheterization. Adenosine has negative chronotropic effect on the sinoatrial node. Non-invasive and reliable sinus node function test with intravenous adenosine was investigated. METHODS AND RESULT: The clinical value of rapid intravenous injection of adenosine for assessing sinus node dysfunction was examined in 14 patients with sick sinus syndrome (SSS) and 31 controls. After prophylactic insertion of a temporary pacemaker in the right ventricle, overdrive suppression test was conducted using the standard technique and CSNRT was measured to evaluate the sinus node function. Then, the CSNRT after administration of an intravenous bolus of adenosine (6 mg and 12 mg) was measured. Post-adenosine corrected sinus node recovery time (ADO: SNRT) was calculated by subtracting the basal sinus cycle length from the longest sinus cycle length. When ADO: SNRT over 550 msec was assumed as an indicator of sinus node dysfunction, intravenous injection of 6 mg of adenosine had a sensitivity of 85% and specificity of 100%, and 12 mg of adenosine had a sensitivity of 100% and specificity of 90% for detection of sick sinus syndrome. There were significant differences in ADO: SNRT between patient and control group (6 mg 1501+/-1081 msec vs 64+/-109 msec; 12 mg 4005+/-2055 msec vs 216+/-315 msec, respectively). CONCLUSION: he ADO: SNRT was a highly sensitive and specific index for diagnosing sick sinus syndrome, and should be considered as an alternative to invasive testing in patients with suspected sick sinus syndrome.

Initiation of Torsades de pointes by head-up tilt test in congenital long QT syndrome patient

Long QT syndrome is a cardiac disorder of repolarization which is characterized by elctrocardiographic abnormalities including prolonged QT interval, T-wave abnormalities and polymorphic ventricular tachycardia known as Torsades de Pointes. Its clinical manifestation are recurrent syncope, seizure, and sudden death. Recently,we experienced Torsades de Pointes(TdP) by head-up tilt test in 24 year-old female patient presenting recurrent syncope and long QT interval. Beta-blocker and left cervicothoracic sympathetic ganglionectomy were not effictive, then we tried mexiletine. After mexiletine medication, the QT interval was significantly shortened and there was no more syncope.

A Case of Obstructive Jaundice Caused by Extrinsic Compresson of Biliary Cystadenoma of the Common Hepatic Duct / 대한소화기내시경학회지

Biliary cystadenoma is a rare tumor that arises in the liver or, less frequently, in the extrahepatic ducts. Jaundice in patients with biliary cyst adenoma is not uncomon, but it is very rare that the jaundice is caused by tumor compression of the bile duct. A 43-year-old woman who had a huge biliary cystadenoma occupying the left liver developed deep jaundice. Endoscopic retrograde cholangiopancreatograpy demontrated that this tumor compressed the common hepatic ducts extrinsically which caused the deep jaundice.