AI-Based Quantitative CT Analysis of Temporal Changes According to Disease Severity in COVID-19 Pneumonia.

OBJECTIVE: To quantitatively evaluate computed tomography (CT) parameters of coronavirus disease 2019 (COVID-19) pneumonia an artificial intelligence (AI)-based software in different clinical severity groups during the disease course. METHODS: From March 11 to April 15, 2020, 51 patients (age, 18-84 years; 28 men) diagnosed and hospitalized with COVID-19 pneumonia with a total of 116 CT scans were enrolled in the study. Patients were divided into mild (n = 12), moderate (n = 31), and severe (n = 8) groups based on clinical severity. An AI-based quantitative CT analysis, including lung volume, opacity score, opacity volume, percentage of opacity, and mean lung density, was performed in initial and follow-up CTs obtained at different time points. Receiver operating characteristic analysis was performed to find the diagnostic ability of quantitative CT parameters for discriminating severe from nonsevere pneumonia. RESULTS: In baseline assessment, the severe group had significantly higher opacity score, opacity volume, higher percentage of opacity, and higher mean lung density than the moderate group (all P ≤ 0.001). Through consecutive time points, the severe group had a significant decrease in lung volume (P = 0.006), a significant increase in total opacity score (P = 0.003), and percentage of opacity (P = 0.007). A significant increase in total opacity score was also observed for the mild group (P = 0.011). Residual opacities were observed in all groups. The involvement of more than 4 lobes (sensitivity, 100%; specificity, 65.26%), total opacity score greater than 4 (sensitivity, 100%; specificity, 64.21), total opacity volume greater than 337.4 mL (sensitivity, 80.95%; specificity, 84.21%), percentage of opacity greater than 11% (sensitivity, 80.95%; specificity, 88.42%), total high opacity volume greater than 10.5 mL (sensitivity, 95.24%; specificity, 66.32%), percentage of high opacity greater than 0.8% (sensitivity, 85.71%; specificity, 80.00%) and mean lung density HU greater than -705 HU (sensitivity, 57.14%; specificity, 90.53%) were related to severe pneumonia. CONCLUSIONS: An AI-based quantitative CT analysis is an objective tool in demonstrating disease severity and can also assist the clinician in follow-up by providing information about the disease course and prognosis according to different clinical severity groups.

Convalescent (immune) plasma treatment in a myelodysplastic COVID-19 patient with disseminated tuberculosis.

During the ongoing COVID-19 pandemic due to the SARS-CoV-2 virus of which evidence-based medical paradigms cannot be easily applied; difficult clinical decisions shall be required particularly in the 'difficult-to-treat' cases of high risk group with associated comorbidities. Convalescent immune plasma therapy is a promising option as a sort of 'rescue' treatment in COVID-19 immune syndrome, where miraculous antiviral drugs are not available yet. In this report, we aim to convey our experience of multi-task treatment approach with convalescent immune plasma and anti-cytokine drug combination in a COVID-19 patient with extremely challenging comorbidities including active myeloid malignancy, disseminated tuberculosis and kidney failure.

Influenza or other respiratory viruses: does it matter as the cause of acute respiratory failure in the critically-ill patients?

INTRODUCTION: Respiratory virus infections may cause serious respiratory failure requiring intensive care unit (ICU) admission. The objective of this study was to evaluate the clinical features and the outcome in patients with acute respiratory failure (ARF) due to viral infections comparing etiological agents. MATERIALS AND METHODS: ARF patients with positive viral serology were retrospectively recruited. Cohort was evaluated with regard to subgroups as influenza and other respiratory viruses (ORV), as well as survivors and nonsurvivors. RESULT: Out of 938 admitted patients, 319 were followed as ARF and only 149 patients had viral respiratory panel results. In 49 patients with ARF, 52 positive viral results were detected and 47 patients with single positive viral isolates of either influenza or ORV were included. Among them, 62% had ORV with quite similar characteristics with influenza group apart from diabetes mellitus which was encountered more in influenza group (p= 0.02). Overall ICU mortality was 32% and there was no difference between the two groups (p= 0.42). Acute Physiology and Chronic Health Evaluation (APACHE) II score was independently associated with ICU mortality (OR: 1.25; 95% CI: 1.04-1.51; p= 0.02). CONCLUSIONS: This study emphasizes to consider the possibility of other respiratory viruses for the cause of ARF with similar characteristics and mortality as influenza species.

Characteristics of obstetric admissions to intensive care unit: APACHE II, SOFA and the Glasgow Coma Scale.

Objective To evaluate the characteristics of obstetric admissions to an intensive care unit (ICU) and assess the utility of Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and the Glasgow Coma Scale (GCS). Methods This study is consisted of 160 patients admitted to an ICU during the antenatal period or within 7 days at the postpartum period. Clinical characteristics and ICU scores were evaluated. Results The rate of admission to the ICU was 7.8/1000 deliveries. Four cases ended with maternal mortality (2.5%). The most common hospitalization indications were hypertensive disorders of pregnancy, cardiovascular disorders and obstetric hemorrhage, at 40 (25%), 34 (21.2%), and 31 (19.3%) cases, respectively. The receiver operating characteristics (ROC) curve analysis for prediction of maternal mortality revealed area under curve (AUC) values as 0.971 both for APACHE II and predicted mortality rate (PMR), and 24.5 and 47.1 were determined as the cut-offs with sensitivities of 100%. AUCs were also 0.901 and 0.929 for the initial and worst SOFA score, respectively. The cut-off value for the initial and worst SOFA score was 3.5, with a sensitivity of 100%, and was 10 with a specificity of 98.9%, respectively. Conclusion APACHE II and PMR overpredict maternal mortality, but those higher scores predict maternal mortality. Higher SOFA scores are related with maternal mortalities with high specificity.

[Effect of hypophosphatemia on weaning success from mechanical ventilation]. / Mekanik ventilasyon uygulanan hastalarda ventilatörden ayirma basarisini belirlemede hipofosfateminin yeri.

INTRODUCTION: Hypophosphatemia may cause acute respiratory failure and tissue hypoxia. In this study we investigated the effect of hypophosphatemia on weaning success. PATIENTS AND METHODS: A nested case-control study was conducted in a retrospective cohort of 76 patients who received invasive mechanical ventilation in 2005-2010 in the Medical Intensive Care Unit (MICU) of university hospital. Case patients (failure group) were those who could not be weaned in the first trial or who required post-extubation mechanical ventilation after first extubation. Control patients (success group) were successfully extubated in the first weaning attempt. RESULTS: Frequency of hypophosphatemia (P level < 2.5 mg/dL) at admission was 23.7%. Weaning failure rate was 71.1%. Risk of weaning failure in the presence of hypophosphatemia was 88.9%, whereas risk in the absence of hypophosphatemia was 65.5%, resulting in risk ratio of 1.36 (1.06 - 1.74) (p= 0.096). Mean (± SD) P levels in the success and failure groups were 3.6 ± 1.0 and 3.2 ± 1.0 mg/dL, respectively (p= 0.113). Logistic regression analysis revealed four independent risk factors which were presence of underlying chronic pulmonary disease, high organ dysfunction score (SOFA) at admission, high blood urea nitrogen at the day of weaning trial and low P level at admission to predict weaning failure. Each 1 mg/dL increment in P level resulted in decreased probability of weaning failure with an OR of 0.43 (0.21-0.88). CONCLUSION: In conclusion, a relation between hypophosphatemia and weaning failure was determined which has to be confirmed with prospective cohort and interventional studies with adequate power.

SARS-CoV-2 and lung injury: Dysregulation of immune response but not hyperimmune response as in "cytokine storm syndrome".

SARS-CoV-2 infection can present either an asymptomatic or symptomatic; the spectrum of symptomatic infection ranges from mild to critical. A majority of patients have experienced mild symptoms with a good prognosis. But approximately 14% of them have severe infection presenting with hypoxemia and extensive lung involvement. The current mini-review describes the dysregulation of immune response for SARS-CoV-2 viral pneumonia and virus-induced lung injury. Also, many confounding factors can increase lung injury, in addition to virus-induced lung injury. Especially in critically ill patients, confounding factors can cause the inflammatory cascade, acute respiratory distress syndrome (ARDS), and mortality.

The Use of High-Flow Nasal Oxygen Therapy in the Management of Severe Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Feasibility Study.

OBJECTIVE: This study investigated the efficacy of high-flow nasal oxygen therapy in patients with severe acute exacerbation of chronic obstructive pulmonary disease admitted to the intensive care unit. MATERIAL AND METHODS: Totally, 23 patients were enrolled in the study. High-flow nasal oxygen therapy was administered with a predefined protocol. Vital signs, Visual Analog Scale for dyspnea, and arterial blood gas parameters were recorded at the beginning under low-flow oxygen support therapy and the 1st, 6th, 12th, and 24th hours of high-flow nasal oxygen therapy. High-flow nasal oxygen therapy duration, intensive care unit length of stay, and intensive care unit, in-hospital, and 60-day mortality were recorded as outcomes and compared according to the presence of pneumonia upon admission. RESULTS: In 12 patients (52.2%), pneumonia was present. High-flow nasal oxygen therapy was applied for a median of 57 hours [49.2-104.5]. Overall decreases were detected in heart rate (P = .001), respiratory rate (P < .001), and Visual Analog Scale for dyspnea (P = .001) during the first 24 hours of the therapy. Although there was an increase in PaCO2 (P = .001), pH increased (P < .001) over time too. No change in partial arterial oxygen pressure (P = .63) and partial arterial oxygen pressure/fraction of inspired oxygen ratio (P = .22) was noted. Nineteen patients (77%) were successfully weaned from high-flow nasal oxygen therapy. While the high-flow nasal oxygen therapy failure rate was 23%, the in-hospital and 60-day mortality rates were 8.6%. Outcomes were not different between patients with and without pneumonia. CONCLUSION: High-flow nasal oxygen therapy was efficient in relieving respiratory distress and well-tolerated with no adverse out- come in severe acute exacerbation of chronic obstructive pulmonary disease patients admitted to the intensive care unit.

Salbutamol Delivered by Jet Nebulizer: Closed System Design and Impact of a Model Biofilm.

BACKGROUND: Aerosol therapy is commonly used by intensivists during invasive mechanical ventilation. More information is needed to optimize outcomes. The first aim of this study was to assess the deposition of salbutamol on components of a closed mechanical ventilation system, both in the presence and absence of biofilm generated by Acinetobacter baumannii. The second aim was to evaluate the deposition of salbutamol, using a single dose and a double dose, delivered via a jet nebulizer placed between the flexible tube and the heat and moisture exchanger. METHODS: A mechanical ventilator was connected to a standard system, and a jet nebulizer was placed between the heat and moisture exchanger and the flexible tube. Clinical isolates of A. baumanii were used to generate a biofilm layer on the endotracheal tube. Two amounts of salbutamol were delivered via the jet nebulizer. An analytical liquid chromatography tandem mass spectrometry method was developed to evaluate salbutamol deposition. RESULTS: The presence of a biofilm on the endotracheal tube had no impact on salbutamol deposition (P = .83). There was no difference in surface deposition of salbutamol on component parts of the closed system in a comparison of a single dose and a double dose delivered via a jet nebulizer. CONCLUSIONS: Our findings indicate that an A. baumannii biofilm had no impact on the extent of salbutamol deposition. Salbutamol deposition was comparatively low and could be delivered without removal of the heat and moisture exchanger.

Association of baseline diaphragm, rectus femoris and vastus intermedius muscle thickness with weaning from mechanical ventilation.

BACKGROUND: To determine whether baseline diaphragm (Tdi), rectus femoris (RF) and vastus intermedius (VI) muscle thickness (TRF and TRF + VI) are associated with weaning success. MATERIAL AND METHODS: Right Tdi, TRF and TRF + VI were measured by ultrasonography within 36 h of intubation and diaphragmatic excursion (DE) was evaluated at the first spontaneous breathing trial in adult critically-ill patients. Reintubation or death within 7 days after extubation was defined as weaning failure. Weaning failure and success groups were compared in terms of ultrasonographic measurements and clinical features. RESULTS: Thirty-eight patients were assessed for weaning, 15 (39.4%) being in the weaning failure group. The median body mass index (BMI) was lower while the median clinical frailty scale (CFS), vasopressor use, duration of mechanical ventilation, intensive care and hospital mortality rate were higher in the weaning failure group, and the median TRF + VI (14.0 [12.3-26.2] vs 23.6 [21.3-27.1] mm, p = 0.03) and median DE (19.4 [14.6-24.0] vs 25.9 [19.3-38.5] mm, p = 0.045) were lower. The median Tdi was similar in two groups (1.9 [1.5-2.3] vs 2.0 [1.7-2.4] mm, p = 0.26). In ROC analysis, area under the curve for TRF + VI was 0.71 (95% CI: 0.51-0.90; p = 0.035), with 21 mm cut-off having sensitivity of 82% and specificity of 57%. Binary logistic regression analysis revealed TRF + VI < 21 mm as the only predictor of weaning failure with an odds ratio of 10.5 (95% CI: 1.1-97.8, p = 0.038) after adjusting for age, sex, BMI and CFS. CONCLUSIONS: TRF + VI lower than 21 mm, measured by ultrasonography within 36 h of intubation, was associated with weaning failure among critically-ill patients.

Clinical Outcomes and Independent Risk Factors for 90-Day Mortality in Critically Ill Patients with Respiratory Failure Infected with SARS-CoV-2: A Multicenter Study in Turkish Intensive Care Units.

BACKGROUND: There are limited data on the long-term outcomes of COVID-19 from different parts of the world. AIMS: To determine risk factors of 90-day mortality in critically ill patients in Turkish intensive care units (ICUs), with respiratory failure. STUDY DESIGN: Retrospective, observational cohort. METHODS: Patients with laboratory-confirmed COVID-19 and who had been followed up in the ICUs with respiratory failure for more than 24 hours were included in the study. Their demographics, clinical characteristics, laboratory variables, treatment protocols, and survival data were recorded. RESULTS: A total of 421 patients were included. The median age was 67 (IQR: 57-76) years, and 251 patients (59.6%) were men. The 90-day mortality rate was 55.1%. The factors independently associated with 90-day mortality were invasive mechanical ventilation (IMV) (HR 4.09 [95% CI: [2.20-7.63], P < .001), lactate level >2 mmol/L (2.78 [1.93-4.01], P < .001), age ≥60 years (2.45 [1.48-4.06)], P < .001), cardiac arrhythmia during ICU stay (2.01 [1.27-3.20], P = .003), vasopressor treatment (1.94 [1.32-2.84], P = .001), positive fluid balance of ≥600 mL/day (1.68 [1.21-2.34], P = .002), PaO2/FiO2 ratio of ≤150 mmHg (1.66 [1.18-2.32], P = .003), and ECOG score ≥1 (1.42 [1.00-2.02], P = .050). CONCLUSION: Long-term mortality was high in critically ill patients with COVID-19 hospitalized in intensive care units in Turkey. Invasive mechanical ventilation, lactate level, age, cardiac arrhythmia, vasopressor therapy, positive fluid balance, severe hypoxemia and ECOG score were the independent risk factors for 90-day mortality.

Maternal Mortality: 10 Year Experience of a Tertiary Center in Turkey.

We retrospectively evaluated five maternal mortality cases that occurred in our institution within the last 10 years. Rate of maternal mortality was 24.5 per 100000 live births. Maternal mortality causes were cardiopulmonary failure secondary to veno-occlusive disease, septic shock secondary to osteosarcoma, pulmonary thromboembolism secondary to metastatic breast cancer, septic shock secondary to cholecystitis, and postpartum hemorrhage secondary to Niemann-Pick disease. Four out of five cases were evaluated as indirect maternal mortality cases. Three out of five cases ended up with a healthy newborn, while other cases ended up with abortus and postpartum exitus.

Visual and software-based quantitative chest CT assessment of COVID-19: correlation with clinical findings.

PURPOSE: The aim of this study was to evaluate visual and software-based quantitative assessment of parenchymal changes and normal lung parenchyma in patients with coronavirus disease 2019 (COVID-19) pneumonia. The secondary aim of the study was to compare the radiologic findings with clinical and laboratory data. METHODS: Patients with COVID-19 who underwent chest computed tomography (CT) between March 11, 2020 and April 15, 2020 were retrospectively evaluated. Clinical and laboratory findings of patients with abnormal findings on chest CT and PCR-evidence of COVID-19 infection were recorded. Visual quantitative assessment score (VQAS) was performed according to the extent of lung opacities. Software-based quantitative assessment of the normal lung parenchyma percentage (SQNLP) was automatically quantified by a deep learning software. The presence of consolidation and crazy paving pattern (CPP) was also recorded. Statistical analyses were performed to evaluate the correlation between quantitative radiologic assessments, and clinical and laboratory findings, as well as to determine the predictive utility of radiologic findings for estimating severe pneumonia and admission to intensive care unit (ICU). RESULTS: A total of 90 patients were enrolled. Both VQAS and SQNLP were significantly correlated with multiple clinical parameters. While VQAS >8.5 (sensitivity, 84.2%; specificity, 80.3%) and SQNLP <82.45% (sensitivity, 83.1%; specificity, 84.2%) were related to severe pneumonia, VQAS >9.5 (sensitivity, 93.3%; specificity, 86.5%) and SQNLP <81.1% (sensitivity, 86.5%; specificity, 86.7%) were predictive of ICU admission. Both consolidation and CPP were more commonly seen in patients with severe pneumonia than patients with nonsevere pneumonia (P = 0.197 for consolidation; P < 0.001 for CPP). Moreover, the presence of CPP showed high specificity (97.2%) for severe pneumonia. CONCLUSION: Both SQNLP and VQAS were significantly related to the clinical findings, highlighting their clinical utility in predicting severe pneumonia, ICU admission, length of hospital stay, and management of the disease. On the other hand, presence of CPP has high specificity for severe COVID-19 pneumonia.

Is tin fume exposure benign or not? Two case reports.

Stannosis is a non-fibrotic form of pneumoconiosis in which tin-oxide is accumulated in pulmonary parenchyma as a result of inhalation of tin-oxide (stannic oxide) dust and fume. Chest radiograph shows numerous small very dense nodules in both lungs. Although radiological findings of stannosis were apparent, the patients were clinically in good condition, and pulmonary function test (PFT) values showed no disability. Case 1, 70-year-old man had exercise dyspnea for four years. He worked as a tinner for 40 years. A slight restriction was detected in his PFT. Diffused, small, dense, reticulonodular opacities were detected on chest X-ray. Thorax high resolution computerized tomography (HRCT) revealed dense, common noduler lesions, reticulation and honeycomb appearance. Case 2, the patient was a 50-year-old woman. She had been exposed tin fume for 33 years and never smoked. In PFT, a slightly low FEV1 value and a normal FVC value were detected. Diffused reticulonodular opacities were detected on chest X-ray. On thorax HRCT, ground glass densities in some areas, widespread interlobulary septal thickening, peribronchial thickening predominant in perihilar regions in both lungs and subpleural milimetric nodular densities were observed in the upper and middle lobe of the right lung. Two patients who exposed to tin fume are described. However, contrary to what is expected, both patients clinically deterioted and died as a result of respiratory failure.

An unusual case of Wegener's granulomatosis with tongue involvement.

Wegener's granulomatosis is a type of vasculitis characterized by necrotizing granulomatosis respiratory tract lesions and necrotising glomerulonephritis. Nasal, lung and renal biopsies and positive antineutrophil cytoplasmic antibody (c-ANCA) analysis is helpful in diagnosis. Early diagnosis and treatment is critical in prognosis. A 42 years-old male had dyspnea, coughing, hemoptysis, fatigue, loss of appetite, night sweating and arthralgia. Violaceous palpable, purpuric lesions were detected on the sublingual region of the mouth. On chest X-ray, there was nonhomogeneous infiltration in the parenchyma of both lungs. There was alveolar density involving upper lobes of both lungs detected in thoracal computerized tomography as well as patchy densities on the right lung upper-middle lobes. A nasal mucosa biopsy showed strongly destructive vasculitis. c-ANCA test was positive. We report an unusual case with Wegener's granulomatosis, characterized by a rare presentation of tongue involvement and atypical lung radiology with alveolar opacity.

[Severity scores and factors related with mortality in cases with community-acquired pneumonia patients in intensive care unit]. / Yogun bakimda izlenen toplum kökenli pnömoni olgularinin hastalik agirlik skorlamalari ve mortalite üzerine etkili faktörler.

Totally 48 cases with diagnosed as community-acquired pneumonia who were treated in intensive care units of two different university hospital included to the study. The mean age of cases was 67.8, 29 were males and 19 females. Glasgow Coma Score (GCS), Acute Physiology Assesment and Chronic Health Evaluation II (APACHE II), Pneumonia Severity Index (PSI) and Sequential Organ Failure Assessment Score (SOFA) of 46 cases were determined. The most common comorbid disease was cerebrovascular disease. We determined that microbiological tests were made in 30 cases and pathogen agent was established in 7 cases of them. The mean lenght of stay in hospital and intensive care unit were 16.1 days and 8.8 days respectively. The mean GCS was 11.4, the mean PSI was 130.7 and 38 cases were in high risk classes. The mean APACHE II and SOFA scores were 20.7 and 4.4 respectively. We determined that hypotension and intubation increased the mortality risk. The mean blood urea nitrogen, %PNL and respiratory rate were higher in cases who were died. The mortality rate in group 3b and group 4 were respectively 41.2% and 44.0%. Totally 20 (41.7%) cases died.

Restless legs syndrome in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the prevalence of restless legs syndrome (RLS) in patients with chronic obstructive pulmonary disease (COPD) and the relationship between RLS and clinical/laboratory findings of COPD. METHODS: One hundred and thirty-four COPD patients without secondary causes of RLS were included. Thirty-nine (29.1%) patients were diagnosed with RLS and classified as Group 1. The control group consisted of 65 age-matched COPD patients without RLS. Group 1 was divided into subgroups according to the Johns Hopkins Severity (JHS) scale. Patients with a score of 0, 1, or 2 were classified as JHS 0-2 and those with a score of 3 as JHS 3. Group 1 and the control group and subgroups were compared for clinical and laboratory characteristics. RESULTS: We found that the duration of COPD was longer and that airway obstruction, hypercapnia, and hypoxia were more evident in patients with RLS than those without. Similar differences were also detected between JHS subgroups 3 (more severe) and 0-2. Polyneuropathy frequency was significantly higher in Group 1 compared to controls. However, Group 1 subgroups showed a similar frequency of polyneuropathy. In a multivariate analysis, hypercapnia made a significant independent contribution to both JHS 0-2 and JHS 3 patients when RLS severity was set as the dependent variable. Polyneuropathy and the duration of COPD were significant independent variables for patients in the JHS 3 subgroup. Polyneuropathy was the strongest predictor for the JHS 3 patients. CONCLUSIONS: We conclude that RLS is frequent in COPD, particularly in patients with severe hypoxemia/hypercapnia and in late stages of the disease.

Denim sandblasting and silicosis two new subsequent cases in Turkey.

UNLABELLED: In our country quartz is widely used for denim sandblasting and new cases with silicosis are defined. Silicosis is a preventable occupational lung disease caused by inhaled dust containing crystalline silica and no effective treatment for silicosis is available (1). CASE 1: A 23-years old man was admitted to the hospital with dyspnea on effort and cough. He had worked in a denim manufacturing factory for three years at sandblasting and dyeing. Physical examination revealed decreased breath sounds. Chest X-ray showed bilateral reticulonodular densities predominantly at middle and lower zones and minimal pneumothorax. Hypoxemia was determined in arterial blood gas analysis (BGA). Pulmonary function tests (PFTs) showed restrictive disorder. Lymphocytic alveolitis was demonstrated in the bronchoalveolar lavage fluid. Open lung biopsy revealed interstitial fibrosis and foreign particles which were seen more clearly under polarized light in interstitial areas. The patient was diagnosed as accelerated silicosis. CASE 2: A 25-years old man was admitted to the hospital with shortness of breath and haemopthysis. Two years ago, he had worked at the same place for 1.5 years. Bilateral reticulonodular densities at middle and lower zones and minimal unilateral pneumothorax were seen in chest X-ray. Restrictive disorder at PFT and hypoxemia in BGA were observed. Because of the similarity of complaints, radiological findings and occupational history with the former patient, no other further and invasive procedure was planned and the patient was diagnosed as accelerated silicosis. CONCLUSION: The usage of sandblasted denims increase recently and denim sandblasting is being frequently made especially in small work places. Since there is no definite treatment for silicosis, it is important to take necessary precautions to improve the conditions of the factories.

Long-term outcome of chronic obstructive pulmonary disease patients with acute respiratory failure following intensive care unit discharge in Turkey.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) remains a globally significant cause of mortality, although COPD mortality varies from country to country, and across different regions within each country. The primary objective of this study was to determine the mortality rates of COPD patients who present with acute respiratory failure (ARF) to a tertiary care referral center in different stages of their follow-up (ICU, in-hospital and after discharge). The secondary objective was to determine factors associated with mortality in this group of patients. RESULTS: Medical records of consecutive COPD patients over a 10-year period were reviewed.The study included 147 patients. Of these, 72 were treated initially with noninvasive positive pressure ventilation (NIPPV), and 12 of these required intubation after NIPPV failed. Therefore, 86 patients were intubated for invasive mechanical ventilation (IMV), while NIPPV was succesful in 60 patients. Survival time was independently associated with advanced age, high APACHE II score, co-morbidity and the need for IMV. The cumulative mortality was 27% in the medical ICU and 31% in hospital following ICU discharge. The mortality rate at 1, 2 and 5 years was 54%, 66% and 84%, respectively. CONCLUSION: COPD patients admitted to the ICU for ARF have an approximately 70% chance of leaving hospital alive, but half of these may die in the first 6 months after discharge. The risk factors related to mortality were advanced age, high APACHE II score, co-morbidity and IMV requirement.

Daily surveillance with early warning scores help predicthospital mortality in medical wards.

BACKGROUND/AIM: To analyze the potency of a modified early warning score (EWS) to help predict hospital mortality when used for surveillance in nonacute medical wards. MATERIALS AND METHODS: Patients in internal medicine wards were prospectively recruited. First, highest, and last scores; and mean daily score recordings and values were recorded. Nurses calculated scores for each patient upon admission and every 4 h. The last score was the score before death, discharge, or transfer to another ward. The highest scores in total and for each single parameter were used for analysis. RESULTS: Fifty-nine percent of 182 recruited patients had recordings eligible for data analysis. Patients admitted from the emergency room had higher mortality rates than patients admitted from outpatient clinics (15% vs. 1.5%; P = 0.01) as well as patients whose first (40% vs. 4.9%; P = 0.033) and highest scores (18.8% vs. 1.3%; P = 0.003) were equal to or more than 3. The first recorded EWS was not predictive for mortality while the maximum score during the admission period was. CONCLUSION: This study underlines the fact that each physiological variable of EWS may not have the same weight in determining the outcome.

Measurement of pulmonary artery to aorta ratio in computed tomography is correlated with pulmonary artery pressure in critically ill chronic obstructive pulmonary disease patients.

AIM: Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases and a common cause of death. Identification of COPD patients at high risk for complications and mortality is of utmost importance. Computed tomography (CT) can be used to measure the ratio of the diameter of the pulmonary artery (PA) to the diameter of the aorta (A), and PA/A ratio was shown to be correlated with PA pressure (PAP). However, the prognostic value of PA size remains unclear in patients with COPD. We hypothesized that PA enlargement, as shown by a PA/A ratio greater than 1, could be associated with a higher risk of mortality in COPD patients admitted to the intensive care unit. METHODS: Data of patients admitted to a medical intensive care unit of a university hospital were retrospectively reviewed between January 2008 and December 2012. Patients who were identified to have a diagnosis of acute exacerbation of COPD and who had an echocardiogram and CT scan were included. Pulmonary artery to aorta ratio was calculated and patients were grouped as PA/A ≤1 and PA/A >1. Comparisons were made between the groups and between patients who died and survived. Correlation analysis, survival analysis, and logistic regression analysis were done, where appropriate. RESULTS: One hundred six COPD patients were enrolled. There were 40 (37.4%) patients who had a PA/A >1. Echocardiography measured PAP was higher in the group with PA/A >1 than in those with PA/A ≤1 (62.1 ± 23.2 mm Hg vs 45.3 ± 17.9 mm Hg, P = .002). Mortality rate of patients with PA/A >1 was higher (50%) than of those patients with PA/A ≤1 (36.4%), although the difference did not reach a statistical significance (P = .17). Correlation was found between vmeasured PA diameter and PAP (r = 0.51, P = .001) as well as between the Acute Physiology and Chronic Health Evaluation II values and PAP (r = 0.25, P = .025). CONCLUSION: The PA/A ratio is an easily measured method that can be performed on thorax CT scans. Although, we failed to demonstrate a statistically significant association between higher PA/A and increased mortality, PA/A can be used as a surrogate marker to predict the pulmonary hypertension.