ABSTRACT
Coronary artery vasospasm is a rare but fatal postoperative complication of cardiothoracic surgery. This phenomenon can occur directly after surgery or several hours postoperatively. Most reported cases have occurred after CABG surgery and less commonly after valve replacement. Patients can present with various symptoms, and physicians must be familiar with the indications to suspect coronary artery vasospasm to avoid adverse outcomes. We present a case of a 60-year-old female who suffered a cardiac arrest with refractory ventricular fibrillation due to coronary artery vasospasm following aortic valve replacement. During resuscitation, she underwent central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation for hemodynamic support. She subsequently underwent urgent left heart catheterization, revealing vasospasm of the left anterior descending artery, early first diagonal, early first obtuse marginal, and non-dominant right coronary artery. Vasospasm was successfully treated with intracoronary nitroglycerin and nicardipine. This case report demonstrates the importance of early consideration of coronary artery vasospasm as a cause of postoperative arrest following cardiac surgery.
ABSTRACT
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.
Subject(s)
Smoking Cessation , Tobacco Products , Tobacco Use Disorder , Adult , Humans , Nicotiana , Tobacco Use Disorder/drug therapySubject(s)
Electronic Nicotine Delivery Systems , Lung Injury , Vaping , Humans , Lung Injury/etiology , Vaping/adverse effectsABSTRACT
AIM: To characterize and compare total lung capacity (TLC) measured by plethysmography with high-resolution computed tomography (HRCT), and to identify variables that predict the difference between the two modalities. METHODS: Fifty-nine consecutive patients referred for the evaluation of COPD were retrospectively reviewed. Patients underwent full pulmonary function testing and HRCT within 3 months. TLC was obtained by plethysmography as per American Thoracic Society/European Respiratory Society standards and by HRCT using custom software on 0.75 and 5 mm thick contiguous slices performed at full inspiration (TLC). RESULTS: TLC measured by plethysmography correlated with TLC measured by inspiratory HRCT (r = 0.92, P < 0.01). TLC measured by plethysmography was larger than that determined by inspiratory HRCT in most patients (mean of 6.46 ± 1.28 L and 5.34 ± 1.20 L respectively, P < 0.05). TLC measured by both plethysmography and HRCT correlated significantly with indices of airflow obstruction (forced expiratory volume in 1 second/forced vital capacity [FVC] and FVC%), static lung volumes (residual volume, percent predicted [RV%], total lung capacity, percent predicted [TLC%], functional residual capacity, percent predicted [FRC%], and inspiratory capacity, percent predicted), and percent emphysema. TLC by plethysmography and HRCT both demonstrated significant inverse correlations with diffusion impairment. The absolute difference between TLC measured by plethysmography and HRCT increased as RV%, TLC%, and FRC% increased. Gas trapping (RV% and FRC%) independently predicted the difference in TLC between plethysmography and HRCT. CONCLUSION: In COPD, TLC by plethysmography can be up to 2 L greater than inspiratory HRCT. Gas trapping independently predicts patients for whom TLC by plethysmography differs significantly from HRCT.
Subject(s)
Lung/diagnostic imaging , Lung/physiopathology , Plethysmography , Pulmonary Disease, Chronic Obstructive/diagnosis , Tomography, X-Ray Computed , Total Lung Capacity , Aged , Female , Forced Expiratory Volume , Humans , Linear Models , Male , Middle Aged , Philadelphia , Predictive Value of Tests , Pulmonary Disease, Chronic Obstructive/diagnostic imaging , Pulmonary Disease, Chronic Obstructive/physiopathology , Retrospective Studies , Vital CapacityABSTRACT
BACKGROUND: Chronic sputum production is a significant but variable complaint in COPD; its effect on symptom burden has not been comprehensively described. We sought to characterize the daily burden of chronic sputum production in severe COPD and the phenotype of those with chronic sputum symptoms. METHODS: We studied 50 outpatients with severe COPD who used an electronic diary to document peak expiratory flow (PEF) and respiratory symptoms daily for up to 2 years. A sputum index was derived based on complaints of sputum quantity, color, and consistency, and patients were divided into groups based on average daily sputum index (Low, Medium, High). The presence and severity of respiratory symptoms were scored by a novel method using daily changes in symptoms and PEF from baseline and were categorized into mild, moderate, and severe. Percent emphysema was measured using quantitative CT. RESULTS: In the 14,500 observation days, severe symptom days were greater in the Medium and High groups (379/6089, 1609/4091, and 2624/4317 observation days in Low, Medium, and High, p < 0.0001). The same trend was found even when sputum complaints were removed from the symptom severity score. Observed/predicted PEF ratio was lower in the High group (0.56 ± 0.24, 0.55 ± 0.19, and 0.42 ± 0.12 in each group, p < 0.05 for High compared to Medium and Low). Percent emphysema inversely correlated with average sputum index and quantity (r = -0.449 and r = -0.584, respectively, p < 0.05). CONCLUSIONS: Increased sputum production in severe COPD is frequently encountered daily and is associated with more respiratory symptoms, worse airflow obstruction, and less emphysema.
Subject(s)
Pulmonary Disease, Chronic Obstructive/complications , Pulmonary Disease, Chronic Obstructive/physiopathology , Sputum/metabolism , Aged , Female , Humans , Male , Medical Records , Middle Aged , Peak Expiratory Flow Rate , Pulmonary Emphysema/complications , Severity of Illness IndexABSTRACT
The purpose of this study was to determine the elements associated with delay in the evaluation of acute appendicitis at a community teaching hospital. We performed a retrospective chart review of patients undergoing operative exploration for presumed appendicitis in a 12-month period. Cases were categorized by the presence or absence of advanced radiographic imaging. Demographic information and time intervals from triage to operative incision were compared. One hundred twenty-four patients underwent operative exploration for presumed appendicitis. Forty-one patients had no advanced imaging, 67 had a CT scan, 8 had a sonogram, and 8 had both CT/sonogram. Patients using advanced radiographic imaging prior to operative exploration were no less likely to have a normal appendix at surgery. Diagnostic imaging significantly increased the preoperative emergency department length of stay. Two-thirds of patients with presumed acute appendicitis were imaged before operative exploration. The use of abdominal CT and sonogram resulted in significantly increased preoperative emergency department length of stay with no apparent improvement in diagnostic accuracy.