Flow-volume loops: clinical correlation

Flow volume loops are an essential part of spirometry testing. Their appearance can give information that can be helpful in the differential diagnosis of a patient's clinical condition. We present two clinical scenarios in which careful evaluation of the flow-volume loop gives an insight into the cause of the disease process.

Hepatopulmonary syndrome

This is a report of a 56-year-old male who was admitted to the Intensive Care Unit of the San Juan V.A. Medical Center with altered mental status and severe hypoxemia. He was diagnosed with severe hyponatremia and hepatopulmonary syndrome.

Acute respiratory distress syndrome in the trauma intensive care unit: the other view

OBJECTIVE: To study the timeliness of the diagnosis of patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) at the Puerto Rico Trauma Center (PRTC) and to determine the overall 28 day mortality for ARDS during the study period. METHOD: A retrospective review of all admissions to the Trauma Intensive Care Unit (TICU) from August 2000 to August 2001 was done. Patients with the diagnosis of ARDS/ALI were selected, records examined, and clinical data obtained for analysis. FINDINGS: Of the 537 patient admitted to the PRTC, 236 patient were admitted to TICU. Of these, 17 patients were identified as having hypoxemic ratios below 200 and 13 patients were identified as having ARDS as established by the American-European Consensus Conference of 1994. Their mean age was 41 years, the main cause of ARDS was due to pulmonary contusion due to blunt chest trauma. The 28-day survival for this group was 43 per cent. Subgroup analysis showed that there was 86 per cent mortality when the polytraumatized patient developed sepsis. CONCLUSION: The majority of the cases of ARDS were correctly identified as such by caregivers at the time of diagnosis. Mortality as predicted by Injury Severity Score in our ARDS patients' correlates with overall mortality in our TICU. Mortality in this group is lower than that of reported literature, in sharp contrast to our medical ICU counterparts.

Acute lung injury/acute respiratory distress syndrome: a need for education

OBJECTIVE: To examine the timeliness of the diagnosis of patients with ALI/ARDS at the San Juan VA Medical Intensive Care Unit. We were also interested in determining the incidence and the overall 28-day mortality for ARDS during the study period. METHODS: Retrospective record review of all admissions to the San Juan Veterans Affairs Medical ICU during a two-year period (1997-1998). RESULTS: During the study period, 587 patients were admitted to the medical ICU. All had APACHE II scoring performed during their first 24 hours of admission. Twenty-three patients were found to have an A-a gradient of 350 or less. However, two patients were later identified as having radiographic changes compatible with Congestive Heart Failure and were excluded from the study. The incidence of ALI/ARDS was found to be 3.6 per cent at our institution. Of the 21 patients with ARDS, in only 4 the diagnosis of ARDS was documented on their charts. CONCLUSION: Our findings suggest that education in the recognition of ARDS should be aggressively done. In order to implement the recently published successful strategies in the mechanical ventilation of patients with ARDS, it should be first recognized. Our patients need it.

Legionnaires' disease: a rare entity in Puerto Rico?

Legionnaires' disease is a severe, often fatal pneumonia, caused by Legionella pneumophila. Its incidence is reported about 6%. In Puerto Rico, there is no data available of the prevalence of Legionnaires' disease. A case of Legionnaires' is presented as well as data to support that the prevalence in our Island is higher than the reported elsewhere.

Substituted judgement: should life-support decisions be made by a surrogate?

OBJECTIVE: To evaluate the utility of the substituted judgement standard in terminally ill patients by determining agreement between patients, family proxies and physicians. BACKGROUND: Several studies have addressed the utility of substituted judgement, showing conflicting data whether surrogates are accurate predicting patient's wishes. METHODS: Patients with acquired immunodeficiency syndrome, congestive heart failure, chronic liver disease admitted to the San Juan Veterans Affairs Medical Center in Puerto Rico from November 1997 to February 1998 were evaluated. A questionnaire presented three hypothetical situations on withholding and withdrawal of life-support and CPR. The percent agreement was used as a measure of concordance between choices made by physician, surrogate and patients. RESULTS: Twenty patients met inclusion criteria (5 chronic liver disease, 9 heart failure, 6 AIDS). Relatives had a higher percent of agreement as compared to physicians in all vignettes. Even though, none did better than chance in predicting patient's wishes (k < 0.4). There was a tendency for relatives not to provide a wanted life-support measure, and for physicians to provide an unwanted life-support measure. CONCLUSION: The poor agreement between patients and surrogates suggests that substituted judgement is not an accurate tool to make end-of-life decisions. These findings, although similar to previous published studies, are unique because the direction of discrepant responses is opposite to the findings of studies published elsewhere. These results could reflect religious, cultural and socioeconomic differences.