Pulmonary small lymphocytic lymphoma (mucosa-associated lymphoid tissue type) associated with pulmonary hyalinizing granuloma.

A case of pulmonary hyalinizing granuloma (PHG) and concomitant low-grade, small lymphocytic lymphoma of the lung is presented. This is the first occurrence of pulmonary lymphoma in patients with PHG ever reported. The infiltrates around a left lower lobe nodule with left pleural effusion and thickening seen on chest CT were histologically proven to be lymphomatous infiltrates of the lung, pleura, and chest wall muscle. We believe that the lymphoma developed around the nodule and spread to the pleura and muscle in our patient. When infiltrates around the nodules, pleural effusion, or adenopathy are developed in a patient with proven PHG, close follow-up, biopsy, or careful cytology should be seriously considered to rule out a developing lymphoma.

Nutrition in chronic critical illness.

Nutritional management of patients with respiratory failure can be a model of nutritional management in chronically critically ill patients. This model requires recognition of the differing metabolic states of starvation and hypermetabolism. Starvation can result in malnutrition, with adverse effect on respiratory muscle strength, ventilatory drive, and immune defense mechanisms. General nutritional goals include preservation of lean body mass by providing adequate energy and positive nitrogen balance. General nutritional prescriptions for both states include a substrate mix of 20% protein, 60% to 70% carbohydrates, and 20% to 30% fat. Positive nitrogen balance is difficult to attain in hypermetabolic patients and energy requirements are increased compared with starved patients. Enteral nutrition should be the mode of initial nutrient delivery unless the gastrointestinal tract is nonfunctional. Monitoring of nutritional support is essential. Complications of nutritional support are multiple. Nutritional hypercapnia is an important complication in a chronically critically ill patient. Outcomes of selected long-term acute patients are poor, with only 8% of patients fully functional 1 year after discharge. Appropriate nutritional therapy is one aspect of management of these patients that has the possibility of optimizing function and survival.

Invasive mechanical ventilation in exacerbations of chronic obstructive pulmonary disease.

Exacerbations of chronic obstructive pulmonary disease are appropriately treated when severe airflow obstruction does not respond to intensive therapy, including, at times, noninvasive mechanical ventilation. Ventilatory strategies include avoidance of the ventilatory complications of dynamic pulmonary hyperinflation with its resultant intrinsic positive end-expiratory pressure, thereby decreasing the risk of hypotension and barotrauma. Initial ventilator settings should include an expiratory flow rate between 8-10 L.min-1, a tidal volume of 8-10 mL.kg-1 and a respiratory rate of 11-14 breaths.min-1 as well as an inspiratory flow rate of 100 L.min-1. Further adjustments are made on the basis of gas exchange and pulmonary mechanics. Medical therapies include beta-agonists and corticosteroids.

Continuous positive airway pressure: patients' and caregivers' learning needs and barriers to use.

OBJECTIVE: To identify learning needs and factors related to postdischarge use of continuous positive airway pressure (CPAP) ventilation. DESIGN: Exploratory descriptive correlational. SETTING: Metropolitan and rural clinics. SUBJECTS: Adult patients (N = 21) and family caregivers, one half 60 years or older. INSTRUMENTS: Family interviews, life satisfaction and quality, family function and relationship, depression and learning preparedness. RESULTS: There were numerous learning needs related to CPAP machine management, monitoring illness severity, and recognizing depressive symptomology, oxygen deficits, and cardiovascular sequelae. Family members are involved in overcoming barriers interfering with nightly CPAP use. Interview and questionnaire data clearly indicate life satisfaction improves after CPAP treatment. CONCLUSION: Predischarge and teaching programs coordinated by expert nurses are needed to address families' learning needs and support habitual long-term CPAP use. Family problem solving and depression interventions, instruction on recognizing symptoms of cardiovascular complications, and long-term follow-up programs are currently being studied.

Intermittent enteral feeding in mechanically ventilated patients. The effect on gastric pH and gastric cultures.

OBJECTIVE: To evaluate the effect of intermittent (16 h/d) enteral feeding (IEF) on gastric pH and gastric microbial growth in mechanically ventilated patients. DESIGN: Prospective, case-controlled study. SETTING: Medical ICU and infectious disease research laboratory in a university hospital. PATIENT POPULATION: Thirteen mechanically ventilated patients receiving continuous enteral feeding (CEF). METHODS: Gastric pH and quantitative gastric cultures were obtained while patients received CEF. Each patient's feeding schedule was changed to IEF. Daily gastric pH and quantitative gastric cultures were obtained for 5 consecutive days. RESULTS: Gastric microbial growth was found in 85% (11/13) of patients receiving CEF. Implementation of IEF did not clear gastric microbial growth, as only one patient subsequently reverted to negative culture. Similar gastric microbial growth continued in 90% (10/11) of patients after institution of IEF. Gastric pH did not decrease with the administration of IEF (gastric pH with IEF, 3.8 +/- 0.6 vs 4.7 +/- 0.5 with CEF (not significant [NS]). The amount of microbial growth was also unchanged with IEF (total growth with IEF, 7.8 x 10(5) +/- 5.2 x 10(5) cfu/mL vs 8.7 x 10(5) +/- 4.6 x 10(5) cfu/mL with CEF) (NS). Thirty-eight percent (5/13) of patients developed new Gram-negative rod growth in gastric cultures while receiving IEF. Gram-negative rod isolates increased from 25% of total isolates (CEF) to 40% (IEF). CONCLUSION: Our preliminary data suggest gastric pH was not lowered and existing microbial growth was not cleared in ventilated patients receiving IEF after previously receiving CEF. Further controlled study in a larger group of patients is necessary to determine whether IEF is of benefit in decreasing gastric colonization and nosocomial pneumonia.

Acute respiratory failure in chronic obstructive pulmonary disease.

Clinically significant chronic obstructive pulmonary disease is a common and important disorder in the United States. As many as 15 million individuals suffer from chronic obstructive pulmonary disease, many of whom have disease requiring hospital or ICU admission. Acute respiratory failure in patients with chronic obstructive pulmonary disease is one of the most common causes of admission to the ICU for this patient population. In this article I address common issues regarding diagnosis and management of acute respiratory failure in chronic obstructive pulmonary disease. Acute respiratory failure will be defined as well as the common and unusual etiologies of acute respiratory failure. Pharmacologic and nonpharmacologic treatment will be addressed, especially the ventilatory treatment of the intubated patient with chronic obstructive pulmonary disease. Special attention has been made to included the most recent investigations regarding diagnosis and treatment of the patient with chronic obstructive pulmonary disease and respiratory failure.

Enteral nutrition in patients with respiratory disease.

Nutritional assessment and management is an important therapeutic modality in patients with respiratory disease. Malnutrition adversely affects respiratory function. Nutritional therapy for the spontaneously breathing patient should include an appropriate diet plus the consideration of nutritional supplements. Complete nutritional support should be undertaken with enteral nutrition in critically ill patients with respiratory failure. Nutritional complications occur. Overfeeding can lead to nutritionally associated hypercapnia.

Pulmonary and critical care medicine.

Asthma mortality has increased not only in the United States but also across the world. Recent studies confirm the benefit of inhaled steroids compared with beta-agonists. Sepsis is now defined as the presence of SIRS with a confirmed infectious process.

Gastroesophageal reflux with nasogastric tubes. Effect of nasogastric tube size.

Pulmonary aspiration of gastric contents results initially from reflux of stomach contents into the esophagus. Small-bore enteral feeding tubes are thought to result in less pulmonary aspiration and less reflux. We prospectively investigated the effect of nasogastric tube size upon gastroesophageal (GE) reflux in normal volunteers in a randomized crossover trial. Reflux was assessed by gastroesophageal scintiscanning, a radioisotopic technique that detects and quantitates GE reflux. A total of 11 subjects were studied three times: control, no nasogastric tube, small-bore (8F) nasogastric tube, and large-bore (14F) nasogastric tube. Reflux was assessed in each subject under each experimental condition by provocative testing in which abdominal pressure was increased from 0 to 100 mm Hg by 20-mm Hg increments with an abdominal pressure device. GE reflux indices were calculated for each measurement and the groups compared. A positive indicator of reflux was defined as a > or = 4% reflux index. Gastroesophageal reflux was not detected at any level of abdominal pressure regardless of the presence or size of a nasogastric tube. With maximum 100 mm Hg abdominal pressure, the reflux index was control, 1.75 +/- 0.45%; small-bore tube, 1.67 +/- 0.28%; and large-bore tube, 1.88 +/- 0.35% (NS). The reflux index was not different between small-bore and large-bore nasogastric tubes. Our data suggest the size of a nasogastric tube is not an important determinant of GE reflux in normal subjects during short-term intubation. Large-bore tubes did not cause more reflux than small-bore tubes. The presence of a nasogastric tube did not cause reflux in normal subjects. These data suggest that factors other than the size of nasogastric tube are more important in GE reflux in normal subjects.

Caregiver learning needs and reactions to managing home mechanical ventilation.

OBJECTIVE: To identify caregivers' learning needs and reactions to providing care for adult patients receiving mechanical ventilation in the home. This report originated from a study that was undertaken to describe family function and reactions of family members. DESIGN: Prospective, descriptive. SETTING: Data collected at clients' homes in a midwestern city. SUBJECTS: Twenty caregivers and adult patients who are dependent on mechanical ventilation at home. INSTRUMENTS: Patients and their caregivers completed family coping and family function instruments. Caregivers also completed a Learning Needs Checklist and a caregiving inventory. RESULTS: The results indicate that caregivers, all relatives, provided an average of 7.3 hours per day direct care with little assistance from extended family or professionals. More disrupted schedules, financial strain, increased burden, and negative reaction to caregiving was associated with increasing ventilator hours per day. Family function was perceived as satisfactory by both patients and caregivers. Survival knowledge and skills were being taught, but additional information was needed by caregivers. There were no differences by gender in perceived learning needs, family function, or tasks of daily caregiving. CONCLUSIONS: Preferences for types of information suggest the use of a three-phase teaching program that should be sensitive to individual learning needs. A variety of coping strategies were used by families to manage home mechanical ventilation including problem-solving and mobilizing help from friends, extended family, community, or church.

The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia.

Intracellular bacteria (ICB) within recovered cells (> 7 percent) obtained via bronchoalveolar lavage (BAL) have been described as predictive of subsequent positive quantitative protected specimen brush (PSB) cultures in patients not receiving antibiotics. To determine the effect of prior or current antibiotic therapy on ICB relative to subsequent PSB culture, we prospectively evaluated 49 consecutive episodes of clinically suspected ventilator-associated pneumonia in 36 patients. Three patient groups were defined based on antibiotic administration: group 1 (current antibiotics), n = 31, samples obtained from patients currently receiving antibiotics; group 2 (recent antibiotics), n = 5, samples obtained from patients who received antibiotics > 48 h but < 72 h prior to sampling; and group 3 (no antibiotics), n = 13, samples from patients receiving no previous antibiotics within 7 days prior to sampling. Overall, PSB cultures (> or = 10(3) cfu/ml) were positive in 14 of 49 (29 percent) samples. In group 1, 2 of 31 (6 percent) samples were positive while 5 of 5 (100 percent) samples in group 2, and 7 of 13 (54 percent) in group 3 were positive. The presence or absence of ICB accurately predicted both positive and negative PSB cultures in 43 of 49 episodes. Of 43 correct predictions, 34 were negative predictions (negative ICB, negative PSB culture). The vast majority of these (29) were obtained from group 1, patients currently receiving antibiotics. In contrast, of nine positive predictions (+ICB, +PSB) virtually all (seven) occurred in group 3, patients receiving no antibiotics. In group 3, 13 of 13 PSB cultures were accurately predicted, either positive or negative, by the presence or absence of ICB. Of seven positive PSB cultures in groups 1 and 2, only 2 (28 percent) were accurately predicted by ICB. From both samples, the cultured organism was resistant to all administered antibiotics. These data suggest both prior and current antibiotic therapy reduces recovery of ICB from BAL and reduces predictive accuracy of ICB for subsequent positive PSB cultures. However, negative prediction by ICB for subsequent negative PSB cultures was good. In contrast, ICB obtained from patients not receiving antibiotics are highly predictive of subsequent PSB culture results, both positive and negative. We do not recommend BAL for evaluation of ICB in patients currently receiving antibiotics or with a recent history of antibiotic use.