Pulmonary function in Thai patients with systemic sclerosis; a single center 6-year retrospective study.

Background: Pulmonary involvement is a major cause of internal organ complication and the leading cause of death in patients with systemic sclerosis (SSc). This study aimed to demonstrate the characteristics of pulmonary function (PF) in Thai patients with SSc and the association between PF and body mass index (BMI) and anti-topoisomerase (anti-Scl70). Methods: All patients diagnosed with SSc in our tertiary care teaching hospital database between 2016 and 2021 were reviewed and analyzed. Results: Of 211 SSc patients, 128 patients who underwent the PF test were enrolled; 102 (79.7%) were female. The mean age was 54 years. The median BMI for all patients was 21.7 kg/m 2. Regarding anti-Scl70, 10.9% of patients were positive, 7.8% were negative, and the status was unreported for 81.3%. The mean (SD) forced expiratory volume in one second (FEV1) forced vital capacity (FVC) ratio was 0.8 (0.1). The mean (SD) % predicted values of FEV1, FVC, and diffusing capacity of the lungs for carbon monoxide (DLCO) were 76.3 (16.3), 69.1 (15.8), and 75.5 (22.8), respectively. A restrictive spirometry pattern (RSP) was found in 78.8% of the patients. DLCO had a moderate positive linear correlation with FVC (r=0.50, p <0.001) and a moderate negative linear correlation with BMI (r=-0.36, p <0.001). However, there was no correlation between FVC and BMI. There was no statistical difference in demographic data or the presence of anti-Scl70 among patients with or without RSP. Conclusions: RSP is common among Thai patients with SSc. However, the power of using demographic data and the presence of anti-Scl70 to determine the probability of pulmonary involvement remains limited.

Clinical Characteristics, Risk Factors, and Outcomes of Acute Pulmonary Embolism in Thailand: 6-Year Retrospective Study.

BACKGROUND: Acute pulmonary embolism (APE) is a fatal disease with varying clinical characteristics and imaging. The aim of this study was to define the clinical characteristics, risk factors, and outcomes in patients with APE at a university hospital in Thailand. METHODS: Patients diagnosed with APE and admitted to our institute between January 1, 2017 and December 31, 2022 were retrospectively enrolled. The clinical characteristics, investigations, and outcomes were recorded. RESULTS: Over the 6-year study period, 369 patients were diagnosed with APE. The mean age was 65 years; 64.2% were female. The most common risk factor for APE was malignancy (46.1%). In-hospital mortality rate was 23.6%. The computed tomography pulmonary artery revealed the most proximal clots largely in segmental pulmonary artery (39.0%), followed by main pulmonary artery (36.3%). This distribution was consistent between survivors and non-survivors. Multivariate logistic regression analysis revealed that APE mortality was associated with active malignancy, higher serum creatinine, lower body mass index (BMI), and tachycardia with adjusted odds ratio (95% confidence interval [CI]) of 3.70 (1.59 to 8.58), 3.54 (1.35 to 9.25), 2.91 (1.26 to 6.75), and 2.54 (1.14 to 5.64), respectively. The prediction model was constructed with area under the curve of 0.77 (95% CI, 0.70 to 0.84). CONCLUSION: The overall mortality rate among APE patients was 23.6%, with APE-related death accounting for 5.1%. APE mortality was associated with active malignancy, higher serum creatinine, lower BMI, and tachycardia.

Acute respiratory distress syndrome following breast augmentation managed by delayed veno-venous extracorporeal membrane oxygenation.

The initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been opposed in late-phase acute respiratory distress syndrome (ARDS) due to an increase in mortality. Herewith an individual case of a 20-year-old female who survived severe ARDS after breast augmentation is reported, whose delayed transfer to our tertiary referral center led to a late initiation of VV-ECMO and multiple mechanical ventilation-associated complications. Nonetheless, her VV-ECMO was decannulated after 45 days of ARDS onset, considering an awake ECMO strategy possibly contributing to her positive outcome. We also provided spirometry results and chest radiography findings over the three years of follow-up. Intensive care specialists need to consider the potential use of ECMO in late-phase ARDS with selected patients.

Association of Monocyte Distribution Width with the Need for Respiratory Support in Hospitalized COVID-19 Patients.

Background: The monocyte distribution width (MDW), a novel inflammatory biomarker reflecting morphological changes in response to inflammation, has been shown to be useful in identifying COVID-19 infection or predicting death. However, data on the association with predicting the need for respiratory support are still limited. The aim of this study was to determine the association of MDW with the need for respiratory support in patients with SARS-CoV-2 infection. Patients and methods: This is a single-center retrospective cohort study. Consecutive hospitalized COVID-19 adult patients who presented at the outpatient department (OPD) or emergency department (ED) between May and August 2021 were enrolled. Respiratory support was defined as any one of the following: conventional oxygen therapy, high-flow oxygen nasal cannula, noninvasive, or invasive mechanical ventilation. The performance of MDW was measured using the area under the receiver operating characteristic (AuROC) curve. Results: Of the 250 enrolled patients, 122 (48.8%) patients received respiratory support. The mean MDW was significantly higher in the respiratory support group: 27.2 ± 4.6 vs 23.6 ± 4.1 (p < 0.001). The MDW ≥ 25 had the best AuROC characteristics of 0.70 (95% CI: 0.65-0.76). Conclusions: The MDW is a potential biomarker that may aid in identifying individuals at risk of requiring oxygen support in COVID-19 and can be easily implemented in clinical practice. How to cite this article: Daorattanachai K, Hirunrut C, Pirompanich P, Weschawalit S, Srivilaithon W. Association of Monocyte Distribution Width with the Need for Respiratory Support in Hospitalized COVID-19 Patients. Indian J Crit Care Med 2023;27(5):352-357.

Clinical characteristics of pulmonary hypertension patients who underwent right heart catheterization in Thailand: 5-year retrospective single-centre study.

Aim: Pulmonary arterial hypertension (PAH) is an uncommon and difficult-to-recognize condition. There is still limited evidence on Asian populations. This study aimed to clarify the clinical characteristics of pulmonary hypertension (PH) patients who underwent right heart catheterization (RHC). Setting and Design: A single-centre retrospective observational analysis. Methods and Material: An observational analysis of adult patients diagnosed with PH by RHC from 2015 to 2019; clinical characteristics and investigations were recorded and compared between PAH and non-PAH. The correlations between maximal tricuspid regurgitation velocity (TRVmax) and mean pulmonary arterial pressure (mPAP) were also estimated. Results: From a total of 243 RHC patients, 79 PH patients were enrolled. The mean (SD) age was 56 (19) years. Dyspnea on exertion (DOE) was the most common clinical manifestation; 70 (89%). Most of them were in functional class II; 58 (73%). PAH was the most prevalent PH group; 46 (58%), followed by PH due to left heart disease; 26 (33%). In the PAH group, congenital heart disease-associated PAH was the most common aetiology; 25 (54%). Compared with the non-PAH group, PAH patients were younger and had fewer comorbidities, particularly atrial fibrillation. There were strong correlations between TRVmax and mPAP (r = 0.62, P < 0.01). Conclusion: PAH was the most prevalent among PH who underwent RHC. The most common presentation of PH patients was DOE. There were strong correlations between parameters from echocardiography and RHC (TRVmax and mPAP).

Unilateral Pulmonary Contusion after Cardiopulmonary Resuscitation Complicated by Delayed Obstructive Atelectasis: A Case Report and Review of the Literature.

We present a previously healthy 57-year-old man who had a sudden cardiac arrest intraoperatively and developed unilateral pulmonary contusion shortly after cardiopulmonary resuscitation. He was gradually improved by supportive management. But, several days later he had worsening of respiratory symptoms and obstructive atelectasis was proven by bronchoscope finding of thick mucus plugging left main bronchus. These are rarely recognized but important post-resuscitation complications. Early detection is crucial to improve outcome. How to cite this article: Klumusuk P, Pirompanich P. Unilateral Pulmonary Contusion after Cardiopulmonary Resuscitation Complicated by Delayed Obstructive Atelectasis: A Case Report and Review of the Literature. Indian J Crit Care Med 2022;26(1):133-135.

Clinical characteristics and outcomes of adults with peripheral extracorporeal membrane oxygenation in a developing country: A single center 8-year retrospective study.

INTRODUCTION: In our institute, we began using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in 2010, and peripheral veno-venous (VV) ECMO in 2015. This study aimed to describe clinical characteristics and outcomes in those patients. METHODS: We reviewed retrospective data of adults receiving peripheral ECMO from January 2010 to December 2017 and divided it into two groups for analysis: VA- and VV-ECMO. RESULTS: There were 28 patients in the VA group and 12 in VV. For VA, the mean (SD) age was 58.5 (17.2) years. The most common indication was cardiac arrest (12 patients, 42.9%); 15 patients (53.6%) were on intra-aortic balloon pump concomitantly. In the VV cohort, the mean age was 53.3 (16.2) years. Eleven (91.7%) patients had acute respiratory distress syndrome as an indication. The mortality rate of VA-ECMO was 85.7%, and VV was 58.3%. CONCLUSION: The mortality rate in our ECMO center was considerably higher than that in the international registry report. Improved team education, rigid patient selection criteria, and a reimbursement protocol should lead to ameliorated outcomes. TRIAL REGISTRATION: TCTR20190120001. Registered January 19, 2019.

Co-infection of SARS-CoV-2 and Bordetella bronchiseptica in a young man with idiopathic non-cystic bronchiectasis and vitamin D3 deficiency.

This is the first reported case, to our knowledge, of co-infection of Bordetella bronchiseptica and SARS-CoV-2 in a young patient with underlying idiopathic bronchiectasis and vitamin D3 deficiency that was treated successfully with a combination therapeutic regime integrating doxycycline, empiric therapies for COVID-19, vitamin D supplementation, and supportive ICU care. Large prospective studies are required to investigate further the role of co-infections in COVID-19 patients with bronchiectasis. Randomized control trials should examine the putative beneficial role of vitamin D supplementation in patients with COVID-19.

Patient characteristics and outcomes of a home mechanical ventilation program in a developing country.

BACKGROUND: There are limited data on home mechanical ventilation (HMV) in developing countries. This study aimed to describe the patient characteristics, feasibility, and outcomes of an HMV program at a university hospital in Thailand. MATERIALS AND METHODS: Data were collected on all patients who were discharged with HMV between October 2014 and August 2015 at Thammasat University Hospital. RESULTS: Twelve patients (eight men and four women) underwent HMV. They were aged 71.5 ± 17.6 years; mean ± standard deviation. Indications for HMV were 6 neurologic diseases (4 amyotrophic lateral sclerosis, 1 multiple system atrophy, and 1 stroke), 2 chronic obstructive pulmonary disease (COPD), 1 tracheomalacia, and 3 combined neurologic diseases and respiratory diseases (2 stroke and COPD, 1 stroke and tracheomalacia). The duration of follow-up was 799.5 ± 780.5 days. The ratio of family income to cost of HMV usage was 77.2:1 ± 5.5:1. All patients had tracheostomies. Modes of HMV were biphasic positive airway pressure (66.7%), pressure-controlled ventilation (16.7%), pressure-support ventilation (8.3%), and volume-controlled ventilation (8.3%). Complications occurred in ten patients (83.3%), including tracheobronchitis (20 events) and ventilator-associated pneumonia (12 events). Overall mortality was 41.7% (5/12 patients), including two patients who died due to ventilator-associated pneumonia. There were no instances of ventilator malfunction. CONCLUSIONS: HMV is feasible for patients with neurological diseases and COPD in a developing country. The relatively high rate of complications indicates the need for more comprehensive clinical services for chronic ventilator-dependent patients in this setting.

Evaluating Extravascular Lung Water in Sepsis: Three Lung-Ultrasound Techniques Compared against Transpulmonary Thermodilution.

BACKGROUND: Excessive extravascular lung water (EVLW) is associated with increased morbidity and mortality. We compared three lung-ultrasound (L-US) techniques against the reference-standard transpulmonary thermodilution (TPTD) technique to access EVLW. MATERIALS AND METHODS: This was a prospective, single-blind, cross-sectional study. Forty-four septic patients were enrolled. EVLW index was measured by the TPTD method, and an index of ≥10 mL/kg was considered diagnostic of pulmonary edema. EVLW index was then compared to three established bedside L-US protocols that evaluate sonographic B-lines: (1) a 28-zone protocol (total B-line score [TBS]) (2) a scanning 8-region examination, and (3) a 4-point examination. RESULTS: Eighty-nine comparisons were obtained. A statistically significant positive correlation was found between L-US TBS and an EVLW index ≥10 mL/kg (r = 0.668,P < 0.001). The 28-zone protocol score ≥39 has a sensitivity of 81.6% and a specificity of 76.5% to define EVLW index ≥10 mL/kg. In contrast, the positive 4-point examination and scanning 8-regions showed low sensitivity (23.7% and 50.0%, respectively) but high specificity (96.1% and 88.2%, respectively). Ten patients with a total of 21 comparisons met criteria for acute respiratory distress syndrome (ARDS). In this subgroup, only the TBS had statistically significant positive correlation to EVLW (r = 0.488,P = 0.025). CONCLUSION: L-US is feasible in patients with severe sepsis. In addition, L-US 28-zone protocol demonstrated high specificity and better sensitivity than abbreviated 4- and 8-zone protocols. In ARDS, the L-US 28-zone protocol was more accurate than the 4- and 8-zone protocols in predicting EVLW. Consideration of limitations of the latter protocols may prevent clinicians from reaching premature conclusions regarding the prediction of EVLW. TRIAL REGISTRATION: ISRCTN11419081. Registered 4 February 2015 retrospectively.

Incidence of chronic thromboembolic pulmonary hypertension in Thammasat University Hospital.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is usually underrecognized due to nonspecific presentations. Undiagnosed CTEPH leads to unnecessary investigations for other diseases, and more importantly, increased morbidities and mortality. OBJECTIVES: The aim of this study was to define overall CTEPH incidence and the rate of CTEPH after acute pulmonary embolism (APE) in a tertiary care university hospital and to record risk factors, clinical and imaging characteristics, diagnosis assessment, and management methods. MATERIALS AND METHODS: The retrospective 5-year data, between 2012 and 2016, was extracted. Out of 1751 patients, we screened, 286 had, at least, evidence of pulmonary embolism. CTEPH was diagnosed in 20 patients, and 12 in this group had characteristics of combined APE or history of APE. RESULTS: The overall incidence of CTEPH was 37.8 cases per million patients, and the incidence of CTEPH after APE was 5.1%. The most common presentation was progressive exertional dyspnea (50%). All patients were diagnosed by computed tomography pulmonary angiography combined with echocardiogram. Surprisingly, only two patients had investigations with ventilation/perfusion lung scan. None underwent the preferred curative surgical treatment of pulmonary endarterectomy and two had balloon pulmonary angioplasty. All patients received anticoagulants, while only 5 patients were treated with pulmonary arterial hypertension-specific drugs. CONCLUSION: CTEPH was uncommon in our institute, with an underuse of the standard test. Suboptimal diagnosis assessment and management remain critical problems. Developing a properly trained CTEPH care team would improve patient outcomes, but cost/resources may be prohibitive for such a relatively rare disease. TRIAL REGISTRATION: TCTR20180220008 registered February 19, 2018.

Correction to: Use of diaphragm thickening fraction combined with rapid shallow breathing index for predicting success of weaning from mechanical ventilator in medical patients.

[This corrects the article DOI: 10.1186/s40560-018-0277-9.].

Use of diaphragm thickening fraction combined with rapid shallow breathing index for predicting success of weaning from mechanical ventilator in medical patients.

BACKGROUND: Weaning failure is a crucial hindrance in critically ill patients. Rapid shallow breathing index (RSBI), a well-known weaning index, has some limitations in predicting weaning outcomes. A new weaning index using point-of-care ultrasound with diaphragmic thickening fraction (DTF) has potential benefits for improving weaning success. The aim of this study was to evaluate the efficacy of a combination of DTF and RSBI for predicting successful weaning compared to RSBI alone. METHODS: This prospective study enrolled patients from the medical intensive care unit or ward who were using mechanical ventilation and readied for weaning. Patients underwent a spontaneous breathing trial (SBT) for 1 h, and then, both hemi-diaphragms were visualized in the zone of apposition using a 10-MHz linear probe. Diaphragm thickness was recorded at the end of inspiration and expiration which supposed the lung volume equal to total lung capacity (TLC) and residual volume (RV), respectively, and the DTF was calculated as a percentage from this formula: thickness at TLC minus thickness at RV divided by thickness at RV. In addition, RSBI was calculated at 1 min after SBT. Weaning failure was defined as the inability to maintain spontaneous breathing within 48 h. RESULTS: Of the 34 patients enrolled, the mean (± SD) age was 66.5 (± 13.5) years. There were 25 patients with weaning success, 9 patients in the weaning failure group. The receiver operating characteristic curves of right and left DTF and the RSBI for the prediction of successful weaning were 0.951, 0.700, and 0.709, respectively. The most accurate cutoff value for prediction of successful weaning was right DTF ≥ 26% (sensitivity of 96%, specificity of 68%, positive predictive value of 89%, negative predictive value of 86%). The combination of right DTF ≥ 26% and RSBI ≤ 105 increased specificity to 78% but slightly decreased sensitivity to 92%. Intra-observer correlation increased sharply to almost 0.9 in the first ten patients and slightly increased after that. CONCLUSIONS: Point-of-care ultrasound to assess diaphragm function has an excellent learning curve and helps physicians determine weaning readiness in critically ill patients. The combination of right DTF and RSBI greatly improved the accuracy for prediction of successful weaning compared to RSBI alone. TRIAL REGISTRATION: Thai Clinical Trials Registry, TCTR20171025001. Retrospectively registered on October 23, 2017.

ASSESSMENT OF A NEW SMOKING CESSATION PROGRAM AT THAMMASAT UNIVERSITY HOSPITAL, PATHUM THANI, THAILAND.

The Smoking Cessation Clinic (SCC) at Thammasat University Hospital had only 27 patients from October 2013 to September 2014 and a quit rate of only 3.7%. A new smoking cessation program was implemented at the end of 2014 to improve success rates. This new program is an interdisciplinary program that includes several health care specialists. The study aimed to examine the characteristics of the smokers and the outcomes after implementing the new program with an interdisciplinary approach at the SCC in order to gain data to improve the efficacy of the SCC. This prospective descriptive study was conducted by the SCC from December 2014 to December 2015. During the study period 111 patients attended the SCC under the new program and all were included in the survey; 100 (90.1%) were men. The mean (±SD) age of these patients was 56.5±13.5 years. The mean (±SD) age of onset of smoking was 18.5±5.5 years. Smoking cessation in the program was checked by measuring the exhaled carbon monoxide levels at 6 months after reporting smoking cessation. A level less than 10 parts per million was considered not to be a smoker. Of the 111 patients, 14 (12.6%) had reported smoking cessation and had an exhaled carbon monoxide level less than 10 parts per million. The new smoking cessation program was attended by more patients and had a higher success rate than the previous smoking cessation program, although the smoking cessation success rate was still low. Further studies are needed to determine which factors improved cessation rates and to determine other factors associated with successful smoking cessation in the study population.

Intravenous Heroin-Associated Delayed Spongiform Leukoencephalopathy: Case Report and Reviews of the Literature.

Heroin-associated spongiform leukoencephalopathy is a rare, and sometimes fatal, condition usually caused by vapor inhalation of heroin. The authors report a 41-year-old man who was diagnosed with delayed spongiform leukoencephalopathy three weeks after injecting heroin intravenously. He had been admitted to another hospital due to acute heroin overdose, which had occurred four hours after intravenous injection of an unknown amount of heroin. His clinical condition showed progressive improvement and he was discharged 12 days after admission. Three weeks after this episode, his cognitive functioning declined. Akinetic mutism, spasticity and hyperreflexia of all extremities were observed. Electroencephalography (EEG) and imaging of the brain showed typical characteristics of spongiform leukoencephalopathy. The three and six-month follow-up of the patient showed clinical improvement and this was corroborated through EEG measures and brain imaging. The discussion summarizes eight previously reported cases of intravenous heroin associated spongiform leukoencephalopathy and compares them to the authors'case.