The Association Between the Mechanical Ventilator Pressures and Outcomes in a Cohort of Patients with Acute Respiratory Failure.

BACKGROUND: Pressures measured during mechanical ventilation provide important information about the respiratory system mechanics and can help predict outcomes. METHODS: The electronic medical records of patients hospitalized between 2010 and 2016 with sepsis who required mechanical ventilation were reviewed to collect demographic information, clinical information, management requirements, and outcomes, such as mortality, ICU length of stay, and hospital length of stay. Mechanical ventilation pressures were recorded on the second full day of hospitalization. RESULTS: This study included 312 adult patients. The mean age is 59.1 ± 16.3 years; 57.4% were men. The mean BMI was 29.3 ± 10.7. Some patients had pulmonary infections (46.2%), and some patients had extrapulmonary infections (34.9%). The overall mortality was 42.6%. In a multi-variable model that included age, gender, number of comorbidities, APACHE 2 score, and PaO2/FiO2 ratio, peak pressure, plateau pressure, driving pressure, and PEEP all predicted mortality when entered into the model separately. There was an increase in peak pressure, plateau pressure, and driving pressure across BMI categories ranging from underweight to obese. CONCLUSIONS: This study demonstrates that ventilator pressure measurements made early during the management of patients with acute respiratory failure requiring mechanical ventilation provide prognostic information regarding outcomes, including mortality. Patients with high mechanical ventilator pressures during the early course of their acute respiratory failure require more attention to identify reversible disease processes when possible. In addition, increased BMIs are associated with increased ventilator pressures, and this increases the complexity of the clinical evaluation in the management of obese patients.

Association between acute respiratory failure requiring mechanical ventilation and the production of advanced glycation end products.

Patients with acute respiratory failure often have hyperglycemia. Elevated glucose levels could cause acute lung injury through the production of advanced glycation end products. We measured glucose, advanced glycation end products, glycated albumin, circulating glycated hemoglobin, and soluble receptor for advanced glycation end product (sRAGE) levels on admission, at 24 hours, and at 72 hours in 40 patients with acute respiratory failure requiring mechanical ventilation. We compared these values with healthy control subjects. The mean age was 63.3±11.2 years. Fifty percent of the patients were women. Thirteen patients (32.5%) died during this hospitalization. The mean maximum glucose level on the day of admission was 215.7±171.1 mg/dL. Compared with control subjects, there was a significant reduction in advanced glycation end product levels (p=0.0001) in the patients at all 3 time points. Circulating glycated hemoglobin levels were significantly higher in patients compared with control subjects. We also observed a moderate increase in glycated albumin levels on admission and at 24 hours when compared with the control samples. Overall sRAGE levels were similar to controls, but patients with dense infiltrates on chest X-ray had increased levels compared with patients who did not have these dense infiltrates on the day of admission. Patients with acute respiratory failure requiring mechanical ventilation have decreased levels of advanced glycation end products and increased levels of circulating glycated hemoglobin. The results from this pilot study suggest that the acute stress associated with respiratory failure might create glycated proteins which could contribute to disease pathogenesis.

Advanced glycation end products and glycosaminoglycans in patients with diabetic ketoacidosis.

In some patients diabetic ketoacidosis (DKA) causes acute endothelial injury and multiorgan failure. Measurement of glycosaminoglycan (GAG) and advanced glycation end products (AGE) could provide information to help understand the biochemical events associated with poor outcomes in these patients. This study included 37 patients with DKA admitted to an intensive care unit. Blood was collected from these patients during the first day of hospitalization, 24 hours after the first sample, and 72 hours after the first sample when possible. ELISA-based assays were used to measure glucose, hemoglobin A1c, AGE, glycated albumin, and GAG levels in serum. Twenty healthy control subjects with no history of diabetes donated 1 blood sample. Control subjects had a mean age of 36.3±12.1 years; patients with DKA had a mean age of 38.1±18.5 years. Admission laboratory tests in patients with DKA included glucose 546±296 mg/dL, bicarbonate 10.1±5.5 mEq/L, anion gap 31.8±7.8 mEq/L, and creatinine 1.1±1.0 mg/dL. Patients with DKA had significantly higher level glucose and free glycated hemoglobin. Control subjects had significantly higher levels of AGE and glycated albumin. There were no differences in soluble receptor for AGE levels or GAG levels between the control subjects and patients with DKA. Patients with DKA had lower circulating levels of AGE and glycated albumin than control subjects. These results may reflect absorption of these proteins to damaged capillary surfaces or loss of proteins into interstitial spaces secondary to increased endothelial permeability.

Sinonasal and Laryngeal Sarcoidosis-An Uncommon Presentation and Management Challenge.

Sarcoidosis is a chronic inflammatory disease of uncertain etiology characterized by the formation of noncaseating granulomas. The thorax is involved in 95% of cases, but any organ can be involved. Sinonasal or laryngeal involvement is uncommon and can be difficult to diagnose. The reported incidence of sarcoidosis in the upper airway clearly depends on study characteristics, and this creates uncertainty about the actual incidence. In a large prospective study in the United States, upper respiratory tract involvement occurred in 3% of the patients. Some patients have upper airway involvement without thoracic disease, and this presentation may cause delays in diagnosis. These patients have nonspecific symptoms which range from minimal nasal stuffiness to life-threatening upper airway obstruction. Currently, there is no established standard therapy for the management of upper airway sarcoidosis. These patients often respond poorly to nasal and/or inhaled corticosteroids and require long courses of oral corticosteroids. Patients with poor responses to oral corticosteroids or severe side effects may respond to tumor necrosis factor alpha inhibitors. In this review, we will discuss the clinical presentation, pathogenesis, diagnostic tests, drug treatment, surgical management options and the challenges clinicians have managing these patients.

Thiamine Deficiency: An Important Consideration in Critically Ill Patients.

Thiamine is an essential cofactor for 4 enzymes involved in the production of energy (ATP) and the synthesis of essential cellular molecules. The total body stores of thiamine are relatively small, and thiamine deficiency can develop in patients secondary to inadequate nutrition, alcohol use disorders, increased urinary excretion and acute metabolic stress. Patients with sepsis are frequently thiamine deficient, and patients undergoing surgical procedures can develop thiamine deficiency. This deficiency can cause congestive heart failure, peripheral neuropathy, Wernicke's encephalopathy, Korsakoff's syndrome and gastrointestinal beriberi. In addition, thiamine deficiency can contribute to the development of intensive care unit complications, such as heart failure, delirium, critical care neuropathy, gastrointestinal dysfunction and unexplained lactic acidosis. Consequently, clinicians need to consider thiamine deficiency in patients admitted to intensive care units and the development of thiamine deficiency during the management of critically ill patients. Intravenous thiamine can correct lactic acidosis, improve cardiac function and treat delirium.

Chronic peritoneal indwelling catheters for the management of malignant and nonmalignant ascites.

Ascites is a debilitating condition affecting patients with end-stage liver disease and advanced abdominal malignancies. Serial paracentesis can reduce symptoms in these patients; indwelling peritoneal catheters provide an alternative approach that allows patients to manage their symptoms at home. A literature search was conducted to identify studies with at least 20 patients published in the last 15 years that reported indwelling catheter placement in patients with chronic ascites. Fourteen studies with 957 patients (687 with malignancy and 270 with cirrhosis) were reviewed. Symptom improvement was reported in all studies. The most common complication in patients with malignant ascites was catheter dysfunction (39/687). Infection rates for patients with malignancy and patients with nonmalignant ascites were 5.4% (37/687) and 12.2% (33/270), respectively. Infection risk significantly increased with devices in place for >12 weeks. The average survival time after catheter placement was 7.2 weeks for patients with malignancy and 164 weeks for patients without malignancy. In conclusion, indwelling peritoneal catheters are an effective alternative to paracentesis for palliation in patients with refractory ascites. Peritonitis is a definite risk in patients with nonmalignant ascites in whom prolonged use is expected.

Gastric Ulceration and Bleeding with Hemodynamic Instability Caused by an Intragastric Balloon for Weight Loss.

Obesity in the United States is a medical crisis with many people attempting to lose weight with caloric restriction. Some patients choose minimally invasive weight loss solutions, such as intragastric balloon systems. These balloon systems were approved by the Federal Drug Administration (FDA) in 2015-2016 and have been considered safe, with minimal side effects. We report a patient with a two-day history of melena, abdominal pain, hypotension, and syncope which developed five months after placement of an intragastric balloon. Esophagogastroduodenoscopy with balloon removal revealed a small 8-mm gastric ulcer in the incisura. This gastric ulcer probably developed secondary to mechanical compression of the stomach mucosa by the gastric balloon which contained 900 mL of saline. The FDA is now investigating five deaths since 2016 associated with these second-generation balloons. Clinicians should be aware of these complications when evaluating patients with gastrointestinal complications, such as bleeding.

The Complexity of Characteristics, Diagnoses and Treatment of Older Patients With Pulmonary Hypertension.

BACKGROUND: Older patients with pulmonary hypertension (PH) are more likely to have complex comorbidity than younger patients with pulmonary arterial hypertension (PAH). The best approach to the evaluation and management of these patients is unclear. METHODS: We, retrospectively, reviewed the clinical records of patients older than 60 years referred for evaluation for PAH. We recorded patient demographics, comorbidity, functional classification (FC), right heart catheterization data, echocardiographic data, chest radiographic images and pulmonary function results. We recorded the final diagnoses according to World Health Organization (WHO) subgroups and treatment outcomes based on changes in FC. RESULTS: Ninety-seven records were reviewed in detail. The mean age was 71.2 ± 7.5 years with 66% women. Cardiovascular disease was the most frequent comorbidity. Mean PA pressure by catheterization was 39.5 ± 12.2mmHg (n = 65). The overall distribution after evaluation included 21 (21.6%) Group 1, 35 (36.1%) Group 2, 16 (16.5%) Group 3, 18 (18.6%) mixed Group 2 and 3, 6 (6.2%) Group 4 and 1 (1%) Group 5 patients. Group 1 patients were treated with PAH specific drug, and 12 patients had an improvement in FC with treatment. CONCLUSIONS: Older patients with suspected PH often have significant cardiovascular and respiratory comorbidity. Comprehensive evaluations are needed to determine the severity of PH and associated diseases and to initiate treatment focused on FC. Patients in WHO Group 2 and mixed Group 2 and 3 were frequently identified and constituted a diagnostic and treatment challenge in this study. Older patients with PAH may benefit from PAH specific drugs.

Pulmonary veno-occlusive disease: An important consideration in patients with pulmonary hypertension.

Pulmonary veno-occlusive disease is a rare subcategory of pulmonary arterial hypertension (WHO Group 1). The disease is poorly understood and difficult to diagnose; it has no definitive cure to date. These patients present with nonspecific symptoms, including dyspnea, exercise intolerance, and weakness. Chest x-rays sometimes differ from idiopathic pulmonary arterial hypertension and may demonstrate alveolar infiltrates and pleural effusions. High resolution computed tomography scans reveal ground glass opacities, interlobular septal thickening, and lymphadenopathy. Echocardiography can estimate the level of pulmonary artery pressures; right heart catheterization is needed for complete hemodynamic characterization of these patients. Lung biopsies demonstrate remodeling of the venules and small veins with intimal and adventitial fibrosis. This can result in total venous occlusion and subsequent recanalization. Similar changes occur in the small arteries and arterioles but are less pronounced than the venous changes. There is no effective medical therapy for these patients, and treatment with the pulmonary arterial hypertension specific medications often causes acute deterioration with pulmonary edema. The recent discovery of the biallelic mutations of the EIF2AK4 gene as an etiology for heritable form of pulmonary veno-occlusive disease increases our understanding of the disease pathogenesis and potentially identifies a future approach to treatment. Without definitive treatment, the prognosis is very poor, and the life expectancy of these patients is much shorter than patients with pulmonary arterial hypertension. These patients need early referral to transplantation centers.

Sinonasal and laryngeal sarcoidosis.

Sarcoidosis is a chronic granulomatous inflammation of uncertain etiology that can involve any organ system in the body. Sinonasal and laryngeal involvement is rare, poorly understood, and difficult to diagnose. Additionally, the extent of the disease is variable, and the response to systemic corticosteroids is often poor. We report a case of a 55-year-old woman with prior cutaneous sarcoidosis who presented with chronic nasal congestion, difficulty breathing, dysphonia, and stridor, and biopsy of the nasal vestibule revealed noncaseating granulomatous inflammation.

Islamic Medicine in the Middle Ages.

The Islamic culture flourished between the 9th and 13th centuries. Scholars from this era made significant contributions in mathematics, science and medicine. Caliphs and physicians built hospitals that provided universal care and the foundation for medical education. Physician-scientists made significant advances in medical care, surgery and pharmacology. Notable authorities include al-Razi (865-925 CE) who wrote the Kitab al-Hawi fi al-tibb (The Comprehensive Book on Medicine), a 23-volume textbook that provided the main medical curriculum for European schools into the 14th century. Ibn Sina (980-1037 CE), an extraordinary Persian polymath, wrote al Qanun fi al-Tibb (The Canon of Medicine), an encyclopedic treatment of medicine that combined his own observations with medical information from Galen and philosophy from Aristotle. Mansur (1380-1422 CE) wrote the first color illustrated book on anatomy. Other important physicians compiled information on the use of medication from plants, advanced surgical techniques, including cataract extraction and studied physiology, including the pulmonary circulation. These books and ideas provided the basis for medical care in Europe during its recovery from the Dark Ages.

Characteristics of Patients With Congestive Heart Failure or Chronic Obstructive Pulmonary Disease Readmissions Within 30 Days Following an Acute Exacerbation.

BACKGROUND: The Hospital Readmissions Reduction Program targets Medicare patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) and penalizes hospitals that have increased 30-day readmission rates for these patients. The main goals of this study were to determine the clinical explanations for readmissions within 30 days, to identify possible deficiencies in patient care, and to identify typical characteristics of patients who were readmitted to the hospital. METHODS: The medical records department at University Medical Center in Lubbock, Texas, generated a list of patients with a primary discharge diagnosis of either acute exacerbation of CHF or an acute exacerbation of COPD who were readmitted within 30 days of discharge. Data collected from the electronic medical records included demographic information, clinical information, laboratory data, electrocardiographic information, echocardiographic results, and radiographic information for the index admission and readmission hospitalization. The indication for readmission was determined after review of all clinical data. RESULTS: The final study cohorts included 58 admission-readmission events for acute exacerbations of CHF (47 patients) and 27 admission-readmission events for acute exacerbations of COPD (16 patients). Patients in both cohorts had significant comorbidity and frequent admissions during the 12 months prior to their index admissions. Patients with COPD had predominantly an emphysematous phenotype. Chest radiographs in patients with CHF showed cardiomegaly, pulmonary edema, and pleural effusions. Patients with CHF were discharged with suboptimal medication regimens. Referral to outpatient rehabilitation programs was low in both groups. CONCLUSIONS: Patients with acute exacerbations of COPD or CHF who require readmission within 30 days have complex comorbidity. They appear to have typical clinical profiles (emphysematous-type COPD patients and CHF patients with fluid overload), are frequently discharged with suboptimal medication regimens, and are not referred to outpatient rehabilitation. These patients had frequent hospitalizations prior to index hospitalizations. This information provides the basis for a focused review of patients admitted to the hospital to identify factors that might contribute to readmission.

The Frequency of White Blood Cell and Temperature Events During Mechanical Ventilation and Their Association With Ventilator-Associated Events.

BACKGROUND: Changes in white blood cell (WBC) counts and/or temperature could have important implications in patients on ventilators, but the frequency of these events is uncertain. METHODS: We reviewed the medical records from 281 ventilation episodes in our medical intensive care unit to determine patient characteristics and the indications for ventilation. We determined the number of days during each ventilation episode in which the temperature (<96.8°F, >100.4°F) or WBC count (<4000/µL, >12 000/µL) was out of the normal range. RESULTS: This study included 257 patients with a mean Acute Physiology and Chronic Health Evaluation 2 score of 13.5 ± 5.9 and a mean initial Pao2/Fio2 of 210 ± 110. The median number of ventilator days was 4 (interquartile range, 3-9). One hundred ninety-six of 275 eligible ventilator episodes (71.3%) had 1 or more temperature events, and 194 of 253 eligible ventilator episodes (76.7%) had 1 or more WBC events. Nineteen patients met the Center for Disease Control criteria for a ventilator-associated event (VAE). Twelve patients had an increased WBC count during the VAE period, and 11 had an increased temperature during this period. CONCLUSIONS: White blood cell counts and temperature events occur frequently in patients on ventilators and need evaluation but do not reliably identify patients with ventilator-associated complications.

Complications and Resource Utilization Associated With Mechanical Ventilation in a Medical Intensive Care Unit in 2013.

INTRODUCTION: Evolving strategies for ventilator management could reduce the frequency of complications, but there is limited information about complications in contemporary intensive care units. METHODS: We retrospectively collected information about patient demographics, chest x-ray abnormalities, complications, including pneumothoraces, ventilator-associated events, self-extubation, and resource utilization in 174 patients who required mechanical ventilation in 2013. RESULTS: The mean age was 57.8 ± 16.8 years, the number of ventilator days was 7.5 ± 7, and the overall in-hospital mortality was 32.2%. The mean fluid balance per day during the mechanical ventilation period was 1539 ± 1721 mL. Three (1.7%) patients developed pneumothoraces, and 5 patients required chest tubes. Twenty-five (14.4%) patients had ventilator-associated events. Ten patients had episodes of self-extubation, and 11 had episodes of failed extubation. Chest X-rays showed new or increasing infiltrates in 113 (64.9%) patients and new or increasing pleural effusions in 29 (16.7%) patients. These patients had 1.2 ± 0.4 X-rays per day on the ventilator, and they had 10.0 ± 9.4 arterial blood gases and 0.7 ± 0.7 central lines. CONCLUSION: The frequency of ventilator-associated complications was low in this study. However, these patients frequently developed increasing infiltrates, and these outcomes need attention during patient management and are a potential focus for future studies.

Glucose Levels in Patients With Acute Respiratory Failure Requiring Mechanical Ventilation.

BACKGROUND: Recent studies suggest that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) frequently develop hyperglycemia, which has been linked to adverse outcomes. METHODS: We retrospectively collected information about patient demographics, admission diagnosis, comorbidities, use of insulin, and glucose levels and related tests in 174 patients who required mechanical ventilation for acute respiratory failure. RESULTS: These patients had a mean age of 57.8 ± 16.8 years, a mean Acute Physiology and Chronic Health Evaluation (APACHE II) score of 13.8 ± 6.1, and an overall mortality of 32.2%. The mean number of ventilator days was 7.5 ± 7.1. The mean highest glucose level was 239.3 ± 88.9 mg/dL in patients with COPD (n = 41) and 259.1 ± 131.7 mg/dL in patients without COPD (n =133). Patients with diabetes had higher glucose levels than patients without this diagnosis ( P < .05). Patients receiving corticosteroids did not have increased glucose levels ( P > .05). The mortality rate was higher in patients with glucose levels >140 mg/dL than in patients below 140 mg/dL (35.1% vs 10.5%, P < .05 unadjusted analysis). CONCLUSION: In this study, hyperglycemia occurred in 89% of the patients with acute respiratory failure requiring mechanical ventilation. The most important risk factor for this was a premorbid diagnosis of diabetes.

Pulmonary vein stenosis complicating radiofrequency catheter ablation for atrial fibrillation: A literature review.

Radiofrequency catheter ablation has become a widely used intervention in the treatment of atrial fibrillation. Pulmonary vein stenosis (PVS) is one of the most serious complications associated with this procedure; the degree of stenosis ranges from mild (<50%) to complete venous occlusion. The natural history of PVS and the risk of progression of existing PVS are uncertain. Symptomatic and/or severe PVS is a serious medical problem and can be easily misdiagnosed since it is an uncommon and relatively new medical problem, often has low clinical suspicion among clinicians, and has a non-specific presentation that mimics other more common respiratory or cardiac diseases. The estimated incidence varies in literature reports from 0% to 42% of ablation procedures, depending on technical aspects of the procedure and operator skill. Most patients with significant PVS remain asymptomatic or have few symptoms. Symptomatic patients usually present with dyspnea, chest pain, or hemoptysis and are usually treated with balloon angioplasty and/or stent placement. Little is known about the long term effect of PV stenosis/occlusion on the pulmonary circulation and the development of pulmonary hypertension. Evolving technology may reduce the frequency of this complication, but long term studies are needed to understand the effect of therapeutic atrial injury and adverse outcomes. This review summarizes the current literature and outlines an approach to the evaluation and management of these patients.

Making of a Successful Early Mobilization Program for a Medical Intensive Care Unit.

OBJECTIVES: To provide a guideline for intensive care unit (ICU) early mobilization program development and implementation and to describe the patient characteristics and endpoints for those who participated in our hospital's early mobilization program. METHODS: An ICU early mobilization program was developed with five guiding principles: analgesia/sedation optimization, sedation minimization, protocol of progressive mobility, physical therapy and occupational therapy recruitment, and nursing education. This program began in April 2014, and the initial 32 patients who ambulated while receiving mechanical ventilation were retrospectively assessed and their characteristics described. RESULTS: After program implementation, more than 50 mechanically ventilated patients ambulated in the first year following early mobilization initiation. Patients with an FiO2 as high as 1.0 and on nonconventional modes of mechanical ventilation successfully ambulated without adverse events. The mean ambulation distance was 102 ± 152 f. and usually required three ICU staff members with 5 to 10 minutes of preparation before ambulation. After implementation, a retrospective analysis revealed a decrease in the average length of ICU stay, from 4.8 to 4.1 days. CONCLUSIONS: Addressing analgesia and sedation practices, along with instituting a progressive mobility protocol and recruiting physical and occupational therapy, may serve as a guide to the creation of a successful early mobilization program. This study provides additional supportive evidence that early mobilization in the ICU is safe and effective.