A score to predict Pseudomonas aeruginosa infection in older patients with community-acquired pneumonia.

BACKGROUND: In Thailand, the incidence of community-acquired pseudomonal pneumonia among 60- to 65-year-olds ranges from 10.90% to 15.51%, with a mortality rate of up to 19.00%. Antipseudomonal agents should be selected as an empirical treatment for elderly patients at high risk for developing this infection. The purpose of this study was to identify risk factors and develop a risk predictor for Pseudomonas aeruginosa infection in older adults with community-acquired pneumonia (CAP). METHODS: A retrospective data collection from an electronic database involved the elderly hospitalized patients with P. aeruginosa- and non-P. aeruginosa-causing CAP, admitted between January 1, 2016, and June 30, 2021. Risk factors for P. aeruginosa infection were analysed using logistic regression, and the instrument was developed by scoring each risk factor based on the beta coefficient and evaluating discrimination and calibration using the area under the receiver operating characteristic curve (AuROC) and observed versus predicted probability (E/O) ratio. RESULTS: The inclusion criteria were met by 81 and 104 elderly patients diagnosed with CAP caused by P. aeruginosa and non-P. aeruginosa, respectively. Nasogastric (NG) tube feeding (odd ratios; OR = 40.68), bronchiectasis (B) (OR = 4.13), immunocompromised condition (I) (OR = 3.76), and other chronic respiratory illnesses (r) such as atelectasis, pulmonary fibrosis, and lung bleb (OR = 2.61) were the specific risk factors for infection with P. aeruginosa. The "60-B-r-I-NG" risk score was named after the 4 abbreviated risk variables and found to have good predicative capability (AuROC = 0.77) and accuracy comparable to or near true P. aeruginosa infection (E/O = 1). People who scored at least two should receive empirically antipseudomonal medication. CONCLUSIONS: NG tube feeding before admission, bronchiectasis, immunocompromisation, atelectasis, pulmonary fibrosis and lung bleb were risk factors for pseudomonal CAP in the elderly. The 60-B-r-I-NG was developed for predicting P. aeruginosa infection with a high degree of accuracy, equal to or comparable to the existing P. aeruginosa infection. Antipseudomonal agents may be started in patients who are at least 60 years old and have a score of at least 2 in order to lower mortality and promote the appropriate use of these medications.

A successful treatment of a lobar atelectasis in a patient with cystic fibrosis.

Lobar atelectasis may be a complication of pulmonary exacerbations in cystic fibrosis (CF). There are no established guidelines on the management of this condition in patients with CF. Therapeutic bronchoscopy with recombinant human deoxyribonuclease (rhDNase) instillation has been described to be successful in patients not responding to conservative measures. We describe a case of a young man with CF, with previously mild impaired lung function, presenting with cough, desaturation, and worsening dyspnea, persisting for over 6 weeks, despite conservative therapy. Thoracic imaging showed right lower lobe atelectasis, which was successfully treated with bronchoscopy and instillation of rhDNase. Long-term resolution of the atelectasis was confirmed with chest magnetic resonance imaging follow-up.

A case of endobronchial actinomycosis as a challenging cause of lung atelectasis.

BACKGROUND: Primary endobronchial actinomycosis is exceptionally uncommon and can be misdiagnosed as unresolving pneumonia, endobronchial lipoma, bronchogenic carcinoma or foreign body. Predisposing factors are immunosuppressive conditions, chronic lung diseases, poor oral hygiene or foreign body aspiration. CASE PRESENTATION: We reported a case of 88-year old woman with a 4 days history of mild exertional dyspnea, productive cough with purulent sputum and fever up to 37.8 °C, who developed left sided endobronchial actinomycosis in absence of any pre-existent risk conditions; endobronchial de-obstruction and specific antibiotic treatment were performed with success, achieving a full resolution of the disease, with bronchoscopy playing a key role in the diagnosticand therapeutic pathways. CONCLUSIONS: This case raises the necessity for increased awareness in the management of endobronchial lesions and in cases of suspected endobronchial actinomycosis; bronchoscopy plays a key role in the diagnostic and therapeutic process; prompt recognition of this entity can expedite proper treatment and recovery.

Bronchoscopic surfactant administration in premature neonate with persistent lobar atelectasis: the new concept.

Neonatal pulmonary atelectasis (NPA) is the collapse or closure of a lung resulting in reduced or absent gas exchange. NPA is a common clinical complication among premature neonates and can contribute to a need for prolong mechanical ventilation and poor prognosis. It is usually unilateral. Chests X-ray, CT scan, and recently ultrasonography are diagnostic aids. Unfortunately, there are little experiences in the treatment of this condition. Administration of surfactant by ultrathin bronchoscope illustrates here as new concept in the treatment of persistent NPA in small size neonates.

Lung Collapse during Mini-Thoracotomy Reduces Penetration of Cefuroxime to the Tissue: Interstitial Microdialysis Study in Animal Models.

Background: Single-lung ventilation facilitates surgical exposure during minimally invasive cardiac surgery. However, a deeper knowledge of antibiotic distribution within a collapsed lung is necessary for effective antibiotic prophylaxis of pneumonia. Patients and Methods: The pharmacokinetics/pharmacodynamics (PK/PD) of cefuroxime were compared between the plasma and interstitial fluid (ISF) of collapsed and ventilated lungs in 10 anesthetized pigs, which were ventilated through a double-lumen endotracheal cannula. Cefuroxime (20 mg/kg) was administered in single 30-minute intravenous infusion. Samples of blood and lung microdialysate were collected until six hours post-dose. Ultrafiltration, in vivo retrodialysis, and high-performance liquid chromatography-tandem mass spectrometry were used to determine plasma and ISF concentrations of free drug. The concentrations were examined with non-compartmental analysis and compartmental modeling. Results: The concentration of free cefuroxime in ISF was lower in the non-ventilated lung than the ventilated one, evidenced by a lung penetration factor of 47% versus 63% (p < 0.05), the ratio between maximum concentrations (65%, p < 0.05), and the ratio between the areas under the concentration-time curve (78%, p = 0.12). The time needed to reach a minimum inhibitory concentration (MIC) was 30%-40% longer for a collapsed lung than for a ventilated one. In addition, a delay of 10-40 minutes was observed for lung ISF compared with plasma. The mean residence time values (ISF collapsed lung > ISF ventilated lung > plasma) could explain the absence of practically important differences in the time interval with the concentration of cefuroxime exceeding the MICs of sensitive strains (≤4 mg/L). Conclusion: The concentration of cefuroxime in the ISF of a collapsed porcine lung is lower than in a ventilated one; furthermore, its equilibration with plasma is delayed. Administration of the first cefuroxime dose earlier or at a higher rate may be warranted, as well as dose intensification of the perioperative prophylaxis of pneumonia caused by pathogens with higher MICs.

Diffuse Large B-Cell Lymphoma Arising from the Lesion of Chronic Lobar Atelectasis.

Pulmonary lymphoma is rare, accounting for < 1% of primary lung cancers. Most primary pulmonary lymphomas (PPL) are low-grade mucosa-associated lymphoid tissue (MALT)-type, and among PPL, diffuse large B-cell lymphoma (DLBCL) is extremely rare. In contrast, there has been an increase in the incidence of DLBCL among patients with autoimmune disorders and recurrent or chronic bacterial infection. A subset of DLBCL has been reported to develop through transformation of preexisting or concurrent MALT. The respiratory symptoms are non-specific, and the chest X-ray findings demonstrate the presence of interstitial and mixed alveolar infiltrates, nodular lesions, and localized homogeneous consolidations; the diagnosis of pulmonary DLBCL is thus challenging and often leads to a misdiagnosis or delayed diagnosis. We herein report a case of DLBCL which was assumed to have arisen from the lesion of chronic atelectasis that was successfully diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). A 74-year-old woman with diffuse bronchiectasis and chronic atelectasis of the left lower lobe suffered from productive cough and high fever. Increased airway filling with mucoid secretion was repeatedly observed within the area of atelectasis with bronchiectasis, and left lower lobe atelectasis developed. Subsequently, the hilar and mediastinal lymph nodes gradually became enlarged, and DLBCL was pathologically confirmed. In the present case, DLBCL was considered to have arisen in the lesion of chronic atelectasis. Physicians should recognize that DLBCL may develop at the site of chronic atelectasis during disease course of diffuse bronchiectasis, and thus DLBCL may be misdiagnosed as superimposed infection of chronic atelectasis.

Pleuritis por Cryptococcus neoformans en paciente inmunocompetente / Cryptococcus neoformans pleuritis in an immunocompetent patient

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Clinical Analysis of 122 Cases with Mycoplasma Pneumonia Complicated with Atelectasis: A Retrospective Study.

INTRODUCTION: This study aims to explore the clinical characteristics, treatment, and prognosis of mycoplasma pneumonia complicated with atelectasis. METHODS: A retrospective analysis was performed on 122 children with mycoplasma pneumonia complicated with atelectasis. These children were hospitalized in the Xiamen Campus of the Pediatric Hospital of Fudan University and the Children's Hospital of Xiamen between December 2015 and December 2018. A diagnosis was made for each case on the basis of the clinical symptoms and signs, Mycoplasma pneumoniae-specific IgM antibody, and imaging results. RESULTS: Among the 122 cases with mycoplasma pneumonia complicated with atelectasis, all cases had retractable M. pneumoniae infection, 102 cases underwent fibrobronchoscopic lavage treatment, and all cases were treated with macrolide antibiotics after a definite diagnosis was made. Furthermore, 107 cases improved and were discharged. Follow-up was performed for 3-4 weeks for all patients, and all patients, including the five cases with retractable disease, recovered well. CONCLUSION: The major clinical manifestations for M. pneumoniae pneumonia are fever and stimulatory dry cough. Macrolide antibiotics remain the treatment of choice.

Atelectasia persistente en paciente con fibrosis quística: ¿debemos tratarla siempre con antibioterapia? / Persistent Atelectasis in a Patient With Cystic Fibrosis: Are Antibiotics Always Needed?

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Hypertrophic pyloric stenosis following repair of oesophageal atresia and tracheo-oesophageal fistula in a neonate.

Development of hypertrophic pyloric stenosis (HPS) after a few weeks of repair of an oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) is a rare condition in early infancy. Although vomiting or feeding intolerance in operated cases of OA+TOF are attributed to oesophageal stricture, gastro-oesophageal reflux and oesophageal dysmotility, it may also be caused by HPS. Herein, we report a newborn infant who had OA and TOF operation on day 2 of life and diagnosed to have HPS at 15th day of age. Even though it is a rare anomaly, HPS should be kept on mind in the presence of persistent vomiting following repair of OA.

Mycoplasma pneumoniae 23S rRNA A2063G mutation does not influence chest radiography features in children with pneumonia.

Objective To measure the rate of the A2063G mutation in the Mycoplasma pneumoniae ( M. pneumoniae) 23S rRNA domain V in children with pneumonia and to determine the correlation between radiographic findings and the presence of the A2063G mutation. Methods Patients who were hospitalized with a confirmed diagnosis of M. pneumoniae pneumonia were enrolled in this study. M. pneumoniae strains were collected for genotype analysis. Chest radiography was performed on all children prior to and following macrolide treatment. Clinical and imaging data were obtained. Results Of 211 patients, 195 (92.42%) harboured M. pneumoniae with the A2063G mutation. No significant differences were identified in inflammation score, chest radiography inflammation absorption grade before and after macrolide treatment, or pulmonary complications (atelectasis, hydrothorax, or pleuritis) prior to macrolide treatment when children were stratified based on the presence or absence of the A2063G mutation. Conclusions A high proportion of children with pneumonia harboured strains of M. pneumoniae with the A2063G mutation in the 23S rRNA domain V. However, no obvious chest radiographic features of M. pneumoniae pneumonia were associated with the A2063G variant.

Right middle lobe atelectasis in children with asthma and prognostic factors.

BACKGROUND: Although right middle lobe (RML)-atelectasis of the lungs is a common complication of asthma, the relevant data is limited. The aim of this study is to define the characteristics of RML atelectasis in asthma during childhood. METHODS: Children with asthma who had recently developed RML atelectasis were included; anti-inflammatory medications, clarithromycin, and inhaled salbutamol were prescribed, chest-physiotherapy (starting on the sixth day) was applied. Patients were reevaluated on the sixth, fourteenth, thirtieth, and ninetieth days, chest X-rays were taken if the atelectasis had not resolved at the time of the previous visit. RESULTS: Twenty-seven patients (6.8 (4.8-8.3) years, 48.1% male) with RML atelectasis were included. Symptoms started 15 (7-30) days before admission. The thickness of the atelectasis was 11.8 ± 5.8 mm; FEV1% was 75.9 ± 14.2 and Childhood Asthma Control Test scores were 11.8 ± 5.6 at the time of admission. The atelectasis had been resolved by the sixth (n = 3), fourteenth (n = 9), thirtieth (n = 10), and ninetieth days (n = 3). The treatment response of the patients whose atelectasis resolved in fourteen days was better on the sixth-day (atelectasis thickness: 4.7 ± 1.7 vs. 11.9 ± 7.3 mm, p = 0.021) compared to those whose atelectasis resolved later. Nearly half (54.5%) of the patients whose atelectasis had resolved by fourteen days were using controller medications at the time of admission. However, only two patients (13.3%) were on controller treatment in the latter group (p = 0.032). Regression analysis didn't reveal any prognostic factors for the early resolution of atelectasis. CONCLUSIONS: Early diagnosis and treatment of RML atelectasis prevents complications. Patients who had early resolution of atelectasis had already been on anti-inflammatory medications, and responded better to aggressive treatment within the first week.

Overcoming inactivation of the lung surfactant by serum proteins: a potential role for fluorocarbons?

In many pulmonary conditions serum proteins interfere with the normal adsorption of components of the lung surfactant to the surface of the alveoli, resulting in lung surfactant inactivation, with potentially serious untoward consequences. Here, we review the strategies that have recently been designed in order to counteract the biophysical mechanisms of inactivation of the surfactant. One approach includes protein analogues or peptides that mimic the native proteins responsible for innate resistance to inactivation. Another perspective uses water-soluble additives, such as electrolytes and hydrophilic polymers that are prone to enhance adsorption of phospholipids. An alternative, more recent approach consists of using fluorocarbons, that is, highly hydrophobic inert compounds that were investigated for partial liquid ventilation, that modify interfacial properties and can act as carriers of exogenous lung surfactant. The latter approach that allows fluidisation of phospholipid monolayers while maintaining capacity to reach near-zero surface tension definitely warrants further investigation.

Bronchial responsiveness in an elastase-induced mouse model of emphysema.

Bronchial responsiveness during methacholine (MCh) challenge was analysed in an elastase-induced mouse model of emphysema to explore the magnitude of the response in this model. Swiss mice were intratracheally instilled with saline or elastase (0.3 or 0.6 U). Twenty days afterward, mechanical ventilation data were collected from the closed and opened thorax of baseline and MCh (vehicle, 50 and 100 mg/mL) challenged mice. The lungs were prepared for morphometric analysis. In the 0.6 U group, airway resistance (Raw) and tissue elastance (H) were decreased, and hysteresivity (η) was increased (closed thorax). MCh increased Raw, G and H in all groups, but this increase was attenuated in the elastase-induced emphysema groups, the largest attenuation was observed in the 0.6 U (closed thorax condition). Elastase increased hyperinflation of the alveoli, alveolar collapse and the Lm and reduced the normal area. MCh reduced respiratory mechanics in elastase-induced emphysema, and this reduction was modulated by the collapsed and/or hyperinflated areas, which increased the heterogeneity of the lungs.

The use of dornase alpha for post-operative pulmonary atelectasis after congenital heart surgery.

OBJECTIVE: To investigate the efficacy of dornase alpha, a mucolytic agent, in children who developed pulmonary atelectasis after congenital heart surgery. DESIGN: Retrospective case-control study. SETTING: Paediatric cardiac intensive care unit at a tertiary care hospital. PATIENTS: Between July, 2011 and July, 2012, 41 patients who underwent congenital cardiac operations and developed post-operative pulmonary atelectasis that was resistant to conventional treatment and chest physiotherapy. INTERVENTIONS: In all, 26 patients received dornase alpha treatment. As a control group, 15 patients were treated with conventional medications and chest physiotherapy. MAIN RESULTS: The median age of patients was 25.5 (3-480) days in the study group and 50.0 (3-480) days in the control group. A total of 15 (57.6%) patients in the study group and 8 (53.3%) patients in the control group were male. The median weight was 4.2 (2.9-14.2) kg and 4.0 (3.5-13.6) kg in the study and control group, respectively. In the study group, pulmonary atelectasis was diagnosed at a median period of 5 (2-18) days after operations, whereas in the control group atelectasis was diagnosed at a median period of post-operative 6 (3-19) days. In the study group, the median atelectasis score decreased from 3.4 (1-6) to 0.8 (0-3) (p = 0.001). The median pO2 level increased from 69 (17-142) mmHg to 89 (30-168) mmHg (p = 0.04). In addition, heart rate and respiratory rate per minute were significantly decreased (p < 0.05). There were no significant changes in these parameters in the control group. CONCLUSIONS: The use of dornase alpha can be effective for the management of pulmonary atelectasis that develops following congenital heart surgery.

Successful treatment of atelectasis with Dornase alpha in a patient with congenital muscular dystrophy.

A 28-year-old neuromuscular patient chronically treated with nocturnal noninvasive ventilation developed pulmonary lobar atelectasis and daytime hypoxemia. Twenty four-hour 5L/min oxygen was begun, while mechanical cough assist aids were applied for seven days. In the following three days, treatment with nebulized Dornase alpha (rhDNase) b.i.d. was tested, without any significant improvement. On 11 and 13th days rhDNase was instilled by flexible bronchoscopy. A rapid resolution of the atelectasis was observed with relief of hypoxemia, without significant side effects. On day 16 the patient was discharged without oxygen requirements. In non-intubated neuromuscular patients with atelectasis who do not respond successfully to non-invasive treatments intrabronchial instillation of rhDNase may safely help to improve airway clearance.

Inhaled Dornase alfa (Pulmozyme) as a noninvasive treatment of atelectasis in mechanically ventilated patients.

BACKGROUND: Lobar or segmental collapse of the lung in mechanically ventilated patients is a common occurrence in the intensive care unit. Management is labor and time intensive and not highly effective. METHODS: We conducted a randomized, placebo-controlled, double-blind pilot study to determine whether nebulized Dornase alfa improves radiologic and clinical outcomes in ventilated patients with lobar atelectasis. Drug or placebo was administered twice daily until extubation, death, or transfer. The primary outcome was the total chest x-ray score: secondary outcomes of interest were oxygenation, lung compliance, and rate of extubation over the first 5 days. The groups consisted of 14 intervention patients and 16 control patients. RESULTS: There were no significant differences in "Total Chest X-Ray Score" or compliance over the 5 days of study. There was an improvement in oxygenation for the intervention group at day 5 (P = .03). In addition, this group was less likely to remain intubated over the first 24 hours of the study, a difference that did not persist over the course of the study. CONCLUSIONS: Dornase alfa does not improve the appearance of atelectasis on chest radiographs, or the "Total Chest X-Ray Score" over the first 5 days of treatment in mechanically ventilated patients. The intervention group's higher rate of extubation during the first 24 hours as well as its improved oxygenation on day 5 were likely chance findings given the multiple potential confounders for extubation and low study power.