Deterioration Of Respiratory Status Research Articles

Index of Suspicion in the Nursery

A 2,435-g male infant is born at 38 weeks gestational age to a 22-year-old G2P1001 woman who is blood group O+ and negative for group B Streptococcus. Labor had been induced for intrauterine growth restriction. Rupture of membranes with clear fluid occurred 3 hours before delivery, and the baby is delivered by emergency cesarean section for fetal bradycardia. Apgar scores are 8 at 1 minute and 8 at 5 minutes. The baby is suctioned by bulb and nasogastric tube. At 8 minutes of age, the baby's lungs sound wet, with a pulse oximetry reading of 68%, and 40% blow-by oxygen is started. By 15 minutes of age, he is breathing room air with a pulse oximetry reading of 98%. Physical examination in the newborn nursery yields normal results, with a Ballard score of 39 weeks, weight between the 10th and 25th percentiles, length at the 75th percentile, and head circumference at the 25th percentile. He has one low temperature of 35.4°C initially, but the capillary blood glucose measurements are 59 mg/dL (3.3 mmol/L) or more. He does well on formula feedings, with a weight loss of 15 g at 12 hours and 40 g at 36 hours. At 45 hours of age, after an uneventful hospital stay, the baby develops tachypnea and moderate intercostal and subcostal retractions. His pulse oximetry reading is 85% to 89%. He is placed on oxygen by nasal cannula, and an evaluation is undertaken that reveals the source of his respiratory distress. A 23-day-old male infant presents to the clinic because of persistent crying. Yesterday, he was seen in the emergency department, where colic was diagnosed. Today, his mother appears overwhelmed, stating that the baby cries throughout the day and night. She is concerned that the infant has abdominal pain or pain in his left …

Urinary Incontinence in Adolescent Females with Cystic Fibrosis

Urinary incontinence has been found to be common in girls and women with cystic fibrosis (CF). This often can have a marked impact on daily activities and quality of life. It may also lead to potential deterioration of respiratory status due to reduced adherence to forced expiratory manoeuvres (cough, lung function tests and exercise) by the girls trying to avoid occurrence of urinary incontinence (UI). Analysis of the literature is limited by the fact that different definitions and a variety of questionnaires have been used. There is little literature regarding UI in men and boys which is thought to be less common than in females. National guideline recommendations in the management of CF in Australia and the United Kingdom have in recent years changed to incorporate screening and management of UI. No studies to date have looked at outcomes of interventions in children and adolescents with CF or other respiratory conditions; however those working with this population need to be aware of the problem of UI as it is a treatable condition and could potentially be prevented.

Unexpectedly large aortoesophageal fistula inconsistent with CT imaging due to the thrombus working as the tamponade

A 69-year-old woman with a history of graft replacement of descending aortic aneurysm was referred to our hospital due to massive hematemesis with shock status. Additionally, the deterioration of respiratory status made us start the management under mechanical ventilation. The emergent gastrointestinal endoscopy by a general practitioner showed ulcer-like lesion of the upper esophagus and arterial bleeding. A contrast-enhanced computed tomography showed thoracic aortic aneurysm surrounded by low density mass and contrast medium protruding from the aneurysm. The findings suggested that thoracic aortic aneurysm perforated into esophagus and made an aortoesophageal fistula. Hemodynamic deterioration rapidly progressed and she passed away 4 days after her hospitalization. Autopsy showed that a new thoracic aortic aneurysm arose from the proximal site of the graft. The aneurysm ruptured to esophagus with 6.0 cm x 5.0 cm sized fistula. The fistula was filled with a large thrombus. The large thrombus filling with the fistula worked as the tamponade and prevented her from the fatal exsanguinations and sudden death. The mechanism of the sentinel bleeding and the fatal exsanguinations known as Chiari's triad was revealed in our report.

Acute exacerbation of interstitial pneumonia associated with collagen vascular diseases

BackgroundAcute exacerbation (AE) is currently established as a distinct condition with acute deterioration of respiratory status in idiopathic pulmonary fibrosis (IPF). Recently, several studies have reported that AE also occurred in interstitial pneumonias other than IPF, such as collagen vascular disease-associated interstitial pneumonia (CVD-IP). However, the incidence of AE in CVD-IP and its clinical characteristics remain to be fully determined. This study was conducted to elucidate cumulative incidence of AE in CVD-IP and its clinical features.MethodsWe reviewed 83 biopsy-proven CVD-IP patients, estimated cumulative incidence of AE, and examined its clinical characteristics.ResultsAmong 83 CVD-IP patients, six patients with a mean age of 65.7 years developed AE (overall incidence, 7.2%; 1-year incidence, 1.25%). Underlying CVDs included rheumatoid arthritis (RA) (n = 5; overall incidence, 20.0%) and primary Sjögren syndrome (n = 1; overall incidence, 5.9%). Patients with AE showed acute respiratory deterioration with severe hypoxemia (mean PaO2/FiO2 ratio, 131). Radiologically, ground-glass opacity was superimposed on the underlying reticular abnormalities. Preexisting histological patterns included three usual interstitial pneumonia (UIP) and two non-specific interstitial pneumonia (NSIP). Five (83.3%) of six patients died of respiratory failure despite intensive therapy. Univariate Cox's proportional hazards analysis showed that age and RA diagnosis were significantly associated with AE. Multivariate Cox's proportional hazards analysis indicated that age was an independent significant factor predicting AE.ConclusionsThese data suggest that AE can occur in CVD-IP, and this condition is closely similar to that of IPF with poor prognosis. AE is most common in RA, and associated with higher ages.

Pneumopathie médicamenteuse sous traitement par venlafaxine et propranolol

Venlafaxine and propranolol have rarely been identified as causes of pulmonary pathology. We describe a case of drug-induced pneumonitis occurring in a patient treated with these two medications. A 55 years old woman with liver cirrhosis treated with venlafaxine for 1 year and propranolol for 1 month was admitted to the intensive care unit because of acute respiratory failure. A Mycoplasma pneumoniae pneumonitis was diagnosed. After initial improvement under antibiotics, a new deterioration of respiratory status was observed 4 days after the reintroduction of venlafaxine and propranolol. Spontaneous recovery occurred after these treatments were withheld. Co administration of venlafaxine and propranolol, 2 drugs with affinity for the same cytochrome P450 isoenzyme (CYP2D6), may have contributed to drug accumulation and pulmonary toxicity. The liver cirrhosis of our patient may also have contributed to decreased cytochrome P450 enzymatic activity. Venlafaxine and propranolol share the same metabolic pathway and their co-administration may be complicated by drug induced pneumonitis.

Successful treatment of congenital pulmonary alveolar proteinosis with intravenous immunoglobulin G administration

The authors report a female patient with congenital pulmonary alveolar proteinosis (PAP). She had two brothers who died from the same disease. BAL did not improve her progressive respiratory failure. After intravenous immunoglobulin G (IVIG) administration for complicated hypogammaglobulinemia, she recovered from respiratory failure. The efficacy of IVIG was confirmed by recovery from deterioration in respiratory status and improvement in chest CT findings on two separate occasions. Subsequently, the patient remains free from respiratory symptoms for more than 3 years on an ongoing regimen of monthly IVIG. She had no surfactant protein (SP) B deficiency. Alveolar macrophages (AM) obtained from her BAL fluid were small and showed decreased phagocytotic activity. Immunostaining revealed weak expression of PU.1 in her AM, a key protein in AM maturation. All nucleotide sequences of granulocyte-macrophage colony stimulating factor (GM-CSF), GM-CSF-receptor and PU.1 were normal. Endotoxin-induced GM-CSF release from peripheral mononuclear cells (PMNC), and proliferation of PMNC in response to GM-CSF were normal. In addition, an antibody against GM-CSF, as seen in adult patients with idiopathic PAP, was not detected in the serum or BAL fluid. Although the patient's PMNC secreted only small amounts of IgG and IgM, an EB virus-derived cell line of her B cells secreted IgM as much as normal control cells. In a flow cytometric study, IgM was expressed on the cell surface. In conclusion, an abnormality in a single gene may have decreased secretion of immunoglobulin from the B cells and the AM phagocytotic activity in the patient.

Clinical Evaluation of an Automated Turning Bed

The purposes of this study were to assess client comfort and sleep quality, client physiologic response (skin and respiratory status), the effect on the need for caregiver assistance, and cost when using an automated turning bed. Nonexperimental, evaluative study. Twenty-four adult home or long-term care resident subjects who had a degenerative disease, spinal cord injury, stroke, cerebral palsy, or back surgery. Each subject agreed to use the automated turning bed for four weeks. Researchers completed a demographic survey and skin assessment, and assessed each subject for pressure ulcer risk and for the need of assistance of a care giver for turning before and after the four weeks of using the turning bed. Subjects rated the turning bed in terms of comfort and sleep quality. Subjects rated the turning bed as more comfortable than their own bed and expressed satisfaction at the pain relief attained when on the turning bed. While using the turning bed, there was a significant improvement in sleep quality. No skin breakdown or deterioration in respiratory status occurred. Fewer subjects required the assistance of a caregiver for turning when on the turning bed. This automated turning bed shows great promise in meeting a need for patients with limited mobility whether they are homebound or in a residential community. Future studies that further investigate use of the turning bed for postoperative back patients while still in the acute care setting are indicated. Replicative studies with a larger sample size are also indicated.

Alteration of cellular adhesion molecule gene expressions in the lungs of newborn mice exposed to hyperoxia. † 1569

Hyperoxic lung injury is a frequent and unfortunate consequence of supraphysiologic oxygen therapy. Relative to adults, newborns of most species are resistant to lung O2 toxicity. However, the development of newborn lung exposed to hyperoxia is profoundly affected with a marked inhibition of normal alveolization. We have previously shown increases in intercellular adhesion molecule-1 (ICAM-1), platelet endothelial cell adhesion molecule 1(PECAM-1), and P-Selectin in adult mouse lungs exposed to hyperoxia that coincided with a rapid deterioration of respiratory status. In the present study, we will compare the gene expression of ICAM-1, PECAM-1, and P-Selectin in the lungs of newborn mice exposed to 100% O-2 for 4, 7 or 10 days. Age-matched animals exposed to room air will serve as control. Cellular adhesion molecule (CAM) mRNA expression was assessed by in situ hybridization. In control animals, only PECAM-1 mRNA was detected in the endothelium of large arteries with a slight increase at 10 days. ICAM-1 mRNA was not detected before 7 d of hyperoxia, whereas it was abundantly expressed in the alveoli and airway epithelium. A marked increase in PECAM-1 mRNA expression was also seen in endothelial cells, and alveoli after 7 d of hyperoxia. In contrast, only barely detectable P-Selectin mRNA was observed in the endothelial cells of large vessels of the same animals. Both ICAM-1 and PECAM-1 expression appeared maximum at 7 days of hyperoxia. In contrast to the adult mouse, the increase in CAMs expression occurred later and was not associated with lethal lung damage. Moreover, the increase in PECAM-1 mRNA was higher than in the adults, but P-Selectin increase was smaller. We speculate that the induction of some CAMs during hyperoxia could be beneficial by promoting the healing process.

Outcome of neonates transported between Level III centres depends upon centre of care

This study aimed to clarify whether the adverse outcomes seen in babies transported between New Zealand Level III intensive care nurseries were due to the transport itself or to possible differences in care in different centres. The outcomes of 34 infants inborn at National Women's Hospital, Auckland but transported to other centres were compared with those of 68 matched controls inborn at the receiving centres and with 68 controls inborn and cared for at National Women's Hospital. Transport was associated with a transient (non-significant) deterioration in respiratory status but no increase in chronic lung disease. However, infants cared for elsewhere, whether transported or control, had more periventricular hemorrhage than Auckland babies (23% and 29% vs 15%, P = 0.03) and worse neurodevelopmental outcome (70% and 66% vs 88% of those whose outcomes were known were normal at follow up, P = 0.002). We conclude that differences in care between centres may be more important than the transport itself in determining the long-term outcome of transported neonates.

Nosocomial adenovirus infection

Nosocomial transmission of adenovirus type 3 associated with fatalities in infants has not been frequently reported. This report describes the nosocomial spread of adenovirus types 2 and 3 among infants with bronchopulmonary dysplasia in a chronic (transitional) care facility. The index case developed pneumonia with a clinical deterioration in respiratory status 8 days after admission. Within the next 10 to 30 days 9 other infants and 2 health care personnel became ill with respiratory symptoms. Three of these 10 infants had progressive respiratory failure and 2 of them died. All of these infants had underlying chronic lung disease of bronchopulmonary dysplasia. The overall attack rate was 30% (10 of 33). Further spread of adenovirus was prevented by using barrier precautions and masks while performing tracheostomy care. Adenovirus isolates were serotyped as Ad3 in 4 patients and 1 staff member, as Ad2 in 3 patients, and as a combination of Ad2 and Ad3 in 1 patient. Two fatalities were associated with Ad3 infection. Three isolates from 2 patients and 1 staff member were not available for typing. Restriction endonuclease analysis was performed on all of these isolates of Ad3 and Ad2. There was no genetic heterogeneity in the isolates, suggesting a common source.

Chest radiograph scoring system for use in preterm infants

We thank I. Hyde for this interest in our paper (Yuksel et al. 1991). Two of our patients had undergone lobectomy for gross cystic degeneration following localized severe pulmonary interstitial emphysema. Both infants were ventilator-dependent at the time of lobectomy with deteriorating blood gases. As a consequence of this deterioration in respiratory status it was decided that they should undergo lobectomy following which their respiratory status improved and it was possible to extubate the infants.

Delayed Presentation of a Right-Sided Diaphragmatic Hernia and Group B Streptococcal Sepsis

Group B streptococcal sepsis was associated with delayed presentation of an unsuspected right-sided diaphragmatic hernia in two neonates. These unusual clinical observations and a review of 24 similar cases from the literature form the basis of this report. Infants present with respiratory distress during the first few hours of life and have group B streptococcal sepsis confirmed by results of blood cultures. The right side of the diaphragm appears normal on the initial chest roentgenogram in the majority of cases. After initial improvement with antibiotic therapy and ventilatory support, sudden deterioration of respiratory status may occur. Subsequent chest roentgenograms often demonstrate herniated viscera in half of the cases, while ultrasound examination, isotopic liver scan, and peritoneography are useful in achieving a diagnosis in the other cases. If recognized, survival is 100% following hernia repair. Persistent respiratory symptoms in a neonate who is recovering from group B streptococcal sepsis should prompt a careful evaluation of the right side of the diaphragm for the presence of an unsuspected posterolateral hernia.

Unusual Clustering of Allergic Bronchopulmonary Aspergillosis in Children With Cystic Fibrosis

Allergic bronchopulmonary aspergillosis has been recognized in association with cystic fibrosis in children since 1965. Since then, however, there have been a paucity of reports of pediatric cystic fibrosis complicated by allergic bronchopulmonary aspergillosis, and, in most cases, these have been diagnosed retrospectively. A cluster of five acute cases seen during a 4-month period in a single cystic fibrosis center with a systemic illness and deterioration in respiratory status are described. In all five patients, reversible bronchoconstriction and infiltrative changes on x-ray films suggested the diagnosis. This was confirmed by the presence of (1) peripheral blood eosinophilia, (2) elevated total IgE and Aspergillus fumigatus-specific IgE, and (3) circulating serum precipitins against A fumigatus in all cases. All children tested had positive type 1 immediate hypersensitivity to skin tests for A fumigatus, in sputum eosinophilia, and Aspergillus cultured from sputum. Only three of five children were previously noted to be atopic and none had severe advanced suppurative lung disease. All children had previously received bronchodilator therapy and appropriate antibiotics. Following treatment with corticosteroids, acute symptoms and radiologic changes resolved for 1 to 5 months. To date, no children have had recurrence of their allergic bronchopulmonary aspergillosis while receiving alternate-day steroid treatment for 6 months.

Survival and prognostic factors in severe Pneumocystis carinii pneumonia requiring mechanical ventilation.

Severe Pneumocystis carinii pneumonia (PCP) necessitating mechanical ventilation has been associated with a high mortality rate in several previous studies. This has discouraged physicians from recommending, as well as patients from accepting, mechanical ventilation when respiratory failure developed. Analysis of 19 records of patients with first episode PCP who were intubated and received mechanical ventilation showed a mortality of 57.8%. A constellation of clinical and laboratory findings was found that identified those patients more likely to survive, including a shorter duration of symptoms prior to admission, better arterial oxygenation on admission, deterioration of respiratory status soon after bronchoscopy, decrease in serum lactic acid dehydrogenase and rapid improvement in arterial blood gas determinations after institution of mechanical ventilation. Mean survival for the group that recovered from PCP after mechanical ventilation was not different from that of other patients with PCP who did not require mechanical ventilation. Thus, patients at risk for PCP should be advised to present to medical facilities as soon as symptoms of this disease develop and, when appropriate, should be encouraged to undergo intubation with respiratory support if it becomes necessary.

PNEUMOCYST1S CARINII PNEUMONIA IN CHILDREN WITH HIV INFECTION

Thirteen HIV infected patients with pneumonitis (9/13, less than 1 year of age) underwent 16 invasive diagnostic procedures to determine the etiology of their pulmonary disease. Procedures were: Open lung biopsy (OLB) in 7 patients (one patient had 2 OLBs), bronchial lavage (BL) in 7 patients and bronchoscopy in 1 patient. OLB was diagnostic 8/8 times, (6 were PCP and 2 were lymphoid interstitial pneumonia). OLB was associated with chest tube placement, continued intubation and ventillation in all 8 patients and two patients had dramatic deterioration in respiratory status at the time of OLB. 2/8 patients died, one related to PCP. Bronchoscopy was non-diagnostic in the one patient. This patient who had bronchoscopy developed laryngospasm requiring intubation and ventilatory support. Because of the morbidity associated with these procedures, in November, 1985, we began performing BL through an endotracheal tube by instilling and suctioning 10-15 cc's of saline through a suction catheter wedged in a small bronchus. The lavage material was cytocentrif uged and stained with Grocott and Diff Quik staining methods. 5/7 specimens were positive for PCP. In the 2 which were negative, PCP was diagnosed by OLB within 24 hours in 1 patient and the second patient had no evidence of PCP at autopsy, 4/7 were intubated, 2 prior to lavage for worsening respiratory status and 3/7 subsequently died, 1 of these deaths was related to PCP. BL is a successful and less invasive alternative for the diagnosis of PCP. It's use as the initial diagnostic procedure for pneumonitis may obviate the need for OLB.

Polypoid cervicitis in cystic fibrosis patients receiving oral contraceptives

Three of the 4 women in a cystic fibrosis clinic who used a combined form of oral contraceptive developed acute polypoid cervicitis. In one woman, the polyp recurred on reinstitution of the medication. There was resolution of the polyp in each instance on discontinuation of the drugs. In 2 of the 3 affected women, there was coincidental deterioration of respiratory status. Therefore, it is suggested that cystic fibrosis patients who are using oral contraception be observed closely regarding pulmonary and gynecologic status.