Diagnosis Of Acute Respiratory Failure Research Articles

Diffuse Alveolar Hemorrhage Following Allogeneic Bone Marrow Transplantation in Children

Diffuse alveolar hemorrhage (DAH) is a frequent life-threatening complication of bone marrow transplantation (BMT) in adults. This noninfectious pulmonary disorder is rarely reported following BMT in neonates and children. To review the clinical features and course of children who underwent allogeneic BMT and developed DAH in the posttransplant period. A retrospective 6-year chart review. Pediatric ICU in a university hospital. At total of 138 children who had undergone allogeneic BMT for nonmalignant (n = 66) or malignant (n = 72) diseases. Six of 138 children (4.3%) aged 2 months to 10 years (male/female ratio, 1:1) developed DAH. Each had a fulminant course with rapidly developing severe respiratory failure, mandating mechanical ventilation within 24 h following symptom onset. They were all treated with methylprednisolone, 6 mg/kg/d for 3 days. Only one child survived, and there have been no sequelae at 2 years post-BMT. Four children died of respiratory causes, and one died of multiorgan failure. DAH is a potentially fatal respiratory complication that should be included early in the differential diagnosis of acute respiratory failure in children following allogenic BMT for both malignant and nonmalignant diseases. Therapy with high doses of steroids apparently do not affect the course of the disease.

Intensive care for very elderly patients: outcome and risk factors for in-hospital mortality.

To evaluate outcome and risk factors, particularly the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, for in-hospital mortality in very elderly patients after admission to an intensive care unit (ICU). Retrospective chart review of patients > or =85 years admitted to the ICU. We recorded age, sex, previous medical history, primary diagnosis, date of admission and discharge or death, APACHE II score on admission, use of mechanical ventilation and inotropics, and complications during ICU admission. 104 patients > or =85 years (1.3% of all ICU admissions) were studied. The ICU and in-hospital mortality rates for these patients were 22 and 36% respectively. Factors correlated with a greater in-hospital mortality were: an admission diagnosis of acute respiratory failure (chi2; P = 0.007), the use of mechanical ventilation (chi2; P = 0.00005) and inotropes (chi2; P = 0.00001), complications during ICU admission (chi2; P = 0.004), in particular acute renal failure (chi2; P = 0.005), and an APACHE II score > or =25 (chi2; P = 0.001). The APACHE II scoring system and the use of inotropes were independently correlated with mortality. ICU and in-hospital mortality are higher in very elderly patients, particularly in those with an APACHE II score > or =25. The most important predictors of mortality are the use of inotropes and the severity of the acute illness.

Coronavirus Pneumonia Following Autologous Bone Marrow Transplantation for Breast Cancer

Infectious bronchitis virus, otherwise known as coronavirus, can cause mild upper respiratory tract illnesses in children and adults. Rarely has coronavirus been linked, either by serology or nasal wash, to pneumonia. We report a case of a young woman who, following treatment for stage IIIA breast cancer using a high-dose chemotherapy regimen followed by autologous bone marrow and stem cell transplantation, developed respiratory failure and was found to have coronavirus pneumonia as diagnosed by electron microscopy from BAL fluid. We propose that coronavirus should be considered in the differential diagnosis of acute respiratory failure in cancer patients who have undergone high-dose chemotherapy and autologous hematopoietic support.

Factors Associated With Change in Resuscitation Preference of Seriously Ill Patients

Background: During serious illness, patient preferences regarding life-sustaining treatments play an important role in medical decisions. However, little is known about life-sustaining preference stability in this population or about factors associated with preference change. Methods: We evaluated 2-month cardiopulmonary resuscitation (CPR) preference stability in a cohort of 1590 seriously ill hospitalized patients at 5 acute care teaching hospitals. Using multiple logistic regression, we measured the association of patient demographic and health-related factors (quality of life, function, depression, prognosis, and diagnostic group) with change in CPR preference between interviews. Results: Of 1590 patients analyzed, 73% of patients preferred CPR at baseline interview and 70% chose CPR at follow-up. Preference stability was 80% overall—85% in patients initially preferring CPR and 69% in those initially choosing do not resuscitate (DNR). For patients initially preferring CPR, older age, non—African American race, and greater depression at baseline were independently associated with a change to preferring DNR at follow-up. For patients initially preferring DNR, younger age, male gender, less depression at baseline, improvement in depression between interviews, and an initial admission diagnosis of acute respiratory failure or multiorgan system failure were associated with a change to preferring CPR at follow-up. For patients initially preferring DNR, patients with substantial improvements in depression score between interviews were more than 5 times as likely to change preference to CPR than were patients with substantial worsening in depression score. Conclusions: More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments. Arch Intern Med. 1996;156:1558-1564

Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

During serious illness, patient preferences regarding life-sustaining treatments play an important role in medical decisions. However, little is known about life-sustaining preference stability in this population or about factors associated with preference change. We evaluated 2-month cardiopulmonary resuscitation (CPR) preference stability in a cohort of 1590 seriously ill hospitalized patients at 5 acute care teaching hospitals. Using multiple logistic regression, we measured the association of patient demographic and health-related factors (quality of life, function, depression, prognosis, and diagnostic group) with change in CPR preference between interviews. Of 1590 patients analyzed, 73% of patients preferred CPR at baseline interview and 70% chose CPR at follow-up. Preference stability was 80% overall-85% in patients initially preferring CPR and 69% in those initially choosing do not resuscitate (DNR). For patients initially preferring CPR, older age, non-African American race, and greater depression at baseline were independently associated with a change to preferring DNR at follow-up. For patients initially preferring DNR, younger age, male gender, less depression at baseline, improvement in depression between interviews, and an initial admission diagnosis of acute respiratory failure or multiorgan system failure were associated with a change to preferring CPR at follow-up. For patients initially preferring DNR, patients with substantial improvements in depression score between interviews were more than 5 times as likely to change preference to CPR than were patients with substantial worsening in depression score. More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments.

Evaluation of definitions for adult respiratory distress syndrome.

We conducted a cohort study of 423 intensive care unit (ICU) admissions with a primary clinical diagnosis of acute respiratory failure, a PaO2/FIO2 on ICU admission of < 300 mm Hg, and an ICD-9 discharge diagnosis of adult respiratory distress syndrome (ARDS) (518.5 or 518.82) drawn from a nationally representative database of 17,440 ICU admissions to evaluate current and proposed revisions for definitions of ARDS. A variety of nonpulmonary physiologic risk factors, from shock to elevated serum bilirubin measurements, were significant (p < 0.01) for hospital mortality. Multivariable analysis using the admission APACHE III score, primary ICU admission diagnosis, and treatment location before ICU admission provided greater accuracy in prediction (ROC = 0.80) than the individual PaO2/FIO2 (ROC = 0.68). Patients were given an individual risk of hospital mortality based on their admission APACHE III score, treatment location before ICU admission, and ICU admitting diagnosis. Dividing the patient population into groups using a PaO2/FIO2 < or = 150 resulted in a wide range of individual risk for hospital mortality, from < 10 to > 90% in both groups. We conclude that ARDS is a complex clinical entity with a variety of pulmonary and nonpulmonary risk factors for both its development and its prognosis. Current and proposed categorical definitions based on the severity of hypoxemia result in a wide distribution of individual patient risks. Use of these findings in the design and conduct of future clinical trials would improve the evaluation of new therapies.

Familial infantile myasthenia: a neuromuscular cause of respiratory failure

Acute respiratory failure can be the product of any of a great number of muscular, neuromuscular, and neurologic causes. The family history may be extremely helpful in narrowing the differential diagnosis. We report the case of a girl who, during the course of a slight upper respiratory infection, presented with acute respiratory failure requiring mechanical ventilation. The family history was significant for a brother who had arthrogryposis and died at 15 h of life, also from respiratory failure. The patient herself had a history of palpebral ptosis in the evening. The absence of electromyographic and muscle biopsy abnormalities and the patient's positive response to anticholinesterase therapy supported the diagnosis of familial infantile myasthenia. We emphasize the importance of considering the myasthenic syndromes in the differential diagnosis of acute respiratory failure, since appropriate therapy can rapidly resolve the symptoms. Furthermore, an accurate diagnosis allows appropriate genetic counseling for the hereditary forms.

Fatal nonthyroidal illness may impair nocturnal thyrotropin levels

purpose: This study was undertaken to assess whether circadian variation of thyrotropin (TSH) is affected by the severity of a nonthyroidal illness. patients and methods: On the second day of admission to a medical intensive care unit, 20 consecutive patients with the major diagnosis of acute respiratory failure underwent TSH measurements at 8 A.M., 9 P.M., 11 P.M., and 1 A.M., with two sensitive assays. results: Six patients died, five of whom had hypothyroxinemia (thyroxine [T 4] less than 5.5 μg/dL) (83%) on the day of the study, whereas only three of the 14 survivors had low T 4 (21%; p <0.05). Baseline 8 A.M. TSH measured with the two assays was similar in both groups and there was a progressive increase in TSH in survivors and a decrease in nonsurvivors at 9 P.M. and 11 P.M. However, the difference at these time points was not statistically significant. At 1 A.M., TSH levels were significantly lower among nonsurvivors (0.75 ± 0.34 μU/mL with assay 1, and 0.7 ± 0.4 μU/mL with assay 2) than in survivors (2.3 ± 0.46 μU/mL with assay 1, and 2 ± 0.5 μU/mL with assay 2; p <0.005; Wilcoxon test). Five of the nonsurvivors and none of the survivors had a suppressed 1 A.M. TSH level (p <0.001), suggesting a good correlation between suppressed 1 A.M. TSH and mortality. After exclusion of patients receiving drugs known to affect TSH levels (two nonsurvivors and four survivors), the same dissociation in TSH changes was observed, and significantly lower 1 A.M. TSH levels were observed in nonsurvivors than in survivors (0.13 ± 0.08 μU/mL versus 2.7 ± 0.6 μU/mL with assay 1; p <0.01). Cortisol levels were significantly higher only at 8 A.M. in nonsurvivors whether patients receiving drugs were included in the analysis (41.6 ± 3.2 versus 28.4 ± 2.7 μU/mL; p <0.01) or not (45.3 ± 4.6 versus 30.5 ± 3.6 μU/mL; p <0.01). At other times, cortisol levels were similar in both groups. The 24-hour TSH areas under the curve were also lower in nonsurvivors than in survivors whether patients receiving drugs known to affect TSH levels were included or not. However, cortisol areas under the curve were similar in both groups. conclusion: It is concluded that fatal illness is associated with a suppression of the late night TSH surge.

Mechanical Ventilatory Support

The pathophysiology and differential diagnosis of acute respiratory failure are elucidated. The authors discuss mechanical ventilation at length, giving practical advice on the application of positive end-expiratory pressure, on weaning from the ventilator, and on the patient who is fighting the ventilator. Suggestions for the rapid treatment of hypoxia and hypercarbia are also given.

Normal values of functional residual capacity in the sitting and supine positions.

The measurement of functional residual capacity (FRC) has assumed new importance in the diagnosis of acute respiratory failure. However few reference values exist for FRC in supine positions for both sexes. We measured the FRC in 100 healthy subjects with the helium dilution closed circuit method in the sitting and supine positions. There were 50 women aged 20 to 63 years and 50 men aged 22 to 65 years. Fifty five subjects were smokers (25 women and 30 men) but no significant differences were found between FRC of smokers and nonsmokers. The FRC always decreased when the subject changed from the sitting to supine position. In this study, the correlation coefficients between FRC and height were statistically significant for both sexes, the influence of age and weight on FRC being negligible. Our results provide useful reference values for FRC in the supine position.

Acute Respiratory Failure in Infants and Children

Lack of published data on morbidity in relation to the treatment of respiratory failure in the pediatric age group, points up the need for agreement upon certain criteria for the diagnosis of acute respiratory failure in this age group and for a multi-institutional assessment of the effectiveness of intensive respiratory care in reducing the morbidity and mortality associated with respiratory failure.