Diffuse Bilateral Infiltrates Research Articles

Patterns of Chest Radiographic Findings in Neonates with Respiratory Distress Admitted to the Neonatal Intensive Care Unit in Tikur Anbesa Specialized Hospital

Background: Neonatal respiratory distress accounts for most admissions to intensive care units in the immediate newborn period. Chest radiograph is the primary and most important imaging modality in the evaluation of causes of respiratory distress (RD) and its complications. Methodology: A cross-sectional study was conducted from October 2011 to August 2012 in Tikur Anbessa Specialized Hospital (TASH). A convenient sampling method was used and 150 neonates who had chest radiographs with different causes of RD from the neonatal ICU admissions were included in the study period. Result: Of the 150 neonates with RD, chest radiographs showed 66(44%) neonates had abnormal chest radiographic findings. Pneumonia 24(36.4%) and HMD 23(34.8%) accounting the majority of causes of RD. Neonates with congenital pneumonia presented with lobar or multi lobar asymmetric consolidation in 18(75%) neonates followed by fine diffuse, bilateral, symmetrical reticulogranular and reticulonodular infiltrates with normal lung volume in 6(25%) neonates. All 23 neonates with HMD presented with fine, diffuse, bilateral reticular or reticulogranular infiltrates with decreased lung volume. There is no significant association between independent variables like maturity of neonates, premature rupture of membrane (PROM), prolonged labor or route of delivery with either clinical or radiological diagnosis of causes of RD in neonates. all 23 neonates with HMD presented with fine diffuse bilateral reticular or reticulogranular infiltrates with decreased lung volumes. There is no significant association between independent variables like maturity of neonates, premature rupture of membrane (PROM), prolonged labor or route of delivery with either clinical or radiological diagnosis of causes of RD in neonates. Conclusion: The study showed HMD and infections (EONS, pneumonia) were the most common causes of RD in neonates and most other researches also show comparable results of causes and radiographic findings of RD in neonates.

PO-0301 Non-invasive Mechanical Ventilation (nimv) In A Case Of Severe Acute Respiratory Distress Syndrome (ards) Due To Fat Embolism Syndrome (fes)

Background FES is a rare complication of long bone fracture in children and adolescents. Mortality ranges from 1%-15%. Typical presentation: hypoxemia, neurological abnormality and petechial rash. FES and thoracic trauma are known causes of ARDS. NIMV is being increasingly used in respiratory failure. Aim To report the intensive care management of a previously healthy 16-year-old male who developed severe ARDS. Methods The patient was transferred to our Paediatric Intensive Care Unit, because of respiratory distress, 2 h after being submitted to intra medullary nailing of left femur, for a closed diaphyseal fracture post motorcycle accident. Upon admission, patient was oriented, hemodynamically stable and manifested hemoptysis and hypoxemic respiratory failure –pO 2 /FiO 2 = 88,6 mmHg, Alveolar-arterial gradient (AaG)= 572 mmHg (normal= 5,9 mmHg)- not responding to supplemental O 2 through a nonrebreathing face mask with reservoir. Chest X-ray: diffuse bilateral infiltrates. ECG and transthoracic echocardiogram : normal. Blood analysis: anaemia, thrombocytopenia, hypoalbouminemia, hypocalcaemia hypophosphatemia, CPK total 6870 IU/L (CK-MB normal) and d-Dimers 12450 (normal 2 O, Peep 10 cm H 2 O, FiO 2 0.7) Petechial rash on trunk appeared later, confirming FES diagnosis. Additional treatment: RBC transfusion, methylprednisolone 60 mg/day, stress-ulcer prophylaxis, sbc LMWH, antibiotic and nutritional support. Results Patient improved and was gradually weaned from NIMV 7 days later. Conclusion NIMV has fewer complications and may be effective even in severe ARDS.

Protocolo diagnóstico del síndrome de hemorragia alveolar difusa

Diffuse alveolar hemorrhage (HAD) is a clinical syndrome of rapidly progressive establishment, usually poor prognosis, requiring swift action and aggressive management due to its high morbidity and mortality and has its origin in a variety of diseases. Is clinically defined by the presence of hemoptysis, anemia, and bilateral diffuse alveolar infiltrates on chest radiograph and hypoxemia. Histopathological findings include the presence of red blood cells in the alveoli and hemosiderin detection macrophages 48–72 hours after hemorrhage. It can be classified by their histology in pulmonary capillaritis without bleeding, and bleeding from diffuse alveolar damage, the first being the most frequent cause. A thorough history and detailed physical examination, blood tests, serology for hepatitis B and C and the determination of antibodies specific for connective tissue diseases and systemic vasculitis are needed to guide the etiological diagnosis. Confirmation of the diagnosis of HAD to be established by the early completion of bronchoscopy and findings in bronchoalveolar lavage (BAL) when the material obtained after aspiration is progressively hemorrhagic. The mainstay of treatment is corticosteroids, immunosuppressants and plasmapheresis, in some cases.

Complications of Oral Anticoagulant Therapy in over 65 Years, a Case Report

Case description: Woman, 79 years old. Medical history: hypertension, Atrial fibrillation (AF) permanent treated with acenocoumarol and mitral insufficiency. Barthel 90, Lowton-Brody. 2. The patient came to the emergency room for rib pain (musculoskeletal) in last two weeks, without other symptoms. We initiated analgesia and the patient was discharged. She came back with new symptoms: epistaxis and dyspnea. Exploration and complementary tests: cardio-pulmonary auscultation arrhythmic tones with sternal border systolic murmur left, crakling sounds in the lungs, with decreased breath sounds. Chest x-ray: right hilar mass with right pleural thickening, and diffuse bilateral infiltration. CBC: hemoglobin 7.9 g/dl (First: 11.6 g/dl), WBC 11.57x10l. Biochemistry: PCR 72.90 mg/l, urea 85 mg/l. Coagulation: INR undetermined, activity prothrombin <12.5%. Diagnosis: bilateral alveolar hemorrhage. Diagnosis Differential: bilateral alveolar hemorrhage, bilateral pneumonia, heart failure congestive (Acute Lung Edema). Conclusion: 0.5% of the population uses oral anticoagulants, between 6.8-11.1% by FA an INR>, increases the risk of bleeding. This is a patient with multimorbidity, moderately dependent, with poor treatment compliance and anticoagulation control. Given these data (anemia, no signs of infection or heart failure), and the test results, we opted for the first possibility alveolar hemorrhage diagnosed.

Complications of Oral Anticoagulant Therapy in over 65 Years, a Case Report

Case description: Woman, 79 years old. Medical history: hypertension, Atrial fibrillation (AF) permanent treated with acenocoumarol and mitral insufficiency. Barthel 90, Lowton-Brody. 2. The patient came to the emergency room for rib pain (musculoskeletal) in last two weeks, without other symptoms. We initiated analgesia and the patient was discharged. She came back with new symptoms: epistaxis and dyspnea. Exploration and complementary tests: cardio-pulmonary auscultation arrhythmic tones with sternal border systolic murmur left, crakling sounds in the lungs, with decreased breath sounds. Chest x-ray: right hilar mass with right pleural thickening, and diffuse bilateral infiltration. CBC: hemoglobin 7.9 g/dl (First: 11.6 g/dl), WBC 11.57x10l. Biochemistry: PCR 72.90 mg/l, urea 85 mg/l. Coagulation: INR undetermined, activity prothrombin <12.5%. Diagnosis: bilateral alveolar hemorrhage. Diagnosis Differential: bilateral alveolar hemorrhage, bilateral pneumonia, heart failure congestive (Acute Lung Edema). Conclusion: 0.5% of the population uses oral anticoagulants, between 6.8-11.1% by FA an INR>, increases the risk of bleeding. This is a patient with multimorbidity, moderately dependent, with poor treatment compliance and anticoagulation control. Given these data (anemia, no signs of infection or heart failure), and the test results, we opted for the first possibility alveolar hemorrhage diagnosed.

ABSTRACT 496

Background and aims: Idiopathic pulmonary hemosiderosis (IPH) may occasionally be associated with coeliac disease (CD); this association is known as the Lane-Hamilton syndrome, first reported in 1971 in a young adult. Aims: Since then a few cases have been reported in literature. Methods: Case presentation. Results: A four year old boy presented to us with history of respiratory distres and an episode of hemoptysis. Anamnestic there were no medical problems, despite pallor and prolonged fatique. On auscultation, end inspiratory rales are heard. Investigation showed a hemoglobin level of 2.2 g/dl. Chest radiograph showed bilateral diffuse alveolar infiltrates over middle and lower zones. On fallow up he got respiratory failure and he was ventilated with low tidal volume ventilation. The lung biopsy showed haemosiderin laden macrophages in the alveolar spaces. Since an assosiation between CD and IPH has been previously described a workup for CD was also performed. Positive IgA endomysial antibody (1/320 titer) and IgA antigliadin antibody levels were detected. Duodenal biopsy showed partial villous atrophy and increased numbers of intra-epithelial lymphocytes, confirming the diagnosis of CD. Immunosuppressive therapy and gluten free diet was started. The patient was extubated after 26 days of invasive ventilation and he was put on non invasive ventilation. He was discharged after a hospital day of 48 days. During 1 years of fallow -up he had no occurance episodes of intrapulmonary hemorrhage. Conclusions: In conclusion, IPH and CD may have a common pathogenetic link and patients with IPH should be screened for CD even in the absence of gastrointestinal symptoms.

Late onset interstitial pneumonia induced by bepridil: A case report

A 63-year-old man was prescribed bepridil for paroxysmal atrial fibrillation in May 2011. He was referred to our hospital with the chief complaint of slight dyspnea in October 2012. Radiography and computed tomography indicated diffuse bilateral peribronchial infiltration. Since an examination of the bronchial alveolar lavage fluid revealed inflammatory lymphocytes and a drug lymphocyte stimulation test was strongly positive for bepridil, he was diagnosed with bepridil-induced interstitial pneumonia. In our case, the patient developed dyspnea 517 days after beginning bepridil treatment. Here, we describe an extremely rare case of late onset interstitial pneumonia induced by bepridil.

Revisiting opioid overdose induced acute respiratory distress syndrome

Sir, Opioids are commonly used analgesic drug class with morphine like activity. Although respiratory system is the most affected organ system in opioid overdose; acute lung injury and acute respiratory distress syndrome (ARDS) are infrequently reported. A 25-year-old male presented after ingesting unknown amounts of hydrocodone. Patient was found to be unresponsive, with agonal respiration. Initial vital signs showed blood pressure 100/60 mmHg, pulse 110 beats/min, respiratory rate 8 breaths/min and oxygen saturation (SpO2) of 70%. Chest examination revealed decreased air entry bilaterally with bibasal crackles. Initial arterial blood gas (ABG) analysis showed respiratory acidosis with pH 7.22, partial pressure of carbon dioxide (PaCO2) at 70 mmHg, partial pressure of oxygen (PaO2) at 42 mmHg and SpO2 of 72%. An emergent orotracheal intubation was performed due to severe hypoxemia and to maintain a patent airway. Pink frothy secretions were seen in the endotracheal tube immediately after intubation and a chest radiograph showed diffuse bilateral infiltrates [Figure 1]. Mechanical ventilation was started at assist control mode with initial tidal volume of 500 ml, fraction of inspired oxygen (FiO2) at 100% and positive end expiratory pressure (PEEP) at 5 cm H2 O. Patient remained hypoxemic and repeat ABG analysis showed partial pressure of PaO2 42 mm Hg and SpO2 80% prompting increase in the PEEP up to 10 cm H2O, which improved PaO2 to 85 mm Hg. Based on initial PaO2/FiO2 ratio of 52 and characteristic radiographic bilateral opacities, severe ARDS was diagnosed. An echocardiogram showed normal left ventricular function and serum levels of brain natriuretic peptide (BNP) was normal at 88 pg/ml. Lung protective ventilation to achieve adequate oxygenation was continued. Furosemide was given to maintain a negative fluid balance. Patient could be successfully extubated on the 2nd day. Chest radiograph on day 3 showed complete resolution of ARDS [Figure 2]. Figure 1 An antero-posterior chest radiograph demonstrating diffuse pulmonary edema in the intubated patient Figure 2 A postero-anterior chest radiograph in the same patient 48 h later demonstrates complete resolution of the pulmonary edema Opioid overdose has been implicated as a cause of ARDS.[1] Sporer and Dorn described 27 patients of non-cardiogenic pulmonary edema (NCPE) secondary to heroin overdose.[2] Overall, clinical presentation of opioid-induced ARDS is generally indistinguishable from other causes of ARDS. Presence of frothy, sometimes blood tinged pulmonary secretions and bilateral diffuse infiltrates on chest radiograph are characteristic. Occasionally, it may be necessary to demonstrate normal cardiac pump function through measurements of serum BNP levels, echocardiogram and rarely right heart catheterization. The mechanisms behind opioid induced NCPE and ARDS remain largely unknown. The role of increased pulmonary capillary permeability due to hypoxemia, potent histamine release and respiratory acidosis caused by depression of medullary respiratory centers have been implicated.[3,4] Interestingly, the use of reversal agents like naloxone itself has also been described as the primary cause of pulmonary edema.[5] Patients with opioid-induced NCPE and ARDS can have severe hypoxemia frequently needing invasive mechanical ventilation. An early orotracheal intubation should be considered in obtunded or severely hypoxemic patients. Following intubation, general management strategies used in any form of ARDS comprising of lung protective strategies of ventilation, appropriate PEEP and diuretics are used. Overall prognosis remains good with most patients recovering within 24 h. In summary, our case demonstrates an infrequently seen respiratory complication in opioid overdose. Timely management decisions about adequate use of reversal agents and considering early mechanical ventilation in severely hypoxemic patients can be lifesaving.

Surgical lung biopsy to diagnose Behcet's vasculitis with adult respiratory distress syndrome.

A 34-year-old female presented with fever and abdominal pain. Past medical history includes Crohn's and Behcet's disease. Examination revealed multiple skin ulcerations, oral aphthae, and bilateral coarse rales. She developed respiratory distress with diffuse bilateral alveolar infiltrates on chest radiograph requiring intubation. PaO2/FiO2 ratio was 132. The chest computed tomography revealed extensive nodular and patchy ground-glass opacities. Bronchoalveolar lavage demonstrated a predominance of neutrophils. Methylprednisolone 60 mg every 6 h and broad-spectrum antimicrobials were initiated. No infectious etiologies were identified. Surgical lung biopsy demonstrated diffuse alveolar damage (DAD) mixed with lymphocytic and necrotizing vasculitis with multiple small infarcts and thrombi consistent with Behcet's vasculitis. As she improved, steroids were tapered and discharged home on oral cyclophosphamide. Pulmonary involvement in Behcet's is unusual and commonly manifests as pulmonary artery aneurysms, thrombosis, infarction, and hemorrhage. Lung biopsy findings demonstrating DAD are consistent with the clinical diagnosis of adult respiratory distress syndrome. The additional findings of necrotizing vasculitis and infarcts may have led to DAD.

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Introduction: Chlorine is an irritant gas that is commonly used for water treatment and as part of household bleach. We present a case of ARDS in a homemaker secondary to household use of chlorine-based bleach. Case Presentation: A 46-year-old African-American woman presented to the emergency room with 1-day history of rapidly progressive dyspnea after using a relatively higher than usual amount of bleach with poor ventilation at home. In the past, she used to have some fatigue after use of this bleach which resolved over few hours. On examination, she was in obvious respiratory distress with tachycardia, tachypnea and oxygen saturation at 79% on ambient air. She had diffuse coarse crackles bilaterally on lung auscultation, but no wheezing. Arterial blood gas analysis showed a pH of 7.41, pCO2 of 37 and pO2 of 66 on FiO2 of 40% (PaO2/FiO2 ratio of 165). CT scan of the chest showed bilateral diffuse interstitial infiltrates and multifocal patchy areas of solid consolidation, both worse in upper lung zones. She was admitted to the intensive care unit and was started on intravenous steroids for presumed acute inhalation lung injury. Her hypoxia and dyspnea improved over the next 2 days and she was discharged on day 4 of hospitalization with a slow prednisone taper starting at 40 mg daily over 1 month and supplemental oxygen at rest and activity. At 1-month follow up, her oxygen saturation was normal at 100% on ambient air. Repeat CT chest at 2-month follow up showed complete resolution of previously seen infiltrates. Discussion: The usual description of accidental chlorine injury is reactive airway dysfunction syndrome, while non-cardiogenic pulmonary edema and ARDS have been reported in association with high levels of exposures such as transportation accidents, industrial or swimming pool spills. Our case is rare as the patient had a near-fatal presentation from household exposure to bleach which she has otherwise been using in the past. Both acute and chronic exposures to chlorine have been associated with airflow obstruction and bronchial airway hyperreactivity (AHR). Our patient did not show any evidence airflow obstruction on spirometry performed 4 weeks after the acute event. A methacholine challenge test was performed and it did not demonstrate any AHR as well. Animal models of high-dose chlorine exposure have shown that much of chlorine damage is oxidative in nature. There is histologic evidence of airway and alveolar epithelial damage and alveolar edema that usually resolves in 10 days. It is likely that genetic susceptibility to oxidative injury determines which patients would present with AHR versus alveolar damage. Conclusion: Household exposure to chlorine-based bleach may present with ARDS in susceptible individuals. Apart from a rare presentation of household chlorine exposure, this case also highlights the importance of detailed exposure history in the context of clinical presentation. Our patient had no recurrence of symptoms after switching to non-chlorine based bleach.

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Introduction: Transfusion Related Acute Lung Injury (TRALI) is a form of acute lung injury (ALI) seen after exposure to blood products. We present a case of respiratory failure secondary to TRALI in an 18 year old status post scoliosis surgery. We review the medical literature and present diagnostic criteria, pathophysiology and differential diagnosis of TRALI. An 18 year old male with severe spastic quadraparesis and scoliosis with scoliotic curve 80 degrees and restrictive lung disease without prior respiratory requirement was admitted to our pediatric critical care unit (PCCU) status post posterior spinal fusion of T2-S1. Operative course was significant for coagulopathy causing approximate blood loss of 2 liters requiring transfusion of 6 units of packed red blood cells, 4 units of fresh frozen plasma and 2 units of platelets. While in the recovery room his oxygen was easily weaned to a Fi02 of 40%. In the PCCU, he remained intubated and sedated. Three hours after arrival, he developed significant hypoxia with a PaO2/FiO2 ratio of less than 300 suggestive of ALI. His x-ray 4 hours post transfusion revealed diffuse bilateral infiltrates consistent with pulmonary edema and no cardiomegaly. His ventilator requirements significantly increased to a PEEP of 15 and FiO2 of 80% to maintain oxygen saturation above 90%. He remained afebrile and hemodynamics remained stable off vasoactive medications. There were no findings of infection. On post-operative day 2, he tolerated weaning of oxygen. His imaging revealed improvement of pulmonary edema. He was extubated successfully on post-operative day 3 and was transferred to the pediatric floor on postoperative day 4. Our patient met all the criteria for TRALI (acute onset ALI within 6 hours of exposure to blood products, bilateral pulmonary infiltrates and no evidence of fluid overload or cardiogenic pulmonary edema. Given his surgery he fits the two hit theory hypothesized as pathophysiology of TRALI. Non-immune mediated cases are thought to be due to bioreactive lipids and cytokines that accumulate during the storage of blood products. These are referred to as biologic response modifiers (BRM). The non-immune reaction is not caused solely by BRMs. The proposed hypothesis involves a preceding event presensitzing a patient's lungs and leukocytes to this transfusion reaction. This theory is often referred to as the two hit theory. The first hit includes a predisposing event such as infection, a malignancy or a surgery as in our patient above. This first hit activates neutrophils in the pulmonary endothelium. The second hit involves the transfused BRMs causing further neutrophil activation and endothelial damage. The mortality rate from TRALI ranges from 5% to 25%. Most patients recover within 72 hours; as did our patient. However, there have been cases of severe TRALI lasting about 7 days cited in the literature. Morbidity and mortality may be underappreciated because of lack of recognition and underreporting of this diagnosis. Since TRALI is a transient form of ALI, management is usually supportive with mechanical ventilatory support. The pulmonary infiltrates and hypoxemia usually resolve completely without sequelae.

Ceftaroline‐Induced Eosinophilic Pneumonia

We present a case of eosinophilic pneumonia due to ceftaroline used for the treatment of methicillin-resistant Staphylococcus aureus bacteremia associated with a postoperative spinal infection. Our patient developed shortness of breath and hypoxemia on the fifth week of ceftaroline therapy. Chest imaging disclosed diffuse bilateral infiltrates. Laboratory abnormalities included peripheral eosinophilia and eosinophilic predominant bronchoalveolar lavage fluid. The combination of ceftaroline discontinuation plus initiation of steroid treatment resulted in complete resolution of signs, symptoms, and radiologic abnormalities. We speculate about possible mechanisms underlying this adverse event and diagnostic criteria for drug-induced eosinophilic pneumonia.

Postobstructive pulmonary edema following accidental near-hanging.

Patient: Female, 14Final Diagnosis: Postobstructive pulmonary edenmaSymptoms: Chest indrawing • bilateral pulmonary crepitations • tachypneaMedication: —Clinical Procedure: Controlled ventilatory support • positive end expiratory pressureSpecialty: Intensive careObjective:Unusual clinical courseBackground:Postobstructive pulmonary edema (POPE) is a life-threatening complication that occurs after the relief of an upper airway obstruction. POPE occurs rarely in children, primarily after non-lethal hanging.Case Report:We report the case of a 14-year-old girl who developed POPE after accidental near hanging. She had chest in-drawing, the SpO2 was 81% on room air, and pulmonary auscultation revealed bilateral crepitations. The chest x-ray showed bilateral diffuse infiltrates consistent with pulmonary edema. The intensive care management consisted of controlled ventilatory support with high-level positive end expiratory pressure. On the third day of hospitalization, the patient was weaned from the ventilator and extubated with a full recovery.Conclusions:This case confirms the importance of early recognition of POPE and the value of adapted treatment, which can lead to a favorable outcome and full recovery in cases of near hanging.

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Case Reports: A 34 year old female with history of Behcet’s disease presented with fever and disabling abdominal and bilateral leg pain. Her history included Crohn’s disease as well as recurrent exacerbations of Behcet’s disease refractory to multiple immunosuppressive regimens. Examination revealed a left mandibular deep soft-tissue ulcer, multiple healed punched-out skin ulcerations, oral aphthae and bilateral coarse rales. On day 3 of hospitalization, she developed progressive hypoxia and respiratory distress requiring mechanical ventilation with diffuse bilateral alveolar infiltrates seen on chest radiograph. PaO2/FiO2 ratio was 132 mm Hg. Chest CT revealed extensive nodular and patchy ground-glass opacities. Bronchoalveolar lavage fluid demonstrated a predominance of neutrophils. Methylprednisolone 60 mg every 6 hours and broad-spectrum antibiotics were initiated. No infectious etiologies were identified. Surgical lung biopsy demonstrated diffuse alveolar damage mixed with lymphocytic and necrotizing vasculitis with multiple small infarcts and thrombi consistent with Behcet’s vasculitis. She began to show significant improvement and was extubated on day 11. Steroids were slowly tapered and she was started on oral cyclophosphamide to continue as an outpatient.We report a rare case of Behcet’s disease complicated by acute respiratory distress syndrome (ARDS). Behcet’s disease is a multisystem vasculitis involving blood vessels of all sizes and is characterized by recurrent mucocutaneous ulcers and uveitis. Although the disease can affect any organ, pulmonary involvement is unusual and most commonly manifests as pulmonary artery aneurysm, thrombosis, infarction and hemorrhage. ARDS with histopathologic confirmation in association with Behcet’s disease has only rarely been described. The findings on lung biopsy demonstrating diffuse alveolar damage are consistent with our clinical diagnosis of ARDS. The additional findings of necrotizing vasculitis and infarcts may have been the inciting insult which led to diffuse alveolar damage. To our knowledge, only one other case of ARDS secondary to Behcet’s disease with diffuse alveolar damage on biopsy has been described.

An innovative approach to predict the development of adult respiratory distress syndrome in patients with blunt trauma

Pulmonary contusion (PC) is a common injury associated with blunt chest trauma. Complications such as pneumonia and adult respiratory distress syndrome (ARDS) occur in up to 50% of patients with PC. The ability to predict which PC patients are at increased risk of developing complications would be of tremendous clinical utility. In this study, we test the hypothesis that a novel method that objectively measures percent PC can be used to identify patients at risk to develop ARDS after injury. Patients with unilateral or bilateral PC with an admission chest computed tomographic angiogram were identified from the trauma registry. Demographic, infectious, and outcome data were collected. Percent PC was determined on admission chest computed tomography using our novel semiautomated, attenuation-defined computer-based algorithm, in which the lung was segmented with minimal manual editing. Factors contributing to the development of ARDS were identified by both univariate and multivariable logistic regression analyses. ARDS was defined as PaO2/FiO2 ratio of less than 200 with diffuse bilateral infiltrates on chest radiograph with no evidence of congestive heart failure. Quantifying percent PC from our objective computer-based approach proved successful. We found that a contusion size of 24% of total lung volume or greater was most significant at predicting ARDS, which occurred in 78% of these patients. Such patients also had a significantly higher incidence of pneumonia when compared with those with contusions less than 24%. The specificity of contusion size of 24% or greater was 94%, although sensitivity was 37%; positive predictive value was 78%, and negative predictive value was 72%. We developed and describe a software-based methodology to accurately measure the size of lung contusion in patients of blunt trauma. In our analyses, contusions of 24% or greater most significantly predict the development of ARDS. Such an objective approach can identify patients with PC who are at increased risk for developing respiratory complications before they happen. Further research is needed to use this novel methodology as a means to prevent posttraumatic lung injury in patients with blunt trauma. Prognostic/epidemiologic study, level III; diagnostic study, level IV.

Role of computed tomography in the diagnosis of acute lung injury/acute respiratory distress syndrome

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a complex pulmonary pathology with high mortality rates, manifesting over a wide range of severity. Clinical diagnosis relies on the following 4 criteria stated by the American-European Consensus Conference: acute onset of impaired gas exchange, severe hypoxemia defined as a PaO2 to FiO2 ratio <300 (PaO2 in mmHg), bilateral diffuse infiltration on chest X-ray; pulmonary artery wedge pressure of ≤18 mmHg to rule out cardiogenic causes of pulmonary edema. The aim of this study was to determine the usefulness of CT in the diagnosis and management of this condition.

Bronchoscopic Lung Biopsy Using Noninvasive Ventilatory Support: Case Series and Review of Literature of NIV-Assisted Bronchoscopy

Fiberoptic bronchoscopy and lung biopsy are important diagnostic tools in patients with diffuse pulmonary infiltrates. However, these patients often have hypoxemic respiratory failure that makes this procedure hazardous. Noninvasive ventilation (NIV) has been shown to improve oxygenation in hypoxemic patients. To report the efficacy and safety of an innovative technique of NIV-assisted bronchoscopic lung biopsy in a small case-series of hypoxemic subjects with diffuse parenchymal infiltrates; also to systematically review the literature on NIV-assisted bronchoscopy. Subjects with bilateral diffuse parenchymal infiltrates and P(aO(2))/F(IO(2)) < 200 mm Hg underwent bronchoscopic lung biopsy under NIV support. NIV was initiated 10 min before the procedure and continued for 30 min after the procedure. The primary outcomes were performance of successful procedure and episodes of decline in S(pO(2)) < 90%. Secondary end points were the change in the respiratory and hemodynamic parameters during the procedure and occurrence of complications such as pneumothorax, hemorrhage, and endotracheal intubation. Six subjects, with a mean ± SD age of 44.5 ± 11.6 years, were included in the study. The median (interquartile range [IQR]) P(aO(2))/F(IO(2)) prior to lung biopsy was 164.5 mm Hg (146.3-176.3 mm Hg), and the median (IQR) inspiratory and expiratory positive airway pressures were 14 cm H(2)O (12-15 cm H(2)O) and 5 cm H(2)O. Fiberoptic bronchoscopy was well tolerated and all subjects maintained S(pO(2)) > 92% during the procedure. One subject required endotracheal intubation due to hemoptysis. A definite diagnosis was obtained in 5 of the 6 subjects. A repeat procedure was performed in one subject, which again yielded no diagnosis. No other periprocedural complications were encountered. NIV-assisted bronchoscopic lung biopsy is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.

Retrospective analysis of relationship between radiological features and prognoses of pneumocystis pneumonia in non-AIDS immunocompromised patients

To elucidate the relationship between the radiological features and prognoses of pneumocystis pneumonia (PCP) in non-acquired immunodeficiency syndrome (non-AIDS) immunocompromised patients. Retrospective analyses were performed for the radiological features and prognoses of 36 non-AIDS immunocompromised PCP patients hospitalized at Peking University First Hospital from April 2006 to April 2010. There were 24 males and 12 females with an average age of (51.7 ± 18.9) years. All patients underwent chest photographic examinations and chest computed tomography (CT) was performed on 29 of them. The overall case fatality rate (CFR) of 36 patients was 33.3% (12/36). At the start of anti-PCP treatment, there were normal chest radiography (n = 7), bilateral diffuse infiltration (n = 21), bilateral diffuse consolidation (n = 8), aerothorax, mediastinal emphysema or pneumohypoderma (n = 6) and numbers of deceased patients (n = 0, 8, 5 and 5 respectively). The CFRs of the patients with normal chest radiography and aerothorax, mediastinal emphysema or pneumohypoderma were both statistically significant as compared with the overall rate (P < 0.05). At the start of anti-PCP treatment, there were bilateral diffuse ground glass opacities (GGO) (n = 29), "mosaic sign" (n = 19), air bronchogram (n = 19), pulmonary consolidation (n = 17), bilateral pleural effusion (n = 7), thickened lobular septa (n = 6), cystic lesions (n = 5), aerothorax, mediastinal emphysema or pneumohypoderma (n = 4) and numbers of deceased patients (n = 8, 5, 5, 5, 2, 2, 2 and 4 respectively). The CFRs of the patients with aerothorax, mediastinal emphysema or pneumohypoderma were statistically significant as compared with the overall rate (P < 0.05). The major radiological features of PCP in non-AIDS immunocompromised patients are bilateral diffuse infiltration. And bilateral diffuse GGO on chest CT scans are usually accompanied with "mosaic" sign, air bronchogram or pulmonary consolidation. The prognoses are excellent for the patients with normal chest radiograph and poor for those with aerothorax, mediastinal emphysema or pneumohypoderma.

Massive hemoptysis, the etiology is aorto-bronchial fistula

sis. On physical examination, auscultation of the lung reveals inspiratory crackles, predominantly located in the lower posterior lung zones and auscultation of the heart reveals 2/6 systolic souffle in all of the cardiac zones. During the observation in emergency room, the patient’s hemoglobin values decreased from 15.5 mg/dL to 11.7 mg/dL. Because of this reason, erytrocyte suspension transfusion had been processed. Bilateral diffuse infiltration could be seen in postero-anterior chest X-ray. In the computed tomography (CT) of thorax, there was bilateral parenchymal ground glass opacities and consolidations (Figure 1). During bronchoscopy, active bleeding from bilateral bronchial system was observed. Since intraalveolar hemorrhage was considered at the patient, etiology oriented examinations were evaluated. Patient was extubated after the hemopthysis had been controlled and then, he was transferred to the chest diseases clinique from the intensive care unit. Both in bronchoscopic samples and sputum samples of the patient, there was no acid resistant bacterium in direct microbiological examination and cultures for acid resistant bacterium were negative. In the evaluation of the patient in terms of vasculitic syndromes; anti-nuclear antibody, anti-neutrophilic cytoplasmic antibody and ENA panel were detected and they were all negative. In the medical consultation made with cardiothoracic surgery, there was no additional suggestion. In the control bronchoscopy for hemorrhage, only a former bleeding focal point on the left main bronchi has been observed. During bronchoscopy; bronchial lavage, bronchoalveolar lavage (from the right middle lobe bronchi) and transbronchial biopsy samples were obtained. However, those samples weren’t useful for a specific diagnosis. Three months later, in the control CT of thorax of the case, ground glass

Acute megakaryoblastic leukemia and severe pulmonary fibrosis in a child with down syndrome: Successful treatment with ultra low-dose cytarabine using GATA1 mutation to monitor minimal residual disease

Acute megakaryoblastic leukemia and severe pulmonary fibrosis in a child with down syndrome: Successful treatment with ultra low-dose cytarabine using GATA1 mutation to monitor minimal residual disease