Extrapulmonary Causes Research Articles

The starting temperature of high-flow nasal cannula and perceived comfort in critically ill patients: A pragmatic randomized controlled trial.

High-flow nasal cannula (HFNC) therapy is a non-invasive respiratory treatment characterized by high tolerability, which largely derives from the patient's comfort. The primary aim of this study was to explore whether the patient's perceived comfort was the same regardless of different approaches used to reach the target humidification temperature. The secondary aim was to assess the patient's perceived nasal dryness and humidity. This single-centre, pragmatic, randomized trial was registered at clinicaltrials.gov (NCT05688189). Patients in the intensive care unit (ICU) in need of HFNC therapy were randomly assigned to one of three study arms: a two-step increase (31 to 34 to 37°C), a one-step increase in temperature (34-37°C) or no temperature increase (started and remained at 37°C). The patients were asked to rate their perceived comfort, as well as their perceived nasal dryness and humidity on a scale from 1 (lowest value) to 5 (highest value). We enrolled 21 patients, aged 34-85 years. The mean (±1 standard deviation) comfort level was 3.3 (1.3) for patients who received a one-step increase, 3.1 (1.3) for those who received no increase and 2.7 (1.7) for those who received a two-step increase (p = .714). There was also no difference in nasal dryness (p = .05) or humidity (p = .612) across the study arms. Greater comfort was fairly correlated with less nasal humidity (ρ = -0.34, 95% confidence interval -0.68 to 0.07) but not with nasal dryness (ρ = 0.01, p = .94). After 30 min of HFNC therapy at a target temperature of 37°C, overall comfort was rated similarly in the three study arms. Additional studies are needed to accumulate evidence corroborating the findings of this study. The temperature of the mixture of air and oxygen is a fundamental component of HFNC therapy. A pragmatic approach irrespective of the initial temperature setting seems to yield a similar comfort score in hospitalized patients with mild respiratory failure because of extrapulmonary causes.

LA DETRESSE RESPIRATOIRE CHEZ LENFANT

The objective of this study was to examine the clinical and epidemiological characteristics of respiratory distress in children, identify the responsible pathologies, and describe the therapeutic management. This retrospective study analyzed medical records of children aged between 1 month and 14 years admitted for respiratory distress over a one-year period, with a sex ratio (M/F) of 1.4. Dyspnea was the primary symptom (100%), cough was present in 57% of cases, feeding difficulties in 18%, and influenza-like illness in 15%. Pneumonia was the leading cause of pulmonary respiratory distress in our study, accounting for 35.5% of cases, while congenital heart defects were the most common extrapulmonary cause (16% of cases). The outcome was favorable in 76.5% of patients. Death was noted in 21% of cases. Respiratory distress is a true emergency that requires a thorough clinical assessment to quickly detect signs of severity necessitating urgent, symptomatic, and etiological management.

Assessment of pulmonary fibrosis severity at autopsy in patients after COVID-19: comparison with quantitative CT scan data in the acute phase of the disease

INTRODUCTION: After the COVID-19 pandemic, there is increasing evidence that many patients show fibrous changes in lung tissue accompanied by functional lung disorders. Objective data on the histopathogenesis of such changes is still insufficient. Prospective studies are required to fully assess the consequences of these clinical manifestations.OBJECTIVE: Evaluation of the capabilities of digital processing of histological preparations of lung tissue and their comparison with quantitative CT data of lung patients in the acute phase of COVID-19.MATERIALS AND METHODS: The study included data from patients after COVID-19 (7 women and 3 men aged 47 to 93 years) who died after the acute phase of COVID-19 from extrapulmonary causes. The control group included data from 7 people (5 women and 2 men aged 35 to 93 years) who died shortly after hospitalization from extrapulmonary causes (myocardial infarction or acute cerebral stroke), with no signs of lung diseases, including autopsy results. Digital processing of histological preparations of lung tissue obtained during autopsy was carried out, and their comparison with the results of quantitative semi-automatic processing of CT data.Statistics. Beta regression (mgcv library) was used. The model was characterized by a pseudodetermination coefficient R2. The association was considered statistically significant at p<0.05.RESULTS: A reliable dependence of the severity of fibrous changes in histological samples on the results of quantitative analysis of CT images of patients in the acute period of COVID-19 was demonstrated.DISCUSSION: Extrapolation of lung autopsy data through quantitative CT assessment is one of the ways to pre-diagnose and identify groups of patients who require specific treatment of post-COVID-19 pulmonary fibrosis.CONCLUSION. Computerized digital processing of histological images made it possible to correctly compare the histopathological examination data with the CT picture in COVID-19, which could potentially have a prognostic value in the search for more effective treatment strategies.

The Effect of Pulmonary Rehabilitation on Length of Hospitalization, Alveolar-Arterial Oxygen Gradient, and Interleukin-8 Levels in Hospitalized Non-Severe Community-Acquired Pneumonia Patients at Prof. I.G.N.G Ngoerah General Hospital

Background: Community-acquired pneumonia is an acute infection of the lung parenchyma that can lead to inflammatory fluid exudation, thereby impairing oxygen diffusion. Pulmonary rehabilitation is a series of therapies aimed at enhancing respiratory efficiency, lung expansion, respiratory muscle strength, and clearing respiratory system secretions. Interleukin-8 (IL-8) is a pro-inflammatory cytokine that reflects epithelial injury in the respiratory system. The alveolar-arterial oxygen gradient (A-a O2) measures the oxygen difference between alveoli and arteries, which is clinically important for assessing diffusion function and distinguishing between pulmonary and extra-pulmonary causes of hypoxemia. Methods: This study is a systematic, single-center randomized controlled trial (RCT) conducted at Prof. I.G.N.G. Ngoerah Hospital from July to September 2024. The study examined the effect of pulmonary rehabilitation on length of hospitalization, A-a O2 gradient, and IL-8 levels. Results: The length of group P1 (pulmonary rehabilitation and conventional therapy) was significantly shorter by 1.16 days (p = 0.013). Pulmonary rehabilitation significantly reduced A-a O2 and IL-8 levels, with a median decrease from day one to day five of 16.00 mmHg in group P1 and 7.50 mmHg in group P2 (conventional therapy) (p = 0.000). IL-8 levels also significantly decreased, with a median reduction of 41.81 pg/ml in group P1 and 18.35 pg/ml in group P2 (p = 0.025). Conclusion: The combination of pulmonary rehabilitation and antibiotic therapy effectively reduces the length of hospitalization, A-a O2 levels, and IL-8 in hospitalized non-severe community-acquired pneumonia patients.

Acute respiratory distress syndrome heterogeneity and the septic ARDS subgroup.

Acute respiratory distress syndrome (ARDS) is an acute diffuse inflammatory lung injury characterized by the damage of alveolar epithelial cells and pulmonary capillary endothelial cells. It is mainly manifested by non-cardiogenic pulmonary edema, resulting from intrapulmonary and extrapulmonary risk factors. ARDS is often accompanied by immune system disturbance, both locally in the lungs and systemically. As a common heterogeneous disease in critical care medicine, researchers are often faced with the failure of clinical trials. Latent class analysis had been used to compensate for poor outcomes and found that targeted treatment after subgrouping contribute to ARDS therapy. The subphenotype of ARDS caused by sepsis has garnered attention due to its refractory nature and detrimental consequences. Sepsis stands as the most predominant extrapulmonary cause of ARDS, accounting for approximately 32% of ARDS cases. Studies indicate that sepsis-induced ARDS tends to be more severe than ARDS caused by other factors, leading to poorer prognosis and higher mortality rate. This comprehensive review delves into the immunological mechanisms of sepsis-ARDS, the heterogeneity of ARDS and existing research on targeted treatments, aiming to providing mechanism understanding and exploring ideas for accurate treatment of ARDS or sepsis-ARDS.

Clinical study on the relationship between the exosomes in bronchoalveolar lavage fluid and plasma and the severity of lung injury and outcome in early acute respiratory distress syndrome patients

Objective: To investigate the relationship between the levels of exosomes in bronchoalveolar lavage fluid (BALF) and plasma and the severity of lung injury and its outcome in patients with acute respiratory distress syndrome (ARDS). Methods: Patients who were admitted to the Department of Critical Care Medicine, Zhongda Hospital Affiliated to Southeast University and received invasive mechanical ventilation were selected from August 2020 to April 2021, and they were divided into ARDS group and non-ARDS group. Finally, 33 ARDS patients were included, including 18 males and 15 females, aged (65.5±15.5) years; 10 non-ARDS patients, 8 males and 2 females, aged (57.2±15.3) years. The BALF and plasma of the two groups of patients were collected within 24 hours after enrollment, and the total exosomes of the samples were collected by ultracentrifugation. Nanoparticle tracking analysis (NTA) was used to detect and compare the differences in exosome content between the two groups. Correlation of content with the severity and prognosis of lung injury in ARDS patients. Results: There was no significant difference in gender and age between ARDS group and non-ARDS group (both P>0.05). The exosome in plasma of ARDS group was significantly higher than that of non-ARDS group [(25.3±1.2)/ml vs (24.2±1.6)/ml, P=0.031], while the exosomes in BALF of ARDS group was also higher than that of non-ARDS group [(26.5±1.6)/ml vs (24.6±1.1)/ml, P=0.001]. The exosomes in BALF of patients with ARDS caused by intrapulmonary causes was higher than that in ARDS group caused by extrapulmonary causes [(26.9±1.5)/ml vs (25.2±0.9)/ml, P=0.01], and the infection caused by bacterial shows that the highest exosome level in BALF. The exosomes in the BALF of the mild ARDS group was significantly lower than that of the severe ARDS group [(25.7±1.3)/ml vs (27.2±1.5)/ml, P=0.038]; the exosomes in BALF of ARDS patients was negatively correlated with P/F ratio (r=-0.38, P=0.03); and it was positively correlated with Murray lung injury score (r=0.47, P=0.01). However, the static compliance levels, length of hospital stay, duration of mechanical ventilation, and 28-day outcome were not associated with the exosomes in BALF. Conclusion: Compared with non-ARDS patients, ARDS patients have significantly higher levels of exosomes in BALF and plasma, there is a certain correlation between exosomes derived from BALF and the severity of lung injury in ARDS.

Функция аппарата внешнего дыхания при раке легкого, развившемся на фоне хронической обструктивной болезни легких

INTRODUCTION: Clinical observations ascertain a comorbid development of chronic obstructive pulmonary disease (COPD) and lung cancer (LC). Here, a more favorable prognosis for patients with LC depends on detection of the disease in early stages, when radical treatment is possible. This determines the importance of a detailed examination of the function of the external respiration using modern methods to identify predictors of lung cancer. AIM: To study the peculiarities of disorders in the apparatus of external respiration (AER) in patients with LC developed with the underlying COPD (LC + COPD). MATERIALS AND METHODS: A clinical and functional examination of 33 individuals was conducted — 10 healthy (control group), 12 patients with COPD and 11 patients with LC + COPD, using methods of spirography, pneumotachography and body plethysmography. RESULTS: In patients with COPD, as well as in those with LC + COPD, a statistically significant decrease in the median values of vital capacity of lungs (VCL), forced expiratory volume in 1 second (FEV1), flow-volume curve (PFER, MEF50, MEF75) and an increase in respiratory minute volume (RMV), residual lung volume (RLV), the ratio of residual lung volume to total lung capacity (RLV/TLC) and bronchial resistance (Raw) were revealed. It was found that in patients with LC + COPD, the median values of VСL, RLV/TLC, Raw did not differ, while the values of flow-volume curve were reduced as compared to patients with COPD. The observed decrease in the air flow rate parameters in the absence of differences in Raw indicates the extrapulmonary causes of these changes. CONCLUSION: In the course of the study, high reserve capacities of the apparatus of external respiration were found. The obtained parameters turned out to be of low informative value for diagnosis of development of LC with the underlying COPD. In patients with LC + COPD, the study of AER function, in addition to spirography and pneumotachography, should include body plethysmography, to avoid overdiagnosis of broncho-obstructive syndrome.

Cystic fibrosis with liver involvement in adults has a benign course. Results from a tertiary referral center cohort.

Cystic Fibrosis Liver Disease is a poorly understood entity, especially in adults, in terms of its real prevalence, natural history and diagnostic criteria, despite being the most important extrapulmonary cause of mortality. The aim was to evaluate the prevalence, characteristics and potential risk factors of liver disease in adults with cystic fibrosis, according to two diagnostic criteria accepted in the scientific literature. Patients were recruited in a tertiary referral hospital, and laboratory, ultrasound, non-invasive liver fibrosis tests (AST to Platelet Ratio Index; Fibrosis-4 Index) and transient elastography (Fibroscan) were performed. The proportion of patients with liver disease according to the Debray and Koh criteria were evaluated. 95 patients were included, 48 (50.5%) females, with a mean age of 30.4 (28.6-32.2) years. According to the Debray criteria, 6 (6.3%) patients presented liver disease. According to the Koh criteria, prevalence increased up to 8.4%, being statistically different from the 25% value described in other published series (p = 0.005). Seven (7.5%) presented ultrasonographic chronic liver disease. Eleven (13%) presented liver fibrosis according to the APRI score; 95 (100%) had a normal FIB-4 value. Mean liver stiffness value was 4.4 (4.1-4.7) kPa. FEV1 (OR=0.16, p 0.05), meconium ileus (OR=14.16, p 0.002), platelets (Pearson coefficient -0.25, p 0.05) and younger age (Pearson coefficient -0.19, p 0.05) were risk factors. Prevalence and severity of liver disease in adult cystic fibrosis patients were lower than expected. Meconium ileus, platelets, age and respiratory function were confirmed as risk factors associated to cystic fibrosis liver disease.

Respiratory distress syndrome. Systematic review

Respiratory distress syndrome is a prevalent cause of morbidity and mortality, however, patients who survive have sequelae due to lung damage which reduces their quality of life. Objective: to examine the empirical evidence on respiratory distress syndrome. Methodology: A systematic review of articles was carried out in databases such as Pubmed, Scopus, Scielo, Liliacas, using the key words "Respiratory Distress Syndrome, Risk Factors". We searched for articles written in Spanish, published in the last 10 years. Results: the most prevalent factors for developing respiratory distress syndrome are pulmonary clinical causes such as pneumonia, aspiration of gastric contents and thoracic trauma, mechanical ventilation and extrapulmonary causes such as shock, sepsis, severe trauma, blood transfusions, among others, and genetic factors. Conclusion: acute respiratory distress syndrome (ARDS) is a life-threatening lung injury, most people with ARDS are already in the hospital due to trauma or disease.

Respiratory distress syndrome. Systematic review

Respiratory distress syndrome is a prevalent cause of morbidity and mortality, however, patients who survive have sequelae due to lung damage which reduces their quality of life. Objective: to examine the empirical evidence on respiratory distress syndrome. Methodology: A systematic review of articles was carried out in databases such as Pubmed, Scopus, Scielo, Liliacas, using the key words "Respiratory Distress Syndrome, Risk Factors". We searched for articles written in Spanish, published in the last 10 years. Results: the most prevalent factors for developing respiratory distress syndrome are pulmonary clinical causes such as pneumonia, aspiration of gastric contents and thoracic trauma, mechanical ventilation and extrapulmonary causes such as shock, sepsis, severe trauma, blood transfusions, among others, and genetic factors. Conclusion: acute respiratory distress syndrome (ARDS) is a life-threatening lung injury, most people with ARDS are already in the hospital due to trauma or disease.

Lung function and breathing patterns in hospitalised COVID-19 survivors: a review of post-COVID-19 Clinics

IntroductionThere is relatively little published on the effects of COVID-19 on respiratory physiology, particularly breathing patterns. We sought to determine if there were lasting detrimental effect following hospital discharge and if these related to the severity of COVID-19.MethodsWe reviewed lung function and breathing patterns in COVID-19 survivors > 3 months after discharge, comparing patients who had been admitted to the intensive therapy unit (ITU) (n = 47) to those who just received ward treatments (n = 45). Lung function included spirometry and gas transfer and breathing patterns were measured with structured light plethysmography. Continuous data were compared with an independent t-test or Mann Whitney-U test (depending on distribution) and nominal data were compared using a Fisher’s exact test (for 2 categories in 2 groups) or a chi-squared test (for > 2 categories in 2 groups). A p-value of < 0.05 was taken to be statistically significant.ResultsWe found evidence of pulmonary restriction (reduced vital capacity and/or alveolar volume) in 65.4% of all patients. 36.1% of all patients has a reduced transfer factor (TLCO) but the majority of these (78.1%) had a preserved/increased transfer coefficient (KCO), suggesting an extrapulmonary cause. There were no major differences between ITU and ward lung function, although KCO alone was higher in the ITU patients (p = 0.03). This could be explained partly by obesity, respiratory muscle fatigue, localised microvascular changes, or haemosiderosis from lung damage. Abnormal breathing patterns were observed in 18.8% of subjects, although no consistent pattern of breathing pattern abnormalities was evident.ConclusionsAn “extrapulmonary restrictive” like pattern appears to be a common phenomenon in previously admitted COVID-19 survivors. Whilst the cause of this is not clear, the effects seem to be similar on patients whether or not they received mechanical ventilation or had ward based respiratory support/supplemental oxygen.

A Comparative Study Between-Small Bore and Large Bore Tubes for Therapeutic Pleural Drainage

Introduction: Pleural effusions due to various pulmonary and extra pulmonary causes are common clinical problems. Some pleural diseases require therapeutic pleurocentesis to decompress the pleural space like in malignant and benign pleural effusions, pyothorax, chylothorax, pneumothorax, complicated parapneumonic effusion and haemothoraces. Traditionally large bore tubes have been used with trocar or through blunt dissection. Nowadays small-bore catheters are gaining popularity, as they are less painful and believed to be equally efficacious as compared to large bore tubes.&#x0D; Aims &amp; Objectives: To compare the success rate of small bore tubes with standard large bore chest tubes in therapeutic pleural drainage and to compare complications rate between small bore and large bore drains.&#x0D; Place and duration of study: The study was conducted at Department of Pulmonology of FPGMI, Shaikh Zayed Hospital, during one year (2015-2016).&#x0D; Material &amp; Methods: Total 152 patients who required therapeutic evacuation of pleural space suffering from pneumothorax, empyema, parapneumonic and malignant effusion, were enrolled and underwent therapeutic drainage with small bore (&lt; 20 F size) and large bore tubes (&gt; 20 F size), randomized by lottery method.&#x0D; Results: The mean duration of drain placement for large bore drain was 7.9±3.8 days, which was significantly higher than small bore drains with a mean value of 3.0±1.6 days (p-value &lt;0.001). The pain score was also quite high in large bore group with mean value 5.67±1.68 as compared to small bore 1.07±0.81(p-value&lt;0.001). Similarly the mean bleeding during the procedure was significantly higher in large bore group as compared to small bore with mean values 11.9±7.8 and 0.1±0.2 ml respectively (p-value&lt;0.001). The wound infection which is a significant complication was found only in large bore group with 14.5% cases as compared to none in small bore group (p-value 0.001). In large bore group surgery was required for 9(11.8%) cases while in small group there were 2(2.6%) patients referred for surgical intervention.&#x0D; Conclusion: Small bore thoracostomy drains are more effective than large bore tubes, for the treatment of pleural disorders requiring therapeutic drainage and they are associated with minimal pain and other complications.

A comparison of four different models of acute respiratory distress syndrome in sheep

BackgroundAcute respiratory distress syndrome (ARDS) can have various causes. The study objective was to investigate whether different pathophysiologic models of ARDS would show different respiratory, cardiovascular and inflammatory outcomes.MethodsWe performed a prospective, randomized study in 27 ventilated ewes inducing ARDS using three different techniques to mimic the pulmonary causes of ARDS (ARDSp): warm saline lavage (n = 6), intratracheal hydrochloric acid (HCl; n = 6), intratracheal albumin (n = 10), and one technique to mimic an extrapulmonary cause of ARDS (ARDSexp): intravenous lipopolysaccharide (LPS iv; n = 5). ARDS was defined when PaO2 was < 15 kPa (112 mmHg) when ventilated with PEEP 10 cm H2O and FiO2 = 1.0. The effects on gas exchange were investigated by calculating the oxygenation index (OI) and the ventilation efficacy index (VEI) every 30 min for a period of 4 h. Post mortem lung lavage was performed to obtain broncho-alveolar lavage fluid (BALF) to assess lung injury and inflammation. Lung injury and inflammation were assessed by measuring the total number and differentiation of leukocytes, the concentration of protein and disaturated phospholipids, and interleukine-6 and -8 in the BALF. Histology of the lung was evaluated by measuring the mean alveolar size, alveolar wall thickness and the lung injury score system by Matute-Bello et al., as markers of lung injury. The concentration of interleukin-6 was determined in plasma, as a marker of systematic inflammation.ResultsThe OI and VEI were most affected in the LPS iv group and thereafter the HCl group, after meeting the ARDS criteria. Diastolic blood pressure was lowest in the LPS iv group. There were no significant differences found in the total number and differentiation of leukocytes, the concentration of protein and disaturated phospholipids, or interleukin-8 in the BALF, histology of the lung and the lung injury score. IL-6 in BALF and plasma was highest in the LPS iv group, but no significant differences were found between the other groups. It took a significantly longer period of time to meet the ARDS criteria in the LPS iv group.ConclusionsThe LPS model caused the most severe pulmonary and cardiovascular insufficiency. Surprisingly, there were limited significant differences in lung injury and inflammatory markers, despite the different pathophysiological models, when the clinical definition of ARDS was applied.

Histopathologic and Radiologic Assessment of Unused Donor Lungs: When to Decline or Not?

Donor organ shortage, in combination with a 70% decline rate of offered donor lungs, results in significant wait list mortality and time with poor quality of life. Assessing donor lungs for transplant suitability is based on donors' history, gas exchange, chest X-ray, bronchoscopy, and in situ visual inspection; but donor lung acceptance remains subjective. We performed an in depth histopathologic and radiologic assessment of retrieved but unused donor lungs. We assessed 62 donor lungs not used for transplantation for various reasons between 2010 and 2019. These lungs were air-inflated, frozen, scanned with computed tomography, systematically sampled on 4 different locations, assessed macroscopically and microscopically by two experienced lung pathologists and by an experienced thoracic radiologist, all blinded for the reason of decline. Reasons for non-use are summarized in the figure. Thirty-nine (63%) lungs were not used for allograft-related reasons. In 13/39 (33%) lungs, the reason for decline could not be confirmed by histologic assessment (emboli, n=7; pneumonia, n=3; contusion, n=2; emphysema, n=1), in an additional 8/39 (21%) lungs, histologic abnormalities were only considered focal and mild (emphysema, n=5; pneumonia, n=3). In 16/39 (41%) lungs, radiology could not confirm the reason for decline. Twenty-three (37%) of 62 unused donor lungs were not transplanted due to extra pulmonary causes, of which 3 (13%) lungs displayed severe histologic abnormalities (pneumonia, n=2; emphysema, n=1), in addition to mild emphysema in 9 (39%) lungs and mild bronchopneumonia in 1 lung (4%). Radiology revealed ground-glass opacities in 8/23 (35%) and emphysema in 4/23 (17%) of these donor lungs. Histologic and radiologic assessment of unused donor lungs revealed substantial discrepancy with the clinical reason for decline. Prior chest CT imaging and frozen sections in selected cases might contribute to adequate donor assessment and augment current yield of donor lungs.

Histopathologic and radiologic assessment of nontransplanted donor lungs.

Donor organ shortage results in significant waiting list mortality. Donor lung assessment is currently based on donors' history, gas exchange, chest X-ray, bronchoscopy findings, and ultimately in situ inspection but remains subjective. We correlated histopathology and radiology in nontransplanted donor lungs with the clinical indications to decline the offered organ. Sixty-two donor lungs, not used for transplantation (2010-2019), were procured, air-inflated, frozen, scanned with computed tomography, systematically sampled, and histologically and radiologically assessed. Thirty-nine (63%) lungs were declined for allograft-related reasons. In 13/39 (33%) lungs, histology could not confirm the reason for decline, in an additional 8/39 (21%) lungs, histologic abnormalities were only considered mild. In 16/39 (41%) lungs, radiology could not confirm the reason for decline. Twenty-three (37%) donor lungs were not transplanted due to extrapulmonary causes, of which three (13%) lungs displayed severe histologic abnormalities (pneumonia, n=2; emphysema, n=1), in addition to mild emphysema in 9 (39%) lungs and minor bronchopneumonia in 1 (4%). Radiology revealed ground-glass opacities in 8/23 (35%) and emphysema in 4/23 (17%) lungs. Histopathologic and radiologic assessment of nontransplanted donor lungs revealed substantial discrepancy with the clinical reason for decline. Optimization of donor lung assessment is necessary to improve current organ acceptance rates.

Assessment of gradient between partial pressure of arterial carbon dioxide and end-tidal carbon dioxide in acute respiratory distress syndrome

ContextEnd-tidal carbon dioxide (EtCO2) is used as a noninvasive bedside test to assess the adequacy of ventilation and physiologic dead space in mechanically ventilated patients. The gradient difference between EtCO2 and partial pressure of arterial carbon dioxide (PaCO2) is directly related to an increase in the physiologic dead space.AimThe aim of this study was to evaluate the role of measuring the gradient between EtCO2 and PaCO2 in adults with acute respiratory distress (ARDS).Settings and designThis was a prospective consecutive enrollment study.Patients and methodsOverall, 51 cases were recruited after the diagnosis of ARDS was made according to the Berlin definition. Patients were mechanically ventilated as per the lung-protective protocol. Daily arterial blood gases were collected and for every sample, the EtCO2 value was collected electronically by capnography using an endotracheal tube for the first 5 days.ResultsCases were classified into survivors and nonsurvivors: 26 cases were because of extrapulmonary causes and 25 cases were because of pulmonary causes. The mean value of the APACHE II score for all cases on admission was 21.6. The mean length of ICU stay was 12.7 days. For all study cases, PaO2/FiO2 was the lowest at day 1 and the highest at day 5. We found a significant negative correlation between PaO2/FiO2 and the gradient at days 2, 4, and day 5, and a significant positive correlation between the gradient on admission and the APACHE II score (r=0.4, P≤0.05). Nonsurvivors had a significantly higher gradient and lower EtCO2 and PaO2/FiO2 levels at all time intervals, whereas PaCO2 alone was found to be nonsignificant.ConclusionIn ARDS, EtCO2 and gradient are reliable indicators of severity.

Pulmonary dysfunction due to combination of extra-pulmonary causes and alveolar damage is present from first the day of hospital admission in the early phase of acute pancreatitis

BackgroundOnly few studies have attempted to evaluate the pulmonary function in the early phase of acute pancreatitis (AP), although pulmonary dysfunction is the most frequent complication in the early phase of AP. We aimed to evaluate the changes in pulmonary function tests during the early phase of AP. MethodsProspective cohort study including 44 patients (52% men; median age 54 years) admitted with first attack of AP and 22 healthy controls. Patients underwent assessments on day 1, 2, 3, 6, and 10 as well as one month after discharge. Pulmonary function tests included the % predicted: forced expiratory volume during the first second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), diffusion lung capacity (DLCO) and the ratio between DLCO and alveolar volume (DLCO/VA). ResultsIn total, 9% developed severe acute pancreatitis, 7% died, and 14% required treatment at the intensive or semi-intensive care unit. From admission, patients had impaired FEV1, FVC, DLCO, and TLC compared with controls (p < 0.0001 in all analyses). Patients with CRP >150 mg/L had significantly lower lung function tests. One month after discharge, lung function tests improved but patients had lower FEV1 (p = 0.014), FVC (p = 0.022), TLC (p = 0.020), and DLCO (p < 0.001) compared with controls. ConclusionThis study found that patients with AP had evidence of pulmonary impairment from the first day after hospital admission. The impairment lasted several weeks after hospital discharge.

Clinical profile and survival outcome of acute respiratory distress syndrome in a rural tertiary care hospital

Background: Acute respiratory distress syndrome (ARDS) is characterized by rapid onset severe dyspnea, hypoxemia, and diffuse bilateral pulmonary infiltrates leading to respiratory failure. This syndrome can occur even without primary damage to the lung parenchyma, and thus, they are more often classified as ARDS due to pulmonary and extrapulmonary causes. Mortality estimates range from 26% to 44% in different studies. There are several critical care scores that are in vogue in intensive care units. This study was undertaken to describe the clinical profile of ARDS and along with that the study also intended to correlate the outcome of ARDS patients with reference to these critical care scores and try to establish which score would be best to prognosticate ARDS. Aims: This study aims to study the clinical profile and survival outcome of ARDS in a rural tertiary care hospital. Materials and Methods: All patients fulfilling the inclusion criteria as per the 1994 American European Consensus Conference on ARDS definition of ARDS were included in the study. The severity of ARDS was measured by various critical care scores such as the Acute Physiology and Chronic Health Evaluation Score, Multiple Organ Dysfunction Score (MODS), Lung Injury Score (LIS), and Sequential Organ Dysfunction Assessment (SOFA score). Results: The ratio of male and female (male: female) was 1.7:1.0. Proportion of males (62.5%) was significantly higher than that of females (37.5%) (Z = 3.53;P

Comorbidities in chronic obstructive pulmonary disease: Results of a national multicenter research project

Chronic obstructive pulmonary disease (COPD) is associated with various comorbidities, which influence the course of COPD and worsen prognosis. The aim of this study was to analyze the comorbidities in a cohort of COPD patients in Poland during 12 months of observation. A total of 444 COPD patients (median age: 66.1 years) in all stages of airflow limitation severity were enrolled. Medical histories and a questionnaire concerning comorbidities were analyzed at baseline and after 12 months (data of 267 patients available). Anthropometric data, pulmonary function, and body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE index) were assessed. No comorbidities were reported in 9 patients (2.0%), 101 patients (22.7%) had 1-2 comorbidities, 243 (54.7%) had 3-5, and 91 (20.6%) had more than 5 comorbidities. Cardiovascular diseases (CVDs) were the most frequent ones, followed by peptic ulcer, obstructive sleep apnea (OSA), diabetes, gastroesophageal reflux disease (GERD), and osteoporosis; 11 patients had a history of lung cancer. Cachexia was observed in 11 cases, overweight in 136 cases and obesity in 139 cases. The incidence of CVDs increased with time. The number of comorbidities correlated with the body mass index (BMI) and the number of hospitalizations for extra-pulmonary causes, but not with airflow limitation. The BODE index score increased with the number of comorbidities. In a cohort of Polish COPD patients, the most frequent comorbidities were CVDs. The number of comorbidities affected the BODE index, but not airflow limitation. The BODE index is better than forced expiratory volume in 1 s (FEV1) in the rating of COPD patients' condition. The BMI correlated with the number of comorbidities as well as the number of hospitalizations for extra-pulmonary causes.

Bronchopulmonary Dysplasia: Can We Agree on a Definition?

The advances in obstetric and neonatal care over the last half century have resulted in changes in pathophysiology and clinical presentation of bronchopulmonary dysplasia (BPD). In contrast to the original description of BPD by Northway et al as a severe lung injury in relatively mature preterm infants, the most common form of BPD currently is characterized by chronic respiratory insufficiency in extremely preterm infants. This evolution in the presentation of BPD, along with changes in respiratory support strategies such as increased use of nasal cannula oxygen, has presented a unique challenge to find a definition that describes the severity of lung damage and predict the long-term respiratory outcomes with some accuracy.The limitations of current definitions of BPD include inconsistent correlation with long-term respiratory outcomes, inability to classify infants dying from severe respiratory failure prior to 36 weeks' postmenstrual age, and potential inappropriate categorization of infants on nasal cannula oxygen or with extrapulmonary causes of respiratory failure. In the long term, the aim for a new definition of BPD is to develop a classification based on the pathophysiology and objective lung function evaluation providing a more accurate assessment for individual patients. Until then, a consensus definition that encompasses current clinical practices, provides reasonable prediction of later respiratory outcomes, and is relatively simple to use should be achieved.