Room Air Oxygen Saturation Research Articles

Index of Suspicion in the Nursery

A 1-day-old male infant develops lower extremity cyanosis after feeding. The infant was born at 38 weeks’ gestation and had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. There were no prenatal complications. Today he has lower extremity saturations of 80% and upper extremity saturations of 97%. Results of limited/preliminary echocardiography are reported as “pulmonary hypertension and possible aortic arch obstruction.” After starting an infusion of prostaglandin E1, the infant is transferred to a tertiary care center for cardiac evaluation. The initial physical examination reveals a warm, pink neonate who is experiencing no significant distress. His length is at the 75th percentile and weight is at the 25th percentile for age. His temperature is 37.0°C, heart rate is 120 beats/min, respiratory rate is 28 breaths/min, and cuff blood pressure in the right upper extremity is 75/45 mm Hg. No blood pressure gradient is evident between the upper and lower extremities. Oxygen saturation in room air is 98% in the left upper extremity and 85% in the left lower extremity. Lungs are clear and no retractions are noted. Cardiovascular examination reveals a fixed, widely split second heart sound (S2) without an appreciable murmur. Pulses are +2 and equal in …

Results of Exercise Stress Testing in Patients with Diffuse Pulmonary Arteriovenous Malformations

Patients with diffuse pulmonary arteriovenous malformations (PAVMs) are subject to frequent complications and need to be followed closely. As part of this follow-up, we have employed exercise stress testing (EST) as an aid to assess their status. Twenty patients from a cohort of 35 with diffuse PAVMs have undergone EST using a standard cycle ergometer test. All patients had previously undergone pulmonary angiography, noncontrast chest computed tomography (CT), and repair of large focal PAVMs, prior to EST. Mean room air oxygen saturation at baseline and at maximum exercise (85% of maximum heart rate) were tabulated. Serial studies in six children and young adults were plotted by year and compared using the patient as their own control. Fourteen females and six males ranging in age from 4 to 50 years (mean 22 years) were studied. Baseline mean oxygen saturation was 84% and fell to 73% at maximum exercise. There was no significant difference between those with unilateral and bilateral involvement (P = 0.09). In four of the six patients with serial EST, the baseline and exercise oxygen saturations were quite stable. In the two patients who became symptomatic, with age, growth, and more activity, complete embolization of one or more segments of the lung improved their EST and functionality. Based on our previous work in patients with diffuse PAVMs, EST appears to offer a relatively safe and noninvasive method for assessing these patients. Our limited experience with serial EST suggests a good correlation with decreased functionality in these patients.

Modified Central Aortopulmonary Shunt with End-to-End Anastomosis of the Shunt to the Pulmonary Trunk: Early Results of a Novel Shunt Procedure for First-Stage Palliation of Infants with Pulmonary Atresia and Hypoplastic Pulmonary Arteries

The aim was to investigate a novel palliative shunt performed between the ascending aorta and the main pulmonary artery in patients with pulmonary atresia. Thirteen patients with intracardiac defects [tetralogy of Fallot (seven patients); tetralogy of Fallot and major aortopulmonary collateral arteries (one patient); ventricular septal defect and major aortopulmonary collateral arteries (two patients); tricuspid atresia (three patients)] and pulmonary atresia underwent shunt operation. Patient selection was made based on preoperative echocardiography and perioperative findings. Eight of the patients were female and five were male. Ages and weight ranged between 1-235 days and 2,950-7,900 g, respectively. Preoperative room air oxygen saturation ranged between 68-83 %. Operations were performed through a median sternotomy. The main pulmonary artery was transected from the right ventricular outflow tract and using a 3-3.5 mm diameter graft, a modified central aortopulmonary shunt was created (graft anastomosis was end-to-end to the pulmonary artery and side-to-side to the aorta). Postoperative oxygen saturation increased 5-10% and diastolic blood pressure decreased by 3-6 mmHg. One hospital mortality occurred, due to sepsis, and two late deaths, one due to pneumonia and one sudden death, occurred in the follow-up period. Patients were followed up for 3-16 months after the operations. During the follow-up period four patients received corrective operations, one unifocalization and three total corrections. Modified central aortopulmonary shunt with end-to-end anastomosis of the shunt to the pulmonary trunk is a novel palliative shunt operation. Our early results with this technique indicate rapid palliation and early achievement of bilateral homogenous adequate pulmonary artery size with a low incidence of overflow to pulmonary circulation and minimal arterial distortion.

Clinical and Diagnostic Features of Delayed Hypoxic Leukoencephalopathy

Clinical and Diagnostic Features of Delayed Hypoxic Leukoencephalopathy

Index of Suspicion

Index of Suspicion

Bile-stained vomiting in the infant: green is not good!

Daniel was 3 weeks of age when his parents took him to casualty. He had not been feeding well during the previous 12 h. Vomiting was now their main concern...

Bovine Valved Xenograft (Contegra) Conduit in the Extracardiac Fontan Procedure: The Preliminary Experience

Constructing a competent valve using the xenograft valved conduit (Contegra) in the extracardiac Fontan connection may maintain better forward flow into the pulmonary circulation. The preliminary results and potential advantages of using the Contegra are discussed in this review. A retrospective review of 18 patients who underwent the extracardiac Fontan connection using the Contegra conduit from June 2002 to September 2005. Median age at the time of operation was 4.5 year (range 2.5-34 years). In 15 patients (83%) a 4 mm fenestration was created. Overall operative mortality was 11 % (two patients); one patient died because of arrhythmia & sepsis, and the other one due to thrombosed Fontan connection. The ranges of intensive care unit stay, chest tube duration, and hospital stay were 1-18 days (median, 2 days), 4-38 days (median, 7 days), and 5-47 days (median, 12.5 days), respectively. Follow-up is available for 15 (94%) patients at a mean of 15.8 months (range 8-48 months) postoperatively. They were all asymptomatic and their room air oxygen saturation ranged between 88% and 100% (mean, 96.1%). There have been no further thromboembolic episodes during follow up. Echocardiograms demonstrated patent conduit in all patients with no hepatic vein reversal flow except to a minimal degree in five patients; however the valve competency was demonstrated radiologically. The Contegra xenograft is a potential alternative conduit for the extracardiac Fontan connections. These encouraging preliminary results may support better pulmonary forward flow.

A 49-year-old Woman With Acute Mastoiditis, Meningitis, and Subdural Empyema

A 49-year-old emergency nurse presented to her place of work with a 3-day history of right-sided ear pain, rhinorrhea, nausea, vomiting, and diffuse right-sided headache. Her triage vital signs were as follows: oral temperature, 37.1°C (98.8°F); heart rate, 88 beats per minute; blood pressure, 139/77 mm Hg; and room air oxygen saturation, 99%. Kelsey L.B. Jakubauskas, Austin Chapter, is Staff Nurse, South Austin Hospital Emergency Department, Austin, Tex.

Does propofol and alfentanil-induced sedation cause periodic apnoea in chronic renal failure patients?

There is evidence suggesting that the respiratory response to sedation is different in patients with sleep apnoea, which is common in patients with chronic renal failure (CRF). This study examined the respiratory response of sedation with propofol and alfentanil, whose pharmacokinetics are not affected by the renal function, in CRF patients. Chronic renal failure patients who underwent arteriovenous-fistular surgery (CRF group) and patients who underwent chemoport insertion (control group) were enrolled in this study. Sedation was induced by infusing propofol 1.5 micro/ml and alfentanil 0.2 micro/kg/min continuously in both groups. In the desaturation study, the respiratory rate and peripheral oxygen saturation in room air were checked. In the apnoea-hypopnoea study, the patient's sedation (Observer's Assessment of Alertness/Sedation) score, apnoea-hypopnoea index (AHI) was recorded using a portable ventilation effort recorder (microMesam) while applying 5 l/min of oxygen through a facial mask. The desaturation event was more common (21.5/h vs. 2/h, p = 0.001) in the CRF patients. Apnoea and hypopnoea (AHI: 13.0 vs. 1.6, p = 0.012, per cent of patients with an AHI > 5: 53.3% vs. 7.1%, p = 0.014) occurred more frequently in the CRF patients but the sedation score was not different. Chronic renal failure patients have a higher risk of developing apnoea and hypopnoea during sedation, which highlights the need for careful monitoring and management in these patients.

An Elderly Man with Non-Resolving Fever and a Pulmonary Infiltrate

A 62-year-old Pakistani man presented with fever and chest pain of five-day duration. He was non-smoker and he had no history of hemoptysis, wheezing, loss of weight or exposure to tuberculosis. Other history was unremarkable. Physical examination revealed a heart rate of 116 beats/min, BP of 121/ 58 mm Hg, temperature of 38.5°C, and a room air oxygen saturation of 92 %. There was no cervical, axillary, or inguinal lymphadenopathy. Chest examination revealed bronchial breath sounds in the right middle and lower zones. Cardiac examination revealed tachycardia with no gallops or murmurs. Abdomen was nontender without hepatosplenomegaly. Extremities were free of cyanosis, edema, and clubbing. There were no skin lesions

Dexamethasone for Bronchiolitis—The Controversy Continues

Infectious Diseases| October 01 2007 Dexamethasone for Bronchiolitis—The Controversy Continues AAP Grand Rounds (2007) 18 (4): 38–39. https://doi.org/10.1542/gr.18-4-38 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dexamethasone for Bronchiolitis—The Controversy Continues. AAP Grand Rounds October 2007; 18 (4): 38–39. https://doi.org/10.1542/gr.18-4-38 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bronchiolitis, dexamethasone Source: Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007; 357:331–339; doi:10.1056NEJMoa071255 The bronchiolitis study group of the Pediatric Emergency Care Applied Research Network (PECARN) evaluated the effectiveness of a single oral dose of dexamethasone for bronchiolitis in a double-blinded, randomized, controlled trial. The study was conducted in 20 pediatric emergency departments during the months of November through April 2004 to 2006. Only previously healthy infants with a first episode of bronchiolitis that was assessed as moderate or severe based on a Respiratory Distress Assessment Instrument (RDAI) score of >6 (range 0 to 17) were eligible. A total of 600 infants two to 12 months old were enrolled in the study; 305 were randomized to the dexamethasone group (dose: 1 mg/kg, maximum 12 mg) and 295 to the placebo group. Study children received other treatments, such as inhaled bronchodilators, at the discretion of the examining physician. Eight infants were excluded from further analysis: two were admitted prior to receiving study medication, five received the wrong medication, and one received an insufficient dose of the medication. Respiratory Assessment Change Score (RACS), respiratory and heart rates, temperature, and oxygen saturation in room air were recorded one and four hours after drug administration and the decision to admit or discharge was made at the four-hour time point. Parents of study patients were contacted by telephone seven to ten days after the visit to determine if subsequent hospitalization, unscheduled medical visits, or adverse events had occurred. The primary outcome was whether the patient was discharged or hospitalized at the four-hour time point; RACS was a secondary outcome. Similar analyses comparing the efficacy of dexamethasone and placebo in the sub-group of children with a history of eczema or family history of asthma, were also conducted Baseline demographic and clinical characteristics were similar in the two groups. Among the 269 infants tested for respiratory syncytial virus (RSV), no difference in rate of hospitalization was found between those who were RSV-positive or -negative. There were no significant differences between infants in the dexamethasone or placebo group for mean RACS value and hospitalization rate (39.7% vs 41%, P=.74). Among those hospitalized the lengths of stay for infants in the two treatment groups were also not significantly different. Sub-group analyses had similar results. There were few adverse events, with no differences between the two groups. The authors conclude that one dose of oral dexamethasone failed to alter the respiratory status and subsequent outcome of infants with bronchiolitis. Drs. Rathore and Barton have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The use of corticosteroids in infants with bronchiolitis has been controversial, with several small studies providing contradictory results.1,2 A recent publication from one institution in Thailand, reviewed in these pages, found that a single dose of dexamethasone (0.6 mg/kg) administered to hospitalized... You do not currently have access to this content.

Uncommon Odynophagia: An Unusual Presentation of Retropharyngeal Free Air in an Adolescent

A previously healthy 15-year-old woman presented to the Emergency Department complaining of a 12-h history of severe odynophagia. She denied any recent fever, trauma, and ingestion of foreign body, and she reported only nasal congestion without cough or dyspnea. Her vital signs were as follows: temperature of 37°C, heart rate of 84 beats/min, respiratory rate of 16 breaths/min, blood pressure of 116/73 mm Hg, and a room air oxygen saturation of 100%. The oropharyngeal examination revealed erythema of the pharynx and 1+ tonsils without exudate, petechiae, asymmetry, or uvular deviation.

Pulmonary edema and respiratory failure associated with clenbuterol exposure

Background: Clenbuterol is a long-acting β 2-adrenergic agonist used outsidethe United States for treating pulmonary disorders and within the United States in veterinary medicine. Due to itspromotion of muscle growth and lipolysis ( β 3 effects), clenbuterol is illicitly exploited for livestock growth promotion and by bodybuilders. Recently, there have been reports of clenbuterol contamination of heroin and cocaine, resulting in prolonged tachycardia, hypokalemia, hypophosphatemia, and myocardial injury. We report a case of clenbuterol toxicity causing pulmonary edema and respiratory failure. Case report: The patient was a 33-year-old man who inhaled an unknown white powder and developed immediate onset of chest pain, palpitations, tremors, headache, nausea and vomiting. He presented to the emergency department, where the following initial vital signs were recorded: sinus tachycardia, 146 bpm; wide pulse pressure, 116/27 mm Hg; respiratory rate, 20/min; room air oxygen saturation, 99%. He was diaphoretic with a fine tremor and enlarged, reactive pupils. His electrocardiogram showed 1-millimeter ST depressions laterally. A working diagnosis of cocaine toxicity was made, and he was treated with 5 milligrams of intravenous lorazepam and 3 liters of normal saline without significant change in vital signs. Laboratory results were as follows: hypokalemia, 1.9 mmol/L; hypophosphatemia, 0.4 mg/dL; hyperglycemia, 230 mg/dL; lactate, 7.2 mmol/L; anion gap, 18. The patient was admitted to the intensive care unit, and treated with benzodiazepines and haloperidol for agitation, chest pain, and persistent tachycardia. Six hours after presentation, he desaturated to 64% on 100% oxygen. He was intubated for respiratory failure and CXR showed bilateral pulmonary edema. Ultrasound revealed bilateral oculated pleural effusions; creatinine kinase, 8880 U/L (normal rate, 25-185 U/L); creatinine kinase myocardial band, 57 ng/mL (normal rate, <5 ng/mL); troponin I, 1.18 ng/mL (normal rate, <0.4 ng/mL). He was extubated on hospital day 4 and discharged 9 days after initial presentation. His toxicology screen was negative for cocaine. His serum and urine analysis confirmed the presence of clenbuterol, at 6 and 874 ng/mL, respectively. Conclusion: Pulmonaryedema is a known complication of intravenous β 2-adrenergic agonists with a reported incidence of 5% in the obstetrics literature. The etiology is unknown but likely multifactorial, and can include cardiogenic mechanisms such as fluid overload and catecholamine-induced myocardial necrosis, and noncardiogenic mechanisms such as direct toxicity and increased pulmonary vessel permeability. This is the first documented case of pulmonary edema after inhalational β 2-adrenergic agonist exposure. Based on the recent epidemic of clenbuterol exposure, clinicians should be aware of the possibility of pulmonary edema and consequent respiratory failure.

Pulse oximetry coupled with spirometry in the emergency department helps differentiate an asthma exacerbation from possible vocal cord dysfunction

Spirometry performed by adolescents with refractory wheeze or stridor and respiratory distress, with normal room air oxygen saturation, may differentiate subjects not having an acute asthma exacerbation (AE-) from those who are (AE+). A subpopulation may also be identified that has flow volume loop (FVL) patterns consistent with vocal cord dysfunction (VCD). Spirometry was performed by adolescents who presented to a pediatric emergency department (ED) with respiratory distress attributed to an acute AE who, after therapy, were still symptomatic and had room air oxygen saturation > or = 97%. Spirometry findings were classified as: (a) consistent with an acute AE, (b) variable extrathoracic airway obstruction pattern consistent with VCD, (c) a combination of the two, or (d) normal airflow. Of 2,073 adolescent visits for asthma seen in the ED in 2005, 20 encounters among 17 adolescents were examined during the period of 0700-2200 on weekdays when an investigator was available, of which, 15 encounters were classified as AE-. In the AE- group, nine had FVL evidence of variable extrathoracic airway obstruction consistent with VCD, and six had normal spirometry. Three of the five encounters that were AE+ had FVL evidence consistent with VCD. Spirometry, performed on therapy-resistant wheezing or stridorous adolescent patients in respiratory distress with oxygen saturation > or =97%, may help differentiate patients who are not having an acute AE from those who are. In those subjects not having an acute AE, respiratory distress may prove to be due to VCD.

Cardiac complications of a dengue fever outbreak in Sri Lanka, 2005

A high incidence of cardiac complications was observed in an outbreak of dengue fever at General Hospital, Peradeniya, Sri Lanka, in 2005. This report describes 120 serologically confirmed dengue fever patients who presented during the outbreak. Seventy-five (62.5%) of these patients had electrocardiogram changes (T inversion, ST depression, bundle branch blocks) and were assigned to the 'cardiac group' (50 females, 25 males; median age 34 years, range 13-76). These patients were more susceptible to fatigue, dyspnoea, low peripheral oxygen saturation in room air (P=0.001), chest pain (P=0.001) and flushing of skin (P=0.05) than 45 (37.5%) patients who had normal electrocardiograms and made up the 'non-cardiac group'. In the cardiac group there were 31 primary and 44 secondary dengue patients. In the cardiac group, 17 (23%) patients had hypotension and 58 (77%) developed tachycardia and bradycardia (P<0.001) compared to four (9%) in the non-cardiac group, suggestive of significant cardiac dysfunction. There was no correlation between pulse rate and body temperature: cardiac group (r=0.05; P=0.63); non-cardiac group (r=0.11, P=0.46). RT-PCR detected DEN-3 in three cardiac patients.

Presentation of Congenital Heart Disease in the Neonate and Young Infant

Presentation of Congenital Heart Disease in the Neonate and Young Infant

Bi-fascicular block on EKG as the initial presenting sign of cardiac sarcoidosis

A 41-year-old commercial painter with a history of tobacco use presented to the emergency department with complaints of cough, pleuritic chest pain and worsening dyspnea with exertion beginning 3 days prior to arrival. He had not responded to an outpatient regimen of bronchodilators and antibiotics. The patient denied any constitutional symptoms.

Bilateral Whole Lung Lavage in the Treatment of Pulmonary Alveolar Proteinosis

To the Editor: We present a case of pulmonary alveolar proteinosis managed by bilateral whole lung lavage. A 45-year-old woman weighing 56 kg presented with worsening dyspnea and was diagnosed with pulmonary alveolar proteinosis. Her room air oxygen saturation was 78%–83%, and her Pao2 was 56 mm Hg. Whole lung lavage was recommended to improve her symptoms (1,2). Anesthesia was induced with propofol. Her trachea was intubated with a 35F double-lumen tube, and we verified that the lungs could be isolated. Anesthesia was maintained with propofol (75–100 μg · kg−1 · min−1). Muscle relaxation was provided with rocuronium. The lungs were ventilated using 100% O2. The lungs were isolated, and the right lung was lavaged with warm isotonic saline until the effluent became clear, while the left lung was ventilated. After lavage, the right lung was suctioned and ventilated until tidal volume returned to baseline. The left lung was then lavaged in the same manner. Her hemodynamics remained stable throughout the procedure. Marked radiologic improvement was evident the next day (Fig. 1), and the room air Pao2 improved to 77 mm Hg.Figure 1.: Radiographs showing marked improvement after bilateral whole lung lavage.Palas Kumar, MD Saikat Sengupta, MD, DNB Amitava Rudra, MD, MNAMS Gaurab Maitra, MD Department of Anesthesiology, Perioperative Medicine and Pain Suresh Ramasubban, AB (Pulm Med) Ansuman Mukhopadhyay, MD, DNB Department of Pulmonary Medicine Apollo Gleneagles Hospitals Kolkata, India [email protected]

Pediatric hepatopulmonary syndrome is seen with polysplenia/interrupted inferior vena cava and without cirrhosis

Hepatopulmonary syndrome (HPS) is a triad of liver dysfunction, hypoxemia, and intrapulmonary vascular dilatation. We describe the prevalence and clinical features of HPS at a pediatric liver transplant center. Patients referred to Children's Healthcare of Atlanta/Emory University transplant program from February 1999 to May 2005 were reviewed. Oxygen saturation in room air was screened by percutaneous pulse oximetry. HPS cases were compared with similar age non-HPS recipients (n = 38) to determine differences in clinical characteristics, Pediatric End-Stage Liver Disease (PELD) scores, and posttransplantation survival. Of 211 patients referred and 114 patients transplanted, 7 met criteria for HPS (3.3% and 6.1%, respectively). Patients with HPS had lower PELD score (-0.4 +/- 5.9 vs. 11 +/- 11; P = 0.01) and total bilirubin (1.7 +/- 1.1 vs. 11.2 +/- 10.1; P = 0.02) at the time of transplantation. Four of 7 patients with HPS had polysplenia/interrupted inferior vena cava (PS/IVC) compared with 0 of 38 age-matched controls (P = 0.0002). Three patients with HPS did not have cirrhosis; 2 of these 3 had PS/IVC. All HPS cases normalized room air oxygen saturation by 6 months, and survival after transplantation in HPS cases was 100%. Marked hepatic synthetic or biochemical dysfunction may not be present, and cirrhosis is not a requirement for the development of HPS in children. HPS in children is frequently associated with PS/IVC. Histologic evidence of abnormal intrahepatic portal vein flow and the demonstration of portosystemic communications at any level should be sought in children presenting with unexplained intrapulmonary vascular dilatation. Liver transplantation for HPS in childhood may be appropriate even in the absence of cirrhosis.

SPIROMETRY COUPLED WITH PULSE OXIMETRY IN THE EMERGENCY DEPARTMENT TO RULE OUT STATUS ASTHMATICUS AND SUGGEST VOCAL CORD DYSFUNCTION

PURPOSE: Normal room air oxygen saturation measured by pulse oximetry in adolescents presenting with refractory wheeze and respiratory distress may suggest a condition other than status asthmaticus. Spirometry performed by these individuals may delineate those that are not in status asthmaticus (SA-) from those who are (SA+). A subpopulation may also be identified that has flow volume loop (FVL) patterns consistent with vocal cord dysfunction (VCD).