Predictors Of Respiratory Failure Research Articles

Application of the Rox Index as a Predictor of Respiratory Failure in Pediatric Patients Receiving High-Flow Oxygen Therapy Support at the Roberto Gilbert Elizalde Hospital

Background: High-flow oxygen therapy is an ideal treatment for managing respiratory failure. It avoids orotracheal intubation; however, some patients are refractory to this treatment. The ROX Index aims to detect early failure in high-flow oxygen therapy; nevertheless, its use has been poorly studied in pediatrics. Objective: To evaluate the applicability of the ROX Index as a tool to determine the failure of high-flow oxygen therapy in pediatric patients admitted to the Roberto Gilbert Hospital. Methodology: Observational, prospective, longitudinal cohort study with a descriptive approach including 209 patients between 1 month and 17 years old who required high-flow oxygen therapy within the first 24 hours. ROX Index measurements were taken at 2, 4, 6, 12, and 24 hours with follow-up to determine the outcome. Result: A total of 209 patients meeting the inclusion criteria were obtained; 27 (12.9%) required endotracheal intubation (ETI), and 182 (87%) received high-flow oxygen therapy (HFNC). A higher frequency of younger infants was observed among patients who required ETI, with a median age of 12 months. A significant difference in the ROX index was found from two hours onwards with cutoff points on the AUROC curve above 0.5. Conclusion: It was determined that the ROX Index can be used as a complementary tool to strengthen decision-making in pediatrics.

Diabetes Mellitus Predicts Severe Respiratory Failure After Aortic Arch Replacement

Objective: The lung is a target organ of diabetes mellitus (DM) via glycation of pulmonary elastin and collagen. In addition, hyperglycemia facilitates hypercapnic respiratory failure, which is instead mitigated by low‐carbohydrate high‐lipid (LC‐HL) nutrition. We sought to determine the association between diabetes and severe respiratory failure (SRF, i.e., need of reintubation\tracheostomy) after open aortic arch replacement (AAR).Methods: Machine learning algorithms were evaluated for precision and recall (F2 score) and for clinical applicability to predict SRF. Conditional regression evaluated independent predictors of SRF after 1:2 propensity‐score matching.Results: Information on diabetic status was available in 1275 patients undergoing AAR (1997–2023). Although support vector machine presented the highest F2 score (F2 = 0.337), conditional inference trees provided the most clinically applicable algorithm: diabetes was the best predictor of SRF, which occurred in 20/150 diabetics (13.3%) vs. 40/1125 nondiabetics (3.6%) (p < 0.01). In diabetics, left ventricular ejection fraction (LVEF) was the next best predictor of SRF, which occurred in 8/20 diabetics with LVEF ≤ 30% (40%) vs. 12/130 diabetics with LVEF >30% (9.2%) (p = 0.02). In nondiabetics, chronic obstructive pulmonary disease (COPD) was the next best predictor of respiratory failure, which occurred in 14/177 nondiabetics with COPD (7.9%) vs. 26/948 nondiabetics without COPD (2.7%) (p = 0.01). In the matched sample, diabetes was independently able to predict SRF (OR 2.20, 95% CI 1.10 | 4.42).Conclusions: DM was the best predictor of SRF after AAR. Strict glycemic control and LC‐HL nutrition should be evaluated as measures to reduce postoperative SRF in diabetic patients.

Postprandial hypotension as a predictor of respiratory failure in patients with foodborne botulinum intoxication – a case-control study in outbreak investigation

ObjectivesBotulism is a rare syndrome characterized by acute, flaccid paralysis with possible involvement of respiratory muscle-producing pump failure requiring mechanical ventilation. A predominance of autonomic involvement can occur. MethodsWe enrolled patients affected by foodborne botulism during an outbreak. All patients underwent the detection of the toxin in stool specimens, and 24-hour ambulatory blood pressure monitoring (ABPM). A blinded expert operator analyzed ABPM data for the diagnosis of hypertension and postprandial hypotension (PPH). ResultsTwenty male patients met the inclusion and exclusion criteria. Thirty-four healthy subjects matched for sex and age were enrolled as a control group. PPH was significantly more frequent in the botulin group than in healthy subjects (40% vs 2.9%, P <0.0001). At the logistic regression, the probability that patients affected by botulinum could require ventilation was increased by 733% (adjusted odds ratio: 8.33) when PPH is encountered. ConclusionsThe likelihood of resorting to ventilation in subjects with botulinum intoxication was seven times greater in patients presenting PPH. These results could allow the prompt identification of patients at high risk for requiring ventilation.

An S-like curve relationship between systemic inflammation response index (SIRI) and respiratory failure in GBS patients.

Our study examined the association between the initial systemic inflammation response index (SIRI) and respiratory failure in patients with Guillain-Barré syndrome (GBS). The weighted linear regression model, weighted chi-square test, logistic regression models, smooth curve fittings, and the two-piece linear regression model were utilized for data analysis. Among the 443 GBS patients, 75 (6.9%) had experienced respiratory failure. According to logistic regression models, there existed no consistent linear relationship between respiratory failure and SIRI in model 1 (OR = 1.2, p < 0.001), model 2 (OR = 1.2, p < 0.001), and model 3 (OR = 1.3, p = 0.017). However, smooth curve fittings found an S-like curve relationship between SIRI and respiratory failure. Furthermore, when SIRI was < 6.4, there existed a positive correlation between SIRI and respiratory failure in model 1 (OR = 1.5, 95% CI = (1.3, 1.8), p < 0.0001), higher correlation in model 2 (OR = 1.6, 95% CI = (1.3, 1.8), p < 0.0001), and highest correlation in model 3 (OR = 1.6, 95% CI = (1.3, 2.5), p < 0.0001). SIRI can be used as a predictor of respiratory failure in GBS, and an S-like relationship exists between SIRI and respiratory failure at an infliction point of 6.4. When the SIRI was less than 6.4 and increased, SIRI was associated with a higher occurrence of respiratory failure. The risk of respiratory failure was no longer increased when the SIRI was over 6.4.

The Value of Interleukin-6 among Several Inflammatory Markers as a Predictor of Respiratory Failure in COVID-19 Patients

The Value of Interleukin-6 among Several Inflammatory Markers as a Predictor of Respiratory Failure in COVID-19 Patients

Analysis of Clinical Features and Risk Factors in Pregnant Women With Miliary Pulmonary Tuberculosis After In Vitro Fertilization Embryo Transfer.

PurposeMiliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies.MethodThe demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann–Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure.ResultsA total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366–995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159–184.213, P = 0.008) were independent predictors for respiratory failure.ConclusionTube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

Predictors of respiratory failure after thoracic surgery: a retrospective cohort study with comparison between lobar and sub-lobar resection.

ObjectiveOnly approximately 15% of patients with lung cancer are suitable for surgery and clinical postoperative outcomes vary. The aim of this study was to investigate variables associated with post-surgery respiratory failure in this patient cohort.MethodsPatients who underwent surgery for lung cancer were retrospectively studied for respiratory function. All patients had undergone lung resection by a mini-thoracotomy approach. The study population was divided into two subgroups for comparison: lobectomy group, who underwent lobar resection; and sub-lobar resection group.ResultsA total of 85 patients were included, with a prevalence of lung cancer stage IA and adenocarcinoma histotype. Lobectomy (versus sub-lobar resection), the presence of chronic obstructive pulmonary disease (COPD), and a COPD assessment test (CAT) score >10, were all associated with an increased risk of respiratory failure. The partial pressure of arterial oxygen decreased more in the lobectomy group than in the sub-lobar resection group following surgery, with a significant postoperative between-group difference in values. Postoperative CAT scores were also better in the sub-lobar resection group.ConclusionsPost-surgical variations in functional parameters were greater in the group treated by lobectomy. COPD, high CAT score and surgery type were associated with postoperative development of respiratory failure.

AN UNUSUAL CAUSE OF RECURRENT PNEUMONIAS

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Granulomatosis with polyangiitis (GPA) is a necrotizing small vessel vasculitis classically involving the upper and lower respiratory tract and kidneys. We present a patient with GPA which initially presented as "recurrent pneumonias" unresponsive to antibiotics ultimately culminating in a presentation with alveolar hemorrhage and respiratory failure. CASE PRESENTATION: A 70-year-old man presented to the Emergency Department with dyspnea and hemoptysis. He had been hospitalized several times over the preceding month for recurrent pneumonia, and recently had been started on systemic anticoagulation for a pulmonary embolism. On arrival he was afebrile, tachycardic, hypoxemic and tachypneic. Exam revealed coarse bilateral breath sounds. Laboratory studies were significant for anemia, leukocytosis, acutely elevated creatinine and microscopic hematuria. CT Chest showed diffuse consolidation and ground glass opacities markedly worse than 1 week prior. He was initiated on broad spectrum antibiotics and admitted to the ICU. The patient was intubated for progressive respiratory failure and hemoptysis; bronchoalveolar lavage demonstrated a progressively bloody return. C-ANCA and PR3 antibodies were positive; broad infectious evaluation and other autoimmune serologies were negative. A presumptive diagnosis of ANCA associated vasculitis was made and treatment with methylprednisolone 1,000 mg daily was initiated then transitioned to prednisone 1 mg/kg daily after 3 days. Renal biopsy confirmed GPA; rituximab was added with rapid improvement. DISCUSSION: GPA is a systemic vasculitis with variable pulmonary manifestations, ranging from asymptomatic disease to respiratory failure. Specific manifestations include tracheobronchial stenosis, inflammatory lesions, interstitial lung disease, and diffuse alveolar hemorrhage (DAH). Image findings include pulmonary nodules with or without cavitation, ground glass and consolidation. Delayed diagnosis is common, necessitating a high index of suspicion. Involvement and disruption of the alveolar capillaries leads to alveolar hemorrhage, and early bronchoscopy can facilitate identification of DAH, exclusion of other potential etiologies, and lead to early diagnosis and treatment. Induction therapy for severe GPA, defined as life or organ threatening disease, includes high dose intravenous corticosteroids in combination with cyclophosphamide or rituximab. While DAH may be a life-threatening complication of GPA, most patients achieve remission and survive to hospital discharge. CONCLUSIONS: Severe presentations of GPA include diffuse alveolar hemorrhage and respiratory failure. Image findings may be non-specific, and early bronchoscopy in the setting of persistent symptoms and pulmonary findings can accelerate identification and initiation of life saving treatment. REFERENCE #1: Chung MP, Yi CA, Lee HY, Han J, Lee KS. Imaging of Pulmonary Vasculitis. Radiology. 2010;255(2):322-341. doi:10.1148/radiol.10090105 REFERENCE #2: Polychronopoulos VS, Prakash UBS, Golbin JM, Edell ES, Specks U. Airway Involvement in Wegener's Granulomatosis. Rheumatic Disease Clinics of North America. 2007;33(4):755-775. doi:10.1016/j.rdc.2007.09.004 REFERENCE #3: Cartin-Ceba R, Diaz-Caballero L, Al-Qadi MO, et al. Diffuse Alveolar Hemorrhage Secondary to Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Predictors of Respiratory Failure and Clinical Outcomes. Arthritis & Rheumatology. 2016;68(6):1467-1476. doi:10.1002/art.39562 DISCLOSURES: No relevant relationships by Scott Canepa, source=Web Response No relevant relationships by Bryan Kelly, source=Web Response No relevant relationships by Alexander Niven, source=Web Response

The Value of Interleukin-6 among Several Inflammatory Markers as a Predictor of Respiratory Failure in COVID-19 Patients.

Patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure within a short period during the clinical course. It is essential to predict respiratory deterioration in the short term. We investigated the use of inflammatory markers to predict respiratory distress within three days from their analysis in COVID-19 patients. This retrospective observational study included 81 patients admitted with COVID-19. Patients were divided into two groups according to whether the maximum fraction of inspired oxygen (FiO2) for three days from the blood marker measurements was ≥0.4 (high FiO2 group; HFG) or <0.4 (low FiO2 group; LFG). Interleukin-6 (IL-6), C-reactive protein (CRP), lactate dehydrogenase (LDH), white blood cell, D-dimer, and creatinine levels were compared between the two groups. The levels of all markers were significantly higher in HFG patients. Areas under the receiver operating characteristic curve of IL-6, CRP, and LDH had high values of 0.85, 0.82, and 0.81, respectively. The odds ratio of IL-6 which was crude and adjusted for dexamethasone administration initiated before laboratory measurement, showed the high value of 29.1 (5.6–295.6) and 53.9 (4.5–3242.8), respectively. IL-6 can be used as a reliable marker for predicting respiratory illness within three days after assessment.

Lactate dehydrogenase and C-reactive protein as predictors of respiratory failure in CoVID-19 patients

ObjectiveThe dramatic worldwide CoVID-19 infection requires the identification of a reliable and inexpensive tool to quickly discriminate patients with a more unfavorable outcome. MethodsWe performed routine laboratory tests suitable to identify tissue damage and inflammatory status in 123 consecutive CoVID-19 patients admitted to the Emergency Department of the hospital of Piacenza (Emilia-Romagna, Northern Italy). The results were correlated with patients’ respiratory function evaluated by the partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2). ResultsThe most common laboratory abnormalities were lymphocytopenia and elevated values of C-reactive protein (CRP) and lactate dehydrogenase (LDH). Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK) were also increased. The respiratory performance (PaO2/FiO2) showed a strong inverse correlation with LDH (r = 0.62, r2 0.38, p value < 0.0001) and CRP (r = 0.55, r2 0.31, p value < 0.0001). PaO2/FiO2 values also showed a significant inverse correlation with age (r = −0.37, p < 0.0001), AST (r = −0.31, p < 0.01), WBC (r = −0.49, p < 0.0001), neutrophils count (r = −0.5, p < 0.001). ROC curves showed a sensitivity of 75% and specificity of 70% for the LDH cut-off value of 450 U/L and a sensitivity of 72% and specificity of 71% for the CRP cut-off value of 11 mg/dl in identifying CoVID-19 with moderate-severe ARDS. ConclusionsLDH and CRP may be related to respiratory function (PaO2/FiO2) and be a predictor of respiratory failure in CoVID-19 patients. LDH and CRP should be considered a useful test for the early identification of patients who require closer respiratory monitoring and more aggressive supportive therapies to avoid poor prognosis.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair.

Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7kg/m2, age of 58.5 ± 12.4years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24h respiratory support with ezPAP, CPAP, or biPAP(RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

Predictors of respiratory failure in acute organophosphorus compound poisoning

Predictors of respiratory failure in acute organophosphorus compound poisoning

Predictors of Respiratory Failure in Patients Supported with Continuous Flow Ventricular Assist Devices and the Effect on Survival

Predictors of Respiratory Failure in Patients Supported with Continuous Flow Ventricular Assist Devices and the Effect on Survival

Predictors of respiratory failure in patients with Guillain-Barré syndrome: a systematic review and meta-analysis.

To systematically review the literature regarding the ability of clinical features to predict respiratory failure in patients with Guillain-Barré syndrome (GBS). We searched the PubMed and Ovid MEDLINE databases with the search terms "guillain barre syndrome" OR "acute inflammatory demyelinating polyneuropathy" OR "acute motor axonal neuropathy" OR "acute motor sensory axonal neuropathy" AND "respiratory failure" OR "mechanical ventilation". We excluded articles that did not report the results of original research (eg, review articles, letters), were case reports or series (ten or fewer patients), were not available in English, reported research in paediatric populations (16 years of age or younger), or were interventional studies. Article quality was assessed with the Newcastle-Ottawa quality assessment scale. Thirty-four relevant studies were identified. Short time from symptom onset to hospital admission (less than 7 days), bulbar (odds ratio [OR], 9.0; 95% CI, 3.94-20.6; P < 0.001) or neck weakness (OR, 6.36; 95% CI, 2.32-17.5; P < 0.001), and severe muscle weakness at hospital admission were associated with increased risk of intubation. Facial weakness (OR, 3.74; 95% CI, 2.05-6.81; P < 0.001) and autonomic instability (OR, 6.40; 95% CI, 2.83-14.5; P < 0.001) were significantly more frequent in patients requiring intubation in our meta-analyses; however, the differences were not statistically significant in individual multivariable analysis studies. Four predictive models have been developed to assess the risk of respiratory failure for patients with GBS, each with good to excellent discriminative power (area under the receiver operating characteristic curve, 0.79-0.96). Early identification of GBS patients at risk of respiratory failure could reduce the rates of adverse outcomes associated with delayed intubation. Algorithms that predict a patient's risk of subsequent respiratory failure at hospital admission appear more reliable than individual clinical variables.

Bronchial Mismatch as a Predictor of Respiratory Failure After Congenital Tracheal Stenosis Repair

The purpose of this study was to identify predictors of postoperative respiratory failure after surgical tracheoplasty for congenital tracheal stenosis. Between February 2011 and April 2017, 16 infants underwent congenital tracheal stenosis repair. Preoperative computed tomography evaluation of the trachea and mainstem bronchi was performed. The primary outcome was midterm freedom from postoperative respiratory failure defined as persistent need for mechanical ventilation or surgical tracheobronchial reoperation. Bronchial mismatch, defined as [1- (smaller bronchus diameter / larger bronchus diameter)]× 100, was analyzed in relation to the primary outcome. Median age was 106 days (range, 1 to 406) and median weight was 5.3 kg (range, 2.6 to 8 kg). Four patients were neonates (25%) and 6 had genetic abnormalities (37.5%). There were no early nor late deaths. Median ventilation time was 5.5 days (range, 3 to 45). Mean follow-up time was 2.2 years (range, 0.1 to 4.5). Four patients with bronchial mismatch greater than 20% had postoperative respiratory failure (p= 0.002). Two of them underwent tracheostomy and were discharged with ventilation home care support. One underwent successful reoperation consisting of bilateral bronchial plasty with autologous cartilage rib grafts, and the other underwent successful right bronchial and tracheal reconstruction. One patient with bilateral bronchial hypoplasia underwent slide tracheoplasty associated with preemptive bilateral bronchial plasty and made a full recovery. Surgical treatment of congenital tracheal stenosis in neonates and infants portends a good outcome. Bronchial mismatch greater than 20% can identify a subset of patients at increased risk for surgical reintervention and chronic respiratory failure. Slide tracheoplasty with preemptive bronchial reconstruction may prevent postoperative respiratory failure.

Phrenic Nerve Conduction Study in the Early Stage of Guillain-Barre Syndrome as a Predictor of Respiratory Failure.

Background:Guillain-Barré syndrome (GBS) has unpredictable clinical course with severe complication of respiratory failure.Objective:To identify clinical profiles and electrophysiological study particularly non-invasive Phrenic nerve conduction study in patients of early GBS to predict respiratory failure.Methods:64 adult (age≥18yrs) patients of early GBS (onset ≤ 14 days) during the study period from January 2014 to October 2015 were evaluated by clinical profiles of age, gender, antecedent infection, time to peak disability, single breath counts, cranial nerve involvement, autonomic dysfunction and non-invasive Phrenic nerve conduction study. Patients with predisposition factors of polyneuropathy like diabetes mellitus, hypothyroidism, vitamin deficiency, renal failure were excluded.Results:Among 64 patients abnormal phrenic nerve conduction study was seen in 65.62% cases (42/64) and 45.23% (19/42) of them developed respiratory failure. Phrenic nerve sum latency, amplitude, duration and area were abnormal in those who developed respiratory failure and they had sum of phrenic nerve latency >28 msec, sum of CMAP amplitude <300 μV, sum of CMAP duration >50 msec and sum of area < 4 mVmS. None with normal phrenic nerve study developed respiratory failure. It was found that age, gender, preceding infection, autonomic involvement and types of GB syndrome had no influence on development of respiratory failure (p>0.05). Rapid disease progression to peak disability, more severe disease, shorter single breath counts and cranial nerve involvement were seen more often in patients with respiratory failure.Conclusion:Abnormal Phrenic nerve conduction study in the early Guillain-Barré syndrome might be of great value independently in predicting impending respiratory failure.

Advances in Management of Diffuse Alveolar Hemorrhage in ANCA-Associated Vasculitis

SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a potential complication of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV). The clinical course of these patients varies making triage difficult. Herein, we describe an AAV case that presented with DAH and progressed to respiratory failure. Recent literature will be applied to outline clues to predict respiratory failure in this patient and treatment recommendations will be discussed. CASE PRESENTATION: A 21 year old male with granulomatosis with polyangiitis presented with a cough and dyspnea. Chest x-ray demonstrated bilateral pulmonary infiltrates. He was saturating 93% on room air and labs demonstrated a hemoglobin of 11.0 g/dL. He was admitted to the general floor. Bronchoscopy was completed and demonstrated progressively bloodier return confirming diffuse alveolar hemorrhage. BAL showed 66% neutrophils. He progressed to respiratory failure and required intubation. He was treated with high-dose glucocorticoids, plasma exchange and rituximab and responded to therapy with no recurrences of DAH or flares of his disease. DISCUSSION: DAH is potentially life-threatening. In one study of patients with AAV and DAH 47% required mechanical ventilation and there was an 11% mortality rate.1 Factors that predicted respiratory failure in DAH included Sp02/Fi02 <450 at presentation, >30% neutrophils on BAL and CRP >25 mg/dl with the Sp02/Fi02 ratio having the greatest predictive value. This patient had signs of impending respiratory failure with a Sp02/Fi02 ratio of 442 on admission and 66% neutrophils present on BAL. With this new evidence, consideration may have been given to triage this patient to a higher level of care on admission and promptly initiate therapy. There is little evidence regarding choice of induction agent in patients with AAV and DAH who require mechanical ventilation. One recent study suggests similar mortality rates and increased remission rates when rituximab compared to cyclophosphamide is used for induction in this patient population.1 The evidence for plasma exchange for DAH is limited with only a few retrospective studies with conflicting results published to date. The ongoing PEXIVAS trial will add insight into its utility. CONCLUSIONS: DAH is a severe disease manifestation of AAV that requires prompt definitive treatment. The Sp02/Fi02 ratio is the strongest predictor for progression to respiratory failure and should be used to triage patients. Rituximab is at least as effective as cyclophosphamide for remission induction in patients with DAH, even those in respiratory failure. The role of PLEX for DAH remains unknown. This is currently being explored by the ongoing PEXIVAS trial. Reference #1: Cartin-Ceba R, Diaz-Caballero L, Alqadi MO, Tryfon S, Fervenza FC, Ytterberg SR, Specks U. Diffuse alveolar hemorrhage secondary to ANCA-associated vasculitis: Predictors of respiratory failure and clinical outcomes. Arthritis Rheumatol. 2015;29. DISCLOSURE: Ulrich Specks: Grant monies (from industry related sources): Genentech <$10,000 in 2016 The following authors have nothing to disclose: Gwen Thompson, Rodrigo Cartin-Ceba No Product/Research Disclosure Information

Risk factors for and impact of respiratory failure on mortality in the early phase of acute pancreatitis

BackgroundThe incidence of respiratory failure and other respiratory complications in the early phase of acute pancreatitis (AP) is not well investigated. ObjectiveTo evaluate the incidence and risk factors of respiratory failure, and its impact on mortality in the early phase AP. MethodsRetrospective cohort study including 359 patients admitted with acute pancreatitis. Information was gathered from electronic patient records. We defined respiratory failure based on the modified Marshall scoring system in the revised Atlanta criteria. Predictors of respiratory failure were evaluated in univariable and multivariable logistic regression analysis. ResultsThe cohort included 188 women and 171 men with a mean age of 56.1 years. Respiratory complications including pleural effusion, pneumonia and atelectasis were registered in 80 patients (22%), 100 (29%) needed oxygen therapy, 27 (8%) continuous positive airway pressure, and six (2%) mechanical ventilation. Thirty-two patients (9%) were treated with bronchodilators and 12 (3%) with steroids. Thirty-one patients (9%) fulfilled the diagnostic criteria for respiratory failure. Five of these patients (16%) did not have effusion, atelectasis or pneumonia. Predictors of respiratory failure in multivariable analysis were age (OR 1.04; CI 95% (1.03–1.07)) and smoking (OR 2.67; CI 95% (1.21–5.86)). Thirteen patients died in hospital. The Kaplan-Meier curves and log-rank tests showed that patients with respiratory failure had increased in-hospital mortality as did patients with cardiovascular and renal failure (P < 0.01 for all analyses). ConclusionsRespiratory complications are frequent in the early phase of AP. Respiratory, cardiovascular and renal failure is associated with a poor outcome. The fact that patients without effusion, atelectasis, or pneumonia may develop respiratory failure, suggests that acute lung injury, possibly associated with systemic inflammation, may be important.

Lung Ultrasound as a Predictor of Mechanical Ventilation in Neonates Older than 32 Weeks

Background: The prognosis of neonatal respiratory distress may be difficult to estimate at admission. Lung ultrasound is a useful diagnostic tool that is quick, requires little training, and is radiation free. Objective: This study aims to analyze whether early lung ultrasound can predict respiratory failure. Methods: From January to December 2014, lung ultrasound was performed on neonates admitted with breathing difficulties if they were older than 32 weeks and not intubated. A neonatologist, not aware of the patient's clinical condition, analyzed the stored ultrasound images. The findings were classified into the following 2 groups according to the potential risk of a bad respiratory outcome: low risk (normal or transient tachypnea of the newborn) or high risk (respiratory distress syndrome, meconium aspiration syndrome, pneumothorax, or pneumonia). A second investigator made the same classification after reading the chest X-rays. Respiratory failure was defined as a need for mechanical ventilation during the first day of life. Results: In total, 105 neonates were recruited (64.8% in the low-risk sonography group and 35.2% in the high-risk sonography group). Of those, 20% needed intubation, and this was more frequent in the high-risk group (relative risk = 17.5; 95% CI 4.3-70.9, p < 0.01). As predictors of respiratory failure, lung ultrasound and chest X-ray showed a high index of agreement (κ coefficient = 0.91; 95% CI 0.83-1, p < 0.01) and good accuracy (ultrasound: 95% sensitivity, 82.5% specificity, and a negative predictive value of 98.5%). Conclusions: Early lung ultrasound is a useful tool to determine which neonates admitted with respiratory distress will require mechanical ventilation. It may help the clinician to carrying out appropriate transfers.

Role of Repetitive Nerve Stimulation, Serum Creatine Phosphokinase and Lactate Dehydrogenase in Early Prediction of Respiratory Failure in Acute Organophosphorus Poisoning

The most serious complication associated with acute organophosphorus (OP) poisoning is intermediate syndrome (IMS) due to the possibility of developing respiratory failure. Abnormalities observed in repetitive nerve stimulation (RNS) may help to assess severity of IMS and eventually help to predict the cases which are more liable to develop respiratory failure. Also, some researchers suggested that IMS is associated with rhabdomyolysis which is followed by a rise in creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) serum levels. The aim of this work was to study the role of RNS and serum levels of CPK and LDH in predicting respiratory failure in acute OP poisoning. The study was carried out on 55 patients who were diagnosed as acute OP poisoning and admitted at Poison Control Center, Zagazig University Hospitals in the period from April 2013 to June 2014. The patients were subjected to estimation of serum pseudocholinesterase, CPK and LDH levels at time of admission and repeated at the 4th day of poisoning. Also, RNS test at 3 hertz (HZ) frequency was done to all patients at 2nd, 3rd and 4th day of poisoning (the period at which IMS is expected). At the end of the study, it was found that the patients who developed respiratory failure showed significant increase in decrement response recorded by RNS and in serum CPK level. On the other hand, there was non-significant difference between patient who developed respiratory failure and those who didn’t as regard serum LDH level. It was concluded from this study that, RNS test at 3 HZ and serum CPK level can be used as early predictors of respiratory failure in acute OP poisoning and it’s recommended to use them especially in patients who are clinically diagnosed as severe poisoning at time of admission.