Pulmonary Collapse Research Articles

Acute respiratory distress following an otherwise normal, uneventful, screening colonoscopy

A 62-year-old man with a past history of sleep apnea syndrome, umbilical and left inguinal hernia repairs, was referred to the emergency room for acute respiratory distress. He had underwent a screening colonoscopy 12 h earlier for a family history of colonic adenoma. This colonoscopy was complete, normal, and uneventful.A plain chest X-ray showed a distended colon extending to the upper third of the right side of the chest (Fig. 1). Further anamnesis helped the patient to remember a right diaphragmatic hernia, well-documented by CT-scan years ago. He had not previously mentioned this condition, when evaluated for colon screening.The patient was admitted to the surgical intensive care unit. A CT-scan confirmed a right diaphragmatic hernia with terminal ileum and ascending colon content, no sign of mesenteric ischemia, and massive pulmonary collapse. Conservative treatment with nasogastric suction quickly improved the patient's condition. He was discharged at day-6. Diaphragmatic hernia repair was scheduled 10 weeks later. Laparoscopy showed a complete agenesis of the right diaphragmatic dome (Fig. 2; Fig. 3), and was therefore converted into laparotomy for complete surgical repair. Postoperative course was unremarkable. Patient was discharged on day-6. Follow-up at 1 month was uneventful.Congenital diaphragmatic hernias are rare and usually diagnosed in the pre- natal period or in neonates with respiratory distress, calling for emergency neonatal repair [1,2]. In underdiagnosed or neglecting adults, the condition can be life-threatening, as seen in our patient [3,4]. Surgical repair is therefore strongly recommended, even in asymptomatic patients [5]. Recurrences are exceptional.

Assessment of Chest Tube Management Knowledge among Critical Care Nurses in a Tertiary Care Cardiac Hospital: A Descriptive Study

Objectives: Chest tubes play a critical role in managing intra-pleural pressure imbalances and preventing potentially fatal outcomes such as pulmonary collapse. The management of chest tubes is primarily the responsibility of nursing care in patients reliant on this intervention. This study aimed to assess the level of knowledge regarding chest tube management among critical care nurses at a tertiary care cardiac hospital in Karachi, Pakistan. Methodology: This descriptive cross-sectional study utilized a convenient sampling method, involving a sample size of n=120 participants. Data collection involved a structured questionnaire comprising demographic parameters followed by an 18-item questionnaire assessing knowledge of chest tube management. Knowledge scores were calculated as the percentage of correct responses to the 18 knowledge-related questions. Results: Among the 120 nurses surveyed, 59.2% (71) were male, 55% (66) were under 36 years of age, and 66.7% (80) had up to 10 years of work experience. Only 20% (24) had participated in training courses regarding thoracic diseases. The mean knowledge score was 57.3 ± 17.2, with 30% (36) categorized as having low knowledge (<50%), 65% (78) as moderate knowledge (50% to 80%), and 5% (6) as high knowledge (>80%). Conclusion: The study revealed a moderate level of knowledge concerning chest tube management among critical care nurses in a tertiary care cardiac center. There is a need for structured and comprehensive training programs focusing specifically on chest tube management to enhance nurses proficiency in this critical area of patient care.

Advanced mask region-based convolutional neural network based deep-learning model for lung cancer detection

Millions of individuals are affected each year by lung cancer, a serious global health concern. It may also cause numerous potentially fatal pulmonary problems, including infections, hemorrhage, or collapse. Finding a consistent and an effective way to ascertain lung cancer using medical imaging techniques is one of the primary issues in medical image processing. The difficulty of this task stems from the fact that the regions of the lungs that are affected by cancer might differ greatly in expressions of their size, location, shape, and aesthetics. Identifying whether the identified area is benign (non-cancerous) or malignant (cancerous) is another difficult task. Finding the appropriate course of treatment for the patient will depend on this. A critical stage in the identification of lung malignancy is identifying the knobs that are expected to be malevolent. To solve these issues, in this study work we employ a deep learning methodology based on Mask region-based convolutional neural network (Mask-RCNN). For the purpose of identifying and locating infected lung regions on computed tomography (CT) scan images, model is built utilizing the customized Mask-RCNN. In accordance with the evaluation's findings, the model scored 99.32% for accuracy and 99.45% for mean DICE, respectively.

Phenotyping Down syndrome: discovery and predictive modelling with electronic medical records.

Individuals with Down syndrome (DS) have a heightened risk for various co-occurring health conditions, including congenital heart disease (CHD). In this two-part study, electronic medical records (EMRs) were leveraged to examine co-occurring health conditions among individuals with DS (Study 1) and to investigate health conditions linked to surgical intervention among DS cases with CHD (Study 2). De-identified EMRs were acquired from Vanderbilt University Medical Center and facilitated creating a cohort of N=2282 DS cases (55% females), along with comparison groups for each study. In Study 1, DS cases were one-by-two sex and age matched with samples of case-controls and of individuals with other intellectual and developmental difficulties (IDDs). The phenome-disease association study (PheDAS) strategy was employed to reveal co-occurring health conditions in DS versus comparison groups, which were then ranked for how often they are discussed in relation to DS using the PubMed database and Novelty Finding Index. In Study 2, a subset of DS individuals with CHD [N=1098 (48%)] were identified to create longitudinal data for N=204 cases with surgical intervention (19%) versus 204 case-controls. Data were included in predictive models and assessed which model-based health conditions, when more prevalent, would increase the likelihood of surgical intervention. In Study 1, relative to case-controls and those with other IDDs, co-occurring health conditions among individuals with DS were confirmed to include heart failure, pulmonary heart disease, atrioventricular block, heart transplant/surgery and primary pulmonary hypertension (circulatory); hypothyroidism (endocrine/metabolic); and speech and language disorder and Alzheimer's disease (neurological/mental). Findings also revealed more versus less prevalent co-occurring health conditions in individuals with DS when comparing with those with other IDDs. Findings with high Novelty Finding Index were abnormal electrocardiogram, non-rheumatic aortic valve disorders and heart failure (circulatory); acid-base balance disorder (endocrine/metabolism); and abnormal blood chemistry (symptoms). In Study 2, the predictive models revealed that among individuals with DS and CHD, presence of health conditions such as congestive heart failure (circulatory), valvular heart disease and cardiac shunt (congenital), and pleural effusion and pulmonary collapse (respiratory) were associated with increased likelihood of surgical intervention. Research efforts using EMRs and rigorous statistical methods could shed light on the complexity in health profile among individuals with DS and other IDDs and motivate precision-care development.

One-lung ventilation with a bronchial blocker in thoracic patients

BackgroundLung isolation is a technique used in a multitude of surgeries to ensure single-lung ventilation with collapse of the contralateral lung, as to achieve improved access and visualization of relevant anatomical structures. Despite being accepted and having favorable outcomes, bronchial blockers (BBs) are not to this day the main device of choice among anaesthesiologists.MethodsIn this retrospective and descriptive study, we analyzed the safety and efficacy of a BB in all types of thoracic surgeries in our centre between 2015 and 2022, excluding patients with massive hemoptysis or empyema, or who had undergone a prior pneumonectomy.ResultsOne hundred and thirty-four patients were intervened due to lung cancer (67.9%), respiratory disease (23.9%), and non-respiratory disease (8.2%) undergoing lung surgeries (65.7%), pleural and mediastinal surgeries (29.9%), chest wall surgeries (3.0%) and other surgeries (1.5%). In most cases, lung collapse was considered excellent (63.9%) or good (33.1%) with only 4 cases (3.0%) of poor lung collapse. More than 90% of patients did not present intraoperative or immediate postoperative complications. No statistically significant differences were found between lung collapse and the demographic, clinical or BB-related variables (p > 0.05). However, we found a significatively higher proportion of excellent lung collapses in VATS surgeries and lateral decubitus positioning, as well as a significatively less proportion of poor lung collapses (p < 0.05). Moreover, there was a significantly higher proportion of excellent lung collapses when the BB was placed in the left bronchus (p < 0.05).ConclusionsWith these results, in our experience BBs constitute an effective alternative, capable of achieving pulmonary collapse in all kinds of thoracic procedures with satisfactory safety rates due to their minimal complications.

Complications of prolonged mechanical ventilation after cardiac surgery in children with Down syndrome: A single-center retrospective observational study

Background: Patients with Down syndrome (DS) are known to have an increased risk of congenital heart diseases, which can be a predictor of prolonged mechanical ventilation (PMV) after cardiac surgery. PMV is a factor that enhances postoperative complications and morbidities. Thus, we aimed to explore the risk factors of the PMV, and relevant complications associated with it. Subjects and Methods: This retrospective study included 94 patients with DS who underwent 97 cardiac repair surgeries between 2010 and 2022. Patients were dichotomized into two groups. The first group was with the patients on mechanical ventilation (MV) for &lt;72 h and the PMV group with MV for more than ≥72 h. Results: We reviewed the association between various risk factors and PMV in patients with DS. The presence of seizure disorder (P = 0.028), preoperative administration of prostaglandin (P = 0.028), and continuous positive airway pressure (CPAP) (P = 0.043) had significantly increased risk of PMV. We found a significantly increased incidence of sepsis (P = 0.009), delayed sternal closure (P = 0.01), feeding intolerance (P = 0.014), prolonged intensive care unit (ICU) stay (P = 0.0001), and pulmonary collapse (P = 0.001) in patients with PMV. There was no difference in the incidence of pulmonary hypertension, postoperative respiratory infection, pneumothorax, and chylothorax between children between the two groups. Conclusions: The presence of seizure disorder, preoperative usage of prostaglandin, and CPAP were significant risk factors for PMV. Incidence of sepsis, delayed sternal closure, feeding intolerance, prolonged ICU stay, and pulmonary collapse was significantly higher with PMV.

Spontaneous Tension Pneumothorax is a Rare and Life-Threatening Complication of COVID-19 Infection: A Case Report and Literature Review

The coronavirus disease is a recent pandemic infection, with the first case being discovered in Wuhan, China, in December 2019. Iran is one of the countries that has been afflicted by this pandemic. A 34-year-old man with no history of pre-existing disease and smoking has been hospitalized in another hospital for the past two weeks due to COVID-19 infection and symptoms of fever, cough, and dyspnea. He received standard medical treatments in that hospital. After two weeks, he was discharged from the hospital with his consent. In the afternoon of the same day, he came to the emergency department of our hospital with severe dyspnea. Tension pneumothorax in the left hemithorax, pulmonary collapse, and shifting mediastinal elements to the contralateral side were observed in his chest x-ray. Tension pneumothorax is an unusual symptom in patients with SARS-CoV-2. Pneumothorax has been reported in 1% of COVID-19 patients who need hospitalization, 2% of those who need intensive care unit admission, and 1% of those who die from the infection. Spontaneous pneumothorax must be ruled out in COVID-19 patients with dyspnea and chest pain, tachycardia, tachypnea, or hypoxemia. It is critical to be familiar with these symptoms to make an accurate diagnosis and treatment plan. A thorough physical examination and serial chest X-rays can be helpful tools in the diagnosis and management of the disease.

Nationwide Outcomes After Thoracoscopic Versus Open Resection of Congenital Pulmonary Airway Malformations in Newborns.

Purpose: Elective resection of congenital pulmonary airway malformations (CPAM) has been debated for decades and varies significantly between individual surgeons. However, few studies have compared outcomes and costs associated with thoracoscopic and open thoracotomy approaches on a national level. This study sought to compare nationwide outcomes and resource utilization in infants undergoing elective lung resection for CPAM. Materials and Methods: The Nationwide Readmission Database was queried from 2010 to 2014 for newborns who underwent elective surgical resection of CPAM. Patients were stratified by operative approach (thoracoscopic versus open). Demographics, hospital characteristics, and outcomes were analyzed using standard statistical tests. Results: A total of 1716 newborns with CPAM were identified. Elective readmission for pulmonary resection was performed in 12% (n = 198), with 63% of resections completed at a different hospital than the newborn stay. Most resections were thoracoscopic (75%), compared to only 25% via thoracotomy. Infants treated with thoracoscopic resection were more often male (78% versus 62% open, P = .040) and were older at the time of resection. Patients who had an open thoracotomy experienced a higher rate of serious complications (40% versus 10% thoracoscopic, P < .001), including postoperative hemorrhage, tension pneumothorax, and pulmonary collapse. Readmission costs were higher for infants treated via thoracotomy (P < .001). Conclusion: Thoracoscopic lung resection for CPAM is associated with lower cost and fewer postoperative complications than thoracotomy. Most resections are performed at different hospitals than the place of birth, which may affect long-term outcomes from single institutional studies. These findings may be used to address costs and improve future evaluations of elective CPAM resections.

Rational use of corticosteroid treatment in the early phase of severe COVID-19

Mechanisms of hypoxemia in COVID-19 pneumonia include pulmonary inflammation, alveolar collapse, atelectasis, and pulmonary intravascular coagulopathy due to a hyperinflammatory response to SARS-CoV-2 infection. Systemic corticosteroids are widely applied as a standard treatment for hospitalized COVID-19 patients after several studies have shown favorable outcomes. However, the standard dosing and tailoring of corticosteroids in COVID-19 patients have not been established. Differences in dosing and timing of corticosteroid use may affect the outcome of COVID-19 patients. Inappropriate use of corticosteroids can lead to less benefit and potentially harmful adverse events. Dexamethasone is the most widely used corticosteroid as a result of the positive outcome from the RECOVERY study and its high anti-inflammatory potency. Although several studies have shown the benefit of higher dose corticosteroids in severe COVID-19 patients, serious adverse events associated with the use of corticosteroids, such as superimposed bacterial and/or fungal infections, have also been observed. Therefore, in this article, we reviewed current evidence of corticosteroid usage in COVID-19 patients and suggested a strategy for tailoring corticosteroid usage according to the clinical severity and risk of the patients.

Serine/Threonine Protein Phosphatases 1 and 2A in Lung Endothelial Barrier Regulation.

Vascular barrier dysfunction is characterized by increased permeability and inflammation of endothelial cells (ECs), which are prominent features of acute lung injury (ALI), acute respiratory distress syndrome (ARDS), and sepsis, and a major complication of the SARS-CoV-2 infection and COVID-19. Functional impairment of the EC barrier and accompanying inflammation arises due to microbial toxins and from white blood cells of the lung as part of a defensive action against pathogens, ischemia-reperfusion or blood product transfusions, and aspiration syndromes-based injury. A loss of barrier function results in the excessive movement of fluid and macromolecules from the vasculature into the interstitium and alveolae resulting in pulmonary edema and collapse of the architecture and function of the lungs, and eventually culminates in respiratory failure. Therefore, EC barrier integrity, which is heavily dependent on cytoskeletal elements (mainly actin filaments, microtubules (MTs), cell-matrix focal adhesions, and intercellular junctions) to maintain cellular contacts, is a critical requirement for the preservation of lung function. EC cytoskeletal remodeling is regulated, at least in part, by Ser/Thr phosphorylation/dephosphorylation of key cytoskeletal proteins. While a large body of literature describes the role of phosphorylation of cytoskeletal proteins on Ser/Thr residues in the context of EC barrier regulation, the role of Ser/Thr dephosphorylation catalyzed by Ser/Thr protein phosphatases (PPases) in EC barrier regulation is less documented. Ser/Thr PPases have been proposed to act as a counter-regulatory mechanism that preserves the EC barrier and opposes EC contraction. Despite the importance of PPases, our knowledge of the catalytic and regulatory subunits involved, as well as their cellular targets, is limited and under-appreciated. Therefore, the goal of this review is to discuss the role of Ser/Thr PPases in the regulation of lung EC cytoskeleton and permeability with special emphasis on the role of protein phosphatase 1 (PP1) and protein phosphatase 2A (PP2A) as major mammalian Ser/Thr PPases. Importantly, we integrate the role of PPases with the structural dynamics of the cytoskeleton and signaling cascades that regulate endothelial cell permeability and inflammation.

Esketamine opioid-free intravenous anesthesia versus opioid intravenous anesthesia in spontaneous ventilation video-assisted thoracic surgery: a randomized controlled trial.

Opioid-free anesthesia (OFA) provides adequate analgesia and can reduce postoperative opioid consumption, but its efficacy in spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has not been demonstrated. We aimed to investigate the hypothesis that OFA could provide the same perioperative pain control as opioid anesthesia (OA), maintain safe and stable respiration and hemodynamics during surgery, and improve postoperative recovery. Sixty eligible patients (OFA group: n=30; OA group: n=30) treated between September 15, 2022, and December 15, 2022, at The First Hospital of Guangzhou Medical University were included. They were randomized to receive standard balanced OFA with esketamine or OA with remifentanil combined with sufentanil. The primary outcome was the pain numeric rating score (NRS) at postoperative 24 h, and the secondary outcomes were intraoperative respiratory and hemodynamic data, opioid consumption, vasoactive drug dosage, and recovery in the post-anesthesia care unit and ward. There was no significant difference in the postoperative pain scores and recovery quality between the two groups. The OFA group had a significantly lower dose of phenylephrine (P=0.001) and a lower incidence of hypotension (P=0.004) during surgery. The OFA group resumed spontaneous respiration faster (P<0.001) and had a higher quality of lung collapse (P=0.02). However, the total doses of propofol and dexmetomidine were higher (P=0.03 and P=0.02), and the time to consciousness was longer (P=0.039) in the OFA group. OFA provides the same level of postoperative pain control as OA, but it is more advantageous in maintaining circulatory and respiratory stability and improving the quality of pulmonary collapse in SV-VATS.

Intra-Operative and Post-Operative Common Complications of Hysterectomy

Background: The most prevalent gynaecological surgeries in the US is the hysterectomy. With more than 600,000 procedures carried out year. This study aims to find intra-operative and post-operative common complications of hysterectomy. Methods: A study conducted that was cross-sectional in the Unit 1 Gynecological Department Services Hospital in Lahore. The purposive sampling technique was applied to collect data. Total 120 gynecologist’s participants were investigated during this research. The target demographic was between the ages of 25 and 50. Consultants, PGRs, and SRs completed the questionnaire. The information gathered was written down, compared, and then examined. Results: According to the findings of this study, the most common intra-operative complication of hysterectomy is bowel injury (16.7%), followed by genitourinary (GU) and gastrointestinal (GI) tract injury (0.8%). The most prevalent post-operative complication was anuria (19.2%). Pulmonary Embolism (Bronchitis, Pulmonary Collapse) was responsible for 8% of the problems, whereas Hematoma Formation was responsible for 19.2%. Practical implication: The research on the common complications hysterectomy in the intra and post operative settings will allow for us to plan interventions in accordance to these complications which will better the medical intervention procedure and add to the literature of the subject. Conclusion: It is clear that the most common intra-operative complication of hysterectomy is Bowel Injury, the most common post-operative complication is Anuria. Keywords: Hysterectomy, Abdominal hysterectomy, vaginal hysterectomy, Intra-operative complications, Post-operative complications, surgical procedures, operating room.

Integrating electrical impedance tomography and transpulmonary pressure monitoring to personalize PEEP in hypoxemic patients undergoing pressure support ventilation

Monitoring with electrical impedance tomography (EIT) during a decremental PEEP trial has been used to identify the PEEP that yields the optimal balance of pulmonary overdistension and collapse. This method is based on pixel-level changes in respiratory system compliance and depends on fixed or measured airway driving pressure. We developed a novel approach to quantify overdistension and collapse during pressure support ventilation (PSV) by integrating transpulmonary pressure and EIT monitoring and performed pilot tests in three hypoxemic patients. We report that our experimental approach is feasible and capable of identifying a PEEP that balances overdistension and collapse in intubated hypoxemic patients undergoing PSV.

Retrospective outcomes analysis of tracheostomy in a paediatric burn population

IntroductionPrevious analyses of tracheostomy in paediatric burns was hindered by a lack of multi-institution or nationwide analysis. This study aims to explore the effects of tracheostomy in paediatric burn patients in such an analysis. De-identified data was obtained from the TriNetX Research Network database. MethodsTwo cohorts were identified using ICD and CPT codes: paediatric burn patients with tracheostomy (cohort 1) and paediatric burn patients without tracheostomy (cohort 2). Cohorts were matched according to age at diagnosis and pulmonary condition, specifically influenza and pneumonia, respiratory failure, acute upper respiratory infection, and pulmonary collapse. Cohorts were also matched for age at burn diagnosis and surface area burned. Several parameters including infection following a procedure, sepsis, volume depletion, respiratory disorders, laryngeal disorders, pneumonia, and other metrics were also compared. ResultsA total of 152 patients were matched according to age and pulmonary condition. Cohort 1 and cohort 2 had a mean age of 4.45 ± 4.06 and 4.39 ± 3.99 years, respectively. Matched patients with tracheostomy had a higher risk for pneumonia, respiratory failure, other respiratory disorders, diseases of the vocal cord and larynx, sepsis, volume depletion, pulmonary edema, and respiratory arrest. The risk ratios for these outcomes were 2.96, 3.5, 3.13, 3.9, 2.5, 2.5, 3.3, and not applicable. Analysis of longitudinal outcomes of paediatric burn patients with tracheostomy vs. those without demonstrated the tracheostomy cohort suffered much worse morbidity and experienced higher health burden across several metrics. ConclusionThe potential benefits of tracheostomy in paediatric burn patients should be weighed against these outcomes.

Serum Surfactant Protein-D (SP-D) Level: Does it Correlates with Pulmonary Compliance and ARDS in Severe Cases of COVID-19?

Acute Respiratory Distress Syndrome (ARDS) happens to 67% of all severe COVID-19 cases with mortality rate of 50-94%. Main characteristics of ARDS are poor oxygenation and non-compliant lungs. The lungs are like inflatable balloons that are actively inflated by the positive pressure within and/or the negative pressure created in the pleural cavity. Compliance is the ability of the lungs to distend at a certain level of transpulmonary pressure. Surfactant lowers the surface tension of the alveoli so that end-expiratory pulmonary collapse could be prevented and pulmonary compliance could be maintained. Surfactants also play an important role in the host's defense against infection. Surfactants comprise of phospholipids, cholesterol and surfactant proteins (SP) SP-A, -B, -C and –D. Previous study showed that concentration of SP-D was significantly higher in ARDS patients. Higher serum SP-D concentrations were associated with a greater risk of death, fewer ventilator-free days, and fewer organ failure-free days. This review highlights the role of surfactant especially SP-D in pulmonary compliance and ARDS in COVID-19.

Total unilateral pulmonary collapse secondary to allergic bronchopulmonary aspergillosis: a case series of an unusual cause of complete atelectasis

BackgroundAllergic bronchopulmonary aspergillosis (ABPA) is a bronchopulmonary disease caused by a complex hypersensitivity to Aspergillus and is usually associated with underlying respiratory diseases such as asthma or cystic fibrosis. Mucus plugging can lead to segmental or lobar atelectasis, but complete lung atelectasis has been exceptionally reported in the literature, making it difficult to diagnose. The diagnosis of ABPA may however be suggested in patients without known predisposing respiratory disorder, even in the absence of other relevant radiographic findings.Case presentationWe report five cases of total unilateral lung collapse secondary to ABPA in 70–81-year-old women. Two of them had a past history of ABPA, while total unilateral lung collapse was the first sign of the disease in the other three patients, contributing to the initial misdiagnosis. Flexible bronchoscopy was initially performed to remove mucus plugs from the obstructed airways but was inefficient in four cases. Corticosteroid and/or antifungal treatment was needed.ConclusionABPA can cause total unilateral lung collapse even in patients without known underlying chronic respiratory disease, making the diagnosis difficult. Flexible bronchoscopy should be considered when lung collapse is associated with respiratory distress but corticosteroids are the mainstay treatment for ABPA.

Successful treatment of interstitial pneumonitis with anakinra in a patient with adult-onset Still’s disease

A 29-year-old African woman with active adult-onset Still’s disease (AOSD) that developed at the end of 2018 presented to our hospital in September 2019 with pleuritic right-sided pain and respiratory...

Effects of preoperative physiotherapy on signs and symptoms of pulmonary collapse and infection after major abdominal surgery: secondary analysis of the LIPPSMAck-POP multicentre randomised controlled trial

BackgroundPreoperative education and breathing exercise training by a physiotherapist minimises pulmonary complications after abdominal surgery. Effects on specific clinical outcomes such as antibiotic prescriptions, chest imaging, sputum cultures, oxygen requirements, and diagnostic coding are unknown.MethodsThis post hoc analysis of prospectively collected data within a double-blinded, multicentre, randomised controlled trial involving 432 participants having major abdominal surgery explored effects of preoperative education and breathing exercise training with a physiotherapist on postoperative antibiotic prescriptions, hypoxemia, sputum cultures, chest imaging, auscultation, leukocytosis, pyrexia, oxygen therapy, and diagnostic coding, compared to a control group who received a booklet alone. All participants received standardised postoperative early ambulation. Outcomes were assessed daily for 14 postoperative days. Analyses were intention-to-treat using adjusted generalised multivariate linear regression.ResultsPreoperative physiotherapy was associated with fewer antibiotic prescriptions specific for a respiratory infection (RR 0.52; 95% CI 0.31 to 0.85, p = 0.01), less purulent sputum on the third and fourth postoperative days (RR 0.50; 95% CI 0.34 to 0.73, p = 0.01), fewer positive sputum cultures from the third to fifth postoperative day (RR 0.17; 95% CI 0.04 to 0.77, p = 0.01), and less oxygen therapy requirements (RR 0.49; 95% CI 0.31 to 0.78, p = 0.002). Treatment effects were specific to respiratory clinical coding domains.ConclusionsPreoperative physiotherapy prevents postoperative pulmonary complications and is associated with the minimisation of signs and symptoms of pulmonary collapse/consolidation and airway infection and specifically results in reduced oxygen therapy requirements and antibiotic prescriptions.Trial registrationANZCTR 12613000664741; 19/06/2013.

Acute Intestinal Occlusion Revealing a Post-Traumatic Diaphragmatic Strangulated Hernia: A Case Report

Introduction: The post-traumatic diaphragmatic hernia is a particular lesion in traumatology, which may go undetected in the acute phase of the trauma. Its detection is then often made following a digestive or respiratory complication. Acute intestinal occlusion is one of the complications revealing a strangulated diaphragmatic hernia. Case Presentation: 37-years-old patient with acute intestinal occlusion syndrome. His history included a closed thoracoabdominal trauma following a vehicular accident three years ago. The thoracoabdominal CT scan showed a distension of the haemic coves, transverse and ascending colon above a strangulation of the left colonic angle through a left diaphragmatic defect, with left pleural effusion of high abundance, responsible for a pulmonary collapse. The diagnosis retained is an intestinal occlusion on a strangulated post-traumatic left diaphragmatic hernia. Surgical exploration showed a distension of the hail and colic coves above a strangulated left diaphragmatic hernia with necrotic transverse colic content. The patient has benefited of a hernia reduction with transverse colic resection removing the necrotic colon and suture of the diaphragmatic breach. The evolution was favorable. Conclusion: The eventuality of a diaphragmatic hernia must always be suggested in case of violent thoraco abdominal trauma. Among the causes of intestinal occlusion, the strangulation of a diaphragmatic hernia should be considered, especially if there is a history of thoracoabdominal trauma.

DON'T TAKE MY BREATH AWAY: A CASE OF HIGH-RISK PULMONARY EMBOLISM IN THE SETTING OF PATENT FORAMEN OVALE REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary emboli precipitate cardiovascular collapse by mechanical obstruction of the right ventricular outflow tract and pulmonary artery vasoconstriction, leading to right ventricular overload. The presence of a patent foramen ovale (PFO) can subvert this typical physiology by creating a right-to-left shunt, permitting left ventricular filling and near-normal cardiac output. However, this also causes intracardiac mixing of oxygenated and deoxygenated blood, which can further worsen hypoxemia. Here, we present a patient with saddle pulmonary emboli who was incidentally found to have a PFO due to persistent hypoxemia. CASE PRESENTATION: A 67-year-old man with a past medical history of coronary artery disease, alcohol abuse, hypertension, hyperlipidemia, and obstructive sleep apnea presented with word-finding difficulty and behavioral changes. He was found to have acute occlusion of the bilateral middle cerebral arteries, requiring mechanical thrombectomy. He was recovering successfully when he suddenly developed dyspnea and lightheadedness with exertion, which rapidly progressed to mechanical ventilation. He remained hypoxic on optimal ventilator settings and inhaled nitric oxide, prompting suspicion for acute pulmonary embolism. Chest x-ray was unchanged. EKG showed inferior ST-segment elevations, and a trans-thoracic echocardiogram revealed a newly dilated and overloaded right ventricle with an underfilled left ventricle, as well as McConnell's sign. Transesophageal echocardiogram showed a saddle pulmonary embolus and an incidental PFO with right-to-left shunting. Veno-venous extracorporeal membrane oxygenation (ECMO) was initiated as a bridge to mechanical thrombectomy. His course was complicated by cardiogenic shock, septic shock, and progression of his initial ischemic stroke. Encephalopathy remained a barrier to extubation. DISCUSSION: Recent studies have recognized ECMO as a promising adjunctive therapy for pulmonary emboli for those who are too unstable for surgical thrombectomy or who have contraindications to systemic thrombolysis. Our patient was not a candidate for thrombolysis given his recent stroke. His PFO, while beneficial in preventing florid cardiogenic shock by offloading the right ventricle, caused hypoxemia refractory to mechanical ventilation alone. As such, ECMO was a crucial temporizing measure until the patient was stable enough for surgical thrombectomy. CONCLUSIONS: This case highlights, prompt recognition of intracardiac shunts in cases of refractory hypoxemia, and the importance of early identification of patients who need advanced intervention such as ECMO. REFERENCE #1: Al-Bawardy R, Rosenfield K, Borges J, Young MN, Albaghdadi M, Rosovsky R, Kabrhel C. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a case series and review of the literature. Perfusion. 2019 Jan;34(1):22-28. doi: 10.1177/0267659118786830. Epub 2018 Jul 16. PMID: 30009670. REFERENCE #2: Askari K, Sneij W, Krick S, Alvarez RA. Going with the Flow: Saddle Pulmonary Embolism Complicated by Severe Hypoxemia without Shock. Annals of the American Thoracic Society. 2017;14(9):1479-1484. doi:10.1513/annalsats.201702-145cc REFERENCE #3: Corsi F, Lebreton G, Bréchot N, Hekimian G, Nieszkowska A, Trouillet JL, Luyt CE, Leprince P, Chastre J, Combes A, Schmidt M. Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation. Crit Care. 2017 Mar 28;21(1):76. doi: 10.1186/s13054-017-1655-8. PMID: 28347320; PMCID: PMC5369216 DISCLOSURES: No relevant relationships by Sonali Bishnoi, source=Web Response No relevant relationships by Scott Blumhof, source=Web Response No relevant relationships by Amy Lam, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Jeffrey Wright, source=Web Response