Radiographic Evidence Of Pulmonary Edema Research Articles

Complexity in clinical diagnoses of acute exacerbation of chronic obstructive pulmonary disease

BackgroundAcute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a clinical syndrome with various causes. It is not uncommon that COPD patients presenting with dyspnea have multiple causes for their symptoms including AECOPD, pneumonia, or congestive heart failure occurring concurrently.MethodsTo identify clinical, radiographic, and laboratory characteristics that might help distinguish AECOPD from another dominant disease in patients with a history of COPD, we conducted a retrospective cohort study of hospitalized patients with admitting diagnosis of AECOPD who were screened for a prospective randomized controlled trial from Sep 2016 to Mar 2018. Clinical characteristics, course in hospital, and final diagnosis at discharge were reviewed and adjudicated by two authors. The final diagnosis of each patient was determined based on the synthesis of all presenting signs and symptoms, imaging, and laboratory results. We adhered to AECOPD diagnosis definitions based on the GOLD guidelines. Univariate and multivariate analyses were performed to identify any associated features of AECOPD with and without other acute processes contributing to dyspnea.ResultsThree hundred fifteen hospitalized patients with admitting diagnosis of AECOPD were included. Mean age was 72.5 (SD 10.6) years. Two thirds (65.4%) had spirometry defined COPD. The most common presenting symptom was dyspnea (96.5%), followed by cough (67.9%), and increased sputum (57.5%). One hundred and eighty (57.1%) had a final diagnosis of AECOPD alone whereas 87 (27.6%) had AECOPD with other conditions and 48 (15.2%) did not have AECOPD after adjudication. Increased sputum purulence (OR 3.35, 95%CI 1.68–6.69) and elevated venous pCO2 (OR 1.04, 95%CI 1.01 – 1.07) were associated with a diagnosis of AECOPD but these were not associated with AECOPD alone without concomitant conditions. Radiographic evidence of pleural effusion (OR 0.26, 95%CI 0.12 – 0.58) was negatively associated with AECOPD with or without other conditions while radiographic evidence of pulmonary edema (OR 0.31; 95%CI 0.11 – 0.91) and lobar pneumonia (OR 0.13, 95%CI 0.07 – 0.25) suggested against the diagnosis of AECOPD alone.ConclusionThe study highlighted the complexity and difficulty of AECOPD diagnosis. A more specific clinical tool to diagnose AECOPD is needed.

Early detection of myocardial dysfunction in a cat that gradually progressed to endomyocardial form of restrictive cardiomyopathy

BackgroundRestrictive cardiomyopathy (RCM) is a common myocardial disease in cats, characterized by diastolic dysfunction and atrial enlargement without myocardial hypertrophy. Especially, endomyocardial form of RCM, one of the subtypes in RCM, is characterized by endocardial fibrosis, endocardial scar bridging the interventricular septum and left ventricular (LV) free wall, and deformation and distortion of the LV. However, it is unclear how the myocardial dysfunction and the endocardial scar contribute to the pathophysiology of RCM disease progression.Case presentationA 3 years and 2 months old, intact male, Domestic shorthaired cat was presented for consultation of cardiac murmur. At the first visit (day 0), the notable abnormal finding was echocardiography-derived chordae tendineae-like structure bridging the interventricular septum and the LV free wall, resulting high-speed blood flow in the left ventricle. Electrocardiography, thoracic radiography and noninvasive blood pressure measurements were normal. No left atrial enlargement was observed, and LV inflow velocity showed an abnormal relaxation pattern. Although there was no abnormality in tissue Doppler imaging-derived myocardial velocity, two-dimensional speckle tracking echocardiography (2D-STE) revealed a decrease in the LV longitudinal strain and an increase in endocardial to epicardial ratio of the LV circumferential strain on day 0. On day 468, obvious left atrium enlargement and smoke like echo in the left atrium were observed. The LV inflow velocity was fused, and the tissue Doppler imaging-derived early-diastolic myocardial velocity of the septal mitral annulus decreased. Regarding 2D-STE, LV circumferential strain was further decreased, and right ventricular strain was additionally decreased. Although the general condition was good, we made a clinical diagnosis of endomyocardial RCM based on the above findings. On day 503, the cat showed the radiographic evidence of pulmonary edema and congestive heart failure signs.ConclusionsCats with abnormal LV structure and associated myocardial dysfunction like this case needs careful observation. Additionally, 2D-STE indices may be useful for early detection of myocardial dysfunction in feline RCM.

Annals for Educators - 15 January 2019.

Annals for Educators - 15 January 2019.

Characterizing post-extubation negative pressure pulmonary edema in the operating room\u2014a retrospective matched case-control study

BackgroundPost-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesia-related emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices. This study investigated the incidence and associated risk factors for post-extubation NPPE during emergence.MethodsThis retrospective, matched case-control study was conducted by reviewing the post-anesthesia records in Tzu Chi General Hospital, Taiwan. Patients reported of having acute hypoxemia (SpO2 < 92%) shortly after the removal of the endotracheal tube or supraglottic airway, associating with radiographic evidence of pulmonary edema and/or pink frothy sputum, were identified as definite NPPE cases. The potential risk factors were compared with the matched controls, who were randomly selected from the same database.ResultsA total of 85,561 patients received general anesthesia with airway instrumentation during the 8.5-year study period. A total of 16 patients were identified as definite cases of NPPE. Compared with the matched controls (n = 131), males, active smokers, emergency operation, endotracheal intubation, use of desflurane, and prolonged operation time carried significantly higher risks of developing NPPE (P < 0.05). Multivariate logistic regression analysis illustrated that active smoking (AOR 7.66, 95% CI 1.67–35.3; P = 0.009) and endotracheal intubation (AOR 10.87, 95% CI 1.23–100; P = 0.03) were the two most significant independent variables of post-extubation NPPE.ConclusionWe present the first clinical comparative study demonstrating that the overall incidence of NPPE immediately after extubation in the operating room is 0.019%. Our results highlight that active smokers and patients receiving endotracheal intubation general anesthesia are associated with significantly higher risks of developing NPPE following extubation in the operating room.

Left Ventricular Unloading by Impella Device Versus Surgical Vent During Extracorporeal Life Support

Patients supported with extracorporeal life support (ECLS) can experience severe complications from increased left ventricular (LV) afterload. The Impella (Abiomed, Danvers, MA) percutaneous ventricular assist device (PVAD) may offer an attractive option for unloading the LV in these patients. This study describes the efficacy and outcomes of PVAD use during ECLS compared with surgically placed LV vent. In this retrospective study, we reviewed patients supported by ECLS with PVAD or surgical LV vent for cardiogenic shock between April 2010 and May 2016. Included were 23 patients with PVADs and 22 with surgical vents. Patients' baseline characteristics, hemodynamic data, and outcomes were collected immediately preceding combined support initiation, at 48 hours, intensive care unit discharge, and 30 days. After 48 hours, pulmonary artery diastolic pressure was significantly reduced in the PVAD (23.3 ±8.4 vs 15.6 ± 4.2, p= 0.02) and surgical vent groups (20.1 ± 5.9 vs 15.6 ± 5.4, p= 0.01), and radiographic evidence of pulmonary edema was reduced or unchanged in 90% of PVAD patients and in 76% of surgical vent patients. The primary end points of survival to 30 days (43% vs 32%, p=0.42) and intensive care unit discharge (35% vs 23%, p= 0.37) were not different between the two methods of support. The PVAD and surgical vent groups were also not significantly different in the rate of vascular complications or in the number decannulated from ECLS and transitioned to durable LV assist device. PVAD use in ECLS patients is an effective means of LV unloading and preventing worsened pulmonary edema, with outcomes and complications that are comparable to surgical LV vent.

Hybrid technique for ventricular septal defect closure in a dog using an Amplatzer® Duct Occluder II

A left-to-right shunting muscular ventricular septal defect (VSD) was diagnosed in a 4-month-old, female, 1.8 kg Bichon Frise – poodle mix dog. Echocardiographic evidence of cardiac remodeling, calculated pulmonary blood flow (Qp) to systemic blood flow (Qs) ratio of 2.8, and radiographic evidence of pulmonary edema supported the diagnosis of a hemodynamically important VSD. Using a combination of surgery and interventional catheter-based techniques to approach the VSD through the right ventricle, the VSD was occluded with an Amplatzer® Duct Occluder (ADO) II device. The ADO II is a low profile, flexible device originally developed for patent ductus arteriosus closure in humans that has been used to close muscular and perimembranous VSD in children. This report describes the hybrid procedure and imaging that was essential for successful occlusion of the VSD in this dog.

Left ventricular systolic dyssynchrony in acute decompensated heart failure

Acute decompensated heart failure (ADHF) is a common and potentially fatal condition. Acute ischemia, hypertensive crisis, fluid retention, mitral regurgitation and tachyarrhythmias can precipitate ADHF, yet very often no clinical trigger was apparent [1]. Left ventricular systolic dyssynchrony (LVSD) is important in the pathogenesis of heart failure [2], yet evaluation of LVSD is usually performed in stable clinical conditions. Patients can have transient episodes of LVSD leading to acute elevation of LV filling pressure and pulmonary edema. Recent studies revealed that LVSD can change dynamically with exercise [3] and pharmacological stress [4,5]. Herein, acute LVSD may be a hidden triggering mechanism for ADHF. Echocardiography with tissue Doppler imaging (TDI) during episodes of ADHF can provide a better appreciation of acute LVSD. To test the hypothesis that patients who presented with ADHF may have more LVSD than those who had chronic stable heart failure (CSHF) without recent exacerbation, we prospectively performed echocardiography with TDI in 145 HF subjects, including 84 consecutive patients presented with ADHF (defined as acute respiratory distress with clinical and/or radiographic evidence of pulmonary edema; LV ejection fraction b 50%) requiring hospitalization, comparing them to 61 CSHF patients identified from outpatient database who had no HF exacerbation or hospitalization in the past 6 months. Patients with acute coronary syndrome, primary valvular disease, atrial fibrillation, and pacemaker implantation were excluded. Echocardiography (Vivid 7, VingmedGeneral Electric, Horten, Norway) was performed within 48 h of ADHF admission. Color-coded TDI (frame rate optimized to 100 Hz or higher) was used to assess LVSD. Myocardial velocity curves were reconstituted offl ine using the 12-segment (6-basal 6-mid) model[3] .T ime to peak systolicvelocityduringejection(Ts) wasmeasured foreachsegmentwith reference to the onset of QRS complex. The standard deviation of Ts (TsSD) of the 12 LV segments was calculated to evaluate LVSD. Significant LVSD was defined as Ts-SD N 33 ms as previously published [2] .L ongitudinal myocardial function was assessed by averaging the peak myocardial systolic (mean Sm) and early diastolic (mean Em) velocities at the 6 basal segments. LV and left atrial dimensions were measured according to guideline recommendations [6]. The effective regurgitant orifice (ERO) of any mitral regurgitation was calculated by the proximal isovelocity surface area method [7]. Group comparisons were performed by independent student's t test or Pearson χ 2 test as appropriate. Pearson

Translational Research Efforts in Biomarkers and Biology of Early Transplant-Related Complications

In the time since the first allogeneic hematopoietic stem cell transplantation (HSCT) was performed over 40 years ago, this life-saving procedure has been used increasingly for patients with hematologic, metabolic, and malignant diseases. Despite major advances in our understanding of the immunologic processes (both beneficial and injurious) that are associated with HSCT and improvements in supportive and critical care medicine, successful outcomes are still limited by several serious complications. As such, the establishment of effective therapeutic strategies for these complications will be crucial as increasing numbers of high-risk transplants are performed each year. The development of such approaches is fundamentally dependent upon a basic understanding of pathophysiologic mechanisms of disease and also on our ability to successfully translate these insights back to the bedside. This brief review will highlight breakthroughs in translational research endeavors that have paved the way for the development of novel strategies intended to change the standard of care and optimize outcomes for patients in whom allogeneic HSCT offers the only hope for a cure.

Serum B-Type Natriuretic Peptide: a Marker of Fluid Resuscitation After Injury?

Excessive volume resuscitation after injury is associated with severe complications. B-type natriuretic peptide (BNP) is secreted from myocardium under increased wall stretch and is used in medical intensive care units (ICUs) as a noninvasive method to detect heart failure. However, the use of BNP as a marker of fluid overload during resuscitation from injury has not been previously described. Serum BNP levels were prospectively followed in 134 trauma ICU patients. Levels were obtained at admission and at 12, 24, and 48 hours. Repeated measures analysis of variance was used to test for differences in BNP levels over time. Post hoc pairwise comparisons were made with Bonferroni correction when the omnibus test indicated significance. Chest films were obtained at 24 hours and scored for the presence of pulmonary edema by a radiologist blinded to BNP measurements (n = 45). Twenty-four hour BNP levels for patients with or without radiographic evidence of pulmonary edema were compared using nonparametric analysis (Mann-Whitney U). Admission BNP levels were low and increased with fluid resuscitation over time in all patients (p = 0.002) as well as in a subgroup of patients <60 years of age (p = 0.003). At 24 hours, 25 patients had no pulmonary edema evident on chest X-ray, whereas 20 were scored indicating that pulmonary edema was present. Patients with evidence of pulmonary edema had higher mean BNP levels at 24 hours (110 +/- 31 pg/mL) than did patients without edema (47.0 +/- 10.8 pg/mL) (p = 0.04). Serum BNP levels increase with resuscitation after injury and levels are higher in patients who develop pulmonary edema. These findings suggest that BNP might be a marker of excessive volume resuscitation after injury.

Radiographic evidence of pulmonary edema during high-intensity interval training in women

The purpose was to determine if an intense interval training session could produce transient pulmonary edema in women. Fourteen females [(27+/-4 years; body mass index of 21.6+/-1.5 kg/m(2)); maximal oxygen consumption = 3.12+/-0.42 L/min] performed three sets of 5 min sea-level cycling exercise with 10-min recovery between each set. Average oxygen consumption at minute 5 of each set was 96+/-5% of maximum and arterial plasma lactate concentration at minute 5 of each set was 16.0+/-3.3 mmol/L. Chest radiographs were obtained before and 33.2+/-6.1 min after exercise. Four different chest radiologists independently reviewed the radiographs for edema, and scored seven validated radiographic characteristics on a three-point scale (0-2). The overall edema score increased from 1.3+/-1.6 before exercise to 1.9+/-2.0 after exercise [P<0.05; Delta = +0.7+/-1.8, 95% CI, 0.2 to +1.1]. This study shows that an intense interval training session can cause mild, detectable pulmonary edema in some women.

Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project.

Congestive heart failure (CHF) is increasing as a public health problem in the United States. The ability to quantify this problem has been limited by a lack of data regarding the validity of CHF identification. To assess the validity of the use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD) codes to identify hospitalizations with clinical evidence of an episode of acute CHF in data of The Corpus Christi Heart Project, a population-based surveillance program for hospitalized coronary heart disease. The validation standard was a composite variable including the presence of physician diagnosed acute CHF or radiographic evidence of pulmonary edema. Data were abstracted from the medical records of 5083 patients identified as hospitalized for possible acute myocardial infarction, aortocoronary bypass surgery, percutaneous transluminal coronary angioplasty, and related revascularization procedures in the Corpus Christi Heart Project. Discharge diagnoses, a secondary source of data, were used to apply 3 computer algorithms to assess the assignment of ICD codes. The prevalence of clinically documented CHF was 27.1% (1376/5083). The ICD code 428 (CHF), assigned as the primary or a secondary discharge diagnosis, was associated with 62.8% sensitivity, 95.4% specificity, 83.5% positive predictive value, 87.4% negative predictive value, and a 24.8% underenumeration of CHF-related hospitalizations. An algorithm based on a series of ICD codes was associated with 67.1% sensitivity, 92.6% specificity, 77.1% positive predictive value, 88.3% negative predictive value, and a 13.0% underenumeration of CHF-related hospitalizations. Reliance on ICD codes results in the exclusion of one third of the patients with clinical evidence of acute CHF. This underenumeration is compounded by the typical reliance on the first listed diagnosis. Congestive heart failure may be a greater public health problem than currently recognized. The allocation of resources for relevant surveillance, research, medical care, and preventive efforts should be reevaluated.

Radiographic evidence of interstitial pulmonary edema after exercise at altitude.

Pulmonary function abnormalities after exercise are suggestive of pulmonary edema; however, radiographic evidence is lacking. Well-trained cyclists were studied to determine whether there is radiographic evidence of pulmonary edema after endurance exercise (cycling distance 5.3-131.5 km) at altitude. Chest radiographs obtained before exercise were coded for later interpretation. Films obtained after exercise were coded with a different number. A total of 74 sets of posteroanterior and lateral films were analyzed by three radiologists for signs of pulmonary edema. Radiographic changes were graded on a three-point scale. An edema score was calculated by summing the score for each individual radiographic finding for each radiologist and an overall edema score representing the mean scores from all three radiologists. The overall edema score increased from 0.8 +/- 1.2 before exercise to 1.8 +/- 1.6 after exercise (P < 0.01). These results suggest that, after prolonged high-intensity exercise at moderate altitude, there is radiographic evidence of early pulmonary edema in some cyclists.

Glutathione Decreases the Pulmonary Reimplantation Response in Canine Lung Autotransplants

The pulmonary reimplantation response (PRR) is a form of membrane permeability pulmonary edema occurring in lung transplants. The severity of the PRR reflects the quality and duration of lung graft preservation. Free radicals formed during ischemia with reperfusion in the autotransplanted dog lung may play a role in producing PRR. We hypothesized that the addition of reduced glutathione (GSH) to the preservative solution could decrease PRR if hydroperoxides are being formed. Six dogs underwent left lung autotransplantation after the lung was flushed with Euro-Collins solution (EC). These dogs demonstrated radiographic and histopathologic evidence of bilateral pulmonary edema, greatest in the transplanted left lung. They also had increases in lung wet to dry weight (W/D) ratios in both lungs (left, 12.0 +/- 0.9; right, 10.1 +/- 0.8) as compared with a group of five unmanipulated control animals (left, 6.0 +/- 0.5; right, 7.0 +/- 0.4). Malondialdehyde (MDA) concentrations were significantly increased in the transplanted left lungs (14 +/- 4) from this group as compared with the controls (5 +/- 7). Five additional dogs underwent left lung autotransplantation with GSH added to the EC cryopreservation fluid. These animals did not develop histologic or radiographic evidence of pulmonary edema, and W/D ratios as well as MDA concentrations were not different from those in controls. To evaluate the effect of ischemia alone on changes in lung GSH concentrations, ten additional dogs underwent left pneumonectomy. Left lungs were cryopreserved in EC + GSH. In five of the animals, the right lung was removed and preserved in EC alone. In the other five animals, the right lung remained in vivo for 3 h and was then removed. Lung GSH concentrations were doubled after 3 h of ischemia when incubated in EC + GSH compared to in vivo controls and to EC-treated lungs. These data suggest that GSH added to the preservation fluid prevents PRR following transplantation and that lung GSH concentrations actually increase during preservation prior to reimplantation and reperfusion if the lung graft is exposed to GSH in the preservation fluid.

Anesthetic Management of Infants Receiving an Adult Kidney Transplant

Renal transplantation in infants has been associated with a high incidence of acute tubular necrosis and of renal artery thrombosis. Since 1978, 24 infants who received an adult kidney transplant at the University of Minnesota have had aggressive administration of intravenous colloids to increase the central venous pressure to 16-20 mm Hg before renal reperfusion. Acute tubular necrosis developed in only two infants, and there were no cases of renal artery thrombosis. Chest radiographic evidence of pulmonary edema was present in the recovery room in seven patients (29%) and within the first four postoperative days in five patients (21%). Yet, only two infants (8.3%) required postoperative mechanical ventilation beyond 24 h to manage fluid overload. With aggressive intravenous colloid administration, infants in renal failure can receive an adult kidney transplant with a low incidence of active tubular necrosis or renal artery thrombosis, but pulmonary edema may develop requiring ventilatory support.

The Relationship of the Colloid Osmotic-Pulmonary Artery Wedge Pressure Gradient to Pulmonary Edema and Mortality in Critically III Patients

The relationship of serum colloid osmotic pressure (COP) and pulmonary artery wedge pressure (PAWP) to pulmonary edema and mortality was investigated in 76 critically ill patients. Forty patients suffered from circulatory shock and 36 did not. The COP-PAWP gradient and radiographic evidence of pulmonary edema were measured at the time of diagnosis. The COP-PAWP gradient was markedly decreased in both shock and non-shock patients with pulmonary edema. Decrease of the COP-PAWP gradient correlated with mortality only in those patients with shock. The shock patients who died had a significantly higher incidence of pulmonary edema than those who survived, whereas there was no difference in the incidence of pulmonary edema for surviving or dying non-shock patients. We conclude that marked decreases of the COP-PAWP gradient predict pulmonary edema in the critically ill, but predict mortality only for patients with circulatory shock.

Studies of colloid osmotic pressure in pregnancy-induced hypertension

Pulmonary edema, although infrequently encountered, may cause death in severe cases of PIH. The mechanisms that account for edema in these instances are unclear. With a transducer-membrane system to directly measure serum COP, 22 patients with PIH were compared to 23 normal pregnant patients at term. In the PIH group the antepartum and postpartum COP values were significantly lower (17.9 and 13.7 mm Hg, respectively) than comparable values for the control group (22.0 and 17.2 mm Hg, respectively). Two patients in the PIH group in whom the antepartum COP values were 13.1 and 14.7 mm Hg exhibited clinical and radiographic evidence of pulmonary edema. Pulmonary artery wedge pressure (PAW) recorded in one patient with pulmonary edema was only moderately elevated to 18 mm Hg. We believe that serial COP determinations combined with pulmonary artery pressure monitoring may be helpful to guide fluid therapy in critically ill patients with PIH.