Respiratory Failure Complications Research Articles

Pneumothorax as a complication of respiratory failure – two case reports and literature review

Pneumothorax as a complication of respiratory failure – two case reports and literature review

Short and Mid-Term Economic Impact of Pulmonary Artery Catheter Use in Adult Cardiac Surgery: A Hospital and Integrated Health System Perspective.

ObjectiveA monitoring pulmonary artery catheter (PAC) is utilized in approximately 34% of the US cardiac surgical procedures. Increased use of PAC has been reported to have an association with complication rates: significant decreases in new-onset heart failure (HF) and respiratory failure (RF), but increases in bacteremia and urinary tract infections. We assessed the impact of increasing PAC adoption on hospital costs among cardiac surgery patients for US-based healthcare systems.MethodsAn Excel-based economic model calculated annualized savings for a US hospital with various cardiac surgical volumes and PAC adoption rates. A second model, for an integrated payer-provider health system, analyzed outcomes/costs resulting from the cardiac surgical admission and for the treatment of persistent HF and RF complications in the year following surgery. Model inputs were extracted from published literature, and one-way and probabilistic sensitivity analyses were performed.ResultsFor an acute care hospital with 500 procedures/year and 34% PAC adoption, annualized savings equalled $61,806 vs no PAC utilization. An increase in PAC adoption rate led to increased savings of $134,751 for 75% and $170,685 for 95% adoption. Savings ranged from $12,361 to $185,418 at volumes of 100 and 1500 procedures/year, respectively. For an integrated payer-provider health system with the base-case scenario of 3845 procedures/year and 34% PAC adoption, estimated savings were $596,637 for the combined surgical index admission and treatment for related complications over the following year.ConclusionPAC utilization in adult cardiac surgery patients results in reduced costs for both acute care hospitals and payer-provider integrated health systems.

Clinical and experimental studies of immunо-infl ammatory mechanisms of anthracosilicosis formation

Introduction. In the structure of occupational diseases of employees of the main professions of the coal industry, respiratory diseases are widespread, in the process of formation of which the key role belongs to the immune system of the body. Early manifestations of the development of professional pathology, as a rule, remain unnoticed, and therefore there is a need to study the pathogenetic mechanisms underlying its formation, not only in clinical, but also in experimental conditions, allowing to assess the premorbid state of the body for timely diagnosis and treatment and prevention.The aim of the study is to study the immune-infl ammatory mechanisms of anthracosilicosis formation on the basis of clinical and experimental studies.Materials and methods. We examined 204 miners working in underground conditions with a signifi cant dustiness of workplaces exceeding the maximum permissible concentration by 10 or more times. Th e main group consisted of 115 workers with a previously established diagnosis of “anthracosilicosis”. Th e comparison group was formed from 89 miners without a diagnosis of respiratory pathology, working in similar sanitary conditions. To assess the dynamics of immuno-infl ammatory mechanisms in the experiment, modeling of dust pathology of the lungs was performed on 310 white male laboratory rats (220-experimental and 90 — control).Results. In patients with anthracosilicosis, the development of immune failure of humoral immunity mechanisms was revealed, which was manifested by a signifi cant decrease in the level of serum IgG against the background of an increase in the absolute and relative number of B-lymphocytes. Th e formation of anthracosilicosis is characterized by the active development of the immuno-infl ammatory process (an increase in the level of pro-infl ammatory cytokines and proteins of the acute phase of infl ammation), the severity of which increases when the disease is complicated by respiratory failure. Activation of the synthesis of anti-infl ammatory IL-4, which is a powerful inhibitor of macrophage infl ammation and slows down the processes of fi brosis in the bronchopulmonary system, acts as a protective mechanism that prevents the formation of respiratory failure in miners with anthracosilicosis. Experimental modeling of anthracosilicosis revealed phase changes in the immune response. In the early period of exposure to dust factor was observed activation of humoral (increased level of all classes of immunoglobulins) and the subsequent development of the inflammatory process (increased concentrations of acute phase proteins of inflammation) in the background of the balance between subpopulations of T-lymphocytes to ensure proper development of protective immune response. Long-term intake of antigen was characterized by violations of humoral immunity, the predominance of cell-type reactions and the chronization of the infl ammatory process.Conclusions. Th e study of immuno-infl ammatory mechanisms of anthracosilicosis formation in clinical and experimental conditions indicates the activation of urgent adaptation and maintenance of compensatory and adaptive reactions of the body in the early period of contact with dust antigen. Th e chronic form of anthracosilicosis is characterized by an imbalance of regulatory mechanisms, ineffi ciency of local immunity and the intensive development of generalized immune infl ammation, which increases with the addition of infection and complication of respiratory failure.

Study on clinical phenotype of coal workers pneumoconiosis

Objective: To explore the clinical phenotypic characteristics of coal worker's pneumoconiosis for guiding the individualized treatment of various types of patients with coal worker's pneumoconiosis. Methods: Collect clinical data of 121 cases of coal worker's pneumoconiosis in different stages, and select 16 clinical variables (age, smoking index, years of underground dust exposure, stages of pneumoconiosis, types of work, family history, main symptoms, secondary symptoms, CAT score, imaging manifestations, FVC%, FEV(1)/FVC, FEV(1)%, DLCO%, respiratory failure complications, pulmonary heart disease complications) . Principal Component Factor Analysis (PCA) was used to analyze 16 clinical variables of 121 patients with coal worker's pneumoconiosis. Extracted 2 principal components and 8 related variables from 16 clinical variables, then coal worker's pneumoconiosis patients were divided into three types according to CCC values. Variance analysis or χ(2) test were used to analyze the characteristics of these three types of clinical data, then summarized the clinical phenotype composition ratio and clinical data characteristics. Results: The patients with coal worker's pneumoconiosis were initially divided into three types, including 73 cases (60.3%) in type 1, 18 cases (14.9%) in type 2 and 30 cases (24.8%) in type 3. Patients in type 1 are mainly middle-aged, with little damage to lung function and mild clinical symptoms, the imaging manifestations of type 1 patients are mainly diffuse nodules, and the stages of pneumoconiosis are mostly one-stage and second-stage. Patients in type 2 are mainly in middle-aged and elderly patients.the main pulmonary impairment is diffuse function decline. The clinical symptoms are severe and the imaging manifestations are complex. The stages of pneumoconiosis are one, second and third stages. Patients in type 3 are mainly middle-aged and elderly patients, with more pulmonary function impairment (decreased ventilation and diffusion) , severe clinical symptoms, complex imaging manifestations (micro nodules, emphysema, mass shadow, fibrosis) , and those pneumoconiosis stages are mainly in the second and third stages. Conclusion: According to the clinical characteristics, the patients with coal worker's pneumoconiosis were divided into 3 types by cluster analysis method, the treatment plan has certain guiding value in clinical work according to different classifications.

PSU5 ECONOMIC IMPACT OF PULMONARY ARTERY CATHETER UTILIZATION AMONG CARDIAC SURGERY PATIENTS: PERSPECTIVES FOR AN ACUTE CARE HOSPITAL AND AN INTEGRATED PAYER-PROVIDER HEALTH SYSTEM

A recent study demonstrated pulmonary artery catheter (PAC) use surrounding cardiac surgery is associated with a significant decrease in the incidence of new onset heart failure (HF) and respiratory failure (RF), while bacteremia and urinary infection complication rates significantly increased, as compared to patients that did not receive a PAC. We evaluated the economic impact of perioperative monitoring PAC utilization for adult cardiac procedures to support decision-making regarding PAC adoption for an acute care hospital and an integrated payer-provider health system. An Excel-based model was created to estimate the annualized savings for a US acute care hospital utilizing a monitoring PAC perioperatively for cardiac procedures during the index visit. A second model for an integrated payer-provider included costs for the index visit and for treatment of persistent index visit-related HF and RF complications over the following year (excluding patients with history of these conditions). Complication rates, costs, and healthcare utilization inputs were extracted from literature and a national database. Scenario analyses with varying surgical volume and PAC adoption rates were performed, as were one-way and probabilistic sensitivity analyses. For an acute care hospital, base-case (500 cardiac surgeries/year, 34% PAC adoption) annualized savings for the index visit totaled US$61,806 vs. no PAC utilization. Scenario analyses with cardiac surgical volumes of 100 and 1,500 procedures/year resulted in estimated savings of US$12,361 and US$185,418, respectively. Increased PAC adoption rates (75% and 95%) were associated with increased savings: US$134,751 and US$170,685, respectively, for 500 procedures/year. HF and RF treatment costs had the largest impact on savings. For an integrated payer-provider, base-case (3,845 cardiac surgeries/year, 34% PAC adoption) resulted in estimated savings of US$596,637 for the index visit and treatment of related complications over the following year. Monitoring PAC utilization for adult cardiac surgeries generates significant savings for acute care hospitals and integrated payer-provider systems.

MULTIPLE ENDOBRONCHIAL PLASMACYTOMAS IN A PATIENT WITH PLASMA CELL LEUKEMIA

SESSION TITLE: Pulmonary Manifestations of Systemic Diesase SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Plasma cell leukemia (PCL) is a rare and aggressive plasma cell malignancy with an increased frequency of extramedullary involvement compared with multiple myeloma. We present a rare case of newly diagnosed PCL with multiple endobronchial lesions. CASE PRESENTATION: The patient is a 62-year-old woman with past medical history of COPD and granular cell tumor of the epiglottis who presented with increasing lethargy and altered mental status over a five-day period. She was cachectic and found to be oriented only to self, with initial lab work showing evidence of acute renal failure and hyperkalemia as well as a leukocytosis of 32,000/μl, hemoglobin level of 5.5 g/dl, and lipase of 7,676. Chest X-ray revealed multifocal opacities and broad-spectrum antibiotics were started for presumed pneumonia. CT of the head revealed a small intraventricular hemorrhage. She required intubation for progressive respiratory failure as well as vasopressors and CVVH. A bronchoscopy was performed, revealing two nodular endobronchial lesions in the right and left main stem bronchi; cryobiopsy of both lesions showed fibrotic tissue with a dense infiltrate of CD138-positive, lambda-restricted atypical cells, consistent with a high-grade plasma cell leukemia. Peripheral flow cytometry also revealed circulating plasma cells. Cultures sent from BAL were unrevealing. Critical illness precluded a more intensive regimen of chemotherapy and a course of intravenous dexamethasone was initiated. DISCUSSION: PCL is a rare and aggressive form of hematologic malignancy with a very poor prognosis, and can be either primary or secondary to end-stage multiple myeloma. It features a higher frequency of extramedullary involvement, anemia, thrombocytopenia, and acute renal failure than multiple myeloma. Extramedullary involvement in PCL is most commonly seen as hepatosplenomegaly and/or lymphadenopathy, with other reported sites of extraosseous involvement including soft tissue adjacent to bone, skin, liver, breast, and kidneys. Endobronchial involvement, particularly in multiple locations, appears to be an exceedingly rare form of extramedullary spread in both MM and PCL. A literature search reveals only two case reports describing the finding of multiple endobronchial plasmacytomas on histology obtained from bronchoscopy, neither in the setting of plasma cell leukemia. Plasma cell infiltration of the lung, termed “myeloma lung,” is a rare cause of acute respiratory failure in multiple myeloma & PCL, and may have explained persistent consolidations on CT scans that did not improve with antibiotics. Due to the severity of her illness, treatment was palliative, and she ultimately passed from complications of respiratory failure. CONCLUSIONS: The presence of multiple endobronchial plasmacytomas is a very rare presentation of extramedullary involvement in multiple myeloma and plasma cell leukemia and likely predicts an very poor prognosis. Reference #1: Niels W. C. J. van de Donk, Henk M. Lokhorst, Kenneth C. Anderson and Paul G. Richardson. “How I treat plasma cell leukemia.” Blood. 2012; 120(12):2376-2389. Reference #2: Joan Blade, Carlos Fernandez de Larrea, Laura Rosinol, Maria Teresa Cibeira, Raquel Jimenez, Ray Powles. “Soft-Tissue Plasmacytomas in Multiple Myeloma: Incidence, Mechanisms of Extramedullary Spread, and Treatment Approach.” Journal of Clinical Oncology. Oct 2011; 29(28):3805-3812. Reference #3: Carmen Montero, Ana Souto, Iria Vidal, Maria del Mar Fernandez, Marina Blanco, Hector Verea. Three Cases of Primary Pulmonary Plasmacytoma. Archivos de Bronconeumologia. 2009; 45(11):564-566. DISCLOSURES: No relevant relationships by Steven Cassady, source=Web Response No relevant relationships by Madhurima Koka, source=Web Response no disclosure on file for Matthew Paparo; No relevant relationships by Edward Pickering, source=Web Response No relevant relationships by Ashutosh Sachdeva, source=Web Response

Acute respiratory failure secondary to esophageal dilation from undiagnosed achalasia.

Achalasia is an idiopathic motility disorder causing progressive dysphagia and dilation of the esophagus. Rarely this esophageal dilation can cause acute respiratory insufficiency and/or failure. We describe a 63-year-old woman presenting for total knee arthroplasty in whom induction of anesthesia was complicated by pulmonary aspiration requiring postoperative ventilation, hypotension requiring vasopressor therapy, and postextubation, recurrent, acute respiratory failure. Computed tomography of the chest performed for suspected pneumothorax revealed severe esophageal dilation with a mass effect. As this case describes, achalasia may present with the life-threatening complication of respiratory failure and requires a high index of suspicion for timely diagnosis and appropriate interventions.

Adenovirus Serotype 3 and 7 Infection with Acute Respiratory Failure in Children in Taiwan, 2010–2011

ObjectiveIncreased incidence of adenovirus infection in children was noticed since September 2010 in Taiwan and severe cases requiring intensive care were noted later. We did this study to find the clinical characteristics and risk factors associated with severe adenovirus infection.Patients and MethodsWe collected cases of severe adenovirus infection between November 2010 and June 2011 to analyze their clinical characteristics in two medical centers in northern Taiwan. Severe adenovirus infection was defined as laboratory-confirmed adenovirus cases with required intensive care. Hexon gene sequencing was performed for molecular genotyping.Results45 patients were included, 22 cases (49%) were infected with serotype 7, 19 (42%) with serotype 3, and 4 with serotype 2. The median age (range) was 2.75 years (0.08–15.43 years); 87% were below 5 years. Male to female ratio was 1.65 (28 to 17). Of these patients, 56% had underlying neurological diseases, 50% experienced fever higher than 40°C and 69% suffered fever longer than one week. The clinical diagnosis included pneumonia in 40 (89%) patients, bronchopneumonia in 5 (11%), and encephalitis in 7 (16%). At least 22 patients had pleural effusion. They had complications of respiratory failure (53%), acute respiratory distress syndrome (24%), hypotension (40%), and 6 (13%) patients needed extracorporeal membranous oxygenation. Ten (22%) patients died, all with underlying major systemic diseases and 7 (70%) infected with serotype 7.ConclusionsAdenovirus serotype 7 and 3 can cause severe disease–even death–in children, especially those with underlying neurological diseases. Patients infected with adenovirus serotype 7 tended to have a higher case-fatality rate.

Surfactant Therapy for Acute Respiratory Distress in Severe Pediatric Burn Injury

After severe burn injury, pediatric patients often succumb to complications of respiratory failure. Surfactant has been used to improve pulmonary gas exchange for severe respiratory distress in other pediatric populations but has not been studied in pediatric burn-injured patients. Here, the authors report a case series of seven severely burned pediatric patients who received surfactant for acute respiratory distress and severe hypoxemia. Seven cases were reviewed of pediatric patients who received surfactant for severe acute respiratory distress. Data analyzed included age, TBSA burned, height, weight, mechanism of injury, total intensive care unit days, hospital days, and ventilator days. Modes of ventilation, peak inspiratory pressure, oxygen requirement, arterial blood gas analysis, blood pressure, and heart rate were analyzed before and the day following surfactant therapy. Four patients had reduced oxygen requirements following surfactant administration (FiO(2): 0.66 ± 0.23-0.48 ± 0.025). Three patients showed no reduction in oxygen requirements (FiO(2): 0.95 ± 0.09-0.90 ± 0.0). The remaining four patients who had reduced oxygen requirements received surfactant earlier following their injury (4.8 ± 0.9 days postinjury vs 17.7 ± 8 days postinjury) and had less derangement in oxygenation before surfactant dosing (PaO(2):FiO(2) ratio: 105.2 ± 26.4 vs 64.5 ± 5.2). Surfactant therapy may offer a therapeutic option during acute respiratory distress for severely burned pediatric patients. Surfactant may be useful early in the course of severe hypoxemia and acute respiratory distress but may not be effective as a salvage modality.

Consultation with the Specialist

Consultation with the Specialist

Report on the first year's activities of a multidisciplinary respiratory intensive care unit.

During the first twelve months of its existence, our RICU treated 140 patients in acute respiratory failure with a survival rate of 128/140 (91%). Fifty-four of these patients required mechanical ventilation for > 24 hr. The survival rate in the mechanically ventilated patients was 42/54 (78%). Eight of the 12 deaths were related to sepsis. The most frequent complications of respiratory failure were atelectasis and pneumonia. A unit excelling in respiratory care provides a sound foundation for multidisciplinary support of the critically ill.

Intensive care in acute respiratory failure

Patients requiring acute intensive respiratory therapy may have ventilatory failure and/or severe ventilatory insufficiency. The former group will have varying degrees of dyspnea and abnormal blood gases, the latter ventilatory fatigue. Therapy should be directed towards the establishment of a clear airway, easy removal of secretions and improvement of blood gas exchange. Depending on the nature and severity of the underlying condition as well as the blood gas abnormalities, the following therapeutic measures may be taken: oxygen, assisted IPPB, and tracheostomy with assisted or controlled IPPB. The role of infections, humidification of inspired gases, bronchodilator drugs, expectorants, monitoring of blood gases and pH, cardiac management and certain complications of respiratory failure are emphasized.