Ali A. Hasan

B-lines: Transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases.

OBJECTIVE: This prospective study was conducted to evaluate the value of sonographic B-lines (previously called “comet tail artifacts”), which are long, vertical, well-defined, hyperechoic, dynamic lines originating from the pleural line in assessment of interstitial lung diseases (ILD) and compare them with the findings of chest high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs). MATERIALS AND METHODS: Sixty-one patients with ILD underwent transthoracic lung ultrasound for assessment of the presence of B-lines and the distance between them. These findings were compared with that of chest HRCT (ground glass, reticular, nodular or honey combing) and PFT as forced vital capacity (FVC), total lung capacity (TLC), diffusion capacity for carbon monoxide (DLCO) and partial arterial oxygen pressure (PaO2). RESULTS: All patients had diffuse bilateral B-lines. The distance between each of the two adjacent B lines correlated with the severity of the disease on chest HRCT where B3 (the distance was 3 mm) correlated with ground glass opacity and B7 (the distance was 7 mm) correlated with extensive fibrosis and honey combing. Also, the distance between B-lines inversely correlated with FVC (r = −0.848, P < 0.001), TLC (r = −0.664, P < 0.001), DLCO (r = −0.817, P < 0.001) and PaO2 (r = −0.902, P < 0.001). CONCLUSION: B-lines that are lung Ultrasound signs seem to be useful in the assessment of ILD.

Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients.

AIM To evaluate role of diaphragmatic thickening and excursion, assessed ultrasonographically, in predicting extubation outcome. METHODS Fifty-four patients who successfully passed spontaneous breathing trial (SBT) were enrolled. They were assessed by ultrasound during SBT evaluating diaphragmatic excursion, diaphragmatic thickness (Tdi) at end inspiration, at end expiration and diaphragmatic thickness fraction (DTF%). Simultaneously traditional weaning parameters were recorded. Patients were followed up for 48h after extubation. RESULTS Out of 54 included patients, 14 (25.9%) failed extubation. Diaphragmatic excursion, Tdi at end inspiration, at end expiration and DTF% were significantly higher in the successful group compared to those who failed extubation (p<0.05). Cutoff values of diaphragmatic measures associated with successful extubation were ≥10.5mm for diaphragmatic excursion, ≥21mm for Tdi at end inspiration, ≥10.5mm for Tdi at end expiration, ≥34.2% for DTF% giving 87.5%, 77.5%, 80% and 90% sensitivity respectively and 71.5%, 86.6%, 50% and 64.3% specificity respectively. Combining diaphragmatic excursion ≥10.5mm and Tdi at end inspiration ≥21mm decreased sensitivity to 64.9% but increased specificity to 100%. Rapid shallow breathing index (RSBI) <105 had 90% sensitivity but 18.7% specificity. CONCLUSION Ultrasound evaluation of diaphragmatic excursion and thickness at end inspiration could be a good predictor of extubation outcome in patients who passed SBT. It is recommended to consider the use of these parameters with RSBI consequently to improve extubation outcome.

Brain natriuretic peptide as a predictor of weaning from mechanical ventilation in patients with respiratory illness

BACKGROUND Cardiovascular dysfunction has been reported as an important mechanism of weaning failure. Brain natriuretic peptide (BNP) is a sensitive and specific marker for cardiovascular dysfunction. OBJECTIVE To determine the value of BNP levels measured at initiation and end of a 2h spontaneous breathing trial (SBT) as a predictor of successful weaning of mechanical ventilation in patients with respiratory illness. PATIENTS AND METHODS Thirty consecutive patients ready for weaning were prospectively enrolled in this cross-sectional analytic study over a 6-month period. All patients had been on spontaneous mode of weaning for at least 2h. Tidal volume, respiratory rate, rapid shallow breathing index (RSBI), minute ventilation and PaO2/FiO2 were observed at initiation of SBT. BNP was measured at the initiation (BNP1) and at the end of SBT (BNP2). Weaning failure is defined as either the failure of SBT or the need for reintubation within 48 h following extubation. RESULTS Out of the 30 included patients, 14 (46.6%) patients had failed weaning. PaCO2 and BNP2 were significantly higher in the patients with failed weaning as compared to those with successful weaning (P = 0.025, P = 0.031 respectively). However, BNP1 levels were not statistically significant between the 2 groups (P = 0.722). On multiple regression analysis, BNP% (percent change in the BNP level during the 2-h SBT) was the only predictor of weaning success. As compared to other weaning parameters, BNP% ≤ 14.9 had the best sensitivity, specificity, positive and negative predictive value. CONCLUSION Measuring the percentage change in the BNP level during a SBT may be a good predictor of weaning success from mechanical ventilation in respiratory patients.

Scope on idiopathic pulmonary fibrosis in Upper Egypt

Background: Clinical features of idiopathic pulmonary fibrosis (IPF) are not the same in all patients and are characterized by being nonspecific. Symptoms range from nothing at all to severe disabling dyspnea. Aim: To explore the demographic, clinical and physiological characteristics of IPF patients attending the outpatient clinic at El-Minia and Assiut University Hospitals to see whether they match with or differ from the common features of the disease known worldwide. Patients and methods: One hundred-twenty six patients diagnosed as IPF underwent detailed history taking, clinical examination, spirometery, oxygen saturation and trans-thoracic echocardiography. Results: About 43% of patients developed IPF before age of 50 and the mean age at time of diagnosis was 48.6 ± 12.9 years. Eighty four (66.7%) patients were males. Ninety (71.4%) patients had significant tobacco smoke exposure. Dyspnea was present in 120 (95.2%) patients and the majority had grade 3 and 4 dyspnea. Ninety-five percentage of patients had cough. Clubbing of fingers was present in 72 (57.1%). All patients had bilateral basal crepitation. The mean of FVC was 52.5 ± 15.2% while the mean O 2 saturation was 91.9 ± 4.8%. One third of patients (33.3%) had corpulmonal and those have significantly longer duration of illness and significantly lower FVC and O 2 saturation (P < 0.001 for each). Conclusion: In our locality IPF patients had younger age of presentation while other demographic, clinical and physiological features were more or less similar to those recorded worldwide.

Acute Pulmonary Thromboembolism in Emergency Room: Gray‐ Scale versus Color Doppler Ultrasound Evaluation

Pulmonary thromboembolism (PTE) remains under‐diagnosed fatal disease at emergency units suggesting the need for alternative, easy, and noninvasive bedside diagnostic approaches.

Does hepatitis C virus enhance prevalence of idiopathic pulmonary fibrosis and affect its severity? An Egyptian study

Background Idiopathic pulmonary fibrosis (IPF) is the most common and severe form of pulmonary fibrosis characterized by gradual loss of pulmonary function. Despite rigorous research, the etiology of IPF has remained unknown. Viruses, for example, hepatitis C virus (HCV), had been implicated in IPF etiology; however, data on the prevalence of HCV infection in IPF patients were limited. Aim of the study Our aims were to assess the prevalence of HCV antibodies in IPF patients and to assess the relationship between severity of pulmonary and hepatic dysfunction. Materials and methods IPF patients were prospectively enrolled from Chest Department, Assiut University Hospital. HCV antibodies were detected using the third-generation enzyme-linked immunosorbent assay. Patients′ pulmonary and hepatic functions were evaluated. Results HCV antibodies were significantly higher in IPF patients than in controls (29.4 vs. 14%, P = 0.04). Patients with HCV had significantly more severe hypoxemia and lower diffusing capacity for carbon monoxide than those without HCV (47.7 ± 11.3 vs. 54 ± 18.7, P = 0.03 and 52.7 ± 8.4 vs. 67.3 ± 9.5, P = 0.01, respectively). There was no significant difference between HCV-positive IPF patients and HCV-negative IPF patients regarding spirometric parameters and liver function parameters. Conclusion This higher prevalence of HCV and its effect on pulmonary functions in IPF patients may contribute in IPF pathogenesis, which hopefully will allow currently available antiviral drugs or novel therapeutic approaches to treat or modify the course of this devastating disease.

Authors' response to "Brain natriuretic peptide as a predictor for weaning or outcome?".

Thank you for your interest and precise analysis of our study hat surely increases the value of the study and opens the window or further researches. First, BNP was not routinely used in our ICU and thus analysis ould not be done immediately. We were interested in that point f research as cardiovascular dysfunction was a common cause f weaning failure.1 During research work-up, we collected blood amples at beginning and at the end of SBT. Decision of weaning was ased on SBT and other weaning parameters such as RSBI, minute entilation. At that time we were blind of the results of BNP levls and that could be a strong point in our research. During result nalysis, we analysed the data with the results of BNP at the time f SBT and that was done in other studies which collected samples nd stored it.2,3 I agree with you that transthoracic Echo was more simple ethod for detection of cardiac dysfunction. The problems known ith transthoracic Echo was the fact that it needed an experienced chocardiographist in such patients.4 Moreover, TTE cannot be perormed in patients with poor echo window and atrial fibrillation.5 oreover, it might be not sensitive for detection of minor changes n cardiac function.2 We faced these problems in our respiratory CU: No experienced echocardiographist was available and also our OPD patients had poor echo window. As regards to management of weaning failure, therapy was not ased on BNP levels as we were blind to these results. We agree ith you that NIV decreases the myocardial tension by decreasing he cardiac output.6 We used NIV in patients either prophylactic or s a treatment of weaning failure. But it was not our aim in that tudy to evaluate the effect of NIV on BNP levels but could be good oint for further research. On assessing weaning outcome, we evaluated arterial blood ases, RSBI and minute ventilation together with BNP levels as redictor of weaning. RSBI, PaO2 and minute ventilation were not

Authors’ response to “Difficult to wean patients”

I would like to thank you for your comment on that paper.1 The pathophysiology of weaning failure is complex and multile causes for difficult weaning may exist in any single patient.2 enerally, weaning from MV fails due to an imbalance between espiratory muscle function and the respiratory muscle load.3 The auses of respiratory muscle dysfunction include central inhibition, hrenic nerve injury, neuropathies and muscle weakness of varius etiologies. The causes of increased ventilatory demand include ncreased central respiratory drive, sepsis, fever, pain, increased ead space ventilation, and decreased lung and chest wall elastic ecoil.4 Because weaning failure has various causes, use of multiple arameters of weaning are seemed to be more accurate.5,6 Howver in that study, we tried to stress on BNP levels as predictors of eaning and compared it with simple traditional weaning paramters. We finally recommended the use of BNP% of change during BT in the protocol of assessment of patients with difficult weaning.