Anita Orlando

Modified Lung Ultrasound Score for Assessing and Monitoring Pulmonary Aeration

Purpose Lung Ultrasound Score (LUSS) is a useful tool for lung aeration assessment but presents two theoretical limitations. First, standard LUSS is based on longitudinal scan and detection of number/coalescence of B lines. In the longitudinal scan pleura visualization is limited by intercostal space width. Moreover, coalescence of B lines to define severe loss of aeration is not suitable for non-homogeneous lung pathologies where focal coalescence is possible. We therefore compared longitudinal vs. transversal scan and also cLUSS (standard coalescence-based LUSS) vs. qLUSS (quantitative LUSS based on % of involved pleura). Materials and methods 38 ICU patients were examined in 12 thoracic areas in longitudinal and transversal scan. B lines (number, coalescence), subpleural consolidations (SP), pleural length and pleural involvement (> or ≤ 50 %) were assessed. cLUSS and qLUSS were computed in longitudinal and transversal scan. Results Transversal scan visualized wider (3.9 [IQR 3.8 - 3.9] vs 2.0 [1.6 - 2.5] cm, p < 0.0001) and more constant (variance 0.02 vs 0.34 cm, p < 0.0001) pleural length, more B lines (70 vs 59 % of scans, p < 0.0001), coalescence (39 vs 28 %, p < 0.0001) and SP (22 vs 14 %, p < 0.0001) compared to longitudinal scan. Pleural involvement > 50 % was observed in 17 % and coalescence in 33 % of cases. Focal coalescence accounted for 52 % of cases of coalescence. qLUSS-transv generated a different distribution of aeration scores compared to cLUSS-long (p < 0.0001). Conclusion In unselected ICU patients, variability of pleural length in longitudinal scans is high and focal coalescence is frequent. Transversal scan and quantification of pleural involvement are simple measures to overcome these limitations of LUSS.

Technical aspects of bedside respiratory monitoring of transpulmonary pressure

Background: To determine the prognostic value of tumor length in predicting overall survival (OS) for patients with esophageal cancer. Methods: Patients who were diagnosed with esophageal cancer between 2010 and 2014 were identified from the Surveillance Epidemiology and End Results (SEER) data. We performed Kaplan-Meier survival analysis and developed a Cox regression proportional hazard model to explore the effect of tumor length on survival. Results: A total of 6,897 esophageal cancer patients were identified. The patients were classified according to tumor length: 2,334 patients had a tumor length ≤3 cm, and 4,563 patients had a tumor length >3 cm. Patients with a tumor length >3 cm were more likely to have poorer histological grade (P 3 cm than in those with a tumor length ≤3 cm both in the Cox regression univariate analysis [hazard ratio (HR): 1.790; 95% CI: 1.667–1.922; P=0.000] and the multivariate analysis (HR: 1.447; 95% CI: 1.341–1.561; P=0.000). A stratified analysis based on different T stages showed that the HR for death was 1.84 (P=0.000) for T1 stage patients, 1.227 (P=0.046) for T2 stage patients, and 1.157 (P=0.012) for T3 stage patients; there was no difference in survival for T4 stage patients. Conclusions: Tumor length significantly influences the OS of esophageal cancer patients, especially in early T stage patients. Further prospective trials are needed to validate the prognostic value of tumor length among esophageal cancer patients.

Acute respiratory failure from esophageal dilatation

A 44-year-old woman with a history of asthma was intubated for severe acute respiratory failure with stridor, not responding to bronchodilators and steroids. In ICU, passive respiratory mechanics under volume-controlledventilation excluded both peripheral obstructive disease (airways resistance 13 cm H2O/l/s) and restrictive disease (respiratory system compliance 50 ml/cm H2O), with rapid normalization of gas exchange. An upper airways obstruction was suspected, consistent with no air leak at the endotracheal tube’s cuff deflation test. A chest x-ray (Fig. 1a) showed a mid-proximal esophageal kinking and important dilatation, with large amounts of air and ingested food and thickened esophageal walls. This orients to extrinsic tracheal compression as the cause of acute respiratory failure related to a sudden pressure increase in the esophagus due to food ingestion. Recognition of esophageal dilatation redirected therapeutic management. Esophageal emptying by esophagogastroduodenoscopy is the key treatment to allow restoration of tracheal patency and therefore weaning from mechanical ventilation; nasogastric tube placement is crucial to prevent subsequent postprandial relapses. If a partial tracheal compression is visualized by CT-scan (Fig. 1b), despite esophageal emptying, the patient should be oriented to surgical treatment (Heller myotomy).

A 70-Year-Old Develops Refractory Hypotension in the ICU

A 70-year-old woman is admitted to the ICU for status epilepticus requiring intubation and mechanical ventilation. Her medical history includes ischemic stroke with no sequelae and breast cancer, treated surgically 12 months earlier; she is still undergoing radiochemotherapy. At day 6, despite good control of electrical activity with adequate therapy, she remains unconscious (Glasgow Coma Scale, 4) and mechanically ventilated; a tracheostomy is performed.

A 44-Year-Old Woman Presents to the ED With Agitation, Dyspnea, and Hypotension

In the ED she becomes more hypotensive (BP, 90/ 60 mm Hg), so she is shifted to an acute-care bed and given intravenous fluids. Arterial blood gas analysis shows compensated lactic acidosis and hypoxemia (pH 7.38; lactates, 7 mM; PaCO2, 27 mm Hg; PaO2, 60 mm Hg). Further history reveals chronic anemia and hemorrhoids; digital rectal exploration shows purulent fluid. A surgical consultation is requested (it having been determined that there was no need for urgent surgery).

Temperature Monitoring During Ecmo: An in Vitro Study

The need of heat exchanger in the ECMO circuit is controversial. Moreover, how to monitor patient central temperature during extracorporeal support is still not clear, but potentially useful for the detection of “unexpressed” fever, eventually related to septic complications.

Automatic monitoring of plateau and driving pressure during pressure and volume controlled ventilation

Plateau pressure (Pplat) limitation is routinely used to avoid ventilator-induced lung injury. Recently, driving pressure (ΔP) was strongly associated with survival in ARDS patients [1].

Artificial Lung Gas Exchanges Depend On Ecmo Settings

Artificial membrane lung (AL) gas exchanges are usually evaluated according to PaO2/FiO2 ratio. in addition, dead space ventilation and shunt fraction can be measured by the same equations used for native lungs [1].

Automatic Detection of Patients’ Spontaneous Activity During Pressure Support Ventilation

The occurrence of significant patient-ventilator asynchronies in assisted ventilation modes is an impellent problem in clinical practice. Addressing this question, an original software has been developed and is here proposed. This tool implements a new automatic technique to identify the beginning and the end of the patient’s respiratory effort, events that are sometimes missed or detected with significant delay by the ventilator. Its improved skills have been evaluated on a set of signals coming from 6 ICU patients and including 6445 respiratory acts, and proved to outperform the machine in increasing the amount of respiratory acts assisted without significant delay from 22 to 70%. The presented tool is the first step in the development a hardware-software device to be directly interfaced with the ventilator in order to represent a monitoring aid for the clinician and possibly to directly drive the device activity.