Carlos Martinez-Balzano

Bilateral Vocal Cord Paralysis Requiring Tracheostomy Due to Neuroborreliosis

Neuroborreliosis can cause multiple cranial and peripheral neuropathies; however, involvement of both recurrent laryngeal nerves is rare. We report the case of a 90-year-old man who presented with dysphonia and right upper and lower extremity weakness. His course was complicated by bilateral vocal cord paralysis and respiratory failure requiring tracheostomy. The diagnosis of borreliosis was made by detection of IgM and IgG antibodies against Borrelia burgdorferi on enzyme immunoassay and Western blot. The patient received IV ceftriaxone for 2 weeks, followed by complete recovery of motor and vocal function over 2 months. Our case is the third report of bilateral vocal cord paralysis in the literature, and the first one, to our knowledge, presenting with respiratory failure requiring an artificial airway. Physicians should be aware of this unusual complication of neuroborreliosis.

An educational intervention optimizes the utilization of arterial blood gases across intensive care units from different specialties: a quality improvement study.

BACKGROUND: Overuse of arterial blood gas (ABG) determinations leads to increased costs, inefficient use of staff work hours, and patient discomfort and blood loss. We developed guidelines to optimize ABG use in the ICU. METHODS: ABG use guidelines were implemented in all adult ICUs in our institution: three medical, two trauma‐surgery, one cardiovascular, and one neurosurgical ICU. Although relying on pulse oximetry, we encouraged the use of ABG determination after an acute respiratory event or for a rational clinical concern and discouraged obtaining ABG measurements for routine surveillance, after planned changes of positive end‐expiratory pressure or Fio2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected. ABG measurements and global ICU metrics were collected before (year 2014) and after (year 2015) the intervention. RESULTS: We saw a reduction of 821.5 ± 257.4 ABG determinations per month (41.5%), or approximately one ABG determination per patient per mechanical ventilation (MV) day for each month (43.1%), after introducing the guidelines (P < .001). This represented 49 L of saved blood, a reduction of

An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study

39,432 in the costs of ICU care, and 1,643 staff work hours freed for other tasks. Appropriately indicated tests rose to 83.4% from a baseline 67.5% (P = .002). Less than 5% of inappropriately indicated ABG determinations changed patient management in the postintervention period. There were no significant differences in MV days, severity of illness, or ICU mortality between the two periods. CONCLUSIONS: The large scale implementation of guidelines for ABG use reduced the number of inappropriately ordered ABG determinations over seven different multidisciplinary ICUs, without negatively impacting patient care.

PS01.14: Diagnostic Yield in Patients Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Single Center Experience: Topic: Pulmonology

BACKGROUND: Overuse of arterial blood gas (ABG) determinations leads to increased costs, inefficient use of staff work hours, and patient discomfort and blood loss. We developed guidelines to optimize ABG use in the ICU. METHODS: ABG use guidelines were implemented in all adult ICUs in our institution: three medical, two trauma‐surgery, one cardiovascular, and one neurosurgical ICU. Although relying on pulse oximetry, we encouraged the use of ABG determination after an acute respiratory event or for a rational clinical concern and discouraged obtaining ABG measurements for routine surveillance, after planned changes of positive end‐expiratory pressure or Fio2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected. ABG measurements and global ICU metrics were collected before (year 2014) and after (year 2015) the intervention. RESULTS: We saw a reduction of 821.5 ± 257.4 ABG determinations per month (41.5%), or approximately one ABG determination per patient per mechanical ventilation (MV) day for each month (43.1%), after introducing the guidelines (P < .001). This represented 49 L of saved blood, a reduction of

A 66-Year-Old Man With a Past History of Relapsing Polychondritis Presented With Right Upper Lobe Consolidation, Nodular Airway Lesions, and a Corticosteroid-Responsive Chronic Cough

39,432 in the costs of ICU care, and 1,643 staff work hours freed for other tasks. Appropriately indicated tests rose to 83.4% from a baseline 67.5% (P = .002). Less than 5% of inappropriately indicated ABG determinations changed patient management in the postintervention period. There were no significant differences in MV days, severity of illness, or ICU mortality between the two periods. CONCLUSIONS: The large scale implementation of guidelines for ABG use reduced the number of inappropriately ordered ABG determinations over seven different multidisciplinary ICUs, without negatively impacting patient care.

High Prevalence and Heterogeneity of Diabetes in Patients With TB in South India: A Report from the Effects of Diabetes on Tuberculosis Severity (EDOTS) Study

Background: Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) is an established diagnostic tool in the evaluation of lung cancer with a variable diagnostic yield, ranging from 62 % 93 %. Although the procedure can be performed under moderate sedation (MS) or general anesthesia (GA) , the impact of sedation type on the diagnostic yield has yielded variable results with some authors reporting a higher yield with deep sedation, whereas others note no difference between MS and GA. We present findings of a retrospective study that looked at the diagnostic yield using an artificial airway under GA compared to conscious sedation through a natural airway in patients undergoing EBUS-TBNA. Methods: Demographic information on age, sex, race and co-morbidities were used to compute an age adjusted Charlson Co-morbidity index for each of 88 patients. Pathology reports were reviewed and an EBUS-TBNA was determined to be diagnostic if any of the sampled lymph nodes yielded a diagnosis. Assessment of the impact of using an artificial airway under GA on diagnostic yield was determined using multivariate logistic regression. Continuous variables are presented as means (± SD) and categorical variables are reported as counts and percentages. For all tests, two-sided P values < 0.05 were considered statistically significant. Results: Patients in the GA group were older (65 years versus 57.6, p1⁄4 0.005), had a higher age-adjusted Charlson comorbidity index, (3.7 versus 1.9, p < 0.001) and a higher ASA classification (3 versus 2 p1⁄4 0.004). Average lymph node size was smaller in the artificial airway group (16.2 mm versus 20.7mm, p1⁄4 0.01). Despite these differences, the diagnostic yield was the same (61.4 % in each group). In multivariate analyses, female sex and lymph node size were the only predictors of a diagnostic EBUS-TBNA. OR 3.3, 95 % CI, 1.23 e 9.1 for female gender, (p1⁄4 0.02) and 1.1, 95 % CI, 1.00 e 1.18 for lymph node size (p1⁄4 0.04). Diagnoses made were: adenocarcinoma of the lung 42.6 %, Sarcoidosis 16.7 %, Small cell lung cancer 14.8 %, Squamous cell carcinoma 11.1 %. Conclusion: EBUS-TBNA performed under general anesthesia through an artificial airway was not associated with an increased diagnostic yield, and therefore conscious sedation should be considered where appropriate, with general anesthesia reserved for those patients who are older, and with a higher perioperative risk. More research assessing the determinants of a positive diagnosis including physician pretest likelihood and PET/ CT avidity are needed to improve diagnostic outcomes.

Original Research: Chest InfectionsHigh Prevalence and Heterogeneity of Diabetes in Patients With TB in South India: A Report from the Effects of Diabetes on Tuberculosis Severity (EDOTS) Study

A 66-year-old male nonsmoker from Arizona was referred to our practice for evaluation of chronic cough. He had a history of biopsy-proven relapsing polychondritis manifesting as right auricular and nasal pain and swelling 9 months prior to presentation. The onset of his cough coincided with the diagnosis of relapsing polychondritis, and he was prescribed prednisone 90 mg/d, which promptly relieved his rheumatologic and respiratory symptoms. A chest radiograph, obtained prior to the initiation of therapy, was normal. Any attempts at decreasing the dose of the glucocorticoid to < 30 mg/d resulted in recurrence of the cough but not of the auricular or nasal symptoms. A second chest radiograph done 6 months before presentation, while the patient was receiving prednisone 20 mg/d, was normal as well. In anticipation of our evaluation, he stopped all glucocorticoids for 7 days. He was not receiving any other medications, and he had no history of an atopic diathesis.