Chih-Feng Chian

Acute Respiratory Distress Syndrome After Zinc Chloride Inhalation: Survival After Extracorporeal Life Support and Corticosteroid Treatment

No standard protocol exists for the treatment of acute respiratory distress syndrome induced by inhalation of smoke from a smoke bomb. In this case, a 23-year-old man was exposed to smoke from a smoke grenade for approximately 10 to 15 minutes without protective breathing apparatus. Acute respiratory distress syndrome developed subsequently, complicated by bilateral pneumothorax and pneumomediastinum 48 hours after inhalation. Despite mechanical ventilation and bilateral tube thoracostomy, the patient was severely hypoxemic 4 days after hospitalization. His condition improved upon treatment with high-dose corticosteroids, an additional 500-mg dose of methylprednisolone, and the initiation of extracorporeal life support. Arterial oxygenation decreased gradually after abrupt tapering of the corticosteroid dose and discontinuation of the life support. On day 16 of hospitalization, the patient experienced progressive deterioration of arterial oxygenation despite the intensive treatment. The initial treatment regimen (ie, corticosteroids and extracorporeal life support) was resumed, and the patients arterial oxygenation improved. The patient survived.

Effects of Implementing Adaptive Support Ventilation in a Medical Intensive Care Unit

BACKGROUND: Adaptive support ventilation (ASV) facilitates ventilator liberation in postoperative patients in surgical intensive care units (ICU). Whether ASV has similar benefits in patients with acute respiratory failure is unclear. METHODS: We conducted a pilot study in a medical ICU that manages approximately 600 mechanically ventilated patients a year. The ICU has one respiratory therapist who manages ventilators twice during the day shift (8:00 am to 5:00 pm). No on-site respiratory therapist was present at night. We prospectively enrolled 79 patients mechanically ventilated for ≥ 24 hours on pressure support of ≥ 15 cm H2O, with or without synchronized intermittent mandatory ventilation, FIO2 ≤ 50%, and PEEP ≤ 8 cm H2O. We switched the ventilation mode to ASV starting at a “%MinVol” setting of 80–100%. We defined spontaneous breathing trial (SBT) readiness as a frequency/tidal-volume ratio of < 105 (breaths/min)/L on pressure support of ≤ 8 cm H2O and PEEP of ≤ 5 cm H2O for at least 2 h, and all spontaneous breaths. The T-piece SBT was considered successful if the frequency/tidal-volume ratio remained below 105 (breaths/min)/L for 30 min, and we extubated after successful SBT. The control group consisted of 70 patients managed with conventional ventilation modes and a ventilator protocol during a 6-month period immediately before the ASV study period. RESULTS: Extubation was attempted in 73% of the patients in the ASV group, and 80% of the patients in the non-ASV group. The re-intubation rates in the ASV and non-ASV groups were 5% and 7%, respectively. In the ASV group, 20% of the patients achieved extubation readiness within 1 day, compared to 4% in the non-ASV group (P = <.001). The median time from the enrollment to extubation readiness was 1 day for the ASV group and 3 days for the non-ASV group (P = .055). Patients switched to ASV were more likely to be liberated from mechanical ventilation at 3 weeks (P = .04). Multiple logistic regression analysis showed that, of the independent factors in the model, only ASV was associated with shorter time to extubation readiness (P = .048 via likelihood ratio test). CONCLUSIONS: Extubation readiness may not be recognized in a timely manner in at least 15% of patients recovering from respiratory failure. ASV helps to identify these patients and may improve their weaning outcomes.

Role of Open Lung Biopsy in Patients with Diffuse Lung Infiltrates and Acute Respiratory Failure

BACKGROUND AND PURPOSE Open lung biopsy (OLB) is the standard procedure for the diagnosis of specific parenchymal lung diseases. The purpose of this study was to investigate the influence of OLB on subsequent treatment strategy and outcome in patients with diffuse lung infiltrates and acute respiratory failure. METHODS This retrospective review included 32 patients (aged 50.6 +/- 21.7 years) with acute respiratory failure and diffuse pulmonary infiltrates who underwent OLB from 1990-2002. Data analyzed included diagnoses, treatment alterations, 30-day survival, oxygenation status, and histologic results. RESULTS Specific diagnoses were made in 53.1% of patients (17/32), 23 (71.9%) of whom had acute respiratory distress syndrome (ARDS). Diagnostic yields did not differ with immunity status or ARDS. OLB led to specific decisions of treatment in 46.9% of patients (15/32), and only 7 of these 32 patients (21.8%) survived. Overall mortality was 56.2% (18/32) and was not influenced by pre-OLB oxygenation or histologic results. Although perioperative complications affected 40.6% of patients (13/32), none of the deaths were surgery-related. Complication rates were significantly higher in patients with ARDS (p = 0.04). CONCLUSIONS OLB is associated with a low perioperative mortality rate and acceptable morbidity rate in patients with diffuse lung infiltrates and acute respiratory failure, including those patients with ARDS. In this study, a specific diagnosis was obtained by OLB in more than half of patients with diffuse pulmonary infiltrates and ARDS. In addition, OLB resulted in either use of a new therapeutic strategy or elimination of unnecessary treatment in nearly one-half of patients (46.9%).

Intravenous immunoglobulin replacement therapy to prevent pulmonary infection in a patient with Good's syndrome

Goods syndrome is an acquired immunodeficiency state associated with thymoma and characterized by recurrent pulmonary infections. We describe a 67-year-old woman who presented with respiratory symptoms caused by concomitant disseminated cytomegalovirus infection and Pneumocystis jiroveci pneumonia 38 months after thymectomy for a thymoma. Immunologic analysis revealed hypogammaglobulinemia with absent B-cell population as demonstrated by flow cytometry, consistent with Goods syndrome. Following treatment with sulfamethoxazole/trimethoprim and ganciclovir, the patient improved with resolution of her respiratory symptoms. However, the patient subsequently experienced additional infections, necessitating additional subsequent hospital admissions. During the last admission, intravenous immunoglobulin (IVIG) replacement therapy was initiated and continued after discharge. Infection has been prevented for one year after beginning IVIG replacement therapy. This case reveals that in patients with combined humoral and cell-mediated immune deficiency, concomitant infection with different pathogens is not unusual, and immediate specific therapy is important. Periodic IVIG infusion, to maintain adequate Ig levels, is recommended.

Multiple Pulmonary Nodules in Ectopic Adrenocorticotropic Hormone Syndrome: Cause or Result?

Objective: To report a case of invasive pulmonary aspergillosis mimicking lung cancer with lung to lung metastases in ectopic adrenocorticotropic hormone syndrome (EAS). Clinical Presentation and Intervention: A 60-year-old man suffering from hypokalemic alkalosis, hypertension and limbs paralysis was referred to our hospital. EAS caused by malignancy of lung was highly suspected due to multiple pulmonary nodules presenting on chest film and positron emission tomography (PET) images. Video-assisted thoracic surgical biopsy tissue was used to confirm invasive aspergillosis instead of malignancy. Finally, the patient died of opportunistic infection. Conclusion: This case showed that although EAS is usually associated with solid tumors, multiple pulmonary nodules secondary to opportunistic infections such as invasive aspergillosis must be kept in mind.

Risk factors for the development of pulmonary oil embolism after transcatheter arterial chemoembolization of hepatic tumors.

Pulmonary oil embolism (POE) is a rare fatal complication after transcatheter arterial embolization (TAE) and transcatheter arterial chemoembolization (TACE). As risk factors have not been clearly delineated, the aim of the present study was to identify the risk factors for development of POE after TACE. A retrospective analysis was carried out on patients with unresectable hepatocellular carcinoma who received TAE or TACE at the Tri-Service General Hospital (Taiwan) between January 2005 and December 2008. The diagnosis of TAE-induced or TACE-induced POE was based on development of respiratory signs and symptoms relatively soon after the procedure, as well as based on characteristic radiographic findings. Of the 219 enrolled patients in this study, 20 were diagnosed with POE after TAE or TACE. On univariate logistic regression analysis, patients developing POE were found to be older (67.95±15.95 vs. 61.44±12.59 years, P=0.033), with a lower serum albumin level (3.25±0.58 vs. 3.62±0.57 g/dl, P=0.009), a higher grade of liver cirrhosis as classified on the basis of Child’s criteria (P<0.006), a larger tumor size (8.55±4.52 vs. 4.78±3.97 cm in diameter, P<0.001), a higher lipioidol dose (22.35±11.01 vs. 13.69±7.66 ml, P=0.003), and a higher doxorubicin dose (50.27±7.05 vs. 40.75±13.61 mg, P<0.001). Following multivariate logistic regression analysis, only lipiodol dose was found to be a significant risk factor for POE (odds ratio=1.133, 95% confidence interval: 1.004, 1.279; P=0.044). The receiver operator characteristic curve cutoff point for lipiodol dose level was 14.5 ml, with a sensitivity of 80% and a specificity of 66.3%. In conclusion, the lipiodol dose could be considered as a predictive factor for POE after TAE or TACE in hepatic malignant tumor patients. On the basis of this retrospective study, the safe lipiodol dose to minimize the risk for POE is 14.5 ml or lower; however, larger, prospective studies are needed to determine the optimally safe and yet efficacious dose.

Influenza a Infection with Rhabdomyolysis and Acute Renal Failure

Influenza A virus can be transmitted widely throughout the community. Although patients with influenza often present with myalgia, rhabdomyolysis is rarely seen. Very few results were obtained in an online search for case reports on rhabdomyolysis and acute renal failure associated with influenza. We present the case of a 78-year-old man who was admitted to our emergency department with myalgia, dry cough, fever, progressive lower limb pain, and tea-colored urine. On investigation, the serum creatine kinase level was found to be elevated and myoglobinuria was detected; these signs were indicative of rhabdomyolysis. Renal function impairment was also noted. Influenza A infection was confirmed by the positive antigen test of a nasal swab. The clinical presentation and medical history of the patient strongly suggested that rhabdomyolysis was caused by influenza A virus. The patients renal function was restored and he was discharged after appropriate therapy for rhabdomyolysis. This case highlights the importance of recognizing influenza A infection as a cause of acute renal failure secondary to rhabdomyolysis during influenza pandemics, despite the fact that rhabdomyolysis complicated by acute renal failure is rarely seen in patients with influenza A.

Small Cell Lung Cancer Presenting as Ectopic ACTH Syndrome with Hypothyrodism and Hypogonadism

Background: Small-cell lung cancer accounts for 15–20% of all lung cancers, and it is the cell type most commonly associated with paraneoplastic syndrome. Small-cell lung cancer presenting as ectopic adrenocorticotropic hormone (ACTH) syndrome associated with hypothyrodism and hypogonadotropic hypogonadism is clinically very rare. Case Report: A 43-year-old man who presented with bilateral lower-extremity edema and hypokalemia had a mass lesion in his left hilum base visible on chest radiograph. Biopsy identified the mass as smallcell lung cancer with focal ACTH staining. The endocrine tests disclosed hypercortisolism, hypogonadism and hypothyroidism. Results: Partial remission as evidenced by regression of the tumor mass and return to normal serum cortisol and ACTH levels occurred after the first course of combination chemotherapy using cisplatin and etoposide. An unexpected left-sided spontaneous pneumothorax developed after the first course of chemotherapy and was treated with thoracostomy and a chest tube. The patient developed persistent air leakage and chronic empyema. The patient received surgery of the Eloesser flap and reconstruction with the latissimus dorsalis flap. The treatment of the complicated problems was successful. Conclusion: Combination chemotherapy may prove effective in the treatment of small-cell lung cancer with ectopic ACTH syndrome, hypothyroidism and hypogonadism.

Sonographic Septation as One Predictor for Pleural Drainage in Patients with Non-purulent Parapneumonic Effusions

Background: The American College of Chest Physician (ACCP) has identified 4 categories of parapneumonic effusion (PPE) to guide treatment. The modality in assessing anatomy of pleural fluid is not well-defined, making differentiation of category 2 from category 3 PPE difficult. We investigated whether sonographic septation predicts category 3 PPE in guiding early pleural drainage. Methods: Medical records of patients with lung abscess or pneumonia at admission were reviewed retrospectively. All patients had a plain chest radiograph upon admission. Patients classified as AACP category 2 or 3 who underwent chest sonography with thoracentesis revealing non-purulent parapneumonic effusions with neutrophils predominance were included. Inter-observer variations in determining PPE category were analyzed. Further, positive predictive value (PPV), relative risk (RR) and reading agreement of positive sonographic septation in predicting category 3 PPE were determined. Results: 51 patients of the total 97 recruited had sonographic septation. The reading agreement between thoracic radiologists in determining the category of pleural fluid by plain chest radiograph was low with a kappa coefficient (κ) of 0.29. In contrast, reading agreement of positive sonographic septation was substantial (κ = 0.73). A signifi cantly higher PPV for category 3 effusion was observed in patients with sonographic septation (86.3%) compared to those with no septation (43.5%) (p ＜ 0.001). The RR of category 3 PPE with sonographic septation was 1.98 (95% CI: 1.40-2.81; p＜0.001). Conclusions: Sonographic septation is a useful sign in predicting category 3 PPE, and may in conjunction with plain chest radiograph, enable a more accurate diagnosis or screening way of patients with lung abscess and pneumonia.

Successful Treatment of a Patient with Severe CarbonMonoxide Intoxication Complicated with ARDS UsingECMO and HFO Ventilation

Carbon monoxide (CO) intoxication is a common and underestimated problem. We report a 39-year-old woman who was exposed to CO for more than 12 hours and presented in an unconsciousness state with acute pulmonary edema. Extracorporeal membrane oxygenation (ECMO) and high frequency oscillatory ventilation (HFOV) were used because of acute respiratory distress syndrome (ARDS) and complicated bilateral pneumothorax during hospitalization. ECMO and HFOV were instituted for 30 days and 10 days, respectively. Full recovery of consciousness and cognition were observed, and her activities were not limited in the 6-month follow-up. (Thorac Med 2011; 26: 325-331)