Chung-Chieh Yu

The effects of heated humidifier in continuous positive airway pressure titration.

BackgroundPrevious studies have shown that routine heated humidifier (HH) do not provide any benefit during continuous positive airway pressure (CPAP) titration if there are no significant naso-pharyngeal symptoms. In clinical practice, nasal diseases and upper airway symptoms are very common. This study investigates the effects of HH during CPAP titration in subjects with or without naso-pharyngeal symptoms.MethodsFifty-two patients who received polysomnography with CPAP titration were randomly assigned to HH and non-HH groups. Their nasal cavity, pharynx, and naso-pharynx were evaluated before CPAP titration, and a questionnaire on subjective sensation, including naso-pharyngeal symptoms, willingness to further use CPAP, and sleep improvement, was used. Objective (e.g., leak, apnea–hypopnea index (AHI) reduction, and optimal CPAP pressure level) and subjective data were analyzed between the two groups.ResultsIn subjective sensation, the HH group did not have any benefit in further willingness to use CPAP and in sleep improvement, but had improved naso-pharyngeal symptoms (p = 0.043). There were no significant differences in leak, AHI reduction, and optimal CPAP pressure, even in patients with significant naso-pharyngeal symptoms.ConclusionRoutine use of HH is not necessary during CPAP titration regardless of naso-pharyngeal symptoms.

Comparing hydrocortisone and methylprednisolone in patients with septic shock

IntroductionIntravenous hydrocortisone of 200–300 mg/day for 7 days is suggested for patients with septic shock who require vasopressors to maintain mean artery pressure ≥65 mmHg, despite adequate fluid resuscitation. No study to date has compared the effects between physiologic doses of hydrocortisone and methylprednisolone in patients with septic shock.MethodsFrom July 2007 to June 2008, patients who were admitted to the intensive care unit at Chang Gung Memorial Hospital, Keelung, Taiwan, with low-dose steroid therapy due to septic shock were enrolled in this study. The typical steroid therapy included 7 days of intravenous hydrocortisone 50 mg every 6 hours. Methylprednisolone (20 mg every 12 hours) was replaced in these patients from January 2008 because no hydrocortisone could be prescribed.ResultsA total of 21 patients were prescribed hydrocortisone and 19 patients were prescribed methylprednisolone. The survival rates for patients receiving hydrocortisone were relatively higher compared with those receiving methylprednisolone, but the difference was not significant. There were no significant differences in the Kaplan-Meier curves for the time to reverse shock between patients who received hydrocortisone, or methylprednisolone. Further regression analysis showed no significant independent factors associated with the survival rates and the time to reverse shock among age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, histories, and adverse events.ConclusionsLow-dose methylprednisolone and hydrocortisone might have a similar effect for the treatment of patients with septic shock.

Liver Cirrhosis and Diabetes Mellitus Are Risk Factors for Staphylococcus aureus Infection in Patients with Healthcare-Associated or Hospital-Acquired Pneumonia

Background. The risk factors for Staphylococcus aureus (S. aureus) pneumonia are not fully identified. The aim of this work was to find out the clinical characteristics associated with S. aureus infection in patients with healthcare-associated pneumonia (HCAP) and hospital-acquired pneumonia (HAP), which may be applicable for more appropriate selection of empiric antibiotic therapy. Methods. From July 2007 to June 2010, patients who were admitted to the intensive care unit with severe HCAP/HAP and severe sepsis were enrolled in this study. Lower respiratory tract sample was semiquantitatively cultured. Initial broad-spectrum antibiotics were chosen by Taiwan or American guidelines for pneumonia management. Standard bundle therapies were provided to all patients according to the guidelines of the Surviving Sepsis Campaign. Results. The most frequently isolated pathogens were Pseudomonas aeruginosa, S. aureus, Acinetobacter baumannii, Klebsiella pneumoniae, and Escherichia coli. Patients with positive isolation of S. aureus in culture had significantly higher history of liver cirrhosis and diabetes mellitus, with odds ratios of 3.098 and 1.899, respectively. The S. aureus pneumonia was not correlated with history of chronic obstructive pulmonary disease, hypertension, and hemodialysis. Conclusion. Liver cirrhosis and diabetes mellitus may be risk factors for S. aureus infection in patients with severe HCAP or HAP.

Factors Associated With In Vitro Interferon-gamma Production in Tuberculosis

BACKGROUND/PURPOSE Macrophage activation assisted by interferon-gamma (IFN-γ) is a primary mechanism by which Mycobacterium tuberculosis is killed, but IFN-γ (production is inhibited in tuberculosis (TB) patients. The production of IFN-γ is influenced by many factors, such as interleukin (IL)-10, IL-12, IL-18, and clinical diseases; but the relative importance of each factor is unclear. METHODS We evaluated the effects of these factors in 46 healthy individuals, 81 patients with TB, and 88 patients with non-TB pneumonia. The responses of IFN-γ, IL-10, IL-12 and IL-18 were determined from phytohemagglutinin-stimulated peripheral blood mononuclear cells (PBMCs). RESULTS General linear model analysis showed that disease status and IL-12 response were the independent factors associated with the IFN-γ response. The production of IFN-γ was not affected by IL-10 and IL-18. There was a significant relationship between the IFN-γ response and the IL-12 response among patients with non-TB pneumonia, patients with TB, and healthy participants (Pearsons correlation coefficients of 0.466, 0.483, and 0.464, respectively). CONCLUSION Production of IFN-γ in PBMCs was associated with active pulmonary TB and IL-12 response.

Acute Pulmonary Edema after Upper Airway Obstruction-A Case Report and Review of the Literature

Pulmonary edema induced by upper airway obstruction is classified as a disease of noncardiogenic or unclear origin, is associated with a high rate of mortality, and is typified by the rapid onset of a resolvable disease that may arise after the upper airway obstruction has been relieved. The possible pathophysiology of this type pulmonary edema involves intrathoracic pressure alternations, hemodynamic alternations, and arterial hypoxemia. Acute pulmonary hemorrhage may occasionally be associated with pulmonary edema, due to capillary stress failure resulting from the same pathophysiology. In this report, we present our experience with a 34-year-old otherwise healthy male suffering from an upper airway obstruction caused by food allergy-aggravated angioedema. The patient was intubated because of the severe upper airway obstruction. Upon relief of the upper airway obstruction, the patient developed acute pulmonary edema and pulmonary hemorrhage. We administered mechanical ventilation and medical therapy for angioedema. His pulmonary status improved rapidly and he was extubated without further complications. He completely recovered without any sequel and was discharged from our hospital 8 days later. The total protein ratio of the lung edema fluid collected from the BAL, corrected with a dilution factor to plasma, was 5.6%. We inferred the change of hydrostatic pressure to be more predominant than the change in capillary permeability in this patient.