Daniel Baram

Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit.

Context:In critically ill intubated patients, signs of respiratory infection often persist despite treatment with potent systemic antibiotics. Objective:The purpose of this study was to determine whether aerosolized antibiotics, which achieve high drug concentrations in the target organ, would more effectively treat respiratory infection and decrease the need for systemic antibiotics. Design:Double-blind, randomized, placebo-controlled study performed from 2003 through 2004. Setting:The medical and surgical intensive care units of a university hospital. Patients:Critically ill intubated patients were randomized if: 1) ≥18 yrs of age, intubated for a minimum of 3 days, and expected to survive at least 14 days; and 2) had ventilator-associated tracheobronchitis defined as the production of purulent secretions (≥2 mL during 4 hrs) with organism(s) on Gram stain. Of 104 patients monitored, 43 consented for treatment and completed the study. No patients were withdrawn from the study for adverse events. Intervention:Aerosol antibiotic (AA) or aerosol saline placebo was given for 14 days or until extubation. The responsible clinician determined the administration of systemic antibiotics (SA). Patients were followed for 28 days. Main Outcome Measures:Primary: Centers for Disease Control National Nosocomial Infection Survey diagnostic criteria for ventilator-associated pneumonia (VAP) and clinical pulmonary infection score. Secondary: white blood cell count, SA use, acquired antibiotic resistance, and weaning from mechanical ventilation. Results:Most patients had VAP at randomization. With treatment, the AA group had reduced signs of respiratory infection: reduced Centers for Disease Control National Nosocomial Infection Survey VAP (14/19; 73.6%) to (5/14; 35.7%) vs. placebo (18/24; 75%) to (11/14; 78.6%), reduction in clinical pulmonary infection score, lower white blood cell count at day 14, reduced bacterial resistance, reduced use of SA, and increased weaning (all p ≤ .05). Conclusions:In critically ill patients with ventilator-associated tracheobronchitis, AA decrease VAP and other signs and symptoms of respiratory infection, facilitate weaning, and reduce bacterial resistance and use of systemic antibiotics.

Sedation during mechanical ventilation : A trial of benzodiazepine and opiate in combination

Objective:To compare the efficacy of continuous intravenous sedation with midazolam alone vs. midazolam plus fentanyl (“co-sedation”) during mechanical ventilation. Design:A randomized, prospective, controlled trial. Setting:A ten-bed medical intensive care unit at a university hospital. Patients:Thirty patients with respiratory failure who were expected to require >48 hrs of mechanical ventilation and who were receiving a sedative regimen that did not include opiate pain control. Interventions:An intravenous infusion of either midazolam alone or co-sedation was administered by a nurse-implemented protocol to achieve a target Ramsay Sedation Score set by the patients physician. Study duration was 3 days, with a brief daily “wake-up.” Measurements and Main Results:We recorded the number of hours/day that patients were “off-target” with their Ramsay Sedation Scores, the number of dose titrations per day, the incidence of patient-ventilator asynchrony, and the time required to achieve adequate sedation as measures of sedative efficacy. We also recorded sedative cost in U.S. dollars and adverse events including hypotension, hypoventilation, ileus, and coma. Compared with the midazolam-only group, the co-sedation group had fewer hours per day with an “off-target” Ramsay Score (4.2 ± 2.4 and 9.1 ± 4.9, respectively, p < .002). Fewer episodes per day of patient-ventilator asynchrony were noted in the co-sedation group compared with midazolam-only (0.4 ± 0.1 and 1.0 ± 0.2, respectively, p < .05). Co-sedation also showed nonsignificant trends toward a shorter time to achieve sedation, a need for fewer dose titrations per day, and a lower total sedative drug cost. There was a trend toward more episodes of ileus with co-sedation compared with midazolam-only (2 vs. 0). Conclusions:In mechanically ventilated patients, co-sedation with midazolam and fentanyl by constant infusion provides more reliable sedation and is easier to titrate than midazolam alone, without significant difference in the rate of adverse events.

Use of the All Patient Refined-Diagnosis Related Group (APR-DRG) Risk of Mortality Score as a Severity Adjustor in the Medical ICU.

Objective To evaluate the performance of APR-DRG (All Patient Refined—Diagnosis Related Group) Risk of Mortality (ROM) score as a mortality risk adjustor in the intensive care unit (ICU). Design Retrospective analysis of hospital mortality. Setting Medical ICU in a university hospital located in metropolitan New York. Patients 1213 patients admitted between February 2004 and March 2006. Main results Mortality rate correlated significantly with increasing APR-DRG ROM scores (p < 0.0001). Multiple logistic regression analysis demonstrated that, after adjusting for patient age and disease group, APR-DRG ROM was significantly associated with mortality risk in patients, with a one unit increase in APR-DRG ROM associated with a 3-fold increase in mortality. Conclusions APR-DRG ROM correlates closely with ICU mortality. Already available for many hospitalized patients around the world, it may provide a readily available means for severity-adjustment when physiologic scoring is not available.

Growing PET positive nodule in a patient with histoplasmosis: case report.

BackgroundPulmonary histoplasmosis is a mycotic infection that often resembles pulmonary malignancy and continues to complicate the evaluation of pulmonary nodules.Case presentationWe report a case of an immunocompetent patient who, despite adequate treatment for known histoplasmosis lung infection, presented with radiological and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) findings mimicking primary lung malignancy which eventually required surgical resection.ConclusionHistoplasmosis infection may radiologically resemble pulmonary malignancy, often causing a diagnostic dilemma. PET imaging is currently used for and considered accurate in the evaluation of pulmonary nodules. However, overlap in PET standardized uptake value (SUV) between granulomatous and malignant lesions decreases the accuracy of PET as a diagnostic modality. Future advances in PET imaging are needed to improve its accuracy in the evaluation of pulmonary nodules in areas where histoplasmosis is endemic.

Stable Patients Receiving Prolonged Mechanical Ventilation Have a High Alveolar Burden of Bacteria

INTRODUCTION In patients receiving prolonged mechanical ventilation (PMV), quantitative bronchoscopic culture has not been validated for the diagnosis of ventilator-associated pneumonia (VAP). OBJECTIVE To measure the alveolar burden of bacteria in patients receiving PMV. SETTING Respiratory care units of a university hospital and a long-term care facility. PATIENTS Fourteen patients requiring PMV without clinical evidence of pneumonia. MEASUREMENTS Quantitative culture of BAL from the right middle lobe and lingula. RESULTS In 29 of 32 lobes, there was growth of at least one organism at > 10(4) cfu/mL. Most lobes had polymicrobial growth. CONCLUSIONS Stable patients receiving PMV without clinical pneumonia have a high alveolar burden of bacteria. The bacterial burden in most patients exceeds the commonly accepted threshold for diagnosing VAP. The utility of quantitative bronchoscopic culture in the diagnosis of VAP in this patient population requires further study.

Sublobar resection in nonsmall cell lung carcinoma.

Purpose of review Though lobectomy remains the standard of care for resection of nonsmall cell lung cancer, a number of studies have been published in the last 24 months exploring the role of sublobar resection in the treatment of stage I nonsmall cell lung cancer. Recent findings Large retrospective studies comparing lobar and sublobar resection show similar overall and disease-free survival. Survival and local control for sublobar resections are best for tumors smaller than 2 cm and with margins greater than 2 cm. Importantly, sublobar resections commonly have less thorough nodal dissection and incomplete pathologic staging; this may have important therapeutic consequences. No formal comparison of segmentectomy to wedge resection has been performed although bias towards segmentectomy resulting in better outcomes than nonanatomic wedge resection continues. Sublobar resection is especially interesting for patients with prior resection, bronchoalveolar carcinoma, and the elderly. Radiologic criteria for selecting candidates appropriate for sublobar resection are evolving. Summary Sublobar resection is an alternative therapy for stage I nonsmall cell lung cancer for patients with physiologic impairment unable to undergo lobectomy. The literature also suggests a role for patients with prior lung resection, bronchoalveolar carcinoma, peripheral tumors less than 2 cm, and for the elderly.

FDG-PET imaging in patients with pulmonary carcinoid tumor.

Purpose This study aimed to assess the imaging findings in patients with pathologically proven carcinoid tumors and determine if SUV can help to differentiate typical from atypical (more aggressive) pulmonary carcinoid tumors. Patients and Methods A retrospective review of patients with a biopsy-proven diagnosis of a pulmonary carcinoid tumor at our institution from 2002 to 2010 that had a preoperative PET scan was performed after institutional review board approval was obtained. PET results, including SUV uptake and location, were recorded as well as all data from pathology reports. Carcinoids were considered to be more aggressive if they showed pathological diagnosis consistent with atypical carcinoid, lymph node invasion, poor histological grade (poorly differentiated), or evidence of systemic metastases. Atypical carcinoid pathology consisted of focal necrosis or a higher mitotic index (2–10 per square millimeter) with features of nests, trabeculae, pleomorphic cells, or dense hyperchromasia. SUV uptake was then evaluated and compared between the typical and atypical carcinoid groups using nonparametric statistical methods. Results We identified 29 patients from 2002 to 2010 at our institution with a pathological diagnosis of pulmonary carcinoid. Twenty-three were histopathologically typical, and the other 6 showed atypia. Mean (SD) nodule size was 2.4 (1.3) cm in the typical group versus 5.0 (3.2) cm in the atypical group (P = 0.065). Mean (SD) SUV uptake in the typical carcinoid group was 2.7 (1.6) and in the atypical group the SUV was 8.1 (4.1) (P < 0.01). A cutoff SUV of 6 or greater is predictive of malignancy (odds ratio, 23.6; P < 0.01), as well as a nodule size of 3.5 cm or greater (odds ratio, 5.1; P = 0.024). Conclusions Preoperative PET imaging result is frequently positive in carcinoid tumors, and the biological behavior correlates well with SUV; however, size is not as strong of a predictor of malignancy. Size of 3.5 cm or greater and SUV of 6 or greater have a predictive value of greater than 95% for malignant histology.

Eosinophilic Pneumonia Due to Duloxetine

A 32-year-old man presented with a 2-month history of worsening fever, chills, and cough despite therapy with oral antibiotics. Chest radiographs demonstrated migrating, peripheral upper lobe infiltrates. A CBC count demonstrated significant eosinophilia. At bronchoscopy, eosinophil-rich mucus was seen impacted throughout his bronchi. A transbronchial biopsy confirmed the diagnosis of eosinophilic pneumonia. Symptoms, eosinophilia, and radiographic abnormalities were reversed with cessation of duloxetine. This case report briefly reviews the diagnosis of drug-induced pulmonary infiltrates with eosinophilia (PIEs) and eosinophilic pneumonia. To our knowledge, this is the first reported case of PIEs due to duloxetine.

Pulmonary infiltration from chronic lymphocytic leukemia.

We present 2 patients with chronic lymphocytic leukemia infiltration of the lung resulting in centrilobular nodularity on computed tomography. We present the x-ray and computed tomography patterns with pathological findings in these cases.

Computed Tomographic Assessment of the Posterior junction Line and Its Association With Emphysema

Background: Visualization of a posterior junction line (PJL) on chest x-ray is evidence for emphysema. The correlation between the assessment of the PJL on computed tomography (CT) and emphysema is less clear. Methods: One hundred thirty-seven patients were identified with CT and pulmonary function tests (PFTs) performed within 3 months of each other in a University hospital. The width of the PJL was measured at 2 levels by a blinded investigator: superiorly at the superior border of the aorta and inferiorly 2 cm below the aortic arch. This was correlated to clinical and PFT data and to CT evidence of emphysema. Results: Narrowness of the junction line showed poor correlation with PFT findings of emphysema as assessed by forced expiratory volume in 1 second-forced vital capacity ratio and diffusing capacity of the lung for carbon monoxide percent predicted. The PJL also correlated weakly to CT emphysema severity scoring (r2 = 0.06; P < 0.002). The area under the receiver operator characteristic curve was 0.652, with maximum accuracy at a width of 1.3 cm. Conclusions: Our data suggest that despite statistical correlation between the narrowness of the PJL and emphysema, its clinical use is limited.