David A. Solomon

Significant Tracheal Obstruction Causing Failure to Wean in Patients Requiring Prolonged Mechanical Ventilation: A Forgotten Complication of Long-term Mechanical Ventilation

INTRODUCTION Modern low-pressure, high-volume cuffed tracheotomy tubes have been shown to decrease tracheal injury. However, injury still occurs in patients requiring prolonged mechanical ventilation and prevents weaning, delays decannulation, prolongs hospitalization, and may totally obstruct the airway. We describe 37 patients, including the first reported case of failure to wean due to tracheal obstruction. METHODS Over a 3-year period, from September 1994 to August 1997, the hospital records of 37 patients requiring prolonged mechanical ventilation (> 4 weeks) and found to have tracheal obstruction were reviewed retrospectively. They were a subgroup of 756 patients admitted to hospitals during the same period. The average endotracheal/tracheostomy cannulation time was 3 weeks/12 weeks (range 2 to 4 weeks/8 to 14 weeks). Average age was 76 years (range, 34 to 81). Underlying diseases included COPD, postcoronary artery bypass graft surgery, postpneumonectomy, severe pneumonia, acute lung injury, and ischemic heart disease. RESULTS All 37 patients who initially failed to wean had difficulty in breathing and developed intermittent high peak airway pressures either early or during the weaning process or just on being ventilated. The insertion of a longer tracheal tube bypassed the obstruction, reestablished the airway, decreased peak airway pressures, and allowed the patient to breathe more easily. The obstruction was confirmed on bronchoscopy. Treatment consisted of either placement of a longer tracheal tube (34 of 37 patients) or placement of a tracheal stent. All but two of the patients (5.4%) were able to be weaned within a week. The two patients who still failed to be weaned were subsequently diagnosed as having amyotrophic lateral sclerosis. CONCLUSION Tracheal obstruction in patients requiring prolonged mechanical ventilation prevented weaning. Reestablishment of the airway with a longer tracheal tube or tracheal stent allowed most of the patients to be weaned.

Clinical Investigations in Critical CareSignificant Tracheal Obstruction Causing Failure to Wean in Patients Requiring Prolonged Mechanical Ventilation: A Forgotten Complication of Long-term Mechanical Ventilation

INTRODUCTION Modern low-pressure, high-volume cuffed tracheotomy tubes have been shown to decrease tracheal injury. However, injury still occurs in patients requiring prolonged mechanical ventilation and prevents weaning, delays decannulation, prolongs hospitalization, and may totally obstruct the airway. We describe 37 patients, including the first reported case of failure to wean due to tracheal obstruction. METHODS Over a 3-year period, from September 1994 to August 1997, the hospital records of 37 patients requiring prolonged mechanical ventilation (> 4 weeks) and found to have tracheal obstruction were reviewed retrospectively. They were a subgroup of 756 patients admitted to hospitals during the same period. The average endotracheal/tracheostomy cannulation time was 3 weeks/12 weeks (range 2 to 4 weeks/8 to 14 weeks). Average age was 76 years (range, 34 to 81). Underlying diseases included COPD, postcoronary artery bypass graft surgery, postpneumonectomy, severe pneumonia, acute lung injury, and ischemic heart disease. RESULTS All 37 patients who initially failed to wean had difficulty in breathing and developed intermittent high peak airway pressures either early or during the weaning process or just on being ventilated. The insertion of a longer tracheal tube bypassed the obstruction, reestablished the airway, decreased peak airway pressures, and allowed the patient to breathe more easily. The obstruction was confirmed on bronchoscopy. Treatment consisted of either placement of a longer tracheal tube (34 of 37 patients) or placement of a tracheal stent. All but two of the patients (5.4%) were able to be weaned within a week. The two patients who still failed to be weaned were subsequently diagnosed as having amyotrophic lateral sclerosis. CONCLUSION Tracheal obstruction in patients requiring prolonged mechanical ventilation prevented weaning. Reestablishment of the airway with a longer tracheal tube or tracheal stent allowed most of the patients to be weaned.

Treatment of Tuberculosis by the Nonpulmonary Physician

Because tuberculosis is currently being treated in many instances by the nonpulmonary physician, an evaluation of the skill with which he performs in this capacity was made. A group of 130 patients who had been treated by such physicians was analyzed, using generally accepted criteria for appropriate therapy. Seventy-three of the group were found to have been treated inappropriately. The use of isoniazid in those likely to be resistant to that drug, the use of a single drug in bacteriologically positive disease, and inadequate or excessive drug dosages were among the more common errors. Two thirds of the physicians caring for these patients were internal medicine specialists, half of them board certified. Increased education efforts in regard to this disease at all levels of training must be made.

Isoniazid Chemoprophylaxis: Association With Detection and Incidence of Liver Toxicity

The hepatotoxicity of isoniazid was studied in a double blind fashion in 120 adult patients receiving the drug for chemoprophylaxis. The incidence of abnormal SGOT values was significantly higher in those on the drug, 18.3% having elevated values as compared to 6.7% of those on placebo during the three-month study period. There was no statistical difference in the frequency of symptoms suggestive of liver diseases between the isoniazid and placebo groups. Furthermore, there was no significant relationship between symptoms and elevated SGOTs. Therefore, symptomatology would not appear to be a sensitive method for detecting early isoniazid liver toxicity. From available evidence, biochemical monitoring would appear to detect liver toxicity at an earlier and more reversible stage.

Azelastine and desmethylazelastine suppress acetylcholine-induced contraction and depolarization in human airway smooth muscle

We examined the effects of a new anti-asthmatic drug, azelastine, and its principal metabolite, desmethylazelastine, on the in vitro electromechanical response of human airway smooth muscle during cholinergic stimulation. Membrane potential and isometric force were simultaneously measured using an intracellular microelectrode and a microforce transducer. Desmethylazelastine significantly suppressed acetylcholine-induced depolarization and contraction at 10(-6) M, whereas azelastine produced similar results at 10(-4) M, suggesting that the metabolite may be the principal compound acting upon the airway smooth muscle cell.

Significant Reduction of Ventilator-Associated Pneumonia Rates Associated With the Introduction of a Prevention Protocol and Maintained for 10 Years

Objective: To determine if the institution of a ventilator-associated pneumonia (VAP) prevention protocol was associated with VAP decrease in mechanically ventilated patients at a long-term acute care (LTAC) hospital over time. Introduction: VAP is the most common serious nosocomial infectious disease in mechanically ventilated patients. It has a high mortality and morbidity and significantly increases the cost of care. Design: A prospective preintervention and postintervention observational study comparing the number of episodes of VAP per 1000 patient ventilator-days in the 16 months preceding and 120 months (10 years) after the introduction of a VAP prevention protocol. Setting: A 73-bed, university-affiliated LTAC hospital. Methods: The implementation of a VAP prevention protocol included the following: (1) head of bed raised at 30°; (2) twice-weekly whole-body chlorhexidine-based bath with mupirocin 2% ointment applied to nares; (3) adequate hand washing; (4) adequate nutrition; (5) early tracheotomy...

When cardiac patients become surgical patients.

Given the 28 million cardiac patients in the U.S., the problems of their preoperative assessment and pre-, peri-, and postoperative management when they become surgical patients comprise an important part of general medical practice. The broad range of cardiovascular disorders—arteriosclerotic, arrhythmic, valvular, hypertensive—is examined in the light of the risks incurred by a variety of surgical procedures.

Early versus delayed right heart catheterization in evaluation of pulmonary arterial hypertension

When pulmonary arterial hypertension (PAH) is suspected by clinical signs and symptoms, screening echocardiography is recommended for initial evaluation of the disease. Because of the inherent inaccuracy of echocardiographic estimates of pulmonary pressures, right heart catheterization (RHC) is the standard of care for assessing pulmonary vascular hemodynamics and confirming PAH. However, current diagnostic algorithms for PAH do not stress the importance of confirmation of PAH with RHC. Guidelines recommend that a work-up for underlying causes be performed prior to confirmation of PAH by RHC. We conducted a retrospective review of patients referred for RHC based on echocardiographic findings to illustrate the importance of confirming PAH by RHC early in the diagnostic process. We retrospectively reviewed 190 patients with pulmonary artery systolic pressure (PaSP) 440 mm Hg on transthoracic echocardiogram who also underwent RHC at Tampa General Hospital between January 2007 and October 2009. The average mean pulmonary artery pressure (mPAP) at RHC was compared with the average PaSP by echocardiogram using Pearson’s correlation. World Health Organization (WHO) Group 1 PAH was diagnosed if mean pulmonary artery pressure (mPAP) was 425 mm Hg with a pulmonary artery wedge pressure (PaWP) of r15 mm Hg, and WHO Group 2 PAH was diagnosed if mPAP was 425 mm Hg and PaWP was 415 mm Hg. The positive predictive value of echocardiography to predict a diagnosis of PAH at RHC was calculated. Institutional review board approval (No. 108617) for this study was obtained from the University of South Florida. Table 1 shows the characteristics of the study population. There was a modest correlation between PaSP obtained by echocardiography and PaSP obtained at RHC (r 1⁄4 0.68, p o 0.001). The distribution of RHC results is shown in Fig. 1 Only 67 of 190 patients (35%) with elevated PaSP on echocardiogram met the criteria for the diagnosis of WHO Group 1 PAH. Seventy of 190 patients (37%) with elevated PaSP on echocardiogram had mPAP r25 mm Hg at RHC. Interestingly, 53 of 190 patients (28%) with elevated PASP on echocardiogram and mPAP 425 mm Hg on RHC were reclassified as WHO Group 2 PAH (pulmonary venous hypertension). In this study, only about one third of patients referred for RHC based on elevated PaSP on echocardiography actually had WHO Group 1 PAH. One third of patients were reclassified as WHO Group 2 PAH based on elevated PaWP, and one third had normal mPAP measured directly on RHC. Although there was a modest correlation between

Reflux of Contrast into the Inferior Vena Cava: A Sign of Right Ventricular Failure Due To Multiple Conditions

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