David Sotello

High-Flow Nasal Cannula Oxygen in Adult Patients: A Narrative Review

Abstract:High-flow nasal cannula oxygen (HFNC) is a relatively new therapeutic innovation being used in adults with severe respiratory disease. It delivers heated humidified oxygen through short nasal prongs and supplies much higher flow rates than traditional nasal cannula systems. These higher flows match patient flow demands better, reduce anatomic dead space and provide a slightly positive pressure in the upper airway. Randomized trials, nonrandomized prospective trials and case series using HFNC in adults were identified in the PubMed, Google Scholar and Cochrane databases for the period of June 1981 to December 2013. Fifteen studies meeting our inclusion criteria were analyzed; 5 were randomized controlled studies. These studies included 943 patients managed in intensive care units. Common clinical diagnoses included postoperative status, cancer and pneumonia. These studies demonstrated that HFNC provided better or comparable oxygenation when compared with conventional face masks and nasal cannulas. Side effects included epistaxis, nasal discomfort and dryness. No unexpected side effects were reported in the studies reviewed. Current studies demonstrate that HFNC can improve oxygenation adults with hypoxemic respiratory failure. In some patients, it is superior to traditional oxygen delivery systems and may obviate the need for positive pressure ventilation. More studies are needed to compare HFNC with noninvasive ventilation.

High Flow Nasal Cannulas for Oxygenation: An Audit of Its Use in a Tertiary Care Hospital.

Background:High flow nasal cannulas (HFNCs) provide humidified oxygen at higher flow rates and higher FiO2s than conventional delivery devices and are typically used in special care units. There is limited information on their use in general hospital settings. Methods:The medical records of all patients who were treated with HFNC during the calendar year 2014 were retrospectively reviewed to collect information on age, sex, indications, arterial blood gases when available, O2 saturations and outcomes. Results:One hundred six patients received oxygen supplementation by HFNC in their hospital in 2014. The average age was 61.6 ± 16.2 years; 62 patients were men. The indications for HFNC included dyspnea (1 patient), hypoxemic respiratory failure (101 patients) and hypercapneic respiratory failure (4 patients). The PaO2 increased from 68.2 ± 16.3 mm Hg to 83.1 ± 32.2 mm Hg (N = 32, P = 0.02) with the change to HFNC. The O2 saturation increased from 93.1 ± 4.5% to 95.1 ± 3.0% (N = 106, P = 0.00015). The mean duration of use was 4.3 ± 3.7 days. Sixty-five patients did not require intubation or noninvasive ventilation (NIV). Sixteen required NIV, 16 required intubation and 9 required both. The overall mortality was 15%. Conclusions:HFNC oxygen therapy is used relatively frequently in their hospital on surgical and medical services. PaO2s and O2 saturations improved when patients were switched to this mode of oxygenation, but some patients subsequently required NIV and/or intubation. Patients on HFNC need careful monitoring for deterioration in their respiratory status.

Coccidioidomycosis with diffuse miliary pneumonia.

Coccidioidomycosis is a well-known infection in the southwestern United States, and its occurrence is becoming more frequent in endemic areas. This disease can have a significant economic and medical impact; therefore, accurate diagnosis is crucial. In conjunction with patient symptoms, residence in or travel to an endemic area is essential for diagnosis. Diagnosis is usually made with serology, culture, or biopsy and confirmed with DNA probe technology. Pulmonary disease is the most common presentation and is seen in almost 95% of all cases. One-half to two-thirds of all Coccidioides infections are asymptomatic or subclinical. Most pulmonary infections are self-limited and do not require treatment except in special populations. When treatment is warranted, itraconazole and fluconazole are frequently used. Diffuse miliary pneumonia is uncommon and is especially rare in immunocompetent patients. Herein we describe a rare presentation of miliary coccidioidomycosis in a nonimmunocompromised patient.

Choriocarcinoma presenting with thyrotoxicosis.

We describe a 26-year-old man with metastatic choriocarcinoma who presented with hyperthyroidism associated with elevated β-human chorionic gonadotropin (B-HCG) and respiratory failure secondary to diffuse lung metastasis. After the first cycle of chemotherapy, the concentration of B-HCG dramatically decreased and the patient became euthyroid, allowing us to discontinue antithyroid medications. The patients hyperthyroidism was caused by stimulation of the thyroid gland by high B-HCG levels, as shown by the marked improvement of the patients thyroid function panel after chemotherapy.

Autoimmunity in cystic fibrosis: significance and clinical implications

Anti-neutrophil cytoplasmic antibodies specific for bactericidal/permeability-increasing protein (BPI-ANCA) are frequently present in cystic fibrosis patients. These autoantibodies are believed to develop in response to infection and colonization by Pseudomonas aeruginosa. Development of BPI-ANCA has been shown to correlate with the severity of lung infection and poor prognosis in cystic fibrosis patients.

Risk factors and prevention of dabigatran-related gastrointestinal bleeding in patients with atrial fibrillation

Dabigatran, as compared with warfarin, was associated with lower rates of stroke and systemic embolism with similar rates of major hemorrhage. But it has a significantly higher risk of gastrointestinal bleeding (GIB). There are limited data on how to prevent GIB from dabigatran and what are the risk factors.

Toxoplasma Infection in an Immunocompetent Host: Possible Risk of Living with Multiple Cats

A 32-year-old man presented with agitation, headache, and confusion. He was immunocompetent and had been living with multiple cats for many years. His vital signs were stable. He was afebrile. Multiple blood tests did not show any serious problem. Brain magnetic resonance imaging (MRI) revealed multiple ring-enhancing white matter lesions. Cerebrospinal fluid analysis did not show any signs of infection. Based on a presumptive diagnosis of multiple sclerosis, high-dose corticosteroid treatment was started. However, this caused worsening of the symptoms and increased the size of the lesions. Corticosteroids were discontinued and biopsy was done. Biopsy of the lesions confirmed Toxoplasma gondii infection, and treatment with pyrimethamine/sulfadiazine was initiated. Treatment decreased the size of the lesions dramatically. Toxoplasma infection of the central nervous system (CNS) is rare in immunocompetent hosts. Living with multiple cats is believed to be a risk factor for Toxoplasma infection in immunocompetent hosts.

Newly diagnosed acromegaly presenting with hypertriglyceridemic pancreatitis with normal amylase and lipase levels.

The incidence of hypertriglyceridemia in acromegaly is three times higher than in the normal population, and it is the most common dyslipidemia in acromegaly. We present a case of hypertriglyceridemic pancreatitis confirmed by imaging, with normal pancreatic enzymes. Hypertriglyceridemia in this patient was likely secondary to acromegaly. The hypertriglyceridemic pancreatitis appears to be secondary to somatotrophic pituitary adenoma.