Epameinondas Zakynthinos

Systemic and airway inflammation and the presence of emphysema in patients with COPD

The aim of this study was to determine the impact of HRCT-confirmed emphysema on biomarkers evaluating airway and systemic inflammation in COPD patients. Forty-nine consecutive male COPD outpatients with stable COPD were divided in two groups according to the presence or absence of emphysema on HRCT. Patients underwent pulmonary function tests, plus assessment of exercise capacity, body composition and quality of life. Biomarkers were measured in serum (CRP, interleukin-6, TNF-alpha, leptin, adiponectin, osteocalcin, insulin growth factor-1, and systemic oxidative stress), in plasma (fibrinogen and VEGF) and in whole blood (B-type natriuretic peptide). TNF-alpha, 8-isoprostane and pH were additionally measured in exhaled breath condensate. Patients with emphysema had more severe lung function impairment, lower body-mass index and fat-free mass index, and poorer quality of life. Additionally, they presented increased systemic oxidative stress and plasma fibrinogen and lower BNP compared to patients without emphysema. After proper adjustment for disease severity, all differences remained with the exceptions of body-mass index, fat-free mass index and BNP. COPD patients with HRCT-confirmed emphysema present increased systemic oxidative stress and fibrinogen, suggesting that they may be more prone to the systemic consequences of COPD compared to patients without emphysema.

Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients.

Presence of a nasogastric tube is a risk factor for the development of ventilator-associated pneumonia (VAP). Alternatively, gastrostomy can be used for administration of enteral feedings. To determine whether early performance of gastrostomy affects frequency of VAP, a randomised, controlled study was carried out in patients mechanically ventilated for stroke or head injury. In the gastrostomy group, patients underwent the procedure within 24 h of intubation. A nasogastric tube was inserted in controls. Individual subjects were studied for 3 weeks. In total, 20 subjects (mean age 48±15.2 yrs) were allocated to the gastrostomy group, and 21 to the control group (46.6±15.4 yrs). Of these groups, two (10%) and eight (38.1%) developed VAP, respectively. Four patients with gastrostomy and three controls did not complete the study (due to weaning from ventilatory support or death). After excluding these subjects, difference in VAP frequency persisted: two out of 16 subjects with gastrostomy had VAP (12.5%) versus eight out of 18 controls (44.4%). There were no differences in duration of hospitalisation or mortality between the two groups. In conclusion, in patients mechanically ventilated for stroke or head injury early gastrostomy is associated with a lower frequency of ventilator-associated pneumonia compared with a nasogastric tube.

Intensive care unit dissemination of multiple clones of linezolid-resistant Enterococcus faecalis and Enterococcus faecium

OBJECTIVES Outbreaks caused by linezolid-resistant (LR) enterococci remain rare. We report the epidemiological and molecular characteristics of the multiclonal dissemination of LR enterococci in the intensive care unit (ICU) of a Greek hospital. METHODS All LR enterococcal isolates recovered from patients hospitalized in the ICU of the University Hospital of Larissa, Greece, between January 2007 and October 2008 were included. Isolates were tested by PFGE and PCR followed by sequence analysis of the entire 23S rRNA gene. Patient records were retrieved to access patterns of acquisition and outcome. RESULTS Sixteen separate patients were infected and/or colonized by 22 LR enterococcal isolates (17 Enterococcus faecium and 5 Enterococcus faecalis). Linezolid MICs varied from 8 to 16 mg/L; 12 isolates showed cross-resistance to vancomycin. Genotyping revealed as many as seven and three PFGE types among E. faecium and E. faecalis isolates, respectively, indicating multiclonal spread of LR enterococci. Nine patients had received linezolid prior to the recovery of LR enterococci, while the remaining seven patients were not exposed to the drug. All isolates carried the mutation G2576T; the mutated position was heterogeneous in 12 isolates and homogeneous in 10. CONCLUSIONS The multiclonal composition of LR enterococci indicates that linezolid resistance possibly occurred on several independent occasions. Its acquisition was often not related to linezolid administration; patients might have acquired their LR isolate from another patient that had received linezolid or, alternatively, resistance may have arisen by mutation that occurred independently.

Sepsis-associated takotsubo cardiomyopathy can be reversed with levosimendan.

Sepsis is a stressful physical condition, and at the acute phase, overstimulation of the sympathetic nervous system may occur; these events have the potential to induce cardiomyopathy. Takotsubo cardiomyopathy (TTC) is a form of catecholamine-induced cardiomyopathy, which occurs very rarely in sepsis. However, TTC management in critically ill patients with sepsis may be challenging because the use of exogenous catecholamines for circulatory support might augment further TTC. Herein, we report a rare case of TTC after urosepsis; and we point out that cardiac function may improve after catecholamine withdrawal and the application of calcium channel sensitizer levosimendan.

Intermittent recruitment with high-frequency oscillation/tracheal gas insufflation in acute respiratory distress syndrome

In acute respiratory distress syndrome (ARDS), recruitment sessions of high-frequency oscillation (HFO) and tracheal gas insufflation (TGI) with short-lasting recruitment manoeuvres (RMs) may improve oxygenation and enable reduction of subsequent conventional mechanical ventilation (CMV) pressures. We determined the effect of adding HFO-TGI sessions to lung-protective CMV on early/severe ARDS outcome. We conducted a prospective clinical trial, subdivided into a first single-centre period and a second two-centre period. We enrolled 125 (first period, n=54) patients with arterial oxygen tension (Pa,O2)/inspiratory oxygen fraction (FI,O2) of <150 mmHg for >12 consecutive hours at an end-expiratory pressure of ≥8 cmH2O. Patients were randomly assigned to an HFO-TGI group (receiving HFO-TGI sessions with RMs, interspersed with lung-protective CMV; n=61) or CMV group (receiving lung-protective CMV and RMs; n=64). The primary outcome was survival to hospital discharge. Pre-enrolment ventilation duration was variable. During days 1–10 post-randomisation, Pa,O2/FI,O2, oxygenation index, plateau pressure and respiratory compliance were improved in the HFO-TGI group versus the CMV group (p<0.001 for group×time). Within days 1–60, the HFO-TGI group had more ventilator-free days versus the CMV group (median (interquartile range) 31.0 (0.0–42.0) versus 0.0 (0.0–23.0) days; p<0.001), and more days without respiratory, circulatory, renal, coagulation and liver failure (p≤0.003). Survival to hospital discharge was higher in the HFO-TGI group versus the CMV group (38 (62.3%) out of 61 versus 23 (35.9%) out of 64 subjects; p=0.004). Intermittent recruitment with HFO-TGI and RMs may improve survival in early/severe ARDS.

Cardiac systolic function in Greek children with obstructive sleep-disordered breathing

BACKGROUND Obstructive sleep-disordered breathing (SDB) in children has been associated with increased ventricular strain and decreased left ventricle (LV) diastolic function. The aim of this study was to assess systolic myocardial function in children with SDB of variable severity. METHODS Children who were referred for polysomnography during the study period underwent echocardiography (two-dimensional, Doppler and tissue Doppler imaging). RESULTS A total of 46 subjects (age 6.4+/-2.6years) were recruited. Fourteen of them had moderate-to-severe SDB (obstructive apnea-hypopnea index (OAHI): 16.6+/-11.6 episodes/h), 13 children had mild SDB (OAHI: 3.1+/-0.7 episodes/h) and 19 subjects had primary snoring (OAHI: 1.2+/-0.6 episodes/h). Children with moderate-to-severe SDB had significantly lower LV shortening fraction (SF) and ejection fraction (EF) than subjects with primary snoring (p<0.05). SF in moderate-to-severe SDB, mild SDB and primary snoring groups was: 34.3+/-5.5%, 36.9+/-3.2% and 37.7+/-4.4%, respectively, and EF: 66.9+/-7.9%, 71.7+/-6.4% and 72.3+/-5.9%, respectively. OAHI, age, and systolic blood pressure were significant predictors of SF and EF (p<0.01). CONCLUSIONS In children with obstructive SDB, LV systolic function is inversely associated with severity of intermittent upper airway obstruction during sleep.

Diabetes and Hemoglobin A1c as Risk Factors for Nosocomial Infections in Critically Ill Patients

Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. Inclusion criteria: ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91–20.17; P = 0.002) and blood transfusion 3.33 (1.23–9.02; P = 0.018) were independent risk factors for VAP. BSI in ICU (P = 0.044) and ICU mortality (P = 0.038) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14–5.29; P = 0.022) and stroke on admission2.77 (1.12–6.88; P = 0.029). Sepsis 3.34 (1.47–7.58; P = 0.004) and parenteral feeding 6.29 (1.59–24.83; P = 0.009) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU.

Correlation of urinary excretion of sodium with severity of sleep-disordered breathing in children: A preliminary study†

Nocturnal urinary sodium excretion is related to blood pressure (BP) levels. Elevated BP and increased nocturnal natriuresis have been demonstrated in adults with sleep apnea. Although evidence indicates increased BP in children with obstructive sleep‐disordered breathing (SDB), it is unknown whether these children have also enhanced urinary sodium excretion.

A 73-year-old woman with tracheobronchiomalacia

Dear Sir: We wish to report the case of a 73-year-old woman with tracheobronchiomalacia (TBM) [1] and abnormal bronchus of the right upper lobe (RUL). She was admitted to the intensive care unit (ICU) due to severe hypoxaemia after hospitalization in a medical ward due to ‘‘asthma exacerbation’’ (presented with dyspnoea, wheezing, productive cough and fever) with poor treatment response. Her history was marked by similar episodes, although milder, during the past 4 years. At the ICU, chest examination revealed right-sided crepitations. Arterial blood analysis showed PaO2 46 mmHg, PaCO2 42 mmHg, pH = 7.27 and HCO3 = 11 mmol/ L (FiO2 = 0.5). Chest X-ray showed RUL atelectasis. Shortly after her intubation, high airway pressures and inspiratory resistance were noticed; oxygenation deteriorated further (SaO2 \ 80%, FiO2 = 1) despite secretion suctioning, bronchodilation and recruitment manoeuvres. Bronchoscopy revealed thick purulent secretions obstructing the airway, almost collapsed trachea posteroanteriorly indicating TBM, and abnormal takeoff of a segmental RUL bronchus. After cleaning secretions we advanced the orotracheal tube close to the main carina to prevent tracheal collapsing. Collapsing of abnormal segmental RUL bronchus due to inflated cuff certainly could not be excluded. Nevertheless, inspiratory airway resistance normalized and hypoxaemia resolved. The patient was extubated the next day. However, low fever and purulent secretions persisted, while barking cough and hypoxaemia (refractory to non-invasive ventilation) developed, leading to re-intubation 4 days later. Thoracic computed tomography (CT) confirmed TBM and abnormal takeoff of RUL bronchus (Fig. 1). Following unsuccessful weaning attempts, marked by respiratory distress during spontaneous breathing (and by wheezing when the tube was removed from the carina), tracheostomy under bronchoscopy was performed on the 21st ICU day. A long tracheostoma reaching to 2 cm above the main carina was placed. The patient was discharged 1 week later and was seen as an outpatient at 3, 6 and 9 months. During this period she remained on a long tracheostoma speaking valve and followed a rehabilitation program; she has experienced no respiratory infection/distress. However, two attempts to close the tracheostomy were marked by recurrence of barking cough, dyspnoea and hypoxaemia.

Pre-intensive care unit intubation and subsequent delayed intensive care unit admission is independently associated with increased occurrence of ventilator-associated pneumonia: TSAKIRIDOU et al.

Critically ill intubated patients are at risk for ventilator‐associated pneumonia. However, intubation may not occur in intensive care unit (ICU) and subsequent ICU admission may be delayed.