Harpreet Ranu

Thrombolysis for massive pulmonary embolism in pregnancy - A report of three cases and follow up over a two year period

We read with interest the recent literature review submitted by te Raa et al regarding treatment options in massive pulmonary embolism during pregnancy [1]. As highlighted venous thromboembolism is a leading cause ofmaternal mortality in the UK [2]. Treatment options for pregnant patients that develop pulmonary embolism are often considered high risk with possible effects to both mother and foetus. We describe our total experience of thrombolysis for the treatment of massive PE in pregnancy over the last 5 years.

A retrospective review to evaluate the safety of right heart catheterization via the internal jugular vein in the assessment of pulmonary hypertension.

Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk.

Successful Endobronchial Seal of Surgical Bronchopleural Fistulas Using BioGlue

Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.

Removal of Long-Term Tracheal Stents With Excellent Tracheal Healing

Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.

A is for airway

A 61 year old man was referred to our outpatient department because of breathlessness. He was able to walk only 50 metres before having to stop to catch his breath. He denied any chest pain or cough. In the 1980s he had fallen down a lift shaft, which had caused substantial trauma. He had needed mechanical ventilation in the intensive care unit, with tracheostomy formation and prolonged respiratory wean. He had never smoked. Examination of his chest was normal. Oxygen saturations on room air were 96%. His chest radiograph was normal. Figure 1⇓ shows the results of another test that was performed. ### 1 What test has been performed? #### Short answer Spirometry was performed, and maximal expiratory and inspiratory flow volume loops and a flow volume curve were produced. The expected expiratory curve is shown in black and the patient’s observed expiratory and inspiratory curves are shown in blue. #### Long answer A variety of pulmonary functions tests are available, including spirometry, flow volume curves, measurement of diffusion capacity, and lung volumes. These tests are effort dependent and require patient cooperation. Predicted values depend on age, height, sex, and race and are determined by published studies of large …

Breathlessness and chest pain in a patient with sickle cell disease

A 47 year old woman with sickle cell disease presented to the accident and emergency department with shortness of breath and chest pain. She had been admitted many times in the past with similar symptoms and had needed treatment, including simple and exchange blood transfusions. She had developed side effects after different forms of iron chelation treatment in the past. On admission her oxygen saturations were 93% on room air (decreasing to 82% on walking to the toilet), systemic blood pressure was 90/50 mm Hg, and heart rate was 100 beats/min. She had a low grade fever. Her jugular venous pressure was raised, with a gallop rhythm and a loud second heart sound. Breath sounds were quiet and she found it painful to breathe in. Her haemoglobin was 68 g/L (reference range 115-150), with haemoglobin S 55.8%, white cell count was 18×109/L (4-11), and serum ferritin was 26 964 pmol/L (27-337). Chest radiography showed basal alveolar shadowing. ### 1 What is the differential diagnosis in this patient? #### Short answer The differential diagnosis includes an acute chest syndrome, a pulmonary embolism including a fat embolus, and pulmonary infection. #### Long answer Acute chest syndrome is one of the most common reasons for hospital admission in patients with sickle cell disease.1 It is defined by the presence of a new pulmonary infiltrate consistent with alveolar consolidation and is often accompanied by cough, chest pain, wheeze, fever, and an increased respiratory rate.2 It is commonly precipitated by community acquired infection, with an infectious cause being identified in more than half of patients admitted with the syndrome, most often atypical bacteria …

A case of progressive breathlessness.

A 57 year old white man was seen in the outpatient clinic with a four month history of breathlessness on exertion, particularly when climbing the stairs. The breathlessness had started after a protracted episode of fever, weight loss, and breathlessness. His only medical history was pleurisy as a child, which had resolved after a routine course of antibiotics. He had no long term sequelae from this disease. He was a lifetime resident of the United Kingdom. On examination the patient did not have a fever or any palpable lymphadenopathy. His heart rate was 76 bpm in normal sinus rhythm, jugular venous pressure (venous pulse) raised at 11 cm above the right atrium, and blood pressure 122/76 mm Hg, and his heart sounds were normal. His chest was clear but examination of his abdomen showed hepatomegaly. He had no pedal oedema. Oxygen saturations were 99% on room air. He did not desaturate after exercising up and down stairs; however, he did become tachycardic with a heart rate of 140 bpm. Computed tomography pulmonary angiogram showed no evidence of pulmonary emboli; however, pericardial thickening was noted. An echocardiogram showed inspiratory decrease of transmitral early diastolic flow, dilated inferior vena cava without inspiratory collapse, and a bright pericardium. Cardiac catheterisation showed minor coronary artery disease, with equal diastolic pressures in the left and right atria and ventricles. The patient underwent cardiac magnetic resonance imaging (figs 1⇓ and 2⇓). Figure 1 Figure 2 Bloods tests showed a bilirubin concentration of 54 μm/l, alkaline phosphatase of 556 U/l, γ glutamyltransferase of 864 U/l, and alanine transaminase of 43 U/l. A tuberculin skin test was performed (2 tuberculin units in 0.1 ml solution for injection), and the palpable raised area measured 22 mm. An interferon gamma test was not performed because the test …

An ominous cough

A 55 year old woman with bronchiectasis, lobe sequestration, and recurrent respiratory infections failed to respond to medical treatment. Pulmonary function tests showed forced expiratory volume in one second of 2.3 l/ (85% of predicted) and diffusion lung capacity for carbon monoxide (a test of the integrity of the alveolar-capillary surface area for gas transfer) of 5.56 mmol/min/kPa (66% of predicted). She underwent right lower lobectomy, but four weeks later she developed fever, cough with frothy serosanguinous sputum, and right pleuritic chest pain. She was admitted to hospital and chest radiography was performed (fig 1)⇓. Fig 1 The patient’s c hest radiograph ### 1 What is the most likely diagnosis? #### Short answer The chest radiograph shows an air fluid level at the right intermediate bronchus close to the site of the bronchial stump. In addition, opacification of the right lower zone of the hemithorax is obscuring the right hemidiaphragm and right heart border, probably because of a right pleural effusion (fig 2⇓). This radiograph combined with the clinical history suggests the presence of a postoperative bronchopleural fistula. Fig 2 Chest radiograph showing an air fluid level close to the bronchial tree at the level of the bronchial …

A pain in the leg and breathlessness

A 45 year old man with no previous medical problems was admitted to hospital with progressive breathlessness and discomfort in his left leg. He had no other symptoms and was not on any regular medications. On examination he was alert, with a pulse of 80 beats per minute, blood pressure 130/70 and respiratory rate of 20 breaths per minute. Peripheral oxygen saturations were 97% on room air. Heart sounds, jugular venous pressure, and respiratory examination were normal, but his left calf and thigh were markedly swollen and tender. He was initially treated with oxygen via a face mask and intravenous fluids. Doppler ultrasound of his left leg confirmed extensive thrombus extending into the common iliac vein. A later computed tomography pulmonary angiogram identified a large filling defect within the left main pulmonary artery. 1 What single blood test would be most useful to guide management in this patient? 2 Which other non-invasive test would you request? 3 What systemic treatment should this patient have? 4 What are the long term complications of venous thromboembolism? ### 1 What single blood test would be most useful to guide management in this patient? #### Short answer A serum cardiac troponin level (I or T) will help identify whether this patient is at increased risk of clinical deterioration and help guide treatment of his large pulmonary embolism. #### Long answer From the information given, the patient has a large pulmonary embolus, but is haemodynamically stable without clinical evidence of right ventricular dysfunction secondary to his pulmonary embolus. Elevated cardiac troponins have a high sensitivity for myocardial injury.1 They are released as a result of right ventricular dilatation caused by a sudden rise in pulmonary artery and right ventricular pressures in patients with large pulmonary embolisms.2 Therefore, a raised cardiac troponin might indicate right ventricular microinfarction, dilatation, or both, and is a risk factor for early mortality after a pulmonary …