Horiana B. Grosu

Diaphragm muscle thinning in patients who are mechanically ventilated.

BACKGROUND Approximately 40% of patients in medical ICUs require mechanical ventilation (MV). Approximately 20% to 25% of these patients will encounter difficulties in discontinuing MV. Multiple studies have suggested that MV has an unloading effect on the respiratory muscles that leads to diaphragmatic atrophy and dysfunction, a process called ventilator-induced diaphragmatic dysfunction (VIDD). VIDD may be an important factor affecting when and if MV can be discontinued. A sensitive and specific diagnostic test for VIDD could provide the physician with valuable information that might influence decisions regarding extubation or tracheostomy. The purpose of this study was to quantify, using daily sonographic assessments, the rate and degree of diaphragm thinning during MV. METHODS Seven intubated patients receiving MV during acute care were included. Using sonography, diaphragm muscle thickness was measured daily from the day of intubation until the patient underwent extubation or tracheostomy or died. We analyzed our data using standard descriptive statistics, linear regression, and mixed-model effects. RESULTS The overall rate of decrease in the diaphragm thickness of all seven patients over time averaged 6% per day of MV, which differed significantly from zero. Similarly, the diaphragm thickness decreased for each patient over time. CONCLUSION Sonographic assessment of the diaphragm provides noninvasive measurement of diaphragmatic thickness and the degree of diaphragm thinning in patients receiving MV. Our data show that diaphragm muscle thinning starts within 48 h after initiation of MV. However, it is unclear if diaphragmatic thinning correlates with diaphragmatic atrophy or pulmonary function. The relationship between diaphragm thinning and diaphragm strength remains to be elucidated.

Safety and effectiveness of microdebrider bronchoscopy for the management of central airway obstruction.

Microdebrider bronchoscopy is a relatively new modality for the management of central airway obstruction (CAO) of both benign and malignant origin. Our objective was to describe our experience with this technique, with special attention to its safety and effectiveness.

Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study

Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS‐TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS‐TBNA in this setting.

Amiodarone-induced Acute Respiratory Distress Syndrome Masquerading as Acute Heart Failure

BACKGROUND Amiodarone use has been rarely associated with the development of acute respiratory distress syndrome (ARDS), usually in association with surgery or pulmonary angiography. In patients with preexisting left ventricular dysfunction, the diagnosis may be overlooked. CASE REPORT A 92-year-old woman with a history of atrial fibrillation who was on low-dose amiodarone presented to the Emergency Department with sudden onset of shortness of breath. The patient was started on treatment for acute heart failure based on the physical examination and the elevated brain natriuretic peptide level. Despite adequate diuresis, the patient showed no improvement. A chest computed tomography scan revealed acute interstitial pneumonitis. The patient received corticosteroids due to suspected amiodarone-induced acute interstitial pneumonitis resulting in ARDS. She returned to her baseline activity within 2 weeks of the therapy. CONCLUSION Although rare, clinicians should be vigilant for amiodarone-induced acute interstitial pneumonitis resulting in ARDS, as delay in treatment may result in a high risk of mortality. In addition, the development of ARDS occurred in our patient in the absence of precipitating factors such as surgery or pulmonary angiography.

Desmosine and Isodesmosine as a Novel Biomarker for Pulmonary Arterial Hypertension: A Pilot Study

Delayed diagnosis is common in patients with pulmonary arterial hypertension (PAH). Right-sided heart catheterization, the gold standard for diagnosis, is invasive and cannot be applied for routine screening. Some biomarkers have been looked into; however, due to the lack of a clear pathological mechanism linking the marker to PAH, the search for an ideal one is still ongoing. Elastin is a significant structural constituent of blood vessels. Its synthesis involves cross-linking of monomers by 2 amino acids, desmosine and isodesmosine (D&I). Being extremely stable, elastin undergoes little metabolic turnover in healthy individuals resulting in very low levels of D&I amino acids in the human plasma, urine, or sputum. We hypothesized that in PAH patients, the elastin turnover is high; which in turn should result in elevated levels of D&I in plasma and urine. Using mass spectrometry, plasma and urine levels of D&I were measured in 20 consecutive patients with PAH confirmed by cardiac catheterization. The levels were compared with 13 healthy controls. The mean level of total plasma D&I in patients with PAH was 0.47 ng/mL and in controls was 0.19 ng/mL (P = 0.001). The mean levels of total D&I in the urine of PAH patients was 20.55 mg/g creatinine and in controls was 12.78 mg/g creatinine (P = 0.005). The mean level of free D&I in the urine of PAH patients was 10.34 mg/g creatinine and in controls was 2.52 mg/g creatinine (P < 0.001). This is the first study highlighting that the serum and urine D&I has a potential to be a novel screening biomarker for patients with PAH. It paves the way for larger studies to analyze its role in assessing for disease severity and response to treatment.

Critical Airway Obstruction due to Pseudomembranous Aspergillus tracheitis

A 35-year-old woman with recently diagnosed acute leukemia complicated with necrotizing tracheitis due to Aspergillus infection was transferred to our institution complaining of worsening dyspnea. Before presentation she received 28 days of induction chemotherapy with steroids. She developed cough and hoarseness 3 weeks after initiation of chemotherapy and was admitted with neutropenic fever. Laboratory data revealed neutropenia for the past 5 weeks, and sputum culture grew Aspergillus terreus. Aside from empiric antimicrobial therapy, she was treated with voriconazole. Computed tomography of the chest revealed evidence of circumferential thickening of the trachea throughout its course. In addition, curvilinear densities with the appearance of sloughedoff material were seen within the lumen of the trachea (Figures 1A and 1B). The decision was made to proceed with bronchoscopy for airway evaluation. The bronchoscopy demonstrated up to 80% obstruction of the trachea, with white necrotic, but firm, pseudomembranes, secondary to severe tracheitis. The anterior wall of the trachea and the proximal airway were severely destroyed, and cartilaginous rings were visible (Figures 2A and 2B). Therapeutic rigid and flexible bronchoscopy was performed with cryotherapy recanalization and therapeutic aspiration of the sloughed-off material. A 4-cm white piece of tissue was removed (Figure 2C), resulting in residual luminal narrowing of less than 25%. Pathologic examination showed extensive necrosis, with deposition of fungal-hyphae organisms, compatible with Aspergillus infection (Figures 2E and 2F). Immunocompromised patients can develop disseminated pulmonary aspergillosis and rarely necrotizing tracheobronchitis (1). There are a few reports in the literature of airway obstruction, but the condition typically has lethal outcomes. When the bronchus or trachea overlying the pulmonary artery is infected, a fatal hemorrhage can occur if the obstructing mass is manipulated (2). There is no consensus on bronchoscopic management of these patients, and bronchoscopic debridement has only been mentioned in case reports. Our patient was treatedwith inhaled amphotericin B, voriconazole, and caspofungin initially. Due to side effects, this was switched to posaconazole, which led to a complete clinical and radiological response. A bronchoscopy performed a year after diagnosis and before stem cell transplantation showed no evidence of disease (Figure 2D). n

Speech prosthesis aspiration

A 68-year-old woman with a history of laryngeal cancer status post-laryngectomy was referred to the emergency room for an abnormal chest CT scan. …

Diaphragm Muscle Thinning in Subjects Receiving Mechanical Ventilation and Its Effect on Extubation.

BACKGROUND: Diaphragm muscle weakness and atrophy are consequences of prolonged mechanical ventilation. Our purpose was to determine whether thickness of the diaphragm (TDI) changes over time after intubation and whether the degree of change affects clinical outcome. METHODS: For this prospective, longitudinal observational study, we identified subjects who required mechanical ventilation and measured their TDI by ultrasonography. TDI was measured at baseline and repeated 72 h later and then weekly until the subject was either liberated from mechanical ventilation, was referred for tracheostomy, or died. The analysis was designed to determine whether baseline TDI and change in TDI affect extubation outcome. RESULTS: Of the 57 subjects who underwent both diaphragm measurements at 72 h, 16 died, 33 were extubated, and 8 underwent tracheostomy. Only 14 subjects received mechanical ventilation for 1 week, and 2 subjects received mechanical ventilation for 2 and 3 weeks. Females had significantly thinner baseline TDI (P = .008). At 72 h, TDI had decreased in 84% of subjects. We found no significant association between the rate of thinning and sex (P = .68), diagnosis of COPD (P = .36), current smoking (P = .85), or pleural effusion (P = .83). Lower baseline TDI was associated with higher likelihood of extubation: 12.5% higher for every 0.01-cm decrease in TDI (hazard ratio 0.875, 95% CI 0.80–0.96, P = .003). For every 0.01-cm decrease in TDI at 72 h, the likelihood of extubation increased by 17% (hazard ratio 0.83, 95% CI 0.70–0.99, P = .041). CONCLUSIONS: Although most of the subjects showed evidence of diaphragm thinning, we were unable to find a correlation with outcome of extubation failure. In fact, the thinner the diaphragm at baseline and the greater the extent of diaphragm thinning at 72 h, the greater the likelihood of extubation. Thickening ratio or other measurement may be a more reliable indicator of diaphragm dysfunction and should be explored.

Intrapleural Fibrinolytic Therapy in Patients With Nondraining Indwelling Pleural Catheters.

Background:Tissue plasminogen activator (tPA) has been successfully used to relieve obstruction of dysfunctional devices, including vascular catheters. Intrapleural tPA is used by some centers to restore flow of nondraining indwelling pleural catheters (IPCs) in symptomatic patients with malignant pleural effusions (MPEs). Because few studies have evaluated its safety and effectiveness, we conducted a retrospective cohort study of outcomes after tPA treatment during a 10-year period at our institution. Methods:We studied 97 patients with MPE and a nondraining IPC in the setting of persistent pleural fluid who were treated with intrapleural tPA. The primary outcome was restoration of flow after treatment. Secondary outcomes included complication rates and the need for further pleural interventions. Symptomatic relief was assessed using the Borg perceived scale. Results:We identified 97 patients with MPE and a nondraining IPC who were treated with tPA. Flow was restored after 1 tPA dose in 83 of 97 patients (86%; 95% confidence interval, 77%-92%). Reocclusion after 1 dose was seen in 27 of 83 patients (32%), and 22 (81%) of these patients were treated with a second tPA dose. Among these 22, flow was restored in 16 (72%; 95% confidence interval, 44%-84%). Borg score improvement was only seen in patients who had restored flow (P=0.024). This finding was independent of the size of the effusion upon chest x-ray. There were 5 complications: 2 hemothoraxes and 3 infectious complications. Conclusion:On the basis of our finding of successful flow restoration with few complications, we recommend intrapleural tPA treatment for symptomatic patients with nondraining IPCs in the setting of persistent pleural fluid.

Needle Fracture during Endobronchial Ultrasound–guided Transbronchial Needle Aspiration

Needle Fracture during Endobronchial Ultrasound–guided Transbronchial Needle Aspiration Macarena R. Vial, John O. O’Connell, Horiana B. Grosu, David E. Ost, George A. Eapen, and Carlos A. Jimenez Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and Department of Pulmonary Medicine, Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile