Jeffrey Albores

Hypocretin Deficiency Associated with Narcolepsy Type 1 and Central Hypoventilation Syndrome in Neurosarcoidosis of the Hypothalamus.

We report a case of a 53-year-old man presenting with depressed alertness and severe excessive sleepiness in the setting of neurosarcoidosis. Neuroimaging demonstrated hypothalamic destruction due to sarcoidosis with a CSF hypocretin level of 0 pg/mL. The patient also experienced respiratory depression that presumably resulted from hypocretin-mediated hypothalamic dysfunction as a result of extensive diencephalic injury. This is a novel case, demonstrating both hypocretin deficiency syndrome, as well as respiratory dysfunction from destruction of hypocretin neurons and extensive destruction of key diencephalic structures secondary to the underlying neurosarcoidosis.

A 26-Year-Old Woman With a Small Right Lung and a Right-Sided Heart

A 26-year-old woman presented with abnormal findings on a chest radiograph. She had no significant history other than a fever 4 months prior to presentation that had resolved without a definite cause identified. She denied cough, shortness of breath, chest pain, history of smoking, environmental exposures, or prior pregnancies. She remained physically active.

Noninvasive Ventilation in Difficult Endotracheal Intubation

Prediction of the difficulty of intubation should include the ease of visualizing the airway as well as the tolerance of apnea during the intubation process. NIV can be useful in difficult intubation by improving the quality of preoxygenation. In addition, clinicians can use NIV during endotracheal intubation. NIV can provide a pneumatic stent for the upper airway and maintain oxygenation and ventilation during the intubation process.

Predictability of Prevention of Hypoxia by Nasal High-flow System in Dental Procedures

To the Editor:—We read with great interest the article by Sago et al describing the use of a nasal high-flow (NHF) system during a dental procedure under intravenous sedation (IVS). In our opinion, this is an interesting, novel, and practical approach to maintain safe oxygenation during highrisk dental surgical procedures. More importantly, the findings of this study could implicate the beneficial effect and safety of the NHF system in conscious anesthesia. However, we consider some key practical aspects that need to be addressed. First, this is one of the first studies showing the benefits of NHF on ventilation and gas exchange during IVS. The positive effect of high-flow systems on partial pressure of arterial carbon dioxide (PaCO2) has been reported previously in hypoxemic patients after cardiothoracic surgery, but there are reports showing the opposite effect and an increase in PaCO2 after NHF treatment in patients with acute hypoxemic respiratory failure. Although higher flow rates might indeed decrease the anatomic dead space and increase CO2 washout, we argue that interpretation of CO2 trends and accuracy of PaCO2 values among the 3 groups need deeper consideration. Breathing pattern under deep sedation, respiratory rate, and variability of upper airway resistance are relevant parameters that directly affect ventilation and might be necessary for adequate interpretation of the effect of NHF during conscious sedation during a dental procedure. In addition, Sago et al evaluated and compared changes at baseline and after the procedure, but in our opinion, desaturation and PaCO2 could be assessed with more sensitivity by capnography to detect early changes. This additional support could improve monitoring of respiratory activity and improve patient safety during procedural sedation, especially during moderate sedation. In fact, the American Association of Oral and Maxillofacial Surgeons board of trustees mandated monitoring using capnography during moderate sedation. Second, thepositivepressureeffect ofNHFneeds tobe interpreted cautiously. Futurepractical considerations of usingNHF need to consider that an open mouth affects positive pressure stability and potentially compromises its effect on lower airways. Moreover, the risk of gastric insufflation as a collateral complication needs to be taken into account. Third, IVS and propofol administration could lead to multiple complications, including a decrease in arterial blood pressure, propofol-induced pain on injection, or airway complications. To better assess the safety of the method, better insight into hemodynamic data might be necessary.

A 65-Year-Old Man With Persistent Cough and Large Nodular Opacity

A 65-year-old Asian man with a history of chronic hepatitis B infection presented to our pulmonary clinic for second opinion of his chronic, persistent, nonproductive cough. He was evaluated 10 months earlier with chest CT scan, which revealed a large lingular nodular opacity that was diagnosed as nodular cryptogenic organizing pneumonia by CT scan-guided percutaneous lung biopsy. Systemic corticosteroids were initiated and continued over the next 10 months. The dry cough persisted, and he developed intermittent left-sided pleuritic chest pain. He denied fevers, night sweats, hemoptysis, weight loss, or dyspnea. He was a lifelong nonsmoker and moved to the United States from China during childhood.

A 44-Year-Old Man With Bilateral Pneumothorax

A 44-year-old man presented with a 3-day history of persistent upper-back pain, chest discomfort, and dyspnea. He denied any precipitating events such as trauma or vigorous activity before the presentation of symptoms. His exercise capacity had been excellent. He is a lifetime nonsmoker and never had significant lung problems apart from intermittent asthma for which he had several ED visits in the past. Chest CT scan performed during an asthma exacerbation 2 years earlier demonstrated two left-side lung blebs. He had no prior surgical procedures.

A 34-Year-Old Woman With Recurrent Right-Sided Chest Pain and Dyspnea

A 34-year-old woman presented with her third episode of acute-onset right-sided chest pain and dyspnea. She had two prior similar occurrences of right-sided sharp, pleuritic chest pain with radiation to the back and dyspnea. Chest radiographs during these presentations revealed a small apical right-sided pneumothorax that was managed conservatively with high-flow oxygen. All three presentations were associated with vigorous exercise and the first day of her menses. She denied cough, hemoptysis, fever, smoking history, airplane travel, scuba diving, or trauma during these presentations. The patient has been trying to conceive for the past year but has been unsuccessful because of uterine fibroids but no history of endometriosis.

A 22-Year-Old Nonsmoker With Diffuse Cystic Lung Disease

A 22-year-old previously healthy woman was evaluated in pulmonary clinic for shortness of breath and cough that had been slowly progressive over 3 months. She otherwise reported being fully functional and attended her college graduation a week prior to evaluation. She had no history of smoking, illicit drug use, connective tissue disease, or noxious exposures.

Noninvasive ventilation in difficult endotracheal intubation: systematic and review analysis.

Noninvasive ventilation has been widely used in the management of acute respiratory failure in appropriate clinical settings. In addition to known benefit of alleviating the need for invasive mechanical ventilation, recent literature suggested its beneficial use in the process of endotracheal intubation. Search of the PubMed database and manual review of selected articles investigating the methods and outcomes of endotracheal intubation in difficult airway due to hypoxemic respiratory failure and the role of noninvasive ventilation in this process. Large randomized controlled studies focused on alternative approaches to endotracheal intubation in severe hypoxemic respiratory failure are largely missing but there are several retrospective cohort analysis and reports describing the novel technique describing the application of noninvasive ventilation during endotracheal intubation. Noninvasive ventilation can be used as an adjunct intervention that may maintain oxygenation and ventilation, prevent significant hemodynamic instability and provide a pneumatic stent to maintain upper airway patency, thus reducing the risks of intubation-related complications.