Jonathan Caronia

Successful use of noninvasive ventilation in pregnancy

To the Editor: Acute respiratory failure (ARF) occurs in less than 0.1% of pregnancies; however, it is one of the most common reasons for obstetric admissions to the intensive care unit (ICU) and carries a high mortality for both mother and fetus. Pulmonary physiological and anatomic adaptations during pregnancy affect the overall management, as well as predispose patients to complications during respiratory illness. Pregnancy-related upper airway mucosal oedema may obstruct visualisation of the airway during intubation and can make invasive airway management difficult. The pregnant female requiring endotracheal intubation has a four-fold higher risk of having a difficult airway and an eight-fold higher risk of a failed intubation [1]. The application of noninvasive ventilation (NIV) in the treatment of ARF continues to expand as its benefits are increasingly recognised. NIV is often avoided in pregnancy due to the theoretical risk of aspiration. However, our current knowledge regarding the safety and efficacy of NIV for the management of respiratory failure in pregnancy is based on weak evidence. Only a few case reports and small case series have been published. Given the limited data, we review the current literature and report two cases of pregnant females who developed ARF from acute respiratory distress syndrome (ARDS) and were successfully and safely managed with NIV. A 30-year-old gravida 2 para 1 with an uncomplicated twin pregnancy presented with premature rupture of membranes at 30 weeks of gestation. She had also complained of a dry cough for 1 week prior to presentation and a low grade fever. Corticosteroids, antibiotics and tocolytic therapy were administered. …

Focused Renal Sonography Performed and Interpreted by Internal Medicine Residents

Intensivist‐performed focused sonography, including renal sonography, is becoming accepted practice. Whether internal medicine residents can be trained to accurately rule out renal obstruction and identify sonographic findings of chronic kidney disease is unknown. The purpose of this study was to test the ability of residents to evaluate for this specific constellation of findings.

Focused Transthoracic Echocardiography Performed and Interpreted by Medical Residents in the Critically Ill

Purpose. Intensivist-performed focused echocardiography (FE) is accepted practice. Whether medical residents can perform and interpret quality FE in the critically ill is unknown. Methods. Novice residents trained in an 8-hour module in FE, evaluating ejection fraction (EF), pericardial effusion, right ventricular (RV) strain, valvular pathology, wall motion abnormalities (WMAs), and inferior vena cava collapsibility in patients awaiting comprehensive echocardiograms. The Fleiss kappa (κ), sensitivity, specificity, positive predictive values, and negative predictive values were calculated against the comprehensive echocardiogram. Results. Seven residents performed 102 FE, demonstrating substantial agreement with cardiologists for EF as decreased versus normal or hyperdynamic (κ = .67, P < .001, sensitivity = 94%, specificity = 93%) and pericardial effusion (κ = .60, P < .001, sensitivity = 85%, specificity = 93%); moderate agreement for aortic stenosis (κ = .54, P < .001, sensitivity = 56%, specificity = ...

Incidental tracheal diverticulum discovered 30 years after tracheo-esophageal fistula repair.

Tracheo-esophageal fistula is a well-described congenital abnormality treated surgically upon diagnosis. Although respiratory-related and reflux-related complications are frequent, recurrent fistula and diverticulum can occur. This case report describes the rare occurrence of a gross type B fistula repaired at birth, which was then asymptomatic for nearly 30 years until presentation with chest pain. Upon workup, the patient was found to have an isolated tracheal diverticulum without recurrent fistula. We highlight the need for a focused workup despite the length of time since fistula repair and the varied treatment modalities described in the literature.