Juan B. Figueroa-Casas

A 38-Year-Old Pregnant Woman with Hemoptysis and Acute Renal Failure

and dysmorphic red blood cell casts. A quantitative serum pregnancy test was positive. Bronchoalveolar lavage retrieved blood-tinged fluid, numerous red blood cells and hemosiderin-laden macrophages but few neutrophils. Microbiology studies for bacteria, mycobacteria and fungi in the bronchoalveolar lavage fluid were negative. Perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) with specificity for myeloperoxidase (MPO) were positive (5.5 U/ml, normal ! 0.4). Serologies for antiglomerular basement membrane, antinuclear antibodies, C-ANCA, antiproteinase 3 (PR3-ANCA), antinuclear antibodies, antiphospholipid panel, and HIV were negative.

Inter-observer agreement of spontaneous breathing trial outcome.

BACKGROUND: Spontaneous breathing trials (SBTs) are a very important test in the weaning process. The trial involves evaluation of multiple objective and subjective variables. These characteristics could lead to variability in interpreting outcomes with important clinical implications. We aimed to measure the inter-observer agreement between respiratory therapists when analyzing SBT outcomes. METHODS: In the context of a respiratory therapist-driven weaning protocol, 2 respiratory therapists independently interpreted the subjective variables (use of accessory muscles, agitation, and diaphoresis) and the overall outcome of SBTs (success vs failure) performed in adult subjects mechanically ventilated for any duration. Raw agreements between respiratory therapists and kappa statistics were calculated. RESULTS: One-hundred fifty-one SBTs were interpreted. The overall trial outcome raw agreement was 93.3% (95% CI 88.2–96.3) and kappa 0.63 (95% CI 0.47–0.79). Raw agreement for subjective variables ranged between 92.1% (agitation) and 99.3% (diaphoresis). The group with disagreements in overall trial outcome had higher breathing frequency, breathing-frequency-to-tidal-volume ratio, and systolic blood pressure prior to the trial. CONCLUSIONS: Within a respiratory therapist-driven weaning protocol, we found a near 90% inter-observer agreement in the interpretation of SBT outcomes. Our findings illustrate the complexity of interpreting fluctuating subjective and objective variables and their integration into one result: SBT success versus failure. Refining the definitions of variables and their limits for failure along with education might reduce this variability.

Preventive Use of Noninvasive Ventilation After Planned Extubation

Despite a thorough weaning assessment, including a spontaneous breathing trial (SBT), liberation from mechanical ventilation via endotracheal extubation is associated with re-intubation rates of up to 24%.[1][1] Re-intubation, in turn, is associated with an increased risk of mortality, intensive

Changes in Breathing Variables During a 30-Minute Spontaneous Breathing Trial

BACKGROUND: Spontaneous breathing trials (SBTs) are increasingly performed. Significant changes in monitored breathing variables and the timing of those changes during the trial have important implications for its outcome determination and supervision. We aimed to study the magnitude and timing of change in breathing variables during the course of a 30-min SBT. METHODS: Breathing variables were continuously measured and averaged by minute during the SBT in 32 subjects with trial success and 8 subjects with trial failure from a general ICU population. Percentage changes in breathing variables during the trial and proportions of subjects showing a ≥ 20% change at different time points relative to the second minute of the trial were calculated. RESULTS: The commonly monitored breathing variables (frequency, tidal volume, their ratio, and minute ventilation) showed median coefficients of variation of < 15% throughout the trial and a median change of less than ± 20% by the end of the trial. Changes in a detrimental direction of ≥ 20% at the end of the trial but not already present at 10 min were noted in ≤ 5% of all subjects. CONCLUSIONS: During the course of a 30-min SBT, breathing variables remain relatively constant, and potentially significant changes in these variables after 10 min into the trial are uncommon. These findings should be considered when addressing aspects of duration and supervision of SBTs in weaning protocols.

Severe Acute Pulmonary Toxicity Associated with Brentuximab in a Patient with Refractory Hodgkin’s Lymphoma

Acute pulmonary toxicity associated with brentuximab appears to be a rare but serious adverse effect that can be potentially fatal. We report the case of a twenty-nine-year-old female with Hodgkins lymphoma who was treated with brentuximab and later presented with severe acute pulmonary toxicity; she improved after the discontinuation of brentuximab and administration of antibiotics and glucocorticoid therapy. Currently there is very little data in the literature in regard to the clinical manifestations and characteristics of patients taking brentuximab and the potential development of acute severe pulmonary toxicity, as well as the appropriate therapeutic approach, making this particular case of successful treatment and resolution unique.

Difference in inspiratory flow between volume and pressure control ventilation in patients with flow dyssynchrony

Purpose: Flow dyssynchrony is common during volume control ventilation but minimized during pressure control. Characterizing inspiratory flow during pressure control breaths can inform adjustments of the fixed flow of volume control to address flow dyssynchrony. This study compared inspiratory flow peak and pattern between volume control and adaptive pressure control breaths. Material and methods: Subjects with or at risk for ARDS were ventilated with volume control decreasing ramp flow at different tidal volumes and subsequently with adaptive pressure control targeting those same tidal volumes. Inspiratory flows of volume control breaths exhibiting flow dyssynchrony, and those of pressure control breaths at the same set tidal volumes without flow dyssynchrony were analyzed, for a total of 17 subject‐tidal volume conditions. Peak flow and flows at 10, 25, 50 and 75% of inspiratory time were compared between modes. Results: Group peak flows were not different between modes, but at 50 and 75% of inspiratory time flows were higher during adaptive pressure control. In 8 subject‐tidal volume conditions VT were higher (> 1 ml/kg PBW) on adaptive pressure control than on volume control. Conclusions: In patients with flow dyssynchrony during volume control ventilation, adjustment of inspiratory flow pattern should be considered to minimize this dyssynchrony. HighlightsFlow dyssynchrony is common during volume control ventilation with low tidal volume.Flows on pressure control better reflect patient demand, but volume is not controlled.Setting volume control flow to meet demand can minimize this dyssynchrony.Between pressure and volume control flows differ in pattern rather than in peak.