Meng-Chih Lin

The cuff-leak test is a simple tool to verify severe laryngeal edema in patients undergoing long-term mechanical ventilation

Objective:The cuff-leak test has been proposed as a simple tool to clinically predict stridor or respiratory distress secondary to laryngeal edema following extubation. However, the true incidence of laryngeal edema in patients on long-term mechanical ventilation is uncertain. The relationship between upper airway obstruction (detected by video bronchoscopy) and the cuff-leak test value for patients with prolonged translaryngeal intubation during percutaneous dilatational tracheostomy (PDT) was investigated. Design:Prospective, clinical investigation. Setting:Intensive care unit of a university hospital. Patients:Ninety-five patients with prolonged translaryngeal intubation requiring PDT were enrolled during a 12-month period. Interventions:Cuff-leak test, PDT, video bronchoscopy. Measurements and Main Results:The average duration of translaryngeal intubation was 28.1 ± 17.6 days. The incidence of severe laryngeal edema was 36.8% (35/95). We chose 140 mL as the threshold cuff-leak volume below which edema is indicated. The rate of cuff-leak test positivity was 38.9% (37/95). The sensitivity and the specificity of the test were 88.6% and 90.0%, respectively. The positive and negative predictive values were 83.8% and 93.1%, respectively. Patients who developed severe laryngeal edema had a smaller leak volume than those who did not, expressed in absolute values (53.9 ± 56.2 vs. 287.9 ± 120.0 mL; p < .001) or in relative values (10.1 ± 10.2 vs. 55.3 ± 22.7%, p < .001). The occurrence of severe laryngeal edema was not associated with age, gender, body weight, respiratory failure due to pneumonia, duration of translaryngeal intubation, endotracheal tube diameter, Acute Physiology and Chronic Health Evaluation II score, or history of self-extubation. Conclusions:A reduced cuff-leak volume measured before PDT may signal the presence of severe laryngeal edema in patients on long-term mechanical ventilation.

Community-acquired spontaneous bacterial meningitis in adult diabetic patients: an analysis of clinical characteristics and prognostic factors.

Abstract.Background: We analyzed the clinical characteristics and prognostic factors of community-acquired spontaneous bacterial meningitis (CASBM) in adult diabetic patients. Patients and Methods: Over a period of 15 years, 47 adult diabetic patients with CASBM were identified. The clinical characteristics, laboratory data and therapeutic outcome of these 47 patients were statistically analyzed. Results: The 47 patients were 31 men and 16 women, aged 22 to 79 years, and they accounted for 38.5% (47/122) of our adult patients with culture-proven CASBM. The most common causative pathogen was Klebsiella pneumoniae (n = 32), followed by pathogens of the streptococcal species (n = 6). Besides classic manifestations of bacterial meningitis, bacteremia and focal suppuration, especially liver abscess, were common features in this group of patients. Liver cirrhosis and/or alcoholism were the other frequent underlying conditions. 27 patients survived in the course of therapy. The prognostic factors with statistical significance were glucose ratio and cerebrospinal fluid (CSF) white blood cell (WBC) count. Conclusion: This study showed the high incidence of diabetes mellitus (DM) among the adult patients with CASBM in Taiwan. K. pneumoniae was the most frequent causative pathogen. Bacteremia and focal suppuration, especially liver abscess, were common findings. The values of glucose ratio and CSF WBC count had a statistically significant influence on the prognosis of our patients.

Hypokalemic Muscular Paralysis Causing Acute Respiratory Failure Due to Rhabdomyolysis with Renal Tubular Acidosis in a Chronic Glue Sniffer

Case Report: A 34-year-old male was admitted to the emergency department with the development of quadriparesis and respiratory failure due to hypokalemia after prolonged glue sniffing. The patient was subsequently given mechanical ventilatory support for respiratory failure. He was weaned from the ventilator 4 days later after potassium replacement. Toluene is an aromatic hydrocarbon found in glues, cements, and solvents. It is known to be toxic to the nervous system, hematopoietic system, and causes acid-base and electrolyte disorders. Acute respiratory failure with hypokalemia and rhabdomyolysis with acute renal failure should be considered as potential events in a protracted glue sniffing.

Alto valor de la combinación de la concentración sérica de proteína C reactiva y la puntuación BODE para la predicción de la mortalidad en pacientes con EPOC estable

INTRODUCTION Both BODE score (body mass index, degree of airflow obstruction, functional dyspnea, and exercise capacity) and serum C-reactive protein (CRP) are validated predictors of mortality in patients with chronic obstructive pulmonary disease (COPD). The aim of this study is to investigate the predictive value of combined serum CRP and BODE score for mortality in COPD patients. PATIENTS AND METHODS A cohort of 114 clinically stable COPD patients was assessed for predictors of longitudinal mortality. Variables included age, gender, current smoking status, pack-years, maximal inspiratory/expiratory pressure, BODE score (body mass index, degree of airflow obstruction, functional dyspnea, and exercise capacity), serum CRP, and fibrinogen. Predictors were assessed by Cox proportional hazards regression model. Survival was estimated by Kaplan-Meier method and log-rank test. RESULTS Serum CRP (P=0.005; HR=1.042; 95% CI=1.019-1.066) and BODE score (P=0.032; HR=1.333; 95% CI=1.025-1.734) were independent predictors of survival in the multivariate analysis. The cumulative survival rates of COPD patients were sorted from the worst to the best as following: serum CRP >3mg/L & quartile 3-4; serum CRP >3mg/L & quartile 1-2; serum CRP ≤3mg/L & quartile 3-4; serum CRP ≤3mg/L & quartile 1-2 (P<0.001). CONCLUSIONS Serum CRP and BODE score are independent predictors of survival in stable COPD patients. Combination of serum CRP and BODE score has higher predictive value in clinical practice.

Change in Demographic Picture and Increase of Drug Resistance in Pulmonary Tuberculosis in a 10-Year Interval in Taiwan

AbstractBackground: This study was designed to compare the change in demographics, medical characteristics and drug resistance of patients with active pulmonary tuberculosis (TB) betwen two time periods within a 10-year interval. Patients and Methods: We retrospectively reviewed the clinical records and chest radiographs of 1,826 patients with active pulmonary TB for two time periods from 1992–1996 (n = 884) and 1982–1986 (n = 942). Results: The mean age was significantly higher and there were significantly more female patients in the 1992–1996 period than in the 1982–1986 period. In the 1992–1996 period, there were significantly fewer patients with the main complaints of cough, fever and body weight loss at the time of diagnosis but significantly more patients who had diabetes mellitus, obstructive airway disease, cancer other than lung cancer or who were on corticosteroid therapy. During the 1992–1996 period, single drug resistance against isoniazid (INH), rifampin (RIF) and streptomycin increased by 0.5%, 3% and 0.7%, respectively. Multiple drug resistance against both INH and RIF increased by 2% in the 1992–1996 period. A history of pulmonary TB and extensive pulmonary involvement were two significant factors for drug resistance against INH, RIF or ethambutol (EMB). Conclusion: In the 1992–1996 period, the mean age of patients and number of female patients significantly increased. There were more patients with diabetes mellitus, obstructive airway diseases, cancer other than lung cancer and prior steroid therapy but fewer patients presenting with classic clinical symptoms of TB. In consideration of the high prevalence and increasing rate of single and multiple drug resistance, we recommend an initial four-drug regimen (INH, RIF, EMB, pyrazinamide) for the treatment of pulmonary TB in Taiwan.

Spontaneous variability of cardiac output in ventilated critically ill patients.

Objective: To define the magnitude of spontaneous cardiac output variability over time in sedated medical intensive care unit patients attached to a continuous cardiac output monitor, and to determine whether high level positive end‐expiratory pressure or inverse inspiratory‐to‐expiratory (I:E) ratio ventilation resulted in greater variability over time than low positive end‐expiratory pressure with conventional I:E ratio ventilation. Design: Prospective study. Setting: Medical intensive care unit in a tertiary medical center. Patients: A total of 22 hemodynamically stable acute respiratory failure patients with a pulmonary artery catheter inserted for hemodynamic monitoring Interventions: After being sedated, patients were randomized alternately to receive pressure control ventilation first at setting A (high positive end‐expiratory pressure [15 cm H2O] with conventional I:E ratio [1:2]) and then at setting B (low positive end‐expiratory pressure [5 cm H2O] with inverse I:E ratio [2:1]), or vice versa, and then at setting C (low positive end‐expiratory pressure [5 cm H2O] with conventional I:E ratio [1:2]). Each ventilation setting period lasted 1 hr. Measurements and Main Results: Cardiac output (CO) was measured continuously. The continuous CO value displayed was updated every 30‐60 secs. The updated value reflected an average of the previous 3‐6 mins. The coefficient of variation (CV) of CO for each setting in each patient was calculated to represent the spontaneous variability. The mean CO ± SD and CV of each setting was 5.7 ± 1.8 L/min and 4.4% for setting A, 5.6 ± 1.5 L/min and 4.6% for setting B, and 5.9 ± 1.7 L/min and 4.8% for setting C. Analysis of variance revealed no significant differences between the CVs of the three settings. The 95% confidence interval for the COs for each setting was approximately the mean CO ± 0.1 × mean CO measured. Conclusions: In critically ill sedated medical intensive care unit patients with stable hemodynamics, the spontaneous variability of cardiac output over time was not significant. High positive end‐expiratory pressure (15 cm H2O) and inverse ratio ventilation (2:1) did not contribute to increased spontaneous variability of cardiac output.

Experience of Cancer Care for Metastasis-Induced Acute Pancreatitis Patients with Lung Cancer

Introduction: Little information is available concerning the prognosis and treatment of metastasis-induced acute pancreatitis (MIAP) with lung cancer. The aim of this study was to investigate the prognostic factors of MIAP patients with lung cancer. Methods: A retrospective study of 20 MIAP patients with lung cancer was performed. Survival was estimated using Kaplan-Meier method. Prognostic factors were assessed with Cox proportional hazards regression model. Results: There were 14 men and six women; 15 cases were non-small cell lung cancer and five cases were small cell lung cancer. The median age was 68 (range, 41–83). The mean duration from lung cancer to MIAP diagnosis of having MIAP was 139.8 days (range, 3–892). However, two small cell lung cancer cases had preceded presentation with acute pancreatitis. Chemotherapy (p = 0.008; hazards ratio = 4.99; 95% confidence interval = 1.51–16.54) and an Eastern Cooperative Oncology Group (ECOG) performance status (PS) (p = 0.007; hazards ratio = 6.13; 95% confidence interval = 0.04–0.61) were significant prognostic factors for survival. ECOG PS 3 to 4 at diagnosis of MIAP was 11/20. Survival of MIAP with lung cancer was 108.7 days. Patients with ECOG PS 3 to 4 had shorter mean survival than those with PS 0 to 2 (33.7 versus 226.4 days; p = 0.003). Chemotherapy group had longer mean survival than those without chemotherapy (161.9 versus 25.0 days; p = 0.01). Conclusion: Chemotherapy can improve survival of MIAP from bronchogenic carcinoma in the selected patients.

Gastric intramucosal PCO2 and pH variability in ventilated critically ill patients.

ObjectiveGastric intramucosal Pco2 (Pico2) and pH (pHi) are currently used as indices of the adequacy of splanchnic perfusion and as end points to guide therapeutic intervention. However, little is known about their spontaneous variability over time. The present study was designed to define the magnitude of spontaneous variability of Pico2 and pHi in sedated medical intensive care unit (ICU) patients using an automated recirculating air tonometer and to test whether high-level positive end-expiratory pressure (PEEP) or inverse inspiratory/expiratory (I:E) ratio ventilation resulted in a greater variability than low PEEP with conventional I:E ratio ventilation. DesignProspective study. SettingMedical ICU in a tertiary medical center. PatientsTwenty-three acute respiratory failure patients. InterventionsAfter being sedated, patients were randomized to undergo pressure control ventilation at the following three settings: A, high PEEP (15 cm H2O) with conventional I:E ratio (1:2), and B, low PEEP (5 cm H2O) with inverse I:E ratio (2:1) alternately, and then C, low PEEP (5 cm H2O) with conventional I:E ratio (1:2). Each ventilation setting period lasted 1 hr. Measurements and Main Results The Pico2 and pHi were measured at baseline (time 0), and at 15, 30, 45, and 60 mins thereafter. The corresponding coefficients of variation (CVs) of Pico2 for overall pooled group and settings A, B, and C were 4.0%, 4.4%, 3.4%, and 4.2%, respectively. The corresponding CVs of pHi for overall pooled group and settings A, B, and C were 0.36%, 0.37%, 0.33%, and 0.4%, respectively. Analysis of variance showed no significant difference in the CVs of Pico2 or pHi between the three settings. The 95% confidence interval is approximately ±8% variability for Pico2 and ±0.7% variability for pHi. ConclusionsIn critically ill medical ICU patients with stable hemodynamics, the spontaneous variability of Pico2 or pHi are not substantial. High PEEP (15 cm H2O) and inverse ratio ventilation (2:1), which does not change the cardiac output or hemodynamics, does not contribute to increased spontaneous variability in Pico2 or pHi.

Neutrophil elastase inhibitor reduces ventilation-induced lung injury via nuclear factor-κB and NF-κB repressing factor in mice

Mechanical ventilation used in patients with acute lung injury can damage pulmonary epithelial cells through production of inflammatory cytokines, oxygen radicals, and neutrophil infiltration, termed ventilator-induced lung injury. Neutrophil elastase, nuclear factor-κB (NF-κB), and NF-κB repressing factor (NRF) have previously been shown to participate in the regulation of macrophage inflammatory protein-2 (MIP-2) during airway inflammation. However, the mechanisms regulating interactions among mechanical ventilation, neutrophil influx, and NF-κB/NRF remain unclear. Thus, we hypothesized that neutrophil elastase inhibitor attenuated ventilation-induced neutrophil recruitment and MIP-2 production through inhibition of the NF-κB/NRF pathway. Male C57BL/6 mice were exposed to low-tidal-volume (6 mL/kg) or high-tidal-volume (30 mL/kg) mechanical ventilation using room air with or without 2 µg/g NF-κB inhibitor SN50 or 6 µg/g NRF short interfering RNA or 100 µg/g neutrophil elastase inhibitor administration. Nonventilated mice served as a control group. Evan blue dye, lung wet-to-dry weight ratio, free radicals, myeloperoxidase, histopathologic grading of lung tissue, inflammatory cytokines, Western blot of NF-κB and NRF, and gene expression of NRF were measured to establish the extent of lung injury. Neutrophil elastase inhibitor ameliorated high-tidal-volume ventilation-induced lung injury, neutrophil influx, production of MIP-2 and malondialdehyde, activation of NF-κB and NRF, apoptotic epithelial cell death, and disruption of bronchial microstructure in mice. Mechanical stretch-augmented acute lung injury was also attenuated through pharmacological inhibition of NF-κB activity by SN50 and NRF expression by NRF short interfering RNA. Our data suggest that neutrophil elastase inhibitor attenuates high-tidal-volume mechanical ventilation-induced neutrophil influx, oxidative stress, and production of MIP-2, at least partly, through inhibition of NF-κB/NRF pathway. Understanding the protective effects of neutrophil elastase inhibitor associated with the reduction of MIP-2 allow clarification of the pathophysiological mechanisms regulating severe lung inflammation and development of possible therapeutic strategies involved in acute lung injury.

Primary Endobronchial Minute Leiomyoma-A Case Report

Primary endobronchial minute leiomyoma is a rare benign tumor of the lung. In this report, we discuss a case of this rare tumor in a 78-year-old male who presented with hemoptysis and was diagnosed as endobronchial leiomyoma based on the histopathological examination of a bronchial biopsy from the posterior segmental bronchus of the left upper lobe. Bronchofiberscopy revealed a polypoid tumor (0.1×0.1 cm) in the posterior segmental bronchus of the left upper lobe, which was easily extirpated by transbronchial forceps biopsy. We could not find another primary lesion or metastases in any other organ. Following treatment, this patient has been asymptomatic with no recurrence of haemoptysis.