Peter Doelken

American College of Chest Physicians/La Société de Réanimation de Langue Française Statement on Competence in Critical Care Ultrasonography

OBJECTIVEnTo define competence in critical care ultrasonography (CCUS).nnnDESIGNnThe statement is sponsored by the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Société de Réanimation de Langue Française (SRLF). The ACCP and the SRLF selected a panel of experts to review the field of CCUS and to develop a consensus statement on competence in CCUS.nnnRESULTSnCCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component part, the panel defined the specific skills that the intensivist should have to be competent in that aspect of CCUS.nnnCONCLUSIONnIn defining a reasonable minimum standard for CCUS, the statement serves as a guide for the intensivist to follow in achieving proficiency in the field.

Pathophysiology of Pneumothorax Following Ultrasound-Guided Thoracentesis

STUDY OBJECTIVESnPneumothorax following ultrasound-guided thoracentesis is rare. Our goal was to explain the mechanisms of pneumothorax following ultrasound-guided thoracentesis in a setting where pleural manometry is routinely used.nnnMETHODSnWe reviewed the patient records and procedure reports of 401 patients who underwent ultrasound-guided thoracentesis. When manometry was performed, pleural space elastance was determined. A model assuming dependence of the pleural space elastic properties on respiratory system elastic properties was used to isolate cases with presumed normal pleural space elastance. Elastance outside mean +/- SD x 2 of the isolated sample was considered abnormal. Four radiographic criteria of unexpandable lung were used: visceral pleural peel, lobar atelectasis, basilar pneumothorax, and pneumothorax with ipsilateral shift.nnnRESULTSnThere were 102 diagnostic thoracenteses, 192 therapeutic thoracenteses with pleural manometry, and 73 therapeutic thoracenteses without manometry. There was one pneumothorax that occurred from lung puncture and eight unintentional pneumothoraces, all of which showed radiographic evidence of unexpandable lung. Four of eight unintentional pneumothoraces had abnormal elastance; none had excessively negative pleural pressure (< -25 cm H(2)O).nnnCONCLUSIONSnUnintentional pneumothoraces cannot be prevented by monitoring for symptoms or excessively negative pressure. These pneumothoraces were drainage related rather than due to penetrating lung trauma or external air introduction. We speculate that unintentional pneumothoraces are caused by transient, parenchymal-pleural fistulae caused by nonuniform stress distribution over the visceral pleura that develop during large-volume drainage if the lung cannot conform to the shape of the thoracic cavity in some patients with unexpandable lung. These fistulae appear to be pressure dependent, and the resulting pneumothoraces rarely require treatment. Drainage-related pneumothorax is an unavoidable complication of ultrasound-guided thoracentesis and appears to account for the vast majority of pneumothoraces occurring in a procedure service.

A Program to Improve the Quality of Emergency Endotracheal Intubation

Objective: To assess the results of a quality improvement (QI) project designed to improve safety of emergency endotracheal intubation (EEI). Design: Single center prospective observational. Setting: 16-bed intensive care unit. Participants: Nine pulmonary/critical care fellows. Interventions: For 3 years, EEI performed by the medical intensive care unit team were analyzed to identify interventions that would improve quality of the procedure. By segmental process analysis, the procedure of EEI was subjected to iterative change. Major components of process improvement were development of a combined team approach, a mandatory checklist, use of crew resource management (CRM) tactics, and postevent debriefing. Quality analysis and improvement included training of fellows using scenario-based training (SBT) with computerized patient simulator (CPS) to improve mechanical skills of intubation and team leadership. Fellows received 15 sessions of SBT with CPS using a combined checklist and team approach before assuming team leadership position during real-life EEI. Measurements: For a 10-month period, fellows carried digital voice recorders to EEI; which, when combined with recording of continuous oximetry and BP monitoring were used to assess the quality of EEI. Main Results: 128 EEI were performed of which 101 had full data recorded. Complications were 14% severe hypoxemia (<80% saturation), 6% severe hypotension (SBP<70 mm Hg), 1% death, 20% difficult EEI (≥3 attempts), 11% esophageal intubations, 2% aspiration, and 1% dental injury; 62% EEI were successfully achieved on first attempt, 11% required >3 attempts. Conclusions: EEI may be performed by pulmonary/critical medicine (PCCM) fellows with safety comparable to that described in other studies on EEI. Important parts of the program included the use of formal iterative QI approach, the use of intensive SBT with CPS, basic CRM, a comprehensive checklist, and a combined team approach. A key benefit of the program was to make the process of EEI fully transparent for ongoing quality and safety improvement.

Pleural Fluid Analysis in Chylous Pleural Effusion

OBJECTIVESnChyle is a noninflammatory, lymphocyte-predominant fluid that may cause a pleural effusion as a consequence of thoracic duct leakage into the pleural space. Although chyle is reported to have protein concentrations in the transudative range, chylous effusions are typically exudative, as defined by the standard criteria. We hypothesized that chylous effusions from a thoracic duct leak alone have low lactate dehydrogenase (LDH) concentrations due to the absence of inflammation and are lymphocyte-predominant, protein-discordant exudates. Consequently, pleural effusions that do not meet these criteria but with triglyceride concentrations of > 110 mg/dL or are positive for chylomicrons should be associated with other diagnoses contributing to pleural fluid formation.nnnSTUDY DESIGNnRetrospective.nnnMETHODSnThe pleural fluid analyses of 876 consecutive thoracenteses were reviewed. All cases with a triglyceride concentration of > 110 mg/dL or the presence of chylomicrons were retrieved. The effusions were then classified as transudates, concordant exudates, protein-discordant exudates, and LDH-discordant exudates, and according to lymphocyte predominance (> 50%). The causes of these pleural effusions were determined after the review of the medical record.nnnRESULTSnTwenty-two pleural effusions had elevated triglyceride concentrations and/or were positive for chylomicrons. Eleven effusions were lymphocyte-predominant, protein-discordant exudates, and two of these were associated with chylous ascites. The remaining effusions were transudates (n = 7) or concordant exudates (n = 4); all were associated with conditions known to cause pleural effusion apart from chyle leakage.nnnCONCLUSIONnChylous effusions caused solely by conditions known to cause chylothorax were lymphocyte-predominant, protein-discordant exudates. Protein concentrations in the transudative range or elevated LDH concentrations were associated with a coexisting condition that may impact the management of these chylous effusions.

The unexpandable lung

Unexpandable lung is the inability of the lung to expand to the chest wall allowing for normal visceral and parietal pleural apposition. It is the direct result of either pleural disease, endobronchial obstruction resulting in lobar collapse, or chronic atelectasis. Unexpandable lung occurring as a consequence of active or remote pleural disease may present as a post-thoracentesis hydropneumothorax or an effusion that cannot be completely drained because of the development of anterior chest pain. Pleural manometry is useful for identifying unexpandable lung during initial pleural drainage. Unexpandable lung occurring as a consequence of active or remote pleural disease may be separated into two distinct clinical entities termed trapped lung and lung entrapment. Trapped lung is a diagnosis proper and is caused by the formation of a fibrous visceral pleural peel (in the absence of malignancy or active pleural inflammation). The mechanical effect of the pleural peel constitutes the primary clinical problem. Lung entrapment may result from a visceral pleural peel secondary to active pleural inflammation, infection, or malignancy. In these cases, the underlying malignant or inflammatory condition is the primary clinical problem, which may or may not be complicated by unexpandable lung due to visceral pleural involvement. The recognition of trapped lung and lung entrapment as related, but distinct, clinical entities has direct consequences on clinical management. In our practice, pleural manometry is routinely performed during therapeutic thoracentesis and is useful for identification of unexpandable lung and has allowed us to understand the mechanisms surrounding a post-thoracentesis pneumothorax.

Successful Real-Time Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of a Hilar Lung Mass Obtained by Traversing the Pulmonary Artery

The utility and safety of transbronchial needle aspiration is well described. Serious complications from transbronchial needle aspiration are exceedingly rare. The addition of endoscopic ultrasonographic techniques in the form of endoscopic ultrasonography and, more recently, endobronchial ultrasonography has added valuable information regarding lymphatic anatomy of the hilum and mediastinum. In addition, the use of real-time ultrasound gives the operator visual feedback of needle placement and proximity to major surrounding structures such as the heart and great vessels. Here, the authors present the case of a 74-year-old man with a left hilar mass who underwent biopsy by means of intentional traverse of the pulmonary artery.

Pleural Fluid Analysis and Radiographic, Sonographic, and Echocardiographic Characteristics of Hepatic Hydrothorax

BACKGROUNDnThere are limited published data defining complete pleural fluid analysis, echocardiographic characteristics, or the presence or absence of ascites on sonographic or CT imaging in patients with hepatic hydrothorax.nnnMETHODSnWe reviewed pleural fluid analysis and radiographic, sonographic, and echocardiographic findings in 41 consecutive patients with hepatic hydrothorax referred to the Pleural Procedure Service for thoracentesis.nnnRESULTSnAscites was detected on sonographic or CT imaging in 38 of 39 patients (97%). Diastolic dysfunction was found in 11 of 21 patients (52%). Contrast echocardiography with agitated saline demonstrated an intrapulmonary shunt in 18 of 23 cases (78%). Solitary hepatic hydrothorax had a median pleural fluid pH of 7.49 (fifth to 95th percentile, 7.40-7.57), total protein level of 1.5 g/dL (0.58-2.34), and lactate dehydrogenase (LDH) level of 65 IU/L (36-138). The median pleural fluid/serum protein ratio and pleural LDH/upper limit of normal serum LDH ratio were 0.25 (0.10-0.43) and 0.27 (0.14-0.57), respectively. The median absolute neutrophil count (ANC) was 26 cells/μL (1-230). Only a single patient had a protein discordant exudate despite 83% of patients receiving diuretics. When comparing solitary hepatic hydrothorax and spontaneous bacterial pleuritis, there was no statistically significant difference among pleural fluid total protein (P = .99), LDH (P = .33), and serum albumin (P = .47). ANC was higher in patients with spontaneous bacterial pleuritis (P < .0001).nnnCONCLUSIONSnHepatic hydrothorax virtually always presents with ascites that is detectable on sonographic or CT imaging. The development of an exudate from diuretic therapy is a rare phenomenon in hepatic hydrothorax. In contrast, diastolic dysfunction and intrapulmonary shunting are common in patients with hepatic hydrothorax. There was no statistically significant change in pleural fluid parameters with spontaneous bacterial pleuritis, except an increased ANC.

Dasatinib-induced pleural effusions: a lymphatic network disorder?

Dasatanib, which has been approved for rescue therapy for patients with imatinib-resistant chronic myelogenous leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia, is a novel, orally available multitargeted kinase inhibitor of BCR-ABL and SRC family kinases (Quintas-Cardama et al, J Clin Oncol 2007;25:3908-14). It binds to both active and inactive conformations of the ABL gene and is 325 times more potent than imatinib in inhibiting the growth of BCR/ABL cells in vitro (Morelock and Sahn, Chest 1999;116:212-21; Huggins and Sahn, Clin Chest Med 2004;25:141-53). Although dasatinib is a generally well-tolerated drug in the treatment of Philadelphia chromosome positive hematopoetic malignancies, pleural effusions have been frequently noted and have been reported in up to 35% of patients (Sahn SA. Drug-induced pleural disease. In: Camus P, Rosenow E, editors. Drug-induced iatrogenic lung disease. London: Hodder Arnold; 2009). Although there have been numerous reports of effusions, none have provided complete pleural fluid analysis; therefore, we report 2 patients with dasatinib-induced pleural effusion with complete pleural fluid analysis.

Clinical Implications of Unexpandable Lung Due to Pleural Disease

Unexpandable lung due to pleural disease may manifest itself as a hydropneumothorax after pleural drainage procedure or as an inability to completely drain a pleural effusion due to chest pain. The condition is a mechanical complication of a variety of pleural disorders. Of these, malignant lung entrapment and inflammatory lung entrapment are considered complications of active pleural disease, and management is primarily dependent on the nature of the active process. Trapped lung is a sequela of remote inflammation of the pleural space. Trapped lung is usually asymptomatic but may be the cause of dyspnea in some patients. The only available treatment of symptomatic trapped lung is surgical decortication. Surgical decortication should only be considered after other causes of dyspnea have been excluded.

Intrapleural therapy: Intrapleural therapy

Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant‐related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non‐small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5u2003months in patients with non‐small cell lung cancer with a malignant pleural effusion.