Sang-Bum Hong

Acute Exacerbation of Idiopathic Pulmonary Fibrosis: Incidence, Risk Factors, and Outcome

Although acute exacerbation of idiopathic pulmonary fibrosis (IPF) has become well recognised, the reported incidence and outcomes are highly variable, and risk factors are unknown. The aim of this study was to estimate the incidence, risk factors and impact of acute exacerbations, and other known causes of rapid deterioration. This was a retrospective review of 461 patients with IPF (269 cases were biopsy-proven). The median follow-up period was 22.9 months. Rapid deterioration requiring hospitalisation occurred in 163 (35.4%) patients, with multiple episodes in 42 patients. Acute exacerbation was the most frequent cause (55.2%), followed by infection. The 1- and 3-yr incidences of acute exacerbation were 14.2 and 20.7%, respectively. Never having smoked and low forced vital capacity (FVC) were significant risk factors. The in-hospital mortality rate was 50.0%, and the 1- and 5-yr survival rates from the initial diagnosis were 56.2 and 18.4%, respectively. Acute exacerbation was a significant predictor of poor survival after the initial diagnosis, along with increased age, low FVC and diffusing capacity of the lung for carbon monoxide, and steroid use with or without cytotoxic therapy. 1- and 3-yr incidences of acute exacerbation were 14.2 and 20.7%, respectively. Never having smoked and low FVC were risk factors. Acute exacerbation had a serious impact on the overall survival of the patients with IPF.

Comparison of two commercial interferon-γ assays for diagnosing Mycobacterium tuberculosis infection

The clinical usefulness of ex vivo interferon-γ assays may largely depend on the assay format and epidemiological status of tuberculosis (TB) in the region studied. From July 2004 to June 2005 a prospective comparison study was undertaken at a tertiary referral hospital in South Korea. The results of tuberculin skin tests (TST) and the commercially available QuantiFERON-TB Gold (QFT-G) and T SPOT-TB (SPOT) assays were compared in an intermediate TB-burden country. Of the 224 participants studied, results from all three tests (TST, QFT-G, and SPOT) were available in 218; 87 with active TB and 131 at a low risk for TB. Using 10 mm as a cut-off for TST, SPOT sensitivity (96.6%) was significantly higher than that seen for TST (66.7%) and QFT-G (70.1%). QFT-G showed superior specificity over TST (91.6 versus 78.6%). Although the specificity of QFT-G was higher than that of SPOT (91.6 versus 84.7%), the difference was not statistically significant. Whilst some differences were found in the performance of the two commercialised interferon-γ assays, they seemed to be superior in their detection of Mycobacterium tuberculosis infection compared with tuberculin skin tests. The most appropriate choice of interferon-γ assay to use may depend on the clinical setting.

Diagnostic utility of the soluble triggering receptor expressed on myeloid cells-1 in bronchoalveolar lavage fluid from patients with bilateral lung infiltrates

BackgroundDifferential diagnosis of patients with bilateral lung infiltrates remains a difficult problem for intensive care clinicians. Here we evaluate the diagnostic role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in bronchoalveolar lavage (BAL) specimens from patients with bilateral lung infiltrates.MethodsWe conducted a prospective observational study on 80 patients with bilateral lung infiltrates with clinical suspicion of infectious pneumonia. Patients were categorized into three groups: bacterial or fungal infection, intracellular or viral infection, and noninfectious inflammatory disease. sTREM-1 concentrations were measured, and BAL fluid and Clinical Pulmonary Infection Score (CPIS) were analyzed.ResultsThe sTREM-1 concentration was significantly increased in patients with bacterial or fungal pneumonia (n = 29, 521.2 ± 94.7 pg/ml), compared with that in patients with viral pneumonia, atypical pneumonia or tuberculosis (n = 14, 92.9 ± 20.0 pg/ml) or noninfectious inflammatory disease (n = 37, 92.8 ± 10.7 pg/ml). The concentration of sTREM-1 in BAL fluid, but not CPIS, was an independent predictor of bacterial or fungal pneumonia, and a cutoff value of more than 184 pg/ml yielded a diagnostic sensitivity of 86% and a specificity of 90%.ConclusionThe sTREM-1 level in BAL fluid from patients with bilateral lung infiltrates is a potential marker for the differential diagnosis of pneumonia due to extracellular bacteria.

Analysis of progression in risk, injury, failure, loss, and end-stage renal disease classification on outcome in patients with severe sepsis and septic shock

INTRODUCTION A few studies have assessed risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria in patients with severe sepsis and septic shock, a setting in which acute kidney injury (AKI) is common and dramatically worsens outcome. METHODS Study subjects included all consecutive patients with severe sepsis and septic shock who had been admitted to the medical intensive care unit between January 2005 and December 2006. RESULTS Of 326 patients admitted during the study period, 291 were included. According to RIFLE criteria, 204 patients (70.1%) had AKI (risk, 26.1%; injury, 26.5%; failure, 17.5%) on admission. Overall, 28-day mortality rate was 48.5%. Mortality was not associated with admission RIFLE (risk, 44.7%; injury, 53.2%; failure, 51.0%; P = .58). However, maximum RIFLE was associated with increased 28-day mortality (P < .01). After adjustment for age, sex, Acute Physiology and Chronic Health Evaluation II score, and Sequential Organ Failure Assessment score, independent risk factors for 28-day mortality were newly developed AKI (odds ratio [OR], 11.4; P < .01), progression of RIFLE risk to higher RIFLE class (OR, 14.5; P < .01), maximum RIFLE injury (OR, 5.58; P < .01), and maximum RIFLE failure (OR, 7.64; P < .01). CONCLUSIONS Progression of RIFLE class and newly developed AKI after hospital admission were better able to predict 28-day mortality than RIFLE criteria on the first day of admission in patients with severe sepsis and septic shock.

Video laryngoscopy versus direct laryngoscopy for tracheal intubation during in-hospital cardiopulmonary resuscitation

AIM Tracheal intubation during cardiopulmonary resuscitation (CPR) is a high-risk procedure. Here, we investigated the efficacy of video laryngoscopy for tracheal intubation during CPR. METHODS Data regarding tracheal intubation during CPR from in-hospital cardiac arrests occurring between January 2011 and December 2013 (n=229) were prospectively collected and retrospectively analyzed. RESULTS The initial laryngoscopy method was video laryngoscopy in 121 patients (52.8%) and direct laryngoscopy in 108 patients (47.2%). The rate of successful intubation at the first attempt was higher with video laryngoscopy (71.9%; 87/121) than with direct laryngoscopy (52.8%; 57/108; p=0.003). The rate of success at the first attempt was higher for experienced (73.0%; 84/115) than inexperienced operators, including residents (52.6%; 60/114; p=0.001). Mortality at day 28 after CPR was not significantly different between patients with successful tracheal intubation at the first attempt and without (68.1% [98/144] vs. 67.1% [57/85]; p=0.876). In multivariate logistic regression analysis, a predicted difficult airway (odds ratio [95% confidence interval]=0.22 [0.10-0.49]; p<0.001), intubation by an experienced operator (2.63 [1.42-4.87]; p=0.002), and use of video laryngoscopy rather than direct laryngoscopy (2.42 [1.30-4.45]; p=0.005) were independently associated with a successful tracheal intubation at the first attempt. CONCLUSION Use of video laryngoscopy during CPR from in-hospital cardiac arrest is independently associated with successful tracheal intubation at the first attempt.

A Comparison of Acute Kidney Injury Classifications in Patients With Severe Sepsis and Septic Shock

Introduction:Acute kidney injury (AKI) is a common and serious complication in patients with severe sepsis and septic shock. AKI can be classified using the RIFLE (Risk, Injury, Failure, Loss and End-stage) and/or the Acute Kidney Injury Network (AKIN) criteria. The aim of this study was to determine which of the 2 systems better predicted 28-day mortality in patients with severe sepsis and septic shock. Methods:We retrospectively examined the medical records of all patients with severe sepsis and septic shock who were admitted to our medical intensive care unit (ICU) between January 2005 and December 2006 and compared the ability of the RIFLE and AKIN criteria to predict mortality. Results:Of the 326 patients admitted during the study period, 291 were included. AKI 48 and 72 hours after ICU admission was observed in 62.9% and 55.5% of patients, respectively, according to RIFLE criteria and in 65.6% and 59.2%, respectively, according to AKIN criteria. The overall 28-day mortality rate was 48.5%, and mortality was significantly associated with the severity of AKI, by both RIFLE and AKIN criteria. Both criteria had a similar ability to predict 28-day mortality 48 hours (0.65-69, P < 0.01) and 72 hours (0.66-70, P < 0.01) after ICU admission. Conclusions:The incidence of AKI in patients with sepsis and septic shock was slightly higher using AKIN than RIFLE criteria. However, using the AKIN criteria did not enhance the ability of AKI to predict 28-day mortality in such patients.

Clinical Outcomes of Witnessed and Monitored Cases of In-Hospital Cardiac Arrest in the General Ward of a University Hospital in Korea

BACKGROUND: There are few studies of the epidemiology and clinical outcomes of patients with in-hospital cardiac arrest (IHCA) in a general hospital ward. OBJECTIVE: To investigate the clinical outcomes of IHCA cases that occurred in the general ward of a university hospital and that were witnessed and/or monitored. METHODS: We prospectively gathered data on all IHCAs in the general ward of Asan Medical Center, Seoul, South Korea, that were recorded by the Medical Emergency Team between March 2008 and February 2010. The main outcomes included survival to hospital discharge, incidence of IHCA, and prognostic factors related to hospital mortality. We also investigated preventable cases. RESULTS: We identified 238 index cases of IHCA. The average incidence of IHCA was 0.145 IHCAs per 1,000 patient admissions. Survival to hospital discharge was 19% (46 cases), 66% of which were due to non-cardiac causes, and 77% were due to medical illnesses. The most common first documented rhythm was pulseless electrical activity (38%). Two hundred three cases (85.3%) of IHCA were witnessed at the event; 135 cases (56.7%) were monitored at the event. Non-witnessed cases, monitored cases, night onset, medical illness, metastatic cancer, intubation, and long duration of cardiopulmonary resuscitation were significantly associated with hospital mortality. We identified 91 preventable cases (38%). Respiratory insufficiency (37 cases, 41%) was one of major cause of preventable IHCA. CONCLUSIONS: Witnessed IHCAs in the general ward had a higher rate of survival to hospital discharge; however, monitored cases had a lower rate of survival to hospital discharge. Respiratory insufficiency was a major preventable cause of IHCA. In consideration of the preventable IHCAs, further studies should be performed on monitoring practices in general wards.

Characteristics of Mechanical Ventilation Employed in Intensive Care Units: A Multicenter Survey of Hospitals

A 1D point-prevalence study was performed to describe the characteristics of conventional mechanical ventilation in intensive care units (ICUs). In addition, a survey was conducted to determine the characteristics of ICUs. A prospective, multicenter study was performed in ICUs at 24 university hospitals. The study population consisted of 223 patients who were receiving mechanical ventilation or had been weaned off mechanical ventilation within the past 24 hr. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic respiratory failure (15%) (including tuberculosis-destroyed lung [5%]), coma (13%), and neuromuscular disorders (6%). Mechanical ventilation was delivered via an endotracheal tube in 68% of the patients, tracheostomy in 28% and facial mask with noninvasive ventilation (NIV) in 4%. NIV was used in 2 centers. In patients who had undergone tracheostomy, the procedure had been performed 16.9±8.1 days after intubation. Intensivists treated 29% of the patients. A need for additional educational programs regarding clinical practice in the ICU was expressed by 62% of the staff and 42% of the nurses. Tuberculosis-destroyed lung is a common indication for mechanical ventilation in acute exacerbation of chronic respiratory failure, and noninvasive ventilation was used in a limited number of ICUs.

Intratracheal Administration of Umbilical Cord Blood-Derived Mesenchymal Stem Cells in a Patient with Acute Respiratory Distress Syndrome

Umbilical cord blood (UCB)-derived mesenchymal stem cells (MSCs) have been introduced as a possible therapy in acute lung injury and acute respiratory distress syndrome (ARDS). This case history is reported of a 59-yr-old man who was treated with MSCs in the course of ARDS and subsequent pulmonary fibrosis. He received a long period of mechanical ventilation and weaning proved difficult. On hospital day 114, he underwent the intratracheal administration of UCB-derived MSCs at a dose of 1 × 106/kg. After cell infusion, an immediate improvement was shown in his mental status, his lung compliance (from 22.7 mL/cmH2O to 27.9 mL/cmH2O), PaO2/FiO2 ratio (from 191 mmHg to 334 mmHg) and his chest radiography over the course of three days. Even though he finally died of repeated pulmonary infection, our current findings suggest the possibility of using MSCs therapy in an ARDS patient. It is the first clinical case of UCB-derived MSCs therapy ever reported.

Optimal insertion depth of central venous catheters—Is a formula required? A prospective cohort study

INTRODUCTION To determine the optimal length for initial insertion of central venous catheters (CVCs) and to evaluate whether a recommended depth predicted optimal positioning of CVCs. MATERIALS AND METHODS All patients who were CVC-cannulated and who underwent chest computed tomography (CT) during a 10-month period were included. We measured the distance from catheter insertion to the superior vena cava/right atrium (SVC/RA) junction and calculated a recommended insertion depth. We compared the accuracy of the recommended depth with that suggested by the formula of Peres for predicting optimal positioning of a CVC. RESULTS Of the 1238 patients who were CVC-cannulated over 10 months, 106 underwent chest CT. Based on the mean distance from the CVC insertion point to the distal SVC, we determined that the recommended depth of insertion should be 14 cm for the right subclavian vein, 15 cm for the right internal jugular vein, 17 cm for the left subclavian vein and 18 cm for left internal jugular vein. Using these guidelines, initial placement of a CVC in the distal SVC was more accurate than when the Peres formula was used (91.5% vs. 77.4%, p<0.05). CONCLUSIONS For Asian populations, we found that these guidelines are more accurate than those derived from the Peres formulae and more simple to use, thus increasing the likelihood of optimal tip location within the SVC on the first attempt and eliminating the need for later repositioning.