Shereen Farghaly

Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients.

AIM To evaluate role of diaphragmatic thickening and excursion, assessed ultrasonographically, in predicting extubation outcome. METHODS Fifty-four patients who successfully passed spontaneous breathing trial (SBT) were enrolled. They were assessed by ultrasound during SBT evaluating diaphragmatic excursion, diaphragmatic thickness (Tdi) at end inspiration, at end expiration and diaphragmatic thickness fraction (DTF%). Simultaneously traditional weaning parameters were recorded. Patients were followed up for 48h after extubation. RESULTS Out of 54 included patients, 14 (25.9%) failed extubation. Diaphragmatic excursion, Tdi at end inspiration, at end expiration and DTF% were significantly higher in the successful group compared to those who failed extubation (p<0.05). Cutoff values of diaphragmatic measures associated with successful extubation were ≥10.5mm for diaphragmatic excursion, ≥21mm for Tdi at end inspiration, ≥10.5mm for Tdi at end expiration, ≥34.2% for DTF% giving 87.5%, 77.5%, 80% and 90% sensitivity respectively and 71.5%, 86.6%, 50% and 64.3% specificity respectively. Combining diaphragmatic excursion ≥10.5mm and Tdi at end inspiration ≥21mm decreased sensitivity to 64.9% but increased specificity to 100%. Rapid shallow breathing index (RSBI) <105 had 90% sensitivity but 18.7% specificity. CONCLUSION Ultrasound evaluation of diaphragmatic excursion and thickness at end inspiration could be a good predictor of extubation outcome in patients who passed SBT. It is recommended to consider the use of these parameters with RSBI consequently to improve extubation outcome.

Brain natriuretic peptide as a predictor of weaning from mechanical ventilation in patients with respiratory illness

BACKGROUND Cardiovascular dysfunction has been reported as an important mechanism of weaning failure. Brain natriuretic peptide (BNP) is a sensitive and specific marker for cardiovascular dysfunction. OBJECTIVE To determine the value of BNP levels measured at initiation and end of a 2h spontaneous breathing trial (SBT) as a predictor of successful weaning of mechanical ventilation in patients with respiratory illness. PATIENTS AND METHODS Thirty consecutive patients ready for weaning were prospectively enrolled in this cross-sectional analytic study over a 6-month period. All patients had been on spontaneous mode of weaning for at least 2h. Tidal volume, respiratory rate, rapid shallow breathing index (RSBI), minute ventilation and PaO2/FiO2 were observed at initiation of SBT. BNP was measured at the initiation (BNP1) and at the end of SBT (BNP2). Weaning failure is defined as either the failure of SBT or the need for reintubation within 48 h following extubation. RESULTS Out of the 30 included patients, 14 (46.6%) patients had failed weaning. PaCO2 and BNP2 were significantly higher in the patients with failed weaning as compared to those with successful weaning (P = 0.025, P = 0.031 respectively). However, BNP1 levels were not statistically significant between the 2 groups (P = 0.722). On multiple regression analysis, BNP% (percent change in the BNP level during the 2-h SBT) was the only predictor of weaning success. As compared to other weaning parameters, BNP% ≤ 14.9 had the best sensitivity, specificity, positive and negative predictive value. CONCLUSION Measuring the percentage change in the BNP level during a SBT may be a good predictor of weaning success from mechanical ventilation in respiratory patients.

Outcome of short-term systemic steroid therapy in chronic obstructive pulmonary disease patients with acute exacerbation

Background There are insufficient data on the optimum duration of systemic steroid therapy during acute exacerbation of chronic obstructive pulmonary disease (COPD). Aim To evaluate the outcome of short-term systemic steroid therapy in patients hospitalized with acute exacerbation of COPD and to identify factors associated with treatment failure. Patients and methods Fifty severe and very severe COPD patients with acute exacerbation were consecutively included in this study. Patients were assessed by a clinical symptom score, peak expiratory flow rate (PEFR), arterial blood gases and laboratory investigations [blood count indices, high sensitive C-reactive protein, erythrocyte sedimentation rate (ESR) and fibrinogen level]. Short-term systemic steroids were initiated and the outcome was assessed at day 5 of therapy and the patients were classified into treatment success group or failure group. Results Treatment failure was observed in 27 (54%) of patients. Patients with treatment failure had significantly higher cough and chest tightness scores, higher partial pressure of CO2 in arterial blood (PaCO2), lower partial pressure of O2 in arterial blood (PaO2), lower PEFR, higher red distribution width (RDW), and higher ESR compared with the success group. By binary logistic regression, higher PaCO2, lower PaO2, and higher ESR were independent risk factors associated with treatment failure. The optimum cutoff level of PaCO2, PaO2, and PEFR associated with treatment failure was more than or equal to 59.5 mmHg, up to 43.5 mmHg, and up to 225 l/min, respectively. ESR first hour of at least 35 and RDW of at least 15.5% were also associated with treatment failure. Conclusion Most severe and very severe COPD during acute exacerbations need prolonged course of systemic steroids (>5 days). Clinical evaluation, gasometric parameters, PEFR, RDW, and ESR could be good predictors of treatment failure on short-term systemic steroid.

Bedside inflammatory mediators in pulmonary tuberculosis

Background Monitoring of pulmonary tuberculosis (PTB) especially in poor countries is a major challenge aiming to find cheap valuable indices. Objective The objective of this study was to evaluate the use of simple laboratory parameters as complete blood count (CBC), especially platelet (PLT) indices, for assessment and monitoring of PTB activity. Patients and methods Totally, 140 PTB patients in addition to 30 healthy individuals as a control group were included in this case–control study. Patients were divided into three groups: 66 newly diagnosed active patients (group I), 39 patients after sputum and culture conversion (group II), and 35 patients defined as cured cases (group III). On the basis of chest radiography, only active PTB patients were classified into minimal, moderate, and far advanced cases. Laboratory parameters including CBC with PLT indices, erythrocyte sedimentation rate, and C-reactive protein (CRP) were performed for all enrolled participants. Results Compared with the control group, hemoglobin, mean PLT volume, and platelet distribution width (PDW) were significantly lower in group I and increased after treatment in groups II and III. On the other hand, PLT count, platelet crit %, CRP, and erythrocyte sedimentation rate were significantly higher in group I compared with the control group and decreased after treatment. In addition, there were significant correlations between CRP and all PLT indices. Regarding radiological extension, hemoglobin and mean PLT volume were significantly lower in far advanced PTB compared with both moderate and mild PTB, whereas PLT crit was significantly higher in moderate PTB compared with minimal PTB. Conclusion CBC, especially PLT indices, could be considered valuable cheap markers in assessment and monitoring of PTB activity.

Average volume-assured pressure support ventilation mode in the management of acute hypercapnic respiratory failure

Background Although average volume-assured pressure support (AVAPS) mode has been studied in chronic respiratory failure, studies evaluating its efficacy in acute hypercapnic respiratory failure (AHRF) are limited. Objective The aim of this study was to investigate the benefits of spontaneous timed AVAPS (ST/AVAPS) mode in delivering noninvasive ventilation (NIV) for patients with AHRF compared with the conventional ST/BiPAP (ResMED, San Diego, California, USA) mode.

Pulmonary fibrosis as a risk factor for thromboembolic disease

Background: Chronic obstructive pulmonary disease (COPD) and lung cancer are well known to be associated with increased risk for venous thromboembolism (VTE). However, there are few data about the association between idiopathic pulmonary fibrosis (IPF) and VTE. Aim of this study: The aim of the study was to investigate the prevalence of venous thromboembolic events in hospitalized IPF patients and compare it with the incidence in COPD patients. Patients and methods: We retrospectively analyzed the database of interstitial lung disease from 2007 to 2013. We included 629 IPF patients after exclusion of patients with secondary pulmonary fibrosis and those with a concurrent diagnosis of COPD or lung cancer. VTE disease was defined as either deep venous thrombosis, pulmonary embolism, or both deep venous thrombosis and pulmonary embolism. For comparison, we also analyzed the database of COPD patients. Results: Out of the 629 included IPF patients, 13 had thromboembolic events, showing a prevalence for VTE in IPF that is significantly higher than that in COPD (2.1 vs. 1.1%; odds ratio: 1.9; confidence interval: 1.039-3.530; P = 0.035). The prevalence is also significantly higher in female and nonsmoker IPF patients compared with COPD patients (P = 0.008 and 0.011 respectively). Among IPF patients, men had significantly lower risk for VTE compared with women (P = 0.045). Conclusion: IPF, especially in women, is associated with increased risk for VTE, being greater than the risk in COPD.

Authors' response to "Brain natriuretic peptide as a predictor for weaning or outcome?".

Thank you for your interest and precise analysis of our study hat surely increases the value of the study and opens the window or further researches. First, BNP was not routinely used in our ICU and thus analysis ould not be done immediately. We were interested in that point f research as cardiovascular dysfunction was a common cause f weaning failure.1 During research work-up, we collected blood amples at beginning and at the end of SBT. Decision of weaning was ased on SBT and other weaning parameters such as RSBI, minute entilation. At that time we were blind of the results of BNP levls and that could be a strong point in our research. During result nalysis, we analysed the data with the results of BNP at the time f SBT and that was done in other studies which collected samples nd stored it.2,3 I agree with you that transthoracic Echo was more simple ethod for detection of cardiac dysfunction. The problems known ith transthoracic Echo was the fact that it needed an experienced chocardiographist in such patients.4 Moreover, TTE cannot be perormed in patients with poor echo window and atrial fibrillation.5 oreover, it might be not sensitive for detection of minor changes n cardiac function.2 We faced these problems in our respiratory CU: No experienced echocardiographist was available and also our OPD patients had poor echo window. As regards to management of weaning failure, therapy was not ased on BNP levels as we were blind to these results. We agree ith you that NIV decreases the myocardial tension by decreasing he cardiac output.6 We used NIV in patients either prophylactic or s a treatment of weaning failure. But it was not our aim in that tudy to evaluate the effect of NIV on BNP levels but could be good oint for further research. On assessing weaning outcome, we evaluated arterial blood ases, RSBI and minute ventilation together with BNP levels as redictor of weaning. RSBI, PaO2 and minute ventilation were not

Authors’ response to “Difficult to wean patients”

I would like to thank you for your comment on that paper.1 The pathophysiology of weaning failure is complex and multile causes for difficult weaning may exist in any single patient.2 enerally, weaning from MV fails due to an imbalance between espiratory muscle function and the respiratory muscle load.3 The auses of respiratory muscle dysfunction include central inhibition, hrenic nerve injury, neuropathies and muscle weakness of varius etiologies. The causes of increased ventilatory demand include ncreased central respiratory drive, sepsis, fever, pain, increased ead space ventilation, and decreased lung and chest wall elastic ecoil.4 Because weaning failure has various causes, use of multiple arameters of weaning are seemed to be more accurate.5,6 Howver in that study, we tried to stress on BNP levels as predictors of eaning and compared it with simple traditional weaning paramters. We finally recommended the use of BNP% of change during BT in the protocol of assessment of patients with difficult weaning.