Sumalee Kiatboonsri

Acute respiratory failure due to Pneumocystis pneumonia: outcome and prognostic factors.

OBJECTIVES To examine the outcome and prognostic factors of in-hospital mortality in patients with acute respiratory failure (ARF) caused by Pneumocystis pneumonia (PCP) admitted to a medical intensive care unit. METHODS A retrospective review was conducted of all patients with ARF from PCP in Ramathibodi Hospital between 2000 and 2006. Patient characteristics, clinical presentation, and laboratory, radiological and microbiological findings, as well as therapy and clinical course were included in the analysis of prognostic factors of death. RESULTS A total of 14 HIV-infected and 30 otherwise immunosuppressed patients were identified. The overall mortality rate was 63.6%. Logistic regression analysis demonstrated that APACHE II score on day 1 and level of PEEP used on day 3 of respiratory failure were associated with higher hospital mortality. In a comparison between the HIV group and the non-HIV group, the early mortality rate was significantly higher in the HIV group, but late hospital mortality was not different between the two groups. Using a univariate logistic regression model, four parameters were found to be significantly associated with death in the HIV group: sex, APACHE II score on day 1, CMV co-infection, and level of PEEP on day 3 of ARF. In the non-HIV group, corticosteroid use prior to diagnosis of PCP and level of PEEP on day 3 of ARF were found to be the significant parameters. CONCLUSION The mortality rate in patients with ARF caused by PCP was high. Various variable factors were related to a poor prognosis. For improved survival, multimodality treatments are needed to reduce these risk factors.

Survey of asthma control in Thailand.

Objective:  The aim of the study was to determine whether asthma management in Thailand is succeeding in achieving the levels of control, specified in national and international asthma guidelines.

Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound

PURPOSE The purpose of this study is to determine the diagnostic accuracy of portable ultrasound for detection of laryngeal edema (LE) in intubated patients. MATERIALS AND METHODS We conducted a prospective, observational study from December 2010 to September 2011. We measured air column width differences (ACWD) in planned extubation patients admitted in intensive care unit by ultrasound. The primary outcome was the diagnostic accuracy of ACWD to predict the presence of LE. RESULTS A total of 101 patients were enrolled. The prevalence of LE was 16.8%. Baseline characteristics were similar between intubated patients with and without LE. The mean difference of increasing of air column width in patients without LE was higher than in LE group (1.9 vs 1.08 mm, P<.001). The sensitivity and specificity at ACWD higher or equal to 1.6 mm were 0.706 and 0.702, respectively. The positive predictive value and negative predictive value were 0.324 and 0.922, respectively. The area under the receiver operating characteristic curve of laryngeal ultrasound was 0.823 (95% confidence interval, 0.698-0.947) and that of cuff leak test was 0.840 (95% confidence interval, 0.715-0.964). CONCLUSION Portable intensive care unit ultrasound visualizing ACWD between predeflation and postdeflation cuff balloon is a promising objective tool, which aids in prediction of successful extubation regarding LE.

Efficacy and tolerability of budesonide/formoterol added to tiotropium compared with tiotropium alone in patients with severe or very severe COPD: A randomized, multicentre study in East Asia

Triple combination therapy with tiotropium plus budesonide/formoterol has improved lung function and reduced exacerbation risk in patients with chronic obstructive pulmonary disease (COPD) in Western countries, but no such data exist for East Asian patients. This study aimed to evaluate the efficacy and tolerability of adding budesonide/formoterol to tiotropium compared with tiotropium alone in East Asian patients with severe/very severe COPD.

Association between admission delay and adverse outcome of emergency medical patients.

Aim To determine whether admission delay (lead-time) and other factors are associated with hospital mortality rates of emergency medical patients. Methods Patients presenting with emergency conditions during August to November 2009, and admitted to medical wards, including intensive care units, were enrolled. The time each patient spent in the ED, and other parameters were recorded. The primary outcome was the association between lead-time and hospital mortality. The secondary outcome was the association between lead-time and delta Modified Early Warning Score (MEWS) (MEWS at ward − MEWS at ED). Results 381 cases were analysed. The overall mortality rate was 8.9%. By univariate analysis, the significant factors associated with mortality outcome were lead-time, ECOG (Eastern Cooperative Oncology Group) score, MEWS at ED, delta MEWS and sepsis. By multivariate analysis, the remaining significant factors were MEWS at ED, delta MEWS and sepsis. There was no significant relationship between delta MEWS and lead-time. In a sub-group of patients admitted to intensive care units, however, there was a positive correlation between lead-time and delta MEWS. Conclusion MEWS, delta MEWS and sepsis were predictors of hospital mortality in emergency medical patients. Lead-time was not associated with mortality, which could be due to benefits of various treatments initiated in the ED. In patients requiring intensive care, however, the longer lead-time probably led to higher MEWS and mortality.

Transthoracic ultrasound assessment of B-lines for identifying the increment of extravascular lung water in shock patients requiring fluid resuscitation.

Introduction: Several studies have shown that the number of B-lines was related to the amount of extravascular lung water (EVLW). In our study, we aimed to demonstrate the magnitude of the incremental B-lines in shock patients with positive net fluid balance and the association with gas exchange impairment. Materials and Methods: We performed trans-thoracic ultrasound at admission (T0) and at follow-up period (TFL) to demonstrate the change of B lines (ΔB-lines) after fluid therapy. We compared the total B-line score (TBS) at T0 and TFL and calculated the Pearsons correlation coefficient between the ΔB-lines and PaO2/FiO2 ratio. Results: A total of 20 patients were analyzed. All patients had septic shock. Net fluid balance was + 2228.05 ± 1982.15 ml. The TBS at T0 and TFL were 36.6 ± 23.73 and 63.80 ± 29.25 (P < 0.01). The ΔB-lines along anterior axillary line (AAL) correlated to the ΔTBS (r = 0.90, P < 0.01). The ΔB-lines along AAL had inverse correlation to PaO2/FiO2 ratio (r = −0.704, P < 0.05). The increase of B-lines ≥ 10 was related to the decrease of PaO2/FiO2 ratio. The inter-observer reliability between two ultrasound readers was high (r = 0.92, P < 0.01). Discussion: The number of B-lines increased in shock patients with positive net fluid balance and correlated to impaired oxygenation. These data supported the benefit of ultrasound for assessing the EVLW.

Assessment of diaphragmatic function parameters by intensive care ultrasound compared to conventional parameters during spontaneous breathing trial

Ultrasound can demonstrate the characteristics of the diaphragm functions that involve to the weaning process.

Expiratory air trapping during asthma exacerbation: Relationships with clinical indices and proximal airway morphology

OBJECTIVES To semi-quantitatively assess expiratory air trapping (AT(exp)) and structural changes in the proximal airways in asthma during asthma exacerbation (AE) and to explore the relationships among AT(exp), clinical indices, and proximal airway changes. METHODS Paired inspiratory-dynamic forced expiratory CT scans of 36 asthmatics (30 women, 6 men; mean age, 49.2±18.9 years) performed during AE were retrospectively reviewed for the total AT(exp) score (summed scores [extent grading (0-4)×pattern grading (1-4)] of the twelve lung zones), morphologic parameters and expiratory bronchial collapse (BC(exp)) of the proximal airways. The relationships of the score with clinical indices and proximal airway morphology (normalized by body surface area [BSA]) were analyzed. A p value of <0.05 was considered statistically significant. RESULTS The mean total AT(exp) score was 110.1±43.4 (range, 8-166). It was higher in the lower zones and in patients older than 60 years, having BMI of <27.5 kg/m(2), and peak expiratory flow rate (PEFR) of <60% predicted. Correlation existed between the score and age (r=0.331), BMI (r=-0.375), BSA (r=-0.442), % predicted PEFR (r=-0.332), right upper lobe apical segmental bronchus (RB1)-wall area (WA)/BSA (r=0.467), %RB1-WA (r=0.395), and RB1-bronchial wall thickness (BWT)/BSA (r=0.378). The score showed no correlation with BC(exp) and other morphologic bronchial parameters. Area under receiver-operating-characteristic curve 0.724 (95% CI) showed that the score of 110 could discriminate patients with PEFR of <60% predicted from those with PEFR of ≥60% predicted. CONCLUSION During AE, there was a high prevalence of extensive AT(exp) which was correlated with patients age, BMI, BSA, AE severity and RB1 morphology but not correlated with BC(exp).