Zachary Mulkey

High-Flow Nasal Cannula Oxygen in Adult Patients: A Narrative Review

Abstract:High-flow nasal cannula oxygen (HFNC) is a relatively new therapeutic innovation being used in adults with severe respiratory disease. It delivers heated humidified oxygen through short nasal prongs and supplies much higher flow rates than traditional nasal cannula systems. These higher flows match patient flow demands better, reduce anatomic dead space and provide a slightly positive pressure in the upper airway. Randomized trials, nonrandomized prospective trials and case series using HFNC in adults were identified in the PubMed, Google Scholar and Cochrane databases for the period of June 1981 to December 2013. Fifteen studies meeting our inclusion criteria were analyzed; 5 were randomized controlled studies. These studies included 943 patients managed in intensive care units. Common clinical diagnoses included postoperative status, cancer and pneumonia. These studies demonstrated that HFNC provided better or comparable oxygenation when compared with conventional face masks and nasal cannulas. Side effects included epistaxis, nasal discomfort and dryness. No unexpected side effects were reported in the studies reviewed. Current studies demonstrate that HFNC can improve oxygenation adults with hypoxemic respiratory failure. In some patients, it is superior to traditional oxygen delivery systems and may obviate the need for positive pressure ventilation. More studies are needed to compare HFNC with noninvasive ventilation.

Multilobar lung infiltrates after exposure to dust storm: the Haboob Lung Syndrome.

Dust-associated pneumonia has been known to have occurred in the Dust Bowl era (1930s) in the southern plains of the US. However, this entity is currently not recognized, and there are no case reports or literature about this from the US despite the presence of occasional dust storms (also known as the haboob). We report 4 cases of multilobar infiltrates/pneumonia in healthy people within a few days of unprotected exposure to a dust storm. This entity presents with dyspnea and severe desaturation. The clinical details of patients are given in the Table. Two of the 4 patients needed ntubation and one expired. Although dust has been proposed to impair the ciliary otility and cause increased chance of infections, the blood nd sputum cultures obtained from these patients were sterle. The exact mechanism of bilateral lung infiltrates in these atients is not clear, although a superimposed infection after nhalation of dust could still be the reason. Dust has been mplicated in causation of lung disease in the literature. ang et al, in a 9-year retrospective study from Taipei, reported increased rates of hospitalization for pneumonia on the days with sandstorms and those immediately following it compared with the days without sandstorms. Al Eskan disease, “Desert Storm pneumonitis,” is a condition first described in 1992 among US veterans exposed to the fine sand dust of the Central and Eastern Saudi Arabian peninsula. Korényi-Both et al reported that the fine Saudi sand ust ( 1 micron in size) triggered a hyperergic lung conition, which was aggravated by some organic pathogenic omponents, leading to opportunistic lung infections. In an elegant prospective study among 320,143 male Swedish construction workers, exposure to inorganic dust was found to cause increased mortality in infectious pneumonia, especially lobar and pneumococcal pneumonia. Wu et al reported the effects of dust on 7 first esponders who were exposed to it during the collapse of

Familial Thoracic Aortic Aneurysm with Dissection Presenting as Flash Pulmonary Edema in a 26-Year-Old Man

We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a patient with familial TAAD and discusses the associated genetic loci and available screening methods. It is important to recognize potential cases of familial TAAD and understand the available screening methods since early diagnosis allows appropriate management of risk factors and treatment when necessary.

Anti-N-methyl-D-aspartate receptor encephalitis.

Abstract:A case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis with an atypical finding of transient increased intracranial pressure is reported. Anti-NMDAR encephalitis is an underrecognized, novel and treatable form of encephalitis being increasingly identified as an explanation of encephalitis in young adults. Management of these patients requires a multidisciplinary approach involving neurologists, internists, nursing and rehabilitation staff. It is important for internists to recognize this condition and consider it in the differential diagnosis of encephalopathy. Internists also need to be familiar with the clinical manifestations and the treatment of the disease as they have an important role in the care of these patients during their prolonged stay in the hospital. Increased intracranial pressure is an atypical and underrecognized finding that has been only noted in a previous review on this disorder. It may present a diagnostic or management challenge in patients with anti-NMDAR encephalitis.