Noninvasive ventilation in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials

The clinical benefits of noninvasive ventilation (NIV) for patients with acute hypoxemic respiratory failure (AHRF) is still inconclusive. We aimed to evaluate the effect of NIV compared with conventional oxygen therapy (COT)/high-flow nasal cannula (HFNC) in this patient population. We searched for relevant studies from PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CINHAL, Web of Science up to August 2019 for randomized controlled trials (RCTs) that compared NIV with COT/HFNC in AHRF. The primary outcome was the tracheal intubation rate. Secondary outcomes were intensive care unit (ICU) mortality, and hospital mortality. We applied the GRADE approach to grade the strength of the evidence. Seventeen RCTs that recruited 1738 patients were included in our meta-analysis. When comparing NIV versus COT/HFNC, the pooled risk ratio (RR) for the tracheal intubation rate was 0.68, 95% confidence interval (CI) 0.52-0.89, p = 0.005, I² = 72.4%, low certainty of evidence. There were no significant differences in ICU mortality (pooled RR = 0.87, 95% CI 0.60-1.26), p = 0.45, I² = 64.6%) and hospital mortality (pooled RR = 0.71, 95% CI 0.51-1.00, p = 0.05, I² = 27.4%). Subgroup analysis revealed that NIV application with helmet was significantly associated with a lower intubation rate than NIV with face mask. NIV did not show a significant reduction in intubation rate compared to HFNC. In conclusion, NIV application in patients with medical illness and AHRF was associated with a lower risk of tracheal intubation compared to COT. NIV with helmet and HFNC are promising strategies to avoid tracheal intubation in this patient population and warrant further studies. NIV application had no effect on mortality.The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018087342).

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand

Background

The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality.

Methods

A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included.

Results

A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was ‘cannot control symptoms’ (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality.

Conclusion

The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01009-z.

Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand

BACKGROUND

There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI).

METHODS

This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined.

RESULTS

A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55-4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10-3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37-0.80 and aHR 0.57, 0.33-0.96, respectively). Etomidate dosage was not associated with mortality in our study.

CONCLUSION

In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.

Number of attempts required by emergency physicians to achieve competency in diaphragmatic ultrasound imaging

PURPOSE

This research aimed to determine the number of attempts that emergency physicians need to become proficient in undertaking diaphragmatic ultrasound imaging.

METHODS

A prospective observational study was conducted at the emergency department (ED) of a tertiary-care university hospital. Sixteen emergency physicians were each required to obtain a set of images of the right hemidiaphragm of five dyspneic patients using both diaphragmatic excursion and thickness techniques. The images were subsequently reviewed by a specialist using American College of Emergency Physician guidelines. If the evaluations of a physician did not reach the expected standard, the physician was to be given feedback and requested to collect images from another five patients. The process was to be repeated until such time as the images obtained by the physician were deemed to be up to standard.

RESULTS

Eighty patients, twelve emergency medicine residents, and four attending physicians were enrolled. Following a didactic session on diaphragmatic ultrasound imaging and its interpretation, practicing on five patients proved sufficient to achieve an adequate level of competency in conducting diaphragmatic ultrasound examinations.

CONCLUSION

Practicing on five patients is sufficient for emergency physicians to achieve an adequate level of competency in conducting right-sided diaphragmatic ultrasound examinations.

Nasal High-flow Oxygen Versus Conventional Oxygen Therapy for Acute Severe Asthma Patients: A Pilot Randomized Controlled Trial

Background

Nasal high flow (NHF) has demonstrated efficacy in relieving dyspnea in various patients with hypoxemic and hypercapnic respiratory failure. It may also reduce dyspnea in patients with acute severe asthma in the emergency department (ED). The aim of the study was to compare the efficacy of NHF with conventional oxygen therapy (COT) in improving dyspnea in acute severe asthma patients with hypoxemia in the ED.

Methods

This pilot nonblinded randomized controlled trial was conducted involving 37 patients aged ≥ 18 years with acute severe asthma and hypoxemia in the ED of Siriraj Hospital, Bangkok, Thailand (TCTR20180926003). The participants were randomly allocated to receive either COT (n = 18) or NHF (n = 19) for 120 minutes. The primary outcome was comparing the intervention effects on the patients’ degree of dyspnea measured using the modified Borg scale (MBS). The secondary outcomes were comparing the interventions based on the numeric rating scale (NRS) of dyspnea, the dyspnea scale assessing accessory muscle use, vital signs, and blood gas results.

Results

The intention‐to‐treat analysis included 37 patients (COT group n = 18 and NHF group n = 19). The baseline mean MBS was 7.8 in both groups. At 120 minutes, the mean (±SD) MBSs in patients receiving COT and NHF were 3.3 (±2.5) and 1.4 (±2.5), respectively (mean difference = 1.9 [95% CI = 0.2 to 3.8], p = 0.043). The trends in NRS and dyspnea score results were similar to those of MBS. Respiratory rates were lower with NHF (mean difference = 4.7 [95% CI = 1.5 to 7.8], p = 0.001). No between‐ or within‐group differences in blood gas results were found.

Conclusion

Nasal high flow reduced the severity of dyspnea and respiratory rate in hypoxemic patients with acute severe asthma in the ED.

The utility of the rapid emergency medicine score (REMS) compared with SIRS, qSOFA and NEWS for Predicting in-hospital Mortality among Patients with suspicion of Sepsis in an emergency department

Background

Many early warning scores (EWSs) have been validated to prognosticate adverse outcomes secondary to sepsis in the Emergency Department (ED). These EWSs include the Systemic Inflammatory Response Syndrome criteria (SIRS), the quick Sequential Organ Failure Assessment (qSOFA) and the National Early Warning Score (NEWS). However, the Rapid Emergency Medicine Score (REMS) has never been validated for this purpose. We aimed to assess and compare the prognostic utility of REMS with that of SIRS, qSOFA and NEWS for predicting mortality in patients with suspicion of sepsis in the ED.

Methods

We conducted a retrospective study at the ED of Siriraj Hospital Mahidol University, Thailand. Adult patients suspected of having sepsis in the ED between August 2018 and July 2019 were included. Their EWSs were calculated. The primary outcome was all-cause in-hospital mortality. The secondary outcome was 7-day mortality.

Results

A total of 1622 patients were included in the study; 457 (28.2%) died at hospital discharge. REMS yielded the highest discrimination capacity for in-hospital mortality (the area under the receiver operator characteristics curves (AUROC) 0.62 (95% confidence interval (CI) 0.59, 0.65)), which was significantly higher than qSOFA (AUROC 0.58 (95%CI 0.55, 0.60); p = 0.005) and SIRS (AUROC 0.52 (95%CI 0.49, 0.55); p < 0.001) but not significantly superior to NEWS (AUROC 0.61 (95%CI 0.58, 0.64); p = 0.27). REMS was the best EWS in terms of calibration and association with the outcome. It could also provide the highest net benefit from the decision curve analysis. Comparison of EWSs plus baseline risk model showed similar results. REMS also performed better than other EWSs for 7-day mortality.

Conclusion

REMS was an early warning score with higher accuracy than sepsis-related scores (qSOFA and SIRS), similar to NEWS, and had the highest utility in terms of net benefit compared to SIRS, qSOFA and NEWS in predicting in-hospital mortality in patients presenting to the ED with suspected sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00396-x.

Predictors of Mortality in Elderly and Very Elderly Emergency Patients with Sepsis: A Retrospective Study

Introduction

Elderly patients are at increased risk of developing sepsis and its adverse outcomes. Diagnosing and prognosing sepsis is particularly challenging in older patients, especially early at emergency department (ED) arrival. We aimed to study and compare the characteristics of elderly and very elderly ED patients with sepsis and determine baseline factors associated with in-hospital mortality. We also compared prognostic accuracy of the criteria for systemic inflammatory response syndrome, quick sequential organ failure assessment (qSOFA), and the National Early Warning Score in predicting mortality.

Methods

We conducted a retrospective study at the ED of Siriraj Hospital Mahidol University in Bangkok, Thailand. Patients over 18 years old who were diagnosed and treated for sepsis in the ED between August 2018–July 2019 were included. We categorized patients into non-elderly (aged <65 years), elderly (aged 65–79 years), and the very elderly (aged >80 years) groups. The primary outcome was in-hospital mortality. Baseline demographics, comorbidities, source and etiology of sepsis, including physiologic variables, were compared and analyzed to identify predictors of mortality. We calculated and compared the area under the receiver operator characteristics curves (AUROC) of early warning scores.

Results

Of 1616 ED patients with sepsis, 668 (41.3%) were very elderly, 512 (31.7%) were elderly, and 436 (27.0%) were non-elderly. The mortality rate was highest in the very elderly, followed by the elderly and the non-elderly groups (32.3%, 25.8%, and 24.8%, respectively). Factors associated with mortality in the very elderly included the following: age; do-not-resuscitate (DNR) status; history of recent admission <3 months; respiratory tract infection; systolic blood pressure <100 millimeters mercury (SBP<100); oxygen saturation; and Glasgow Coma Scale (GCS) score. Factors associated with mortality in the elderly were DNR status, body temperature, and GCS score. qSOFA had the highest AUROC in predicting in-hospital mortality in both very elderly and elderly patients (AUROC 0.60 [95% confidence interval {CI}, 0.55–0.65] and 0.55 [95% CI, 0.49–0.61, respectively]).

Conclusion

The mortality rate in the very elderly was higher than in the younger populations. Age, DNR status, recent admission, respiratory tract infection, SBP<100, oxygen saturation. and GCS score independently predicted hospital mortality in very elderly patients. The qSOFA score had better but only moderate accuracy in predicting mortality in elderly and very elderly sepsis patients.

Diagnostic and prognostic utility of presepsin for sepsis in very elderly patients in the emergency department

BACKGROUND

Presepsin, a biomarker for sepsis diagnosis, has not been studied in very elderly population. The study aimed to evaluate the diagnostic and prognostic value of Presepsin in very elderly patients compared to point-of-care Procalcitonin (PCT), C-reactive protein (CRP), and early warning scores (EWSs).

METHODS

This study prospectively enrolled 250 patients aged at least 75 years old, presenting to the Emergency Department of Siriraj Hospital with suspected sepsis during September 2019 and January 2020. They were classified into three groups: non-sepsis, sepsis, and septic shock. Biomarkers and EWS values at admission were determined. PCT was analyzed with non-BRAHM method.

RESULTS

Presepsin had valuable diagnostic utility for sepsis (AUC 0.792), comparable to PCT (AUC 0.751, p = 0.22) and CRP (AUC 0.767, p = 0.47). It also showed similar prognostic accuracy (AUC 0.683) with PCT (AUC 0.691, p = 0.68) and CRP (AUC 0.688, p = 0.85). The combination of Presepsin, PCT, and an EWS yielded the highest diagnostic accuracy for sepsis and septic shock and highest prognostic accuracy for 30-day mortality.

CONCLUSION

Presepsin is a valuable diagnostic and prognostic biomarker for sepsis in very elderly emergency patients. The combination of Presepsin, PCT, and an EWS was the best modality for early sepsis diagnosis and prognostication.

The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients

BACKGROUND

Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients.

METHODS

A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures.

RESULTS

Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge.

CONCLUSION

The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study

STUDY OBJECTIVE

Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED.

METHODS

This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs.

RESULTS

Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose.

CONCLUSION

High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

A 56-Year-Old-Man With Common Variable Immunodeficiency and Worsening Dyspnea

CASE PRESENTATION

A 56-year-old man with a history of common variable immunodeficiency (CVID), in addition to recurrent bronchitis and pneumonia, presented with progressively worsening shortness of breath over a period of a few months. He was able to conduct his activities of daily living at baseline; however, his condition declined over a period of months to the point of shortness of breath with climbing a flight of stairs. The patient also developed a frequent dry cough and wheezing. He denied fever, chest pain, weight loss, and hemoptysis. He had been diagnosed with CVID in 1968, at 7 years of age, after recurrent episodes of bronchitis and pneumonia, and was treated with IV immunoglobulin monthly for decades. The patient was a lifelong nonsmoker and had no significant environmental or occupational exposures. He was referred to our hospital for further management.

The feasibility of the 1-h high-sensitivity cardiac troponin T algorithm to rule-in and rule-out acute myocardial infarction in Thai emergency patients: an observational study

Background

The 3-h high-sensitivity cardiac troponin T (hs-cTnT) algorithm is the most commonly used scheme to diagnose acute myocardial infarction. The 1-h hs-cTnT algorithm has recently been approved by the European Society of Cardiology as an alternative algorithm for earlier diagnosis. If the hs-cTnT test cannot discriminate the diagnosis of the patient at 1 h, the patient is defined as observational group. Their test must be repeated at 3 h. A high prevalence of this group may indicate a low clinical utility of the 1-h hs-cTnT algorithm. This study was aimed to estimate the proportion of the observational group in Thai emergency department (ED) patients and also the time to rule-in/out between both the algorithms.

Methods

A historical control study was conducted in patients with chest pain for 1–12 h at the ED of Siriraj Hospital, Bangkok, Thailand. The study compared two groups: one prospective group of all patients evaluated with the 1-h hs-cTnT algorithm between June and September 2017 and one historical control group evaluated with the 3-h hs-cTnT algorithm between January and March 2017.

Results

A total of 130 patients were included (3-h hs-cTnT algorithm group n = 65 and 1-h hs-cTnT algorithm group n = 65). Twelve patients [18.5% (95% CI 10.0–30.1)] were categorized as observational group in the 1-h hs-cTnT algorithm group. The mean rule-in/out times in the 3-h hs-cTnT algorithm and 1-h hs-cTnT algorithm groups were 238 min (SD 63.3) and 134 min (SD 68.5), respectively (both p < 0.001). The time to disposition was also shortened in the 1-h hs-cTnT algorithm group (p <  0.001). Multivariable regression analysis performed to identify and adjust for confounders among patient characteristics revealed no significant confounders.

Conclusions

The use of the 1-h hs-cTnT algorithm in the ED resulted in an acceptable proportion in the observational group and a decreased time to rule-in/out compared with the 3-h hs-cTnT algorithm.

Incorporating body-type (apple vs. pear) in STOP-BANG questionnaire improves its validity to detect OSA

STUDY OBJECTIVE

The aim of this study is to evaluate whether adding the item of "apple body type" to the STOP-BANG questionnaire enhances diagnostic performance of the questionnaire for detecting obstructive sleep apnea (OSA).

DESIGN

Cross-sectional study.

SETTING

Sleep center setting.

PATIENTS

Two hundred and eight subjects who were referred for an evaluation of possible OSA at Tulane Comprehensive Sleep Center. The exclusion criteria were age<18years old, incomplete or absent questionnaire, incomplete body type identification, polysomnography (PSG) refusal, and pregnant women.

INTERVENTIONS

STOP-BANG items and body type data were collected on the initial clinic visit. An overnight PSG was performed on every participant.

MEASUREMENTS

Descriptive analyses of the demographic data and PSG variables were performed. The predictive parameters of STOP and STOP-BANG without and with body type score (STOP-Apple and STOPBANG-Apple) were compared.

MAIN RESULTS

The STOP questionnaire's sensitivity/specificity/positive likelihood ratio (+LR) (cut-off=2) was 96%/11%/1.1, respectively whereas the STOP-Apple questionnaire (cut-off=3) was 88%/39%/1.5. The STOP-BANG's sensitivity/specificity/+LR (cut-off=3) was 96%/19%/1.2, respectively whereas the STOP-BANG-Apple questionnaire (cut-off=4) was 90%/39%/1.5. The area under the Receiver Operating Characteristic (ROC) curve of STOP-Apple was comparable to the STOP-BANG (P=0.25). The addition of the apple body type item to the STOP-BANG questionnaire in participants with a score≥3 led to increased specificity (67.4%), increased the odds ratio of having OSA of 2.5 (95% CI, 1.2-5.3) and odds ratio of having moderate-severe OSA of 4.7 (95% CI, 2.5-8.7).

CONCLUSION

In the sleep center setting, adding the body type item to the STOP-BANG questionnaire improves not only clinical prediction for PSG confirmed OSA but also predicts moderate to severe of OSA.

The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient's comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure.

METHODS

PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated.

RESULTS

Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events.

CONCLUSIONS

Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

The association between glucose levels and hospital outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Corticosteroids used for chronic obstructive pulmonary disease (COPD) exacerbations can cause hyperglycemia in hospitalized patients, and hyperglycemia may be associated with increased mortality, length of stay (LOS), and re-admissions in these patients.

MATERIALS AND METHODS

We did three retrospective studies using charts from July 2008 through June 2009, January 2006 through December 2010, and October 2010 through March 2011. We collected demographic and clinical information, laboratory results, radiographic results, and information on LOS, mortality, and re-admission.

RESULTS

Glucose levels did not predict outcomes in any of the studied cohorts, after adjustment for covariates in multivariable analysis. The first database included 30 patients admitted to non-intensive care unit (ICU) hospital beds. Six of 20 non-diabetic patients had peak glucoses above 200 mg/dl. Nine of the ten diabetic patients had peak glucoses above 200 mg/dl. The maximum daily corticosteroid dose had no apparent effect on the glucose levels. The second database included 217 patients admitted to ICUs. The initial blood glucose was higher in patients who died than those who survived using bivariate analysis (P = 0.015; odds ratio, OR, 1.01) but not in multivariable analysis. Multivariable logistic regression analysis also demonstrated that glucose levels did not affect LOS. The third database analyzing COPD re-admission rates included 81 patients; the peak glucose levels were not associated with re-admission.

CONCLUSIONS

Our data demonstrate that COPD patients treated with corticosteroids developed significant hyperglycemia, but the increase in blood glucose levels did not correlate with the maximum dose of corticosteroids. Blood glucose levels were not associated with mortality, LOS, or re-admission rates.

Pulmonary rehabilitation improves only some domains of health-related quality of life measured by the Short Form-36 questionnaire

BACKGROUND:

Pulmonary rehabilitation (PR) has inconsistent effects on health-related quality of life (HRQL) in patients with chronic lung diseases. We evaluated the effect of PR on HRQL outcomes using the 36-item short form of the medical outcomes (SF-36).

METHODS:

We retrospectively reviewed the files of all patients who completed PR in 2010, 2011, and first half of 2012. We collected information on demographics, symptoms, pulmonary function tests, 6-minute walk tests (6-MWT), and responses on the SF-36 survey, including the physical component score (PCS) and mental component score (MCS).

RESULTS:

The study included 19 women and 22 men. The mean age was 69.8 ± 8.5 years. The diagnoses included chronic obstructive pulmonary disease (COPD; n = 31), asthma (n = 3), interstitial lung disease (n = 5), and obstructive sleep apnea (OSA; n = 2). The mean forced expiratory volume-one second (FEV1) was 1.16 ± 0.52 L (against 60.5 ± 15.9% of predicted value). There was a significant improvement in 6-MWT (P < 0.0001). The PCS improved post-PR from 33.8 to 34.5 (P = 0.02); the MCS did not change.

CONCLUSION:

These patients had low SF-36 scores compared to the general population; changes in scores after PR were low. These patients may need frequent HRQL assessment during rehabilitation, and PR programs should consider program modification in patients with small changes in mental health.

Pulmonary Rehabilitation Increases Gait Speed in Patients With Chronic Lung Diseases

Introduction:

Gait speed provides an integrated index of physical performance; changes in gait speed could reflect deterioration in the underlying medical disorder or a response to medical/surgical interventions. Slower gait speeds reflect the overall level of impairment, especially in patients with chronic lung disease.

Methods:

We retrospectively reviewed the medical files of 119 patients who completed the pulmonary rehabilitation program at the University Medical Center in Lubbock, Texas, and collected demographic, pulmonary function, and 6-minute walk test information. Gait speed was calculated using the 6-minute walk test information.

Results:

The patients in this study had a mean age of 68.8 ± 10.1 years. Most patients (95) had chronic obstructive pulmonary disease/asthma. The mean forced expiratory volume in the first second of expiration (FEV1) was 1.3 ± 0.7 L (47.2% ± 19.7% predicted). The baseline gait speed was 41 ± 15 m/min before rehabilitation and 47 ± 15 m/min after rehabilitation. Baseline gait speed, body mass index, and FEV1 predicted postrehabilitation gait speed (P < .05 for each variable). Ten patients had a gait speed >60 m/min before rehabilitation; this number increased to 29 postrehabilitation. Using multivariable analysis, it was found that only the baseline gait speed predicted a speed of more than 60 m/min postrehabilitation. Seventy-four patients had an increase in 6-minute walk distance of greater than 30 m.

Conclusions:

Patients with chronic lung diseases have slow gait speeds. Most patients improve their speed with rehabilitation but do not increase their speed above 60 m/min and remain frail by this criterion. However, the majority of patients increase their walk distance by 30 m, a distance that represents a minimal clinically important distance.

Is the sinonasal questionnaire a useful screening instrument for chronic sinonasal diseases in pulmonary clinics?

Dixon and coworkers (Dixon AE, Sugar EA, Zinreich SJ, et al. Criteria to screen for chronic sinonasal disease. Chest 2009; 136: 1324-1332.) recently developed a five-item questionnaire for diagnosing chronic sinonasal disease in patients with asthma. Our study was designed to determine how frequently patients attending pulmonary clinics have chronic sinonasal disease and the relationship between questionnaire results and a history of sinus disease and current treatment for sinus disease. The participants were patients in pulmonary clinics at Texas Tech University Health Science Center, who answered the sinonasal questionnaire (SNQ). Additional information included a history of sinus disease or sinus/nasal surgery, smoking status, and current relevant medications. The participants included 28 men and 51 women. Patient ages ranged from 38 to 94 years (mean 62.2 years). Of all the patients, 28 patients (35.4%) had prior sinus disease, 10 (12.7%) had history of sinus or nasal surgery, 24 (30.4%) had history of asthma, and 10 (12.7%) were current smokers. Of them, 14 patients (17.7%) used nasal steroids, 12 (15.2%) used antihistamines, four (5.1%) used decongestants, nine (11.4%) used leukotriene inhibitors, 13 (16.5%) used oral corticosteroids, and two (2.5%) used combinations. The SNQ identified 39 patients (49.4%) as having chronic sinonasal diseases. Therefore, 14% of the participants had sinonasal symptoms but no prior diagnosis of sinus disease. Patients with prior sinus disease and nasal steroid use were more likely to have positive questionnaire result (p<0.001 and p<0.032, respectively). The SNQ can identify patients with chronic sinonasal disease in pulmonary clinics. However, the significance of sinonasal disease and its treatment in these patients needs more study.

Cholestatic Jaundice as a Result of Combination Designer Supplement Ingestion

OBJECTIVE

To report a case of cholestatic jaundice as a result of combination herbal and designer supplement use.

CASE SUMMARY

A 50-year-old Hispanic male presented to the hospital with a 1-week history of significant painless jaundice; total bilirubin on admission was 29.4 mg/dL. He reported use of both herbal (creatine and whey protein) and designer (Incredible Bulk and Spartan 45) supplements concurrently for approximately 2 months. Upon admission, all supplements were discontinued and multiple laboratory and diagnostic tests were ordered. On day 6 of his hospital admission, a liver biopsy was performed, the results of which indicated drug-induced hepatotoxicity. On day 9 he was discharged with prescriptions for ursodeoxycholic acid and hydroxyzine. Three months post hospital discharge, the patient continued to be supplement-free and bilirubin had decreased substantially.

DISCUSSION

Anabolic-androgenic steroids are capable of causing hepatotoxicity, and multiple cases reported in the literature support this. A case report described hepatotoxicity secondary to both creatine and whey protein consumption, and several reports have described liver damage secondary to designer supplement use. To our knowledge, this is the first case to describe hepatotoxicity as a result of combination herbal and designer supplement use. The Roussel Uclaf Causality Assessment Method (RUCAM) score for drug-induced hepatotoxicity indicated a highly probable correlation between the use of combination supplements and cholestatic jaundice.

CONCLUSIONS

Health care professionals need to be aware of complications associated with designer supplement use and should be able to identify patients who would benefit from education on herbal and designer supplement use.

Chiari Syndrome and Respiratory Failure

Background:

Patients with failed extubation requiring reintubation have increased morbidity and mortality. This situation may reflect the severity of the underlying disorder or may reflect an undiagnosed condition that was not apparent at the time of the initial intubation.

Methods:

Case report and literature review.

Results:

A 49-year-old man developed acute hypercapneic respiratory failure during an episode of community-acquired pneumonia. This patient failed extubation 4 times. Routine neurological evaluation, including computed tomography of the head, was within normal limits. A magnetic resonance imaging revealed a severe Chiari malformation type I. The patient eventually required tracheostomy and prolonged mechanical ventilation. We identified 28 cases with Chiari malformations (CM) in the medical literature, who presented with respiratory failure. The mean age was 29.5 years, 46% of the cases were male, 50% had an associated syringomyelia, and 64% required a decompressive surgery. Twenty-five percent had recurrent symptoms postsurgery.

Conclusions:

Patients with CMs can have repeated extubation failures. Some of these patients have normal neurological examinations and studies and are not identified until they have an MRI study. Clinicians need to consider this possibility in patients who are difficult to wean.

Obscure Severe Infrarenal Aortoiliac Stenosis With Severe Transient Lactic Acidosis

A 57-year-old man presented with sudden onset of leg pain, right-sided weakness, aphasia, confusion, drooling, and severe lactic acidosis (15 mmol/L). He had normal peripheral pulses and demonstrated no pain, pallor, poikilothermia, paresthesia, or paralysis. Empiric antibiotics, aspirin, full-dose enoxaparin, and intravenous fluid were initiated. Lactic acid level decreased to 2.5 mmol/L. The patient was subsequently extubated and was alert and oriented with no complaints of leg or abdominal pain. Unexpectedly, the patient developed cardiac arrest, rebound severe lactic acidosis (8.13 mmol/L), and signs of acute limb ischemia. Emergent computed tomography of the aorta confirmed infrarenal aortoiliac thrombosis. Transient leg pain and transient severe lactic acidosis can be unusual presentations of severe infrarenal aortoiliac stenosis. When in doubt, vascular studies should be implemented without delay to identify this catastrophic diagnosis.

Factors affecting chronic obstructive pulmonary disease early rehospitalization

The Centers for Medicare and Medicaid Services has identified early rehospitalization of patients with chronic obstructive pulmonary disease (COPD) exacerbations as a performance measure for hospital care. We retrospectively reviewed patients with COPD who were admitted to University Medical Center, Lubbock, Texas, USA, between October 2010 and March 2011. There were 81 COPD patients with 103 hospitalizations. The mean age was 73.9 years. Pulmonary function tests using the Global initiative for chronic Obstructive Lung Disease criteria had been done in 36 patients (44.4%) and revealed 1 mild (2.8%), 7 moderate (19.4%), 20 severe (55.6%), and 8 very severe (22.2%) cases. Only 38.4% of the patients had prior influenza vaccine. Most patients were treated with antibiotics (81.8%) and corticosteroids (87.9%). The mean length of stay was 4.9 days, and 4 patients died. Most of the patients were discharged home (63.6%) with a median follow-up interval of 14 days. Thirty-two percent did not have long-acting bronchodilators and/or inhaled corticosteroids prescribed on discharge. There were 14 early rehospitalizations within 30 days. Logistic regression analysis indicated that a history of coronary artery disease (odds ratio (OR) 6.4, 95% confidence interval (CI) 1.1–37.4) and unilateral pulmonary infiltrates (OR 12.8, 95% CI 1.9–86.4) significantly increased the early rehospitalization rates. Acute exacerbations of COPD in patients with a history of ischemic heart disease or unilateral pulmonary infiltrates are at increased risk for early readmission. These risk factors should be identified during hospitalization; early follow-up or other interventions may reduce readmissions. Influenza vaccine, maintenance bronchodilators and/or inhaled corticosteroids, and pulmonary function tests were underused, and these standards of care should be provided to improve care.