Effect of post-extubation inspiratory muscle training on diaphragmatic function in mechanically ventilated patients: A randomized controlled trial

BACKGROUND

Diaphragmatic dysfunction is a common problem in patients who have been mechanically ventilated.

OBJECTIVES

The study aimed to evaluate the effectiveness of inspiratory muscle training (IMT) on diaphragm muscle thickness and function in mechanically ventilated patients.

MATERIAL AND METHODS

A single-blind trial was conducted. Twenty patients were randomly assigned to either the conventional physiotherapy (CP) group or to the IMT group for 5 days following extubation. The CP group received only CP, while the IMT group received CP in addition to IMT. Ten healthy controls (HCs) underwent IMT. Maximum inspiratory pressure (MIP) and physical function were recorded. Diaphragm excursion (DE), diaphragm thickness at the end of inspiration (Tdi), diaphragm thickness at the end of expiration (Tde), peak contraction velocity (PCV), and peak relaxation velocity (PRV) were evaluated with ultrasonography before and after the intervention.

RESULTS

The IMT group and HCs showed significant improvements in DE (p = 0.005; p = 0.005, respectively), PCV (p = 0.028; p = 0.015, respectively) and PRV (p = 0.029; p = 0.020, respectively) after 5 days of IMT. A significant increase in MIP was recorded in all groups after the intervention (CP: p = 0.044; IMT: p = 0.005; HC: p < 0.001). There was a significant improvement in the Medical Research Council (MRC) and the Physical Function in Intensive Care Test (PFIT) scores in both the CP and IMT groups (p < 0.001 and p < 0.001, respectively).

CONCLUSIONS

Inspiratory muscle training improves diaphragmatic functions, including MIP, diaphragm excursion, PCV, and PRV. We think that IMT applied after extubation may serve as a tool to prevent and facilitate the recovery of diaphragmatic function.

Evaluation of Patients with COVID-19 Followed Up in Intensive Care Units in the Second Year of the Pandemic: A Multicenter Point Prevalence Study

OBJECTIVE

A 1-day point prevalence study was planned to obtain country data by determining the clinical characteristics, follow-up and treatment methods of coronavirus disease 2019 (COVID-19) cases that required intensive care unit (ICU) treatment in the second year of the pandemic.

MATERIAL AND METHODS

All patients who were hospitalized in the ICUs due to COVID-19 between March 11, 2022, 08.00 am, and March 12, 2022, 08.00 am, were included in the study. Demographic characteristics, intensive care and laboratory data, radiological characteristics, and follow-up results of the patients were recorded.

RESULTS

A total of 811 patients from 59 centers were included in the study, 59% of the cases were male, and the mean age was 74 ± 14 years. At least one comorbid disease was present in 94% of the cases, and hypertension was the most common. When ICU weight scores were examined, Acute Physiology and Chronic Health Evaluation-II: 19 (15-27) and Sequential Organ Failure Assessment: 7 (4-10) were seen. Sepsis was present in 37% (n = 298) of cases. PaO2/FiO2 ratios of the patients were 190 the highest and 150 the lowest and 51% of the cases were followed via invasive mechanical ventilation. On the study day, 73% bilateral involvement was seen on chest x-ray, and ground-glass opacities (52%) were the most common on chest tomography. There was growth in culture in 40% (n = 318) of the cases, and the most common growth was in the tracheal aspirate (42%).

CONCLUSION

The clinical course of COVID-19 is variable, and ICU follow-up was required due to advanced age, comorbidity, presence of respiratory symptoms, and widespread radiological involvement. The need for respiratory support and the presence of secondary infection are important issues to be considered in the follow-up. Despite the end of the second year of the pandemic and vaccination, the high severity of the disease as well as the need for follow-up in ICUs has shown that COVID-19 is an important health problem.

Are Lymphocytes and Eosinophils Associated with the COVID-19 Severity: A Large, Retrospective Study

OBJECTIVE

Coronavirus disease 2019 is an ongoing disease with high morbidity and mortality. We aimed to investigate the relationship between demographics, lymphocytes, eosinophils, and the coronavirus disease 2019 severity at hospital admission.

MATERIAL AND METHODS

A retrospective, observational cross-sectional study was carried out with 5828 coronavirus disease 2019 patients between March 11, 2020, and November 30, 2020. Patients were divided into 3 groups according to where they were followed up as an indicator of disease severity, namely outpatients, inpatients, and critically ill patients. The patients' demographics and hemogram values on admission were recorded. The predictive accuracies of lymphocyte count, lymphocyte percentage, eosinophil count, and eosinophil percentage for predicting severity were determined using receiver operating characteristic curves. Logistic regression analysis was used to predict intensive care unit demand according to lymphocyte and eosinophil values.

RESULTS

Of the 5828 coronavirus disease 2019 patients, 4050 were followed up as outpatients, 1581 were hospitalized in a ward, and 197 were hospitalized in the intensive care unit. Lymphocyte count and lymphocyte percentage were significantly different between the groups, but the difference for eosinophil count and eosinophil percentage was not significant as it was for lymphocytes. Cutoff values for lymphocyte count (1.0 × 109 /L), lymphocyte percentage (22%), eosinophil count (0.052 × 109 /L), and eosinophil percentage (0.08%) were found to indicate a high risk for intensive care unit admission. Coronavirus disease 2019 patients >55 years of age, with a lymphocyte count <1.0 × 109 /L, a lymphocyte percentage <22%, and an eosinophil percentage <0.08% had a 2-fold higher risk of requiring intensive care unit management.

CONCLUSION

Lymphocyte counts and percentages are quick and reliable biomarkers for predicting coronavirus disease 2019 severity and may guide physicians for proper management earlier.

The comparison of the survival rates of intensive and palliative care units

Introduction

Palliative care is a multidisciplinary therapy formed by physical, social, psychological, cultural and spiritual support of patients and families. The aim of the present study is to compare the survival rates of the intensive care unit (ICU) and palliative care unit (PCU).

Materials and Methods

A retrospective observational cohort study was performed using the database of an intensive care unit. Patients with terminal illness admitted to the intensive care unit or palliative care unit were included in the study. Demographic data, comorbidities, time of admission, discharge and death were recorded. The survival estimation was completed using Kaplan Meier survival analysis.

Result

A total of 112 patients were included in the study. Patients were divided into two groups where 60 patients (53.6%) were in Group ICU and 52 (46.4%) were in Group PCU. The Kaplan-Meier estimation of survival curves showed that the overall median time was 29 days. This result demonstrated that 50% of the patients was survived longer than 29 days, in which it was 12 days and 38 days for Group ICU and Group PCU, respectively (𝜒2= 3.475, p= 0.062). The cost of either intensive care unit or palliative care unit did not show any difference (p= 0.902).

Conclusions

The present study showed that long-term survival rates are similar in intensive care unit and palliative care unit.

COVID-19 Pandemic and the Global Perspective of Turkish Thoracic Society

It has been more than 3 months now since the first case of COVID-19 was reported in Turkey. Globally, the number of confirmed cases and deaths reached 9,653,048 and 491,128 respectively, as reported by 216 countries by June 27, 2020. Turkey had 1,396 new cases, 194,511 total cases, and 5,065 deaths by the same date. From the first case until today, the Turkish Thoracic Society (TTS) has been very proactive in educating doctors, increasing public awareness, undertaking academic studies, and assisting with public health policies. In the present report, social, academic, and management perspectives of the pandemic are presented under appropriate subtitles. During this critical public health crisis, TTS has once again demonstrated its readiness and constructive stance by supporting public health, healthcare workers, and the environment. This review summarizes the perspective of TTS on each aspect of the COVID-19 pandemic and casts light on its contributions.

Neutrophil to lymphocyte ratio as a predictor of treatment response and mortality in septic shock patients in the intensive care unit

Background/aim

While C-reactive protein (CRP) is a well-studied marker for predicting treatment response and mortality in sepsis, it was aimed to assess the efficacy of the neutrophil lymphocyte ratio (NLR) as a predictor of mortality and treatment response in sepsis patients in the intensive care unit (ICU).

Materials and methods

In this retrospective cross-sectional study, sepsis patients were divided according to the presence of septic shock on the 1st day of ICU stay, and then subgrouped according to mortality. Patient demographics, acute physiologic and chronic health evaluation II and sequential organ failure assessment scores, NLR and CRP (on the 1st, 3rd, and last day in the ICU), microbiology data, antibiotic responses, ICU data, and mortality were recorded. Receiver operating characteristic (ROC) curves for the area under curve (AUC) were calculated for the inflammatory markers and ICU severity scores for mortality.

Results

Of the 591 (65% male) enrolled patients, 111 (18.8%) were nonsurvivors with shock, 117 (19.8%) were survivors with shock, 330 (55.8%) were survivors without shock, and 33 (5.6%) were nonsurvivors without shock. On the 1st day of ICU stay, the NLR and CRP were similar in all of the groups. On the 3rd day of antibiotic response, the NLR was increased (11.8) in the nonresponsive patients when compared with the partially responsive (11.0) and responsive (8.5) patients. If the NLR was ≥15 on the 3rd day, the mortality odds ratio was 6.96 (CI: 1.4–34.1, P < 0.017). The NLR and CRP on the 1st, 3rd, and last day of ICU stay (0.52, 0.58, 0.78 and 0.56, 0.70, 0.78, respectively) showed a similar increasing trend for mortality.

Conclusion

The NLR can predict mortality and antibiotic responsiveness in ICU patients with sepsis and septic shock. If the NLR is >15 on the 3rd day of postantibiotic initiation, the risk of mortality is high and treatment should be reviewed carefully.

Predictors of mortality in cancer patients who need intensive care unit support: a two center cohort study

Background/aim

Cancer patients frequently need intensive care support due to respiratory failure. We aimed to evaluate the predictors of mortality in cancer patients who were admitted to the intensive care unit (ICU).

Materials and methods

This study was performed in the ICUs of two centers between 1 January 2008 and 31 December 2015. Demographic data, cancer type, causes of respiratory failure, comorbidities, APACHE II scores, treatments, and mortality rates were recorded.

Results

A total number of 583 cancer patients (477 males) were enrolled from the two centers. Of those, 472 patients had lung cancer (81%), while 111 had extrapulmonary malignancies (19%), having similar mortality rates. Causes of respiratory failure were mostly invasion of the cancer itself in 84% of cases and due to infection in 12%. ICU mortality rate was 53% and the 1-year mortality rate was 80%. APACHE II scores were significantly higher in nonsurvivors (P < 0.001). One-year survival was found to be significantly shorter in females than males (9 days vs. 12 days) in patients with lung cancer.

Conclusion

Mortality rates of cancer patients who need ICU support are higher than overall ICU mortality. High APACHE II scores and female sex seem to be related to mortality in these patients.

Eosinophilic and non-eosinophilic COPD patients with chronic respiratory failure: neutrophil-to-lymphocyte ratio as an exacerbation marker

Aim

Increased dyspnea, sputum volume, and purulence are subjective symptoms in COPD patients. To diagnose COPD exacerbations with chronic respiratory failure (CRF) and to assess the requirement for antibiotic treatment, physicians require more objective criteria. We aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR) can be used as an infectious exacerbation marker in COPD patients with CRF.

Patients and methods

This retrospective cross-sectional study was performed in the intensive care outpatient clinic of a tertiary training hospital between 2014 and 2015. Patients admitted with CRF due to COPD and who had complete blood count (CBC) results were enrolled. CBC results and C-reactive protein (CRP) levels were obtained from the hospital online database. The “modified exacerbation model (MEM)” was defined as follows: exacerbation A, leukocytes ≥12,000/mm³, CRP >10 mg/dL; exacerbation B, leukocytes ≥10,000/mm³, CRP >10 mg/dL; exacerbation C, leukocytes ≥10,000/mm³, CRP >8 mg/dL; exacerbation D, leukocytes ≥10,000/mm³, CRP >5 mg/dL. The cutoff value of NLR was defined for each model. Patients were split into two groups based on the NLR cutoff value according to the “NLR exacerbation model” and further subgrouped according to peripheral eosinophil percentage (eosinophils ≥2% and <2%) and compared with the MEM.

Results

A total of 1,066 COPD patients (430 females, 40.3%), with a mean age of 66±13 years, were included. A NLR cutoff value of 3.54 (NLR ≥3.54, n=366, 34%) showed the highest sensitivity and specificity for model A (78%, 69%), model B (63%, 71%), model C (61%, 72%), and model D (58%, 72%). Peripheral eosinophilia (PE ≥2%) was present in 48 patients (4.5%). The ratio of patients with PE <2% in the NLR ≥3.54 group was significantly higher in the MEM (P<0.001).

Conclusion

The NLR presents an attractive option as an exacerbation marker in COPD patients with CRF due to its simplicity and cost-effectiveness. In COPD patients with CRF, where the NLR is ≥3.54, PE levels are <2%, and subjective symptoms are present, antibiotic treatment should be considered.

Risk factors for multiorgan failure and mortality in severe sepsis patients who need intensive care unit follow-up

INTRODUCTION

Multiorgan failure (MOF) is a primary cause of morbidity and mortality in sepsis patients in intensive care units (ICU). Finding risk factors and solving preventable problems of MOF in patients who have sepsis can be a favourable step for decreasing mortality. We aimed to examine multiorgan failure and mortality related risk factors in intensive care unit patients who have sepsis.

MATERIALS AND METHODS

A retrospective data collection and prognostic cohort study was performed. Between January 2009-March 2010, patients accepted to the 22-bed pulmonary intensive care unit with the diagnosis of sepsis were enrolled. Patients' demographic data, ICU severity scores, application of mechanical ventilation, causative agent of sepsis, number of ICU days and presence of mortality were recorded. Logistic regression analysis was carried out for risk factors.

RESULT

347 patients with sepsis were involved in the study. 43 of the patients (12.4%) developed MOF and overall mortality rate was 14.9% (n= 52). Presence of resistant pathogen, presence of shock, application of TPN and high APACHE II score were found to be risk factors for MOF [p= 0.015 Odds ratio (OR) 3.47 confidence interval (CI): 1.27 - 9.47, p= 0.001, OR: 30.8 CI: 11.41 - 83-49, p= 0.028, OR: 3.08, CI: 1.13 - 8.39, p= 0.003, OR: 1.10, CI: 1.04-1.18, respectively]. Risk factors for overall mortality were presence of nosocomial infection, high 3rd day SOFA score, presence of shock, application of TPN and sedation (p= 0.005, OR: 3.39, CI: 1.45 - 7.93; p= 0.001, OR: 1.51, CI: 1.27 - 1.81; p= 0.014, OR: 3.24, CI: 1.27 - 8.25; p= 0.003, OR: 3.64. CI: 1.54 - 8.58; p= 0.001, OR: 3.38, CI: 1.51 - 7.57, respectively).

CONCLUSIONS

In sepsis patients who need ICU follow up, presence of resistant pathogen, presence of shock, application of TPN and high APACHE II scores are risk factors for developing MOF. Thus, rational use of antibiotics, reducing the use of TPN, application of infection control programmes and prevention of shock will further reduce multiorgan failure and mortality.

Thrombocytopenia: A Risk Factor of Mortality for Patients with Sepsis in the Intensive Care Unit

OBJECTIVES

The objective of this study was to evaluate the intensive care unit (ICU) and long-term mortality in sepsis patients with/without thrombocytopenia on the fifth day of ICU admission.

MATERIALS AND METHODS

The retrospective observational cohort study was performed in a teaching hospital, and patients with sepsis who stayed more than 4 days in the ICU between January 2012 and December 2012 were included. Patients were divided into two groups according to thier platelet count at fifth day of ICU stay: Group 1, < 150.000/μL; Group 2, >150.000/μL. Patients having thrombocytopenia on admission were excluded. The patients' characteristics, comorbid diseases, body mass index, arterial blood gas analysis and blood biochemistry results, SIRS criteria, Acute Physiological and Chronic Health Evaluation Score II (APACHE II), implication of invasive and non-invasive mechanical ventilation, use of sedation, nutrition information, and culture results of microbiological samples were recorded. The groups were compared according to the recorded data. Logistic regression analysis was performed for ICU mortality; the Kaplan-Meier test was used to evaluate 12-month survival after ICU discharge.

RESULTS

During the period, 1003 patients were admitted to the ICU; 307 sepsis patients were included in the study. Group 1 (n= 67) and Group 2 (n=240) had similar patient characteristics and sepsis findings. The groups had similar ICU and hospital stays; mortality was higher in Group 1 than in Group 2 (40.3% vs. 17.5%, respectively, p< 0.001). Fifth day thrombocytopenia, septic shock, male gender, and low albumin levels were found to be risk factors of ICU mortality; the respective odds ratios, 95% confidence intervals, and p values for these factors were 3.03, [1.15-7.45], p= 0.025; 4.97, [1.79-13.86], p= 0.002; 3.61, [1.27-10.23], p= 0.001; and 0.19, [0.07-0.52], p= 0.001. Follow-up after a year indicated that 124 out of 238 (52.1%) patients died, and 50% of the deaths occurred in the first 2 months. Kaplan-Meier analysis revealed no statistically significant effects of thrombocytopenia at ICU day 5 on 12-month mortality after ICU discharge.

CONCLUSION

Higher rates of septic shock and mortality were seen in sepsis patients with thrombocytopenia in the ICU. The measurement of thrombocytopenia in the ICU, which is easy and low-cost, may help to predict mortality. Thus, precautions can be taken early in patient treatment and follow-up. As we know, early intervention is crucial in the approach to sepsis.

Does Total Parenteral Nutrition Increase the Mortality of Patients with Severe Sepsis in the ICU?

OBJECTIVES

We aimed to evaluate the independent association between total parenteral nutrition (TPN) and nosocomial infection and intensive care unit (ICU) mortality in patients with severe pulmonary sepsis.

MATERIAL AND METHODS

The present study was designed as a retrospective observational cohort study. We enrolled all patients with severe sepsis due to pulmonary infections who stayed more than 24 h in the respiratory ICU between January 2009 and December 2010. We recorded demographic characteristics, ICU severity scores, Acute Physiologic and Chronic Health Evaluation II (APACHE II) and first day Sequential Organ Failure Assessment (SOFA) score in the ICU, TPN because of intolerance to enteral feeding, ICU data, and mortality. To evaluate the risk factors for mortality, we performed adjusted logistic regression test for TPN, nosocomial infection, and SOFA in the model.

RESULTS

Five hundred and fifty patients (males=375, females=175) with severe sepsis were involved in the study during the study period. The median and interquartile range (IQR) of age, APACHE II, and SOFA score at the time of admission to the ICU were 65 years (53-73), 20 (16-25), and 4 (3-6), respectively. Mortality rate was 18% (n=99). Adjusted odds ratio (OR), confidence intervals (CI) 95%, and p values of TPN, nosocomial infection, and first day SOFA score for mortality were as follows: OR:3.8, CI:2.3-6.1, p<0.001; OR:2.4, CI: 1.4-3.9, p<0.001; and OR: 1.3, CI:1.2-1.4, p<0.001, respectively.

CONCLUSION

Nosocomial infection and the need for TPN because of intolerance of enteral nutrition (EN) is associated with a higher mortality rate in patients with severe sepsis in the ICU. Rational use of antibiotics and application of hospital acquired infection control program will further reduce mortality.

Full-Time ICU Staff in the Intensive Care Unit: Does It Improve the Outcome?

OBJECTIVES

Patients with various severities are cared for in the intensive care unit (ICU) by an experienced ICU physician. We aimed to assess whether there is any difference in intubated ICU patient management when undertaken by a 24-hour intensivist versus a periodic experienced specialist in the ICU.

MATERIAL AND METHODS

A retrospective, cross-sectional, observational study was done in a tertiary teaching hospital ICU. Patients receiving invasive mechanical ventilation (IMV) were classified into: group 1, managed by an experienced ICU pulmonary specialist during night shifts in 2006-2007, and group 2, managed by an intensivist around the clock in 2011. Patients were excluded if they were <18 years old, tracheostomized, or transferred from another ICU. Patient demographics and ICU data (IMV duration, sedation doses and duration, weekend extubation, ICU severity score [APACHE II], length of ICU stay, and mortality) were recorded, and groups were compared.

RESULTS

In group 1, 131 of 215 IMV patients were included in the study, and in group 2, 294 of 374 patients were included. The sedation infusion rate, duration of IMV, self-extubation rate, and lenght of stay (LOS) of ICU were significantly increased in group 1 compared with group 2 (72.5% vs. 40.8%, p<0.0001; 152 vs. 68 hours, p<0.001; 24.4% vs. 13.9%, p<0.006; 13 vs. 8 days, p<0.0001, respectively). The weekend extubation rate and APACHE II scores were significantly lower in group 1 compared with group 2 (7.1% vs. 25.3%, p<0.0001; 22 vs. 25, p<0.017, respectively). Mortality rates were similar in the two groups (35.9% vs. 37.4%, p=0.76).

CONCLUSION

A 24-hour intensivist appears to be better for decreasing IMV duration and LOS in the ICU. These results may be useful to address decreasing morbidity and, as a result, cost of ICU stays by 24-hour intensivist coverage, especially for patients with IMV.

Why do patients with interstitial lung diseases fail in the ICU? a 2-center cohort study

BACKGROUND

Admitting patients with interstitial lung disease (ILD) to the ICU is controversial, due to their associated high mortality when they require invasive mechanical ventilation. We aimed to determine the risk factors for mortality in ILD patients requiring ICU support due to acute respiratory failure.

METHODS

An observational cohort study was performed in 2 chest diseases teaching hospitals. We included all ILD patients with acute respiratory failure admitted between 2008 and 2010. Subject demographics, noninvasive ventilation (NIV) and invasive ventilation use, and mortality were obtained from medical records. Subjects receiving NIV were divided based on their continuous or non-continuous demand for NIV. NIV failure was defined as intubation for invasive ventilation, or death during NIV. Cox regression analysis was used to determine the hazard ratio for NIV failure.

RESULTS

We enrolled 120 subjects: 71 male, median age 66 years. The types of ILD were idiopathic pulmonary fibrosis (n = 96), collagen vascular disease (n = 10), silicosis (n = 9), drug induced (n = 3), and eosinophilic pneumonia (n = 2). The median (IQR) Acute Physiology and Chronic Health Evaluation (APACHE II) score was 24 (19-31), and 75 (62.5%) subjects received NIV on ICU admission, 47 (62.7%) of whom needed continuous NIV. The NIV failure rate was 49.3% (n = 37). The mortality rates of continuous NIV, non-continuous NIV, invasive ventilation, and total ICU were 61.7% (29/47), 10.7% (3/28), 89.7% (61/68), 60% (72/120), respectively. APACHE II > 20 and continuous NIV demand indicated significant risk for NIV failure: hazard ratio 2.77 (95% CI 1.19-6.45), P < .02, and 5.12, (1.44-18.19), P < .01, respectively.

CONCLUSIONS

Because of higher mortality, physicians should consider invasive ventilation cautiously in the ICU management of ILD patients with acute respiratory failure. NIV may be an option in less severely ill patients with APACHE II score < 20.

Intensive care and non-invasive mechanical ventilation in kyphoscoliosis: are new perspectives still needed?

Non-invasive ventilation (NIV) assists breathing and thus improves oxygenation in patients with Kyphoscoliosis. The benefits of short- and long-term intermittent nocturnal in such patients have been reported previously (improvement of vital capacity, total lung capacity, muscle strength, daytime oxygenation, exercise capacity, and pulmonary hypertension). We review this important study reporting patients with kyphoscoliosis and acute respiratory failure along with their long-term outcomes. We believe that this letter may provide important information regarding the prognosis and efficacy of NIV.

Intensive care and non-invasive mechanical ventilation in kyphoscoliosis: are new perspectives still needed?

Non-invasive ventilation (NIV) assists breathing and thus improves oxygenation in patients with Kyphoscoliosis. The benefits of short- and long-term intermittent nocturnal in such patients have been reported previously (improvement of vital capacity, total lung capacity, muscle strength, daytime oxygenation, exercise capacity, and pulmonary hypertension). We review this important study reporting patients with kyphoscoliosis and acute respiratory failure along with their long-term outcomes. We believe that this letter may provide important information regarding the prognosis and efficacy of NIV.

General Characteristics and Prognostic Factors of Pneumonia Cases Developed During Pandemic (H1N1) Influenza-A Virus Infection in Turkey

OBJECTIVE

Unlike seasonal influenza, seen in previous years, the strain identified in the 2009 influenza-A pandemic involved high mortality. In this study, prognostic factors and general characteristics of pneumonia cases developed in Turkey during the H1N1 pandemic between October 2009 and January 2010 were analyzed.

STUDY DESIGN

Multicenter retrospective study.

MATERIAL AND METHODS

This multicentric retrospective study was conducted between August and October 2010 and patients' data were collected by means of standard forms.

RESULTS

The study included 264 pneumonia cases, collected from 14 different centers. Mean age was 47.5±18.6 years. Nineteen patients (7.2%) were pregnant or had a new birth and comorbid diseases were detected in 52.3% of all patients. On admission, 35 (13.8%) cases had altered mental status. Overall, 32.6% were treated in intensive care units (ICU) and invasive/non-invasive mechanical ventilation was performed in 29.7%. The mean duration of ICU stay was 2.9±6.2 and total hospital stay was 12.0±9.4 days. Mortality rate was 16.8% (43-cases). The length of ICU treatment, total hospital stay, and mortality were significantly higher in H1N1-confirmed patients. Mortality was significantly higher in patients with dyspnea, cyanosis, and those who had altered mental status on admission. Patients who died had significantly higher rate of peripheral blood neutrophils, lower platelet counts, higher BUN, and lower SaO2 levels.

CONCLUSION

This study showed that pneumonia developed during H1N1 pandemic in our country had resulted in a high mortality. Mortality was especially high among patients with cyanosis, altered mental state and those with lower SaO2.

Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients

We aimed to establish that a bronchoscopic view can be as reliable as microbiology, and support an empirical tracheobronchial fungal infection (TBFI) treatment decision. We retrospectively studied 95 respiratory failure patients with suspected TBFI admitted to the intensive-care unit (ICU) in 2008 with sticky secretions, hyperaemic mucosa, and whitish plaques on bronchoscopic view. Patients not suspected of having TBFI were chosen as a control group (n = 151). Broncheoalveolar lavage (BAL) fluid was cultured, and biopsy samples were taken from the lesions. Biopsy samples positive for fungi were defined as 'proven', only BAL-positive (+ fungi) cases were 'probable TBFI', and BAL-negative (- fungi) cases were 'possible TBFI'. BAL (+ fungi) and BAL (- fungi) in the control group were defined as 'colonization' and 'no TBFI', respectively. The sensitivity, specificity and positive and negative predictive values of BAL (+ fungi) were 85.1% (63/74), 81.4% (140/172), 66.3% (63/95), and 92.7% (140/151), respectively. Biopsies were performed in 78 of 95 patients, and 28 were proven TBFI with fungal elements, and 100% were BAL (+ fungi). Probable TBFI was seen in 30 of 95 patients with BAL (+ fungi), and possible TBFI (BAL(- fungi)) in 25 of 95. Among the 95 patients, microbiology revealed fungi (90.5% Candida species; 9.5% Aspergillus) in 63 (66.3%). In the controls, the colonization and no TBFI rates were 11 of 151 and 140 of 151, respectively. Observing sticky secretions, hyperaemic mucosa and whitish plaques by bronchoscopy is faster than and may be as reliable as microbiology for diagnosing TBFI. These findings are relevant for empirical antifungal therapy in suspected TBFI patients in the ICU.

C-reactive protein as a predictor of mortality in patients affected with severe sepsis in intensive care unit

Background: Severe sepsis is a primary cause of morbidity and mortality in the intensive care unit (ICU). Numerous biomarkers have been assessed to predict outcome and CRP is widely used. However, the relevance for mortality risk of the CRP level and the day when it is measured have not been well studied. We aimed to assess whether initial and/or third dayCRP values are as good predictors of mortality in ICU patients with severe sepsis as other well-known complex predictors of mortality, i.e., SOFA scores. Methods: An observational cohort study was performed in a 20-bed respiratory ICU in a chest disease center. Patients with severe sepsis due to respiratory disease were enrolled in the study. SOFA scores, CRP values on admission and on the third day of hospital stay, and mortality rate were recorded. ROC curves for SOFA scores and CRP values were calculated. Results: The study included 314 ICU patients with sepsis admitted between January 2009 and March 2010. The mortality rate was 14.2% (n = 45). The area under the curve (AUC) for CRP values and SOFA scores on admission and on the 3rd day in ICU were calculated as 0.57 (CI: 0.48-0.66); 0.72 (CI: 0.63-0.80); 0.72 (CI: 0.64-0.81); and 0.76 (CI: 0.67-0.86), respectively. Sepsis due to nosocomial infection, a CRP value > 100 mg/L and higher SOFA scores on 3rd day, were found to be risk factors for mortality (odds ratio [OR]: 3.76, confidence interval [CI]: 1.68-8.40, p < 0.001, OR: 2.70, CI: 1.41-2.01, p < 0.013, and OR: 1.68, CI: 1.41-2.01, p < 0.0001, respectively). Conclusions: The risk of sepsis related mortality appears to be increased when the 3rd day CRP value is greater than 100 mg/dL. Thus, CRP appears to be as valuable a predictor of mortality as the SOFA score.

C-reactive protein as a predictor of mortality in patients affected with severe sepsis in intensive care unit

BACKGROUND

Severe sepsis is a primary cause of morbidity and mortality in the intensive care unit (ICU). Numerous biomarkers have been assessed to predict outcome and CRP is widely used. However, the relevance for mortality risk of the CRP level and the day when it is measured have not been well studied. We aimed to assess whether initial and/or third dayCRP values are as good predictors of mortality in ICU patients with severe sepsis as other well-known complex predictors of mortality, i.e., SOFA scores.

METHODS

An observational cohort study was performed in a 20-bed respiratory ICU in a chest disease center. Patients with severe sepsis due to respiratory disease were enrolled in the study. SOFA scores, CRP values on admission and on the third day of hospital stay, and mortality rate were recorded. ROC curves for SOFA scores and CRP values were calculated.

RESULTS

The study included 314 ICU patients with sepsis admitted between January 2009 and March 2010. The mortality rate was 14.2% (n = 45). The area under the curve (AUC) for CRP values and SOFA scores on admission and on the 3rd day in ICU were calculated as 0.57 (CI: 0.48-0.66); 0.72 (CI: 0.63-0.80); 0.72 (CI: 0.64-0.81); and 0.76 (CI: 0.67-0.86), respectively. Sepsis due to nosocomial infection, a CRP value > 100 mg/L and higher SOFA scores on 3rd day, were found to be risk factors for mortality (odds ratio [OR]: 3.76, confidence interval [CI]: 1.68-8.40, p < 0.001, OR: 2.70, CI: 1.41-2.01, p < 0.013, and OR: 1.68, CI: 1.41-2.01, p < 0.0001, respectively).

CONCLUSIONS

The risk of sepsis related mortality appears to be increased when the 3rd day CRP value is greater than 100 mg/dL. Thus, CRP appears to be as valuable a predictor of mortality as the SOFA score.

Management of kyphoscoliosis patients with respiratory failure in the intensive care unit and during long term follow up

Background: We aimed to evaluate the ICU management and long-term outcomes of kyphoscoliosis patients with respiratory failure. Methods: A retrospective observational cohort study was performed in a respiratory ICU and outpatient clinic from 2002–2011. We enrolled all kyphoscoliosis patients admitted to the ICU and followed-up at regular intervals after discharge. Reasons for acute respiratory failure (ARF), ICU data, mortality, length of ICU stay and outpatient clinic data, non-invasive ventilation (NIV) device settings, and compliance were recorded. NIV failure in the ICU and the long term effect of NIV on pulmonary performance were analyzed. Results: Sixty-two consecutive ICU kyphoscoliosis patients with ARF were enrolled in the study. NIV was initially applied to 55 patients, 11 (20%) patients were intubated, and the majority had sepsis and septic shock (p < 0.001). Mortality in the ICU was 14.5% (n = 9), reduced pH, IMV, and sepsis/septic shock were significantly higher in the non-survivors (p values 0.02, 0.02, 0.028, 0.012 respectively). Among 46 patients attending the outpatient clinic, 17 were lost to follow up and six were died. The six minute walk distance was significantly increased in the final follow up (306 m versus 419 m, p < 0.001). Conclusions: We strongly discourage the use of NIV in the case of septic shock in ICU kyphoscoliosis patients with ARF. Pulmonary performance improved with NIV during long term follow up.

Management of kyphoscoliosis patients with respiratory failure in the intensive care unit and during long term follow up

BACKGROUND

We aimed to evaluate the ICU management and long-term outcomes of kyphoscoliosis patients with respiratory failure.

METHODS

A retrospective observational cohort study was performed in a respiratory ICU and outpatient clinic from 2002-2011. We enrolled all kyphoscoliosis patients admitted to the ICU and followed-up at regular intervals after discharge. Reasons for acute respiratory failure (ARF), ICU data, mortality, length of ICU stay and outpatient clinic data, non-invasive ventilation (NIV) device settings, and compliance were recorded. NIV failure in the ICU and the long term effect of NIV on pulmonary performance were analyzed.

RESULTS

Sixty-two consecutive ICU kyphoscoliosis patients with ARF were enrolled in the study. NIV was initially applied to 55 patients, 11 (20%) patients were intubated, and the majority had sepsis and septic shock (p < 0.001). Mortality in the ICU was 14.5% (n = 9), reduced pH, IMV, and sepsis/septic shock were significantly higher in the non-survivors (p values 0.02, 0.02, 0.028, 0.012 respectively). Among 46 patients attending the outpatient clinic, 17 were lost to follow up and six were died. The six minute walk distance was significantly increased in the final follow up (306 m versus 419 m, p < 0.001).

CONCLUSIONS

We strongly discourage the use of NIV in the case of septic shock in ICU kyphoscoliosis patients with ARF. Pulmonary performance improved with NIV during long term follow up.

Six minute walking distance in kyphoscoliosis patients with chronic respiratory failure

Aim

To evaluate kyphoscoliosis patients with chronic hypercapnic respiratory failure (CHRF) using the six minute walk test (6MWT) distance (6MWD) and cardio-pulmonary function tests.

Method

This prospective cross-sectional study was carried out in a tertiary training and research hospital in Turkey. Kyphoscoliosis patients with CHRF on home mechanical ventilation (HMV) followed in a respiratory intensive care unit (RICU) out-patient clinic were enrolled. Patients' demographics were recorded as well as transthoracic echocardiography (ECHO), 6MWD, spirometry, arterial blood gas (ABG) values and high resolution chest computed tomography. 6MWT results were compared with other parameters.

Results

Thirty four patients with kyphoscoliosis and chronic respiratory insufficiency admitted to our outpatient clinic were included in the study but 25 (17 M) patients underwent 6MWT (8 patients walked with oxygen supplement due to PaO₂ < 60 mm Hg). The mean 6MWD was 274.4 ± 76.2 (median 270) m and median 6MWD predicted rate was 43.7% (inter quartile ratio, IQR, 37.6% to 47.7%). Median HMV use was 3 years (IQR 2-4). 6MWD predicted rate, body mass index (BMI), HMV duration were similar in male and female patients. 6MWD correlated well with age, BMI, dyspnea score for baseline 6MWT (r: - 0.59, p < 0.002, r: - 0.58, p < 0.003, r: - 0.55, p < 0.005 respectively) but modestly with forced expiratory volume in one second, pulse rate for baseline 6MWT, pulse saturation rate, fatigue and dyspnea score at end of 6MWT (r: - 0.44, p < 0.048; r: 0.44, p < 0.027; r: - 0.43, p < 0.031; r: - 0.42, p < 0.036; r: - 0.42, p < 0.034 respectively). 6MWD predicted rate was only correlated with dyspnea score at baseline (r: - 0.46, p < 0.022). The systolic pulmonary arterial pressure (PAPs) in 6 (24%) cases was more than 40 mmHg, in whom mean PaO₂/FiO₂ was 301.4 ± 55.4 compared to 280.9 ± 50.2 in those with normal PAPs (p > 0.40).

Conclusion

The 6MWT is an easy way to evaluate physical performance limitation in kyphoscoliosis patients with chronic hypercapnic respiratory failure using home mechanical ventilation. Nearly 275 m was the mean distance walked in the 6MWT, but rather than distance in meters, the 6MWD predicted rate according to gender and body mass index equation might be a better way for deciding about physical performance of these patients. Dyspnea score at baseline before the 6MWT may be the most important point that affects 6MWD in this patient population.

Six minute walking distance in kyphoscoliosis patients with chronic respiratory failure

Aim: To evaluate kyphoscoliosis patients with chronic hypercapnic respiratory failure (CHRF) using the six minute walk test (6MWT) distance (6MWD) and cardio-pulmonary function tests. Method: This prospective cross-sectional study was carried out in a tertiary training and research hospital in Turkey. Kyphoscoliosis patients with CHRF on home mechanical ventilation (HMV) followed in a respiratory intensive care unit (RICU) out-patient clinic were enrolled. Patients’ demographics were recorded as well as transthoracic echocardiography (ECHO), 6MWD, spirometry, arterial blood gas (ABG) values and high resolution chest computed tomography. 6MWT results were compared with other parameters. Results: Thirty four patients with kyphoscoliosis and chronic respiratory insufficiency admitted to our outpatient clinic were included in the study but 25 (17 M) patients underwent 6MWT (8 patients walked with oxygen supplement due to PaO2 < 60 mm Hg). The mean 6MWD was 274.4 ± 76.2 (median 270) m and median 6MWD predicted rate was 43.7% (inter quartile ratio, IQR, 37.6% to 47.7%). Median HMV use was 3 years (IQR 2-4). 6MWD predicted rate, body mass index (BMI), HMV duration were similar in male and female patients. 6MWD correlated well with age, BMI, dyspnea score for baseline 6MWT (r: - 0.59, p < 0.002, r: - 0.58, p < 0.003, r: - 0.55, p < 0.005 respectively) but modestly with forced expiratory volume in one second, pulse rate for baseline 6MWT, pulse saturation rate, fatigue and dyspnea score at end of 6MWT (r: - 0.44, p < 0.048; r: 0.44, p < 0.027; r: - 0.43, p < 0.031; r: - 0.42, p < 0.036; r: - 0.42, p < 0.034 respectively). 6MWD predicted rate was only correlated with dyspnea score at baseline (r: - 0.46, p < 0.022). The systolic pulmonary arterial pressure (PAPs) in 6 (24%) cases was more than 40mmHg, in whom mean PaO2/FiO2 was 301.4 ± 55.4 compared to 280.9 ± 50.2 in those with normal PAPs (p > 0.40). Conclusion: The 6MWT is an easy way to evaluate physical performance limitation in kyphoscoliosis patients with chronic hypercapnic respiratory failure using home mechanical ventilation. Nearly 275 m was the mean distance walked in the 6MWT, but rather than distance in meters, the 6MWD predicted rate according to gender and body mass index equation might be a better way for deciding about physical performance of these patients. Dyspnea score at baseline before the 6MWT may be the most important point that affects 6MWD in this patient population.

Chlorine-induced extensive tracheobronchial necrosis concomitantly benzene-induced pancytopenia presented with severe pneumonia

We report a case of 25-year-old woman with severe tracheobronchial necrosis caused by chlorine released from a mixture household cleaning agents. She subsequently exposed benzene while she was fixing the seats with benzene containing gum. The case was found interesting with its history, delayed diagnosis, bronchoscopic features, and fatal outcome. We presented its bronchoscopic and pathological images which has not been shown in the literature up to date.

Influenza A (H1N1) virus pneumonia in intensive care unit

Patients with influenza A (H1N1) virus infection have been admitted to intensive care units (ICU) due to development of severe respiratory failure. We described the clinical and epidemiologic characteristics of the 19 patients admitted to ICU due to influenza A (H1N1) virus infection. Study design is a descriptive case series in a third level-20 bed respiratory ICU at training hospital in Istanbul/Turkey. Influenza A (H1N1) virus infection was laboratory confirmed in specimens using real-time reverse transcriptase-polymerase-chain-reaction (RT-PCR). We collected data concerning demographic, epidemiologic and clinical characteristics of the patients, treatment mortality and outcome. From November 10 to December 31 2009, a total of 19 patients; 7 laboratory confirmed, 12 with high clinical suspicion were treated at ICU. Among 12 patients with high clinical suspicion; 3 patients had negative RT-PCR testing for influenza A (H1N1) virus, 9 patients had no tests. Mean age was 41.6 ± 11.9 (range 21 to 61). Median number of lung zone involvement was 4 (IQR= 3-4). Median PaO2/FiO2 was 105 (IQR= 85-165). Mean severity (APACHE II) and organ failure score (SOFA) were 13 ± 4 and 4.0 ± 1.3 respectively. Non-invasive mechanical ventilation (68.4%, n= 13), invasive mechanical ventilation (21.1%, n= 4) and nasal cannula oxygen (31.5%, n= 6) were implicated. The median length of ICU stay was 6 (IQR= 4-8). Oseltamivir therapy was given as 75 mg bid to 12 patients and 150 mg bid to 7 obese patients. ICU mortality rate was 21.1%. Presenting patients with pneumonia and acute respiratory failure due to influenza A (H1N1) virus infection were treated predominantly and successfully with non invasive mechanical ventilation. Clinicians should be aware of pulmonary complications of influenza A (H1N1) virus infection and that patients can be treated with non invasive mechanical ventilation paying attention to protective measures for health care providers.