Organophosphate (OP) poisoning is still associated with high morbidity and mortality rates, both in resource-poor settings and in well-developed countries. Despite numerous publications dealing with this particular poison, detailed clinical data on more severe overdoses with these agents are relatively sparsely reported. A retrospective study was consequently conducted on 33 patients with OP poisoning admitted to our intensive care unit (ICU) to provide additional data on clinical features. We included moderate to severe poisonings between 2000-2012 who required admission to ICU. Patients ingested dimethyl-OPs in 19 cases, diethyl-OPs in 8 cases and otherwise classified OPs in 6 cases. Death (5/33) occurred rather late and only one of these fatalities died during on-going cholinergic crisis. Of the survivors (28/33), 71% recovered fully while 29% showed predominantly neurological disabilities before being transferred to neurologic rehabilitation. Aspiration pneumonia predominated in 27/33 patients and one patient died in refractory acute respiratory distress syndrome (ARDS). The intermediate syndrome occurred twice and cardiopulmonary resuscitation had to be performed in 6/33 patients. Fatalities showed a higher Poison-severity-score, APACHE-II-score and SOFA-score on admission compared with survivors and they showed significantly longer QTc-time in the ECG, lower systolic blood pressure and heart rate, a lower pH and a lower base excess on admission. Patients with diethyl-OPs required intubation significantly earlier and showed lower and more sustained inhibited activity of the plasma-cholinesterase on admission compared with patients ingesting dimethyl-OPs. Treatment with atropine and obidoxime was comparable between these groups and severity of poisoning, outcome, hemodynamics on admission, duration of mechanical ventilation and length of stay in the ICU did not significantly differ between the involved group of dimethyl- and diethyl-OPs. We conclude that the fatality rate in our patient cohort treated in a well-staffed and equipped ICU of a developed country is quite similarly high compared with the rate observed in developing countries. Patients died rather late when severe cholinergic crisis had mostly been overcome and death was therefore related to non-poison specific complications.

We report a 54-year-old woman who presented with a well-defined, homogeneous, and non-enhancing mass in the retrobronchial region of the bronchus intermedius. The patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for histological confirmation. Serous fluid was aspirated by EBUS-TBNA. Cytological examination identified an acellular smear with negative microbiological cultures. The patient was finally diagnosed with bronchogenic cysts by chest computed tomography (CT) and EBUS-TBNA findings. However, 1 week after EBUS-TBNA, the patient developed bronchogenic cyst rupture and pneumonia. Empirical antibiotics were administered, and pneumonia from the bronchogenic cyst rupture had resolved on follow-up chest CT. To our knowledge, this is the first reported case of pneumonia from bronchogenic cyst rupture after EBUS-TBNA.

PURPOSE:

Pulmonary vascular dysfunction is common during acute respiratory distress syndrome (ARDS), but there is controversy concerning prevalence and prognosis of cor pulmonale during protective ventilation for ARDS.

METHODS:

This was a prospective observational study in an academic medical intensive care unit in France. Two hundred and twenty-six consecutive patients with moderate to severe ARDS (Berlin definition) ventilated with plateau pressure limited at 30 cmH2O (mean PEEP of 8.8 ± 3.6 cmH2O) underwent transesophageal echocardiography (TEE) within the first 3 days after the diagnosis of ARDS. Cor pulmonale was defined as a dilated right ventricle associated with septal dyskinesia.

RESULTS:

Cor pulmonale was detected in 49 patients (prevalence of 22 %; 95 % confidence interval, 16-27 %). Multivariate logistic regression identified infectious causes of lung injury and higher driving pressures as independent factors associated with cor pulmonale. Patients with cor pulmonale exhibited a higher incidence of shock (need for vasoactive drug) at the time of TEE and were more often managed with prone positioning and/or nitric oxide as adjunctive therapy for severe hypoxemia during ARDS course. The 28-day mortality rate was significantly higher in the group with cor pulmonale (60 vs. 36 %, p < 0.01). Multivariate logistic regression identified McCabe and Jackson class, lung injury not related to pneumonia, aspiration, or sepsis, lactic acidosis, driving pressure, and cor pulmonale as independent risk factors for 28-day mortality.

CONCLUSION:

Cor pulmonale occurrence is not negligible in ARDS patients ventilated with airway pressure limitation. Cor pulmonale was associated with sepsis and higher values of driving pressure and was an independent risk factor for 28-day mortality in our series.

BACKGROUND:

Silent aspiration is associated with pneumonia and mortality, and is poorly identified by traditional clinical swallowing evaluation (CSE). The aim of this study was to validate cough reflex testing (CRT) for identification of silent aspiration against aspiration confirmed by instrumental assessment.

METHODS:

Cough reflex threshold testing was completed on all patients using inhaled, nebulised citric acid. Within one hour, 80 patients underwent videofluoroscopic study of swallowing (VFSS) and 101 patients underwent fibreoptic endoscopic evaluation of swallowing (FEES). All tests were recorded and analysed by two researchers blinded to the result of the alternate test.

RESULTS:

Significant associations between CRT result and cough response to aspiration on VFSS (X(2) (2)=11.046, p=.003) and FEES (X(2) (2)=34.079, p<.001) were identified. Sensitivity and specificity were optimised at 0.6mol/L in patients undergoing VFSS (71%, 60% respectively) and at 0.4mol/L in patients undergoing FEES (69%, 71% respectively). A concentration of 0.8mol/L had the highest odds ratio (OR) for detecting silent aspiration (8 based on VFSS; 7 based on FEES).

CONCLUSION:

CRT results are significantly associated with aspiration response on instrumental assessment. Lower concentrations of citric acid provide a better predictive measure of silent aspiration. Clinical Trial Registration Information: Australian & New Zealand Clinical Trials Registry: URL; http://www.ANZCTR.org.au/ACTRN12613000007730.aspx, ACTRN: ACTRN12613000007730.

Significant health issues and service delivery costs are associated with post-stroke pneumonia related to dysphagia. Silent aspiration is known to increase pneumonia and mortality in this population. The utility of cough reflex testing (CRT) for reducing pneumonia in acute stroke patients was the subject of this randomised, controlled trial.Patients referred for swallowing evaluation (N = 311) were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at 3 months post evaluation and other clinical indices of swallowing management.Analysis of the data identified no significant differences between groups in pneumonia rate (P = 0.38) or mortality (P = 0.15). Results of CRT were shown to influence diet recommendations (P < 0.0001) and referrals for instrumental assessment (P < 0.0001).Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved.

BACKGROUND:

/st>Current tracheal tubes (TTs) cannot guarantee a perfect seal against pulmonary aspiration of upper airway secretions. The purpose of this study was to investigate whether a gel layer between the tracheal tube with double cuffs (Double cuffs) prevents fluid leakage past TT cuffs.

METHODS:

/st>In vitro fluid leakage tests were performed using the Double cuff with or without a gel layer between the two cuffs and four commercially available TTs (Euromedical Standard TT, Mallinckrodt Hi-Lo™, Microcuff, and Mallinckrodt TaperGuard™) when placed in artificial tracheas with three-different internal diameters (ID; 16, 20, and 22 mm). Blue-dyed water (5 ml) was placed above the cuff, and the extent of fluid leakage was observed for 48 h. Each test was repeated five times with new tubes at six different intracuff pressures (15, 20, 25, 30, 40, and 50 cm H2O).

RESULTS:

/st>In all of the conventional TTs and the Double cuff without a gel layer, fluid leakage was observed even at clinically acceptable intracuff pressures (25-30 cm H2O). However, in the Double cuff with a gel layer, no fluid leakage was observed for 48 h at all intracuff pressures in three-different sized artificial tracheas. At an intracuff pressure of 20 cm H2O in a 20 mm ID trachea, the average volume of injected gel was 2.0 ml. After removal of the TT, the mean volume of the remaining gel in the trachea was 0.10 ml.

CONCLUSIONS:

/st>A prototype TT with gel-layered Double cuffs completely blocked fluid leakage past the cuffs for 48 h in a bench-top model. Clinical studies are required to determine whether this TT reduces the risk of ventilator-associated pneumonia.

Recurrent/persistent pneumonia in children continues to be a major challenge for the pediatricians. The aim of our study was to establish the prevalence and underlying causes of recurrent/persistent pneumonia in children in Upper Egypt.Assiut University Children Hospital, Assiut, Egypt.Patients, admitted for pneumonia to the hospital during 2 years, were investigated with microbiological, biochemical, immunological and radiological tests in order to establish the prevalence of recurrent/persistent pneumonia and to find out its underlying causes.113 out of 1228 patients (9.2%) met the diagnosis of recurrent/persistent pneumonia. Identified causes were; aspiration syndrome (17.7%), pulmonary TB (14.0%), congenital heart disease (11.5%), bronchial asthma (9.7%), immune deficiency disorders (8.8%) and vitamin D deficiency rickets (7.0%). Other causes included; congenital anomalies of the respiratory tract, interstitial lung diseases, bronchiectasis, and sickle cell anemia. No predisposing factors could be identified in 15% of cases.Approximately 1 out of 10 children with diagnosis of pneumonia in Assiut University Children Hospital had recurrent/persistent pneumonia. The most frequent underlying cause for recurrent/persistent pneumonia was aspiration syndrome, followed by pulmonary TB.

BACKGROUND:

Gallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret's syndrome.

CASE PRESENTATION:

We report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day.

CONCLUSION:

This case shows the importance of considering Bouveret's syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.

With the recent widespread use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), there have been occasional reports on complications associated with its use. Previous reviews on EBUS-TBNA have been limited to studies by skilled operators, thus the results may not always be applicable to recent clinical practice. To assess the safety of EBUS-TBNA for the staging and diagnosis of lung cancer in Japan, a nationwide survey on its current usage status and complications associated with its use was conducted by the Japan Society for Respiratory Endoscopy (JSRE).A questionnaire about EBUS-TBNA performed between January 2011 and June 2012 was mailed to 520 JSRE-accredited facilities.Responses were obtained from 455 facilities (87.5%). During the study period, EBUS-TBNA was performed in 7,345 cases in 210 facilities (46.2%) using a convex probe ultrasound bronchoscope, for 6,836 mediastinal and hilar lesions and 275 lung parenchymal lesions. Ninety complications occurred in 32 facilities. The complication rate was 1.23% (95% confidence interval, 0.97%-1.48%), with hemorrhage being the most frequent complication (50 cases, 0.68%). Infectious complications developed in 14 cases (0.19%) (Mediastinitis, 7; pneumonia, 4; pericarditis, 1; cyst infection, 1; and sepsis, 1). Pneumothorax developed in 2 cases (0.03%), one of which required tube drainage. Regarding the outcome of the cases with complications, prolonged hospitalization was observed in 14 cases, life-threatening conditions in 4, and death in 1 (severe cerebral infarction) (mortality rate, 0.01%). Breakage of the ultrasound bronchoscope occurred in 98 cases (1.33%) in 67 facilities (31.9%), and that of the puncture needle in 15 cases (0.20%) in 8 facilities (3.8%).Although the complication rate associated with EBUS-TBNA was found to be low, severe complications, including infectious complications, were observed, and the incidence of device breakage was high. Since the use of EBUS-TBNA is rapidly expanding in Japan, an educational program for its safe performance should be immediately established.

Non-resolving pneumonia is often an area of concern for pulmonologists. Fiber optic bronchoscopy (FOB) may have a special role in etiologic evaluation of non-resolving pneumonias. There is paucity of recent studies in this field.This study aimed to assess the patients of non-resolving or slowly resolving pneumonia with special emphasis on efficacy of FOB and computed tomography (CT)-guided fine needle aspiration cytology (FNAC) in diagnosis.Prospective, observational study conducted in a tertiary care institute over a period of one year.After fulfilling the definition of non-resolving pneumonia by clinical and radiological parameters, patients were evaluated by FOB with relevant microbiological, cytological, histopathological investigations and CT scan of thorax. CT-guided FNAC was done in selected cases where FOB was inconclusive.Sixty patients were enrolled in the study. Mean age was 51.33 ± 1.71 years with male to female ratio 2:1. Right lung was more commonly involved (65%), and right upper lobe was the commonest site (25%). Pyogenic infection was the commonest etiology (53.3%), bronchogenic carcinoma and tuberculosis accounted for 26.7% and 16.7% cases, respectively. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Both the procedures were safe, and no major complication was observed.Because of the high yield of FOB, it is very useful and safe diagnostic tool for evaluation of non-resolving pneumonia. CT-guided FNAC also gives good yield when cases are properly selected.