Chest

Pulmonary arterial hypertension is most often diagnosed in its advanced stages because of the nonspecific nature of early symptoms and signs. Although clinical assessment is essential when evaluating patients with suspected pulmonary arterial hypertension, echocardiography is a key screening tool in the diagnostic algorithm. It provides an estimate of pulmonary artery pressure, either at rest or during exercise, and is useful in ruling out secondary causes of pulmonary hypertension. In addition, echocardiography is valuable in assessing prognosis and treatment options, monitoring the efficacy of specific therapeutic interventions, and detecting the preclinical stages of disease. (J Am Soc Echocardiogr 2012;-:---.) High CO can be present in hyperkinetic conditions, such as systemic-to-pulmonary shunts (only in the pulmonary circulation), anemia, hyperthyroidism, and so on.

services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml Objective: To define competence in critical care ultrasonography (CCUS). Design: The statement is sponsored by the Critical Care NetWork of the American College of Chest Physicians (ACCP) in partnership with La Socié té de Ré animation de Langue Française (SRLF). The ACCP and the SRLF selected a panel of experts to review the field of CCUS and to develop a consensus statement on competence in CCUS. Results: CCUS may be divided into general CCUS (thoracic, abdominal, and vascular), and echocardiography (basic and advanced). For each component part, the panel defined the specific skills that the intensivist should have to be competent in that aspect of CCUS. Conclusion: In defining a reasonable minimum standard for CCUS, the statement serves as a guide for the intensivist to follow in achieving proficiency in the field. (CHEST 2009; 135:1050 -1060) Abbreviations: ACCP ϭ American College of Chest Physicians; CCE ϭ critical care echocardiography; CCUS ϭ critical care ultrasonography; GCCUS ϭ general critical care ultrasonography; IVC ϭ inferior vena cava; LV ϭ left ventricle, ventricular; RV ϭ right ventricle, ventricular; SRLF ϭ La Société de Ré animation de Langue Française; TEE ϭ transesophageal echocardiography; TTE ϭ transthoracic echocardiography; 2D ϭ two-dimensional

Background: Hypocholesterolemia is common among tuberculous patients and is associated with mortality in miliary cases. Some in vitro studies have shown that cholesterol is necessary for the good functioning of macrophages and lymphocytes. Study objectives: To determine whether a cholesterol-rich diet could accelerate sputum sterilization in patients with pulmonary tuberculosis. Design: An 8-week follow-up, randomized, controlled trial carried out from March 2001 to January 2002. Setting: A third-level hospital for respiratory diseases in Mexico City.

RD, Lovoi MS, et al. Undiagnosed sleep apnea in patients with essential hypertension. Ann Intern Med 1985; 103:190-95 2 Partinen M, Guilleminault C. Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea pa¬ tients. Chest 1990; 97:27-32 3 Palomaki H. Snoring and the risk of ischemic brain infarction. Stroke 1991; 22:1021-25 4 He J, Kryger MH, Zorick FJ, et al. Mortality and apnea index in obstructive sleep apnea: experience in 385 male patients. Chest 1988; 94:9-14 5 Lavie P, Herer P, Peled R, et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep 1995; 18:149-57 6 Krieger J, Follenius M, Sforza E, et al. Effects of treatment with nasal continuous positive airway pressure on atrial natriuretic peptide and arginine vasopressin release during sleep in patients with obstructive sleep apnoea. Clin Sci 1991; 80:443-49 7 Ringler J, Basner RC, Shannon R, et al. Hypoxemia alone does not explain blood pressure elevations after obstructive apneas. J Appl Physiol 1990; 69:2143-48 8 Philip P, Stoohs R, Guilleminault C. Sleep fragmentation in nor¬ mals: a model for sleepiness associated with upper airway resis¬ tance syndrome. Sleep 1994; 17:242-47 9 Phillipson EA, Bowes G, Sullivan CE, et al. The influence of sleep fragmentation on arousal and ventilatory responses to respiratory stimuli. Sleep 1980; 3:281-88 10 Guilleminault C, Tilkian AG, Dement WC. Sleep and respiration in the syndrome "apnea during sleep" in the child. Electroencephalogr Clin Neurophysiol 1976; 41:367-78 11 Berthon-Jones M, Sullivan CE. Ventilatory and arousal responses to hypoxia in sleeping humans. Am Rev Respir Dis 1982; 125:632-39 12 Guilleminault C, Kim Y-D, Stoohs, RA. Upper airway resistance syndrome. Oral Maxillofacial Surg Clin North Am 1995; 7:243-56 13 Kribbs NB, Pack AI, Kline LR, et al. Effects of one night with¬ out nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea.

Although maximal inspiratory pressure (MIP) is used as an index of inspiratory muscular strength, there is no consensus on how to measure it. We compared, during weaning from mechanical ventilation, two methods of measurement to determine which shows the greater values (MIPbest) and is more reproducible. One method measured MIP when negative pressure was maintained for at least 1 s after a forceful expiration, and the other method measured MIP with a unidirectional expiratory valve (MIPuni). Design: The study had a crossover design, and patients randomly performed three measurements of each method (t1). The procedure was repeated by the same observer after 20 min (t2). The maximal value in each method was considered. Setting : ICU, Hospital A.C. Camargo, Sã o Paulo, Brazil. Patients: Fifty-four consecutive patients undergoing short-term mechanical ventilation who became eligible for the study when their physicians decided to restore spontaneous breathing. Results: MIPbest values were arrived at using MIPuni 75% of the time either in t1 or t2. MIPuni yielded a higher average of MIPbest values in t1 and t2 (p < 0.0001). The effort-to-effort coefficient of variation of one method compared with the other during t1 and t2 was similar (p > 0.2 for t1; p > 0.8 for t2). Also, when comparing t1 and t2, the coefficients of variation were similar for each method (p > 0.62). Conclusions: Because MIPuni displayed the maximal values, it is the best method for estimating MIP in patients undergoing short-term mechanical ventilation. The reproducibility of consecutive measurements was similar between the methods, even after a short period of time.

CT image screening inherently involves a complex interplay of many factors: risk of developing lung cancer, quality of screen ing, judicious judgment in evaluation and management of screening fi ndings, competing risks and compliance. Accounting for this complexity is particularly important in evaluating the effect of screening as we try to defi ne how it will work outside the context of a controlled study. As the risk of lung cancer increases, so do the risks of competing causes of death and potential complication of screen ing and treatment. The elevation in risk associated with the presence of COPD is an intriguing example. Although COPD increases the risk of lung cancer, it also hinders the interpretation of CT scans, increases the risks associated with surgical treatment, and overall shortens life expectancy-all features that detract from the benefi ts of CT image screening. We look forward to carefully constructed modeling studies that help shed light on these matters.

A practical diagnostic algorithm for approaching the solitary pulmonary nodule (SPN), stratifying clinical risk factors in a standardized manner and blending this information with radiologic clues, would point the physician toward a benign or malignant cause. 1-7 Such an approach would be expected to spare patients with benign causes the morbidity and cost associated with invasive tissue sampling and, at the same time, guide the physician toward recommending invasive tests for the nodules likely to be malignant.

... DISCLOSURE: Fidaa Shaib, No Financial Disclosure Information; No Product/Research Disclosure Information ... WITH SE-VERE SEPSIS REGARDLESS OF THE SITE OF INFECTION Joe G. Zein MD George Nassif MD* Mohammad-Ali El-Harakeh MD Gary T. Kinasewitz MD ...

The anatomy and neurophysiology of cough has been reviewed in the preceding section. The objective of this section is to describe how the varied anatomic components of the respiratory system work in concert to produce an effective cough. Methods: This was accomplished by reviewing (1) the factors needed to produce effective cough pressures and gas velocity in the airways, and (2) the salient features of the interaction between the airflow generated during a cough and the mucus that lines the tracheobronchial tree. The MEDLINE database was searched for this review, and the search consisted of studies published in English between 1960 and April 2004. Search terms were "cough mechanics" and "cough physiology." Results: Inhaling to high lung volumes and glottic closure prior to the expiratory phase of cough facilitate the generation of high intrathoracic pressures. These high intrathoracic pressures (1) provide the driving force for airstream flow during cough and (2) dynamically compress the central airways, which further enhances the cough airstream velocity. Conclusions: High intrathoracic pressures are needed to generate the requisite cough expiratory flows and airstream velocities. However, cough may be effective in individuals with mild-tomoderate degrees of respiratory muscle weakness, as only modest increases in intrathoracic pressure are needed to dynamically compress the large intrathoracic airways and increase cough flow velocity.

Natural disasters, industrial accidents , terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government offi cials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of suffi cient quality were identifi ed. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modifi ed Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care.

Objective: The purpose of this research was to evaluate the discrimination and calibration of mortality prediction of Simplified Acute Physiology Score 2, Simplified Acute Physiology Score 3, Mortality Probability Model II, and Mortality Probability Model III in peripartum women. Design: A retrospective cohort study.

BACKGROUND: Among patients with OSA, a higher number of medical morbidities are known to be associated with those who have obesity hypoventilation syndrome (OHS) compared with OSA alone. OHS can pose a higher risk of postoperative complications after elective noncardiac surgery (NCS) and often is unrecognized at the time of surgery. The objective of this study was to retrospectively identify patients with OHS and compare their postoperative outcomes with those of patients with OSA alone. METHODS: Patients meeting criteria for OHS were identified within a large cohort with OSA who underwent elective NCS at a major tertiary care center. We identified postoperative outcomes associated with OSA and OHS as well as the clinical determinants of OHS (BMI, apnea-hypopnea index [AHI]). Multivariable logistic and linear regression models were used for dichotomous and continuous outcomes, respectively. RESULTS: Patients with hypercapnia from definite or possible OHS and overlap syndrome are more likely to experience postoperative respiratory failure (OR, 10.

Pulmonary diseases are increasingly important causes of morbidity and mortality in the modern world. The COPDs are the most common chronic lung diseases, and are a major cause of lung-related death and disability. [1] Pulmonary rehabilitation has emerged as a ...

Background-Low tidal volume ventilation for Acute Respiratory Distress Syndrome (ARDS) is a well accepted concept. However, controversy persists regarding the optimal ventilator settings for ventilated patients without ARDS. This study tested the hypothesis that ventilator settings influence the development of new ARDS. Methods-Retrospective analysis of patients from the MIMIC-II database who were mechanically ventilated for ≥48 hours between 2001 and 2005. Results-2583 patients required greater than 48 hrs of ventilation. Of 789 patients who did not have ARDS at admission, 152 (19%) went on to develop ARDS. Univariate analysis revealed high peak inspiratory pressure (PIP) (OR 1.53 per standard deviation, 95% confidence interval 1.28-1.84), increasing PEEP (OR 1.35 per SD, 95%CI 1.15-1.58) and tidal volume (OR 1.36 per SD, 95%CI 1.12-1.64) to be significant risk factors. Major non-ventilator risk factors for ARDS included sepsis, low pH, elevated lactate, low albumin, transfusion of packed red blood cells, transfusion of plasma, high net fluid balance, and low respiratory compliance. Multivariable logistic regression showed that peak pressure (OR 1.31 per SD, 95%CI 1.08-1.59), high net fluid balance (OR 1.3 per SD, 95%CI 1.09-1.56), transfusion of plasma (OR 1.26 per SD, 95%CI 1.07-1.49), sepsis (OR 1.57, 95%CI 1.00-2.45) and tidal volume (OR 1.29 per SD, 95%CI 1.02-1.52) were significantly associated with the development of ARDS. Conclusions-The associations between the development of ARDS and clinical interventions, including high airway pressures, high tidal volume, positive fluid balance and transfusion of blood products, suggests that ARDS may be a preventable complication in some cases.

and components of the work of breathing. Pressure support. Changes in ventilatory pattern http://chestjournal.chestpubs.org/content/100/4/1082 can be found online on the World Wide Web at: The online version of this article, along with updated information and services ) ISSN:0012-3692 http://chestjournal.chestpubs.org/site/misc/reprints.xhtml Downloaded from 3.645±0.077 * &Jl conventions are as in Table 1. The ratio ofWOBvror/\VOB ror per minute is the same as that per liter as shown in Table 1. tDenotes p<O.Ol compared with PSL =0 values. jDenotes p<O.OOS compared with PSL=0 values. §Denotes P<.05 compared with PSL=0 values by F test with Bonferroni correction.

and services can be found online on the World Wide Web at: The online version of this article, along with updated information ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml Downloaded from 152 Clinical Investigations

Practice guidelines on weaning should be based on the results of several well-designed randomized studies performed over the last decade. One of those studies demonstrated that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation as compared with a more gradual discontinuation of ventilatory support. Two other studies showed that the ability to breathe spontaneously can be adequately tested by performing a trial with either T-tube or pressure support of 7 cmH 2 O lasting either 30 or 120 min. In patients with unsuccessful weaning trials, a gradual withdrawal for mechanical ventilation can be attempted while factors responsible for the ventilatory dependence are corrected. Two randomized studies found that, in difficult-to-wean patients, synchronized intermittent mandatory ventilation (SIMV) is the most effective method of weaning.

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Background: The aims of this study were to evaluate the incidence of unexplained pulmonary hypertension (PH) among patients with end-stage renal disease (ESRD) and to suggest possible etiologic factors. Methods: The incidence of PH was prospectively estimated by Doppler echocardiography in 58 patients with ESRD receiving long-term hemodialysis via arteriovenous access, and in control groups of 5 patients receiving peritoneal dialysis (PD) and 12 predialysis patients without a known other cause to suggest the presence of PH. Clinical variables were compared between patients with and without PH receiving hemodialysis. Changes in pulmonary artery pressure (PAP) values before and after onset of hemodialysis via arteriovenous access, arteriovenous access compression, and successful kidney transplantation were recorded. Results: PH > 35 mm Hg was found in 39.7% of patients receiving hemodialysis (mean ؎ SD, 44 ؎ 7 mm Hg; range, 37 to 65 mm Hg), in none of the patients receiving PD, and in 1 of 12 predialysis patients. Patients with PH receiving hemodialysis had a significantly higher cardiac output (6.9 L/min vs 5.5 L/min, p ‫؍‬ 0.017). PH developed in four of six patients with normal PAP after onset of hemodialysis therapy via arteriovenous access. One-minute arteriovenous access compression in four patients decreased the mean systolic PAP from 52 ؎ 7 to 41 ؎ 4 mm Hg (p ‫؍‬ 0.024). PH normalized in four of five patients receiving hemodialysis following kidney transplantation. Kaplan-Meier survival analysis according to PAP values revealed significant survival differences (p < 0.024).

Adaptive support ventilation (ASV) is a closed loop mode of mechanical ventilation (MV) that provides a target minute ventilation by automatically adapting inspiratory pressure and respiratory rate with the minimum work of breathing for the patient. The aim of this study was to determine the effect of ASV on total MV duration when compared to Pressure Assist/Control Ventilation (P-ACV). Adult medical patients intubated and mechanically ventilated for more than 24 hours in a medical ICU were randomized either to ASV or P-ACV. Sedation and medical treatment were standardized for each group. Primary outcome was the total MV duration. Secondary outcomes were the weaning duration, number of manual settings of the ventilator and weaning success rates. Two hundred and twenty nine patients were included. Median MV duration until weaning, weaning and total MV duration were significantly shorter in the ASV group [67 (43-94) vs. 92 (61-165) hours, p= 0.003; 2 (2-2) vs. 2 (2-80) hours, p=0.001 ...

For many years adjuvant chemotherapy has been a standard treatment after complete resection in malignancies such as breast and colon but only recently has its use become standard in early stage non-small cell lung cancer (NSCLC). Although surgery is regarded as the best possible treatment for early stage NSCLC, only 20-25% of patients have resectable disease at presentation. Despite optimal surgical treatment, 5-year survival rates for NSCLC remain 50-60% for stage IB, 40-50% for stage II, and 20-30% for stage III (Kohler et al., 2011; Siegel et al., 2011). Adjuvant chemotherapy provides additional survival benefit in resected NSCLC but questions remain as to how to select patients for therapy and which regimen is best. Other than work with tegafur/uracil in Japan, the positive adjuvant trials have all utilized a cisplatin backbone, but the drug(s) to pair with cisplatin are a matter of debate and will be discussed further in this manuscript.

We hypothesized that the increased arousal threshold to upper airway occlusion exhibited by patients with obstructive sleep apnea (OSA) is in part secondary to the disease process itself. To test this hypothesis, we studied the effects of withdrawal of three nights of nasal continuous positive airway pressure (CPAP) treatment on arousal in six male patients with severe OSA who were using nasal CPAP on a long-term basis. During the control week, patients slept with nasal CPAP at home and on the first of 2 nights in the sleep laboratory (night CI, CPAP; night C2, no CPAP). During the apnea week, patients slept without nasal CPAP for 2 nights at home and 2 nights in the sleep lab¬ oratory (API, AP2). The control and apnea weeks were consecutive and in random order. The mean (±SEM) apnea+hypopnea index was 76.9±7.1 on API vs 3.1 ±1.0 events per hour on CI (p<0.05). Thus, the laboratory night (and presumably the 2 nights at home) preceding AP2 had dramatic in¬ creases in apnea compared with the nights preceding C2. The apnea duration during nonrapid eye movement sleep on nights following apnea was greater (AP2: 28.7±1.5 vs C2: 25.5±1.7 s; p<0.05) and the arousal threshold as reflected by the maximum esophageal pressure deflection preceding arousal was higher (DPmax) (AP2: 55.1 ±5.7 vs C2: 45.3±6.4 cm H20; p<0.005). We conclude that prior sleep apnea increases the arousal threshold to upper airway occlusion on subsequent nights and prolongs the apneic events. (CHEST 1996; 109:1490-96)

Pseudomonas aeruginosa airway infection. At study enrollment, patients in the study 1-exacerbation had symptoms indicative of pulmonary exacerbation (n ‫؍‬ 84; < 14 years of age, 31 patients; > 14 years of age, 53 patients); patients in study 2-stable had stable respiratory symptoms (n ‫؍‬ 140; < 14 years of age, 14 patients; > 14 years, 126 patients). Methods: The anchor-based method utilized a global rating-of-change questionnaire (GRCQ) that assessed patients' perceptions of change in their respiratory symptoms after TIS treatment. The mean change from baseline CFQ-R-Respiratory scores were mapped onto the GRCQ to estimate the MCID. The two distribution-based methods were as follows: (1) 0.5 SD of mean change in CFQ-R-Respiratory scores (baseline to end of TIS treatment); and (2) 1 SEM for baseline CFQ-R-Respiratory scores. Triangulation of these three estimates defined the MCIDs. Results: MCID scores were larger for patients in study 1-exacerbation (8.5 points) than for those in study 2-stable (4.0 points), likely reflecting differences in patient disease status (exacerbation/ stable) between these studies.

To develop and validate a model based on smoking rates that will provide reliable estimates of the true prevalence of COPD that include both clinically detected and undetected patients. Design: Model based on literature review. Age-and gender-specific rates of lung impairment by smoking status were applied to US smoking data. Resultant estimates were compared to the actual prevalence of obstructive airway disease as estimated by US national surveys. The model then was applied to estimate the prevalence of COPD in several European countries, where national data on undiagnosed lung disease do not exist. Setting: The model was adapted from both a literature review and health-care data, and the analysis was applied to the United States and Europe. Results: Using smoking rates, we estimate from our model that 15.3 million people who are > 40 years of age in the United States have COPD. The prevalence estimate, based on spirometric definitions for COPD in the same age group using the Third National Health and Nutrition

after coronary artery bypass graft surgery. Time course of recovery from frostbitten phrenics http://chestjournal.chestpubs.org/content/99/5/1112 can be found online on the World Wide Web at: The online version of this article, along with updated information and services ) ISSN:0012-3692 http://chestjournal.chestpubs.org/site/misc/reprints.xhtml

E xtracorporeal membrane oxygenation (ECMO) refers to an extracorporeal circuit through which blood is oxygenated and CO 2 is removed. With current technology, severe respiratory or cardiac failure may be either partially or completely supported with ECMO. Advances in extracorporeal technology and techniques as well as the creation of mobile ECMO teams that can retrieve and transport patients on the mechanical device have contributed to the expansion of its use worldwide. 1,2 The ability of ECMO to replace the function of the heart or lungs, and to do so rapidly and for prolonged periods of time, allows ECMO to be used as a bridge to recovery in cases of potentially reversible organ failure, a bridge to transplant in cases of end-stage cardiac or respiratory failure, a bridge to device therapy in select cases of cardiac failure, or a bridge to decision when the prognosis remains uncertain, for instance, when used in cardiac arrest, referred to as extracorporeal CPR (ECPR) . 3-7 Given the numerous potential applications for ECMO in critically ill patients, ethical issues will inevitably emerge regarding its appropriate initiation and management.