Comparison of efficacy of lung ultrasound and chest X-ray in diagnosing pulmonary edema and pleural effusion in ICU patients: A single centre, prospective, observational study

Background and Aims While chest X-ray (CXR) has been a conventional tool in intensive care units (ICUs) to identify lung pathologies, computed tomography (CT) scan remains the gold standard. Use of lung ultrasound (LUS) in resource-rich ICUs is still under investigation. The present study compares the utility of LUS to that of CXR in identifying pulmonary edema and pleural effusion in ICU patients. In addition, consolidation and pneumothorax were analyzed as secondary outcome measures. Material and Methods This is a prospective, single centric, observational study. Patients admitted in ICU were examined for lung pathologies, using LUS by a trained intensivist;and CXR done within 4 hours of each other. The final diagnosis was ascertained by an independent senior radiologist, based on the complete medical chart including clinical findings and the results of thoracic CT, if available. The results were compared and analyzed. Results Sensitivity, specificity and diagnostic accuracy of LUS was 95%, 94.4%, 94.67% for pleural effusion;and 98.33%, 97.78%, 98.00% for pulmonary edema respectively. Corresponding values with CXR were 48.33%, 76.67%, 65.33% for pleural effusion;and 36.67%, 82.22% and 64.00% for pulmonary edema respectively. Sensitivity, specificity and diagnostic accuracy of LUS was 91.30%, 96.85%, 96.00% for consolidation;and 100.00%, 79.02%, 80.00% for pneumothorax respectively. Corresponding values with CXR were 60.87%, 81.10%, 78.00% for consolidation;and 71.3%, 97.20%, 96.00% for pneumothorax respectively. Conclusion LUS has better diagnostic accuracy in diagnosis of pleural effusion and pulmonary edema when compared with CXR and is thus recommended as an effective alternative for diagnosis of these conditions in acute care settings. Our study recommends that a thoracic CT scan can be avoided in most of such cases.

Emergency Hybrid Correction in a Newborn with Critical Aortic Valve Stenosis with Acute Pulmonary Edema in the First Hour after Birth

Critical aortic valve stenosis in newborns is the cause of a severe clinical condition with the onset of symptoms during first hours after birth.We present a clinical case of a successful surgical correction of a critical aortic stenosis using a hybrid method applied in a newborn during the first day of life.The infant was diagnosed with a hypoplastic left heart complex with an intact atrial septum(aortic and mitral valves stenosis variant),that led to the cardiogenic shock and acute pulmonary edema.The procedure included bilateral banding of the pulmonary artery branches and atrioseptostomy with stenting of the interatrial septum.The surgery was performed through a median sternotomy.

Independent Lung Ventilation for Reexpansion Pulmonary Edema

Reexpansion pulmonary oedema (RPE) is a rare but potentially fatal complication with no clear cut guidelines for its management. When the injury to the lung is primarily one sided, conventional modes of ventilation can be ineffective and at times harmful. Selective or independent lung ventilation (ILV) is one of the therapeutic modality that can be used for the treatment of such cases. We report the successful treatment of reexpansion pulmonary oedema in 19-year-old boy using independent lung ventilation.

Preoperative Atrial Fibrillation and T-Wave Inversion Associated with Postoperative Pulmonary Edema

Background: Atrial fibrillation (AF) and T wave inversion (TWI) are occasionally found on pre-operative electrocardiograms (EKG) of patients with long standing hy-pertension (HTN) associated with left ventricular hypertrophy (LVH). Each of these two pathologies, AF and LVH, can impose negative hemodynamic effects on the car-diac function. Case: We present a case of a patient with AF, TWI and long standing HTN that went into post-operative pulmonary edema. Conclusion: Even returning to base line poorly controlled hypertension, and even more so during a hypertensive cri-sis, their concurrent presence may inflict even more detrimental effect manifested by elevation of pulmonary venous pressure and pulmonary edema.

Clinical,Laboratory and Imaging Features of High Altitude Pulmonary Edema in Tibetan Plateau

Objective To analyze characteristics of high altitude pulmonary edema(HAPE)in Chinese patients.Methods We performed a retrospective study of 98 patients with HAPE.We reviewed the medical records and summarized the clinical,laboratory and imaging characteristics of these cases,and compared the results on admission with those determined before discharge.Results Forty-eight(49.0%)patients developed HAPE at the altitude of 2800 m to 3000 m.Ninty-five(96.9%)patients were man.Moist rales were audible from the both lungs,and moist rales over the right lung were clearer than those over the left lung in fourteen patients.The white blood cells[(12.83±5.55)versus(8.95±3.23)×109/L,P=0.001)]as well as neutrophil counts[(11.34±3.81)versus(7.49±2.83)×109/L,P=0.001)]were higher,whereas the counts of other subsets of white blood cells were lower on admission than those after recovery(all P<0.05).Serum levels of alkaline phosphatase(115.8±37.6 versus 85.7±32.4 mmol/L,P=0.020),cholinesterase(7226.2±1631.8 versus 6285.3±1693.3 mmol/L,P=0.040),creatinine(85.2±17.1 versus 75.1±12.8 mmol/L,P=0.021),uric acid(401.9±114.2 versus 326.0±154.3 mmol/L,P=0.041),and uric glucose(7.20±1.10 versus 5.51±1.11 mmol/L,P=0.001)were higher,but carbondioxide combining power(CO2CP,26.7±4.4 versus 28.9±4.5 mmol/L,P=0.042)and serous calcium(2.32±0.13 versus 2.41±0.10 mmol/L,P=0.006)were lower on admission.Arterial blood gas results showed hypoxemia and respiratory alkalosis on admission.Conclusions In the present research,men were more susceptible to HAPE than women,and in the process of HAPE,the lesions of the right lung were more serious than those of the left lung.Some indicators of routine blood test and blood biochemistry of HAPE patients changed.

Neural histamine in the tuberomammillary nucleus regulates the onset of neurogenic pulmonary edema in rabbits

Objective： To explore the effect of neural histamine in the tuberomammillary nucleus（TM） on neurogenic pulmonary edema （NPE） onset in rabbits and the function of the rostral ventrolateral medulla（RVLM） in the neural histamine modulation of NPE. Methods： NPE was produced by the intracisternal injections of fibrinogen and thrombin. The contents of histamine in the TM and RVLM in rabbits were measured with high performance liquid chromatography（HPLC）. Rabbits were placed on a stereotaxic frame and microinjection cannulae were inserted into the TM and RVLM using brain atlas coordinates. Animals were pretreated with R- a -methylhistamine（MeHA） in the TM and chlorphenamine Mmaleate/cimetidine in the RVLM prior to establishing the NPE model. Changes in the lung water ratio and mean arterial pressure（MAP） were recorded, and paraffin sections of lung tissue were observed by light microscope. Results：We found that the contents of histamine（HA） in the TM and RVLM increased significantly with the onset of NPE. Pretreatment with MeHA in the TM and chlorphenamine Mmaleate in the RVLM significantly decreased MAP, and the lung water ratio and histological characteristics of the NPE in the rabbit model. Pretreatment with cimetidine in the RVLM had no effect on NPE. Conculsion：The results suggest that neural histamine in the TM is involved in the onset of NPE, and this effect of neural histamine is mediated by H1 receptor in the RVLM

Endothelial Nitric Oxide Synthase Gene Polymorphisms Associated with Susceptibility to High Altitude Pulmonary Edema in Chinese Railway Construction Workers at Qinghai-Tibet over 4500 Meters above Sea Level

Objective To examine whether the polymorphisms of endothelial nitric oxide synthase (eNOS) gene are associated with the susceptibility to high altitude pulmonary edema (HAPE) in Chinese railway construction workers at Qinghai-Tibet where the altitude is over 4 500 m above sea level. Methods A case-control study was conducted including 149 HAPE patients in the construction workers and 160 healthy controls randomly recruited from their co-workers, matching the patients in ethnicity, age, sex, lifestyle, and working conditions. Three polymorphisms of eNOS gene, T-786C in promoter, 894G/T in exon 7, and 27bp variable number tandem repeat (VNTR) in intron 4, were genotyped using polymerase chain reaction (PCR) and confirmed with DNA sequencing. Results The frequencies of 894T allele and heterozygous G/T of the 894G/T variant were significantly higher in HAPE patients group than in the control group (P=0.0028 and P=0.0047, respectively). However, the frequencies of the T-786C in promoter and the 27bp VNTR in intron 4 were not significantly different between the two groups. Haplotypic analysis revealed that the frequencies of two haplotypes (H3,T-T-b, b indicates 5 repeats of 27 bp VNTR; H6, C-G-a, a indicates 4 repeats of 27 bp VNTR) were significantly higher in HAPE patients (both P<0.0001). On the contrary, the frequencies of H1 (T-G-b) and H2 (T-G-a) were lower in HAPE patients than in healthy controls (both P<0.001). Conclusions Two haplotypes (T-T-b and C-G-a) may be strongly associated with susceptibility to HAPE. Compared with the individual alleles of eNOS gene, the interaction of multiple genetic markers within a haplotype may be a major determinant for the susceptibility to HAPE.

Unilateral pulmonary hemorrhage caused by negative pressure pulmonary edema:A case report

BACKGROUND Unilateral pulmonary hemorrhage is typically reported in young and healthy men with upper respiratory tract obstruction during anesthesia in special situations.Negative pressure in the lungs is created,resulting in negative pressure pulmonary edema(NPPE).CASE SUMMARY A 78-year-old male patient diagnosed with spinal stenosis was admitted to receive a unilateral laminectomy with bilateral decompression.The patient had been diagnosed with hypertension four years earlier and asthma more than 70 years earlier.We experienced a unilateral alveolar hemorrhage associated with NPPE that occurred in a longstanding asthma patient who bit the intubated endotracheal tube for a short period during posture change at the end of surgery.Because diffuse alveolar hemorrhage accompanied by NPPE was caused in this case by airway obstruction in an older patient with asthma without known risk factors,anesthesiologists should be careful not to induce airway irritation during anesthesia awakening in asthma patients.CONCLUSION Because diffuse alveolar hemorrhage accompanied by NPPE can occur,anesthesiologists should take care not to induce airway irritation.

Diagnosis and Treatment Options for Pulmonary Embolism (PE) in the Acute Care Setting

Thromboembolic diseases continue to be one of the most prevalent medical problems today and can lead to life-threatening conditions, such as pulmonary embolism (PE). Currently, PE diagnosis and treatment are a challenge because of acute onset right ventricular strain with right-sided heart failure, sudden death, pulmonary infarction, and cardiogenic shock, which limit the time for therapeutic success.?The aim of this study was to evaluate our perception, knowledge, and concerns regarding PE, discuss the importance of promptly diagnosing PE to provide appropriate treatment options for this life-threatening condition, list the most common clinical manifestations present when PE is suspected, and review the clinical approach to patients with suspected PE in an inpatient setting.?In addition, this study reviews the risk stratification of patients with PE and treatment options beyond anticoagulation, compares new treatment options for patients presenting with acute symptomatic PE, and compares aspiration catheters (10 F Pronto .035” and 14 F XL extraction catheter (Vascular Solutions, Minneapolis, MN)) and ultrasound-assisted catheter-directed thrombolysis (USAT) versus systemic thrombolysis.This literature review was limited by the quality and number of studies available regarding new treatment options for patients presenting with acute symptomatic PE. Thus, more studies are needed to prove the validity of newer treatment options being trialed, such as aspiration catheters (10 F Pronto .035” and 14 F XL extraction catheter) and USAT, with the hope that further studies will guide patient management and increase our understanding of next generation aspiration catheters, which may provide novel insights on treating acute symptomatic PE.

Studies on monitoring hemodynamics and oxygen dynamics of adult respiratory distress syndrome secondary to high altitude pulmonary edema

To study monitoring hemodynamics and oxygen dynamics of adult respiratory distress syndrome (ARDS) secondary to high altitude pulmonary edema (HAPE),we performed clinic and laboratory studies in 8 patients who preliminarily developed high altitude cerebral edema (HACE) and then ARDS occurred at an altitude of 4 500 m. After an initial emergency treatment on high mountains,all the patients were rapidly transported to a hospital at a lower altitude of 2 808 m. The right cardiac catheterizations were carried out within 5 h after hospitalized. The monitoring hemodynamics and oxygen dynamics were studied via a thermodilution Swan-Gaze catheter. The results showed that before treatments at the beginning of monitoring,there presented a significant pulmonary artery hypertension with a decreased cardiac function,and a lower oxygen metabolism in all the 8 patients. However,after some effective treatments,including mechanical ventilation and using dexamethasone,furosemide,etc,four days later the result of a repeated monitoring showed that their pulmonary artery pressure had been decreased with an improved cardiac function with all the oxygen metabolic indexes increased significantly. Our studies suggested that performing monitoring hemodynamics in patients with ARDS secondary to HAPE will define the clinical therapeutic measures which will benefit the outcome.

Subclinical high altitude pulmonary edema: A clinical observation of 12 cases in Yushu

During the Yushu Earthquake on April 14,2010,a high incidence of acute high altitude illness was observed in the mountain rescuers,and 0.73 % of these patients suffered from high altitude pulmonary edema,of which 12 patients developed subclinical pulmonary edema and concomitantly contracted acute mountain sickness. Symptoms and signs were atypically high heart rate with high respiratory rate,striking cyanosis,and significantly low oxygen saturation,whereas no moist rates were heard on auscultation,and Chest X-ray showed peripheral with a patchy distribution of mottled infiltrations in one or both lung fields. We believe that subclinical high altitude pulmonary edema is an earliest stage of pulmonary edema at high altitude. The possible pathogenesis and the diagnosis were discussed.

Study on pulmonary injury due to acute H_2S inhalation and its therapeutic scheme

Pulmonary injury after acute H2S inhalation was studied with bronchoalveolar lavage（BAL）,ultracentrifuge,and optical and electron microscopy.The changes of the activities oflactate dehydrogenase,alkaline and acid phosphatase,and angiotension converting enzymes inBAL fluid were used as the indicator of cellular damages,those of leucocytic count and the indi-cator of inflammatory response,and those of the concentration of protein and Evans blue as theindicator of vascular permeability.In addition the effects of H2S on lipid peroxidation,naturalantioxidative system and energy substances and the changes of phospholipid concentration inBAL fluid were also observed.The results were as follows:1.Inhalation of H2S exerted a severe cytotoxic effect on the lung tissues resulting in dam-ages on various types of cells and a severe edematogenic effect on lung parenchyma.2.The development of pulmonary edema in H2S intoxication resulted from a combination ofdifferent pathogenic factors.3.The biochemical changes and their recovery occurred earlier than the pathologicalchanges and their recovery.The efficacy of 6 categories of drugs including 25 medicaments against H2S intoxication wasevaluated in mice,and 10 drugs were found to be prophylactically effective.The effects of vari-ous methemoglobin-forming agents and some other drugs were also studied in their treatment ofH2S intoxication in rabbits and dogs.It was concluded that methemoglobin-forming agentscould be used as specific antidotes but could not provent or alleviate the lung damages due toH2S inhalation unless they were administered in association with dexamethasone,vitamin E oranisodamine.A scheme of the medical treatment for H2S intoxication was presented.

Re-expansion pulmonary edema in a boy with spontaneous pneumothorax during an influenza B virus infection

Re-expansion Pulmonary Edema (RPE) is an uncommon complication following rapid re-expansion of the lungs, and the most common disorder associated with RPE is spontaneous pneumothorax. The majority of patients with RPE associated with pneumothorax have been adults;only 4 cases have been reported in children. We present a patient who developed RPE after treatment of spontaneous pneumothorax that occurred during an influenza B virus infection. His condition improved only with oxygen supplementation and intravenous corticosteroids. Infection with influenza B virus leads to increased production of lung epithelial oxidants, which might have contributed to the development of RPE in our patient.

Anesthetic Dilemma: Spinal Anesthesia in a Severe Pre-Eclamptic Patient with Twin Gestation, Heart Failure and Acute Pulmonary Edema

Background: Severe preeclampsia with acute pulmonary oedema possesses great challenges to the anaesthetist. If not well managed, it could be associated with high maternal morbidity and mortality rate as well as fetal wastage. Aim: To sensitize the anaesthetist that when confronted with such a dilemma, well managed low spinal block can be a useful and successful anaesthetic technique. Methods: We report the case of a 23-year-old primigravida with twins gestation at 36 weeks, who presented with severe ante-partum pre-eclapsia, acute pulmonary oedema and acute heart failure. Blood investigations done were normal, and clotting time was within normal range. Her clinical conditions were optimized through a well thoughtful medication after which a low dose spinal anesthesia was performed using 1.5 mls (7.5 mg) of 0.5% hyperbaric bupivacaine (Modified saddle). The baby was delivered through a low segment caesarean section. Conclusion: The procedure was well tolerated and successful. Low spinal is associated with low incidence of hypotension and do not require pre-loading.

Negative Pressure Pulmonary Edema on Extubation of a 9-Month-Old Baby Boy

Background: Negative Pressure Pulmonary Edema (NPPE) is an uncommon, but well recognized clinical entity that continues to be reported as a complication of upper airway obstructions during induction or emergence. It results from the negative intrathoracic pressure generated with spontaneous ventilation with concurrent upper airway obstruction. Aim: To present an unusual case of NPPE and review the pathophysiology and treatment. Case: It usually occurs in young healthy athletic adults. We are reporting NPPE in a nine-month-old ex-premature baby. We discuss his intraoperative events leading to NPPE, subsequent intraoperative course and treatment. Conclusion: NPPE needs to be promptly recognized and treated. If the edema resolves, the patient can be successfully extubated, but should be observed overnight.

Hematocrit level correlates with lungs resistivity in elderly patients with cardiogenic pulmonary edema

Regular monitoring of pulmonary congestion in car-diogenic pulmonary edema (CPE) patients is neces-sary for its adequate management via pharmaceuti-cal treatment. It is well known that the development of CPE is accompanied with an increase in hema-tocrit, plasma protein concentration and colloid os-motic pressure due to the decrease in the plasma volume. In the present study the mean left and right lung resistivity values taken pre- and post treatment with diuretics using a hybrid bio-impedance electri-cal impedance tomography system were correlate to the measured changes in hematocrit level. A marginal significant correlation was found between the abso-lute mean lung resistivity and hematocrit levels (Pearson’s correlation coefficient of R = 0.4, p-value = 0.057). When the change in the mean lung resistivity of a patient was plotted vs. the change in hematocrit readout, a significant linear correlation was found (R = 0.7, p-value = 0.02). These results support the validity of the resistivity measurements using bio-impedance system in monitoring changes of pulmonary edema in CPE patients.

Erratum to “Anesthetic Dilemma: Spinal Anesthesia in a Severe Pre-Eclamptic Patient with Twin Gestation, Heart Failure and Acute Pulmonary Edema”

Background: Severe preeclampsia with acute pulmonary oedema possesses great challenges to the anaesthetist. If not well managed, it could be associated with high maternal morbidity and mortality rate as well as fetal wastage. Aim: To sensitize the anaesthetist that when confronted with such a dilemma, well managed low spinal block can be a useful and successful anaesthetic technique. Methods: We report the case of a 23-year-old primigravida with twins gestation at 36 weeks, who presented with severe ante-partum pre-eclapsia, acute pulmonary oedema and acute heart failure. Blood investigations done were normal, and clotting time was within normal range. Her clinical conditions were optimized through a well thoughtful medication after which a low dose spinal anesthesia was performed using 1.5 mls (7.5 mg) of 0.5% hyperbaric bupivacaine (Modified saddle). The baby was delivered through a low segment caesarean section. Conclusion: The procedure was well tolerated and successful. Low spinal is associated with low incidence of hypotension and do not require pre-loading.

Proteomic identification of human serum biomarkers associated with high altitude pulmonary edema

Objective High altitude pulmonary edema(HAPE), a life-threatening disease, has no biological markers used for the routine prevention, diagnosis and treatment. The aim of this study was to identify serum proteins differentially expressed in patients with HAPE for discovering essential biomarkers. Methods A complete serum proteomic analysis was performed on 10 HAPE patients and on 10 high altitude and 11 sea level healthy people as control using two-dimensional gel electrophoresis, followed by matrixassisted laser desorption/ionization mass spectrometry and peptide mass fingerprinting. Finally, two most significantly changed proteins were validated by enzyme-linked immunosorbent assay(ELISA). Results Eight protein spots stained with differential intensity, respresenting 5 distinct proteins were identified in patients compared with healthy controls through analysis of these composite gels. Among them, four proteins, namely alpha 1-antitrypsin(α1-AT), Haptoglobin(Hp), apolipoprotein A-I(apoA-1) and Complement C3 increased remarkably, while one protein, apolipoprotein A-IV(apoA-IV) decreased significantly. The variation of α1-AT and Haptoglobin, as detected by ELISA, was consistent with the results from proteomic analysis. Conclusions It is well known that Hp, α1-AT and complement C3 are associated with inflammation and apoA-1 and apoA-IV play important roles in lipid absorption, transport and metabolism. Therefore, the significant expression changes of Hp, α1-AT and complement C3 and apoA-1 and apoA-IV between HAPE patients and their corresponding healthy controls highlight the role of inflammatory response system and lipid metabolism system in the pathophysiology of HAPE.