Pneumothorax in patients with respiratory failure in ICU

Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.     

Tropical pyomyositis in a Greek adult

A case of tropical pyomyositis in a 24-year-old Greek is reported. The patient presented with high fever and swelling of the left thigh, generalized lymphadenopathy and multiple infiltrations in both lung fields on X-ray of the chest. Multifocal muscle abscesses were detected by CT scan of the left thigh and gluteal area. Staphylococcus aureus was identified in cultures of the purulent material which was surgically drained. The patient was subsequently treated with appropriate antibiotics. Lack of familiarity with this disease caused diagnostic confusion and delayed the initiation of treatment.     

Delayed closure of persistent postpneumonectomy bronchopleural fistula

A 73-year-old man with a history of postpneumonectomy empyema and a long-term chest tube since 1979 presented with fever, chills, leukocytosis, and purulent fluid from the left tube thoracostomy. CT scan and bronchoscopy demonstrated a right lower lobe pneumonia and a left mainstem dehiscence with direct communication to the left tube thoracostomy. He underwent primary closure of the bronchopleural fistula with latissimus dorsi muscle flap coverage after antibiotic therapy for right lower lobe pneumonia.     

Lung ultrasound in the diagnosis of stroke-associated pneumonia

Pneumonia is a common complication in stroke patients; it is associated with an adverse outcome, prolonged hospital stay and increased health costs. The aim of this study was to assess the ability of lung ultrasound to rule in or rule out pneumonia in patients with stroke. Patients with ischemic or hemorrhagic stroke were included in the study if they had a clinical suspicion of pneumonia. Lung ultrasound imaging and chest X-ray studies were performed within 24 h from the onset of symptoms of pneumonia; the sonographer and radiologists were unaware of the chest X-ray study and ultrasound imaging results, respectively. In case of discordant results, lung computed tomography (CT) was performed if a definitive diagnosis was required to optimize clinical management. Seventy patients were included in the study. Among 24 patients with unilaterally positive chest X-ray studies, the ultrasound imaging was unilaterally positive in 19 cases (79.2 %), bilaterally positive in 3 cases (12.5 %) and negative in 2 cases (8.3 %). Among 44 patients with negative chest X-ray studies, ultrasound imaging was unilaterally positive in 17 cases (38.6 %), bilaterally positive in 2 cases (4.6 %), negative in 19 cases (43.2 %) and non-conclusive in 6 cases (13.6 %). A lung CT scan was performed in 9 of the 21 discordant cases, and it always confirmed the ultrasound imaging results. Ultrasound imaging and chest X-ray studies were concordant in 42 out of 63 cases, 66.7 % (Pearson χ² = 11.97, p = 0.001). In conclusions, this study shows the utility of LUS imaging to rule in or rule out pneumonia in patients with stroke. We believe that lung ultrasound imaging can help clinicians in the diagnosis of stroke-associated pneumonia.     

Rheumatoid arthritis-associated bronchiolitis successfully treated with erythromycin]

A 52-year-old man with a 4-year history of rheumatoid arthritis, and who had an episode of suspected BOOP in early 1994, was admitted to our hospital because of cough and fever. A chest X-ray film on admission showed small patchy infiltrates, and a computed tomographic (CT) scan showed centrilobular nodules and patchy infiltrates with thickened broncho-vascular bundles in both lungs. Transbronchial and thoracoscopic lung biopsies disclosed the coexistence of interstitial pneumonia with BOOP pattern, follicular bronchiolitis, and diffuse panbronchiolitis-like purulent and obliterative bronchiolitis. Due to findings of chronic sinusitis, the patient was treated with erythromycin for 8 weeks, and the abnormal CT shadows regressed. This was an interesting case of various pulmonary lesions associated with rheumatoid arthritis, and successfully treated with erythromycin.     

艾滋病继发卡氏肺囊虫肺炎28例影像学表现

目的探讨艾滋病患者继发卡氏肺囊虫肺炎影像学的表现。方法回顾性分析2009-01～2011-12经临床确诊为艾滋病合并卡氏肺囊虫肺炎28例患者的影像学表现。结果典型的肺部影像学表现为双侧肺野弥漫性渗出性病变分布于肺门两侧周围肺野,病灶呈磨砂玻璃状、网格状、地图样或碎石路征。结论胸部X线片及CT扫描对艾滋病继发卡氏肺囊虫肺炎有重要诊断价值。     

甲型H1N1流感合并肺炎患者临床和影像学表现分析

目的探讨甲型H1N1流感合并肺炎临床和影像学表现。方法分析本院2009年9～2010年3月临床确诊24例甲型H1N1流感合并肺炎患者临床和影像学资料。结果 18例胸片均表现为肺纹理增多,6例表现为单肺斑片状影。CT显示6例单侧肺部炎性渗出影,12例双侧肺部炎性渗出影,4例弥漫性棉絮状病变;2例实质间质混合渗出。12例甲型H1N1流感合并肺炎患者出院1个月做CT检查,7例完全恢复正常;3例斑片状密度增高影2月后复查CT完全吸收;2例纤维条索影。结论影像学表现对于确定病变范围、病程发展变化和治疗后动态观察具有非常重要的参考价值。     

皮肌炎多发性肌炎患者间质性肺病病理资料推断性分析

目的 分析皮肌炎(DM)、多发件肌炎(PM)合并间质性肺病(ILD)患者的胸部X线、胸部高分辨CT(HRCT)及肺功能等肺部表现临床特点及其预后.方法 回顾性分析上海长海医院风湿免疫科1999年1月至2007年1月期间收住院的33例DM/PM合并ILD除外感染患者的临床资料.结果 33例ILD患者经胸部X线及HRCT证实.根据临床-影像学特点并结合血气分析、肺功能测定,参照美国胸科学会和欧洲呼吸协会问质性肺炎的分类诊断标准,推断分析病理类型主要为非特异性间质性肺炎(NSIP)(57%)和寻常性间质性肺炎(UIP)(25%). UIP类型预后差、病死率高(70%).结论 结合患者的影像学资料、肺功能、血气分析推断病理类型主要为NSIP和UIP,其中UIP病死率高、预后差.     

Abscess of residual lobe after pulmonary resection for lung cancer

Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.     

Pneumothorax in the critically ill patient

Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days.     

Chest computed tomography in the staging of pancreatic and periampullary carcinoma

BACKGROUND: Staging of the tumours in the pancreas and periampullary region usually consists of abdominal computed tomography (CT). Laparoscopy is also advocated. Little attention has been paid to extra-abdominal staging. In addition to peritoneal, lymphatic and hepatic metastases, lung metastases are frequently found. The chest CT scan has been demonstrated as better than the plain chest roentgenogram or conventional tomography in demonstrating lung tumours. This study was done to evaluate whether the chest CT scan gives information additional to the plain chest roentgenogram in the staging of pancreatic and periampullary tumours. METHODS: Fifty-three patients with a pancreatic or periampullary tumour underwent helical CT scan of the chest in addition to the abdominal CT scan. The CT scans and the chest roentgenograms were read separately without the result of the other being known; the results were compared with each other and with the clinical and operative findings. RESULTS: In the chest CT scan, 7 out of 53 (13%) patients had nodules in the lungs. The chest pathologies were not seen in the chest roentgenogram except for pneumonia in one patient and lung tumours in another (sensitivity of the chest roentgenogram 2/7 = 29%). Liver metastasis, local invasion of the tumour or poor general condition of the patient made lung biopsy or bronchoscopy unnecessary or impossible. CONCLUSION: Lung metastases seldom appear in patients with pancreatic or periampullary carcinoma without other contraindications for resection, which is why the chest CT scan cannot be recommended in the staging of these tumours for operation.     

卧床老年人肺基底部隐匿性肺炎胸部X线和CT影像学的特征及其差异

目的探讨卧床老年人肺基底部“隐匿性”肺炎的影像学特点及其差异。方法对17例有呼吸道感染症状的卧床老年人分别进行X线胸片及CT检查，分析其影像学改变。结果17例X线胸片均未发现肺部异常；CT则于肺基底部发现局限性炎性病灶，右肺9例、左肺4例、双肺4例。所有病灶均位于膈顶平面以下，即膈穹窿前、后方肺组织内，其中膈穹窿前方2例，后方15例。病灶形态呈斑片状及小片状高密度影，边缘模糊；13例可见局部肺纹理增粗、紊乱；9例见有局部胸膜反应。结论卧床老年人肺炎好发于肺基底部，病灶较小且相对局限，X线胸片检查易被隐匿，CT扫描则易检出病灶，对卧床老年人肺基底部隐匿性肺炎的诊断具有明显的优越性。     

Chest computed tomography in the staging of pancreatic and periampullary carcinoma

Background: Staging of the tumours in the pancreas and periampullary region usually consists of abdominal computed tomography (CT). Laparoscopy is also advocated. Little attention has been paid to extra‐abdominal staging. In addition to peritoneal, lymphatic and hepatic metastases, lung metastases are frequently found. The chest CT scan has been demonstrated as better than the plain chest roentgenogram or conventional tomography in demonstrating lung tumours. This study was done to evaluate whether the chest CT scan gives information additional to the plain chest roentgenogram in the staging of pancreatic and periampullary tumours. Methods: Fifty‐three patients with a pancreatic or periampullary tumour underwent helical CT scan of the chest in addition to the abdominal CT scan. The CT scans and the chest roentgenograms were read separately without the result of the other being known; the results were compared with each other and with the clinical and operative findings. Results: In the chest CT scan, 7 out of 53 (13%) patients had nodules in the lungs. The chest pathologies were not seen in the chest roentgenogram except for pneumonia in one patient and lung tumours in another (sensitivity of the chest roentgenogram 2/7?=?29%). Liver metastasis, local invasion of the tumour or poor general condition of the patient made lung biopsy or bronchoscopy unnecessary or impossible. Conclusion: Lung metastases seldom appear in patients with pancreatic or periampullary carcinoma without other contraindications for resection, which is why the chest CT scan cannot be recommended in the staging of these tumours for operation.     

Pleural effusions in critically ill patients

Pleural effusions (PEs) are common in critically ill patients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients. Their impact on the pathophysiology of acute respiratory failure remains unknown. They are usually small and uncomplicated transudates that are easily overlooked on a supine portable chest X-ray and do not require drainage or infectious exudates that always require thoracocentesis. The diagnosis of PEs in critically ill patients has been revolutionized with the advent of chest ultrasound allowing easy bedside quantification of pleural fluid and making thoracocentesis a safe procedure especially in high-risk patients on mechanical ventilation. CT provides a much more accurate evaluation of the size and location of PEs and is extremely helpful in the guidance of catheters into loculated fluid collections. Hemothorax in critically ill patients is usually related to trauma or surgical interventions and requires early drainage and possibly surgical exploration.     

A case of hypersensitivity pneumonitis caused by a humidifier]

A 58-year-old woman was admitted complaining of dry cough and exertional dyspnea. Physical findings, chest X-ray films, chest CT scan and respiratory function tests were suggestive of interstitial pneumonia. Transbronchial lung biopsy showed specific findings of hypersensitivity pneumonitis. As a result of positive provocation test using her home humidifier, a diagnosis of humidifier lung was made. Many microorganisms including Flavobacterium meningosepticum were cultured from the water left in the humidifier for one week. As both complement fixation test and precipitation test were positive to humidifier water and to extract of Flavobacterium meningosepticum, the humidifier and Flavobacterium meningosepticum were suggested to be causative in this case.     

危重症患者胃食管反流相关问题的研究进展

危重症患者由于存在气管插管/机械通气、鼻饲/肠内营养等诊疗操作加之存在程度不等的意识障碍,长期卧床,腹内压升高等高危因素,使胃食管反流十分常见,其危害性不但引起胃食管反流病,更重要的引起吸入性肺炎、急性肺损伤、源性呼吸窘迫等呼吸系危象,还可导致非心源性胸痛,新生儿猝死.其诸多不良反应并同原发病一起影响患者预后,提高对胃...     

A case of lung adenocarcinoma showing diffuse air-space consolidation with idiopathic interstitial pneumonia]

Routine chest radiography demonstrated abnormal opacities in the right lower lung field of a 54-year-old man with idiopathic interstitial pneumonia. A high-resolution chest CT scan showed diffuse air-space consolidation in the right lower lung with replacement of a honeycomb area. The diagnosis was adenocarcinoma, and a right lower lobectomy was performed. Histopathologic examination showed moderately differentiated adenocarcinoma and the pathological stage was T3 N0 M0 (Stage IIB). About 1 year later, the cancer recurred with diffuse air-space consolidation in the whole of the right lung and the left middle and lower lung, which resulted in the patient's death. It was difficult to discriminate between an acute change for the worse of idiopathic interstitial pneumonia and a recurrence of lung cancer on the basis of the CT findings in this patient. It is important to elucidate the CT features of lung cancer associated with idiopathic interstitial pneumonia.     

Three cases of measles-associated interstitial pneumonia]

It has been reported that measles-associated pneumonia is easily complicated with fatal respiratory failure. During the 6 months from January to June 1998, we treated three young patients with measles-associated pneumonia who had previously been healthy. Their chest X-ray and CT examinations revealed mainly interstitial and partially alveolar pneumonia surrounding extensive areas of bronchiolitis. In one patient, respiratory failure was present, and arterial blood gas analysis showed severe hypoxemia. Therefore, this patient was treated with a mechanical ventilator, which dramatically improved the condition. The other two patients received steroid-pulse therapy and improved rapidly. We believed that in measles-associated pneumonia, steroid pulse therapy is to be recommended for the severely ill patient. According to a report by the Japanese Ministry of Health and Welfare, measles-like disease was widespread in Japan in 1991 and occasionally encountered in 1996. But in Yamanashi Prefecture, the disease was prevalent in 1991, 1994 and 1998. The number of patients in our hospital had reflected the prevalence in the prefecture. It is suggested that the measles is a disease of regional prevalence.     

Mixed connective tissue disease-associated interstitial pneumonia complicated by pneumomediastinum during prednisolone therapy]

A 59-year-old woman was admitted to our hospital with exertional dyspnea. Linear and reticular opacities in the middle and lower fields of both lungs were observed on chest roentgenograms and chest computed tomograms (CT). The presence of anti RNP-antibody and Raynaud's phenomenon, sclerosis of the fingers, and leukopenia yielded a diagnosis of mixed connective tissue disease associated with interstitial pneumonia. The symptoms and lung involvement were alleviated after the administration of prednisolone (40 mg/day). However, the patient experienced the sudden onset of dyspnea during pulmonary function tests. A chest X-ray film disclosed mediastinal air around the left pulmonary artery, and a chest CT scan demonstrated some blebs in the left lower lung field. After tapering the dosage of prednisolone in 5 mg increments per week, the pneumomediastinum disappeared without treatment. The clinical features and laboratory data findings suggested the patient's interstitial pneumonia was associated with systemic lupus erythematosus rather than with progressive systemic sclerosis or dermatomyositis. The pneumomediastinum may have been due to the rupture of blebs secondary to interstitial pneumonia during pulmonary function tests or as a result of steroid therapy.