Therapeutic advances in pulmonary and critical care medicine最新文献

Background: Extracorporeal membrane oxygenation (ECMO) is a life support technique used in patients with respiratory or cardiac failure. Despite the increased use of ECMO, the incidence and risk factors for healthcare-associated infections (HAIs) are highly variable and dependent on healthcare systems.

Objectives: To describe the incidence of HAIs in patients on ECMO secondary to respiratory or cardiac failure, the microorganisms involved, and antibiotic resistance, and to identify risk factors associated with the incidence of HAIs.

Design: Single-center retrospective cohort study.

Methods: We included adult patients (15 years or older) on venovenous ECMO (VV-ECMO) or venoarterial ECMO (VA-ECMO) secondary to respiratory or cardiac failure and who were admitted to the Instituto Nacional del Tórax (Santiago, Chile) between 2022 and 2024. We included confirmed HAIs related to the ECMO procedure between 24 h after ECMO initiation and 48 h after its withdrawal. Microbiological confirmation was obtained through positive cultures, positive pneumonia FilmArray results, or elevated bronchoalveolar lavage galactomannan levels (> 1 mg/L). The data were collected by two researchers and verified by a third party. We conducted multivariable logistic regression to identify risk factors for HAI.

Results: Seventy-two patients were included in our study, with a median age of 46 years (IQR 29.75-59) and 55.56% male. Thirty-eight (52.78%) patients had confirmed HAI. We identified 70 microorganisms, with gram-negative bacilli being the most prevalent. Among these, the majority were Pseudomonas spp. (32.65%), Klebsiella spp. (20.41%), and Enterobacter spp. (16.33%). Among the gram-positive cocci, Staphylococcus aureus was the most frequently detected microorganism (57.9%). Antibiotic resistance patterns included methicillin-susceptible Staphylococcus aureus (n = 9), non-carbapenemase-producing carbapenem-resistant isolates (n = 11), and carbapenemase-producing isolates (n = 10). Multivariable analysis demonstrated that each additional day on ECMO increased HAI risk by 7% (95% CI 1.0-13.4), after adjusting for left ventricular ejection fraction, organ failure type, and ECMO indication.

Conclusion: Half of the patients on ECMO secondary to respiratory or cardiac failure developed HAI. The most frequent microorganisms were gram-negative bacteria, and the primary antibiotic resistance detected was for carbapenems. The only independent risk factor for developing HAI was the length of stay on ECMO.

Background: Muscle wasting is a critical and underrecognized determinant of outcomes in intensive care, yet conventional core muscle measurements such as computed tomography (CT)-derived L3 Skeletal Muscle Index (L3 SMI) may overlook localized muscle loss and be confounded by fluid shifts. Point-of-care ultrasound (POCUS) offers a bedside, repeatable method for assessing peripheral muscle thickness.

Objectives: To determine the prognostic value of peripheral muscle thickness, measured by POCUS, in predicting mortality, frailty, and functional outcomes in critically ill patients; and to compare these findings with core muscle mass assessed by L3 SMI.

Design: Prospective, single-center, observational study of critically ill adults admitted to the ICU with sepsis or requiring organ support.

Methods: Fifty critically ill adults meeting Sepsis-3 criteria or requiring respiratory/vasopressor support underwent POCUS assessments of biceps brachii, rectus femoris, and vastus intermedius thickness at days 1, 7, and 14 post-ICU admission. Twenty-eight patients also had CT scans within 7 days for L3 SMI calculation. The primary outcome was in-hospital mortality; secondary outcomes included Clinical Frailty Score and Zubrod/ECOG performance status, 90-day mortality and hospital readmission, and number of organ dysfunction-free days. Muscle measurements were analyzed both raw and indexed to body surface area, with predictive performance assessed via correlation and receiver operating characteristic analysis.

Results: Day 1 biceps brachii thickness strongly predicted in-hospital mortality (area under the curve [AUC] 0.84; sensitivity 1.0, specificity 0.67) and retained predictive value for 30-day and 90-day mortality. Vastus intermedius thickness on Day 1 was moderately predictive (AUC 0.79). At later time points, larger vastus intermedius measurements correlated negatively with ICU- and ventilator-free days, suggesting edema-related pseudohypertrophy. L3 SMI did not significantly correlate with ultrasound-based muscle measurements or clinical outcomes. POCUS-derived peripheral muscle indexing was associated with frailty indices, highlighting its role in capturing meaningful functional deficits.

Conclusion: POCUS-based muscle assessments, particularly of the biceps brachii and vastus intermedius, provide valuable prognostic insights beyond conventional L3 SMI.

Background: [No revision is required.]Pulmonary cryptococcosis (PC) is common in immunocompetent patients, and its early diagnosis is challenging. Multiple studies have addressed the detection of cryptococcal glucuronoxylomannan (GXM) antigen in serum, but few have investigated its detection in bronchoalveolar lavage fluid (BALF).

Objectives: To evaluate the diagnostic value of the Cryptococcus GXM antigen test in BALF for PC in immunocompetent patients.

Design: We collect the clinical data of 138 patients from October 2018 to March 2023 and divide them into a PC group (n = 48) and a non-PC group (n = 90). Perform serum and BALF GXM antigen test on all cases that meet the inclusion criteria.

Methods: To analyze and compare the clinical characteristics of the PC group and non-PC group. We calculate the positive detection rate (PDR) and negative predictive value of BALF and serum GXM antigen tests, as well as their combination, for the PC group.

Results: Most patients in the PC group are male (59.6%), with an average age of 49.4 years. Most of the patients have no underlying disease (51.9%). Diabetes and hypertension are the most common comorbidities. Most patients (53.8%) are asymptomatic. Cough and sputum are the most frequent clinical symptoms, followed by fever and chest distress. Nodules and exudative consolidation are the most common imaging findings, and the culture positivity rate is 25%. Forty patients are positive according to the BALF GXM test, for a positivity rate of 83.3% and a negative predictive value of 91.8%. Moreover, 39 patients are positive according to the serum GXM test, for a positivity rate of 81.3% and a negative predictive value of 90.9%. The positivity rate for serum plus BALF is 95.8%. There is no significant difference (P > 0.05) in diagnostic value between BALF and serum GXM tests for PC. GXM positivity rates differ significantly among paired BALF, serum, and BALF plus serum groups (P < 0.05).

Conclusion: The BALF GXM test is useful for the early diagnosis of PC in immunocompetent patients. Simultaneous BALF and serum GXM testing would increase the rate of early PC diagnosis in immunocompetent patients.

The Venous Excess Ultrasound Score (VExUS) has produced great interest in venous Doppler ultrasound as a noninvasive means to evaluate right heart hemodynamics. While this score includes Doppler morphologies from sub-diaphragmatic veins, the physiology of transcutaneous venous Doppler velocimetry and its change with cardiac pathology was first studied and described in the internal jugular vein (IJV). Over 50 years ago, the systolic and diastolic velocity waves of the IJV were found to describe the x'- and y-descents of the jugular venous pulse (JVP) in sickness and in health. Therefore, it is established that abnormalities in right heart filling and function are reflected in the jugular venous flow velocity (JVFV) profile. In this narrative review, we highlight the physiology of the JVP, its relationship to right heart performance, and, accordingly, its connection with JVFV. Grounded upon decades-old, pioneering investigations, we briefly highlight JVFV in patients with post-cardiopulmonary bypass physiology, atrial fibrillation, pericardial tamponade, and pulmonary hypertension. We then describe a novel, wireless, and wearable Doppler ultrasound that continuously displays JVFV and consider how this device informs diagnosis and therapy of acute circulatory dysfunction. We touch on gaps in knowledge and suggest future avenues of inquiry with special attention paid to synchronous acquisition and interpretation of venous and arterial Doppler measures. We emphasize the clinical relevance of this technology and physiological framework, including acute, inpatient shock resuscitation, volume removal (eg, "de-resuscitation"), and the possibility for chronic, outpatient monitoring.

Artificial intelligence (AI) is an exciting new technology poised to drastically improve the practice of medicine. Interventional pulmonology (IP) is particularly well situated to implement AI due to the variety of complex diagnostic and therapeutic techniques within its scope. By integrating AI into the field, the procedure planning and management of pulmonary disease should become easier, more accessible, and more effective. AI has already been implemented in the diagnostic techniques of navigational and virtual bronchoscopy, endobronchial ultrasound, and for the rapid onsite evaluation of pathological specimens. The goal of this review is to summarize recent utilization of AI in IP and to discuss the origins of the technology, ethical considerations, and future directions.

Ventilator-associated pneumonia (VAP) remains one of the most common and challenging intensive care unit (ICU)-acquired infections, significantly contributing to mortality, morbidity, and healthcare costs. The diagnosis relies on quantitative analysis of a deep microbiological sample; a combination of clinical and radiological signs is commonly used to raise VAP suspicion in clinical practice. Traditional imaging methods such as chest radiography and computed tomography have limitations in critically ill patients under mechanical ventilation. Lung ultrasound (LUS) has emerged in the last years as a valuable tool in the assessment and monitoring of critically ill patients, including for diagnosis and management of VAP, due to its noninvasive bedside applicability and absence of radiation exposure. This last quality is of particular interest in the specific population of children and newborns, where radiation exposure should be further avoided. LUS allows for daily monitoring of lung aeration and provides a quantitative assessment through the LUS aeration score; an unexpected increase of LUS aeration score may raise the suspicion of superinfection. Key ultrasonographic findings, such as subpleural consolidations and consolidations with dynamic linear-arborescent air bronchogram, improve diagnostic specificity for VAP. Similarly to what happens with traditional radiology, the Ventilator-associated Pneumonia Lung Ultrasound Score (VPLUS) combines ultrasound signs with clinical parameters like purulent secretions to enhance diagnostic accuracy. Furthermore, LUS aeration score plays a crucial role in monitoring the response to treatment, enabling assessment of lung reaeration over time. It helps differentiate between treatment responders and nonresponders, guiding therapy adjustments and identifying complications. This review highlights the evolving role of LUS in the early diagnosis, monitoring, and treatment of VAP across various ICU settings, including its application in adult, pediatric, and neonatal care.

Inflammatory, neurologic, and cardiac biomarkers appear to have varying significance in the prognostication of patients with cardiac arrest. Post-cardiac arrest syndrome is a condition characterized by systemic ischemia with reperfusion injury, neurologic damage, and myocardial dysfunction. The relative significance of these biomarkers remains unclear and is an area of active investigation. In this narrative review, we aim to describe what is currently known about the role of inflammatory, neurologic, and cardiac biomarkers in cardiac arrest. A PubMed review was performed for relevant articles. Articles that studied inflammatory, neurologic, and cardiac biomarkers in adult cardiac arrest were included. This narrative review determined that biomarkers play a key role in facilitating prognostication of patients with cardiac arrest. The release of inflammatory, neurologic, and cardiac biomarkers mediates inflammation, ischemic brain injury, and myocardial dysfunction. Inflammatory and neurologic biomarkers appear to have more clinical utility than cardiac biomarkers. When combined with physical exam, imaging and electroencephalograph findings, blood biomarkers can be useful in making predictions of patient outcomes post-cardiac arrest. Despite this utility, no single biomarker has sufficient power to predict patient outcomes independently. Ongoing research investigating these biomarkers remains an area of strong clinical interest. In conclusion, inflammatory, neurologic, and cardiac biomarkers all play a role in understanding both the short-term and long-term outcomes in patients with cardiac arrest. To date, no single parameter has been shown to reliably predict outcome in cardiac arrest patients. Such biomarkers remain an area of active investigation.

Dynamic left ventricular outflow tract obstruction (dLVOTO) is an important cause of cardiogenic shock to consider as its management differs from garden-variety cardiogenic shock from systolic dysfunction. It is best suited for serial evaluation by point-of-care ultrasound (POCUS) as its dynamic nature may cause it to be missed on routine echocardiograms. We present a case of a 95-year-old male who presented for constipation and went into cardiac arrest after manual disimpaction. After intubation and advanced cardiovascular life support with eventual return of spontaneous circulation, the patient developed cardiogenic shock. He developed persistent lactic acidosis, increasing ventilator requirements, and worsening renal function despite diuresis and escalating epinephrine and norepinephrine requirements. POCUS revealed left ventricular systolic dysfunction with apical hypokinesis and basal hyperkinesis suspicious for stress-induced cardiomyopathy. Moreover, systolic anterior motion of the mitral valve on M-mode ultrasound and a left ventricular outflow tract pressure gradient of 46 mm Hg on spectral Doppler were noted, consistent with dLVOTO. On recognition of dLVOTO, epinephrine and norepinephrine were weaned after adding vasopressin and phenylephrine. The patient's clinical status drastically improved thereafter and he was weaned off vasopressors and the ventilator within 48 hours. POCUS techniques that are often excluded from basic critical care ultrasound exams are required to identify the characteristic features of hemodynamically significant dLVOTO. These features are important to recognize in cardiogenic shock as inotropes and diuresis can lead to paradoxical worsening of the dLVOTO. Instead, these patients should be managed with pure vasopressors and measures to increase left ventricular preload (beta blockers and intravenous fluids).

Background: Ultrasound evaluation of diaphragmatic anatomy and function has recently gained traction as a simple and useful tool to assess the extubation readiness in mechanically ventilated patients, nevertheless, how applicable this approach is in the population of chronically debilitated patients on mechanical ventilation (MV) remains unclear.

Objective: To evaluate ultrasonographic assessment of diaphragmatic thickening fraction (ΔTDI%) as a predictor of extubation success in the population of end-stage liver disease (ESLD) malnourished patients on MV.

Design: Prospective, single-center, observational cohort study.

Methods: We used point-of-care ultrasound to evaluate ΔTDI% and diaphragm thickness during expiration (T _exp) and inspiration (T _insp) as predictors of extubation success in ESLD patients undergoing weaning from mechanical ventilation. The primary end-point was extubation tolerance (ET) assessed at 48 h.

Results: Of 70 enrolled patients, 82.4% (N = 56) tolerated extubation. While there was no difference in ΔTDI% between those who failed extubation (EF) compared to ET at 48 h (21.2% vs 20.1%, P = .64), diaphragms were thicker at expiration in ET patients (T _exp 29.5 ± 8.1 vs 24.8 ± 5.2 mm, P = .047). Commonly used clinical weaning parameters, including rapid-shallow breathing index (RSBI) and negative inspiratory force (NIF) correlated better with diaphragm thickening fraction ΔTDI% than diaphragm thickness indices but were inferior predictors of extubation success compared to T _exp..

Conclusion: Point-of-care ultrasonographic assessment of the diaphragm offers insight into the function of respiratory muscles and the limited ability to predict extubation success. Further research is necessary to better understand its potential use in MV liberation in patients with ESLD and malnutrition.

Background: A previous study at Montfort Hospital (Ottawa, Ontario, Canada) found that only one-fifth of patients treated in 2022 for a severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) were prescribed the appropriate inhaled therapy at discharge. The revised 2023 Canadian Thoracic Society (CTS) COPD pharmacotherapy guidelines now recommend inhaled triple therapy as initial maintenance treatment in patients at high risk of AECOPD.

Objectives: The primary objective of this study was to determine if adherence to the CTS guidelines significantly improved following the publication of the 2023 statement. A secondary objective was to review the proportion of patients receiving appropriate optimization based on whether they were treated exclusively in the emergency department (ED) or required hospitalization.

Design: Retrospective study.

Methods: Subjects treated for AECOPD in the first 12 months after the publication of the 2023 guidelines were reviewed. Patient characteristics and inhaled therapy were charted. Adherence to the guidelines was compared to the prior cohort from 2022.

Results: A total of 169 patients were treated for AECOPD. After excluding individuals who died in the hospital and those who were maintained on inhaled triple therapy, 74 were candidates for review of their inhaled therapy. 27% received recommended medication optimization at discharge compared to 20% in 2022 (P = 0.25). Adherence to the guidelines significantly improved for hospitalized patients (51% vs 27%, P = 0.02). Only 5% of subjects treated exclusively in the ED received appropriate inhaler optimization. The most common deviations from the guidelines were the continued use of prior therapy (35%) and the lack of any long-acting medication (22%).

Conclusions: Adherence to the CTS COPD pharmacotherapy guidelines remained very low in ED-treated patients. The findings highlight the need for structured COPD care plans.