Search

Rationale: Sodium polystyrene sulfonate is commonly administered to treat hyperkalemia. Severe pneumonia due to aspiration of this drug is rare and no survival case has thus far been reported., Patient Concerns: A 45-year-old man was hospitalized for acute decompensated heart failure and acute kidney injury with hyperkalemia. He aspirated sodium polystyrene sulfonate while consuming the drug. Severe acute respiratory distress syndrome (ARDS) developed rapidly, and he was transferred to the intensive care unit (ICU)., Diagnoses: Chest radiography results after aspiration showed new consolidation in the left upper lung. He underwent emergency bronchoscopy, which revealed a considerable amount of yellow mud-like material in the trachea and bronchi. Chest radiography results after the bronchoscopic removal of the foreign material revealed rapid resolution of the left upper lung consolidation., Interventions: In the ICU, mechanical ventilation with low tidal volume and high positive end-expiratory pressure was administered and extracorporeal membrane oxygenation (ECMO) was set up for treating severe ARDS. We arranged an emergency bronchoscopy for diagnosis and removal of polystyrene sulfonate., Outcomes: ECMO was discontinued after 10 days and the patient was discharged after approximately 2 weeks., Lessons: Aspiration of sodium polystyrene sulfonate is not common but can be lethal. Clinicians should be cautious and appropriately inform patients of the aspiration risk while administering this drug. Mechanical ventilation and bronchoscopy were effective treatments for severe ARDS caused by aspiration of this drug.

Background: We evaluated the outcome of subjects with ARDS in relation to etiology and severity in a retrospective cohort study of the ARDS Network randomized controlled trials. The primary outcome was 28-d mortality. The secondary outcomes were 60-d mortality and ventilator- and ICU-free days. For severity of ARDS, subjects were stratified according to P aO2 /F IO2 . The etiology of ARDS was classified into sepsis, pneumonia, aspiration, trauma, and others., Results: A total of 2,914 subjects were included in these trials. Outcomes were modeled with multivariable regressions adjusted for baseline covariates, age, sex, race, Acute Physiology and Chronic Health Evaluation III (APACHE III), vasopressor use, modified lung injury score, diabetes mellitus, cancer status, body mass index, pre-ICU location, ICU location, and study. There was no statistically significant difference in 28-d mortality in relation to ARDS severity. Subjects with trauma, compared with other etiologies of ARDS, had significantly lower mortality at 28 d (odds ratio [OR] = 0.47, 95% CI 0.26-0.83, P = .01). Sixty-day mortality was significantly lower for trauma subjects and those with severe ARDS group (OR = 0.5, 95% CI 0.3-0.85, P = .01 and OR = 0.71, 95% CI 0.52-0.98, P = .034, respectively). There were statistically significantly more ICU-free days and ventilator-free days for the aspiration group (OR = 1.09, 95% CI 1.02-1.17, P = .01 and OR = 1.09, 95% CI 1.02-1.16, P = .01, respectively). There was no statistically significant difference in ICU-free days or ventilator-free days in relation to severity of ARDS., Conclusions: Severity of ARDS based on P aO2 /F IO2 did not impact 28-d mortality, ventilator-free days, or ICU-free days. Among the etiologies of ARDS, trauma subjects had the lowest 28- and 60-d mortality, whereas subjects with aspiration had more ICU-free days and ventilator-free days., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2017 by Daedalus Enterprises.)

Background: Aspiration of oral or gastric contents into the larynx and lower respiratory tract is a common problem in acute stroke patients, which significantly increases the incidence of acute respiratory distress syndrome (ARDS). However, little is known about the clinical characteristics of aspiration-related ARDS in acute stroke patients., Methods: Over 17-month period a retrospective cohort study was done on 1495 consecutive patients with acute stroke. The data including demographic characteristics, clinical manifestations, laboratory examinations, chest imaging, and hospital discharge status were collected to analysis., Results: Aspiration-related ARDS was diagnosed in 54 patients (3.6%). The most common presenting symptom was tachypnea (respiratory rate ≥25 breaths/min) in 50 cases. Computed tomography (CT) images usually demonstrated diffuse ground-glass opacities (GGOs) and inhomogeneous patchy consolidations involving the low lobes. Age, NIHSS score, GCS score, dysphagia, dysarthria, hemoglobin concentration, serum aspertate aminotransferase (AST), serum albumin, serum sodium, and admission glucose level were independently associated with aspiration-related ARDS (odds ratio (OR) 1.05, 95% confidence interval (CI) (1.04-1.07); OR 2.87, (2.68-3.63); OR 4.21, (3.57-5.09); OR 2.18, (1.23-3.86); OR 1.67, (1.31-2.14); OR 2.31, (1.11-4.84); OR 1.68, (1.01-2.80); OR 2.15, (1.19-3.90); OR 1.92, (1.10-3.36) and OR 1.14, (1.06-1.21) respectively)., Conclusions: Aspiration-related ARDS frequently occurs in acute stroke patient with impairment consciousness. It is advisable that performing chest CT timely may identify disease early and prompt treatment to rescue patients.

Reported food-related symptoms of patients may sometimes be misleading. A correct delineation of food-induced symptoms is often difficult and various differential diagnoses have to be considered. We report on two cases of food-induced, predominantly respiratory symptoms (in one case life-threatening) in children with food allergy. First, a two-year-old boy with no history of allergies and suspected foreign body aspiration which was finally diagnosed as an anaphylactic reaction to fish, and secondly a six-year-old girl with multiple food allergies and allergic asthma who during an electively performed oral food challenge developed severe respiratory distress, drop in blood pressure, and asphyxia not due to an anaphylactic reaction but due to choking on an unnoticed sweet. These two cases represent challenging, life-threatening symptom constellations involving food-induced reactions in food allergic children, reminding us to question first impressions., (© 2013 Wiley Periodicals, Inc.)

Objectives: Diabetes has been associated with decreased development of acute respiratory distress syndrome in some, but not all, previous studies. Therefore, we examined the relationship between diabetes and development of acute respiratory distress syndrome and whether this association was modified by type of diabetes, etiology of acute respiratory distress syndrome, diabetes medications, or other potential confounders., Design: Observational prospective multicenter study., Setting: Four adult ICUs at two tertiary academic medical centers., Patients: Three thousand eight hundred sixty critically ill patients at risk for acute respiratory distress syndrome from sepsis, pneumonia, trauma, aspiration, or massive transfusion., Interventions: None., Measurements and Main Results: Diabetes history was present in 25.8% of patients. Diabetes was associated with lower rates of developing acute respiratory distress syndrome on univariate (odds ratio, 0.79; 95% CI, 0.66-0.94) and multivariate analysis (adjusted odds ratio, 0.76; 95% CI, 0.61-0.95). After including diabetes medications into the model, diabetes remained protective (adjusted odds ratio, 0.75; 95% CI, 0.59-0.94). Diabetes was associated with decreased development of acute respiratory distress syndrome both in the subgroup of patients with sepsis (adjusted odds ratio, 0.77; 95% CI, 0.61-0.97) and patients with noninfectious etiologies (adjusted odds ratio, 0.30; 95% CI, 0.10-0.90). The protective effect of diabetes on acute respiratory distress syndrome development is not clearly restricted to either type 1 (adjusted odds ratio, 0.50; 95% CI, 0.26-0.99; p = 0.046) or type 2 (adjusted odds ratio, 0.77; 95% CI, 0.60-1.00; p = 0.050) diabetes. Among patients in whom acute respiratory distress syndrome developed, diabetes was not associated with 60-day mortality on univariate (odds ratio, 1.11; 95% CI, 0.80-1.52) or multivariate analysis (adjusted odds ratio, 0.81; 95% CI, 0.56-1.18)., Conclusions: Diabetes is associated with a lower rate of acute respiratory distress syndrome development, and this relationship remained after adjusting for clinical differences between diabetics and nondiabetics, such as obesity, acute hyperglycemia, and diabetes-associated medications. In addition, this association was present for type 1 and 2 diabetics and in all subgroups of at-risk patients.

Hydrocarbon aspiration causes acute lung injury, which may lead to acute respiratory distress syndrome. Surfactant has been shown to be beneficial in experimentally-induced hydrocarbon-associated acute respiratory distress syndrome. However, there has not been a clinical study evaluating the effect of surfactant application on hydrocarbon aspiration in humans. We report a 17-month-old boy with acute respiratory distress syndrome due to hydrocarbon aspiration and was successfully treated with surfactant application.

Objective: We hypothesize that not all of the traditional risk factors of impacting mortality rate in commonly traumatic populations with posttraumatic acute respiratory distress syndrome (ARDS) are independently associated with those patient populations identified with severe multiple trauma. Rather, we postulate that there may exist significantly different impacting degrees of specific risk factors in stratified patients (surviving beyond 24 and 96 hours)--more severe multiple trauma with higher injury score and long-term mechanical ventilation as well., Methods: This is a retrospective cohort study regarding trauma as a single cause for emergency intensive care unit admission. Twenty-two items of potential risk factors of impacting mortality rate were calculated by univariate and multivariate logistic analyses to find distinctive items in these severe multiple trauma patients., Results: The unadjusted odds ratio and 95% confidence intervals of mortality rate were found to be associated with 6 (out of 22) risk factors, namely, (1) Acute Physiology and Chronic Health Evaluation II score, (2) duration of trauma factor, (3) aspiration of gastric contents, (4) sepsis, (5) pulmonary contusion, and (6) duration of mechanical ventilation. Significant results also appeared in stratified patients., Conclusions: Impact of pulmonary contusion and Acute Physiology and Chronic Health Evaluation II score contributing to prediction of mortality may exist in the early phase after trauma. Sepsis is still a vital risk factor referring to systemic inflammatory response syndrome, infection, secondary multiple organ dysfunction, etc. Discharging trauma factors as early as possible becomes the critical therapeutic measure. Aspiration of gastric contents in emergency intensive care unit admission could lead to incremental mortality rate due to aspiration pneumonia. Long-standing mechanical ventilation should be constrained because it is likely to cause severe refractory complications.

Objective: To study the ability of volume-controlled ventilation and medicated (normal saline plus surfactant) bronchoalveolar lavage in aspiration to reduce the duration of intubation and improve gas exchange., Design: : Randomized controlled clinical trial., Setting: Pediatric intensive care unit., Patients: Twenty children, 1 month to 16 yrs old, who were intubated and mechanically ventilated, were randomized within 6 hrs of aspiration to receive volume-controlled ventilation plus medicated bronchoalveolar lavage (treatment group) or the same ventilation and bronchosuction (control group)., Interventions: Volume-controlled ventilation and positive end-expiratory pressure (10-12 cm H2O) were applied. Medicated bronchoalveolar lavage was performed using five aliquots of 5 mL of saline plus 10 mg/mL Curosurf (porcine surfactant, Chiesi Pharmaceutical SpA, Parma, Italy) in infants, five boluses of 10 mL of saline plus 5 mg/mL Curosurf in children, and four boluses of 25 mL of saline with 2.4 mg/mL Curosurf in adolescents for each affected lobe. One hour after bronchoalveolar lavage, 240 mg of Curosurf was administered locally., Measurements and Main Results: All patients survived. In the treatment group, days of intubation were 4.6 (+/-1.07), oxygenation index and Pao2/Fio2 improved significantly at 24 hrs, and statistical reduction in tidal volume mL/kg was observed from 36 hrs. In the control group, days of intubation were 11.8 (+/-3.22) (p < .0001), no improvement in oxygenation was noted, and pneumonia was observed in seven children (70%)., Conclusions: Even though this was an unblinded small clinical trial and low tidal volume strategy was not employed at an early stage after lung injury, there is some evidence that bronchoalveolar lavage with normal saline and surfactant may have clinical value in treating severe aspiration syndrome in children. More clinical studies are warranted to overcome study limitations and potential bias.

Background: Alterations to pulmonary surfactant composition have been encountered in the Acute Respiratory Distress Syndrome (ARDS). However, only few data are available regarding the time-course and duration of surfactant changes in ARDS patients, although this information may largely influence the optimum design of clinical trials addressing surfactant replacement therapy. We therefore examined the time-course of surfactant changes in 15 patients with direct ARDS (pneumonia, aspiration) over the first 8 days after onset of mechanical ventilation., Methods: Three consecutive bronchoalveolar lavages (BAL) were performed shortly after intubation (T0), and four days (T1) and eight days (T2) after intubation. Fifteen healthy volunteers served as controls. Phospholipid-to-protein ratio in BAL fluids, phospholipid class profiles, phosphatidylcholine (PC) molecular species, surfactant proteins (SP)-A, -B, -C, -D, and relative content and surface tension properties of large surfactant aggregates (LA) were assessed., Results: At T0, a severe and highly significant reduction in SP-A, SP-B and SP-C, the LA fraction, PC and phosphatidylglycerol (PG) percentages, and dipalmitoylation of PC (DPPC) was encountered. Surface activity of the LA fraction was greatly impaired. Over time, significant improvements were encountered especially in view of LA content, DPPC, PG and SP-A, but minimum surface tension of LA was not fully restored (15 mN/m at T2). A highly significant correlation was observed between PaO2/FiO2 and minimum surface tension (r = -0.83; p < 0.001), SP-C (r = 0.64; p < 0.001), and DPPC (r = 0.59; p = 0.003). Outcome analysis revealed that non-survivors had even more unfavourable surfactant properties as compared to survivors., Conclusion: We concluded that a profound impairment of pulmonary surfactant composition and function occurs in the very early stage of the disease and only gradually resolves over time. These observations may explain why former surfactant replacement studies with a short treatment duration failed to improve outcome and may help to establish optimal composition and duration of surfactant administration in future surfactant replacement studies in acute lung injury.