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Heart & Lung : the Journal of Critical... 2021Pneumothorax has been frequently described as a complication of COVID-19 infections.
BACKGROUND
Pneumothorax has been frequently described as a complication of COVID-19 infections.
OBJECTIVE
In this systematic review, we describe the incidence, clinical characteristics, and outcomes of COVID-19-related pneumothorax.
METHODS
Studies were identified through MEDLINE, Pubmed, and Google Scholar databases using keywords of "COVID-19," "SARS-CoV-2," "pneumothorax," "pneumomediastinum," and "barotrauma" from January 1st, 2020 to January 30th, 2021.
RESULTS
Among the nine observational studies, the incidence of pneumothorax is low at 0.3% in hospitalized COVID-19 patients. However, the incidence of pneumothorax increases to 12.8-23.8% in those requiring invasive mechanical ventilation (IMV) with a high mortality rate up to 100%. COVID-19-related pneumothorax tends to be unilateral and right-sided. Age, pre-existing lung diseases, and active smoking status are not shown to be risk factors. The time to pneumothorax diagnosis is around 9.0-19.6 days from admission and 5.4 days after IMV initiation. COVID-19-related pneumothoraces are associated with prolonged hospitalization, increased likelihood of ICU admission and death, especially among the elderly.
CONCLUSION
COVID-19-related pneumothorax likely signify greater disease severity. With the high variability of COVID-19-related pneumothorax incidence described, a well-designed study is required to better assess the significance of COVID-19-related pneumothorax.
Topics: Aged; COVID-19; Humans; Incidence; Mediastinal Emphysema; Pneumothorax; Respiration, Artificial; SARS-CoV-2
PubMed: 34087677
DOI: 10.1016/j.hrtlng.2021.04.005 -
Current Pediatric Reviews 2019Alpha1-antitrypsin (AAT) deficiency is a common, but an underdiagnosed genetic condition, affecting 1 in 1500 individuals. It can present insidiously with liver disease...
IMPORTANCE
Alpha1-antitrypsin (AAT) deficiency is a common, but an underdiagnosed genetic condition, affecting 1 in 1500 individuals. It can present insidiously with liver disease in children. Although clinical practice guidelines exist for the management of AAT deficiency, especially with regards to pulmonary involvement, there are no published recommendations that specifically relate to the management of the liver disease and monitoring for lung disease associated with this condition, particularly in children.
OBJECTIVE
To review the literature on the management of AAT deficiency-associated liver disease in adults and children.
EVIDENCE REVIEW
A systematic search for articles indexed in PubMed and published was undertaken. Some earlier selected landmark references were included in the review. Search terms included: "alpha1-antitrypsin deficiency"; "liver disease"; "end-stage liver disease"; "liver transplantation" and "preventative management". Recommendations for the management of children with suspected or confirmed AAT deficiency were made according to the Strength of Recommendation Taxonomy scale.
FINDINGS
Liver complications arising from AAT deficiency result from the accumulation of mutated AAT protein within hepatocytes. Liver disease occurs in 10% of children, manifested by cholestasis, pruritus, poor feeding, hepatomegaly, and splenomegaly, but the presentation is highly variable. A diagnostic test for AAT deficiency is recommended for these children. Baseline liver function tests should be obtained to assess for liver involvement; however, the only curative treatment for AAT deficiency-associated liver disease is organ transplantation. Conclusion and Relevance: There should be a greater vigilance for AAT deficiency testing among pediatricians. Diagnosis should prompt assessment of liver involvement. Children with AATdeficiency- associated liver disease should be referred to a liver specialist and monitored throughout their lifetimes for the symptoms of AAT-deficiency-related pulmonary involvement.
Topics: Adolescent; Adult; Child; Child, Preschool; Female; Humans; Infant; Liver; Liver Diseases; Liver Transplantation; Male; Transition to Adult Care; alpha 1-Antitrypsin Deficiency
PubMed: 30421678
DOI: 10.2174/1573396314666181113094517 -
The Cochrane Database of Systematic... May 2019Chronic obstructive pulmonary disease (COPD; including chronic bronchitis and emphysema) is a chronic respiratory condition characterised by shortness of breath, cough...
BACKGROUND
Chronic obstructive pulmonary disease (COPD; including chronic bronchitis and emphysema) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. Long-term antibiotic use may reduce both bacterial load and inflammation in the airways. Studies have shown a reduction of exacerbations with antibiotics in comparison to placebo in people with COPD, but there are concerns about antibiotic resistance and safety.
OBJECTIVES
To compare the safety and efficacy of different classes of antibiotics (continuous, intermittent or pulsed) for prophylaxis of exacerbations in patients with COPD.
SEARCH METHODS
We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was conducted on 6 February 2019.
SELECTION CRITERIA
Randomised controlled trials (RCTs) were selected that compared one prophylactic antibiotic with another in patients with COPD.
DATA COLLECTION AND ANALYSIS
We used the standard Cochrane methods. Two independent review authors selected trials for inclusion, extracted data and assessed risk of bias. Discrepancies were resolved by involving a third review author.
MAIN RESULTS
We included two RCTs, both published in 2015 involving a total of 391 participants with treatment duration of 12 to 13 weeks. One RCT compared a quinolone (moxifloxacin pulsed, for 5 days every 4 weeks), with a tetracycline (doxycycline continuous) or a macrolide (azithromycin intermittent).The second RCT compared a tetracycline (doxycycline continuous) plus a macrolide (roxithromycin continuous), with roxithromycin (continuous) alone.The trials recruited participants with a mean age of 68 years, with moderate-severity COPD. Both trials included participants who had between two and five exacerbations in the previous one to two years. In one trial, 17% of patients had previously been using inhaled corticosteroids. In the other study, all patients were positive for Chlamydophila pneumoniae (C pneumoniae).Overall, we judged the evidence presented to be of very low-certainty, mainly due to imprecision, but we also had concerns about indirectness and methodological quality of the included studies. The primary outcome measures for this review included exacerbations, quality of life, drug resistance and serious adverse events.Macrolide + tetracycline versus macrolide There was no clear difference between treatments in improvement in quality of life as assessed by the Chronic Respiratory Questionnaire (CRQ). The CRQ scale ranges from 0 to 10 and higher scores on the scale indicate better quality of life. CRQ sub-scales for dyspnoea (mean difference (MD) 0.58, 95% confidence interval (CI) -0.84 to 2.00; 187 participants; very low-certainty evidence), fatigue (MD 0.02, 95% CI -1.08 to 1.12; 187 participants; very low-certainty evidence), emotional function (MD -0.37, 95% CI -1.74 to 1.00; 187 participants; very low-certainty evidence), or mastery (MD -0.79, 95% CI -1.86 to 0.28; 187 participants; very low-certainty evidence) at 12 weeks. For serious adverse events, it was uncertain if there was a difference between combined roxithromycin and doxycycline versus roxithromycin alone at 48 weeks follow-up after active treatment of 12 weeks (odds ratio (OR) 1.00, 95% CI 0.52 to 1.93; 198 participants; very low-certainty evidence). There were five deaths reported in the combined treatment arm, versus three in the single treatment arm at 48 weeks follow-up after active treatment of 12 weeks (OR 1.63, 95% CI 0.38 to 7.02; 198 participants; very low-certainty evidence).Quinolone versus tetracycline There was no clear difference between moxifloxacin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants, very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Quinolone versus macrolide There was no clear difference between moxifloxacin and azithromycin for the number of participants experiencing one or more exacerbations (OR 1.00, 95% CI 0.32 to 3.10; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.Marcolide versus tetracycline There was no clear difference between azithromycin and doxycycline for the number of participants experiencing one or more exacerbations (OR 0.44, 95% CI 0.14 to 1.38; 50 participants; very low-certainty evidence) at 13 weeks. There were no serious adverse events or deaths reported in either treatment groups. We did not identify any evidence for our other primary outcomes.We did not find head-to-head evidence for impact of antibiotics on drug resistance.
AUTHORS' CONCLUSIONS
It is not clear from the evidence included in this review whether there is a difference in efficacy or safety between different classes or regimens of prophylactic antibiotic, given for 12 to 13 weeks to people with COPD. Whilst no head-to-head comparisons of antibiotic resistance were identified, concerns about this continue. The sample size in this review is small and both included studies are of short duration. Thus, there is considerable uncertainty in effects observed and the effects of different prophylactic antibiotics requires further research.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Disease Progression; Humans; Pulmonary Disease, Chronic Obstructive; Quality of Life; Treatment Outcome
PubMed: 31125127
DOI: 10.1002/14651858.CD013024.pub2 -
Anesthesia, Essays and Researches 2016Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for...
BACKGROUND
Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter.
METHODS
In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted.
RESULTS
Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen.
CONCLUSION
As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.
PubMed: 27212764
DOI: 10.4103/0259-1162.171462 -
Cureus Feb 2024Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is defined by the emergence of sizable bullae causing compression on healthy lung...
Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is defined by the emergence of sizable bullae causing compression on healthy lung tissue. The elusive etiology of VLS mandates a diagnosis based on radiographic evidence showcasing giant bullae occupying at least one-third of the hemithorax in one or both lungs. This report presents a case of VLS in a 36-year-old female smoker devoid of any prior medical history. Additionally, we conducted a systematic review to discern the demographics, risk factors, and treatment modalities for individuals diagnosed with VLS.
PubMed: 38314388
DOI: 10.7759/cureus.53443 -
Medicine Aug 2020Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA)...
Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report.
BACKGROUND
Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis.
AIM
Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported.
METHODS
Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper.
RESULTS-SYSTEMATIC-LITERATURE-REVIEW
Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space.
RESULTS-ILLUSTRATIVE-CASE-REPORT
Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days.
STUDY LIMITATIONS
Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population.
CONCLUSIONS
Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.
Topics: Adolescent; Adult; Conservative Treatment; Diabetic Ketoacidosis; Esophageal Perforation; Female; Humans; Male; Mediastinal Diseases; Mediastinal Emphysema; Nervous System Diseases; Pneumorrhachis; Pneumothorax; Predictive Value of Tests; Prospective Studies; Pulmonary Alveoli; Radiography, Thoracic; Retrospective Studies; Rupture; Subcutaneous Emphysema; Syndrome; Treatment Outcome; Vomiting; Young Adult
PubMed: 32871860
DOI: 10.1097/MD.0000000000021001