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Spontaneous pneumomediastinum following prolonged periods of severe coughing should raise the suspicion of tracheal rupture in COVID-19 patients.

RATIONALE:25 percent of all cases admitted with SARS-COV2 pneumonia are complicated by pulmonary embolism(PE) or in situ thrombosis1 .This is a major predictor for poorer outcome with acute lung injury (ALI). If the thrombotic burden is significant enough to cause right ventricular strain, even “intermediate-high risk”, normotensive patients have a 13% risk of death at three months. Current trials do not support thrombolysis in this group due to excess risk of bleeding. We are narrating our experience of using Sildenafil in patients admitted with SARS-CoV 2 Pneumonia associated ALI ,who developed acute right ventricular (RV) dysfunction and or pulmonary hypertension(PH) secondary to acute sub massive PE/insitu thrombosis.METHOD:Patients who were admitted to intensive care due to SARS-COV 2 related infection and diagnosed as having PE/insitu thrombosis on computed tomographic pulmonary angiography were evaluated with transthoracic echocardiography . Those who developed acute RV dysfunction and or acute PH were started on Sildenafil at an initial dose of 25 mg TDS which was increased to 50mg TDS if possible after 48 hours. The dose was adjusted depending on tolerability in terms of blood pressure, renal function or other e.g. retroviral therapies . All survivors were followed up with repeat transthoracic echocardiography at three months. Sildenafil was discontinued. in those whose pulmonary artery pressure and RV dysfunction had normalized RESULTS:23 out of 44 consecutive patients referred to our specialist team had evidence of PH (18 ) and/or RV dilatation (10) or dysfunction (6 ;TAPSE < 1.7 cm ) . Eight patients died in hospital . At three months,12/15 survivors had no evidence of PH or RV dysfunction and sildenafil was stopped. Three had RV dilatation, none of these had RV dysfunction (TAPSE < 1.7). No side effects associated with sildenafil were reported . CONCLUSION:Having experience of using sildenafil in patients with PE we believed that it would have a role in COVID-19 associated in situ thrombosis/PE particularly given the small peripheral vessels involved. The drug was well tolerated and much less labour intensive to administer than nebulized vasodilator therapies. Eighty percent of survivors had no evidence of PH/RV dilatation at three months .We believe that our encouraging experience suggests that sildenafil may have a role in acute pulmonary thrombosis and PH associated with COVID-19 and that further studies are required to address this .

Rationale: Acute respiratory distress syndrome (ARDS) due to severe viral pneumonia has been shown to cause impaired lung function and persistent radiological abnormalities several years after recovery. Severe COVID-19 causes ARDS in a minority of patients. Corticosteroids were used in previous viral pandemics and have been shown to reduce mortality and severity of COVID-19 infection. The use of high-dose pulsed methylprednisolone and the long-term pulmonary and functional outcomes following its use in severe COVID-19 have not been widely studied. Methods: A retrospective review of electronic records of patients treated with high-dose pulsed methylprednisolone (1000mg once daily for 3 days, followed by 40mg Prednisolone daily reducing by 5mg every 3 days until a stable dose of 10mg) during the first wave of the COVID-19 pandemic in the UK was done. Baseline demographics, microbiological, and radiological data were collected. Survivors were followed at 3 months post-discharge with a CT pulmonary angiogram (CTPA), spirometry, gas transfer, and 6-minute walk test (6MWT). Results: 15 patients were treated. 14 had ARDS whilst one had paediatric multisystem inflammatory syndrome, myocarditis, and mild respiratory failure. Mean age was 51 years. 13 patients were male. 5 patients died (4 male, 1 female), 4 due to COVID-19 infection and 1 due to myocardial infarction. 1 patient developed viral encephalitis and 1 developed a subdural haemorrhage, both of which resolved without specific treatment. 6 patients had follow-up lung function. The most common abnormalities were a low diffusion capacity for carbon monoxide (DLCO) and total lung capacity (TLC) (5 patients each) with DLCO having the lowest mean predicted value (58%), followed by TLC (67%). 10 patients completed follow-up CTPA. The most common CT abnormalities at 3 months were parenchymal bands (7/10, 70%) and 5 developed fibrosis. 8 patients completed a 6MWT. Mean distance walked was 405 metres (standard deviation (SD) 87.4m)/65% predicted (SD 18.5%). Conclusions: In this cohort of severely unwell patients with COVID-19 at 3 months, abnormalities in pulmonary function, CT appearance, and exertional capacity were unsurprisingly common. However, all patients treated at an early stage of their disease survived suggesting there might be some benefit when used sufficiently early, although conclusions about the effect on mortality are not possible with this study. This treatment has been shown to improve outcomes in a small randomized controlled trial. We believe our findings support the need for larger trials to clarify its impact and define the optimal timing for treatment.

Background Although rigid bronchoscopy is widely used there is limited data available on complication rates. A series of 1115 procedures quoted overall complication rates in 44 (3.9%)1 Another study reporting 3449 procedures quoted complication rates in 173 (5%).2 We describe our experience of rigid bronchoscopy and endobronchial intervention at a single tertiary centre. Methods Between October 2007 and July 2020, 2135 rigid bronchoscopies were performed on 1301 patients aged between 18 to 93 years. Each procedure was performed in cardiothoracic theatres by a designated team under general anaesthesia. Indications for the procedure were as follows; ND YAG Laser (690), insertion of tracheal or bronchial stent (505), biopsy of proximal tumour (437), diagnostic inspection of airways (247), dilatation of proximal stricture (121), removal of foreign body (29), removal of stent (34), percutaneous tracheostomy insertion (22), application of bio glue (20), and application of Mitomycin C (30). Results Complications occurred in 24 (1.12%) procedures. There was one fatality (0.05%). Haemorrhage >100 mls occurred in seven (0.33%), all were successfully managed endobronchially. Ten procedures (0.5%) were complicated by pneumothorax and an intercostal drain was required for eight. Five patients received intensive care admission post operatively, all of whom were discharged home. One patient had stent migration. Conclusion Our experience is encouraging and together with the benefit which the treatment offers to patients we believe that further exposure to this technique is warranted in formal respiratory medicine training in the UK. To the best of our knowledge this is the largest single centre collection of data available for rigid bronchoscopy. Moreover, the complication rate is significantly lower compared to previously published studies. We believe that rigid bronchoscopy is a safe and effective procedure when performed in a high volume specialist centre with designated lists involving a specialist multidisciplinary team. References Ost D.E. et al. Chest 2015;148:pp. 450–471 G I Lukomsky et al.Chest,1981;79:3:316–321

Pulmonary hyalinising granuloma is a very rare disease often presenting as multiple smooth rounded nodules within the lung parenchyma and mimicking metastatic disease. Solitary pulmonary hyalinising granuloma is an even rarer subgroup, and to our knowledge, there have been no endoluminal pulmonary hyalinising granulomas reported. A 36-year-old female non-smoker with no significant past medical history presented with a persistent cough and was found to have a right lower lobe bronchial lesion causing lower lobe obstruction. After multiple failed attempts at tissue diagnosis from both percutaneous and endobronchial biopsies, and with worsening haemoptysis, the patient underwent a right thoracotomy and lower bilobectomy. The histopathology was reported as a solitary endobronchial pulmonary hyalinising granuloma. Although benign in nature, tissue diagnosis can be difficult in these lesions, especially when presenting as a solitary mass in a central location. This report demonstrates that these lesions can also be found endobronchially necessitating parenchymal resection for diagnosis and obstructive symptoms.

Tracheal and Bronchial injuries are potentially life threatening complications which require urgent diagnosis and therapeutic intervention. They typically occur in association with blunt and penetrating chest trauma although they are increasingly being encountered in patients following endobronchial intervention and percutaneous tracheostomy insertion. Their precise incidence is unknown. Presenting features include dyspnoea, stridor, respiratory and haemodynamic compromise, haemoptysis, surgical emphysema, pneumothorax and persistent significant airleak. There may be other additional injuries to consider in trauma patients with large airway injury. Familiarity with the diagnosis and management of large airway injuries is important for medical teams engaged in emergency medicine, thoracic surgery and medicine, anaesthesia and intensive care. Although early surgical intervention is the mainstay of treatment, endobronchial manoeuvres to seal defects are receiving increasing attention particularly for patients with medical co-morbidities which may contraindicate formal surgery or transfer or where local surgical expertise is not available.

Introduction: Pulmonary hypertension (PH) is a fascinating subject which interdigitates with many specialities as the classification of the condition into five groups testifies. Knowledge of the condition is, in our experience, poor among medical students. As doctors, this subject is relevant regardless of future career direction. To address this gap, we have arranged a formal training programme for medical students each term at St George’s University of London. Aim: To improve knowledge in PH among our medical students Methods: For over 10 years medical students have been performing specialist subject modules (SSM) in PH over a term. This involves weekly meetings with Professor Brendan Madden, opportunities to attend Right Heart Catheterisation lists, Computed Tomography scanning, lung function testing, cardiac MRI, PH outpatient clinics, multidisciplinary team meetings and ward rounds. At the end of the study period, each student prepares a 4,000 word PH related project and gives a 5 minute presentation; and provides feedback on the course. The grade attained contributes towards their end of year grade. Results: For the past 10 years, 200 second year medical students (10 students each term, for two terms a year), participated in this course. All rated their experience very useful and reported that the lessons learnt helped them with their future medical cases. Patient feedback was also positive. 70% attained an honours grade. None failed. 7 students presented their work at international scientific meetings. Conclusion: We believe that PH is poorly taught at medical school and projects such as ours helps to address this.

Introduction: The role of thrombolysis in the management of patients with haemodynamic compromise in the presence of pulmonary embolism (PE) is recognised although it is unclear whether there is an indication for concomitant use of advanced pulmonary vasodilator therapy. Aims: To assess the potential benefit of sildenafil on outcome when administered acutely with, or without thrombolysis, to patients with large PE. Method: We performed a retrospective review of the outcome of 20 consecutive patients (9 male, 11 female) who presented with acute right heart strain on echocardiographic assessment, computed tomography or biochemical markers (beta natriuretic peptide), in association with large PE, between January 2015–June 2017, who received sildenafil (25mg TDS) at the time of presentation, with or without thrombolysis. Results: Sildenafil was tolerated without complication in 19 patients. There were 2 deaths due to malignancy at 10, and 18 months, and no deaths directly attributable to thromboembolic disease. Of those with calculable pulmonary arterial systolic pressures (PASP) (n=12), the average reduction in PASP at 3-6 months and 12-24 months was -22.04mmHg, and -17.25mmHg respectively. Those receiving sildenafil alone had a greater average reduction in PASP at short and long term follow up (-24.13mmHg, and -25.44mmHg respectively) compared with those also receiving thrombolysis due to haemodynamic compromise (-17.88mmHg, and -1.67mmHg respectively). Our experience suggests that sildenafil can be used safely in this patient group with good haemodynamic outcome, although larger randomised trials are necessary to support this.

Introduction: Rigid bronchoscopy permits endobronchial laser therapy, tracheal and bronchial stenting, airway dilatation and proximal tumour biopsy. Though some can be performed at flexible bronchoscopy, rigid bronchoscopy allows for improved airway control, wide bore suction and ventilation and lung isolation capabilities. Limited studies illustrating its safety and complication rates are available. Aims: To audit our practice against previously reported complications and review indications. Methods: All rigid bronchoscopies, during the study period were retrospectively reviewed. Results: 1711 rigid bronchoscopies were performed. Indication for rigid bronchoscopy was: Nd Yag laser 578 (34%), stent insertion 399 (23%), proximal tumour biopsy 358 (21%), diagnostic inspection of airways 186 (11%), dilatation of proximal stricture 100 (6%), removal of foreign body 28 (2%), removal of stent 21 (1%), percutaneous tracheostomy insertion 16 (1%), application of bioglue 19 (1%) and application of mitomycin C 6 (0.04%). Complications were noted in 18 (1.1%) patients. There was 1 fatality (0.06%) due to tumour erosion and massive haemorrhage, prior to intervention. 7 (0.4%) patients had haemorrhage of ≥100mls and haemostasis was achieved in all endobronchially. Pneumothoraces in 7(0.4%), 5 of whom required chest drain insertion. 3 patients were admitted to the intensive care unit and subsequently discharged home. Conclusion: Large airway intervention using rigid bronchoscopy under general anaesthetic within the confines of a multidisciplinary team is safe, successful and well tolerated. Rigid bronchoscopy at our centre is progressively increasing.

Background:Anaplastic thyroid carcinoma is rare but carries a poor prognosis. Anaplastic thyroid carcinoma leads to tracheal compression, airway compromise and eventually death. Airway compromise, a particularly distressing symptom, can be palliated with tracheal stenting.Method:A retrospective case note analysis was conducted of patients diagnosed with anaplastic thyroid carcinoma between July 2003 and July 2013.Results:Twelve patients with anaplastic thyroid carcinoma were identified. Four patients underwent palliative tracheal stenting. Three patients had no dyspnoea at the time of stenting. Two stented patients subsequently developed dyspnoea secondary to stent migration; this was managed successfully with stent exchange. The other stented patient remained asymptomatic with regards to dyspnoea. All non-stented patients died with or from airway compromise.Conclusion:Tracheal stenting is a relatively safe and effective method for palliation of distressing airway symptoms in patients with anaplastic thyroid carcinoma. Early prophylactic tracheal stenting in anaplastic thyroid carcinoma may be an effective option to prevent development of airway compromise as the disease progresses.

We developed a reproducible and reliable method of using a rubber stamp prospectively to document appearances of the sternal wound. 395 consecutive patients undergoing median sternotomy for cardiac procedures were studied over a period of four months. Data were collected by the Senior House Officer during the ward round for all patients at Day 3 and Day 7 post-operatively. Data were entered for 303 patients using the rubber stamp. 78 patients had no stamp entered in their case notes. 21 patients were recorded as having abnormal wounds, 11 of whom confirmed positive microbiological growth. On the other hand, 282 patients were recorded to have normal wounds, 10 of which had positive bacterial growth. Our initial results have been encouraging with almost 80% compliance and 96% specificity. A simple recording system consisting of proven signs of infection known to medical practitioners was our tool. Keywords: Detection; Infection; Sternal woundOnline: 21 May 2009DOI: 10.3329/bmrcb.v35i1.1815Bangladesh Med Res Counc Bull 2009; 35: 11-14

Endobronchial intervention has an established role in the management of a variety of benign and malignant conditions which lead to large airway compromise. Traditionally, this specialty fell within the remit of thoracic surgery but with increasing awareness and training some physicians are now engaging in this practice. Although patients with large airway compromise can be successfully managed in many instances using fibreoptic bronchoscopy under local anaesthesia, such practice may in part reflect lack of familiarity and training with rigid bronchoscopy. Rigid bronchoscopy under general anaesthesia in a multidisciplinary setting provides a safe, efficient and controlled environment to successfully manage practically any large airway problem which requires either emergency or semi-elective intervention. With increasing advances in anaesthetic and bronchoscopic techniques there are virtually no contraindications to the procedure, and morbidity and mortality rates are very low. Broadly speaking, endobronchial intervention is indicated for patients with a variety of conditions producing intrinsic or extrinsic airway obstruction or for those with airway defects which may or may not communicate with the oesophagus. Endobronchial techniques are available for foreign body retrieval, dilatation, tissue destruction and for endobronchial stenting. Endobronchial intervention can be curative or palliative, or may complement other treatments. It may be an alternative to formal airway surgery for selected patients, including those with medical comorbidities which contraindicate surgery.

Background Sildenafil may be of benefit for selected patients with pulmonary hypertension associated with parenchymal lung and cardiac diseases. However the medium term benefits of this treatment for such patients is unclear. Patients and methods 16 consecutive patients with secondary pulmonary hypertension who had been on maximal appropriate therapy received Sildenafil 50 mg tds following assessment which included right heart catheter, 2D echocardiography and six minute walk test. Right heart catheterisation, 2D echocardiography and six minute walk test were performed after eight weeks treatment, at 12 months and at six monthly intervals thereafter. Baseline medications were continued. Results 16 patients with pulmonary hypertension associated with inoperable chronic pulmonary thromboembolism (6 patients), valvular heart disease (4), chronic obstructive pulmonary disease (3), idiopathic pulmonary fibrosis (2), and obstructive sleep apnoea (1) were studied. The age range was 42 to 81 (median 68) years and the period of follow up was 12 to 51 (median 22) months. Six minute walk increased significantly, p = 0.002, from baseline to long term follow up. The improvement in 14 patients ranged from 14 m to 300 m with a percentage increase of 5% to 567% increase. In one patient there was no change and in one patient the six minute walk test fell as a consequence of progression of known arthritis. The mean pulmonary artery pressure was significantly reduced at long term follow up (p = 0008). The pulmonary vascular resistance (PVR) fell in eleven patients, this reduction ranged from 0.2 woods units to 8.7 woods units (mean reduction 3.3 woods units). The percentage reduction in PVR ranged from 7% to 71% with a mean reduction of 43%. In five patients the pulmonary vascular resistance increased. 2D echocardiography showed a sustained improvement in right ventricular function in 11 patients. There were no deaths during follow up. Conclusion Sildenafil may have a role for selected patients with pulmonary hypertension associated with cardiac and pulmonary diseases. The medication seems well tolerated and for some patients is effective within 8 weeks and results in a sustained long term improvement in haemodynamics and exercise capacity.

Respiratory trainees in the UK have limited exposure to large airway intervention (biopsy, stent insertion and laser ablation) via Rigid Bronchoscopy (RB). The Respiratory Curriculum does not insist on awareness of RB. Aim: To investigate the benefit of experience of RB as part of Respiratory Training. Method: Trainees completing a minimum of a 3 month rotation in an 9Interventional9 job between 2013 and 2014, which involves performing regular RB lists, were asked to complete a written questionnaire on their experience of RB. This included 8 trainees and a 100% response was obtained. Results: At the start, only 20% of trainees were aware of all indications for performing RB. 80% of trainees believed that RB was the domain of Thoracic Surgeons and only 20% had ever seen RB being performed before. The trainees performed an average of 40 supervised procedures, and 10% of them felt that they would confidently be able to attempt RB independently, at the end of the job. 60% of trainees experienced no complications. There were two life threatening bleeds and a stent fracture/migration (all successfully treated endobronchially). All trainees gained confidence during the job, stating that RB experience improved understanding of bronchial anatomy and enabled diagnosis of proximal tumours. 100% of trainees thought that Respiratory Physicians would benefit from experience of RB, but highlighted that RB could only be performed in specialist centres with adequate technical and human resources. Conclusion: Experience of RB is minimal for UK Respiratory trainees. The results suggest that this experience would improve procedural skills and the management of lung cancer, with increased referral rates for diagnosis of proximal tumours.

The definition of pulmonary hypertension (PH) is an elevated resting mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mmHg, determined by right heart catheterisation [1]. It is a progressive and ultimately fatal disease without appropriate management. Many different diseases can be associated with this elevation in mPAP and therefore PH is a diverse clinical entity.

Historically, primary pulmonary hypertension (as it was then termed) has been considered a rapidly progressive, fatal condition with no effective therapies with an average life expectancy of less than 3 years at diagnosis [1]. It has been labelled as a “desperate disease” and upon diagnosis one enters “the kingdom of the near-dead” [2].

Background Sildenafil offers potential to treat patients with pulmonary hypertension by selectively inhibiting phosphodiesterase type five pathways in the lung. It is recommended for selected patients with pulmonary arterial hypertension, but its role in the management of pulmonary hypertension associated with parenchymal lung disease is unclear. Patients and methods Seven patients (68–86 years) with end stage chronic obstructive pulmonary disease (COPD, 4) and idiopathic pulmonary fibrosis (IPF, 3) were referred to our unit. All patients had a long-term history of chronic lung disease and were on maximal appropriate therapy prescribed by their referring pulmonologist. Thromboembolic disease was excluded by pulmonary angiography and all patients had had high resolution thoracic CT scan. At assessment right heart catheterisation, 2D echocardiography and 6-min walk test were performed prior to commencement of sildenafil 50 mg tds. Their medication was otherwise unchanged. After 8 weeks treatment, right heart catheterisation, 2D echocardiography and 6-min walk test were repeated. Results The pulmonary vascular resistance was reduced in six patients (from 13, 3, 3, 6.5, 3.5 and 10.5 wood units to 9.7, 2.5, 2.8, 4.4, 2.5 and 5.4 wood units, respectively). Six-minute walk test increased in six patients (from 110 m, 210 m, 80 m, 30 m, 210 m and 80 m to 130 m, 312 m, 120 m, 82 m, 244 m and 100 m, respectively). One patient with COPD did not demonstrate a favourable response although their cardiac output increased on sildenafil therapy. 2D echocardiography showed a reduction in estimated PA pressure in six patients with an improvement in right ventricular systolic function in two COPD patients. Conclusion Our results suggest that sildenafil may have a role for selected patients with COPD and IPF who have pulmonary hypertension.

The use of tracheobronchial stents for compromised large airways is increasing. We provide a case series highlighting some of the complications of airway management in patients with tracheobronchial stents in situ and propose an approach for dealing with this potentially complicated situation.

Summary Thrombolysis is indicated for patients with massive pulmonary embolism who are haemodynamically unstable. [ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thrombo embolic disease. Chest 1996; 109:233–7; Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltsiz R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right ventricular function and pulmonary perfusion. Lancet 1993; 341:507–11] Its use in the management of patients who have proximal life threatening thrombus in the pulmonary vasculature without systemic hypotension is controversial [ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thrombo embolic disease. Chest 1996; 109:233–7; Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltsiz R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right ventricular function and pulmonary perfusion. Lancet 1993; 341:507–11]. We describe three patients (two males aged 45 and 58 years) and one female (aged 44 years who was 25 weeks pregnant) with acute proximal pulmonary arterial embolism in the absence of systemic hypotension. Surgical embolectomy was considered but our clinical assessment was that the location and extent of the thrombus in each case justified thrombolytic therapy and subsequently heparinisation even though no patient had evidence of systemic hypotension. Each patient was successfully treated with streptokinase (250,000 iu intravenously over 30 min followed by 100,000 iu per h intravenously for 12–24 h). Warfarin was commenced in two patients to achieve a target INR of 3–4 and low molecular weight heparin was continued throughout the remainder of her pregnancy in the third patient. Follow-up pulmonary angiography showed complete resolution of thrombus and there was improvement in 2D echocardiographic appearance. The pregnant lady delivered a healthy baby, normally, at term. In one patient who is now 6 months post-thrombolysis, repeat estimate of pulmonary vascular resistance and 2D echocardiography was normal at 6 months. We suggest that patients with potentially fatal pulmonary emboli should be considered for thrombolytic therapy even if they do not demonstrate haemodynamic instability.

Background Coronary revascularization is associated with respiratory dysfunction and poor gas exchange postoperatively. Cardiopulmonary bypass (CPB) has been implicated as a possible explanation for this phenomenon. This study investigated respiratory function in patients undergoing coronary artery bypass grafting (CABG) on-CPB versus off-CPB to determine whether the off-CPB condition results in improved postoperative pulmonary function. Methods Forty patients were randomized into 1 of 2 groups: CABG on-CPB (group A) or off-CPB (group B). Pulmonary function tests, including spirometry and diffusion studies, were performed preoperatively and on postoperative day 5. Arterial blood gases on 100% oxygen were taken preoperatively (TP1), 15 minutes after sternal closure (TP2), and 3 hours postoperatively (TP3). Results The arterial partial pressure of oxygen (PaO2) on FiO2 1.0 decreased from 59.5 ± 11.5 kPa and 55.7 ± 12.2 kPaat TP1 to 39.5 ± 16 kPa and 39.7 ± 13 kPa at TP2 in groups A and B, respectively (P < 0.001), with no significant difference between groups. At TP3, the PaO2 partially recovered toward preoperative levels (P < 0.05). Spirometry revealed a significant reduction in FEV1 and FVC on the fifth postoperative day (P < 0.001), with no significant difference between groups. The corrected transfer factor for carbon monoxide reduced significantly in group A from 7.9 ± 2.5 mmolmin–1 · kPa–1 preoperatively to 5.1 ± 1.6 mmolmin–1 · kPa–1 postoperatively (P < 0.05). This reduction was not seen in group B. Conclusions Coronary artery surgery is associated with a marked reduction in lung function as measured by pulmonary function tests and PaO2. Diffusion studies revealed that on-CPB patients had significantly reduced diffusion capacities postoperatively compared with patients in the off-CPB group.

Steroids and inhaled nitric oxide (iNO) are not recommended in acute respiratory distress syndrome (ARDS) secondary to H1N1 pneumonia; nevertheless, their effects could benefit in specific cases.

Background Between March 1997 and March 2004 we deployed 80 Ultraflex metallic expandable stents (Boston Scientific, Waterson, MA) in 69 patients under direct vision using rigid bronchoscopy. We report our medium- to long-term experience in patients for whom these stents were deployed. Methods To date 15 patients have been followed for more than 1 year (median 41 months, range 12 to 83 months) after stent deployment. Indications for stenting in these patients were neoplasia (5), stricture (5), airway malacia (1), iatrogenic tracheal tear (1), and compression from an aortic aneurysm (1), a right interrupted aortic arch (1), and a right brachiocephalic artery aneurysm with tracheomalacia (1). Ten tracheal stents (9 covered, 1 uncovered) and 10 bronchial stents (8 uncovered, 2 covered) were inserted, and 5 patients received two stents. Results Five of these patients experienced no long-term problems. Complications included troublesome halitosis (5), which was difficult to treat despite various antibiotic regimes; granulation tissue formation above and below the stent that was successfully treated with low-power Nd:YAG laser therapy (7); and metal fatigue (1). We did not encounter stent migration. Conclusions We conclude that Ultraflex expandable metallic stents have an important role in the management of selected patients with diverse endobronchial pathologies and are well tolerated in the long-term. Although associated granulation tissue can be successfully treated with Nd:YAG laser, halitosis can be a difficult problem to address.

We describe a 57-year-old man who developed a primary psoas abscess after treatment for acute allograft rejection, 5 years after orthotopic heart transplantation. The infective organism was methicillin-resistant Staphylococcus aureus (MRSA), and the patient underwent successful treatment with computed tomography-guided percutaneous drainage combined with teicoplanin and fusidic acid.

The experience of using noninvasive ventilation (NIV) in 113 adult cystic fibrosis (CF) patients with chronic respiratory failure, during episodes of acute deterioration in respiratory function is reported. The patients aged 15-44 yrs were divided into three groups. Group A consisted of 65 patients (median forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) 0.7/1.4 L) who were on a lung transplant waiting list. Group B consisted of 25 patients (median FEV1/FVC 0.7/1.4 L) who were being evaluated for lung transplantation. Group C consisted of 23 patients (median FEV1/FVC 0.6/1.2 L) who were not being considered for lung transplantation. The mean duration of NIV support for groups A, B and C was 61 (range: 1-600) days, 53 (1-279) days and 45 (0.5-379) days respectively. Twenty-three patients in group A subsequently received lung transplantation and 12 of these patients had a median survival of 39 months postsurgery. Thirty-nine patients died and three awaited transplantation. Five patients in group B received a transplant four of whom survived; thirteen patients died and seven awaited transplantation. Twenty patients in group C died. Noninvasive ventilation improved hypoxia but failed to correct hypercapnia in these cystic fibrosis patients. Noninvasive ventilation is useful in the treatment of acute episodes of respiratory failure in cystic fibrosis patients with end-stage lung disease who have been accepted, or are being evaluated, for lung transplantation. For these patients, there is a possibility of prolonging life if they are successfully treated for their acute episode of respiratory failure until transplantation. In this group, treatment is not merely prolonging the process of dying.

Objectives This study investigated whether apparently healthy relatives of patients with idiopathic dilated cardiomyopathy (DCM) who have left ventricular enlargement (LVE) have biopsy evidence of underlying myocardial disease. Background Left ventricular enlargement with normal systolic function is common among asymptomatic relatives of patients with DCM. Although there is circumstantial evidence to suggest that LVE may be a marker of early DCM, its pathophysiologic significance remains uncertain. Methods Over six years, 767 asymptomatic relatives of 183 consecutive patients with DCM were evaluated: 37 (5%) had DCM and 104 (14%) had LVE (left ventricular end-diastolic dimension >112% predicted) with normal systolic function. Right ventricular biopsy was performed in 32 relatives with LVE, 14 patients with symptomatic DCM and 6 control subjects with normal ventricular function undergoing elective coronary artery bypass graft surgery. Histologic and immunohistochemical analyses, including quantitative double immunofluorescence, were performed for leukocyte markers (CD3 and CD68), intercellular adhesion molecule-1 (ICAM-1) and human leukocyte antigen class II antigens (DR and DQ). Results Histologic findings consistent with DCM were present in 50% of the patients with DCM, 25% of the relatives with LVE and 0% of the control subjects. The median CD3 count was 2.4/mm2in patients with DCM, 4/mm2in relatives with LVE and 0 in control subjects (p = 0.04). Using a threshold of >7 cells/mm2, 21% of patients with DCM and 25% of relatives with LVE were CD3-positive (p = 0.01). Quantitative analysis demonstrated DR expression on 55.8 ± 22.8%, 63.5 ± 18.8% and 30.9 ± 15.7% of the endothelial surface in patients with DCM, relatives and control subjects, respectively (p = 0.003). Corresponding values for ICAM expression were 35.6 ± 15.1%, 36.7 ± 14.5% and 17.3 ± 7.9% (p = 0.013). When combining inflammatory and histologic changes, 28 (86%) of LVE, 14 (100%) of DCM and no control biopsies were abnormal (p Conclusions Most asymptomatic relatives of patients with DCM with LVE have histopathologic and immunopathologic findings similar to those of patients with established disease. Clinical identification and follow-up of such individuals are warranted to prevent presentation with advanced DCM and to enable assessment of interventions aimed at attenuating disease progression.

A man aged 51 years was referred for tracheobronchial stenting after a poorly differentiated oesophageal carcinoma had progressed to cause stridor. Bronchoscopy revealed a left vocal cord palsy and tumour infiltration into the trachea. A tracheobronchial stent was placed, and after distal migration was endoscopically resited. Returning from theatre, the patient developed severe upper airway obstruction that progressed to cause CO(2) narcosis and loss of consciousness. A rapid sequence induction was initiated, and a Glidescope revealed bilateral vocal cord palsy with severe oedema causing an inability to pass a tube or stylet. Tracheostomy was attempted above the suprasternal notch but was obstructed by the stent. Oxygen saturations dropped steadily, reaching as low as 38%. Emergency cricothyroidotomy was performed, compliant with DAS guidelines, that proved successful. The stent was removed, which was blocked with blood and secretions, and tracheostomy was placed 2 days later. The patient made a full neurological recovery.

Objectives To investigate the acute cardiovascular effects of smoking shisha. Design A cross-sectional study was carried out in six shisha cafes. Participants smoked shisha for a period between 45 min (minimum) and 90 min (maximum). The same brand of tobacco and coal was used. Setting London, UK. Participants Participants were those who had ordered a shisha to smoke and consented to have their blood pressure, heart rate and carbon monoxide levels measured. Excluded subjects were those who had smoked shisha in the previous 24 h, who smoke cigarettes or who suffered from cardiorespiratory problems. Main outcome measures Blood pressure was measured using a sphygmomanometer. Pulse was measured by palpation of the radial artery. Carbon monoxide levels were obtained via a carbon monoxide monitor. These indices were measured before the participants began to smoke shisha and after they finished or when the maximum 90 min time period was reached. Results Mean arterial blood pressure increased from 96 mmHg to 108 mmHg ( p Conclusion The acute heart rate, blood pressure and carbon monoxide levels were seen to rise significantly after smoking shisha. The weak correlation between carbon monoxide levels and the other variables suggests that carbon monoxide levels had not contributed to their significant increase.

We describe a 55-year-old man who developed spinal osteomyelitis and diskitis 14 months after orthotopic heart transplantation. The infective organism was Staphylococcus aureus and the patient was successfully treated with flucloxacillin and fusidic acid.

Endothelin-1 is a potent vasoconstrictor peptide and mitogen for vascular smooth muscle cells. Increased plasma or tissue levels of endothelin-1 have been described after myocardial infarction and in atherosclerosis, suggesting that this peptide may play a pathophysiological role in various coronary syndromes. Here, we have studied regional variations in ET-1 and its receptors in control and atherosclerotic human coronary vasculature using standard immunohistochemistry and in vitro autoradiography. ET-1 immunoreactivity was associated with luminal endothelial cells and smooth muscle cells at regions of atherosclerosis. ET(A) receptors were present on smooth muscle cells of coronary arteries and on cardiac myocytes. Medial ET(B) receptor binding at the proximal region of coronary arteries was weak, but increased significantly towards distal regions of this vessel (p0.005 in control and p0.0005 in ischaemic heart disease). Microvascular endothelial cells in the adventitia of coronary arteries, myocardial microvessels and the endocardial endothelium expressed the ET(B) receptor exclusively. The receptor variations revealed in this study provide supporting evidence that ET-1 is associated with (1) vascular smooth muscle and endothelial cell proliferation, including areas of intimal hyperplasia and regions of neovascularization (2) increased ET-1-induced reactivity of distal portions of the human coronary artery, (3) ET-1-mediated constriction of myocardial microvessels. These results provide new insights into different potential roles for this peptide in healthy and diseased human coronary vasculature.

A 69-year-old man who had a left pneumonectomy for nonsmall cell lung cancer had a bronchopulmonary fistula develop that recurred after surgical closure. He had multiple organ failure develop precluding further operative intervention. Successful resolution of the fistula was achieved using a novel application of a covered expandable metallic stent.

Retrospective and prospective analyses of heart transplant recipients showed no significant association between acute rejection and the detection of cytomegalovirus (CMV) infection by culture or the polymerase chain reaction (PCR) for viral DNA, neither on grounds of the incidence of both conditions nor in relation to which was diagnosed first in the patient. Semiquantitative PCR of serial blood and endomyocardial biopsy specimens from individual patients revealed different patterns in the development of the viral DNA in the blood and the heart, also clear episodes of CMV infection in CMV antibody-negative recipients of hearts from CMV antibody-negative donors, none of whom went on to develop a CMV-specific antibody response. None of these findings was associated with the development of rejection in the patient. On the other hand, in those patients who did experience rejection, peak levels of CMV DNA in the blood and the heart were usually not reached until 6 weeks or more after transplantation, whereas in those in whom rejection was not detected at all during the period of observation, peak levels of CMV DNA were detected earlier, mainly with in the first 6 weeks after transplantation. In several cases, the delayed increase in CMV DNA in those with rejection, albeit not the delay itself, was linked to treatment with steroids. These findings support the view that CMV infection and rejection are independent events, but that the timing of the infection, and whether or not rejection is detected, are indicative of the general status of the immune response in individual patients.

In vitro autoradiographic studies, using sections of human epicardial coronary arteries, have demonstrated dense [125I]-endothelin-l binding to the tunica media and regions of the adventitia. Micro-autoradiography has been employed to localise binding at the cellular level and immunohistochemistry has been used to identify specific cell types on adjacent tissue sections. Adventitial [125I]-ET-1 binding is predominantly to microvessels, including those supplying the perivascular nerves. This binding is markedly reduced in the presence of unlabelled ET-1 and the ETA/ETB receptor antagonist bosentan. These results suggest that, apart from acting on vascular smooth muscle of the tunica media, the action of locally-released ET-1 may also be via adventitial microvessels, including those supplying the perivascular nerves.

We describe a 46-year-old man who developed infective endocarditis, meningitis, sternal abscess, and infective cerebral emboli after cardiac transplantation. Staphylococcus aureus was the infective organism. We successfully managed the patient with flucloxacillin and fusidic acid to treat infection, and with prostacyclin for systemic embolization.

Background Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk. Hypothesis We wished to assess the safety, efficacy, and tolerability of RHC performed via the internal jugular vein (IJV) at our tertiary cardiothoracic center. Methods A retrospective review of the medical records for all patients undergoing RHC via the IJV between January 1, 2007 and July 31, 2009 was performed. We do not routinely use ultrasound guidance or stop anticoagulation. Operators with a median experience of 450 procedures performed the RHCs. Results Right heart catheterization was performed on 349 patients with a median age of 66 years (range, 17–89), median mean pulmonary artery pressure of 30 mm Hg (range, 8–69), and a median internationalized normal ratio of 2.5. Of 349 patients, we were unable to obtain intravenous access in only 1 patient; 342 (98%) patients tolerated RHC with local anesthetic alone; and 6 patients required additional sedation with benzodiazepines. The median time for the procedure was 15 minutes. Complications occurred in 6 patients (1.7%) and included carotid puncture (n = 3), sinus bradycardia below 45 beats/min, which responded promptly to atropine and intravenous fluid (n = 2), and complete heart block without hemodynamic compromise (n = 1). There were no pneumothoraxes, pulmonary hemorrhage, or deaths related to the procedure. Conclusion Right heart catheterization via the IJV is quick, safe, and well tolerated. It is not associated with an increased risk of pneumothorax or other complications when performed by experienced operators. Copyright © 2010 Wiley Periodicals, Inc.

A 55 year old woman with bronchiectasis, lobe sequestration, and recurrent respiratory infections failed to respond to medical treatment. Pulmonary function tests showed forced expiratory volume in one second of 2.3 l/ (85% of predicted) and diffusion lung capacity for carbon monoxide (a test of the integrity of the alveolar-capillary surface area for gas transfer) of 5.56 mmol/min/kPa (66% of predicted). She underwent right lower lobectomy, but four weeks later she developed fever, cough with frothy serosanguinous sputum, and right pleuritic chest pain. She was admitted to hospital and chest radiography was performed (fig 1)⇓. Fig 1 The patient’s c hest radiograph ### 1 What is the most likely diagnosis? #### Short answer The chest radiograph shows an air fluid level at the right intermediate bronchus close to the site of the bronchial stump. In addition, opacification of the right lower zone of the hemithorax is obscuring the right hemidiaphragm and right heart border, probably because of a right pleural effusion (fig 2⇓). This radiograph combined with the clinical history suggests the presence of a postoperative bronchopleural fistula. Fig 2 Chest radiograph showing an air fluid level close to the bronchial tree at the level of the bronchial …