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Prospective, cohort study. To evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI). Academic tertiary care center, USA. Overall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months. Overall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL. Despite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Hepatic cirrhosis is commonly associated with hyperestrogenism. Previous studies have reported morphologic changes in benign and malignant prostate tissue exposed to estrogen or anti-androgens. To our knowledge, histopathologic features of prostatic adenocarcinoma in patients with cirrhosis have not been well-reported. We present a case of incidental, but pathologically significant, prostatic adenocarcinoma detected on autopsy in a 67-year-old male patient with cirrhosis and spider angiomata. The morphologic and immunohistochemical features (including variable ERG expression) of the prostatic adenocarcinoma were consistent with hormone exposure related changes, suggesting that cirrhosis-induced elevated estrogen-to-testosterone ratio and exogenous hormone therapy might induce similar phenotypes.

Spinal cord injury commonly results in neuromuscular weakness that impacts respiratory function. This would be expected to be associated with an increased likelihood of sleep-disordered breathing.(1) Understand the incidence and prevalence of sleep disordered breathing in spinal cord injury. (2) Understand the relationship between injury and patient characteristics and the incidence of sleep disordered breathing in spinal cord injury. (3) Distinguish between obstructive sleep apnea and central sleep apnea incidence in spinal cord injury. (4) Clarify the relationship between sleep disordered breathing and stroke, myocardial infarction, metabolic dysfunction, injuries, autonomic dysreflexia and spasticity incidence in persons with spinal cord injury. (5) Understand treatment tolerance and outcome in persons with spinal cord injury and sleep disordered breathing.Extensive database search including PubMed, Cochrane Library, CINAHL and Web of Science.Given the current literature limitations, sleep disordered breathing as currently defined is high in patients with spinal cord injury, approaching 60% in motor complete persons with tetraplegia. Central apnea is more common in patients with tetraplegia than in patients with paraplegia.Early formal sleep study in patients with acute complete tetraplegia is recommended. In patients with incomplete tetraplegia and with paraplegia, the incidence of sleep-disordered breathing is significantly higher than the general population. With the lack of correlation between symptoms and SDB, formal study would be reasonable. There is insufficient evidence in the literature on the impact of treatment on morbidity, mortality and quality of life outcomes.

Objective To evaluate a strategy of home-based testing to diagnose sleep-disordered breathing and nocturnal hypercapnia in individuals with spinal cord injury (SCI). Design Case series. Setting Referral center. Participants Adults with C1-T6 SCI (N=81). Individuals were eligible if ≥18 years old, with SCI of ≥3 months' duration, living within 100 miles of the study site, and not meeting exclusion criteria. Of the 161 individuals recruited from the SCI Model System database who were not enrolled, reasons were not interested in participating, change of location, prior positive pressure ventilation use, or medical contraindication. Ten individuals did not complete the study. Interventions Performance of an unsupervised home sleep apnea test combined with transcutaneous partial pressure of carbon dioxide/oxygen saturation by pulse oximetry monitoring. Main Outcome Measures Prevalence of sleep-disordered breathing and nocturnal hypercapnia. Clinical and physiological variables were examined to determine which, if any, correlate with the severity of sleep-disordered breathing. Results Obstructive sleep apnea (OSA) was found in 81.3% of individuals, central sleep apnea (CSA) was found in 23.8%, and nonspecific hypopnea events, where respiratory effort was too uncertain to classify, were present in 35%. Nonspecific hypopnea events correlated strongly with CSA but weakly with OSA, suggesting that conventional sleep apnea test scoring may underestimate central/neuromuscular hypopneas. Nocturnal hypercapnia was present in 28% and oxygen desaturation in 18.3%. Neck circumference was the primary predictor for OSA, whereas baclofen use and obstructive apnea/hypopnea index weakly predicted CSA. Awake transcutaneous partial pressure of carbon dioxide and CSA were only marginally associated with nocturnal hypercapnia. Conclusions Unsupervised home sleep apnea testing with transcutaneous capnography effectively identifies sleep-disordered breathing and nocturnal hypercapnia in individuals with SCI.

This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral bronchopleural fistulae (BPF) using minimally invasive techniques. In this study, we present a previously healthy 14-year-old male hospitalized with 2009 H1N1 influenza and methicillin-resistant Staphylococcus aureus coinfection complicated by severe acute respiratory distress syndrome and multifocal necrotizing pneumonia, with significant lung tissue damage requiring prolonged extracorporeal membrane oxygenation (ECMO) support.The development of multiple BPFs precluded lung recruitment necessary to wean from ECMO. Treatment options were very limited and endobronchial valves were considered. However, localizing single airleaks with a fogarty balloon is normally the technique to determine appropriate location to place the valves. With multiple fistulae, this technique would be ineffective. Therefore, the patient was brought to interventional radiology and bronchography was performed for selective fistula mapping. With this precise localization, the multiple fistulae were ultimately controlled using image-guided embolization and the placement of multiple endobronchial valves. The success of this intervention enabled positive pressure ventilator support and rehabilitation required for weaning from ECMO support.This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral BPFs using minimally invasive techniques.

Acute exacerbations of COPD complicated by hypercapnic respiratory failure are associated with significant hospital and short-term mortality. Several aspects of standard medical therapy for COPD have remained largely unchanged for years. Non-invasive positive pressure ventilation (NIPPV) has emerged as a life-saving therapy, reversing respiratory failure and preventing endotracheal intubation. NIPPV is beneficial for select COPD patients with altered mental status, those with do-not-intubate orders and for recently extubated patients at high risk of respiratory failure. In addition to standard medical therapy, in the absence of absolute contra-indication, NIPPV should be initiated for all individuals with acute hypercapnic respiratory failure due to an acute exacerbation of COPD.

The goal of mechanical ventilation is to achieve adequate gas exchange while minimizing haemodynamic compromise and ventilator-associated lung injury. Volume-controlled ventilation can be delivered via several modes, including controlled mechanical ventilation, assist control (AC) and synchronized intermittent mandatory ventilation (SIMV). .In volume-controlled modes, the clinician sets the flow pattern, flow rate, trigger sensitivity, tidal volume, respiratory rate, positive end-expiratory pressure, and fraction of inspired oxygen. Patient ventilator synchrony can be enhanced by setting appropriate trigger sensitivity and inspiratory flow rate. I:E ratio can be adjusted to improve oxygenation, avoid air trapping and enhance patient comfort. There is little data regarding the benefits of one volume-controlled mode over another. In acute respiratory distress syndrome, low tidal volume ventilation in conjunction with plateau pressure limitation should be employed as there is a reduction in mortality with this strategy. This chapter addresses respiratory mechanics, modes and settings, clinical applications, and limitations of volume-controlled ventilation.

Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.

Plasminogen activation to plasmin protects from lung fibrosis, but the mechanism underlying this antifibrotic effect remains unclear. We found that mice lacking plasminogen activation inhibitor–1 (PAI-1), which are protected from bleomycin-induced pulmonary fibrosis, exhibit lung overproduction of the antifibrotic lipid mediator prostaglandin E2 (PGE2). Plasminogen activation upregulated PGE2 synthesis in alveolar epithelial cells, lung fibroblasts, and lung fibrocytes from saline- and bleomycin-treated mice, as well as in normal fetal and adult primary human lung fibroblasts. This response was exaggerated in cells from Pai1–/– mice. Although enhanced PGE2 formation required the generation of plasmin, it was independent of proteinase-activated receptor 1 (PAR-1) and instead reflected proteolytic activation and release of HGF with subsequent induction of COX-2. That the HGF/COX-2/PGE2 axis mediates in vivo protection from fibrosis in Pai1–/– mice was demonstrated by experiments showing that a selective inhibitor of the HGF receptor c-Met increased lung collagen to WT levels while reducing COX-2 protein and PGE2 levels. Of clinical interest, fibroblasts from patients with idiopathic pulmonary fibrosis were found to be defective in their ability to induce COX-2 and, therefore, unable to upregulate PGE2 synthesis in response to plasmin or HGF. These studies demonstrate crosstalk between plasminogen activation and PGE2 generation in the lung and provide a mechanism for the well-known antifibrotic actions of the fibrinolytic pathway.

Objective To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco 2 ) monitoring/oxygen saturation by pulse oximetry (Spo 2 ) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders. Design Retrospective case series analyzed consecutively. Setting Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution. Participants Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco 2 /Spo 2 monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV). Interventions A respiratory therapist brought a calibrated tc-Pco 2 /Spo 2 monitor to the patient's home and provided instructions for data collection during the subject's normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco 2 (ET-Pco 2 ) were recorded at a clinic visit before monitoring. Main Outcome Measures Detection of NH (tc-Pco 2 ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo 2 ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco 2 could predict the presence of NH. Results NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco 2 (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco 2 (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results. Conclusions Home-based, unsupervised monitoring with tc-Pco 2 /Spo 2 is a useful method for diagnosing NH in NMRF.

Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Publisher Summary Systemic inflammatory response syndrome (SIRS) is a clinical syndrome characterized by systemic inflammation and widespread tissue injury. SIRS is defined by several clinical variables including temperature > 38°C or 90 beats/min, respiratory rate > 20 breaths/min or PCO2 12 000 cells/mm3 or