摘要:

Exacerbations of chronic obstructive pulmonary disease (COPD) due to pathogenic microorganisms are a major cause of morbidity and mortality. Three major classes of pathogenic microorganisms have been implicated in exacerbations of COPD: aerobic bacteria, viruses, and atypical bacteria. Sputum cultures and bronchoscopic protected-specimen brush cultures are positive for aerobic bacteria in half the exacerbations of COPD. NontypeableHaemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalisare the most frequently isolated bacterial pathogens. Viral infections are associated with one third of exacerbations.Chlamydia pneumoniaeinfection is associated with 5|X%to 10|X% of exacerbations whereasMycoplasmainfection has been seen only rarely in this setting. As many as half of bacterial exacerbations of COPD are now caused by pathogens that are resistant to aminopenicillins (e.g., amoxicillin). An approach to empiric antibiotic therapy of acute exacerbations on the basis of stratifying exacerbations and patients and choosing antibiotic therapy accordingly is outlined.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Lemierre's syndrome is a rare disorder characterized by pharyngitis, tonsillar and/or jugular vein thrombophlebitis, and septicemia usually caused by the anaerobic bacteriaFusobacterium necrophorum. Over the past 25 years, 85 cases of Lemierre's syndrome have been reported in the English literature. Unusual presentations such as meningitis, septic joints, and soft tissue abscesses may occur in addition to the classic syndrome of jugular vein thrombophlebitis and septic pulmonary emboli. Other pulmonary complications reported with this syndrome include frank lung abscesses, parapneumonic pleural effusions, empyema, acute respiratory distress syndrome, and diffuse alveolar hemorrhage. Empyema was found in 23|X% (14/61) of the evaluable cases. We report a man with Lemierre's syndrome, who, at 45 years of age, is significantly older than the 85 patients previously reported. Although less common now in the antibiotic era, there recently have been several reports of Lemierre's syndrome. Clinicians should be aware of this uncommon infection and its presentation, because late recognition may lead to poor outcome.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Indications for the treatment of sarcoidosis include some 10|X% of patients with critical extrathoracic involvement and some 15|X% with progressive pulmonary involvement. Corticosteroids provide the mainstay of treatment; there is no doubt as to their efficacy in the short or medium term, but their long-term efficacy remains uncertain. Relapse rates severe enough to require further treatment are significant, the rate depending on ethnic group, extent and severity of disease, and patient compliance. Osteopenia is frequent among patients receiving long-term corticosteroid therapy and can be detected in >50|X% of these patients. Intermittent etidronate therapy prevents loss of vertebral and trochanteric bone and significantly reduces the rate of new vertebral fractures. In long-term corticosteroid treatment, deflazacort may have fewer overall side effects and be significantly more sparing in bone demineralization. Hydroxy chioroquine, methotrexate, and azathioprine are steroid sparing and may be particularly helpful in the management of refractory forms of sarcoidosis. Inhaled corticosteroids yield no easily recognizable measured therapeutic benefit in pulmonary sarcoidosis but are helpful in the management of troublesome cough. Chloroquine and ketoconazole inhibit production of excess 1, 25-dihydroxyvitamin D and are helpful in the management of hypercalcemia. Organ transplantation (lung, kidney, heart, and liver) provides excellent medium-term results comparable to those resulting from these procedures in other disorders. Recurrence may occur in the allograft; it is usually asymptomatic and does not compromise patient survival. Cardiac conduction disturbances, arrhythmias, and cardiomyopathy attributable to sarcoidosis may present without obvious cause; sudden death remains likely among those with unrecognized or untreated cardiac lesions. Despite the use of intravenous or oral corticosteroids and other drugs including methotrexate, azathioprine, hydroxychloroquine, cyclosporine, and cyclophosphamide, with occasional recourse to cranial irradiation, the prognosis of CNS involvement by sarcoidosis remains poor with significant mortality and morbidity. Future prospects for therapy are discussed and await a more precise elucidation of the pathogenesis.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The portable chest radiograph (pCXR) plays a key role in the evaluation of critically ill patients, frequently revealing abnormalities that cannot be detected clinically. Unfortunately, high-quality pCXRs may be difficult to obtain in the intensive care unit, where poor patient cooperation, inconsistent technique, and other obstacles may lead to inadequate studies. The value of the pCXR is enhanced by proper technique and state-of-the-art equipment. When interpreting the pCXR, a comprehensive, orderly approach is mandatory. Life-threatening complications, such as malpositioning of the endotracheal tube and tension pneumothorax, must be ruled out immediately. Next, it is important to identify common processes, such as pneumonia, pulmonary edema, and atelectasis, recognizing that their appearance may be altered by preexisting disease. Because patients are often supine, it is critical to recognize the features of disorders such as pneumothorax and pleural effusion when viewed in this position. Finally, when uncertainty exists, other modalities such as CT and ultrasound may prove to be invaluable.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Respiratory monitoring provides a better physiologic understanding of the critically ill patient. Arterial blood gas analysis is a commonly used invasive technique to assess gas exchange and acid base status. However, with the development of noninvasive methods to assess gas exchange, pulse oximetry and capnography have become more popular. Research has also focused on other invasive techniques that assess the degree of tissue hypoxia. Monitoring respiratory neuromuscular function is rarely done at the bedside, but advances in technology enable the measurement of respiratory drive by analyzing breathing patterns. Assessing respiratory muscle function at the bedside is accomplished by measuring respiratory pressures with voluntary maneuvers or stimulation of the phrenic nerve. These measurements provide information on respiratory muscle performance and may predict success or failure after discontinuation of mechanical ventilation. Other tests of pulmonary function in the critically ill patient include compliance and vital capacity measurements and the generation of flow-volume and pressure profile curves. In addition, the ability to measure autopositive end-expiratory pressure provides valuable information on respiratory system mechanics. Most importantly, a complete physical examination coupled with the use of respiratory monitoring equipment greatly enhances the predictive power of all monitoring systems. In this way, a better understanding of the pathophysiology of a patient's disease will be gained.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Sepsis is the dominant illness cared for in intensive care units. Historically, there have been two major concepts of sepsis pathophysiology. The first was the oxygen debt theory, suggesting that inadequate systemic oxygen delivery causes multisystem organ failure (MSOF) and death. Alternatively, the unregulated inflammation hypothesis postulates that MSOF is secondary to unchecked host inflammation. Randomized trials of augmenting oxygen delivery to supernormal levels, testing the first hypothesis, suggest this approach is without benefit. Testing the second hypothesis, mediator-specific, antinflammatory agents (e.g., antitumor necrosis factor [TNF] antibodies, soluble TNF receptors, and antagonists to interleukin-1 receptor), along with antibodies to endotoxin, and high-dose glucocorticosteroids have been used in human sepsis trials. Individual studies show no consistent evidence of improved survival, but pooled analysis of all studies reveals a small benefit of inhibiting circulating proinflammatory mediators, no effect of antiendotoxin antibodies, and a harmful effect of high-dose glucocorticoid use. Future studies using anti-inflammatory agents differently, or with newer agents, may yield novel therapies

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Abstracts from LiteratureSYNOPSIS:The use of intermittent administration of inhaled tobramycin in patients with cystic fibrosis improved pulmonary function, decreased the density of Pseudomonas aeruginosa in sputum, and decreased the risk of hospitalization.SOURCE:Ramsey BW et al. Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. N Engl J Med 1999;340:23–30.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Abstracts from LiteratureSYNOPSIS:A consecutive series of 97 patients with clinical and CT criteria of TNM stage ilia lung cancer or less undergoing positron emission tomography (PET) scan were compared with operative stage, biopsy, staging, or final outcome. PET scan was more accurate than CT in nodal staging and identified unsuspected distant metastases.SOURCE:Saunders CAB et al. Evaluation of fluorine-18-fluorodeoxyglucose whole body positron emission tomography imaging in the staging of lung cancer. Ann Thorac Surg 1999;67:790–7.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Abstracts from LiteratureSYNOPSIS:A randomized, double-blind, placebo-controlled trial showed that sustained-release bupropion alone or in combination with nicotine replacement yielded a significantly higher long-term smoking cessation rate than placebo or nicotine replacement alone.SOURCE:Jorenby DE et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999;340:685–91

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Abstracts from LiteratureSYNOPSIS:A 30-minute trial of spontaneous breathing of patients on mechanical ventilation is as effective as a 120-minute trial in predicting a successful extubation.SOURCE:Esteban A et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med 1999;159:512–8.

ISSN:1068-0640    

出版商:OVID    

年代:1999

数据来源: OVID