Pulmonary alveolar proteinosis - Progress in the first 44 years

Pulmonary alveolar proteinosis is a rare clinical syndrome that was first described in 1958. Subsequently, over 240 case reports and small series have described at least 410 cases in the literature. Characterized by the alveolar accumulation of surfactant components with minimal interstitial inflammation or fibrosis, pulmonary alveolar proteinosis has a variable clinical course ranging from spontaneous resolution to death with pneumonia or respiratory failure. The most effective proven treatment-whole lung lavage-was described soon after the first recognition of this disease. In the last 8 years, there has been rapid progress toward elucidation of the molecular mechanisms underlying both the congenital and acquired forms of pulmonary alveolar proteinosis, following serendipitous discoveries in gene-targeted mice lacking granulocyte-macrophage colony-stimulating factor (GM-CSF). Impairment of surfactant clearance by alveolar macrophages as a result of inhibition of the action of GM-CSF by blocking autoantibodies may underlie many acquired cases, whereas congenital disease is most commonly attributable to mutations in surfactant protein genes but may also be caused by GM-CSF receptor defects. Therapy with GM-CSF has shown promise in approximately half of those acquired cases treated, but it is unsuccessful in congenital forms of the disease, consistent with the known differences in disease pathogenesis

Antibiotic prophylaxis for cardiac surgery in Australia

Objective: To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocols, agent selection and duration of administration

Outcome of patients admitted to the intensive care unit with newly diagnosed small cell lung cancer

Patients with newly diagnosed small cell lung cancer (SCLC) may be considered for admission to an intensive care unit (ICU). Even though SCLC is highly responsive to chemotherapy, it is not clear whether patient outcomes justify the resource use of an ICU. This paper reports the results of a retrospective review of 20 newly diagnosed cases of SCLC who were admitted to one of three ICUs in Melbourne, Australia. Patients who had more than one negative prognostic factor did uniformly poorly, with no survivors beyond 4 months. Five patients were treated with chemotherapy whilst intubated and receiving mechanical ventilatory support. Two of these patients responded to chemotherapy and were extubated 4 days later. Both of these patients were alive and free of tumour recurrence 7 months later. In contrast, patients not treated with chemotherapy died early (within 40 days). We conclude that some patients with SCLC achieve a medium to long-term survival following treatment with chemotherapy instituted during or around the time of their admission to an ICU. The admission to an ICU of selected patients with SCLC may be justified, and prognostic indicators may be of benefit in making these difficult treatment decisions. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved

Chest physiotherapy for the prevention of ventilator-associated pneumonia

Objective: Pneumonia is an important complication in patients who are intubated and mechanically ventilated, when it is commonly referred to as ventilator-associated pneumonia (VAP). Since VAP may be contributed to by impaired sputum clearance, we studied whether chest physiotherapy designed to enhance sputum clearance decreases the occurrence of VAP Design: Prospective controlled systematic allocation trial. Setting: Tertiary teaching hospital ICU. Patients and participants: Sixty adult patients intubated and mechanically ventilated for at least 48 h. Interventions: Chest physiotherapy (intervention group) or sham physiotherapy (control group). Measurements and results: Control and intervention groups were well matched for age, sex, and admission PaO2/FiO(2) ratio, APACHE 11 score, and Glasgow Coma Score. There were no differences in the duration of mechanical ventilation, length of stay in ICU or mortality. VAP was assessed daily by cbined clinical assessment and the clinical pulmonary infection score (CPIS). VAP occurred in 39% (14/36) of the control group and 8% (2/24) of the intervention group (OR=0.14, 95% Cl 0.03 to 0.56, P=0.02). After adjustment was made by logistic regression for other important variables (APACHE 11 score, duration of mechanical ventilation, presence of tracheostomy, and GCS score), chest physiotherapy was independently associated with a reduced occurrence of VAP (adjusted OR=0.16, 95% CI 0.03 to 0.94, P=0.02). Conclusions: In this small trial, chest physiotherapy in ventilated patients was independently associated with a reduction in VAR This suggested benefit of physiotherapy in prevention of VAP requires confirmation with a larger randomised controlled trial

The influence of a blood conserving device on anaemia in intensive care patients

The contribution of iatrogenic blood loss through diagnostic testing to the anaemia of critical illness remains controversial. We measured the effect of an arterial line blood conservation device upon blood loss and anaemia in adult intensive care patients