Usefulness of pulmonary artery diameter in diagnosing pulmonary hypertension in patients admitted to tuberculosis intensive care unit

AbstractObjective/backgroundPulmonary hypertension (PH) can be a complication of patients with severe pulmonary tuberculosis (TB). We aimed to study the correlation between pulmonary artery (PA) diameter (PAD) as measured by computed tomography (CT) and mean PA pressure (mPAP) as measured by echocardiography. We also aimed to determine the accuracy of PAD in diagnosing PH in patients with pulmonary TB.MethodsWe retrospectively investigated the correlation between PAD measured using CT and mPAP measured using echocardiography in 132 patients with TB and PH, and 68 patients with TB but without PH, admitted to the TB intensive care unit at Masih Daneshvari Hospital in Tehran, Iran. We used logistic regression analysis to determine the relationships between PAD, PA diameter to ascending aorta (AA) ratio, and area of PA to area of AA ratio with mPAP. Using receiver operating characteristic analysis, we examined the utility of the PAD in predicting PH (mPAP ⩾25mmHg).ResultsPAD had a significant correlation with mPAP (p<0.005 and r=0.47). Also, PA:AA ratio and area of PA to area of AA ratio had significant correlation with mPAP (r=0.48 and r=0.47, respectively; p<0.001). The threshold of 29mm for PAD was determined using ROC. This index had a sensitivity of 0.55, specificity of 70.2 and area under curve of 0.66.ConclusionAlthough PAD and PA:AA ratio are useful in assessing of presence of PH, we conclude that these CT parameters are not sufficient for ruling in or ruling out PH in this group of patients

Exhaled nitric oxide is not a biomarker for idiopathic pulmonary arterial hypertension or for treatment efficacy

BACKGROUND: Idiopathic pulmonary arterial hypertension (IPAH) is a fatal illness. Despite many improvements in the treatment of these patients, there is no unique prognostic variable available to track these patients. The aim of this study was to evaluate the association between fractional exhaled nitric oxide (FeNO) levels, as a noninvasive biomarker, with disease severity and treatment outcome. METHODS: Thirty-six patients (29 women and 7 men, mean age 38.4 ± 11.3 years) with IPAH referred to the outpatient's clinic of Masih Daneshvari Hospital, Tehran, Iran, were enrolled into this pilot observational study. Echocardiography, six-minute walking test (6MWT), FeNO, brain natriuretic peptide (BNP) levels and the functional class of patients was assessed before patients started treatment. Assessments were repeated after three months. 30 healthy non-IPAH subjects were recruited as control subjects. RESULTS: There was no significant difference in FeNO levels at baseline between patients with IPAH and subjects in the control group. There was also no significant increase in FeNO levels during the three months of treatment and levels did not correlate with other disease measures. In contrast, other markers of disease severity were correlated with treatment effect over the three months. CONCLUSION: FeNO levels are a poor non-invasive measure of IPAH severity and of treatment response in patients in this pilot study

Useful variables during wake and sleep for prediction of positive airway pressure in obstructive sleep apnea titration

Abstract Background Positive airway pressure is the main treatment modality in obstructive sleep apnea. The level of pressure needed for each patient is defined by a positive airway pressure titration study. Predicting those who need higher pressure or bi-level instead of continuous pressure is of a great clinical significance. This study was designed to evaluate whether voluntary breath-holding maneuver could predict Bilevel Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP) as the final optimal pressure in a split night study of patients with obstructive sleep apnea. Polysomnography (PSG) parameters specially oxygen saturation (SaO2) during non-rapid eye movement (NREM), rapid eye movement sleep (REM), and duration of REM in diagnostic part may help determine the type of devices as soon as possible in split night study. Methods The present research was conducted as a cross-sectional study of adults diagnosed as obstructive sleep apnea patients undergoing positive airway pressure (PAP) titration. Demographic, anthropometric, and polysomnographic data were collected. Patients were instructed to hold their breath as long as they could after five tidal breaths in the supine position. Baseline, post breath-holding phase, and recovery SaO2 were recorded. These data were used to predict the pressure level and type of device. Results Seventy-eight participants (56.4% male) with the mean age of 55.7 ± 13.9 years were included in the study. Mean and SD of apnea hypopnea index (AHI) and oxygen desaturation index (ODI) were 55.9 ± 34.4 and 38.3 ± 24 per hour, respectively. Most of the participants (65.3%) were categorized as CPAP group. CPAP and BiPAP groups were similar in terms of age, gender distribution, body mass index (BMI), neck circumference, and certain polysomnographic variables. Voluntary breath-holding maneuver showed a significant correlation between minimum SaO2 and the need for changing to BiPAP during titration. Baseline and post breath-holding SaO2 were not significantly lower in either group. NREM minimum SaO2 and REM duration were the statistically significant correlated variables that predicted the need for BiPAP. Conclusion Minimum oxygen following voluntary breath-holding maneuver along with higher BMI and larger neck circumference are predictors of the need to use BiPAP. Shorter REM duration and NREM minimum SaO2 were other predictors of higher chance of BiPAP during titration of the present OSA participants

The effect of the Iranian family approachspecific course (IrFASC) on obtaining consent from deceased organ donors’ families

Background : A family approach and obtaining consent from the families of potential brain-dead donors is the most important step of organ procurement in countries where an opt-in policy applies to organ donation. Health care staff’s communication skills and ability to have conversations about donation under circumstances of grief and emotion play a crucial role in families’ decision-making process and, consequently, the consent rate. Methods : A new training course, called the Iranian family approach-specific course (IrFASC), was designed with the aim of improving interviewers’ skills and knowledge, sharing experiences, and increasing coordinators’ confidence. The IrFASC was administered to three groups of coordinators. The family consent rate of participants in the same intervals (12 months for group 1, 6 months for group 2, and 3 months for group 3) was measured before and after the training course. The Wilcoxon signed-rank test was used to make comparisons. Results : The family consent rate was significantly different for all participants before and after the training, increasing from 50.0% to 62.5% (P=0.037). Furthermore, sex (P=0.005), previous training (P=0.090), education (P=0.068), and duration of work as a coordinator (P=0.008) had significant effects on the difference in families’ consent rates before and after IrFASC. Conclusions: This study showed that the IrFASC training method could improve the success of coordinators in obtaining family consent

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status