DOCSLIB.ORG

Pulmonary Hypertension in the Intensive Care Unit

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Pulmonary Hypertension in the Intensive Care Unit Pulmonary vascular disease ORIGINAL ARTICLE Heart: first published as 10.1136/heartjnl-2015-307774 on 6 April 2016. Downloaded from Pulmonary hypertension in the intensive care unit. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK Michael Kaestner,1 Dietmar Schranz,2 Gregor Warnecke,3,4 Christian Apitz,1 Georg Hansmann,5 Oliver Miera6 For numbered affiliations see ABSTRACT heterogeneous underlying conditions.1 Distinction end of article. Acute pulmonary hypertension (PH) complicates the between precapillary and postcapillary aetiologies Correspondence to course of several cardiovascular, pulmonary and other (or establishment of a combination of the two) is Dr. Oliver Miera, Department systemic diseases in children. An acute rise of RV important to initiate specific individual therapy. of Congenital Heart Disease afterload, either as exacerbating chronic PH of different and Paediatric Cardiology, aetiologies (eg, idiopathic pulmonary arterial Pathophysiology of acute PH and RV failure Deutsches Herzzentrum Berlin, hypertension (PAH), chronic lung or congenital heart Augustenburger Platz 1, Chronic PH causes adaptation and remodelling of Berlin 13353, Germany; disease), or pulmonary hypertensive crisis after corrective the RV to increased loading conditions. Pulmonary [email protected] surgery for congenital heart disease, may lead to severe hypertensive crisis (PHC) occurs when compensatory circulatory compromise. Only few clinical studies provide mechanisms fail, RV systolic function decompensates This manuscript is a product of evidence on how to best treat children with acute severe and LV preload acutely decreases resulting in abol- the writing group of the 23 European Paediatric Pulmonary PH and decompensated RV function, that is, acute RV ished cardiac output and coronary perfusion. Vascular Disease (PVD) failure. The specific treatment in the intensive care unit Acute elevation of afterload (pulmonary artery pres- Network (Writing Group Chair: should be based on the underlying pathophysiology and sure (PAP)) is poorly tolerated by the unprepared RV. G. Hansmann, Writing Group not only be focused on so-called ‘specific’ or ‘tailored’ In healthy adult individuals, the RV cannot acutely Co-Chair: C. Apitz). ISHLT, drug therapy to lower RV afterload. In addition 4 International Society of Heart generate a mean PAP >40 mm Hg. Adaptive and Lung Transplantation; therapeutic efforts should aim to optimise RV preload, changes of the RV microstructure and function do http://heart.bmj.com/ DGPK, German Society of and to achieve adequate myocardial perfusion, and not work in the setting of acute rise of RV afterload. Paediatric Cardiology. cardiac output. Early recognition of patients at high risk Thus, although myocardial contractility may initially and timely initiation of appropriate therapeutic measures Received 6 March 2015 rise with RV concentric hypertrophy and preserved Revised 28 June 2015 may prevent the development of severe cardiac systolic and diastolic function, excessive pressure Accepted 29 June 2015 dysfunction and low cardiac output. In patients not overload results in maladaptive remodelling with RV responding adequately to pharmacotherapy, (1) novel dilatation and failure.5 Among many others, arrhyth- surgical and interventional techniques, temporary mia, myocardial ischaemia and/or pulmonary disease mechanical circulatory support with extracorporeal such as infections or pulmonary arterial embolism on September 24, 2021 by guest. Protected copyright. membrane oxygenation, (2) pumpless lung assist devices may trigger an acute rise of PAP and PVR (figure 1). (3) and/or lung or heart-lung transplantation should be With subsequent RV dilatation, the contractile sarco- timely considered. The invasive therapeutic measures can mere apparatus is damaged, resulting in RV failure. be applied in a bridge-to-recovery or bridge-to-lung The combination of right-to-left septal shift with sub- transplant strategy. This consensus statement focuses on sequent LV compression, related to limited space the management of acute severe PH in the paediatric within the pericardial sac, results in low LV output, intensive care unit and provides an according treatment systemic arterial hypotension and elevated LVand RV algorithm for clinical practice. end-diastolic pressure. With or without RV hyper- trophy, these factors decrease coronary perfusion leading to myocardial ischaemia that perpetuates RV INTRODUCTION failure.6 The resulting metabolic acidosis further Despite recent advances in the specific treatment of increases PVR and PAP.Moreover, a sudden increase pulmonary hypertension (PH), RV failure following in PAP causes airway obstruction due to arterial dis- or in the context of severe rise of pulmonary vascu- tension of the smaller intrapulmonary arteries and lar resistance (PVR) is a challenging complication lung oedema. The resulting dead space ventilation of PH and is associated with substantial morbidity and ventilation/perfusion mismatch causes hypoxia and mortality. and respiratory acidosis, eventually resulting in even PH leading to a decompensation of the cardio- more elevated PAP and PVR (figure 1).237 To cite: Kaestner M, vascular system can be considered a syndrome with In children with congenital heart disease (CHD) Schranz D, Warnecke G, non-specific signs and symptoms presenting late in and systemic-to-pulmonary shunt, PH crisis may et al. Heart 2016;102: the disease process and may be strongly associated occur following corrective surgery. Factors that – ii57 ii66. with, or directly caused by several, very promote the development of postoperative PH are Kaestner M, et al. Heart 2016;102:ii57–ii66. doi:10.1136/heartjnl-2015-307774 ii57 Pulmonary vascular disease Heart: first published as 10.1136/heartjnl-2015-307774 on 6 April 2016. Downloaded from Figure 1 Schematic drawing of PAH crisis and contributing factors. Pulmonary hypertensive crisis develops with an acute increase of PAP. This leads to an increase in RV pressure and volume causing a shift of the interventricular septum towards the left side and reducing LV volume. Filling http://heart.bmj.com/ pressures of ventricles rise, compensatory tachycardia and the drop in systemic blood pressure compromise coronary perfusion pressure and flow, leading to low cardiac output and metabolic acidosis. Furthermore, the increase in PAP causes decreased pulmonary blood flow and airway obstruction related to arterial distension of the smaller intrapulmonary arteries and lung oedema. Consequently dead space ventilation increases; together with a mismatch of pulmonary ventilation and perfusion this causes hypoxia and respiratory acidosis. PAH, pulmonary arterial hypertension; RVEDV, RV end-diastolic volume; RVEDP, RV end-diastolic pressure; LVEDP, LV end-diastolic pressure; V/Q, pulmonary ventilation and perfusion; PAH, pulmonary arterial hypertension; PAP, pulmonary artery pressure; PVR, pulmonary vascular resistance; CHD, congenital heart disease; NO, nitric oxide; CPB, cardiopulmonary bypass; LR-Shunt, left-to-right shunt; PBF, pulmonary blood flow. on September 24, 2021 by guest. Protected copyright. not yet completely understood, however, endothelial cell dys- unit (PICU), including concise recommendations and a treat- function was found to be a contributing factor preoperatively ment algorithm for clinical practice. – and postoperatively.8 10 Inflammatory response to cardiopul- monary bypass, and ischaemia-reperfusion injury and its impact METHODS on heart-lung function contribute to the rise in PVR.11 Pain, The recommendations given in table 2 relate to the grading awakening reactions in mechanically ventilated children, tracheal system currently suggested by the European Society of secretions or tracheal suctioning may trigger acute severe eleva- Cardiology (ESC) and the American Heart Association (AHA), tion of PVR presenting as PHC and potentially leading to cardi- and was based on paediatric data only (class of recommenda- ocirculatory collapse and death (figure 1). tion, level of evidence). The grading and voting process within In this consensus statement, we distinguish between and elab- the writing group is outlined in the executive summary13 of this orate on three common scenarios: (1) acute PH crisis after online supplement. Computerised searches of the PubMed/ cardiac surgery for CHD, with different management strategies MEDLINE bibliographical database were conducted between subdivided for patients with univentricular and biventricular 1990 and June 2015. Clinical trials, guidelines and reviews physiology (2) acute deterioration in a child with previously limited to paediatric data were searched using the terms ‘pul- known chronic PH (eg, a child with chronic parenchymal lung monary hypertension’ and ‘intensive care’, ‘heart failure’, ‘con- disease and acute viral chest infection and acute deterioration in genital heart’, ‘postoperative’, ‘surgery’, ‘ECMO’, ‘lung assist’, a child with new diagnosis of group 1 PH (pulmonary arterial ‘ventricular assist’, ‘mechanical circulatory support’, ‘cardiopul- hypertension (PAH), eg, idiopathic PAH), and (3) secondary monary bypass’, and ‘pulmonary hypertensive crisis’. The PH.12 We finally focus on the rapid assessment and efficient primary focus of this manuscript is on group 1 PH according to management of acute severe PH in the paediatric intensive care the World Symposium on Pulmonary Hypertension
Load more

Recommended publications
  • Hypertensive Emergency: an Overview of Heart As Target Organ Damage
    ORIGINAL ARTICLE Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 3: 903-906 P-ISSN.2089-1180, E-ISSN: 2302-2914 Hypertensive emergency: an overview of heart as target organ damage Starry Homenta Rampengan1*, H J Sunarto2 ABSTRACT Hypertension is currently still a global problem in the cardiology cells’ death affected heart structure and its function. The symptoms and vascular fields with an increasing trend. One of the emergency that appear can be in the form of acute coronary syndrome or acute conditions related to an increase in blood pressure is emergency heart failure. Some modalities can detect heart structure changes, hypertension. Emergency hypertension is a condition where blood like electrocardiography for general and echocardiography for pressure rises rapidly and severely, resulting in new or progressive specific examination. Hypertensive emergencies can be treated organ damage. Symptoms can range from chest pain, shortness by several rapid-acting antihypertensive agents, which can be of breath to delirium. The heart is one of the organs that can be selected based on the clinical manifestations. As the symptoms damaged by hypertensive emergencies. The availability and related to heart damage are acute coronary syndrome and acute demand for oxygen from the coronary blood vessels to the heart heart failure, so the treatment will be specific, respectively. Good muscle cells will experience an imbalance due to a sudden increase knowledge related to emergency hypertension management and in blood pressure. Lack of oxygen that occurs can cause heart muscle early treatment will reduce patient morbidity. Keywords: hypertensive emergency, heart, organ damage Cite this Article: Rampengan, S.H., Sunarto, H.J.
    [Show full text]
  • Spontaneous Pneumothorax in COVID-19 Patients Treated with High-Flow Nasal Cannula Outside the ICU: a Case Series
    International Journal of Environmental Research and Public Health Case Report Spontaneous Pneumothorax in COVID-19 Patients Treated with High-Flow Nasal Cannula outside the ICU: A Case Series Magdalena Nalewajska 1, Wiktoria Feret 1 , Łukasz Wojczy ´nski 1, Wojciech Witkiewicz 2 , Magda Wi´sniewska 1 and Katarzyna Kotfis 3,* 1 Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70–111 Szczecin, Poland; [email protected] (M.N.); [email protected] (W.F.); [email protected] (Ł.W.); [email protected] (M.W.) 2 Department of Cardiology, Pomeranian Medical University, 70–111 Szczecin, Poland; [email protected] 3 Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70–111 Szczecin, Poland * Correspondence: katarzyna.kotfi[email protected] Abstract: The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic and a burden to global health at the turn of 2019 and 2020. No targeted treatment for COVID-19 infection has been identified so far, thus supportive treatment, invasive and non-invasive oxygen support, and corticosteroids remain a common therapy. High-flow nasal cannula (HFNC), a non-invasive oxygen support method, has become a prominent treatment option for respiratory failure during the SARS-CoV-2 pandemic. Citation: Nalewajska, M.; Feret, W.; HFNC reduces the anatomic dead space and increases positive end-expiratory pressure (PEEP), Wojczy´nski,Ł.; Witkiewicz, W.; allowing higher concentrations and higher flow of oxygen. Some studies suggest positive effects of Wi´sniewska,M.; Kotfis, K. HFNC on mortality and avoidance of intubation.
    [Show full text]
  • Control Study of Pregnancy Complications and Birth Outcomes
    Hypertension Research (2011) 34, 55–61 & 2011 The Japanese Society of Hypertension All rights reserved 0916-9636/11 $32.00 www.nature.com/hr ORIGINAL ARTICLE Hypotension in pregnant women: a population-based case–control study of pregnancy complications and birth outcomes Ferenc Ba´nhidy1,Na´ndor A´ cs1, Erzse´bet H Puho´ 2 and Andrew E Czeizel2 Hypotension is frequent in pregnant women; nevertheless, its association with pregnancy complications and birth outcomes has not been investigated. Thus, the aim of this study was to analyze the possible association of hypotension in pregnant women with pregnancy complications and with the risk for preterm birth, low birthweight and different congenital abnormalities (CAs) in the children of these mothers in the population-based data set of the Hungarian Case–Control Surveillance of CAs, 1980–1996. Prospectively and medically recorded hypotension was evaluated in 537 pregnant women who later had offspring with CAs (case group) and 1268 pregnant women with hypotension who later delivered newborn infants without CAs (control group); controls were matched to sex and birth week of cases (in the year when cases were born), in addition to residence of mothers. Over half of the pregnant women who had chronic hypotension were treated with pholedrine or ephedrine. Maternal hypotension is protective against preeclampsia; however, hypotensive pregnant women were at higher risk for severe nausea or vomiting, threatened abortion (hemorrhage in early pregnancy) and for anemia. There was no clinically important difference in the rate of preterm births and low birthweight newborns in pregnant women with or without hypotension. The comparison of the rate of maternal hypotension in cases with 23 different CAs and their matched controls did not show a higher risk for CAs (adjusted OR with 95% confidence intervals: 0.66, 0.49–0.84).
    [Show full text]
  • Life-Threatening Events in Patients with Pheochromocytoma
    A Riester and others Life-threatening events in 173:6 757–764 Clinical Study pheochromocytoma Life-threatening events in patients with pheochromocytoma Anna Riester, Dirk Weismann1, Marcus Quinkler2, Urs D Lichtenauer3, Sandra Sommerey4, Roland Halbritter5, Randolph Penning6, Christine Spitzweg7, Jochen Schopohl, Felix Beuschlein and Martin Reincke Medizinische Klinik und Poliklinik IV, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Ziemssenstr. 1, D-80336 Munich, Germany, 1Medizinische Klinik und Poliklinik I, Universita¨ tsklinikum Wu¨ rzburg, Correspondence Wu¨ rzburg, Germany, 2Endokrinologie in Charlottenburg, Berlin, Germany, 3Helios Klinik Schwerin, Schwerin, should be addressed Germany, 4Chirurgische Klinik und Poliklinik – Innenstadt, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians- to M Reincke Universita¨ tMu¨ nchen, Munich, Germany, 5Facharztpraxis, Pfaffenhofen, Germany, 6Institut fu¨ r Rechtsmedizin and Email 7Medizinische Klinik und Poliklinik II, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Munich, martin.reincke@ Germany med.uni-muenchen.de Abstract Objective: Pheochromocytomas are rare chromaffin cell-derived tumors causing paroxysmal episodes of headache, palpitation, sweating and hypertension. Life-threatening complications have been described in case reports and small series. Systematic analyses are not available. We took an opportunity of a large series to make a survey. Design and methods: We analyzed records of patients diagnosed with pheochromocytomas in three geographically spread German referral centers between 2003 and 2012 (nZ135). Results: Eleven percent of the patients (ten women, five men) required in-hospital treatment on intensive care units (ICUs) due to complications caused by unsuspected pheochromocytomas. The main reasons for ICU admission were acute catecholamine induced Tako-Tsubo cardiomyopathy (nZ4), myocardial infarction (nZ2), acute pulmonary edema (nZ2), cerebrovascular stroke (nZ2), ischemic ileus (nZ1), acute renal failure (nZ2), and multi organ failure (nZ1).
    [Show full text]
  • Definitions • Septic Shock
    BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Ann Rheum Dis Definitions • Septic shock: Persisting hypotension despite volume resuscitation, requiring vasopressors to maintain mean artery pressure (MAP) ≥65 mmHg and serum lactate level >2 mmol/L (1). • Renal failure: Doubling of basal Creatinine value or urine output <0.5 ml/kg/h for ≥12h (2) • Heart failure: Gradual or rapid change in heart failure signs and symptoms resulting in a need for urgent therapy (3). • Myocarditis: Myocarditis was diagnosed if serum levels of high-sensitivity cardiac troponin I were above the 99th percentile upper reference limit and compatible abnormalities were shown in electrocardiography and echocardiography. • Encephalopathy: Impaired consciousness as change of consciousness level (somnolence, stupor, and coma) or consciousness content (confusion and delirium) (4). • Thrombosis: Clinically or by imaging diagnosed acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism (5). References 1. World Health Organization. Clinical management of severe acute respiratory infection when Novel coronavirus (nCoV) infection is suspected: interim guidance. 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection- when-novel-coronavirus-(ncov)-infection-is-suspected. 2. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012;120:c179-84. 10.1159/000339789. 3. Gheorghiade M, Zannad F, Sopko G, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112(25):3958-3968. 4. Mao L, Jin H, Wang M, et al.
    [Show full text]
  • Allergic Bronchopulmonary Aspergillosis: a Perplexing Clinical Entity Ashok Shah,1* Chandramani Panjabi2
    Review Allergy Asthma Immunol Res. 2016 July;8(4):282-297. http://dx.doi.org/10.4168/aair.2016.8.4.282 pISSN 2092-7355 • eISSN 2092-7363 Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity Ashok Shah,1* Chandramani Panjabi2 1Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India 2Department of Respiratory Medicine, Mata Chanan Devi Hospital, New Delhi, India This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid spu- tum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmo- nary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagno- sis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in pa- tients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hall- mark of AAS.
    [Show full text]
  • Right Heart Pressures in Bronchial Asthma
    Thorax: first published as 10.1136/thx.26.1.39 on 1 January 1971. Downloaded from Thorax (1971), 26, 39. Right heart pressures in bronchial asthma R. F. GUNSTONE St. George's Hospital, London S.W.1 Right heart pressures, electrocardiograms, blood gases, and peak expiratory flow rates were measured in nine patients admitted to hospital with severe bronchial asthma. Low or normal right heart pressures were found despite electrocardiographic changes in five patients consisting of right atrial P waves, abnormal right axis deviation, and in one patient T-wave changes in pre- cordial leads. These electrocardiographic changes reverted towards normal on recovery of the patient from the asthmatic attack. Electrocardiographic changes suggestive of right The procedure was carried out in the general ward heart embarrassment have been noted in acute with the patient in the sitting position supported at 60 bronchial asthma, particularly right atrial P waves to 90 degrees to the horizontal because orthopnoea (P and abnormal right axis deviation was always present. Immediately after catheterization pulmonale) the peak expiratory flow rate was measured with a (Harkavy and Romanoff, 1942; Miyamato, Wright peak flow meter (Wright and McKerrow, Bastaroli, and Hoffman, 1961; Ambiavagar, 1959) and blood (capillary or arterial) was taken for Jones and Roberts, 1967). These observations measurement of pH, Pco2, and standard bicarbonate raise the possibility that death in bronchial asthma by the Astrup method (Astrup, J0rgensen, Andersen, may be due to acute cor pulmonale although and Engel, 1960). The peak flow rate and electro- copyright. necropsy evidence is against this suggestion (Earle, cardiogram were repeated after recovery.
    [Show full text]
  • Severe Asthma Is Associated with a Remodeling of the Pulmonary Arteries in Horses
    bioRxiv preprint doi: https://doi.org/10.1101/2020.04.15.042903; this version posted April 17, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY-NC-ND 4.0 International license. 1 Severe asthma is associated with a remodeling of the pulmonary arteries in horses Remodeling of pulmonary arteries in severe equine asthma Serena Ceriotti1,2, Michela Bullone1, Mathilde Leclere1, Francesco Ferrucci2, Jean-Pierre Lavoie1* 1 Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint- Hyacinthe, Quebec, Canada 2 Department of Health, Animal Science and Food Safety, Università degli Studi di Milano, Milano, Italy Dr. Ceriotti current address is Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA Dr. Bullone current address is Department of Veterinary Science, Università degli Studi di Torino, Grugliasco, Italy *Corresponding author: [email protected] Serena Ceriotti and Jean-Pierre Lavoie conceived and designed the work. Serena Ceriotti, Michela Bullone and Mathilde Leclere acquired clinical data, collected, processed and prepared histological and immunostained samples. Serena Ceriotti performed histomorphometric studies and statistical analysis. Serena Ceriotti, Jean-Pierre Lavoie and Francesco Ferrucci prepared and edited the manuscript prior to submission. Michela Bullone and Mathilde Leclere edited the manuscript prior to submission. 1 bioRxiv preprint doi: https://doi.org/10.1101/2020.04.15.042903; this version posted April 17, 2020. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity.
    [Show full text]
  • Venous Thromboembolism: Lifetime Risk and Novel Risk Factors A
    Venous Thromboembolism: Lifetime risk and novel risk factors A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY Elizabeth Jean Bell, M.P.H. IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Adviser: Aaron R. Folsom, M.D., M.P.H. March 2015 © Elizabeth Jean Bell 2015 ACKNOWLEDGEMENTS This research was supported by a training grant in cardiovascular disease epidemiology and prevention, funded by the National Institutes of Health. This fellowship has significantly enhanced my doctoral training experience. I could not have completed this research without the support of a great many people. I would first like to thank my advisor, Aaron Folsom. Thank you for taking me on as a mentee, not only at the doctorate level, but also at the master’s level. Undoubtedly you were an influence in my choice to continue my education with a doctorate in the first place. I recognize and appreciate the countless hours you have spent teaching and guiding; thank you for your thorough comments, quick turnaround times, and for always challenging me to achieve. I have learned much from you, including a passion for research. A huge thank you to Pam Lutsey, who has served as an informal mentor to me throughout my master’s and doctorate programs. Thank you for a countless number of things, including guiding my data analyses back before I knew how to do data analyses, sharing your expertise on every paper I have led, and being a role model to aspire to. Thank you to Alvaro Alonso and Saonli Basu, who have each offered their expertise through serving on my doctoral committee.
    [Show full text]
  • Pneumothorax in Patients with Idiopathic Pulmonary Fibrosis
    Yamazaki et al. BMC Pulm Med (2021) 21:5 https://doi.org/10.1186/s12890-020-01370-w RESEARCH ARTICLE Open Access Pneumothorax in patients with idiopathic pulmonary fbrosis: a real-world experience Ryo Yamazaki, Osamu Nishiyama* , Kyuya Gose, Sho Saeki, Hiroyuki Sano, Takashi Iwanaga and Yuji Tohda Abstract Background: Some patients with idiopathic pulmonary fbrosis (IPF) develop pneumothorax. However, the charac- teristics of pneumothorax in patients with IPF have not been elucidated. The purpose of this study was to clarify the clinical course, actual management, and treatment outcomes of pneumothorax in patients with IPF. Methods: Consecutive patients with IPF who were admitted for pneumothorax between January 2008 and Decem- ber 2018 were included. The success rates of treatment for pneumothorax, hospital mortality, and recurrence rate after discharge were examined. Results: During the study period, 36 patients with IPF were admitted with pneumothorax a total of 58 times. During the frst admission, 15 patients (41.7%) did not receive chest tube drainage, but 21 (58.3%) did. Of the 21 patients, 8 (38.1%) received additional therapy after chest drainage. The respective treatment success rates were 86.6% and 66.7% in patients who underwent observation only vs chest tube drainage. The respective hospital mortality rates were 13.3% and 38.0%. The total pneumothorax recurrence rate after hospital discharge was 34.6% (n 9). = Conclusions: Pneumothorax in patients with IPF was difcult to treat successfully, had a relatively poor prognosis, and showed a high recurrence rate. Keywords: Idiopathic pulmonary fbrosis, Hospitalization, Pneumothorax, Recurrence, Treatment Background pneumothorax was signifcantly associated with poor Idiopathic pulmonary fbrosis (IPF) is a specifc form survival in patients with IPF [11].
    [Show full text]
  • Pulmonary Embolism Caused by Ovarian Vein Thrombosis During Cesarean Section: a Case Report
    Oda et al. JA Clinical Reports (2018) 4:3 DOI 10.1186/s40981-017-0142-1 CASEREPORT Open Access Pulmonary embolism caused by ovarian vein thrombosis during cesarean section: a case report Yutaka Oda1* , Michie Fujita2, Chika Motohisa3, Shinichi Nakata3, Motoko Shimada1 and Ryushi Komatsu4 Abstract Background: Ovarian vein thrombosis is a rare complication of pregnancy. The representative complaints of patients with ovarian vein thrombosis are abdominal pain and fever. In some cases, however, fatal pulmonary embolism may develop. We report a case of pulmonary embolism presenting with severe hypotension and loss of consciousness during cesarean section possibly caused by ovarian vein thrombosis. Case presentation: A 25-year-old woman at 38 weeks 4 days of gestation was scheduled for repeat cesarean section. Her past history was unremarkable, and the progress of her pregnancy was uneventful. She did not experience any symptoms indicative of deep vein thrombosis. Cesarean section was performed under spinal anesthesia, and a healthy newborn was delivered. After removal of the placenta, she suddenly developed dyspnea, hypotension, and loss of consciousness with decreased peripheral oxygen saturation. Blood pressure, heart rate, and oxygen saturation recovered after tracheal intubation and mechanical ventilation with oxygen. Postoperative computed tomography revealed no abnormality in the brain or in the pulmonary artery, but a dilated right ovarian vein with thrombi, extending up to the inferior vena cava, was found. A diagnosis of pulmonary embolism caused by ovarian vein thrombosis was made, and heparin was administered. The tracheal tube was removed on the first postoperative day. Her postoperative course was uneventful, and she was discharged with no complications.
    [Show full text]
  • Therapy Management Guide
    INLYTA® (axitinib) + pembrolizumab THERAPY MANAGEMENT GUIDE Dosing recommendations and management strategies when INLYTA is used in combination with pembrolizumab for the first-line treatment of advanced RCC When INLYTA is used in combination with pembrolizumab, please refer to the full Prescribing Information for pembrolizumab for full dosing and AR management information INDICATION INLYTA in combination with pembrolizumab is indicated for the first-line treatment of patients with advanced renal cell carcinoma (RCC). IMPORTANT SAFETY INFORMATION Hypertension including hypertensive crisis has been observed. Blood pressure should be well controlled prior to initiating LIN YTA. Monitor for hypertension and treat as needed. For persistent hypertension despite use of antihypertensive medications, reduce the dose. Discontinue INLYTA if hypertension is severe and persistent despite use of antihypertensive therapy and dose reduction of INLYTA, and discontinuation should be considered if there is evidence of hypertensive crisis. Arterial and venous thrombotic events have been observed and can be fatal. Use with caution in patients who are at increased risk for, or who have a history of, these events. Hemorrhagic events, including fatal events, have been reported. INLYTA has not been studied in patients with evidence of untreated brain metastasis or recent active gastrointestinal bleeding and should not be used in those patients. If any bleeding requires medical intervention, temporarily interrupt the INLYTA dose. Please see additional Important
    [Show full text]