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Dealing with Pulmonary

Dr Puneet Khanna
MBBS, MD, IDCCM, FCCP (USA)
Consultant, Department of Respiratory & Critical Care
Medicine, BL Kapur Memorial Hospital

The field of Pulmonary and Critical Care Medicine provides a comprehensive approach to the diagnosis and management of patients with respiratory system disorders. The Pulmonary division usually provides an active consultation service with subspecialty outpatient clinics for diagnosis and management of  tients with acute and chronic lung disease. Special clinical expertise is required to mange patients with asthma, chronic obstructive pulmonary disease, bronchiectasis,sleep disorders, interstitial lung disease, lung cancer, lung transplantation, infectious diseases of the lungs and pulmonary vascular disease.

Diagnostic procedures include fiberoptic bronchoscopy with transbronchial  lung biopsy and bronchoalveolar lavage, pleural biopsy, and pulmonary artery catheterisation. Special facilities often include a pulmonary diagnostic laboratory, an exercise physiology laboratory, a sleep disorders laboratory and specialised procedure suites where diagnostic and therapeutic lung procedures are performed. The critical care services usually focus on a multidisciplinary medical intensive care unit in providing acute care, resuscitation and monitoring of critically sick patients.A typical case presenting to our department is shared below:

Community-acquired a typical pneumonia in a farmer

A 42-year-old farmer, a chronic smoker, presented to the Emergency Room in  acute respiratory distress with a 1-week history of productive cough, myalgia,and low-grade fever. Three days earlier, he was diagnosed as having bronchitis by his primary physician and was treated with amoxicillin / clavulanate 625 mg thrice daily and levofloxacin 500 mg twice daily. On presentation, he complained of shortness of breath, fever, and a worsening cough that was productive of blood-tinged sputum. Additional complaints included headache and pain abdomen. A chest roentgenogram in ER revealed bilateral basilar infiltrates. An arterial blood gas on room air revealed a PaO2 of 52 mm Hg with 88 percent saturation on 2L/min of oxygen. His white blood cell count was 9.5 x 107 lacs, with 55 percent neutrophils, 40 percent band forms, and 4 percent lymphocytes. He was admitted to the hospital with a diagnosis of severe community-acquired pneumonia. The patient’s medical history was unremarkable for any previ-ous hospitalisations or chronic medical illnesses, including heart disease,asthma, or tuberculosis, though patient reported occasional bouts of cough and upper respiratory infections. He was a chronic beedi smoker, about 20 bidis /day, but denied any alcohol use.

On admission, the patient was febrile with a temperature of 39°C, pulse rate of 80 beats per minute, blood pressure of 130/89, and respirations of 20 breaths per minute. The lung examination revealed left-sided creptitations with decreased basilar breath sounds. The cardiac examination was normal, with no murmur or rub and the GIT examination was negative for hepato-splenomegaly.Renal and neurological examinations were normal. Laboratory data revealed a Hb of 11.8 g/dL, a MCV of 76 fL, and platelet counts of 243 lacs/ cu mm. Electrolytes were within normal limits.An ECG showed sinus tachycardia. The patient was started on oxygen with 50 percent ventilation mask and given aero-Malignant MCA Infarction -MIOT Experience Here we present a case scenario which was managed in our institution recently.Mrs R aged 43 years not a known Diabetic or Hypertensive presented to MIOT with sudden onset of weakness of left upper limb and lower limbs since previous day evening. On arrival at MIOT she was hemodynamically stable with HR 84 mt and raised Blood Pressure 180/110. She was conscious but drowsy and found to have dense Hemiplegia on left side with power 0/5 and UMN facial palsy. She was diagnosed as having acute stroke and emergency CT brain showed massive middle cerebral artery infarction – Malignant MCA infarction.She was shifted to the ICU for neuromonitoring and started on antiplatelets and supportive measures.The following day patient had a transient bradycardia, hypertension and unresponsiveness which got corrected after a mannitol infusion. She was electively ventilated and repeat Emergency CT scan showed worsening of edema – infarct with midline shift. She was taken up for emergency Decompressive Craniectomy which was uneventful and shifted back to our Neuro ICU. Gradually over a period of 2 -3 weeks patient stabilized, regained consciousness weaned out of ventilator and Extubated. Her ICU stay was complicated by episode of MDR – Acinetobacter and Candiduria. A follow up Cerebral CT angio done had showed dissection of internal carotid artery with a partial thrombus. She does not give any history of trauma to neck. She was started on oral anticoagulants.Gradually the power of her left lower limb had improved to 3/5 and was able communicate, take oral feeds and was mobilised out of ICU by 4 weeks. Decompressive surgery for malignant MCA infarction has increased over the past 5 years after the results of DESTINY, HAMLET, DECIMAL and their pooled analysis. solised treatments with salbutamol every 6 hours. Empiric antibiotic therapy with IV cefuroxime sodium and Levofloxacin was instituted. About 24 hours later,patient complained of worsening shortness of breath and chest discomfort.An ABG revealed a Pa02 of 46 mmHg on oxygen of 6L/min so he was transferred to ICU and therapy with a 100 percent oxygen non-rebreather mask was started. The patient was oxygenated via nasal prongs and non-invasive ventilation [BIPAP] was initiated. Further history obtained from the patient’s wife revealed that patient had been regularly feeding his pet pigeons and parrots and since 3 months, and several of these had been ill and died. In light of this information, atypical pneumonia was suspected and intravenous clarithromycin 500 mg BD was added to the patient’s antibiotic regimen and levofloxacin was stopped. Serum samples for antibodies to C psittaci and C pneumonia, along with mycoplasma and legionella were obtained.Sputum cultures were negative for acid fast bacilli, and antibodies for legionella and mycoplasma were negative. A subsequent white blood cell count was 6.8 x 107 lacs/cu mm. The patient continued to clinically improve and on the 8th day of hospitalisation, ELISA for chlamydial antibody was reported as positive at 0.99 (0.71 or greater indicated a high level of detectable antibody). Two days later, IgG antibody specific for C psittaci antibody was also reported positive at 1:128 (active infection indicated by a titer of 1:64 or greater). IgG antibody against C pneumoniae was positive at 1:64 (active infection indicated by a titer of 1:256 or greater). Intravenous clarithromycin was discontinued and the patient was placed on oral formulation. A third chest roentgenogram showed significant clearing of the bilateral pulmonary infiltrates. The patient was discharged on the 15th day after hospitalisation. At 1 week 1 month after discharge, the patient was well withno further pulmonary symptoms.


Malignant MCA Infarction -MIOT Experience

Dr Nisheeth T P, MD, DM Critical Care, MRCP (UK), EDIC, Chief Consultant Intensivist, Medical ICU-MIOT Hospitals

Here we present a case scenario which was managed in our institution recently.
Mrs R aged 43 years not a known Diabetic or Hypertensive presented to MIOT with sudden onset of weakness of left upper limb and lower limbs since previous day evening. On arrival at MIOT she was hemodynamically stable with HR 84 mt and raised Blood Pressure 180/110. She was conscious but drowsy and found to have dense Hemiplegia on left side with power 0/5 and UMN facial palsy. She was diagnosed as having acute stroke and emergency CT brain showed massive middle cerebral artery infarction – Malignant MCA infarction. She was shifted to the ICU for neuromonitoring and started on antiplatelets and supportive measures.  The following day patient had a transient bradycardia, hypertension and unresponsiveness which got corrected after a mannitol infusion. She was electively ventilated and repeat Emergency CT scan showed worsening of edema – infarct with midline shift. She was taken up for emergency Decompressive Craniectomy which was uneventful and shifted back to our Neuro ICU. Gradually over a period of 2 -3 weeks patient stabilized, regained consciousness weaned out of ventilator and Extubated. Her ICU stay was complicated by episode of MDR – Acinetobacter and Candiduria. A follow up Cerebral CT angio done had showed dissection of internal carotid artery with a partial thrombus. She does not give any history of trauma to neck. She was started on oral anticoagulants. Gradually the power of her left lower limb had improved to 3/5 and was able to communicate, take oral feeds and was mobilised out of ICU by 4 weeks. Decompressive surgery for malignant MCA infarction has increased over the past 5 years after the results of DESTINY, HAMLET, DECIMAL and their pooled analysis.

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