Pulmonary/Critical Care

Safety of Long-Acting Beta-Agonists in the Treatment of Asthma: Should they be used?

February 21, 2007

Commentary By: Sarah Huen, PGY-3 and David Chong, Director of Critical Care, Bellevue Hospital, Associate NYU Internal Medicine Residency Program Director

The role of long-acting b-agonists (LABAs) in the treatment of asthma continues to be controversial. Growing evidence that LABAs may cause an increased risk of asthma exacerbations and asthma-related deaths prompted the U.S. Food and Drug Administration (FDA) to approve “black box” safety warning labels for Serevent Diskus (salmeterol xinafoate), Advair Diskus (fluticasone propionate; salmeterol xinafoate), and Foradil (formoterol fumarate). Concern about…

What Is XDR-TB?

February 12, 2007

Commentary By: Marshall Fordyce, PGY-3

Extensively drug-resistant tuberculosis (XDR-TB) is as ominous as it sounds. As a second-year resident on the Chest service, you may have treated one or two patients with multi-drug resistant tuberculosis (MDR-TB), which is resistant to at least INH (Isoniazide) and RIF (Rifampin), the two most powerful first-line agents. However, when TB becomes designated as XDR-TB, it implies resistance to any and all Fluoroquinolones and at least one of the three injectable second-line drugs (Amikacin, Capreomycin, and Kanamycin).…

More Smoke From the Tobacco Industry

February 8, 2007

Commentary By: Elizabeth Ross, PGY-3

Cigarette manufacturers have been steadily increasing the nicotine content in cigarettes over the last 7 years. The news broke in August of this year when the Massachusetts Department of Public Health discovered that the level of nicotine that smokers typically consume per cigarette had risen about 10 percent.

The Harvard School of Public Health recently re-analyzed the data with the goal of ascertaining how the tobacco industry managed the increase in nicotine content. The investigators found…

Mystery Quiz #2-The Answer

February 6, 2007

Before you read the answer you will probably want to review the original post of the mystery quiz from last week.

The pathology has been correctly identified. The photomicrograph shows lipoid pneumonia, which in fact was due to chronic mineral oil ingestion (aspiration). The patient suffered from constipation, due to long usage of oxycondone, and medicated himself with mineral oil. The pathology shows lipid material, some of it pooled into large coalescent droplets, some in macrophages.

Lipoid pneumonia…

Mystery Quiz #2 (with a hint…)

January 30, 2007

Since we received little in the way of responses to our mystery quiz, we thought a hint might be in order, so here's the case again this time with a hint. Please submit your answers by clicking on the "comments" link below this post. As always, for those of you who are unwilling to attach your name, you can post your comments anonymously.

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration. As part of a…

Mystery Quiz #2

January 22, 2007

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration. As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below. Click on the thumbnails below for full size images:

A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms…

How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

January 17, 2007

An otherwise healthy 57 year old patient presents with shortness of breath and pleuritic chest pain. The patient is hemodynamically stable without evidence of shock. A chest CT reveals a pulmonary embolus.

Questions: 1. When should an echocardiogram to assess for right heart strain be performed in a patient with a pulmonary embolism? Should stable patients without evidence of shock have a routine echo once a diagnosis of pulmonary embolism is made?

2. If the echo shows signs of right…

Morning Report: How Do You Approach a Patient With Bronchiectasis

January 16, 2007

Chief complaint: 85 year old female presents with worsening shortness of breath for one day.

History of present illness:

The patient's history of present illness begins at the age of 60 when she was diagnosed with asthma, for which she had been treated with inhaled anticholinergics, beta agonists and intermittent oral steroids. Twelve years prior to admission, the patient was diagnosed with diabetes, which was managed with oral medications. Two years prior to admission, the patient was diagnosed with Mycobacterium avium complex…

Mystery Quiz #1-The Answer…

December 20, 2006

Before you read the answer you will probably want to review the original post of the mystery quiz from last week.

The Answer:

The chest film shows a probable mass in the area of the left hilum and associated complete collapse of the left upper lobe. The key findings are loss of volume of the left hemithorax indicated by elevation of the left hemidiaphragm and shift of the mediastinum to the left side. Additionally, the arrows indicate the major…

How do you approach a patient with Pneumomediastinum?

December 19, 2006

BH Morning Report Fast Facts

29 year old male presents with anuria, vomiting, and pneumomediastinum. 1 month prior to admission the patient traveled to South America and developed an upper respiratory infection. He returned to the US after traveling for two weeks feeling well. The patient used ecstasy and marijuana four days prior to presentation. The next day he developed vomiting including one episode of hemetemesis. For the next three days he had intermittent vomiting, no diarrhea. On admission his BUN/CR was 68/7.5. …

Mystery Quiz-Radiology

December 13, 2006

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

62 year old male smoker with past medical history notable for hypertension, copd, comes to clinic complaining of chronic cough x 6 months with minimal sputum, no wheezing. Lung exam shows decreased breath sounds throughout. Pt had the following CXR performed:

Click on Thumbnail to Enlarge

What's your diagnosis and the next step in his evaluation? Please submit your answers by clicking on the "comments" link below this post. …

Fast Facts-Critical Care

November 22, 2006

VA MICU Conference 11/22/06

56 y.o. male with PMH ETOH abuse and COPD presented with a LUL PNA and BCx positive for penicillin-resistant pneumococcus.

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock

Early broad spectrum antibiotics. Goal directed hemodynamic resuscitation with IV fluids pressors PRBCs (for Hct <30) inotropes To maintain: Central Venous Pressure 8-12 mm Hg Arterial Pressure: MAP >65 mm Hg but <90 mm Hg Central Venous Oxygen Saturation >70% Consider cosyntropin stimulation to evaluate for relative adrenal insufficiency. Consider

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Clinical Correlations