June 2024 Pulmonary Case of the Month: A Pneumo-Colic Association

Lewis J. Wesselius MD

Pulmonary Department

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

The patient is a 57-year-old woman who presented to the emergency department with increasing cough and shortness of breath over several days. She has a history of ulcerative colitis complicated by toxic megacolon with subsequent colectomy.

Past Medical History, Family History and Social History

• Ulcerative colitis with history of toxic megacolon (4 years prior), s/p total colectomy

• History of recent respiratory failure thought secondary to ustekinumab (Stelara).  The respiratory failure responded well to steroid therapy.

• She has a history of latent Tb treated with rifampin

• Anxiety

Medications

• Clonazepam 1.0 mg daily at bedtime

• Gabapentin 300 mg TID

• Pantoprazole 40 mg BID

• Prednisone 5 mg daily

Physical Examination

• Mild-moderate respiratory distress

• Afebrile. SpO2 87% on room air. Oxygen saturation 94% on 2 lpm supplemental oxygen.

• Chest: crackles noted at left base

• Cardiovascular: regular rhythm, no murmur

• Extremities: scarring and erythema on both ankles consistent with resolving pyoderma gangrenosum

Laboratory

• Hgb 9.7 g/dL

• White Blood Cell Count 16.9 × 109/L

• Increased neutrophils on differential

• Electrolytes, creatinine, BUN and liver function tests within normal limits

Radiology

A portable AP of the chest was performed in the emergency department (Figure 1).

Figure 1. Portable AP of chest done in emergency department.

Which of the following are appropriate next step(s)? (Click on the correct answer to be directed to the second of six pages)

1. Thoracic CT scan

2. Discharge to home on empiric antibiotics with close follow-up

3. Influenza A/B, Covid and Cocci serology

4. 1 and 3

5. All of the above

Cite as: Wesselius LJ. June 2024 Pulmonary Case of the Month: A Pneumo-Colic Association. Southwest J Pulm Crit Care Sleep. 2024;28(6):74-77. doi: https://doi.org/10.13175/swjpccs023-24PDF

Diagnostic Challenges of Acute Eosinophilic Pneumonia Post Naltrexone Injection Presenting During The COVID-19 Pandemic

Michelle Breuer

Abdulmonam Ali, MD

SSM Health

Mount Vernon, IL USA

Introduction

Acute eosinophilic pneumonia (AEP) is a rare respiratory illness that may present with nonspecific symptoms ranging in severity from cough and dyspnea to potentially fatal acute respiratory distress syndrome. Although the exact etiology of AEP is unknown, it is thought to be a hypersensitivity reaction that can be idiopathic or caused by various infections, inhalation exposures, and medications (1).  Here we present a rare case of AEP secondary to injectable naltrexone.

Case Presentation

A 45-year-old Caucasian male with a history of alcohol use disorder presented to the emergency room with a 3-day history of progressively worsening dyspnea and dry cough. The patient was a lifelong non-smoker with an unremarkable past medical history aside from alcohol abuse and obesity (BMI 41.64 kg/m²). He denied fever or chills, orthopnea, chest pain, or symptoms suggestive of paroxysmal nocturnal dyspnea. He also denied any recent sick contacts, including exposure to COVID-19. Relevant history includes alcohol cessation 1 month before presentation. After 2 weeks of cessation, he received his first injection of naltrexone (Vivitrol®) as part of alcohol relapse prevention. Physical exam was notable for an initial SpO₂ of 69% on room air, sinus tachycardia at a rate of 121 bpm, and obesity. Chest examination exhibited decreased air entry with bilateral fine crackles on auscultation. No skin rashes or peripheral edema were appreciated, and the remaining physical exam was within normal limits. The patient was started on supplemental oxygen (6 liters/minute nasal cannula to maintain SpO2 above 90%).

Workup was performed and chest x-ray showed diffuse bilateral pulmonary infiltrates (Figure 1), hence, the patient was started on empiric antibiotic and steroid therapy.

Figure 1. Chest X-ray showing bilateral ground-glass opacities.

SARS-CoV-2 PCR testing was performed twice due to high clinical suspicion of COVID-19 infection (the patient was seen during the Coronavirus pandemic). Both SARS-CoV-2 tests were negative as well as the rest of the respiratory viral panel. CBC was significant for leukocytosis with an absolute peripheral eosinophil count of 0.49 x 10⁹ cells/L. Bloodwork also revealed mildly elevated troponin, d-dimer, and LDH. However, electrocardiogram showed no significant ST changes and Computerized Tomography (CT) angiography chest showed no evidence of pulmonary embolism but confirmed the chest x-ray findings of diffuse bilateral ground-glass opacities with anterolateral subpleural parenchymal sparing (Figure 2).

Figure 2. CTA chest (axial view, lung window) showing diffuse ground-glass opacities.

An echocardiogram showed an ejection fraction of 60% and normal left ventricular diastolic function. Moderate right ventricular (RV) dilation with reduced systolic function was reported and the peak RV pressure was estimated at 39 mmHg. Extensive blood testing for connective tissue disease was negative for ANCA, CCP, ANA, and cryoglobulins. Immunoglobulin E (IgE) level was within normal limits at 14KU/L (reference range < 214 KU/L).  Infectious disease serology was negative for mycoplasma, strongyloides, coccidioides, and aspergillus. HIV and hepatitis screening were also negative. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and was significant for 27% eosinophils, 42% lymphocytes, 25% monocytes, 6% neutrophils (Figure 3).

Figure 3. Bronchoalveolar lavage (BAL) showing increased numbers of eosinophils.

BAL culture remained negative including mycobacterial and fungal cultures. BAL testing for Pneumocystis Jirovecii was negative as well. BAL cytology showed benign bronchial epithelial cells and inflammatory cells. No parasites were seen in BAL and fungal staining was negative.

The constellation of the above clinical, radiological, and laboratory findings was highly suggestive of acute eosinophilic pneumonia diagnosis. The patient’s methylprednisolone dose was increased to 125mg every 8 hours. Due to high FiO2 requirements and poor pulmonary reserve, the patient remained intubated after his bronchoscopy procedure. Over the following 48 hours, FiO₂ requirements improved significantly and his repeat chest x-ray showed almost complete resolution of the pulmonary infiltrates. The patient was successfully extubated to 2 liters of oxygen via nasal cannula on the third day.  Supplemental oxygen was eventually weaned off to room air. There wasn’t significant desaturation observed with the exercise trial. He was discharged home on a gradually tapering dose of oral steroids over 6 weeks. The patient was later seen at the pulmonary clinic for a follow-up visit. He was doing well and denied any significant respiratory symptoms. A follow-up chest x-ray was within normal limits (Figure 4).

Figure 4. Chest x-ray upon follow-up.

Discussion 

Acute eosinophilic pneumonia (AEP) is defined by rapid eosinophilic infiltration of the lung tissue, resulting in impaired gas exchange. Presenting symptoms are nonspecific and may include cough, progressive dyspnea, chest pain, and fever (2). Chest imaging of patients with AEP shows diffuse bilateral parenchymal infiltrates. Diagnosis can be made in the appropriate clinical and radiological context, with BAL showing at least 25% eosinophils on the fluid differential, and with no other identifiable causes (1).

The pathogenesis of AEP is not completely understood; however, it is hypothesized to involve a hypersensitivity reaction in patients with genetic susceptibility (3,4). AEP can be associated with many identifiable causes including cigarette smoke most notably, as well as other inhalants, infections, and medications. Although antibiotics and nonsteroidal anti-inflammatory drugs are among the more common inciting medications, injectable naltrexone has been implicated in several case reports (3,5,6,7).

The clinical presentations of AEP can mimic SARS-CoV-2 pneumonia, community-acquired pneumonia, or ARDS; hence, a high index of clinical suspicion is essential to avoid delay in therapy. A confident diagnosis of AEP can usually be made without a lung biopsy in patients who meet the following criteria (8):

1) acute onset of febrile respiratory manifestations (≤ 1-month duration before consultation).

2) bilateral diffuse opacities on chest radiography.

3) hypoxemia, with PaO₂ on room air<60 mm Hg, and/or PaO₂/FiO₂≤300 mm Hg, and/or oxygen saturation on room air<90%.4) lung eosinophilia, with >25% eosinophils on BAL differential cell count (or eosinophilic pneumonia at lung biopsy).

5) absence of known causes of AEP, including drugs, infections, asthma, or atopic disease.

In our case, the patient has met most of the suggested criteria for diagnosing AEP in addition to the presence of a triggering factor (a clear temporal relationship between the development of symptoms and the recent naltrexone injection). However, we met with a few obstacles before making the diagnosis of AEP.  During these unprecedented times, any patient presenting with acute hypoxic respiratory failure, and/or ground-glass opacities (both are classic for SARS-CoV-2 pneumonia as well as AEP) must go through an additional screening process to rule out COVID-19, including contact and airborne infection isolation precautions in addition to the standard precautions and SARS-CoV-2 PCR testing.  

On the other hand, several recent reports of AEP presumably triggered by SARS-CoV-2 infection had been described (9-10), which was another factor that contributed to making the diagnosis of AEP more challenging in his case and kept COVID-19 high on the differential diagnosis list. Furthermore, our patient received steroids on the initial presentation which likely affected the accuracy of the total eosinophilic counts in the BAL.

AEP has a higher likelihood than chronic eosinophil pneumonia of presenting with more severe symptoms and has a greater potential of rapid progression to respiratory failure. One review study reported 30-80% of AEP patients required intensive care unit admission and another case review noted 20% of AEP patients required mechanical ventilation (4,11). Treatment includes supportive care, recognition and avoidance of identifiable triggers, and systemic corticosteroids. Most patients rapidly improve with prompt corticosteroid treatment and experience complete recovery (1,3). Relapse of AEP rarely occurs (4).

Numerous conditions can cause pulmonary eosinophilia that needs to be differentiated from AEP. Different classifications have been suggested, but we will list the broad categories and most common etiologies including chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis (EGPA, previously known as Churg-Strauss), drug and toxin-induced eosinophilic lung disease, helminthic, and fungal infection-related eosinophilic lung diseases, idiopathic hypereosinophilic syndrome, neoplasms, interstitial lung disease, coccidioidomycosis, tuberculosis, and allergic bronchopulmonary aspergillosis.

In addition to AEP, several conditions are associated with elevated BAL eosinophils greater than 25%.  These conditions include chronic eosinophilic pneumonia, EGPA, tropical pulmonary eosinophilia.  Other conditions causing BAL eosinophilia, but less than 25%, include connective tissue disease, drug-induced pneumonitis, fungal pneumonia, idiopathic pulmonary fibrosis, pulmonary Langerhans cell histiocytosis, sarcoidosis.

Finally, multiple medications are implicated in drug-induced AEP, however, naltrexone is still not well recognized as a potential cause.  In a recent retrospective review, naltrexone was not included in the medication list compiled (11).

Conclusion

Injectable naltrexone, a long-acting opioid antagonist, is used for the treatment of opioid and alcohol dependence. Although rare, the use of injectable naltrexone is associated with the potentially fatal side effect of AEP. Since AEP shares many clinical attributes with other causes of acute lung injury, including community-acquired pneumonia and SARS-CoV-2 pneumonia, it can be easily overlooked. Therefore, having an accurate history and an appropriate index of suspicion is important for early detection and proper management (3).

References

1. De Giacomi F, Vassallo R, Yi ES, Ryu JH. Acute Eosinophilic Pneumonia. Causes, Diagnosis, and Management. Am J Respir Crit Care Med. 2018 Mar 15;197(6):728-736. [CrossRef] [PubMed]
2. Katz U, Shoenfeld Y. Pulmonary eosinophilia. Clin Rev Allergy Immunol. 2008 Jun;34(3):367-71. [CrossRef] [PubMed]
3. Mears M, McCoy K, Qiao X. Eosinophilic Pneumonia and Extended-Release Injectable Naltrexone. Chest. 2021;160(4): A1676 [Abstract]. [CrossRef]
4. Suzuki Y, Suda T. Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management. Allergol Int. 2019 Oct;68(4):413-419. [CrossRef] [PubMed]
5. Horsley R, Wesselius LJ. June 2107 Pulmonary Case of the Month. Southwest J Pulm Crit Care. 2017;14(6):255-61. [CrossRef]  
6. Esposito A, Lau B. Saved by the BAL: A Case of Acute Eosinophilic Pneumonia After Methyl-Naltrexone Injection. Chest. 2019;156(4):A2210 [Abstract]. [CrossRef]
7. Korpole PR, Al-Bacha S, Hamadeh S. A Case for Biopsy: Injectable Naltrexone-Induced Acute Eosinophilic Pneumonia. Cureus. 2020 Sep 3;12(9):e10221. [CrossRef] [PubMed]
8. Philit F, Etienne-Mastroïanni B, Parrot A, Guérin C, Robert D, Cordier JF. Idiopathic acute eosinophilic pneumonia: a study of 22 patients. Am J Respir Crit Care Med. 2002 Nov 1;166(9):1235-9. [CrossRef] [PubMed]
9. Araújo M, Correia S, Lima AL, Costa M, Neves I. SARS-CoV-2 as a trigger of eosinophilic pneumonia. Pulmonology. 2022 Jan-Feb;28(1):62-64. [CrossRef] [PubMed]
10. Murao K, Saito A, Kuronuma K, Fujiya Y, Takahashi S, Chiba H. Acute eosinophilic pneumonia accompanied with COVID-19: a case report. Respirol Case Rep. 2020 Nov 16;8(9):e00683. [CrossRef] [PubMed]
11. Bartal C, Sagy I, Barski L. Drug-induced eosinophilic pneumonia: A review of 196 case reports. Medicine (Baltimore). 2018 Jan;97(4):e9688. [CrossRef] [PubMed]
12. Salahuddin M, Anjum F, Cherian SV. Pulmonary Eosinophilia. 2021 Dec 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. [PubMed]

Cite as: Breuer M, Ali A. Diagnostic Challenges of Acute Eosinophilic Pneumonia Post Naltrexone Injection Presenting During The COVID-19 Pandemic. Southwest J Pulm Crit Care Sleep. 2022;24(2):26-31. doi: https://doi.org/10.13175/swjpccs002-22 PDF 

A Case Series of Electronic or Vaping Induced Lung Injury

Ronald Ferrer Espinosa DO¹

Abdirahman Hussein MD²

Matthew Sehring DO¹

Mohamad Rachid MD¹

Ryan Dunn MD¹

Deepak Taneja MD¹

Department of Pulmonary and Critical Care Medicine¹

Department of Internal Medicine²

University of Illinois College of Medicine at Peoria

Peoria, Illinois 

Abstract

Introduction: Since their introduction, electronic cigarette use has increased and was even proposed as an alternative to traditional tobacco use. Recently, a series of patients with acute respiratory failure due electronic cigarette, or vaping, associated lung injury (EVALI) in 2019 has been described which has largely been attributed to tetrahydrocannabinol (THC) containing vaporizer itself, as well as vitamin E acetate. Several case series have been published regarding the acute presentation, diagnosis and management. In addition to diagnosis and management of EVALI, we sought to describe potential long-term effects of lung parenchyma in these patients.

Methods: A retrospective review was performed on 16 patients with clinically diagnosed EVALI at OSF St Francis Medical Center between August 01 2019 and February 1 2020. Relevant demographic and clinical data were collected in patients diagnosed with EVALI.

Results: Of the 16 patients in the study the median age (IQR) age was 25.25 (20-29) and 94% were male. The predominant presenting symptoms were dyspnea (94%), cough (56%), nausea 63%), vomiting (63%), abdominal pain (50%), diarrhea (50%), and fever (63%). 2 (13%) patients required endotracheal intubation. Common features of computerized tomography (CT) scan were bilateral diffuse ground glass opacity (93%), septal thickening (53%), and subpleural sparing (47%). Bronchoalveolar lavage (BAL) was obtained in 3 patients and all demonstrated neutrophil predominance of 69% (56-90). One BAL was significant for hemosiderin laden macrophages. Post hospital follow up pulmonary function tests were obtained in 3 and 2 of these were significant for obstructive lung disease.

Conclusions: In this case series of patients diagnosed with vaping associated lung injury, obstructive lung disease may be seen on pulmonary function testing and surveillance of these patients should occur regardless of duration.

Keywords: CT scan, EVALI, bronchoalveolar lavage, electronic cigarette, pulmonary function testing, respiratory failure, tetrahydrocannabinol, vaping, vaping associated lung injury, vitamin E,

Introduction

The first cases of vaping associated lung injury (EVALI) were reported in Wisconsin and Illinois in the summer of 2019 which reached its peak in the fall of 2019 (1). This sudden epidemic of respiratory failure in patients who used tetrahydrocannabinol (THC) containing vaporizing devices lead the Food and Drug Administration (FDA), Center for Disease Control (CDC) and local public health departments to initiate investigations and research into the causative mechanisms of this disease. Currently, it is postulated that vitamin E acetate plays a role in the pathogenesis of VALI, as this substance was found in samples of vaping cartridges and in the bronchoalveolar fluid of patients with the disease (2,3). These pathological pathways are still being elucidated. Little is known about the long-term damage to the respiratory system in patients with EVALI. In this study, we sought to describe the diagnostic commonalities in patients with EVALI and describe potential long-term complications.

Methods

The study was a retrospective cohort analysis. Institutional Review Board (IRB) approval (1593746-1) was obtained through the University of Illinois College of Medicine at Peoria IRB. Data was collected for consecutive patients over 18 years of age who were diagnosed with EVALI between the dates of August 1, 2019 and February 1, 2020. The diagnosis of EVALI was consistent with the outbreak case surveillance definition. A confirmed case required the following to satisfy criteria: e-cigarette or dabbing in 90 days before symptom onset, pulmonary infiltrate, absence of infection, and no evidence of alternative plausible causes. A presumptive case definition included the above definition except for possibility of another cause of the patient’s symptoms such as infection. Data were extracted from the electronic medical record. The recorded data included the following: age, gender, co-morbidities, tobacco and electronic cigarette use history, need for endotracheal intubation, symptoms on presentation to the emergency department, computerized tomography findings, pulmonary function test values, bronchoalveolar lavage fluid studies, and discharge treatment plans. Obstructive lung disease is based on the American Thoracic Society/European Respiratory Society criteria that recommends the fifth percentile of the distribution in a population of healthy lifelong nonsmokers as the lower limit of normal. One patient described in this study has been previously described (4). Continuous variables are presented at median and interquartile range (IQR) with 95% CI. Categorical variables are described as number of patients (percentage).

Results

From August 1, 2019 to February 1, 2020, a total of 16 patients with either confirmed or presumptive vaping associated lung injury were reviewed. Table 1 shows the demographic data obtained from these patients.

 

The median age was 25.25 (IQR, 20-29) and the majority of patients were male 94% (n=15). Only 13% (n=2) of patients had previously diagnosed lung conditions, both of which were asthma. Of the reported THC brands, Dank© was the most commonly reported occurring in 25% (n=4) of patients (Table 2).

However, 50% (n=8) of THC products were not clearly stated in the patient’s medical record. Tobacco cigarette and tobacco electronic cigarette use were also documented, occurring in 63% (n=10) and 44% (n=7) of patients, respectively. Of those reporting tobacco use, the median pack years was 1.5 (IQR, 0.5-4.25). 7 patients reported no prior tobacco use. 13% (n=2) of patients required endotracheal intubation
 

Patients' symptoms are summarized in Table 3.

Any respiratory symptom occurred in 94% (n=15) of patients which included dyspnea 94% (n=15), cough 56% (n=9), chest pain 25% (n=4), and hemoptysis 19% (n=3). Abdominal symptoms were common and occurred in 75% (n=12) of patients. The most common gastrointestinal symptom were both nausea and vomiting 63% (n=10). These were followed by abdominal pain and diarrhea 50% (n=8). Fever was the most common constitutional symptom occurring in 63% (n=10) of patients. Less common constitutional symptoms included fatigue and chills both of which occurred in 13% (n=2) of patients. 

Chest computerized tomography (CT) scans were available in 94% (n=15) of patients. The findings are summarized in Table 4.

The most common radiographic feature was bilateral diffuse ground glass opacity (GGO), which occurred in 93% (n=14) of patients. Septal thickening and subpleural sparing were the next most common radiographic findings, occurring in 53% (n=8) and 47% (n=7) patients, respectively. Less common features that were described on chest CT scan were centrilobular nodular consolidations occurring in 27% (n=4) and reverse haloing occurring in 7% (n=1, Figure 1).

Figure 1.  Reverse halo sign in a patient with EVALI.

Three patients diagnosed with EVALI underwent bronchoscopy with bronchoalveolar lavage which are summarized in table 5.

Bronchoscopy was performed when the outbreak case definition was not met or there was a clinical concern for a secondary pathological process. The “typical” bronchoalveolar lavage (BAL) differential was neutrophilic predominant (56%-90%) with elevated macrophage and/or monocyte counts (4-19%, 0-23%). The lymphocyte count was typically low (0-4%) as well as the eosinophil count (0-1%). All the microbiologic data from these lavage samples were negative and included the following tests: aerobic and anaerobic bacterial cultures, fungal cultures, silver stain, acid fast bacilli smear and culture, varicella zoster polymerase chain reaction (PCR), histoplasma antigen and galactomannan. The results of cytology were different in all three BAL samples and were significant fore alveolar macrophages, atypical glandular cells and hemosiderin laden macrophages. At the time of bronchoscopy, only 1 or 3 patients was on or received systemic steroids therapy.

A few complications occurred in our cohort which included pneumothorax, pneumorrhachis, pulmonary embolism and Takutsubo cardiomyopathy. The case of Takusubo cardiomyopathy has been reported in the literature (4). The rate of pneumothorax was 13% (n=2). The pneumorrhachis 6% (n=1) occurred in a patient with pneumothoraces. Pulmonary embolism was only seen in 1 patient.

The discharge treatment course involved mainly systemic corticosteroids which were given in 81% (n=13) of patients. Antibiotics were continued at discharge in a minority of patients 38% (n=6). The majority of patients (94%) recovered and were asymptomatic at a later clinic visit. One patient remained symptomatic with persistent dyspnea.

Full pulmonary function tests were obtained in 3 patients (Table 6).

The timing of the pulmonary function tests occurred 3-4 weeks post hospital discharge. THC vape duration for these patients ranged from 4-12 weeks and tobacco pack years ranged from 0-2. Forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ratios were 70%, 71%, and 86%. FEV1% ranged from 70 to 119%. FVC ranged from 81% to 119%. The total lung capacity in these three patients ranged from 85% to 109%. Diffusing capacity of carbon monoxide (DLCO) ranged from 60% to 100%. The flow volume loops of two patients demonstrate coving of the expiratory limb (Figure 2).

Pre-EVALI pulmonary function testing was not available for review in any of the patients.

Discussion

In this case series of patients with vaping associated lung injury of 16 patients in Central Illinois from August 1 2019 through February 1, 2020 the majority were younger men with respiratory and gastrointestinal symptoms. The symptomatology was consistent with previously published data (1,5,6,7). The exact pathophysiologic mechanisms implicated in vaping associated lung injury are currently still under investigation, but vitamin E acetate has recently been implicated possibly through the transition of tocopherols induced transition of phosphatidiylcholines from gel to liquid crystalline, causing surfactant dysfunction (2). The same authors proposed an alternative mechanism whereby ketene, created while heating e-cigarette products, causes direct lung irritation. However, many branded vaping products are not commercially produced and the heterogenous ingredients such as propylene glycol and other flavoring ingredients in these products may reflect its informal creation, which may influence the development of different disease mechanisms, clinical phenotypes and imaging findings (8,9).

A growing body of EVALI cases demonstrate predominant features on computerized tomography which include basilar predominant centrilobular nodular ground glass opacities and ground glass opacities with subpleural sparing. An initial study proposed four imaging patterns which included acute eosinophilic pneumonia, diffuse alveolar damage, organizing pneumonia and lipoid pneumonia and predicted the dominant CT scan findings (10). Later in a small case series of pediatric patients, centrilobular ground glass opacities were present in 92% and ground glass opacities with subpleural sparing were present in 75% of patients (11). The importance of recognizing these patterns is essential, especially in the adolescent and young adult populations where disclosure of medical history may prove to be difficult. Our findings support the cases in literature, with 93% of patients having bilateral diffuse basilar predominant GGO (93%), some associated with subpleural sparing (47%) and to a lesser degree centrilobular nodular consolidation (27%).

The role of bronchoscopy in patients with vaping associated lung injury has waned with as the characterization of clinical and radiographic findings has matured. Importantly, there is no finding on bronchoscopy that is specific for diagnosis of EVALI. Recently, the role of bronchoscopy with bronchoalveolar lavage (BAL) has been suggested to be performed in cases with a high pretest probability of EVALI with atypical features that cannot be attributed to vaping (5).  Lipid laden macrophages (LLM) are a non-specific finding in many different illnesses such as infection, aspiration, drug reactions, lipoid pneumonia, pulmonary alveolar proteinosis and autoimmune disorders, but the absence of LLM, argued by Aberegg, would be an atypical finding in EVALI (5,12). Our BAL fluid differentials are consistent with the published data, with elevations in neutrophils and/or monocytes and macrophages, with scant lymphocytes and eosinophils. In our institution, staining for lipid laden macrophages was not routinely performed. However, in one of our cytologic BAL samples hemosiderin macrophages were identified. The inconsistent cytologic findings on BAL in our series supports the notion of heterogenous underlying pathophysiologic mechanisms involved in EVALI.

The long-term effects of EVALI on lung parenchyma are unknown. Prior studies evaluating the effects of electronic cigarette use prior to the EVALI epidemic have suggested airway hyper responsiveness and an obstructive pattern on spirometry. In mice, it has been previously demonstrated that aerosolized nicotine induced airway hyperreactivity (13). A human study of 30 electronic cigarette users with at least 6 months of use compared with matched controls, demonstrated PFTs consistent with peripheral obstruction (14). A different study comparing vaping asthmatics versus healthy controls demonstrated acute declines in the FEV1/FVC ratio (15). Additionally, a few recent reports of pulmonary function testing have been documented in patients diagnosed with EVALI in late 2019 and early 2020. One study of intubated adults reported one follow-up PFT that was significant for only a low DLCO (16). A case series of pediatric patients describes two patients with 6 week follow up PFT’s that were significant for obstructive lung disease, and one of these patients had a low DLCO (11). Our study contributes 3 full PFT’s in adult patients diagnosed with EVALI performed at either 3 or 4 weeks following hospital discharge. Two of these PFT’s demonstrated obstructive lung disease, of which one had a low DLCO. The duration of vaping in these two abnormal cases were 8 and 12 weeks, and the pack years of tobacco use were 2 and 1.25 years. This small data set suggests that patients who participate in electronic cigarette use, or vaping, may be at higher risk for developing obstructive lung disease regardless of the duration of use. It is also important to take into account that a fixed FEV1/FVC ratio may underestimate young patients with obstructive lung disease (17). Using the lower limit of normal in this younger patient population is likely to be more sensitive in detecting obstructive physiology. It is plausible that vaping may cause an accelerated obstructive lung pattern due to the many potential pathways for lung injury. Full pulmonary function testing in any patient who was diagnosed with EVALI or continues to use electronic cigarettes, or vaping, products should be considered.

This study has several limitations. First, this was a retrospective study of patients at a single center in one geographic location. Second, our sample size was relatively small. Third, our clinical follow up rate was only 50%, of which only 37% completed PFT’s.

Conclusions

In our case series of 16 patients, predominantly male, diagnosed with EVALI there was a high incidence of gastrointestinal symptoms on presentation and follow up pulmonary function tests suggested there may be an increased risk for obstructive lung disease. Avoidance of vaping products, especially “Dank” and other similarly formulated products, is strongly recommended.

References

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15. Kotoulas SC, Pataka A, Domvri K, et al. Acute effects of e-cigarette vaping on pulmonary function and airway inflammation in healthy individuals and in patients with asthma. Respirology. 2020 Oct;25(10):1037-1045. [CrossRef] [PubMed]
16. Choe J, Chen P, Falk JA, Nguyen L, Ng D, Parimon T, Ghandehari S. A Case Series of Vaping-Associated Lung Injury Requiring Mechanical Ventilation. Crit Care Explor. 2020 Jan 29;2(1):e0079. [CrossRef] [PubMed]
17. Cerveri I, Corsico AG, Accordini S, et al. Underestimation of airflow obstruction among young adults using FEV1/FVC <70% as a fixed cut-off: a longitudinal evaluation of clinical and functional outcomes. Thorax. 2008 Dec;63(12):1040-5. [CrossRef] [PubMed]

Cite as: Espinosa RF, Hussein A, Sehring M, Rachid M, Dunn R, Taneja D. A Case Series of Electronic or Vaping Induced Lung Injury. Southwest J Pulm Crit Care. 2021;23(2):62-9. doi: https://doi.org/10.13175/swjpcc032-21 PDF 

March 2021 Pulmonary Case of the Month: Transfer for ECMO Evaluation

Nicholas G. Blackstone, MD

April Olson, MD

Angela Gibbs, MD

Bhupinder Natt, MD

Janet Campion, MD

University of Arizona College of Medicine – Tucson

Tucson, AZ USA

History of present illness

A 31-year-old male fire fighter with a history of recurrent “atypical pneumonia”, environmental and drug allergies, nasal polyps, asthma, and Crohns disease (not on immunosuppressants) was transferred from an outside hospital for management of acute hypoxic respiratory failure with peripheral eosinophilia. Prior to admission he reported a 2-week history of worsening dyspnea, productive cough and wheezing, prompting an urgent care visit where he was prescribed amoxicillin-clavulanate for suspected community acquired pneumonia. Despite multiple days on this medication, his symptoms significantly worsened until he was unable to lie flat without coughing or wheezing. He was ultimately admitted to an outside hospital where his labs were notable for a leukocytosis to 22,000 and peripheral eosinophilia with an absolute eosinophil count of 9700 cells/microL. His blood cultures and urine cultures were negative, and a radiograph of the chest demonstrated bilateral nodular infiltrates. With these imaging findings combined with the peripheral eosinophilia there was a concern for Coccidioidomycosis infection and he was subsequentially started on empirical fluconazole in addition to ceftriaxone and azithromycin. Bronchoalveolar lavage (BAL) was performed revealing 80% eosinophils, 14% polymorphic nuclear cells (PMNs), 4% monocytes and 2% lymphocytes, no pathogens were identified. The patient’s clinical status continued to decline despite antimicrobial therapy, and he was intubated for refractory hypoxia. At this point, the patient was transferred to our hospital for further care.

What is the most likely diagnosis in this patient? (Click on the correct answer to be directed to the second of four pages.)

1. Acute asthma exacerbation
2. Bacterial pneumonia
3. Coccidioidomycosis pneumonia
4. Eosinophilic pneumonia
5. Rocky Mountain Spotted Fever

Cite as: Blackstone NG, Olson A, Gibbs A, Natt B, Campion J. March 2021 Pulmonary Case of the Month: Transfer for ECMO Evaluation. Southwest J Pulm Crit Care. 2021;22(3):69-75. doi: https://doi.org/10.13175/swjpcc069-20 PDF

June 2017 Pulmonary Case of the Month

Robert Horsley, MD

Lewis J. Wesselius, MD 

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 61-year-old woman presented to the emergency department for 3 days of fevers up to 102º F, malaise, and progressive shortness of breath. Her symptoms started immediately after he last naltrexone injection for alcohol use disorder.

Past Medical History, Social History and Family History

• Alcohol use disorder
• Treated with monthly naltrexone injections, received 3 doses total, and gabapentin
• No other previous medical issues
• Nonsmoker

Physical Examination

• Vital signs: Pulse 100, BP 108/90, respiratory rate 34, SpO2 93% 10L non-rebreathing mask
• Cyanotic on room air
• Lungs clear

Radiography

A portable chest x-ray was performed in the emergency department (Figure 1).

Figure 1. AP chest radiograph taken in the emergency department.

A thoracic CT scan was performed (Figure 2).

Figure 2. Representative images from thoracic CT in lung windows.

Laboratory

• CBC showed a white blood cell count of 12,000 cells/mcL.
• The differential showed a left shift.
• Lactate was 5.2 mmol/L

Which of the following is (are) true? (Click on the correct answer to proceed to the second of five pages)

1. A lactate level of 5.2 can be a normal finding in a critically ill patient
2. Her symptoms are likely an allergic reaction to naltrexone
3. The most likely diagnosis is an atypical pneumonia
4. 1 and 3
5. All of the above

Cite as: Horsley R, Wesselius LJ. June 2107 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(6):255-61. doi: https://doi.org/10.13175/swjpcc063-17 PDF

May 2017 Pulmonary Case of the Month

Lewis J. Wesselius, MD

Robert W. Viggiano, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 69-year-old man with known heart failure, COPD and prostate cancer with presented with increased shortness of breath. He denied any fever, chills, cough or sputum.

Past Medical History, Social History and Family History

• Diastolic heart failure with a preserved ejection fraction
• Prostate cancer with bone metastasis treated with leuprolide (Lupron^®) 
• COPD treated with salmeterol/fluticasone and tiotropium
• He is married, retired and had quit smoking a number of years ago.
• Family history was unremarkable

Physical Examination

• Oxygen saturation (SpO2) was 93% on room air.
• Physical examination showed jugular venous distention (JVD), bilateral lung rales a laterally displaced pulse of maximal impulse (PMI) and 1+ pretibial edema.

Radiography

A chest x-ray was performed (Figure 1).

Figure 1. Admission chest x-ray.

Based on the history and chest x-ray which of the following is the most likely diagnosis? (Click on the correct answer to proceed to the second of six pages)

1. Community-acquired pneumonia
2. Congestive heart failure
3. COPD exacerbation
4. Metastatic prostate cancer
5. Pulmonary embolism

Cite as: Wesselius LJ, Viggiano RW. May 2017 pulmonary case of the month. Southwest J Pulm Crit Care. 2017;14(5):185-91. doi: https://doi.org/10.13175/swjpcc052-17 PDF

December 2015 Pulmonary Case of the Month

Zachary M. Berg, MD

Kashif Yaqub, MD 

Brian Wojek, MD

Khang Tran, MD

Karen L. Swanson, DO

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

The patient is a 70-year-old man with a history of a chronic dry cough for 5 years, who presented to the emergency department with worsening cough and shortness of breath.

Two weeks prior to symptom onset, was on trip in the United Kingdom, he developed gastroenteritis which spontaneously resolved.

Past Medical History, Social History, and Family History

• Old healed TB scar with positive PPD at 17 years of age prior to joining Air Force.  No treatment given and patient was asymptomatic from a pulmonary point of view since then.
• Squamous cell carcinoma of the skin on the scalp, status post excision complicated by osteomyelitis, status post surgical graft from hip with prolonged course of IV antibiotics in 2010.
• Fractured left clavicle, status post repair 20 years ago.
• Hay fever.
• Hyperlipidemia.
• Squamous cell carcinoma removed from left arm.
• Varicose veins, lower extremity.
• Married. Retired police officer. Does not smoke.
• Family history is noncontributory

Physical Examination

• General:  In moderate respiratory distress.  
• Vitals: SpO2 on room air of 65%, 94% on high flow oxygen.  Blood pressure 124/84, afebrile  
• Lungs:  Fine bibasilar crackles posteriorly.  
• Heart: Regular rhythm without murmur.
• The remainder of the physical examination was normal.

Laboratory Evaluation

• CBC: unremarkable except white blood cell count 20.5 x 10³ cells/ɥL, neutrophil predominant
• BNP: 366 pg/mL
• Mycobacterium Quantiferon: Positive
• Mycoplasma IgM: Positive at 1.18 U/L

Radiography

Initial chest x-ray is shown in Figure 1.

Figure 1. Initial chest x-ray.

What is the best next step in the patient's evaluation? (Click on the correct answer to proceed to the second of five panels)

1. Begin erythromycin or doxycycline for Mycoplasma pneumonia
2. Begin heparin for presumptive pulmonary embolism
3. Thoracic CT scan
4. 1 and 3
5. All of the above

Cite as: Berg ZM, Yaqub K, Wojek B, Tran K, Swanson KL. December 2015 pulmonary case of the month. Southwest J Pulm Crit Care. 2015;11(6):240-5. doi: http://dx.doi.org/10.13175/swjpcc146-15 PDF

Safety and Complications of Bronchoscopy in an Adult Intensive Care Unit

Aarthi Ganesh, MBBS¹

Nirmal Singh, MBBS, MPH²

Gordon E. Carr, MD¹

¹Department of Pulmonary & Critical Care

²Department of Internal Medicine

University of Arizona

Tucson, Arizona

Abstract

Background: Bronchoscopy is a common procedure performed in adult intensive care units (ICU). However, very few studies report the safety and complications of the bronchoscopy and related procedures performed on critically ill patients. The primary aim of this study was to determine the incidence of complications following ICU bronchoscopy.

Methods: We conducted a retrospective chart review of patients admitted to an adult ICU and underwent bronchoscopy with or without bronchoalveolar lavage (BAL) and other bronchoscopic procedures. Data included patient demographics, APACHE II score, hemodynamics, comorbidities, type of ventilation and procedure performed. Data from BAL, including cellular differential and microbiology, were also collected.

Results: We identified 120 patient charts between November 2011 to March 2012. The most common procedure was bronchoscopy with BAL (62%) to evaluate for pneumonia (58%). Other procedures included transbronchial biopsy, APC and cryotherapy, balloon and stent placement, endobronchial biopsy and EBUS. Complications occurred in 18% of the patients, with hypoxia being the most common (7.5%). No deaths occurred related to the procedures. Nine percent of patients who had BAL or inspection had complications compared to 29% who underwent other procedures. Subgroup analysis conducted on patients undergoing BAL revealed significantly higher neutrophil counts (p=0.001) and higher APACHE II score (p=0.02) among those with BAL positive for bacteria and co-infection.

Conclusion: Bronchoscopy with BAL and inspection is relatively safe procedure even in critically ill patients. However, other interventional bronchoscopic procedures should be performed with caution in the ICU.

Abbreviations:

ICU: Intensive care unit

BAL: Bronchoalveolar lavage

EBUS: Endobronchial Ultrasound

APC: Argon Plasma Coagulation

SBP: Systolic Blood Pressure

CI: Confidence Interval

IP: Interventional pulmonary

MAP: Mean arterial pressure

SD: Standard deviation

CHF: Congestive heart Failure

COPD: Chronic Obstructive Pulmonary Disease

ILD: Interstitial Lung Disease

ET: Endotracheal

Introduction

Fiberoptic bronchoscopy is a commonly performed procedure in the medical intensive care unit (ICU). Prior studies have indicated that bronchoscopy is generally safe, making it a relatively low-risk procedure in appropriately selected ICU patients (1-3). Most prior studies reporting the safety of bronchoscopy were performed in early 1990s. The rates of complications or adverse events in these earlier studies ranged from 2% to 40% (2,4-6). The primary aim of this study was to assess the incidence of complications in ICU patients undergoing bronchoscopy in the contemporary era.

Methods

The study was approved by the Institutional Review Board at the University of Arizona. We conducted a retrospective chart review of patients, 18 years or older, admitted to the adult medical intensive care unit, who underwent bronchoscopy with or without bronchoalveolar lavage (BAL) and other bronchoscopic procedures from November 1, 2011 to March 31, 2012. The other bronchoscopic procedures included transbronchial biopsies, endobronchial ultrasound (EBUS) guided biopsy, argon plasma coagulation (APC) and cryotherapy, balloon dilatation with stenting, and endobronchial biopsy. We excluded patients with incomplete charts, and patients who had bronchoscopy as a part of percutaneous tracheostomy procedure. Data included patient demographics, APACHE II scores, hemodynamics, co-morbidities, type of ventilation, type of procedure performed and the complications. Sedation used in the procedures included propofol or midazolam with fentanyl for analgesia. BAL results, including cellular differential and microbiology studies, were also collected. We used pre-specified definitions to assess for complications. We defined hypotension as reduction in systolic blood pressure (SBP) by >20 mm Hg or when a patient required vasopressors to maintain a mean arterial pressure (MAP) > 60 mm Hg during or after the procedure. Hypoxia was defined by drop in saturation to < 90% or when the FiO2 requirement increased by > 20% for more than 2 hours after the procedure. Hemorrhage was indicated as per the procedure note by the bronchoscopist or when the note indicated use of epinephrine or when additional procedures needed to be performed to control the bleeding. During the procedure all the patients FiO2 was increased but was turned down to their previous ventilatory settings unless there was significant hypoxia.

Statistical analysis was performed using STATA/IC 13.1 (StataCorp LP, Texas). Numerical variables are expressed as mean ± standard deviation (SD). Ninety-five percent confidence intervals (CIs) were calculated where appropriate. Univariate comparisons between patients who did and did not develop complications were calculated using a χ2 test or Fischer's exact test for categorical variables and a 2-sample t test for continuous variables applying central limit theorem. All statistical testing was two-tailed with significance level set at the alpha level of ≤0.05.

Results

We identified 140 patients who underwent ICU bronchoscopy during the study period. Eighteen patients were excluded due to incomplete information. Two charts were excluded as the bronchoscopy was performed for percutaneous tracheostomy. Table 1 shows the baseline characteristics of patients undergoing ICU bronchoscopy.

Table 1. Baseline Characteristics of Patients Prior to Bronchoscopy

Key: CAD: Coronary Artery Disease

        CHF: Congestive Heart Failure

        COPD: Chronic obstructive pulmonary disease

        FiO2: Oxygen required

        ILD: Interstitial Lung Disease

        MAP: Mean arterial pressure

        NM Disease: Neuromuscular disease

Sixty-nine percent of the patients were male and average age was 52 ± 16 years. The average APACHE II score was 18 ± 6 with a median of 18 and 88% of the patients were intubated and mechanically ventilated. The mean percentage oxygen (FiO2) requirement in the patients prior to the procedure was 63% ± 26. Sixty-three percent of the patients were immunocompromised, likely related to the large proportion of lung transplant recipients in our study population. Fifty-four percent also had chronic lung disease including chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). Other common co-morbidities included cardiovascular disease including congestive heart failure (CHF) and arrhythmias, malignancy and neuromuscular diseases. Table II shows the indications for ICU bronchoscopy. The most common indication for the procedure was to evaluate for pneumonia or infiltrate in 87 cases (72%), followed by atelectasis/ collapse/ secretions in 19 cases (15.8%) (Table 2).

Table 2. Indications For Procedures

Other indications included tracheal or airway diseases, which included tracheal stenosis, upper airway obstruction, tracheal mass and bronchopleural fistula in 11 (8%) and hemoptysis (2%). The most common procedures performed were bronchoscopy with BAL in 75 (62%) and inspection in 31 (26%) (Table 3).

Table 3. Procedures

Key:  APC: Argon plasma coagulation

         BAL: Bronchoalveolar lavage

         Cryo: Cryotherapy

         EBUS: Endobronchial ultrasound

         ET: Endotracheal tube

Other procedures included transbronchial biopsy, APC and cryotherapy, balloon and stent placement, endobronchial biopsy and EBUS.

Table 4 shows the complications resulting from ICU bronchoscopy in this study population.

Table 4. Complications

Twenty two complications occurred during or within 2 hours after the procedure (18%), with hypoxia being the most common (7.5%). Hypoxia in two patients occurred secondary to hemorrhage. Pneumothorax was seen in one patient who underwent transbronchial biopsy with no fluoroscopic guidance. Hypotension which needed treatment with fluids or vasopressors occurred in 5.8% and hemorrhage in 3.3%. Hemorrhage was unrelated to coagulopathy in the patients. Significant bradycardia requiring treatment with atropine occurred in one patient. No deaths were reported related to the procedures. None of the procedures had to be terminated secondary to the complications. More adverse events were seen among the patients who underwent other bronchoscopic procedures (29%) than those undergoing BAL or inspection only (9%), though this was not statistically significant (p = 0.07).

As depicted in Table 5, none of the complications were significantly affected by the underlying comorbidities or the APACHE scores.

Table 5. Patient Characteristics Stratified by Complications

Key: BAL: Bronchoalveolar lavage

       MAP: Mean Arterial Pressure

Complications were not significantly associated with the amount of oxygen required (FiO2) and the mode of ventilation which the patients were on prior to the procedure. Similarly, neither the mean arterial pressure before the procedure or coagulopathy influenced the rate of complications. Hospital mortality was not different in the group with or without complications.

Figure 1 and Table 6 show the BAL cell differential.

Figure 1. BAL differential in culture with normal respiratory flora (0), bacteria (1), Viral (2), Fungal (3) and Co-infection (4). Each bar represents the differential in percentage.

Key: BAL: Bronchoalveolar lavage

          BAL N: Neutrophil count in BAL (in percentage)

          BAL L: Lymphocyte count in BAL (in percentage)

          BAL M: Macrophages count in BAL (in percentage)

          BAL E: Eosinophils count in BAL (in percentage)

Table 6. Bronchoalveolar Lavage Differential

Patients found to have bacterial pneumonia or mixed viral and bacterial infection had significantly higher neutrophil counts (mean BAL neutrophil count 82% for bacterial infection, and 80% for co-infections) than other patients (p=0.001) (Figure 2).

Figure 2. Neutrophil predominance in bacterial pneumonia. KEY: BAL-N: Bronchoalveolar lavage, neutrophil differential (in percentage).

These patients also had a higher APACHE II score (p=0.02). Hospital mortality was higher among those with BAL positive for bacteria (p= 0.012). Mortality was also significantly higher among patients with underlying malignancy (p= 0.002).

Discussion

In our study of 120 ICU bronchoscopies, we found a complication rate of 18%. No deaths were observed in this study. Hypoxia was the most common adverse event in our study, occurring in 9 procedures (7.5%) as has been noticed in the previous studies. Introduction of a bronchoscope through an endotracheal (ET) tube is known to cause airway obstruction resulting in increasing intra-tracheal pressures and variation in respiratory physiology (6). Almost all the patients who were mechanically ventilated had a size 7.5 - 8.5 ET tube or had tracheostomy in place. As in prior studies, BAL performed for evaluation of pneumonia and atelectasis were the two most common indications of the procedure (72% and 15.8% respectively) in our study (1-7). Even though bronchoscopy has not shown to be routinely superior to chest physiotherapy, certain subset of patient population may benefit from it (3,8,9). Improvement in oxygenation has been shown to occur in certain earlier studies (10,11).

Hypotension is also a known complication occurring during bronchoscopy. Our study had 7 events (5.8%) of hypotension needing vasopressor or fluid infusion. This was likely related to the sedation. Hypertension was observed in one case and bradycardia requiring treatment was seen in one. Cardiovascular abnormalities associated with bronchoscopy is generally related to the sympathetic surge happening during the procedure and the hypoxia (12-14). Per earlier studies, the complication rate of transbronchial biopsies in mechanically ventilated patients range between 0-15% (15,16,17). But it is relatively safe in comparison to open lung biopsy.

With the advent of newer technology, there has been an increase in the number of other bronchoscopic interventional pulmonary (IP) procedures, including endobronchial ablative therapies such as APC and cryotherapy. Endobronchial lesions occupying more than 50% of the airway lumen can alter the airway physiology and result in hypoxia, ventilation perfusion mismatch and hence respiratory failure. Use of ablative therapies can potentially reverse this (18). APC has been an useful tool to remove endobronchial lesions and relieve obstruction. It has been shown to be efficient and relatively safe in outpatient setting, but APC on mechanically ventilated patients has not been very well studied (19). APC in mechanically ventilated patient requires decrease in the FiO2 to less than or equal to 40%. Complications related to IP procedures performed specifically in patients requiring mechanical ventilation are difficult to assess  from the available literature (20). However, given the complexity of these cases and underlying illness, usually the complications are minor. In our study, interventional bronchoscopy procedures like APC, cryotherapy was to relieve airway obstruction which was the cause of mechanical ventilation. In our study, APC case was associated with hemorrhage. The balloon dilatation and stenting which was performed for a case of tracheal stenosis arising from malignancy. This was not associated with any complications related to the procedure in our study. Further study is needed to refine our understanding of the risks of advanced bronchoscopic techniques in ICU patients.

Procedures like EBUS are usually not done in critically ill patients. There are no studies which have looked into the use of and complications of performing EBUS in critically ill patients. Bhaskar et al. (21) report the use of esophageal access for mediastinal sampling through EBUS in ICU patients for the reason of causing hypoxia and changes in airway physiology with the EBUS scope in airway. Our study had one patient who had an EBUS for lung mass and this was not associated with any complications.

Subgroup analysis in our study showed the presence of neutrophilic predominance with neutrophil count of >80% in the BAL differential in patients diagnosed with bacterial infections and co-infections compared to those with viral/ fungal or mixed flora (p=0.001). This was similar to results from earlier studies (22,23). Neutrophilic pleocytosis in BAL fluid is frequently found in patients with pneumonia. As the neutrophil count is higher in bacterial pneumonia, it can indicate towards a differential of bacterial pneumonia even prior to the final microbiology results. Hence BAL differential may be complimentary to final culture results and maybe helpful to initiate or discontinue antibiotics in critically ill patients. Mortality among critically ill patients with bacterial pneumonia was higher compared to others (p=0.012). These patients tend to be sicker with higher APACHE II scores.

The weaknesses of the study includes the fact that it was retrospective chart review. The total number is small, and the number of the IP procedures performed is even smaller. Hence it is important that more studies should be conducted looking into the safety and complications of IP procedures in critically ill patients.

Conclusion

Our study looked into the fiberoptic bronchoscopy with BAL and inspection as well as other therapeutic procedures done in the critically ill patients. It indicates that even in critically ill patients, bronchoscopy with inspection and BAL is safe. Other interventional pulmonary procedures may have more complications. Even though the number of IP procedures performed in the study is low, the evidence of slightly more number of complications with these procedures indicates the need for caution before attempting them in the critically ill patients.

References

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10. Snow N, Lucas AE. Bronchoscopy in the critically ill surgical patient. Am Surg. 1984;50(8):441-5. [PubMed]
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12. Katz AS, Michelson EL, Stawicki J, Holford FD. Cardiac arrhythmias. Frequency during fiberoptic bronchoscopy and correlation with hypoxemia. Arch Intern Med. 1981;141(5):603-6. [CrossRef] [PubMed]
13. Lindholm CE, Ollman B, Snyder JV, Millen EG, Grenvik A. Cardiorespiratory effects of flexible fiberoptic bronchoscopy in critically ill patients. Chest. 1978;74(4):362-8. [CrossRef] [PubMed]
14. Trouillet JL, Guiguet M, Gibert C, Fagon JY, Dreyfuss D, Blanchet F, Chastre J. Fiberoptic bronchoscopy in ventilated patients. Evaluation of cardiopulmonary risk under midazolam sedation. Chest. 1990;97(4):927-33. [CrossRef] [PubMed]
15. Bulpa PA, Dive AM, Mertens L, Delos MA, Jamart J, Evrard PA, Gonzalez MR, Installé EJ. Combined bronchoalveolar lavage and transbronchial lung biopsy: safety and yield in ventilated patients. Eur Respir J. 2003;21(3):489-94. [CrossRef] [PubMed]
16. O'Brien JD, Ettinger NA, Shevlin D, Kollef MH. Safety and yield of transbronchial biopsy in mechanically ventilated patients. Crit Care Med. 1997;25(3):440-6. [CrossRef] [PubMed]
17. Casal RF, Ost DE, Eapen GA. Flexible bronchoscopy. Clin Chest Med. 2013;34(3):341-52. [CrossRef] [PubMed]
18. Seaman JC, Musani AI. Endobronchial ablative therapies. Clin Chest Med. 2013;34(3):417-25. [CrossRef] [PubMed]
19. Morice RC, Ece T, Ece F, Keus L. Endobronchial argon plasma coagulation for treatment of hemoptysis and neoplastic airway obstruction. Chest. 2001;119(3):781-7. [CrossRef] [PubMed]
20. Boyd M, Rubio E. The utility of interventional pulmonary procedures in liberating patients with malignancy-associated central airway obstruction from mechanical ventilation. Lung. 2012;190(5):471-6. [CrossRef] [PubMed]
21. Bhaskar N, Shweihat YR, Bartter T. The intubated patient with mediastinal disease--a role for esophageal access using the endobronchial ultrasound bronchoscope. J Intensive Care Med. 2014;29(1):43-6. [CrossRef] [PubMed]
22. Stolz D, Stulz A, Müller B, Gratwohl A, Tamm M. BAL neutrophils, serum procalcitonin, and C-reactive protein to predict bacterial infection in the immunocompromised host. Chest. 2007;132(2):504-14. [CrossRef] [PubMed]
23. Choi SH, Hong SB, Hong HL, Kim SH, Huh JW, Sung H, Lee SO, Kim MN, Jeong JY, Lim CM, Kim YS, Woo JH, Koh Y. Usefulness of cellular analysis of bronchoalveolar lavage fluid for predicting the etiology of pneumonia in critically ill patients. PLoS One. 2014;9(5):e97346. [CrossRef] [PubMed]

Cite as: Ganesh A, Singh N, Carr GE. Safety and complications of bronchoscopy in an adult intensive care unit. Southwest J Pulm Crit Care. 2015;11(4):156-66. doi: http://dx.doi.org/10.13175/swjpcc106-15 PDF

December 2014 Pulmonary Case of the Month: Bronchiolitis in Adults

Kashif Yaqub, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 61-year-old man was admitted to the hospital with cough, dyspnea and hypoxemia. He had some prior respiratory symptoms about a month prior to admission, but his symptoms worsened recently. He was seen in Family Medicine Clinic on the day of admission and noted to have saturations of 88 – 89%.

A thoracic CT scan was done shortly after his initial symptoms but was negative for lung consolidation or pulmonary embolus. He currently was having fever with temperatures of 99 to 103 degrees and cough that was only slightly productive.

PMH, FH, SH

He had a history of hypertension and obstructive sleep apnea although he was not using continuous positive airway pressure (CPAP).

Medications

• nifedipine
• lisinopril/hydrochlorothiazide
• cough medication

Physical Examination

      General: SpO2 95% on 2l/min by nasal cannula

      Chest: his breath sounds were coarse, but there were no wheezes or crackles.       

      Cardiovascular: regular rate and rhythm with no murmur noted

      Extremities: no clubbing, cyanosis or edema.

      Skin: no rashes noted.

Laboratory

      CBC: Hemoglobin 15.1 d/dL,  WBC 15.3 x 10³ cells/µL, no eosinophilia.

      Procalcitonin: 0.22 ng/mL (normal < 0.15 ng/mL).    

      Nasopharyngeal swab: PCR negative for pertussis, chlamydophila and           mycoplasma pneumonia.

Radiography

His thoracic CT scan at the initial presentation of his illness about a month prior to admission was reviewed (Figure 1).

Figure 1. Representative images from thoracic CT scan in lung windows done about one month prior to admission.

Which of the following are appropriate at this time? (Click on the correct answer to proceed to the next panel)

1. Cocci serology
2. Empirically begin antibiotics for community-acquired pneumonia
3. Repeat the thoracic CT scan
4. Sputum culture
5. All of the above

Reference as: Yaqub K, Wesselius LJ. December 2014 pulmonary case of the month: bronchiolitis in adults. Southwest J Pulm Crit Care. 2014;9(6):297-301. doi: http://dx.doi.org/10.13175/swjpcc149-14 PDF 

November 2014 Pulmonary Case of the Month: BAL Eosinophilia

Salma Imran Patel, MD, MPH

Lewis J. Wesselius, MD

Laszlo T. Vaszar, MD

Departments of Internal Medicine and Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 62 year-old- was admitted to the hospital for 2 weeks of worsening cough, yellowish sputum production, shortness of breath and pleuritic chest pain. The patient has had asthma since the 1970s and presently uses salmeterol/fluticasone and albuterol as a rescue inhaler. He was intubated once four years ago, and has had a total of three hospitalizations for his asthma and 15 courses of prednisone. He is sensitive to cold/hot air, all animals, aspirin and acetaminophen.

PMH, FH, SH

In addition to the asthma, he has a history of type 2 diabetes mellitus, hypertension, gastroesophageal reflux disease, and chronic abdominal pain.

Physical Examination

Vital signs: T 36.6º C, HR 98, BP129/69, RR 20 and SPO2 96% on 2 L of oxygen by nasal cannula. He was mildly distressed and coughing. His pulmonary exam showed diffuse inspiratory and expiratory wheezes. The remainder of his exam was unremarkable.

Laboratory

Significant findings on laboratory evaluation include an elevated white blood cell count of 13,400 cells/ɥL, an elevated absolute eosinophil count of 2,820 eosinophils/ɥL, an elevated glucose of 131 mg/dL, and a low sodium of 120 mEq/L.

Imaging

A thoracic CT scan was performed (Figure 1).

Figure 1. Representative images in lung windows from thoracic CT scan.

Which of the following best describes the CT scan? (click on the correct answer to proceed to the next panel)

1. Cavitary changes in both apices
2. Central consolidation
3. Fibrotic changes at the bases
4. Peripheral opacities
5. Normal

Reference as: Palel SI, Wesselius LJ, Vasczar LT. November 2014 pulmonary case of the month: BAL eosinophilia. Southwest J Pulm Crit Care. 2014;9(5):251-6. doi: http://dx.doi.org/10.13175/swjpcc136-14 PDF

June 2013 Pulmonary Case of the Month: Diagnosis Makes a Difference

Lewis J. Wesselius, MD¹

Henry D. Tazelaar, MD²

Departments of Pulmonary Medicine¹ and Laboratory Medicine and Pathology²

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 64 year old man from Southern Arizona was referred for a second opinion on a diagnosis of chronic eosinophilic pneumonia that was poorly responsive to corticosteroid therapy. The patient first became ill February 2012 with cough and congestion.  His wife was ill at the same time. Both were treated with antibiotics. His wife improved but he never fully recovered with ongoing symptoms of cough and some dyspnea.

He was admitted to another hospital in August 2012 due to worsening shortness of breath and pulmonary infiltrates on chest x-ray. During this admission he underwent bronchoscopy with bronchoalveolar lavage (BAL) that demonstrated 78% eosinophils. A video-assisted thorascopic (VATs) lung biopsy was done and the patient was diagnosed with chronic eosinophilic pneumonia. He was begun on therapy with high dose prednisone (80 mg/day) but had only slight improvement in symptoms.

He was followed by a pulmonologist and continued on prednisone who questioned the possible development of pulmonary fibrosis. Earlier this year he was started on mycophenolate mofetil and the dose was increased to 1000 mg bid while the prednisone was tapered to 5 mg every other day. He was also being treated with fluticasone/salmeterol 250/50 twice a day. The patient continues to have dyspnea with limited activity. His last pulmonary function testing was done in December 2012. At that time his forced vital capacity (FVC) was 51% of predicted and his diffusing capacity for carbon monoxide (DLco) was 40% of predicted.

PMH, SH, FH

He had a history of obstructive sleep apnea (OSA) and had undergone an uvulopharyngoplasty (UPPP). There was also a history of gastroesophageal reflux disease (GERD) and he had a prior Nissen fundoplication. He had a history of osteoarthritis and had undergone a right shoulder replacement.

He had a remote smoking history, a history of modest alcohol use, but no history of using recreational drugs.  He worked as an airline pilot.

His present medications included mycophenolate mofetil 1000 mg twice a day, prednisone 5 mg every other day, voriconazole 200 mg daily (started after BAL showed a few colonies of Aspergillus), and fluticasone/salmeterol 250/50 twice a day.

Physical Examination

Blood pressure 134/88 mm Hg.  Resting oxygen saturation 96%.

Chest:  bibasilar crackles but no wheezes.

Cardiovascular: the heart had a regular rhythm but no murmur.

Extremities: no clubbing or edema.

The remainder of the physical examination was unremarkable.

Chest Radiography

His chest x-ray is shown in figure 1.

Figure 1. Initial chest x-ray.

Which of the following diseases has/have been associated with increased eosinophils in bronchoalveolar lavage fluid?

1. Interstitial lung diseases
2. Acquired immunodeficiency syndrome (AIDS)-associated pneumonia
3. Idiopathic eosinophilic pneumonia
4. Drug-induced lung disease
5. All of the above

Reference as: Wesselius WJ, Tazelaar HD. June 2013 pulmonary case of the month: diagnosis makes a difference. Southwest J Pulm Crit Care. 2013;6(6):247-54. PDF