Annals of the American Thoracic Society
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Review Case Reports
Physiological and management implications of obesity in critical illness.
Obesity is highly prevalent in the United States and is becoming increasingly common worldwide. The anatomic and physiological changes that occur in obese individuals may have an impact across the spectrum of critical illness. Obese patients may be more susceptible to hypoxemia and hypercapnia. ⋯ Logistical issues such as blood pressure cuff sizing, ultrasound assistance for procedures, diminished quality of some imaging modalities, and capabilities of hospital equipment such as beds and lifts are important considerations. Despite the physiological alterations and logistical challenges involved, it is not clear whether obesity has an effect on mortality or long-term outcomes from critical illness. Effects may vary by type of critical illness, obesity severity, and obesity-associated comorbidities.
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Review
Chest wall strapping. An old physiology experiment with new relevance to small airways diseases.
Chest wall strapping (CWS) induces breathing at low lung volumes. Mild to moderate obesity can lead to similar changes in lung volumes, due to chest wall and abdominal restriction. Chest wall strapping is also conceptually similar to a mismatch between significantly oversized donor lungs transplanted into a recipient with a smaller chest cavity. ⋯ In COPD, higher body mass index (BMI) (conceptually like being more tightly strapped) is associated with lower lung volumes, increased airway conductance, and lower risk of progression to emphysema or death. Likewise, in lung transplantation, oversized donor lungs have been linked to higher expiratory airflows, lower risk of bronchiolitis obliterans syndrome, and improved survival. This article reviews the physiology of chest wall strapping and explores how it could enhance the understanding or even the treatment of small airway diseases, such as COPD and bronchiolitis obliterans syndrome.
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Review Case Reports
Hypervitaminosis A causing hypercalcemia in cystic fibrosis. Case report and focused review.
Hypercalcemia is a rare complication of hypervitaminosis A. We report a pediatric patient with cystic fibrosis (CF) and pancreatic insufficiency who was found to have hypervitaminosis A causing hypercalcemia, complicated by nephrocalcinosis and renal impairment. The patient is a 4-year-old girl with pancreatic-insufficient CF, gastroesophageal reflux, oral aversion, and failure to thrive requiring gastrostomy tube placement. ⋯ Diagnosis of chronic hypervitaminosis A complicated by hypercalcemia was made and was managed by holding vitamin A supplements, aggressive diuresis, and prednisolone. This case emphasizes the importance of regular vitamin A monitoring in patients with CF. There is a wide variability for the lowest intake required to cause toxicity, and the lower limit to cause toxicity has not been determined.
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Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. ⋯ In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
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Review Case Reports
Positive end-expiratory pressure. When more may not be better.