The diagnosis of PE can be difficult to make because of protean clinical manifestations. Furthermore, these symptoms are not specific for the diagnosis. In our series of patients, the nonspecific symptoms, signs, and presence of preexisting cardiopulmonary comorbidities precluded the initial diagnosis of PE (Table 1). This resulted in various other initial diagnoses (Table 1). Subsequently, TEE performed for these suspected conditions revealed PE. This explains the need for high index of suspicion for PE in critically ill patients presenting with acute cardiopulmonary signs and symptoms.
Category Archives: Pulmonary Function : Part 7
Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III Patients: Discussion
Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III Patients: Results
Table 1 illustrates the clinical presentation, initial diagnosis, coexisting cardiopulmonary disorders, risk factors for thromboembolism, and indication for TEE in the 14 patients.
Initial diagnosis was heart failure in eight patients, cardiogenic shock in two patients, atrial septal defect in two patients, aortic dissection in one patient, and pneumonia in one patient.
Thirteen of 14 patients had risk factors for developing venous thromboembolism. Seven of 14 patients were immobilized from bed rest or significant impairment of functional activity. Five of 14 patients had preexisting congestive heart failure, 2 patients had major surgery, 1 patient had history of deep vein thrombosis, and 1 patient had history of PE. Only one patient had no previous or present condition predisposing for thromboembolism.
Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III Patients
It is well recognized that pulmonary embolism (PE) may be a difficult diagnosis to establish. The clinical manifestations are similar to those of other cardiopulmonary disorders, and, thus, the diagnosis of PE may not be considered even in patients presenting with classic symptoms. The characteristic symptoms and signs such as dyspnea, chest pain, tachypnea, and hypotension are not specific for a definitive diagnosis. Accurate diagnosis is important because untreated in-hospital mortality is up to 30 percent whereas it is only 8 percent if appropriately treated. Investigators have shown the presence of thromboemboli in the main pulmonary artery by transesophageal echocardiography (TEE) in patients diagnosed as having PE. canadian health & care mall
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey: Conclusion
A number of clinical studies of selected populations of patients with asthma and chronic bronchitis have examined expectorated sputum and have suggested that there are 3 different populations: (1) those with asthma alone, (2) those with chronic bronchitis alone, and (3) those with both clinical syndromes. The constitutive cells in expectorated sputum in these clinical studies are different in the three groups, with asthmatic patients having only eosinophils, patients with chronic bronchitis having predominantly neutrophils, and a subgroup of patients with chronic bronchitis and with increased airways responsiveness having both neutrophils and eosinophils.’ Our results are compatible with these clinical investigations and emphasize the importance of the eosinophil in bronchitis and phlegm production, as well as traditional wheezing syndromes. The recent demonstration that peripheral blood eosinophilia (>250 cells per cubic millimeter) is a predictor of chronic bronchitis independent of increased airway responsiveness gives added credence to the role of the eosinophil as a cellular marker of airway inflammation; however, the immune mechanisms responsible for the associations observed here deserve further investigation.
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey: Discussion
As expected, only the peripheral blood neutrophils and eosinophils were associated with chronic respiratory symptoms. The associations of these leukocytes with respiratory symptoms showed different patterns. As expected, asthma was only associated with eosinophils. In contrast, eosinophils showed no association with persistent cough, although they were associated with both shortness of breath and phlegm production. Phlegm production is classically thought of as a result of cigarette smoking, which usually results in neutrophil recruitment into the lung; however, after controlling for smoking and neutrophil count, the eosinophils made an additional contribution. Even bronchitis showed some association with increased eosinophils, after controlling for smoking and neutrophil counts. These eosinophil associations with nonasthmatic respiratory symptoms are the most interesting findings in this analysis.
The second interesting result is the nature of the dose-response relationships shown in Figures 1 to 5. These show that the increased risks of respiratory illness are not merely occurring in the highest 5 percent or even the highest quartile of leukocyte concentration; rather, they extend over much of the range of leukocyte concentration in the US adult population.
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey: Results
Table 1 shows the distribution of peripheral leukocyte counts and smoking in the sample. The mean rate of respiratory symptom reporting and smoking status by age, race, and sex is shown in Table 2. Phlegm was more common than cough in this population, reflecting the way these questions were asked (see methods). In multiple logistic regression models, asthma was associated with pack-years of cigarettes smoked. Bronchitis was associated with pack-years as well, but dummy variables for current smoking and former smoker were also predictive. For phlegm, significant predictors of symptom status included current smoker, former smoker, cigarettes per day, and pack-years of smoking. For dyspnea, significant predictors were cigarettes per day, pack-years, and years since quitting. For persistent cough, predictive factors included current smoking, years since quitting, and pack-years.
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey: Definitions
The probability of having these respiratory symptoms was modeled in logistic regressions controlling for age, race, sex, and smoking. To assure that no correlation was found with WBCs because of improper adjustment for smoking, we first developed models for each outcome as a function of various aspects of smoking. We considered current smoking (packs per day), cumulative smoking (pack-years), and a dummy variable for former smokers. Risk for former smokers may depend on pack-years of past exposure but also decreased with years since quitting; so years since quitting was also considered in each model. Finally, current smokers may have a dose-independent increase in risk of respiratory symptoms, so a dummy variable for current smokers was considered. Baseline models for each outcome were developed by initially considering all of the smoking variables. Smoking variables were kept in the model if they were at least marginally significant (p<0.10). After these baseline models were developed, neutrophil count, eosinophil count, and lymphocyte count were considered. cialis canadian pharmacy
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey: Materials and Methods
The First National Health and Nutrition Examination Survey was conducted between 1971 and 1975 on a sample of subjects aged 1 to 74 years. The initial survey was collected in 1971 to 1974, with an augmentation survey of adults only collected in 1974 to 1975. Before medical examinations were performed, trained interviewers visited the subjects in their homes to administer socioeconomic and medical history questionnaires. A detailed subsample of 6,913 adults consisting of the augmentation sample and a random subsample of the original subjects was given a more detailed medical history questionnaire. These included questions from the National Heart, Lung, and Blood Institute-American Thoracic Society questionnaire on chronic respiratory disease. They also included whether the subject had ever smoked a hundred cigarettes, current cigarettes smoked per day, maximal cigarettes smoked per day, years of smoking, and years since quitting. Of the 6,913 adults, 6,138 were aged 30 years or older, the same age group we examined in NHANES II. Interviewers and medical examiners who conducted NHANES I were specially trained to ensure that conduct of the survey at each site was standardized. Detailed descriptions of the design of the survey have been published. Samples of venous blood were collected and analyzed by the Centers for Disease Control for standard hematologic parameters, including complete blood cell counts, WBC counts, and WBC differential counts. canadianneighborpharmacy.com
Prediction of Respiratory Symptoms by Peripheral Blood Neutrophils and Eosinophils in the First National Nutrition Examination Survey
Epidemiologic studies suggest that the leukocyte count of peripheral blood is a sensitive cellular marker for a decreased level and an accelerated rate of decline in FEV,; however, the relationship of the differential peripheral blood leukocyte count to the occurrence of respiratory symptoms has been relatively unexplored. We have previously shown that the total peripheral leukocyte count was predictive of respiratory symptoms in adults. These relationships showed a dose-dependent increase across a broad range of WBC concentrations and did not just reflect increased risk at extreme WBC concentrations. Unfortunately, that analysis, using data from the Second National Health and Nutrition Examination Survey (NHANES II), did not have WBC differential counts available. canadian pharmacy mall
Cigarette smoking has been shown to be associated with an elevated leukocyte count in the peripheral blood (and lung). Cigarette smoking has also been shown to inhibit or decrease the production of antiproteases, thus disturbing the protease-antiprotease balance in the lungs. Cigarette smokers have been estimated to have half the antiproteolytic capacity of nonsmokers.
Evaluation of Different Criteria for the Separation of Pleural Transudates From Exudates: Conclusion
Thoracentesis is not indicated in every patient with heart failure and pleural effusion unless a comorbid condition is suspected. In the studies by Hamm et al and Valdes et al, a high proportion of patients with transudative pleural effusion were included and among them, 94 percent and 88 percent, respectively, were due to CHF. Since this type of patient usually has a variety of easily discernible features that permit a fairly precise diagnosis without resorting to thoracentesis for confirmation, it must be presumed that in most of them, this diagnostic procedure would not be indicated in routine clinical practice.
From the results of the present study, the criteria of Light et al appear as the method that offers the highest accuracy for segregating transudates from exudates, demonstrating that they are still very efficient in classifying pleural effusions.