지난 1년간 중환자의학 관련된 주요 연구 결과들이 많이 발표되었다. 우선 급성호흡곤란 증후군 치료에 있어서는 high PEEP이 사망률을 감소시키지는 못하였으나, 저산소증 개선이나 다른 임상 지표의 호전을 가져온다는 대규모 임상 연구 결과들이 발표되어, high PEEP의 유용성이 다시금 주목을 받게 되었다. 패혈증 치료에 있어서는 기존 연구 결과와는 달리 적극적 인슐린 치료나 corticosteroid 치료는 사망률 감소에 도움이 못 된다는 연구 결과가 발표되었고, 혈압 유지에 있어서 vasopressor 간의 차이를 보고자 한 연구들에서도 각 약제 간의 유의한 차이는 보이지 못하였다. 감염 영역에서는 중환자실에서 chlorhexidine으로 매일 환자를 목욕시키는 것이 간편하고 효율적으로 감염을 예방할 수 있는 방법이라는 연구 결과가 있었고, procalcitonin 측정이 항생제 투여 기간을 줄일 수 있었다는 연구 결과도 있었다. 기존의 연구 결과와 유사하게 급성 폐손상 환자에서도 적혈구 수혈이 사망률 증가와 관련 있다는 연구가 발표되었으나, 적혈구 수혈을 줄이기 위해 epoetin alfa 투여를 시도한 연구에서는 적혈구 수혈량을 감소시킬 수는 없었다는 부정적인 결과도 나왔다. 중환자실에서 매일 진정제를 끊고 환자를 깨우면서 동시에 자발 호흡을 시도하는 것이 기존 방법에 비하여 재원기간을 줄이고, 사망률도 감소시킬 수 있음을 보여준 논문이 발표되었고, 새로운 진정제인 dexmedetomidine이 lorazepam에 비해 우월함을 입증한 연구 결과도 발표되었다. 또한, 임종을 맞이한 환자의 보호자들과 의료진과의 긴밀한 의사 소통의 중요성을 강조한 논문도 있었다. 중환자의학은 계속 발전해 나가는 학문으로 매년 새로운 연구 결과들이 발표되고 있으므로 이에 대한 지속적인 관심이 필요할 것으로 사료된다.
Background: Isoniazid (INH, H) is a key drug of the standard first-line regimen for the treatment of tuberculosis(TB), yet some reports have suggested that treatment efficacy was maintained even though INH was omitted from the treatment regimen. Methods: One hundred forty C57BL/6 mice were infected with the H37Rv strain of M. tuberculosis with using a Glas-Col aerosol generation device, and this resulted in depositing about 100 bacilli in the lung. Four weeks after infection, anti-TB treatment was initiated with varying regimens for 4-8 weeks; Group 1: no treatment (control),Group 2 (4HREZ): 4 weeks of INH, rifampicin (R), pyrazinamide (Z) and ethambutol (E), Group 3: 1HREZ/3REZ,Group 4: 4REZ, Group 5: 4HREZ/4HRE, Group 6: 1HREZ/3REZ/4RE, and Group 7: 4REZ/4RE. The lungs and spleens were harvested at several time points until 28 weeks after infection, and the colony-forming unit (CFU) counts were determined. Results: The CFU counts increased steadily after infection in the control group. In the 4-week treatment groups (Group 2-4), even though the culture was negative at treatment completion, the bacilli grew again at the 12-week and 20-week time points after completion of treatment. In the 8-week treatment groups (Groups 5-7), the bacilli did not grow in the lung at 4 weeks after treatment initiation and thereafter. In the spleens of Group 7 in which INH was omitted from the treatment regimen, the culture was negative at 4-weeks after treatment initiation and thereafter. However, in Groups 5 and 6 in which INH was taken continuously or intermittently, the bacilli grew in the spleen at some time points after completion of treatment. Conclusion: TThe exclusion of INH from the standard first-line regimen did not affect the treatment outcome in a murine model of TB in the early stage of disease. Further studies using a murine model of chronic TB are necessary to clarify the role of INH in the standard first-line regimen for treating TB.
Background: The control of active pulmonary tuberculosis is still an issue in community medicine. But there are also considerable needs for supportive management of symptomatic patients with post-tuberculous destroyed lung.Few studies have evaluated clinical characteristics and health-related quality of life in patients with post-tuberculous destroyed lung. Methods: We evaluated lung function, exercise tolerance, HRCT and health-related quality of life measurements using the Korean version of St. George’s Respiratory Questionnaire (SGRQ) in 22 patients with parenchymal damage to more than a half of one lung due to pulmonary tuberculosis. Results: In the pulmonary function test, mixed defects and obstructive defects were observed in 10 (45.0%) and 9 (40.9%) of patients, respectively. In the cardiopulmonary exercise test, the mean VO2max% predicted (39.0%±10.9%) and O2 pulse% predicted (61.3%±13.6%) were markedly decreased. In the SGRQ, the impact score (mean 27.8±18.5) was significantly lower than the symptom score (mean 53.9±20.9) or activity score (mean 50.8±27.3) (p＜0.05,p＜0.01). Cronbach’s alpha coefficient value for reliability was more than 0.7 for each subscale and total score. The total score showed a significant negative correlation with FEV1% predicted (r=−0.46, p＜0.05) and SaO2 (r=−0.60, p＜0.05). On HRCT, a median of 9 (range 5∼15) bronchopulmonary segments were destroyed by less than half, which significantly correlated with SGRQ total score (r=−0.52, p=0.02). Conclusion: The reliability and validity of the Korean version of the SGRQ was acceptable for the measurement of health-related quality of life in patients with post-tuberculous destroyed lung.
Background: Due to the irreversible nature of chronic obstructive pulmonary disease (COPD), the treatment aim in patients with COPD is not to cure but to reduce the symptoms, increase lung function, and improve the quality of life. It has been suggested that depression is a common emotional disturbance in patients with COPD who are faced with a major physical impairment and embarrassing symptoms. This study evaluated the prevalence and risk factors of depression in patients with chronic obstructive pulmonary disease. Methods: A total of 59 patients with a registered diagnosis of chronic obstructive pulmonary disease were selected. Depression was assessed using the Centers for Epidemiologic Studies Depression (CES-D) scale. The quality of life was assessed using the Korean version of the St. George’s Respiratory Questionnaire. Results: The prevalence of depression was 17.0%. In the correlation model, the interaction of the FEV1% over predicted value and SGRQ score(symptom, activity, impact, overall score) was statistically significant. The interaction of the FEV1% over predicted value and depression scale(CES-D) was also statistically significant. There was a positive correlation between the SGRQ scores(symptom, activity, impact, overall score) and the depression scale. Conclusion: The prevalence of depression in patients with chronic obstructive pulmonary disease is relatively high. The pulmonary function and the living standards were found to be significant risk factors for depression
Background: Tracheobronchial suctioning using the closed suctioning system has physiological benefits for critically ill patients. Despite these benefits, there are concerns about increased colonization of tracheobronchial tree by pathogenic organisms. The cost is anotherhinder to the introduction of closed suction system. The aim of this study was to evaluate the incidence of colonization and ventilator associated pneumonia and the cost-effectiveness of closed suction compared with open suction. Methods: During separated one month period, patients admitted MICU were cared by multiple-use, open suction, single-use, open suction and multiple-use, closed suction method, consecutively. Costs, colonization of tracheobronchial tree by MRSA and the incidence of ventilator-associated pneumonia (VAP) were analyzed. Results: One-hundred and six patients were enrolled. Twenty patients were treated with multiple-use, open suction, while 42 and 44 patients were cared with single- use, open catheter and multiple-use, closed catheter, respectively. Colonization by MRSA and the incidence of VAP were not different among three ways of suctioning. The overall costs per patient per day for suctioning were $10.58 for multiple-use, open suction, $28.27 for single-use, open suction and $23.76 for multiple- use, closed suction. Conclusion: Multiple-use, closed suctioning, when suction catheters were changed every 48 hrs, has the similar incidence of colonization of MRSA and occurrence of VAP and is a cost-efficient way of endotracheal suction.
X-linked agammaglobulinemia is the most common type of primary immunodeficiency disorder. Mutation ofthe cytoplasmic tyrosine kinase gene, Btk (Bruton’s tyrosine kinase), is known to be the etiology of X-linked agammaglobulinemia. The patients with this disease manifest a B-cell deficiency and low levels of serum immunoglobulin;due to the deficient antibodies, they suffers from recurrent upper and lower respiratory infections. We report here a 24-year-old male with an initial clinical impression of recurrent pneumonia and bronchiectasis. The patient presented with marked pan-hypogammaglobulinemia and the absence of circulating B lymphocytes on the immunologic study, and he carried a splicing mutation of intron 2 in the Btk gene (IVS2 −3C＞G).
Rectus sheath hematoma (RSH) is a rare condition that’s caused by a sudden disruption of the deep epigastric vessels or direct damage to the rectus abdominis muscle. This condition is associated with old age, childbirth, abdominal surgery, severe cough, severe sneezing, anticoagulation therapy and/or coagulation disorders. RSH is characterized by abdominal pain and an abdominal mass, so that this is often misdiagnosed as a surgical condition such as appendicitis, intraabdominal abscess, torsion of the ovary and ruptured abdominal aortic aneurysm; this can lead to unnecessary surgery. Thus, we have to be cautious not to miss RSH when a patient with predisposing factors is suffered from abdominal pain and an abdominal mass. We report here on a case of rectus sheath hematoma that was induced by severe cough in a patient who was taking warfarin.
A chronic expanding hematoma (CEH) in the thorax is a rare and specific condition of chronic empyema. CEHs in the thorax are often associated with tuberculosis and/or previous surgical procedures. While the incidental detection of a pleural mass and dyspnea are common clinical manifestations, a few cases present with hemoptysis. We encountered a case of CEH in the thorax. This case is unique in that it developed without a prior history of tuberculosis or surgery and presented with massive hemoptysis accompanied by bronchopleural fistula. We report the third case of CEH in the thorax in Korea with a summary of the clinical characteristics of previous cases.
Spontaneous pneumomediastinum is defined as a clinical syndrome that’s characterized by the presence of air in the mediastinal space, which is not due to an old previous injury or surgery. The condition is caused by a sustained increase in the intraalveolar and intrabronchial pressure with extravasated air dissecting along the perivascular spaces of the mediastinum. This is an uncommon complication of sports activity. The most common symptom is chest pain. This diagnosis should be considered for younger people who present with pleuritic chest pain or dyspnea and a characteristic crackling feel (known as subcutaneous crepitation) when touching of the skin covering the chest wall or neck, and they look otherwise well with normal vital signs. Usually no treatment is required, but the mediastinal air will be absorbed faster if the patient inspires high concentrations of oxygen. We present here a case of spontaneous pneumomediastinum that occurred during a Taekwondo match, along with a review of the relevant literature
Inferior vena cava filters are increasingly being used as an alternative to anticoagulation therapy for the prevention of pulmonary embolism. However, using an Inferior vena cava filter may result in clinically significant complications. Phlegmasia cerulea dolens is a rare disease that presents with acute complete venous occlusion due to extensive thrombosis in the lower extremity. It is characterized by intense pain, edema, decreased pulses and a cyanotic extremity. We report here on a case of phlegmasia cerulea dolens that was accompanied with disseminated intravascular coagulation (DIC) as a complication of the placement of an inferior vena cava filter in a patient who had been previously diagnosed with pulmonary embolism, and the patient had recently developed a cerebral hemorrhage due to a traffic accident.
The incidence of appendiceal metastatic cancer is quite low. In particular, in small cell lung cancer, there is a very low incidence of a metastasis to the appendix. A 75-years old man with right lower quadrant pain, cough and sputum was transferred to our hospital. Abdominal CT revealed acute appendicitis with a perforation. The patient underwent surgery. The frozen sections of the tissue obtained during surgery, indicated a malignancy, but a right hemicolectomy was not performed due to the patient’s poor general condition. The histology findings of the appendix were identified as a small cell carcinoma. The abdominal CT scan and chest x-ray at admission day showed a mass in the right lower lobe, and a further evaluation of the lesion was performed including positron emission tomography and flexible bronchoscopy with a biopsy. The pathology findings of the lung mass were also small cell lung cancer. The specimens from both sites stained positive for cytokeratin, cluster designation 56, synaptophysin, chromogranin-A and thyroid transcription factor 1. It was concluded that the appendiceal small cell cancer originated from the lung.
Exogenous lipoid pneumonia is an uncommon disease that’s caused by aspirating lipid formulations. Squalene,obtained from shark liver oil, is one of the causative agent and this is commonly used by some Koreans as a health promoting medication. We report here on a case of exogenous lipoid pneumonia that developed after ingestion of squalene capsules. The case showed milky BAL fluid and multiple pulmonary consolidations