BackgroundIn patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD.MethodsCOPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded.ResultsIn total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%.ConclusionWHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

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In-hospital deaths from AECOPD may be predicted by assessment of WHO-PS and EWS on admission to hospital.

Early infection is a recognised complication after lung transplantation in patients with cystic fibrosis (CF). Our centre uses multiple combination bactericidal testing (MCBT) when determining appropriate peritransplant prophylactic regimens. To evaluate our strategy, we compared the incidence of posttransplant infection in patients whose peritransplant antimicrobial regimens were determined using MCBT versus standard sensitivity testing. Patients with CF who were infected with Pseudomonas aeruginosa and underwent lung transplantations between 2000 and 2010 were included. Data was collected from clinical records and our microbiology database. Microorganisms cultured were mapped against antibiotic resistance, method of sensitivity testing, and antibiotics administered peritransplant. 129 patients were identified (mean age 28, male : female, 63 : 66). Fifty patients (38.8%) had antibiotics determined by MCBT. Two patients in the MCBT group developed septicaemia, 13 in the conventional group (P ≤ 0.05, 2-tailed Fisher's test). Sepsis was attributable to P. aeruginosa in one patient from the MCBT group and seven patients in the conventional group (P = 0.15). P. aeruginosa was recovered from the posttransplant pleural fluid of one patient who received MCBT-guided prophylaxis, six patients in the conventional group (P = 0.25). Patients given antibiotics based on MCBT had significantly lower rates of septicaemia and lower rates of empyema.

Background There have been limited reports looking into the care of patients with asthma exacerbations admitted to tertiary hospitals in Southeast Asia. This study aims to determine the extent in which the 2019 Global Initiative for Asthma (GINA) guidelines were being met. Methods A retrospective study of patients with asthma exacerbations admitted to the University of Malaya Medical Centre (UMMC) and Pantai Hospital Kuala Lumpur (PHKL), Malaysia from 1 July 2019 to 31 December 2019. Results There were significant numbers of patients with previous admissions for asthma in both centres, with almost 50% experiencing an exacerbation in the previous year. Approximately 75% of the patients considered their asthma to be controlled when asked, despite many of them having had a history of acute exacerbations in the previous year. When cross-checked, the level of GINA-defined asthma control remained low, with only 6.4% of the patients deemed to have good control, while asthma was partially controlled in 25.6% of the patients and uncontrolled in 68% of the patients. About 72.1% of the patients reported daytime symptoms, 65.1% of the patients reported night-time symptoms, 70.9% of the patients required frequent usage of rescue inhalers and 72.1% of the patients reported some limitation in their activity prior to the current asthma exacerbation. Almost a quarter of the patients who were admitted had severe or life-threatening exacerbations as defined by GINA. These patients had more hospitalizations in a year and were more likely to have previous admissions requiring non-invasive and invasive ventilation. They were also more likely to be on GINA Step 5 treatment, had a lower mean percent predicted FEV 1 and a higher baseline blood eosinophil count. Multivariate analysis revealed that baseline eosinophil count were independently associated with severe or life-threatening asthma exacerbations (odds ratio: 1.01, 95% confidence interval: 1.00–1.01, p=0.001). Failure to adhere to daily controller medications was high in this study (37.2%). Conclusion Although the management of asthma exacerbations in tertiary hospitals in Southeast Asia is largely congruous with international guidelines, there is room for improvement. As there is a marked discrepancy between patient-perceived and guideline-defined asthma control, efforts to increase awareness on the dangers of uncontrolled asthma are warranted.

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Malignant melanoma (MM) should be considered in the differential diagnoses of young patients with a pleural mass. Early identification is crucial in the management of this disease. Positron emission tomography computed tomography (PET-CT) is both sensitive and specific in identifying MMs.A 29-year-old male Caucasian presented with a 5-month history of left anterior chest pain and dyspnoea. There was no associated cough, haemoptysis, fever, weight loss or night sweats. He was a never smoker with no previous exposure to asbestos.On general examination, he had multiple freckles and tattoos. His lower left chest wall was tender on palpation but no other abnormalities were present. Chest X-ray revealed a lobulated pleural-based soft tissue mass at the left mid-zone. CT showed lobulated left posteromedial pleural thickening with medial extension and encroachment on the left T5/6 neural foramina. PET-CT confirmed CT findings and revealed intense metabolic activity (SUVmax of 11.8 g/ml) within the pleural-based masses but no evidence of abnormal metabolic activity elsewhere (Figure 1a). Ultrasound-guided biopsy revealed cells with irregular nuclei and prominent nucleoli with ample eosinophilic cytoplasm. Some cells contained brown pigment and lesional cells were positive for Melan A and HMB45 (Figure 1b).The overall histological appearances were in keeping with MM. The patient was negative for BRAF mutation. He underwent a left thoracotomy with chest wall and pleural resection. Negative fluorodeoxyglucose uptake elsewhere indicated that there was a chance of complete resection with an opportunity for a long disease-free period. A haemorrhagic tumour with dark pigmentation was removed but complete resection was not possible due to spinal metastatic deposits. He received post-operative radiotherapy but subsequently relapsed 2 months later with metastatic spread to bones and supraclavicular fossa lymph nodes. Unfortunately, he failed to respond to chemotherapy (dacarbazine and cisplatin) and died 6 months after initial diagnosis. We were unable to obtain consent for a post-mortem examination.MM is one of the commonest cancer in young adults aged 25-49.1 It can metastasize to the lung and more rarely, the pleura.2 Primary pleural melanoma is extremely rare and was first described in 1978 3 with only a handful of cases subsequently reported. Jensen and Egedorf have proposed criteria for diagnosing primary pulmonary MM: no previously removed ocular or pigmented skin tumours, solitary tumour from surgery, tumour morphology compatible with a primary tumour, no demonstrable MM in other organs during surgery and autopsy without primary MM elsewhere.

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