High-frequency oscillatory ventilation (HFOV) is used extensively in the neonatal population. In adults, it is still considered an alternative mode of ventilation for cases of severe acute respiratory distress syndrome refractory to conventional mechanical ventilation (CMV). Reported complications with HFOV among adults include pneumothorax, pneumomediastinum, and subcutaneous emphysema. Ventilator-associated necrotizing tracheobronchitis (VANTB) is a well-documented complication with HFOV in neonates. In adults, only 11 cases have been reported, 9 patients on high-frequency jet ventilation, and 2 patients on CMV. We report a case of VANTB in an adult on HFOV, discuss potential causes, and offer management options. (J Bronchol 2005;12:96-99) H igh-frequency oscillatory ventilation (HFOV) is an alternate ventilator mode designed to optimize alveolar volume recruitment in patients with refractory hypoxemia. HFOV applies a constant mean airway pressure (mPaw) much like a conventional continuous positive airway pressure (CPAP) by using rapid cyclic pressure changes generated by an electromagnetic piston. This constant mPaw allows for an ''open lung'' while avoiding low end-expiratory pressures and high peak pressures. 1 Studies of HFOV in neonates demonstrate an improvement in oxygenation without an increased incidence of barotrauma or histopathologic evidence of ventilator-induced lung injury. 2 Recent findings have suggested that intervention early in the course of adult acute respiratory distress syndrome (ARDS) with HFOV may be beneficial. 1,3 Most observational studies have initiated HFOV in severe ARDS after the patient has been designated a conventional mechanical ventilation (CMV) failure. In a multicenter, randomized, controlled trial of HFOV in ARDS, Derdak demonstrated a greater improvement in oxygenation over CMV, although this difference was not sustained beyond 24 hours. 2 In a recent review, pneumothorax, pneumomediastinum, and subcutaneous emphysema are listed as potential complications associated with this mode. 3 To date, no cases of ventilator-associated necrotizing tracheobronchitis (VANTB) have been reported in association with HFOV. CASE REPORTA 41-year-old, previously healthy man presented with signs and symptoms of an acute abdomen and underwent appendectomy; the appendix was normal on pathologic examination. His immediate postoperative course was complicated by daily fevers. On the fifth hospital day, broad-spectrum antibiotics were initiated for progressively worsening hypoxemia and diffuse bilateral infiltrates on his chest radiograph. He was noted to have cervical and supraclavicular lymphadenopathy, and a computed tomography (CT) scan revealed diffuse interstitial infiltrates with mediastinal adenopathy. An excisional biopsy of the supraclavicular lymph nodes revealed anaplastic T cell lymphoma. On the eighth hospital day, he was transferred to the intensive-care unit (ICU) and intubated for hypoxemic respiratory failure with worsening pulmonary infiltrates. A chemotherapy regimen cons...
ImportanceType 2 diabetes (T2D) is the leading cause of kidney disease in the US. It is not known whether glucose-lowering medications differentially affect kidney function.ObjectiveTo evaluate kidney outcomes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) trial comparing 4 classes of glucose-lowering medications added to metformin for glycemic management in individuals with T2D.Design, Setting, and ParticipantsA randomized clinical trial was conducted at 36 sites across the US. Participants included adults with T2D for less than 10 years, a hemoglobin A1c level between 6.8% and 8.5%, and estimated glomerular filtration rate (eGFR) greater than or equal to 60 mL/min/1.73 m2 who were receiving metformin treatment. A total of 5047 participants were enrolled between July 8, 2013, and August 11, 2017, and followed up for a mean of 5.0 years (range, 0-7.6 years). Data were analyzed from February 21, 2022, to March 27, 2023.InterventionsAddition of insulin glargine, glimepiride, liraglutide, or sitagliptin to metformin, with the medication combination continued until the HbA1c was greater than 7.5%; thereafter, insulin was added to maintain glycemic control.Main Outcomes and MeasuresChronic eGFR slope (change in eGFR between year 1 and trial end) and a composite kidney disease progression outcome (albuminuria, dialysis, transplant, or death due to kidney disease). Secondary outcomes included incident eGFR less than 60 mL/min/1.73 m2, 40% decrease in eGFR to less than 60 mL/min/1.73 m2, doubling of urine albumin-to-creatinine ratio (UACR) to 30 mg/g or greater, and progression of Kidney Disease Improving Global Outcomes stage. Analyses were intention-to-treat.ResultsOf the 5047 participants, 3210 (63.6%) were men. Baseline characteristics were mean (SD) age 57.2 (10.0) years; HbA1c 7.5% (0.5%); diabetes duration, 4.2 (2.7) years; body mass index, 34.3 (6.8); blood pressure 128.3/77.3 (14.7/9.9) mm Hg; eGFR 94.9 (16.8) mL/min/1.73 m2; and median UACR, 6.4 (IQR 3.1-16.9) mg/g; 2933 (58.1%) were treated with renin-angiotensin-aldosterone inhibitors. Mean chronic eGFR slope was −2.03 (95% CI, −2.20 to −1.86) mL/min/1.73 m2 per year for patients receiving sitagliptin; glimepiride, −1.92 (95% CI, −2.08 to −1.75) mL/min/1.73 m2 per year; liraglutide, −2.08 (95% CI, −2.26 to −1.90) mL/min/1.73 m2 per year; and insulin glargine, −2.02 (95% CI, −2.19 to −1.84) mL/min/1.73 m2 per year (P = .61). Mean composite kidney disease progression occurred in 135 (10.6%) patients receiving sitagliptin; glimepiride, 155 (12.4%); liraglutide, 152 (12.0%); and insulin glargine, 150 (11.9%) (P = .56). Most of the composite outcome was attributable to albuminuria progression (98.4%). There were no significant differences by treatment assignment in secondary outcomes. There were no adverse kidney events attributable to medication assignment.Conclusions and RelevanceIn this randomized clinical trial, among people with T2D and predominantly free of kidney disease at baseline, no significant differences in kidney outcomes were observed during 5 years of follow-up when a dipeptidyl peptidase 4 inhibitor, sulfonylurea, glucagonlike peptide 1 receptor agonist, or basal insulin was added to metformin for glycemic control.Trial RegistrationClinicalTrials.gov Identifier: NCT01794143
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