We present a case of critical airway obstruction secondary to a solid tracheal mucus plug in a patient with pneumonia. Following failed conventional mucolysis therapy, nebulised N-acetylcysteine acted as a life-saving mucolytic, and prevented imminent cardiorespiratory arrest. Use of oral N-acetylcysteine as a mucolytic has been long established within respiratory medicine in managing chronic airway disease, but is rarely utilised in critically ill or mechanically ventilated patients due to the lack of comparative studies in literature. A 28-year-old female presented to the emergency department with shortness of breath and a productive cough. She was six weeks post-partum with no past medical history. Initial management for a community acquired pneumonia with type 1 respiratory failure included intensive care admission, antibiotics, fluid therapy and bronchodilators. The patient acutely deteriorated 48 h after admission becoming unresponsive and severely hypoxaemic. Intubation did not achieve ventilation, and subsequent direct bronchoscopy revealed a thick, solid, obstructing tracheal mucus plug, superior to the carina. It was resistant to aspiration despite the use of saline flushes, chest physiotherapy and bronchodilators and the bronchoscope could not pass it. N-acetylcysteine, administered via the bronchoscopic port, caused sufficient mucolysis to enable removal of the thick mucus cast, enabling ventilation and gas exchange. Such resistant mucus plugging is a rare cause of failed ventilation, with limited therapeutic options. Here, the unlicensed and rarely reported use of nebulised N-acetylcysteine was a life-saving mucolytic, allowing removal of the obstructing plug and re-establishing ventilation.
Summary Topical application of skin‐lightening cream is increasingly undertaken in many non‐Caucasian populations for cultural and social reasons. It is a rare cause of poisoning that has potential to lead to significant harm due to skin damage and systemic absorption of cream following application over prolonged periods of time. This case report describes for the development of multi‐organ failure in an adult due to salicylate toxicity after whole‐body application of a skin‐lightening cream for 24 h. It highlights the need for vigilance and awareness of the toxic potential of topical salicylates.
The COVID-19 pandemic has resulted in healthcare workers (HCWs) having to wear full personal protective equipment (FPPE) even for routine patient care. When worn for prolonged periods, FPPE has the potential to adversely affect the ability of HCW to carry out their tasks. This study aimed to assess the impact of FPPE on the alertness levels of HCWs in the intensive care unit.Fifty HCWs were tested using psychomotor vigilance test (PVT) and serial sevens test (SST) on two occasions during their shift—once without FPPE and once after they had been in FPPE for at least 2 hours. The median time in FPPE was 2.5 hours. FPPE induced a significant increase in the average reaction time and the number of false responses in PVT. Subjects took longer to complete SST in FPPE compared with without it.This study demonstrates that being in FPPE for as little as 2.5 hours can adversely affect HCW alertness. The findings of this study are relevant in terms of workforce environment considerations as the use of FPPE in certain settings is likely to become a regular feature.
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