The benefit of albumin administration in the critically ill patient is unproven. Epidemiological evidence suggests that there is an increase in death among patients with burns, hypoalbuminaemia, and hypotension treated with human albumin solution (HAS). In critical illness, hypoalbuminaemia is a result of transcapillary leak, decreased synthesis, large volume body fluid losses and dilution caused by fluid resuscitation. When treating patients with hypoalbuminaemia, efforts must be centred around correction of the underlying disorder rather than reversal of hypoalbuminaemia. Problems with using albumin arise because it is an expensive blood product, and can result in systemic changes that include cardiovascular, haematological, renal, pulmonary, and immunological effects. The electronic version of the accompanying article can be found online at
Thunderstorm-related asthma is increasingly recognized in many parts of the world. This review focuses on important advances in the understanding of the mechanism of the role of allergens, in particular fungal spores such as Alternaria, in asthma epidemics associated with thunderstorms. From our observations, we have proposed that the prerequisites for this phenomenon are as follows: 1) a sensitized, atopic, asthmatic individual; 2) prior airway hyperresponsiveness before a sudden, large allergen exposure; 3) a large-scale thunderstorm with cold outflow occurring at a time and location during an allergen season in which large numbers of asthmatics are outdoors; and 4) sudden release of large amounts of respirable allergenic fragments, particularly fungal spores such as Alternaria.
SummaryPneumothorax during pregnancy is uncommon. Recently ambulatory chest drainage has been advised to treat the pneumothorax and to cover the delivery period. This imposes restrictions on the mother with associated co-morbidity. The authors present a case of recurrent chest-tube resistant pneumothorax during pregnancy which had persisted for 4-weeks .To guide management of a patient referred in the third trimester of pregnancy the authors undertook a systematic review. This led to defi nitive video assisted thoracoscopic surgery (VATS) for bullectomy and pleurodesis which was successful without either peri-operative or peri-partum complications or recurrence of pneumothorax. Our review suggests that a VATS approach during pregnancy is both safe and effective. chest drain insertion there was a continued air leak for 4 days. At this point, and after discussion between chest physicians and obstetricians, a high resolution CT (HR-CT) scan was performed. The HR-CT scan showed left apical bullae, the lung was not fully infl ated with the intercostal drain in situ (fi gure 2). Serial foetal ultrasound scanning over this period found a viable breech presentation singleton foetus with parameters in keeping with gestational age. Liquor volume and foetal movements and heart rate variability were within normal limits. She was then referred for thoracic surgery management. TREATMENTThe 2003 British Thoracic Society guidelines on the management of pneumothorax 2 did not include presentation in pregnancy suggesting the rarity of the condition. The 2010 guidelines for the management of pneumothorax 3 state that there is level C evidence that simple observation and aspiration are usually effective during pregnancy, with elective assisted delivery and regional anaesthesia at or near term. The guidelines also state level D evidence that a VATS procedure should be considered after birth.After discussion between the patient, her family and all professionals it was decided to offer a surgical resolution to this recurrent problem to which she gave informed consent.We chose to undertake VATS pneumothorax surgery because:It is our preferred technique for pneumothorax surgery ▶ as it has smaller incisions than open surgery A dose of 12 mg intramuscular betamethasone was given to aid foetal lung maturity in the event of operative complications necessitating delivery. Foetal ultrasound examination was again normal.At 34 weeks gestation the patient underwent a left sided VATS procedure. Three ports were used (2 × 1 cm and 1 × 1.5 cm). Peri-operative foetal cardiotocography remained normal. The surgical procedure took 15 min (after induction of anaesthesia) and was uncomplicated. The left apical bulla was resected and a mechanical pleural abrasion was performed. Two 24 French intercostal chest drains were inserted and connected to 4kPa suction. Chest x-ray confi rmed satisfactory placement of the chest tubes with full re-infl ation of the lung. Suction to the chest drains was applied continuously for 48 h and the drains were removed at 72...
Background and Objective: Malignant pleural effusion (MPE) often results in debilitating symptoms. Relief of dyspnoea and improvement in quality of life can be achieved with either talc pleurodesis or insertion of an indwelling tunneled pleural catheter (IPC). The former requires a lengthy hospital stay and the latter is associated with lower pleurodesis rates. In response to limited hospital bed capacity, we developed a pragmatic approach in managing MPE by combining thoracoscopic talc poudrage and insertion of IPC into a single day case procedure. We present data on the safety and efficacy of this approach.Methods: Patients who had undergone the abovementioned procedure between 2017 and 2020 were analyzed. Demographic data, hospital length of stay (LOS), histological diagnosis, rates of pleurodesis success and procedural related complications were collated. Patients were followed-up for 6 months.Results: Forty-five patients underwent the procedure. Mean age was 68.5 ± 10.4 years and 56% were male. Histological diagnosis was achieved in all cases. 86.7% of patients were discharged on the day of the procedure. Median LOS was 0 (IQR 0–0) days. Successful pleurodesis was attained in 77.8% at 6-month follow-up. No procedure related deaths or IPC related infections were recorded.Conclusion: Ambulatory thoracoscopic poudrage and IPC insertion is a safe and effective option in the management of MPE. All patients received a definitive pleural intervention with 77.8% pleurodesis success at 6-months and majority of them discharged on the same day. Future randomized trials are required to confirm these findings.
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