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ARDS and Pneumococcal Pneumonia
ARDS and Pneumococcal Pneumonia To the Editor:
FIGURE l. Components of the Bird humidifier: cap at top left houses pointed metal supply tube which fits into opaque body. At bottom right of figure is the translucent base with protruding central spindle pointing toward small float. Rubber disc is visible on top of float. Control assembly into which this reservoir/float assembly inserts is not pictured.
limb of an anesthesia circle system for such a case. Several minutes after its placement in the system, a gurgling sound was heard through an intraesophageal stethoscope. Inspection of the inspiratory limb revealed approximately 100 ml of water. The humidifier was removed from the circuit and inspected. It was found that the float was upside down with the rubber seal oriented downward against the cylindrical pin projecting up from the floor of the reservoir and with the metallic capillary tube projecting down into the cylindrical depression on the "underside" of the float. This allowed water to Aow continuously into the reservoir, overAowing and spilling out into the inspiratory limb of the circle system. Only the attentiveness of the anesthetist and the fortuitous placement of the humidifier and the inspiratory limb of the anesthesia circuit below the airway of the patient prevented aspiration of water by the anesthetized patient. Further investigation with several models of the Bird humidifier revealed that if one inverts the device after placing the float in the device but prior to firmly placing the cap with its protruding central core and capillary tube into the reservoir, it is quite easy to cause the float to tumble and up-end itself. Although it is then difficult (requires substantial pressure) to screw the cap securely onto the humidifier, it can be done (and was in the instance reported above). Thus, the cap should be screwed onto the base while the entire assembly is held in the normal vertical position. Other potentially serious mishaps have occurred using this device, 2 but modifications in design now being tested by the manufacturer appear likely to eliminate all of these hazards'. Meanwhile, users of current models of the Bird 3000 humidifier should be aware that potentially fatal malfunctions may occur if care is not exercised. Specifically, the device should be monitored carefully for proper functioning during the first several minutes of operation and should always be placed at a level below the airway of the patient. Thonws j. Poulton , M.D., FC.C.P. , Creighton University School of Medicine , Onwha REFERENCES
Poulton TJ, Downs JB. Humidification of rapidly flowing gases. Crit Care Med 1981; 9:59-63 2 Ward CF, Reisner LS, Zlott LS. Murphy's law and humidification. Anesth Analg 1983; 62:460-61 3 Stokes OW. Reply to Ward et al. Anesth Analg 1983; 62:461
584
We have read with great interest the article entitled "Adult respiratory distress syndrome as a cause of death in pneumococcal pneumonia," by Fruchtman, Gombert and Lyons (Chest 1983; 83:598-602). They described ten patients who developed adult respiratory distress syndrome {ARDS) secondary to pneumococcal pneumonia, five of whom (50 percent) died of respiratory failure. We would like to focus on some aspects of their report. The authors stressed the extreme infrequency of the association of pneumococcal pneumonia and ARDS, reporting that it is, to their knowledge, the first time that Streptococcus pneu11Wniae has been implicated as the etiologic factor. However, we were astonished when we read that four of the ten patients (cases 3, 6, 7 and 8) were diagnosed as having pneumococcal pneumonia without any other positive bacteriologic test results other than sputum culture; the lack of specificity of the latter1 could raise uncertainty in the diagnosis of pneumococcal pneumonia. Furthermore, we have had the opportunity to attend two patients who also developed ARDS due to pneumococcal pneumonia over the last year.' Bronchial smear cultures, obtained by transtracheal aspiration procedures, and blood-cultures yielded in both cases penicillin-sensitive Streptococcus pneu11Wniae. The diagnosis of ARDS was made according to Petty and Ashbaugh. 3 Thus, both patients had arterial oxygen tensions (PaO,) below 50 mm Hg (45 and 39 mm Hg, respectively) despite inspired oxygen concentrations (Flo.) of 50 percent during mechanical ventilation. Pulmonary capillary wedge pressures were 6 and 4 mm Hg, respectively. On admission, chest roentgenograms showed lobar alveolar infiltrates, which evolved into bilateral white lungs. As in those described by Fruchtman et al, both patients were also severely leukopenic (3,000 and 3,500 leukocytes/cu mm, respectively). Despite being placed on suitable antibiotic therapy and supported by mechanical ventilation with positive end-expiratory pressure (PEEP), one patient died while the other recovered satisfactorily. We agree with Fruchtman et al on the importance of the recognition of pneumococcal pneumonia as a potential cause of ARDS. However, in view of the lack of response to specific antibiotic therapy shown by 50 percent of their cases and by one of ours, we would like to suggest the possibility of a superimposed nosocomial infection as the actual cause of these deaths. The lack of response to specific antibiotic therapy could be related to this latter complication, which is well-known in ARDS patients. A Torres, M.D.; A Agusti, M.D.; R. Rodriguez-Raisin , M.D.; f. Martinez, M.D.; and A Agusti-Vidal, M.D. , FC.C.P., Hospital Clinic i Provincial, Barcelona, Spain REFERENCES
Barret-Connor E. The nonvalue of sputum culture in the diagnosis of pneumococcal pneumonia. Am Rev Respir Dis 1971; 103:845-48 2 Torres A, Font J, Estopa R, Agustf A. Manifestaciones radiol6gicas atfpicas en las neumonias por S. pneu11UJniae. Rev Clin Esp 1983; 169:55-7 3 Petty TL, Ashbaugh DC. The adult respiratory distress syndrome. Chest 1971; 60:233-39 4 Andrews CH, Coalson J, Smith J, Johanson W. Diagnosis of nosocomial bacterial pneumonia in acute diffuse lung injury. Chest 1981; 80:254-58
Communications to the Editor
FIGURE l. Components of the Bird humidifier: cap at top left houses pointed metal supply tube which fits into opaque body. At bottom right of figure is the translucent base with protruding central spindle pointing toward small float. Rubber disc is visible on top of float. Control assembly into which this reservoir/float assembly inserts is not pictured.
limb of an anesthesia circle system for such a case. Several minutes after its placement in the system, a gurgling sound was heard through an intraesophageal stethoscope. Inspection of the inspiratory limb revealed approximately 100 ml of water. The humidifier was removed from the circuit and inspected. It was found that the float was upside down with the rubber seal oriented downward against the cylindrical pin projecting up from the floor of the reservoir and with the metallic capillary tube projecting down into the cylindrical depression on the "underside" of the float. This allowed water to Aow continuously into the reservoir, overAowing and spilling out into the inspiratory limb of the circle system. Only the attentiveness of the anesthetist and the fortuitous placement of the humidifier and the inspiratory limb of the anesthesia circuit below the airway of the patient prevented aspiration of water by the anesthetized patient. Further investigation with several models of the Bird humidifier revealed that if one inverts the device after placing the float in the device but prior to firmly placing the cap with its protruding central core and capillary tube into the reservoir, it is quite easy to cause the float to tumble and up-end itself. Although it is then difficult (requires substantial pressure) to screw the cap securely onto the humidifier, it can be done (and was in the instance reported above). Thus, the cap should be screwed onto the base while the entire assembly is held in the normal vertical position. Other potentially serious mishaps have occurred using this device, 2 but modifications in design now being tested by the manufacturer appear likely to eliminate all of these hazards'. Meanwhile, users of current models of the Bird 3000 humidifier should be aware that potentially fatal malfunctions may occur if care is not exercised. Specifically, the device should be monitored carefully for proper functioning during the first several minutes of operation and should always be placed at a level below the airway of the patient. Thonws j. Poulton , M.D., FC.C.P. , Creighton University School of Medicine , Onwha REFERENCES
Poulton TJ, Downs JB. Humidification of rapidly flowing gases. Crit Care Med 1981; 9:59-63 2 Ward CF, Reisner LS, Zlott LS. Murphy's law and humidification. Anesth Analg 1983; 62:460-61 3 Stokes OW. Reply to Ward et al. Anesth Analg 1983; 62:461
584
We have read with great interest the article entitled "Adult respiratory distress syndrome as a cause of death in pneumococcal pneumonia," by Fruchtman, Gombert and Lyons (Chest 1983; 83:598-602). They described ten patients who developed adult respiratory distress syndrome {ARDS) secondary to pneumococcal pneumonia, five of whom (50 percent) died of respiratory failure. We would like to focus on some aspects of their report. The authors stressed the extreme infrequency of the association of pneumococcal pneumonia and ARDS, reporting that it is, to their knowledge, the first time that Streptococcus pneu11Wniae has been implicated as the etiologic factor. However, we were astonished when we read that four of the ten patients (cases 3, 6, 7 and 8) were diagnosed as having pneumococcal pneumonia without any other positive bacteriologic test results other than sputum culture; the lack of specificity of the latter1 could raise uncertainty in the diagnosis of pneumococcal pneumonia. Furthermore, we have had the opportunity to attend two patients who also developed ARDS due to pneumococcal pneumonia over the last year.' Bronchial smear cultures, obtained by transtracheal aspiration procedures, and blood-cultures yielded in both cases penicillin-sensitive Streptococcus pneu11Wniae. The diagnosis of ARDS was made according to Petty and Ashbaugh. 3 Thus, both patients had arterial oxygen tensions (PaO,) below 50 mm Hg (45 and 39 mm Hg, respectively) despite inspired oxygen concentrations (Flo.) of 50 percent during mechanical ventilation. Pulmonary capillary wedge pressures were 6 and 4 mm Hg, respectively. On admission, chest roentgenograms showed lobar alveolar infiltrates, which evolved into bilateral white lungs. As in those described by Fruchtman et al, both patients were also severely leukopenic (3,000 and 3,500 leukocytes/cu mm, respectively). Despite being placed on suitable antibiotic therapy and supported by mechanical ventilation with positive end-expiratory pressure (PEEP), one patient died while the other recovered satisfactorily. We agree with Fruchtman et al on the importance of the recognition of pneumococcal pneumonia as a potential cause of ARDS. However, in view of the lack of response to specific antibiotic therapy shown by 50 percent of their cases and by one of ours, we would like to suggest the possibility of a superimposed nosocomial infection as the actual cause of these deaths. The lack of response to specific antibiotic therapy could be related to this latter complication, which is well-known in ARDS patients. A Torres, M.D.; A Agusti, M.D.; R. Rodriguez-Raisin , M.D.; f. Martinez, M.D.; and A Agusti-Vidal, M.D. , FC.C.P., Hospital Clinic i Provincial, Barcelona, Spain REFERENCES
Barret-Connor E. The nonvalue of sputum culture in the diagnosis of pneumococcal pneumonia. Am Rev Respir Dis 1971; 103:845-48 2 Torres A, Font J, Estopa R, Agustf A. Manifestaciones radiol6gicas atfpicas en las neumonias por S. pneu11UJniae. Rev Clin Esp 1983; 169:55-7 3 Petty TL, Ashbaugh DC. The adult respiratory distress syndrome. Chest 1971; 60:233-39 4 Andrews CH, Coalson J, Smith J, Johanson W. Diagnosis of nosocomial bacterial pneumonia in acute diffuse lung injury. Chest 1981; 80:254-58
Communications to the Editor