Expanding Use of the ProVent Score

Jeon, Kyeongman The Korean Academy of Tuberculosis and Respiratory 2019 Tuberculosis and Respiratory Diseases Vol.82 No.2

Bronchoscopic Findings of Pulmonary Paragonimiasis

Jeon, Kyeongman,Song, Jae-Uk,Um, Sang-Won,Koh, Won-Jung,Suh, Gee Young,Chung, Man Pyo,Kwon, O Jung,Han, Joungho,Kim, Hojoong The Korean Academy of Tuberculosis and Respiratory 2009 Tuberculosis and Respiratory Diseases Vol.67 No.6

Background: Pulmonary paragonimiasis is a subacute to chronic inflammatory disease of the lung caused by lung flukes that result in prolonged inflammation and mechanical injury to the bronchi. However, there are few reports on the bronchoscopic findings of pulmonary paragonimiasis. This report describes the bronchoscopic findings of pulmonary paragonimiasis. Methods: The bronchosocpic findings of 30 patients (20 males, median age 50 years) with pulmonary paragonimiasis between May 1995 and December 2007 were reviewed retrospectively. Results: The diagnoses were based on a positive serologic test results for Paragonimus-specific antibodies in 13 patients (43%), or the detection of Paragonimus eggs in the sputum, bronchial washing fluid, or lung biopsy specimens in 17 patients (57%). The bronchoscopic examinations revealed endobronchial lesions in 17 patients (57%), which were located within the segmental bronchi in 10 patients (59%), lobar bronchi in 6 patients (35%) and main bronchi in 1 patient (6%). The bronchoscopic characteristics of endobronchial lesions were edematous swelling of the mucosa (16/17, 94%) and mucosal nodularity (4/17, 24%), accompanied by bronchial stenosis in 16 patients (94%). Paragonimus eggs were detected in the bronchial washing fluid of 9 out of the 17 patients with endobronchial lesions. The bronchial mucosal biopsy specimens showed evidence of chronic inflammation with eosinophilic infiltration in 6 out of 11 patients (55%). However, no adult fluke or ova were found in the bronchial tissue. Conclusion: Bronchial stenosis with mucosal changes including edematous swelling and mucosal nodularity is the most common bronchoscopic finding of pulmonary paragonimiasis.

Pharmacotherapy for Acute Respiratory Distress Syndrome: Limited Success to Date

( Kyeongman Jeon ) 대한결핵 및 호흡기학회 2017 Tuberculosis and Respiratory Diseases Vol.80 No.3

Preoperative assessment of postoperative pulmonary complication

Kyeongman Jeon 대한외과학회 2016 대한외과학회 학술대회 초록집 Vol.2016 No.11

Extracorporeal membrane oxygenation in acute respiratory distress syndrome

( Kyeongman Jeon ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

Acute respiratory distress syndrome (ARDS) is the most severe form of acute respiratory failure characterized by diffuse alveolar damage, and is associated with poor clinical outcomes, with a pooled mortality rate of approximately 40% despite best standards of care. Current therapeutic strategies are based on improving oxygenation and pulmonary compliance while minimizing ventilator-induced lung injury. Even in recent years, however, severe ARDS still has a high-mortality rate. Extracorporeal membrane oxygenation (ECMO) can be used in patients with severe ARDS to facilitate gas exchange in the setting of refractory hypoxemia or hypercapnic respiratory acidosis. It can also facilitate a reduction in the intensity of mechanical ventilation. In this brief review, the current state of ECMO for ARDS will be discussed. ECMO had been used successfully in adults with ARDS since the early 1970s but, until recently, was limited to small numbers of patients at selected centers. In the last decade, use of venovenous ECMO has increased after publication of the Conventional Ventilatory Support vs. Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) trial and reports of successful use in several countries during the 2009 H1N1 influenza pandemic. Despite increasing use of venovenous ECMO, rigorous evidence is required to establish the appropriate role for this modality in the management of severe ARDS. Therefore, the ATS/ESICM/SCCM practice guideline published in 2017 concluded that evidence was insufficient to make a clinical recommendation for or against the use of venovenous ECMO in patients with severe ARDS. The Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial addressed the limitations of CESAR and randomized adult patients with early, severe ARDS to conventional, standard of care management that included a protocolized lung protective strategy in the control group vs immediate initiation of ECMO combined with an ultra-lung protective strategy in the intervention group. Although it was terminated early for futility (i.e., failure to demonstrate a difference in 60-day mortality of 20%), there was a nonsignificant, but clinically important, reduction in 60-day mortality (35% vs 46%, RR 0.76, 95% CI 0.55-1.04). The key secondary outcome of risk of treatment failure (defined as death in the ECMO group and death or crossover to ECMO in the control group) favored the ECMO group with a RR of 0.62 (95% CI, 0.47-0.82), as did other secondary endpoints such as free days of other organ failure. A major limitation of the trial was that 28% of control group patients ultimately crossed over to ECMO, which diluted the effect of ECMO observed in the intention- to-treat analysis. Mortality of these crossed over patients was 57 vs. 41% among the other patients in the control group (RR 1.39, 95% CI 0.95-2.03). In order to estimate the effect of ECMO on survival times if crossover had not occurred, the authors performed a post-hoc, rank-preserving structural failure time analysis. Although this relies on some assessment regarding the effect of the treatment itself, it showed a hazard ratio for mortality in the ECMO group of 0.51 (95% CI 0.24-1.02). Although the EOLIA trial was not positive by traditional interpretation, all three major analyses and all secondary endpoints suggest some degree of benefit in patients with severe ARDS managed with ECMO. More recently, a post-hoc Bayesian analysis of EOLIA trial demonstrated a high likelihood of mortality benefit, even assuming a strongly skeptical prior distribution. In the early of this year, a systematic review and meta-analysis of the available data from the two largest randomized controlled trials (CESAR and EOLIA) of venovenous ECMO for severe ARDS and from three observational studies with matching revealed that venovenous ECMO was associated with a significant reduction in 60-day mortality compared with conventional mechanical ventilation in patients with severe ARDS. However, a moderate risk of major bleeding was also reported in relation to venovenous ECMO use. Nonetheless, as the EOLIA trial showed that early initiation of ECMO can lead to more favorable outcomes than late rescue, implementation of ECMO should be considered early if adequate oxygenation and ventilation cannot be maintained despite optimal conventional treatment in patients without any contraindication to ECMO. If rescue was successful after initiation of ECMO support, the next step is to wait for the lungs to recover. As time to recover lung function depends on patient, and technology has enabled prolonged use of extracorporeal support, some patients rely on ECMO for a period of two weeks or more, which is usually considered the average duration of ECMO support in patients with severe respiratory failure. Sometimes, the potential regenerative capabilities of the lungs make it possible to be weaned from ECMO with improved lung function even months after initiation. While the longer is the duration of ECMO, the greater is the chance of exposure to complications, several studies have shown that long-term ECMO itself is not a predictor of poor prognosis if adequate management is pursued during ECMO support. I suggest regularly evaluating the reversibility of lung function if using ECMO support for more than four weeks. I recommend maintaining ECMO treatment until the lung recovers if reversibility remains, but a decision about transplantation or futility should be made according to the presence of significant extrapulmonary organ failure if pulmonary failure is irreversible. Patient management should be aimed at preventing further lung injury and maintaining the function of the extrapulmonary organs when ECMO support is to be maintained. For this purpose, awake, spontaneous breathing, and early mobilization are beneficial and can be safely performed in patients on ECMO. In particular, secondary right ventricle (RV) failure may occur if lung condition is not recovered or worsens; thereby, cardiac function monitoring and RV protective management should be performed. Optimal care of patients on ECMO, especially those who require prolonged ECMO, cannot be achieved by the treating physician alone. The ELSO guidelines recommend a multidisciplinary ECMO team approach as one of the key factors in ensuring effective use of ECMO. Therefore, all ECMO centers should have suitable physical facilities and equipment and provide physician and staff training and education for high-quality treatment and optimal outcomes. Ultimately, the results of recent publications remind us of the role of ECMO in patients with severe ARDS. Beyond rescuing a patient dying of refractory hypoxemia, therefore, ECMO should now be considered early to minimize ventilator-induced lung injury (VILI) by reducing the intensity of mechanical ventilation, especially in high-volume ECMO centers with a multidisciplinary team. However, additional research focusing on selection of patients who are more likely to benefit from ECMO support, optimization of daily management of patients under ECMO to reduce extrapulmonary complications, and optimal ventilator management to reduce further VILI during ECMO should be conducted.

Boosted Reaction on Two-Step Tuberculin Skin Test among Military Personnel in South Korea, a Setting with an Intermediate Burden of Tuberculosis and Routine Bacille Calmette-Guerin Vaccination

Kyeongman Jeon,Sang Hoon Ji,Soo Yon Oh,Hee Jin Kim,Chang Min Choi,Jin Beom Lee 대한의학회 2008 Journal of Korean medical science Vol.23 No.3

This study was performed to estimate the rate of boosted reaction in the two-step tuberculin skin test (TST) and to evaluate the associated factors among military personnel of South Korea, which has an intermediate burden of tuberculosis (TB) and a routine bacille Calmette-Guerin (BCG) vaccination policy. Two-step TST was performed on 264 military personnel who did not have a history of close contact to TB. Subjects with a negative reaction to the first test of <10 mm had a second TST applied 1 week later on the other forearm. A positive result (≥10 mm) on the initial TST was observed in 126 (48%) of the subjects. A boosted reaction on the second TST developed in 32 (23%) of the 124 subjects with a negative initial TST. In multiple logistic regression analysis, the size of the initial TST reaction was the only factor associated with a boosted reaction on the second TST. The high rate of boosted reaction among healthy adults in South Korea suggests that two-step TST should be performed to assess the baseline TST reactivity in settings with an intermediate burden of TB and routine BCG vaccination policy, especially among subjects with an initial TST reaction that is ≥5 mm.

Pharmacotherapy for Acute Respiratory Distress Syndrome: Limited Success to Date

Jeon, Kyeongman The Korean Academy of Tuberculosis and Respiratory 2017 Tuberculosis and Respiratory Diseases Vol.80 No.3

Clinical Features of Recently Diagnosed Pulmonary Paragonimiasis in Korea

Jeon, Kyeongman,Koh, Won-Jung,Kim, Hojoong,Kwon, O. Jung,Kim, Tae Sung,Lee, Kyung Soo,Han, Joungho Elsevier 2005 Chest Vol.128 No.3

<P>STUDY OBJECTIVE: Paragonimiasis is a typical food-borne parasitic disease that is common in Southeast Asia, the Far East, Latin American, and Africa. Recently, however, this disease has been seen in many parts of the world, largely due to increases in the numbers of immigrants and overseas travelers. The purpose of this study was to evaluate the clinical and radiologic features of recently diagnosed pulmonary paragonimiasis. PATIENTS: We retrospectively analyzed the clinical and radiologic characteristics of 36 patients (21 men and 15 women; median age 48 years; range, 19 to 75) with pulmonary paragonimiasis whose conditions were diagnosed between October 1994 and September 2004. RESULTS: Thirty-four patients (94%) presented with respiratory symptoms, including hemoptysis (n = 20, 56%) and cough (n = 17, 47%). However, chest pain (n = 5, 14%) and fever (n = 5, 14%) were less frequently reported. Chest radiography revealed intrapulmonary parenchymal lesions (n = 26, 72%), such as nodules (n = 14, 39%), linear opacity (n = 6, 17%), and airspace consolidations (n = 4, 11%), which occurred more commonly than did pleural lesions (n = 10, 28%). Most cases were initially suspected to be lung cancer or tuberculosis. In 13 patients with intrapulmonary parenchymal lesions who underwent bronchoscopy, bronchial luminal narrowing, coupled with congested or edematous mucosal changes, was seen in 7 patients (54%). Bronchial mucosal biopsy specimens exhibited chronic inflammation with eosinophilic infiltrations in three of these seven patients (43%). CONCLUSIONS: Our findings indicate that patients with pulmonary paragonimiasis presented with a variety of clinical and radiologic findings that were different from the classic presentations reported earlier, frequently mimicking those of lung cancer or tuberculosis.</P>

Antibiotic treatment of Mycobacterium abscessus lung disease: a retrospective analysis of 65 patients.

Jeon, Kyeongman,Kwon, O Jung,Lee, Nam Yong,Kim, Bum-Joon,Kook, Yoon-Hoh,Lee, Seung-Heon,Park, Young Kil,Kim, Chang Ki,Koh, Won-Jung American Lung Association 2009 American journal of respiratory and critical care Vol.180 No.9

<P>RATIONALE: The optimal therapeutic regimen and duration of treatment for Mycobacterium abscessus lung disease is not well established. OBJECTIVES: To assess the efficacy of a standardized combination antibiotic therapy for the treatment of M. abscessus lung disease. METHODS: Sixty-five patients (11 males, 55 females, median age 55 yr) with M. abscessus lung disease were treated with clarithromycin, ciprofloxacin, and doxycycline, together with an initial regimen of amikacin and cefoxitin for the first 4 weeks of hospitalization. MEASUREMENTS AND MAIN RESULTS: Treatment response rates were 83% for symptoms and 74% for high-resolution computed tomography. Sputum conversion and maintenance of negative sputum cultures for more than 12 months was achieved in 38 (58%) patients. These rates were significantly lower in patients whose isolates were resistant to clarithromycin (17%, 2/12) compared with those whose isolates were susceptible or intermediate to clarithromycin (64%, 21/33; P = 0.007). Neutropenia and thrombocytopenia associated with cefoxitin developed in 33 (51%) and 4 (6%) patients, respectively. Drug-induced hepatotoxicity occurred in 10 (15%) patients. Because of these adverse reactions, cefoxitin was discontinued in 39 (60%) patients after treatment for a median of 22 days. CONCLUSIONS: Standardized combination antibiotic therapy was moderately effective in treating M. abscessus lung disease. However, frequent adverse reactions and the potential for long-duration hospitalization are important problems that remain to be solved.</P>

Intensive Care Management in the Immunocompromised Patients with Severe Pulmonary Infection

( Kyeongman Jeon ) 대한결핵 및 호흡기학회 2021 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.129 No.0

The proportion of critically ill patients with immune deficiency has risen in recent years to about a third of patients admitted to medical intensive care unit (ICU). Severe pulmonary infection is the leading cause for ICU admission in immunocompromised patients, are often life threatening and associated with hypoxemic acute respiratory failure (ARF), resulting in mortality. Therefore, rapid and accurate diagnosis with extensive investigations and proper respiratory support for hypoxemia caused by pulmonary infection is a major cornerstone for the intensive care of immunocompromised patients with severe pulmonary infection. In this symposium, diagnostic strategy and respiratory management in immunocompromised patients with severe pulmonary infection will be discussed. Existing guidelines for managing pulmonary infections in critically ill immunocompromised patients emphasize the importance of obtaining valid samples for the diagnosis of infection. However, antimicrobial therapy is often started immediately, before adequate samples are collected. As a result, causative microorganisms are identified in only about half the patients even with bacterial pneumonia. Therefore, a detailed analysis of the clinical, laboratory, and radiologic findings would be needed, which can provide valuable diagnostic orientation in these cases. Nevertheless, the frequency of pulmonary infection is probably underestimated as signs and symptoms of infection may be subtle as a result of blunted immune response. On the other hand, non-infectious pulmonary abnormalities may be mistakenly diagnosed as clinically presumed infections. Therefore, the etiological diagnosis can be extremely challenging especially in critically ill immunocompromised patients, as the effects of pulmonary infection can be combined with those of the underlying disease and treatments, creating extraordinarily complicated clinical features. In addition, some patients have more than one concurrent infection, and others have non-infectious causes of ARF that mimic infection. Chest radiography is the preferred initial diagnostic imaging examination in the ICU for evaluation of suspected pulmonary infection in immunocompromised patients. Due to the blunted host immune response, however, radiographic findings may be subtle or occult until more widespread infection has developed. Computed tomography (CT) using thin-section provides superior resolution and can better characterize and localize radiographic abnormalities. In addition, CT scan is helpful in differentiating infectious from non-infectious cause. Furthermore, bronchoalveolar lavage and transbronchial lung biopsy are commonly used for diagnosis even in the ICU, but may cause further respiratory deterioration in patients with mechanical ventilation (MV) support. However, first-line bronchoalveolar lavage should be considered in which patients have a possible diagnosis of atypical pulmonary infections, such as CMV or Pneumocystis pneumonia. Non-invasive diagnostic tests offer an alternative to bronchoalveolar lavage, however, these tests are more sensitive than specific, and the clinical relevance of a positive PCR is sometimes uncertain. Over the past two decades, studies have consistently shown higher mortality in immunocompromised patients who required invasive MV. Therefore, priority has been given to avoidance of invasive MV by use of non-invasive devices. However, a recent multicenter RCT showed that failure of non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) was associated with higher mortality, and previous studies even suggested that early invasive MV was associated with improved survival. These data raise concerns about the use of NIV or HFNC in immunocompromised patients with hypoxemic acute respiratory failure. Therefore, response of patients to HFNC or NIV should be carefully assessed in immunocompromised patients with respiratory failure caused by severe pulmonary infection.