New-onset atrial fibrillation is a common complication in the intensive care unit. The incidence of postoperative atrial fibrillation (POAF) is high, especially after cardiac surgery. Compared with cardiac surgery, the information on POAF occurring in non-cardiac surgery is not sufficient. In non-cardiac surgery, POAF occurs mainly on the postoperative day 2, which prolongs hospital stay and increases mortality rate. Medical prophylactic agents may effectively reduce POAF. After POAF onset, rate-control or rhythm-control is used, but it is unknown whether these treatments are truly effective. In perioperative management, the incidence of POAF differs depending on the type of pulmonary resection surgery. Patients taking statins and beta-blockers before the operation should continue to take them, and patients with POAF should take magnesium sulfate when serum magnesium concentration is low. The definition of POAF differs depending on each study, and there are many uncertain points. In this paper, we discuss POAF epidemiology, risk factors, prophylaxes, and treatments mainly for pulmonary resection, esophagectomy, and lung transplantation.

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Purpose: This retrospective study was conducted to verify the effectiveness of initial chest computed tomography (CT) to predict severity in patients with inhalation injury. Methods: We measured bronchial wall thickness on the initial CT scan of patients with inhalation injury between April 2011 and December 2016 except for cardiopulmonary arrest patients. We reviewed medical records to investigate patient background factors, bronchoscopic findings, and outcomes. Data are represented as median (interquartile range). Results: Patients with inhalation injury comprised 36 patients (age: 64.5 [55.0-71.8] years, burn index: 1 [0-6.9], prognostic burn index: 71 [56.7-81.0], of whom 18 underwent chest CT scan and bronchoscopy. The results show that patients with higher bronchoscopic gradation were likely to have thicker bronchial walls proximally (Grade 1: n=5, 1.55 [1.04-2.01] mm; Grade 2: n=4, 1.89 [1.40-3.31] mm; Grade 3: n=3, 4.39 [2.45-6.58] mm; and Grade 4: n=6, 3.77 [2.97-5.49] mm; P<0.01) and distally (Grade 1: n=5, 1.45 [1.41-2.10] mm; Grade 2: n=4, 2.06 [1.59-2.33] mm; Grade 3: n=3, 3.4 [2.45-3.92] mm; and Grade 4: n=6, 3.62 [2.79-4.07] mm; P<0.01). Conclusion: The initial CT scan may help to predict the severity of inhalation injury earlier than bronchoscopy.

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Bronchiectasis is a chronic progressive disease and represents irreversible morphological changes of the bronchi as a result of inflammation, mainly caused by recurring infection. Acute exacerbation of bronchiectasis can cause potentially life-threatening respiratory complications. However, the optimal treatment remains controversial. We treated a 59-year-old woman with acute exacerbation of bronchiectasis, who complained of respiratory distress. The chest computed tomography scan showed fluid-filled swollen bronchi, suggesting a large volume of sputum. In the ICU, mechanical ventilation, drug therapy including intravenous antibiotics, and postural drainage were performed. However, they did not have sufficient clinical effect in the patient. Therefore, we administered nebulized 120 mg gentamicin every 12 hours. A reduction in purulent sputum and improved respiratory status were observed after a few days, and 34 days after commencing the administration of nebulized gentamicin, we eventually succeeded discontinuing mechanical ventilation. On the 98th day of hospitalization, the patient was discharged. Treatment with nebulized gentamicin might be effective for patients with acute exacerbation of bronchiectasis.

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In amyotrophic lateral sclerosis (ALS) with respiratory onset, no limb weakness at the time of ventilator dependency is rare. A 78-year-old man was transferred to our emergency department with sudden dyspnea and unconsciousness. He was ambulatory and was able to commute the day before. On arrival, his respiration was nearly arrested, with PaCO₂ of 138 mmHg. He was intubated and mechanically ventilated. He regained consciousness, along with improvement of hypercapnia. Ultrasonographic study revealed almost complete paralysis of the bilateral diaphragm, and his differential diagnosis included neuromuscular disease. Nevertheless, he remained ambulatory in our ICU after tracheotomy on day 7, while being dependent on a ventilator. The patient insidiously presented limb muscle atrophy and increased deep tendon reflexes. Neurogenic change in needle electromyography led to a final diagnosis of ALS on day 36. While vital capacity remained approximately 600 ml, frequent recurrence of atelectasis due to decreased airway clearance made weaning difficult and resulted in ventilator dependency. The patient remained ambulatory at the time of ICU discharge on day 118. As diagnosis of ALS is often made during an ICU stay, intensivists should include ALS in differential diagnosis of patients with respiratory muscle paralysis, even without evident limb weakness.

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