Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (κ), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (κ = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.

In the presence of an indeterminate CTA in patients with high clinical suspicion of PE, SPECT V/Q often provides a diagnosis.

Acute respiratory failure (ARF) occurs in less than 0.1% of pregnancies; however, it is one of the most common reasons for obstetric admissions to the intensive care unit (ICU) and carries a high mortality for both mother and fetus. Pulmonary physiological and anatomic adaptations during pregnancy affect the overall management, as well as predispose patients to complications during respiratory illness. Pregnancyrelated upper airway mucosal oedema may obstruct visualisation of the airway during intubation and can make invasive airway management difficult. The pregnant female requiring endotracheal intubation has a four-fold higher risk of having a difficult airway and an eight-fold higher risk of a failed intubation [1].The application of noninvasive ventilation (NIV) in the treatment of ARF continues to expand as its benefits are increasingly recognised. NIV is often avoided in pregnancy due to the theoretical risk of aspiration. However, our current knowledge regarding the safety and efficacy of NIV for the management of respiratory failure in pregnancy is based on weak evidence. Only a few case reports and small case series have been published. Given the limited data, we review the current literature and report two cases of pregnant females who developed ARF from acute respiratory distress syndrome (ARDS) and were successfully and safely managed with NIV. Case 1A 30-year-old gravida 2 para 1 with an uncomplicated twin pregnancy presented with premature rupture of membranes at 30 weeks of gestation. She had also complained of a dry cough for 1 week prior to presentation and a low grade fever. Corticosteroids, antibiotics and tocolytic therapy were administered. On day 2 of admission, she developed acute shortness of breath and complained of severe chest pressure and worsening cough. Her oxygen saturation was 87% while breathing room air. On physical examination, she appeared to be in moderate respiratory distress, was alert and awake, and had reduced breath sounds bilaterally. Rhonchi were auscultated over her right lung field and she was subsequently transferred to the medical ICU.Arterial blood gas (ABG) results on 100% oxygen via a non-rebreather mask showed an oxygen tension (PO 2 ) of 58 mmHg, pH of 7.49 and a carbon dioxide tension (PCO 2 ) of 27 mmHg. Her breathing became more laboured and the decision was made to place her on NIV with an inspiratory pressure of 12 cmH 2 O and an expiratory pressure of 5 cmH 2 O. Inspiratory oxygen fraction (FIO 2 ) was set to 100%. Fetal monitoring was initiated. Her work of breathing and oxygenation rapidly improved. Repeat ABG analysis 1 h later revealed a PO 2 of 152 mmHg on the same settings. Clindamycin was added for suspected aspiration pneumonia. Computed tomography of the chest showed diffuse, bilateral airspace disease. An echocardiogram was unremarkable. Over the next 2 days she was weaned off NIV and her clinical condition continued to improve. She tolerated the mask well and no episodes of aspiration or other complications occurred. However, her contractions...

A 34-year-old female presented with fever and abdominal pain. Past medical history includes Crohn's and Behcet's disease. Examination revealed multiple skin ulcerations, oral aphthae, and bilateral coarse rales. She developed respiratory distress with diffuse bilateral alveolar infiltrates on chest radiograph requiring intubation. PaO2/FiO2 ratio was 132. The chest computed tomography revealed extensive nodular and patchy ground-glass opacities. Bronchoalveolar lavage demonstrated a predominance of neutrophils. Methylprednisolone 60 mg every 6 h and broad-spectrum antimicrobials were initiated. No infectious etiologies were identified. Surgical lung biopsy demonstrated diffuse alveolar damage (DAD) mixed with lymphocytic and necrotizing vasculitis with multiple small infarcts and thrombi consistent with Behcet's vasculitis. As she improved, steroids were tapered and discharged home on oral cyclophosphamide. Pulmonary involvement in Behcet's is unusual and commonly manifests as pulmonary artery aneurysms, thrombosis, infarction, and hemorrhage. Lung biopsy findings demonstrating DAD are consistent with the clinical diagnosis of adult respiratory distress syndrome. The additional findings of necrotizing vasculitis and infarcts may have led to DAD.

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