Giant bullae often mimic pneumothorax on radiographic appearance. We present the case of a 55-year-old man admitted to a referring hospital with dyspnea, cough, and increasing sputum production; he refused thoracotomy for tension pneumothorax and presented to our hospital for a second opinion. A computed tomography (CT) scan at our hospital revealed a giant bulla, which was managed conservatively as an exacerbation of chronic obstructive pulmonary disease. Thoracic surgery was consulted but advised against bullectomy. Giant bullae can easily be misdiagnosed as a pneumothorax, but the management of the two conditions is vastly different. Distinguishing between the two may require CT scan. Symptomatic giant bullae are managed surgically. We highlight the etiology, presentation, diagnosis, and treatment of bullous lung disease, especially in comparison to pneumothorax.

Mechanical ventilation support for acute respiratory distress syndrome (ARDS) patients involves the use of low tidal volumes and positive end-expiratory pressure. Nevertheless, the optimal ventilator strategy for ARDS patients undergoing extracorporeal membrane oxygenation (ECMO) therapy remains unknown. A retrospective analysis of a consecutive series of adult ARDS patients treated with V-V ECMO from October 2012 to May 2015 was performed. Mechanical ventilation data, as well as demographic and clinical data, were collected. We assessed the association between ventilator data and outcomes of interest. The primary outcome was hospital survival. Secondary outcome was 30 day survival posthospital discharge. Sixty-four ARDS patients were treated with ECMO. Univariate analysis showed that plateau pressure was independently associated with hospital survival. Tidal volume, positive end-expiratory pressure (PEEP), and plateau were independently associated with 30 day survival. Multivariate analysis, after controlling for covariates, revealed that a 1 unit increase in plateau pressure was associated with a 21% decrease in the odds of hospital survival (95% confidence interval [CI] = 6.39-33.42%, p = 0.007). In regards to 30 day survival postdischarge, a 1 unit increase in plateau pressure was associated with a 14.4% decrease in the odds of achieving the aforementioned outcome (95% CI = 1.75-25.4%, p = 0.027). Also, a 1 unit increase in PEEP was associated with a 36.2% decrease in the odds of 30 day survival (95% CI = 10.8-54.4%, p = 0.009). Among ARDS patients undergoing ECMO therapy, only plateau pressure is associated with hospital survival. Plateau pressure and PEEP are both associated with 30 day survival posthospital discharge.

The approval of oral treprostinil is a landmark event in the treatment of pulmonary arterial hypertension. Nineteen years after epoprostenol was approved we now have an oral prostanoid available in the USA. Although the current data in prostanoid naïve patients are unimpressive, emerging data suggest that in carefully selected patients oral treprostinil may be able to replace continuously infused treprostinil; however, many hurdles exist for this new medication including overcoming a complex side effect profile, astronomical cost and perhaps other entrants into the oral prostanoid space.

Crit Care Med 2014 • Volume 42 • 12 (Suppl.) for the admission. On HD6-7 she was placed on ECLS for lung protection and to facilitate fluid removal. On HD 7 she was initiated on CRRT. On HD 12, a blood culture returned positive and subsequently grew Pseudomonas aeruginosa with a minimum inhibitory concentration for meropenem of 0.25 mcg/mL. As a result of the positive blood culture, she was initiated on a regimen of vancomycin, meropenem, and amikacin. Meropenem was started with a 40 mg/kg bolus given over 30 minutes after which a continuous infusion of 10 mg/kg/hour (240 mg/ kg/day) was initiated. On HD 15 (ECLS day 9) a meropenem of 21 mcg/mL was obtained, corresponding to a clearance of 7.9 mL/kg/minute, drastically higher compared with 4 mL/kg/min reported in the package insert. Repeat cultures from HD 13-15 (ECLS day 7-9) were sterile. Conclusion A meropenem regimen of a 40 mg/kg bolus followed by a continuous infusion of 240 mg/kg/day was successful in providing a target attainment of 100% for serum concentrations above the MIC for at least 40% of the dosing interval and was associated with a sterilization of blood in this complex patient on concurrent ECLS and CRRT circuits.

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