8/5 cmH2O, gradually increased to14/5 cmH2O. The patient improved (Ta-ble 1), and received NIPSV intermittentlyfor a total duration of 100 h (5 days).Transbronchial lung biopsy showed focalepithelioid granulomas with acid-fast ba-cilli. She was doing well at the follow-upvisit after 2 months.

The second patient was a 39-year oldmale diabetic who presented with low-grade fever and dry cough of 1-month andbreathlessness of 5 days’ duration(APACHE II score 10). Chest radiographyrevealed miliary nodules. Investigationsrevealed anaemia, thrombocytopenia andraised alkaline phosphatase. HIV serologywas non-reactive. Arterial blood gasesshowed severe hypoxaemia (Table 1). Thepatient was started on antituberculoustherapy; NIPSV was initiated through anoro-nasal mask at 8/5 cmH2O and in-creased to 18/7 cmH2O. He improved overthe next 5 days (NIV 105 h). Trans-bronchial lung biopsy showed epithelioidgranulomas and acid-fast bacilli. At2 months chest radiographic results hadnormalized, and the patient was asymp-tomatic.

The third patient was an 85-year oldman who presented with fever and coughof 15 days’ duration and dyspnoea of3 days (APACHE II score 20). Chest radi-ography showed bilateral alveolar opaci-ties. Blood and sputum cultures were ster-ile. Serology for HIV was non-reactive.Investigations showed severe hypoxaemia(Table 1), anaemia and hypoalbu-minaemia. He was managed with antibi-otics and later empirically started on anti-tuberculous therapy. Patient was also initi-ated on NIPSV through an oro-nasal maskat 8/5 cm H2O, gradually increased to12/5 cmH2O. He showed improvement inrespiratory failure (Table 1) and received

NIPSV intermittently for 10 days (175 h).Sputum for acid-fast bacilli was positive.At 2 months repeat chest radiographicfindings were normal.

Noninvasive ventilation is effective inimproving prognosis in chronic respiratoryfailure and acute on chronic failure in pul-monary tuberculosis [4]. TuberculousARDS can occur with miliary disease [1,2, 3] (cases 1, 2) or extensive pneumonia[2, 3] (case 3), and may be rapidly revers-ible with treatment [2, 3]. Hence NIPSV isan option for ventilatory support in thesepatients. A recent systematic reviewshowed that the addition of NIPSV tostandard care in the setting of acute hy-poxaemic respiratory failure reduces therate of endotracheal intubation, ICU lengthof stay, and ICU mortality [5]. The suc-cessful use of NIPSV in our patientsdemonstrates that NIPSV, if applied early,can avoid the complications and costs in-volved with invasive ventilation. In devel-oping countries limited availability of me-chanical ventilators is another constraint inmanaging patients with ARDS that can beovercome with use of NIV. However, cau-tion is advised to recognize failure of NIV,with facilities for endotracheal intubationand invasive ventilation being readilyavailable.

References

1. Zahar JR, Azoulay E, Klement E, De Lassence A, Lucet JC, Regnier B,Schlemmer B, Bedos JP (2001) Delayedtreatment contributes to mortality inICU patients with severe active pulmo-nary tuberculosis and acute respiratoryfailure. Intensive Care Med 27:513–520

Intensive Care Med (2005) 31:1723–1724DOI 10.1007/s00134-005-2823-x C O R R E S P O N D E N C E

Ritesh AgarwalDheeraj GuptaAjay HandaAshutosh N. Aggarwal

Noninvasive ventilation in ARDScaused by Mycobacterium tuberculosis: report of threecases and review of literature

Accepted: 8 September 2005Published online: 30 September 2005© Springer-Verlag 2005

Sir: Mycobacterium tuberculosis is nowrecognized as a cause of acute respiratorydistress syndrome (ARDS) [1, 2]. The useof noninvasive pressure support ventilation(NIPSV) in tuberculous ARDS has notbeen previously reported. We report threecases of tuberculous ARDS [2] successful-ly managed with NIPSV (ResMed, VPAPII) and empirical antituberculous therapy(5 mg/kg isoniazid, 10 mg/kg rifampicin,25 mg/kg pyrazinamide, and 15 mg/kg eth-ambutol daily).

The first patient was 25-year old wom-an who presented with fever and dry coughof 3 months and dyspnoea of 1 week(Acute Physiology and Chronic HealthEvaluation, APACHE, II score 11). Arterialblood gases revealed severe hypoxaemia(Table 1). Chest radiology showed bilateralmiliary mottling. Investigations revealedanaemia, hypoalbuminaemia and raised al-kaline phosphatase. HIV serology wasnon-reactive. She was started on antituber-culous therapy. NIPSV was initiatedthrough an oro-nasal mask at pressures of

Table 1 Clinical parameters and arterial blood gas parameters of the patients at baseline and after application of noninvasive ventilation(IPAP inspiratory positive airway pressure, EPAP expiratory positive airway pressure, fR respiratory rate)

pH PaO2 PaCO2 HCO3 Heart rate fR Oxygen IPAP/EPAP(mmHg) (mmHg) (mEq/l)

Case 10 h 7.35 56 31 17 110 50 50% –1 h 7.36 150 37 20 100 40 15 l/min 8/54 h 7.35 84 36 21 96 36 15 l/min 14/5

Case 20 h 7.48 59 24 18 118 40 50% –1 h 7.48 71 25 18 108 32 15 l/min 8/54 h 7.46 88 26 19 100 32 15 l/min 14/5

Case 30 h 7.48 56 36 20 102 36 50% –1 h 7.41 67 33 20 98 32 15 l/min 8/54 h 7.43 75 31 20 90 30 15 l/min 12/5

2. Lee PL, Jerng JS, Chang YL, Chen CF,Hsueh PR, Yu CJ, Yang PC, Luh KT(2003) Patient mortality of active pul-monary tuberculosis requiring mechani-cal ventilation. Eur Respir J 22:141–147

3. Agarwal R, Gupta D, Aggarwal AN, Behera D, Jindal SK (2005) Experiencewith ARDS caused by tuberculosis in arespiratory intensive care unit. IntensiveCare Med 31:1284–1287

4. Machida K (2003) Management of respiratory failure in patients with pulmonary tuberculosis. Kekkaku78:101–105

5. Keenan SP, Sinuff T, Cook DJ, Hill NS(2004) Does noninvasive positive pressure ventilation improve outcome inacute hypoxemic respiratory failure? A systematic review. Crit Care Med32:2516–2523

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R. Agarwal (✉) · D. Gupta · A. Handa ·A. N. AggarwalDepartment of Pulmonary Medicine,Postgraduate Institute of Medical Education and Research,160012 Chandigarh, Indiae-mail: riteshpgi@gmail.com