rheumatology in the icu

Rheumatology in the ICU

Eduardo Santiago M.D05/16/2012

Airways Problems in Rheumatologic

Disorders

Synovial joints: CA and CT

Laryngeal Involvement in RA

• Cricoarytenoid joint arthritis.• Long standing RA but also in newly diagnosed

patients.• Prevalence: 40%-88%.• Acute or chronic process with slow

progression of airflow obstruction.• Fiberoptic endoscopy is most sensitive:

flexible rhino laryngoscopy.

Laryngeal Involvement in RA

• Intubation can lead to mucosal edema, compromise of airway caliber and stridor and airway obstruction post extubation.

• Risk Factors: Laxity of joint capsule and large synovial folds.

Treatment

• Severe airway obstruction: Secure airways in OR, Surgeon support, awake fiber optic intubation.

• Helium/oxygen mixture improve airflow.• Acute: systemic glucocorticoids, local

periarticular steroids can improve CA function.• Chronic: surgery: lateralizing one of the vocal

folds, arytenoidectomy vs. tracheostomy.

Atlantoaxial instability

• C1-C2 instability causing brain stem or spinal cord compression.

• Prevalence: 25%.• Independent of disease duration or patient’s

age but is most common in patients with severe peripheral joint involvement.

• Ligamentous laxity induced by inflammation.

Atlantoaxial instability

• High risk of neurologic injury for cervical manipulation in RA patients.

• Avoiding hyperextension and maintaining cervical spine in midline w/o extension.

• Awake fiberoptic intubation is recommended.

Wegener Granulomatosis

• Major upper airway life threatening complication.• Subglottic stenosis prevalence: 20%.• Acute inflammation or scar formation.• Corticosteroids, immunosuppression, intralesional

steroids.• Tracheostomy.• Intratracheal dilation injection ( intralesional long

acting corticosteroid injection and mechanical dialtion).

Relapsing Polycondritis

• Recurrent episodes of inflammation of cartilaginous and connective tissue structures.

• Type II collagenous antibodies.• Respiratory involvement associated with high

mortality.• Compromise of glottic, supra or subglottic, trachea

and first and second order bronchi.

Relapsing Polycondritis

• Encroachment of airway by inflammatory swelling.• Formation of mass of fibrous tissue.• Dissolution of tracheobronchial with subsequent

collapse during respiration.• Corticosteroids ( MTP ) and immunosuppression,

plasmapheresis.• Surgery: tracheostomy in cases of subglottic

involvement.• Endotracheal prostheses and stents.

Pulmonary Renal Syndromes in ICU

Anti GBM Disease

• Acute Pulmonary hemorrhage, oliguric acute renal failure and anti GBM antibodies.

• 1 case per 2 million white people.

Anti GBM Disease

• Type IV collagen.• Alpha chains: alpha1 to 6. • Alpha 3: lung, kidney, seminiferous duct, choroids

plexus, optic lens and inner ear.• Autoimmune response to Alpha-3 NC-domain: Anti

GBM Syndrome. • Genetic susceptibility: HL DR15, HLA DR 4

Pathogenesis

Anti GBM Disease

• Anti GBM antibodies ( anti alpha-3, Type IV antibodies).

• Double positive: Anti GBM and ANCA p or ANCA c.

• 20%-30% of Anti GBM are double positive, >75% ANCA p positive.

• 8-10% ANCA vasculitis are double positive.

Anti GBM Disease

• Hemoptysis: severity is variable.• Alveolar hemorrhage: infectious and non

infectious, cigarrete smoking.• HLM in alveolar and small airways, interstitial

infiltrates, lymphocytic infiltration in alveolar septae and peri broncovascular interstitium.

• DAD: proteinaceous infiltrates and hyaline membranes.

Anti GBM Disease

• Crescent formation and GBM destruction.• Epithelial crescents in more than 50% of the

glomeruli is a poor prognostic factor.

Therapy

• Pulse methylprednisolone, cyclophosphamide and plasmapheresis.

• MP: 30mg/kg, on alternate days for 3 doses. Follow by oral prednisone for 12 months.

• CP: 2mg/kg, daily dose, should be reduced by 0.5mg/kg every 3 months.

• Plasma exchange: 4 liter plasma exchanges daily or on alternate days.

Small Vessel Vasculitis

• Wegener's: c-ANCA or PR3 ANCA (65%) or p-ANCA or MPO ANCA (20%).

• Microscopic Polyangiitis and CCS: p-ANCA or MPO ANCA.

Treatment

• Accurate determination of disease severety.• Remission induction phase.• Maintenance phase.

Treatment

• Induction therapy: MP IV 7mg/kg on 3 consecutive days, then prednisone 1mg/kg per day for 1 month, alternate date schedule and the dose is reduced by 10mg/week on the second month.

• IV Cyclophosphamide: 0.5mg/kg at monthly intervals ( less side effects than oral)

• Oral Cyclophosphamide: 2mg/kg per day.

Treatment

• Rituximab (anti CD 20 chimeric monoclonal antibody).

• Infliximab.• Plasma exchange or plasmapheresis, twice daily for 7

days in patients with significant pulmonary hemorrhage and renal failure.

• IVIG in severe pulmonary hemorrhage.

Catastrophic Antiphospholipid Syndrome

• APLS: Thrombosis, thrombocytopenia, recurrent fetal loss and increased APL antibodies.

• CAPS: subset characterize with fulminant clinical course with widespread vascular occlusion involving at least three organs in association with ACL or LA.

• Thrombocytopenia and MAHA.

Pathology and Pathophysiology

• Non inflammatory, thrombotic microangiopathy of small vessels resulting in MOF.

• APL: immunoglobulins that bind plasma proteins or phospholipid micro particles.

• Activation of platelets, monocytes, tumor cells or endothelial cells leading to pro coagulant state.

Role of APL antibodies

• Tissue ischemia and necrosis leading to SIRS.• SIRS= altered hemostasis, increased

coagulation and microvascular fibrin deposition.


• Prior history of APS in 50% to 70%.• Precipitating factors are found in 22%. • Infections, trauma, surgical procedures, tissue

biopsies, pregnancy and post fetal demise, malignancy, withdrawal from anticoagulation.


• Diffuse injury to the capillary endothelial and epithelial cells resulting in ALI and ARDS.

• Microvascular thrombi causing endothelial damage, neutrophil influx and cytokines release.

• Alveolar hemorrhage .


• Valvular vegetations.• Coronary artery occlusion with cardiac failure

and circulatory collapse.• Thrombus formation within the cardiac

chambers.


• Renal thrombotic microangiopathy of the glomerular capillaries and small renal arteries.

Treatment

• Anticoagulation and r/o infection.• Steroids, plasmapheresis, IVIG. • Plasmaphresis: removal of B2GPI, cytokines

and mediators that promote coagulation.

SLE

• Infections is the most common form of pulmonary involvement.

• Lupus Pneumonitis.• Alveolar Hemorrhage.• Acute Reversible Hypoxemia.• Shrinking Lung Syndrome.• Drug Reaction.

Acute Lupus Pneumonitis

• Exclusion diagnosis. Clinical diagnosis.• Dyspnea, cough, fever and hemoptysis.• R/O infection.• Incidence: 0.9-12%.• Initial presentation or in patients who have

been already diagnosed with SLE.• Mortality: 50%


• Inflammation and tissue injury, no vasculitis: alveolitis, alveolar necrosis, alveolar hemorrhage, edema, interstitial pneumonitis, hyaline membranes, capillary thrombosis, deposition of complement and immunoglobulins.


• High dose corticosteroids: 1-2 mg/day.• Cyclophosphamide, Plasmapheresis.

DAH• Mortality 40%-90%.• 2% of SLE patients.• Young woman with new or establish diagnosis

of SLE.• Cough, dyspnea, fever, hemoptysis, fall in

hematocrit (70%-100%) and pulmonary infiltrates.

• Elevated ANA and low complement levels.• Active Nephritis.

DAH

• BAL: Increasingly or persistently bloody returns.

• Mononuclear and polymorphonuclear cell infiltrates, hyaline membranes, alveolar necrosis, edema, microvascular thrombosis, hemosiderin laden macrophages and capillaritis.

DAH

• High dose corticosteroids ( prednisone 1-3 mg/kg/day or MTP 1g/day for 3 days followed by prednisone 60mg/day).

• Adjunctive immunosuppressive ( Cyclophosphamide 500-1000mg/m2/day every 4 weeks) and plasmapheresis ( three to four sessions) in critically ill or non responders.

• Broad spectrum antibiotics.• In patients on MV, antibiotics were continued until

extubation.

Drug Reaction

• Cellular interstitial pneumonia: azathioprine, mycophenolate mofetil.

• Chronic eosinophilic pneumonia: NSAIDS.• Early onset pneumonitis or upper lobe

predominance fibrosis and bilateral pleural thickening: Cyclophosphamide.

• MTX induced lung injury.

Shrinking Lung Syndrome

• Dyspnea, respiratory muscle dysfunction, small lung volume, elevated hemi diaphragms, basilar atelectasis.

• Respiratory muscle weakness, including diaphragmatic dysfunction.

• Steroids.

Acute Reversible Hypoxemia

• Active SLE and acute onset of hypoxemia with normal radiologic imaging studies.

• Endothelial cell and complement-activated neutrophil aggregation within pulmonary capillaries (Pulmonary leuko-aggregation).

• Elevated A-a gradient, reduced VC and DLCO.• Elevated complement degradation products.• Steroids.

Neuropsychiatric Manifestations

• CVA• Transverse Myelitis• Seizures• Aseptic Meningitis

CVA

• RR for stroke: 8.• 5%-20%.• Association with APL antibodies, anti neuronal

antibodies, and emboli from cardiac valvular lesions.

Transverse Myelitis

• Infrequent manifestation. 1%-2%.• Early manifestation or within 5 years of diagnosis.• Vasculitis or arterial thrombosis associated with

APL antibodies.• CSF: elevated proteins, pleocytosis, low glucose

(<30mg/dl)• MRI: Cord edema.• Prednisone, Cyclophosphamide and

Plasmapheresis.

Seizures

• Common manifestation.• Grand mal seizures are most common. • Multifactorial: anti neuronal antibodies, focal

ischemia, infarcts caused by vasculitis or APL antibodies, embolic phenomenon and hemorrhage.

Aseptic Meningitis

• Headache, meningeal signs and CSF pleocytosis (<200-300 cells, lymphocytes).

• Respond to corticosteroids.• Rule out infectious process, NSAIDS or

Azathioprine induced aseptic meningitis.

Renal Failure

• Drugs: NSAIDs• Hypovolemia• Sepsis• Previous renal disease.• Lupus Nephritis: urinary sediment:

proteinuria, casts, RBC.• Low complement levels and elevation of anti

DNA antibody.

SLE/Renal Failure

• Before to start aggressive immunosuppression, considerer degree of disease reversibility.

• Disease reversibility: Renal biopsy?.

Scleroderma

• Limited cutaneous sclerosis (CREST): Raynaud phenomenon and skin thickening in face and distal extremities.

• PAH.• Diffuse systemic sclerosis: aggressive course,

constitutional symptoms, widespread skin thickening, gastrointestinal involvement, pulmonary fibrosis or renal disease.

• PAH• Acute Aspiration• Alveolar Hemorrhage• Renal Crisis

PAH

• Prevalence of PAH is 10-15%.• CREST: isolated phenomenon, absence of

pulmonary fibrosis.• Diffuse Scleroderma: advanced pulmonary

fibrosis.• PAH symptoms can predate SSc manifestations.• More prevalent in patients with limited

cutaneous sclerosis.

PAH• Autoimmune process causing damage of vascular

endothelium.• Transforming Growth Factor Beta and fibroblast

proliferation.• Infiltration of mononuclear cells, Th2 lymphocytes.• High prevalence of anti endothelial cell antibodies (AECA).• IgM AECA has been associated with increase production

of endotelin 1. • Decreased NO and Prostacyclin.• Increased Thromboxane and endotelin 1.

Right Ventricular Failure

• R/O other causes of RVF:• Infectious process• PE• Ischemic cardiomyopathy• Pericardial tamponade


• Oxygen• Diuretics• Vasodilators• Inotropes


• Inhale NO: less risk for systemic hypotension with significant decrease in PVR, mPAP, RVEDP and increases CO.

• PGE1: systemic hypotension, mainly in patients with poor vasoreactivity, low CO or high RAP.


• Dobutamine,amrinone,milrinone, dopexamine: inotropic vasodilators.

• NE rise SBP, does not significantly rise PVR and excellent inotrope.

• Pulmonary vasodilators + systemic vasoconstricting inotropes

• Atrial septostomy?

Pulmonary Renal Syndrome

• Rare complication associated with mortality.• Exclusion diagnosis: DAH + ARF.• More than 80% of patients has normal BP vs.

hypertensive crises in SSc renal crisis. • Associated with MAHA and thrombocytopenia.• Segmental necrotizing crescentic glomerulonephritis.• Plasma renin activity.• Poor response to therapy.

Hypertensive Renal Crisis

• Acute malignant hypertension.• Diffuse cutaneous disease.• High dose corticosteroids.• High renin states.• Large doses of ACEI.• ARB, CCB, prostacyclin, ERA in refractory

cases.

Pathogenesis

• Endothelial cell injury, intimal proliferation with luminal narrowing, decreased renal perfusion, increased renin production, malignant hypertension and RF.

• ET-1

Treatment

• ACEi• HD

Bibliography

Bibliography

• Alveolar Hemorrhage in SLE: Presentation and Management. Chest 2000;118;1083-1090.

• Pulmonary and Thrombotic Manifestations of SLE. Chest 2008;133;271-280.

• Pulmonary Renal Syndromes in the ICU. Crit Care Clin.2002 (18):881-895.

• CAPS. Crit Care Clin.2002(18):805-817.

rheumatology in the icu

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