Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center.

A performance improvement project was instituted at our facility to standardize pediatric inpatient asthma care by instituting an asthma clinical pathway (ACP). Formal asthma education and standardized postdischarge follow-up plans for all asthma inpatients were initiated. Patients treated by following the ACP were compared against historically similar patients from the previous 4 years.

Delayed presentation: negative pressure pulmonary hemorrhage.

Negative pressure pulmonary hemorrhage (NPPH) is a rare, life-threatening complication that develops after an acute upper airway obstruction. A 26 year old, healthy African-American man with no underlying lung disease developed negative pressure pulmonary edema and subsequently NPPH during recovery from general anesthesia for elective spine surgery. Diagnostic bronchoscopy confirmed an alveolar source of the bleeding.

Bronchoscopic view of pulmonary blastomycosis.

Blastomycosis is a chronic fungal infection often diagnosed in the south-central and midwestern United States. Lungs are primarily involved, with lymphatic or hematogenous spread to other organs. Bronchoscopy is considered when the noninvasive tests fail to establish the diagnosis.

Bronchoscopic view of a tuberculosis cavity with actinomyces.

Coexistence of pulmonary actinomycosis with tuberculosis has rarely been reported. The presence of Actinomyces in sputum and bronchoalveolar lavage is inadequate for diagnosis, as it may represent mere colonization. Traditionally, excisional biopsy is considered to be the gold standard for histologic diagnosis.

Acute splenic rupture in an adult with homozygous sickle cell anemia treated with chronic transfusions.

Splenic rupture is a very rare event in adult homozygous sickle cell patients. The authors describe a 19-year-old patient with homozygous sickle cell disease who experienced an acute splenic rupture crisis requiring emergent splenectomy. He had been receiving chronic blood transfusions regularly for 7 years secondary to a previous stroke.