Iloprost-induced rash.

anecdotally, some clinicians seem to consider LTOT to be an absolute contraindica-tion to intubation. Table 1 summarises the outcomes for intubated patients with chronic obstructive pulmonary disease (COPD) in the COPD and Asthma Outcome Study (CAOS), comparing those who were on LTOT before admission with those who were not. It can be seen that, although the two groups of patients had similar 180-day survival rates, the LTOT group had significantly lower EuroQol scores. These differences partly reflect differences in health status before the onset of the acute episode (at that stage 63% of the LTOT group were housebound, chairbound or bedbound compared with 27% of the rest) and partly the higher proportion of the LTOT group who felt that their health at 180 days was worse than it had been before onset. Nevertheless, in our data, 86% would choose ICU and intubation again. The actual number of patients on LTOT who responded to the follow-up questionnaire was small and the confidence interval wide (58–98%). It is also possible that the small numbers of patients with COPD on LTOT currently being admitted to critical care are atypically positive about invasive procedures , at least in retrospect. Nonetheless, the straightforward interpretation of these data is that, from the perspective of the patient with COPD, intubation is not futile—even for those on LTOT. If so, patient preferences must often be frustrated by limits on the availability of ICU beds. What the threshold should be for intubation in terms of probability of survival and how patients' (or carers') perspectives might be brought into decisions on intubation are currently unanswered questions. We report a 59-year-old woman with a background history of CREST syndrome (calcinosis, Raynaud phenomenon, (o)eso-phageal dysmotility, sclerodactyly and tel-angiectasia) and secondary pulmonary hypertension who presented with a bilateral lower limb vasculitic rash. A couple of weeks earlier she had been initiated on nebulised iloprost (Ventavis; Bayer New Zealand, Auckland, New Zealand) for progression of her pulmonary hypertension while on treatment with Sildenafil. She started on 20 mg three times a day, increasing every 3 days to a total of 20 mg every 4 h. Within a few days of reaching the maximum dose she developed a painful vasculitic rash over both lower limbs, which did not respond to analgesia and emollients (see fig 1). The dose of iloprost was reduced slowly over a couple of weeks to 15 mg three times a day. …