RESUMEN
This review of recently published papers focuses on the recent tious disease. Despite advances in thoracic imaging, the chest roentgenogram combined with the clinical history remain the cornerstone in the diagnosis, staging, and follow-up of pulmonary infectious disease. Examination of all prior films to document preexistent anatomic pulmonary or cardiac disease and to establish the progression or regression of the pulmonary infiltrate is essential prior to proceeding with more costly imaging.
Asunto(s)
Pulmón/diagnóstico por imagen , Infecciones del Sistema Respiratorio/diagnóstico por imagen , Diagnóstico Diferencial , Humanos , Enfermedades Pulmonares Fúngicas/diagnóstico , Enfermedades Pulmonares Fúngicas/diagnóstico por imagen , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/diagnóstico por imagen , Neumonía Viral/diagnóstico , Neumonía Viral/diagnóstico por imagen , Radiografía , Sensibilidad y Especificidad , Tecnología Radiológica , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/diagnóstico por imagenRESUMEN
STUDY OBJECTIVES: We sought to determine the adaptability and effectiveness of a new esophageal balloon technique to measure changes in esophageal pressure (Pes) as a reflection of pleural pressure with progressive incremental exercise testing in normal subjects. DESIGN: An 8F (0.9 cm) esophageal balloon catheter (Smart Cath; Allied Health Products; Riverside, Calif), a CP-100 pulmonary monitor (BiCore Monitoring Systems PC-100; Irvine, Calif), and a flow transducer (Var flex; Allied Health Products; Riverside, Calif) were connected to a breathing valve (model 2700; Hans-Rudolph Inc; Kansas City, Mo). This apparatus was then used to measure Pes during a graded cardiopulmonary exercise test (CPX) to symptom limitation. SETTING: University-affiliated Veterans Affairs Hospital. PARTICIPANTS: Eight nonsmoking volunteers with normal results of pulmonary function tests. INTERVENTIONS: Plots of deltaPes against pressure time product (PTP), minute ventilation (VE), and oxygen consumption (VO2) were obtained. Pes at baseline, anaerobic threshold (AT), and maximum oxygen consumption (VO2max) were obtained by comparing the Pes measurements from the computer printout to the corresponding breath-by-breath measurements on the CPX. MEASUREMENTS AND RESULTS: The flow transducer (Varflex) connection added only 20 mL of dead space to the standard mouthpiece apparatus. The mean maximum work performance was 203+/-32 W. The mean VO2max was 29+/-9 mL/kg/min. The Pes at AT was 16+/-3 cm H2O. The Pes at maximal exercise was 42+/-16 cm H2O. CONCLUSION: The small esophageal balloon was well tolerated by all subjects. Plots of deltaPes vs PTP, VE, and VO2 demonstrated a linear correlation. This apparatus could be added to the standard CPX to assess the contribution of the diaphragm and respiratory muscles in patients with dyspnea.
Asunto(s)
Esófago/fisiología , Corazón/fisiología , Pulmón/fisiología , Esfuerzo Físico/fisiología , Adulto , Umbral Anaerobio , Cateterismo/instrumentación , Cateterismo/métodos , Diafragma/fisiología , Disnea/fisiopatología , Prueba de Esfuerzo , Tolerancia al Ejercicio , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Protectores Bucales , Consumo de Oxígeno , Pleura/fisiología , Presión , Espacio Muerto Respiratorio , Pruebas de Función Respiratoria , Músculos Respiratorios/fisiología , Reología/instrumentación , Transductores , Ventilación , TrabajoRESUMEN
The inspiratory flow volume curve is included in the spirometric tracing provided by most pulmonary function laboratories and is useful in assessing upper airway abnormalities. We analyzed the changes in peak inspiratory flow (PIF), forced inspiratory flow at 50% (FIF50), and forced inspiratory vital capacity (FIVC) that occur with bronchodilator challenge testing (3 puffs of a beta-agonist by metered-dose inhaler without a spacer device) in 145 consecutive patients. Fifty-five patients responded to bronchodilators with either a 12% or 200-mL change in FEV1 or FVC. All of these subjects produced forced expiratory maneuvers that fulfilled American Thoracic Society criteria or acceptability. The FIVC was the only inspiratory parameter that consistently showed a similar correlation to the bronchodilator responsiveness demonstrated by the FEV1 or FVC. With the reduction in air trapping, a 12% or 200-mL change in the FIVC is additional confirmatory evidence of bronchodilator responsiveness.
Asunto(s)
Bronquios/efectos de los fármacos , Broncodilatadores/farmacología , Inhalación/efectos de los fármacos , Ventilación Pulmonar/efectos de los fármacos , Agonistas Adrenérgicos beta/administración & dosificación , Agonistas Adrenérgicos beta/farmacología , Pruebas de Provocación Bronquial , Broncodilatadores/administración & dosificación , Volumen Espiratorio Forzado/efectos de los fármacos , Humanos , Inhalación/fisiología , Masculino , Persona de Mediana Edad , Nebulizadores y Vaporizadores , Estudios Prospectivos , Ventilación Pulmonar/fisiología , Espirometría , Capacidad Vital/efectos de los fármacosRESUMEN
BACKGROUND: We wanted to determine if cardiopulmonary exercise testing could better identify the threshold where physiologic function is irreparably impaired for patients with borderline pulmonary function who are being considered for lung cancer resection. METHODS: We performed an open, prospective preoperative trial and a postoperative outcome evaluation with a combined medical, surgical, and exercise physiology evaluation at three university hospitals. All eligible patients had spirometry, lung volume determination, and quantitative perfusion scanning and performed a cardiopulmonary stress test, stair climbing, and a 12-minute walk for distance. Functional status was determined with an Eastern Cooperative Oncology Group score, a dyspnea score, and a cardiopulmonary risk index. RESULTS: We identified 12 patients who met strict criteria for borderline pulmonary function during a 1-year study period. The mean forced expiratory volume in 1 second (FEV1) was 1.38 L (48% of predicted). The mean predicted postoperative FEV1 based on pneumonectomy was 700 mL. Eleven of the patients did the stair climb and 10 passed. All 12 patients achieved a maximum oxygen consumption greater than or equal to 10 mL x kg(-1) x min(-1) (mean value, 13.8 mL x kg(-1) x min(-1)). Thirteen operations were performed on the 12 patients. Nine complications occurred in 7 patients. CONCLUSIONS: Patients with borderline pulmonary function can undergo resection safely if they have an FEV1 equal to or greater than 1.6 L or 40% of its predicted value, a predicted postoperative FEV1 of 700 mL or more, a maximum oxygen consumption of 10 mL x kg(-1) x min(-1) or greater, or stair climbing of three flights or more. Cardiopulmonary stress testing and stair climbing add valuable clinical information for patients with an FEV1 of less than 1.6 L.
Asunto(s)
Selección de Paciente , Neumonectomía/mortalidad , Anciano , Prueba de Esfuerzo , Femenino , Volumen Espiratorio Forzado , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Pruebas de Función Respiratoria , Medición de Riesgo , EspirometríaAsunto(s)
Ciencia del Laboratorio Clínico/economía , Tomografía Computarizada por Rayos X/economía , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/secundario , Análisis Costo-Beneficio , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/economía , Neoplasias Pulmonares/patologíaRESUMEN
BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease are commonly seen and difficult to treat. We sought to determine the bronchodilator efficacy of magnesium sulfate in this situation, as this compound is helpful in acute asthma. METHODS: Subjects who came to either of two Veterans Affairs emergency departments were randomized in a double-blind fashion to receive either 1.2 g of magnesium sulfate or placebo over 20 minutes after they first received albuterol, 2.5 mg by nebulization. Peak expiratory flow, dyspnea scores, arterial hemoglobin oxygen saturation by pulse oximetry, maximal inspiratory and expiratory pressures, and vital signs were monitored for 45 minutes after the start of magnesium sulfate or placebo treatment. RESULTS: Seventy-two individuals were studied. The peak expiratory flow increased 16.6% +/- 27.7% (mean +/- SD) in both groups after the initial albuterol treatment, from 121.2 +/- 55.7 L/min to 136.9 +/- 63.9 L/min. The peak expiratory flow increased from 136.7 +/- 69.7 L/min at the start of the infusion to 162.3 +/- 76.6 L/min at 30 minutes and 161.3 +/- 78.7 L/min at 45 minutes with magnesium sulfate treatment. The peak expiratory flow was 137.0 +/- 58.6 L/min on initiation of the intravenous infusion, 143.0 +/- 72.7 L/min at 30 minutes, and 143.3 +/- 70.5 L/min at 45 minutes in the placebo group. The difference in peak expiratory flow from initiation of the infusion to 30 and 45 minutes later (calculated as means of the 30- and 45-minute values) was significantly different for the two groups (25.1 +/- 35.7 L/min vs 7.4 +/- 33.3 L/min; P = 0.3); the difference was also significant when expressed as percentage increase (22.4% +/- 28.5% vs 6.1% +/- 24.4%; P = .01). There was a statistically nonsignificantly trend toward a reduced need for hospitalization in the magnesium sulfate group as compared with the placebo group (28.1% vs 41.9%; P = .25). There were no significant changes in the other parameters with either treatment. CONCLUSION: Magnesium sulfate, 1.2 g over 20 minutes after beta-agonist administration, is safe and modestly efficacious in the treatment of acute exacerbations of chronic obstructive pulmonary disease, and its bronchodilator effect is greater than that of a beta-agonist given alone and lasts beyond the period of magnesium sulfate administration.
Asunto(s)
Enfermedades Pulmonares Obstructivas/tratamiento farmacológico , Sulfato de Magnesio/uso terapéutico , Anciano , Método Doble Ciego , Femenino , Humanos , Enfermedades Pulmonares Obstructivas/fisiopatología , Masculino , Persona de Mediana Edad , Oximetría , Oxígeno/sangre , Recurrencia , Pruebas de Función Respiratoria , Resultado del TratamientoRESUMEN
The inspiratory flow-volume (FV) curve can be used to identify patients with upper airway obstruction, air trapping, and restriction. Current computed pulmonary function testing equipment often mandates a forced expiratory maneuver (FEM) immediately prior to the forced inspiratory maneuver (standard method). We evaluated the inspiratory FV curve with and without an antecedent FEM in 119 subjects referred for pulmonary function testing. The subjects were divided into four groups by grading the degree of airway obstruction using confidence intervals of the FEV1/FVC percent predicted minus the actual FEV1/FVC percent measured from the best FEM according to Intermountain Thoracic Society recommendations. The forced inspiratory vital capacity (FIVC), forced inspiratory flow 50 (FIF50), and peak inspiratory flow (PIF) from the inspiratory FV curve with an antecedent FEM was compared with the FIVC, FIF50, and PIF without an antecedent FEM in each category of obstructive lung disease. The FIVC without the antecedent FEM was significantly larger than that with an antecedent FEM by 170 ml (p < 0.002) in subjects with severe airway obstruction, but was not significantly different in the other groups. The FIF50 was not significantly different in any group, but approached significance in both normal subjects and subjects with severe obstruction. The PIF was not significantly different in any group, but approached significance in the normal subjects, order for patients with severe obstructive airway disease to generate a valid forced inspiratory FV curve, it should be obtained without an antecedent FEM. When a plateau of the inspiratory FV curve is encountered, we suggest that is useful to generate the inspiratory FV curve prior to the FEM and to analyze its flow and volume characteristics independent of the FEM. The "best" inspiratory FV curve should then be displayed with the "best" FEM for proper evaluation of the FV loop.
Asunto(s)
Ventilación Pulmonar/fisiología , Adulto , Obstrucción de las Vías Aéreas/diagnóstico , Obstrucción de las Vías Aéreas/fisiopatología , Femenino , Flujo Espiratorio Forzado/fisiología , Humanos , Masculino , Persona de Mediana Edad , Pruebas de Función Respiratoria/instrumentación , Pruebas de Función Respiratoria/métodos , Pruebas de Función Respiratoria/estadística & datos numéricos , Fumar/fisiopatologíaRESUMEN
Mycobacterium tuberculosis has reemerged as a significant public health problem. Elderly persons, especially those in long-term care facilities, are among those at high risk for infection with M. tuberculosis. Frequently, their symptoms are not clearly indicative of M. tuberculosis, and the diagnosis may thus be missed. We discuss the investigation of a cluster of skin test conversions on one locked unit in our long-term care facility. During the epidemiologic investigation, four of 25 patients who had previously had negative results of purified protein derivative testing (16%) and eight of 95 employees (11%) had skin test conversions. Despite a comprehensive, costly evaluation, the index case was not found. We identified weaknesses in our employee and patient M. tuberculosis surveillance programs. Employee baseline purified protein derivative testing data were inadequate. Annual skin tests for employees with previously negative results were not mandatory. There was no mechanism in place to encourage compliance. We developed a plan to educate personnel about the reemergence of M. tuberculosis, signs and symptoms in elderly patients, and the placement and interpretation of purified protein derivative skin tests. Documentation of purified protein derivative surveillance of both patients and employees was computerized. The number of inpatient and outpatient negative-pressure rooms was increased. Appropriate personal protective equipment was made available for use in high-risk situations.
Asunto(s)
Prueba de Tuberculina , Tuberculosis/epidemiología , Anciano , Anciano de 80 o más Años , Algoritmos , Análisis por Conglomerados , Georgia/epidemiología , Humanos , Control de Infecciones/métodos , Persona de Mediana Edad , Mycobacterium tuberculosis/aislamiento & purificación , Vigilancia de la Población , Tuberculosis/diagnóstico , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/epidemiologíaRESUMEN
We encountered a clinical problem in a young man who presented with a left upper lobe mass and a diffuse reticular-nodular infiltrate. We thought we had appropriately applied Murphy's Law (the famed bank robber who "went where the money is"), and Ockham's Razor (the philosopher William of Ockham [1285 to 1349]-"Entities are not to be multiplied beyond necessity") as we rapidly diagnosed the lung mass with computed tomography, scintigraphy, and fine-needle aspiration. However, when his invaluable previous chest radiographs arrived, bronchoscopy with transbronchial biopsy, bronchoalveolar lavage, brushings, and postbronchoscopy sputum revealed the more ominous diagnosis in this patient. This case illustrates the complementary nature of current imaging and bronchoscopy techniques; but, even more importantly, it demonstrates the value of the history coupled with the previous radiograph. Even an unusual case can provide lessons in cost containment.
Asunto(s)
Adenocarcinoma/diagnóstico , Enfermedades Pulmonares/diagnóstico , Neoplasias Pulmonares/diagnóstico , Esplenosis/diagnóstico , Adenocarcinoma/complicaciones , Adulto , Biopsia con Aguja , Broncoscopía , Diagnóstico por Imagen , Humanos , Pulmón/patología , Enfermedades Pulmonares/complicaciones , Neoplasias Pulmonares/complicaciones , Masculino , Esplenosis/complicacionesRESUMEN
Referrals to pulmonary physicians for polysomnography to evaluate snoring or the possibility of sleep apnea syndrome often evolve into a multidisciplinary clinical problem. We present a young woman with two congenital abnormalities (Marfan's syndrome and retrognathism) which both may affect her decreased exercise tolerance, daytime hypersomnolence, and fatigue. Polysomnography and pulmonary exercise testing documented improvement in her upper airway diameter and exercise capacity. Her improved sleep pattern and her understanding of her exercise performance limitations afforded her a new outlook on life.
Asunto(s)
Obstrucción de las Vías Aéreas/etiología , Síndrome de Marfan/complicaciones , Retrognatismo/complicaciones , Adulto , Obstrucción de las Vías Aéreas/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , Retrognatismo/cirugía , Síndromes de la Apnea del Sueño/diagnóstico , Síndromes de la Apnea del Sueño/etiologíaRESUMEN
As the HIV epidemic continues and the patients are closely followed throughout the course of the illness from HIV seropositivity to depressed total CD4 counts, the natural history of lung cancer in this population is evolving. HIV-infected patients with lung cancer are in general younger men with significant smoking histories. Adenocarcinoma is the predominant cell type. There has been no correlation between stage of lung cancer and CD4 counts. The lung cancer stage at presentation has also not affected prognosis (no survivors beyond 1 year from diagnosis). While HIV seropositivity has not yet been identified as a risk factor for bronchogenic carcinoma, the current literature suggests that lung neoplasms behave in an aggressive manner in HIV-positive patients. We present two cases to illustrate the value of transbronchial biopsy which should be performed in all patients with masses, nodules, or focal lesions that persist despite appropriate therapy for opportunistic organisms in HIV-positive patients.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/complicaciones , Carcinoma Broncogénico/complicaciones , Neoplasias Pulmonares/complicaciones , Biopsia , Carcinoma Broncogénico/epidemiología , Carcinoma Broncogénico/patología , Seropositividad para VIH , Humanos , Pulmón/patología , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana EdadRESUMEN
We have described the case of a 65-year-old man who had a right hemothorax from rupture of an aneurysm of the ascending thoracic aorta and survived. This type of subacute presentation with survival of the patient has not been documented previously in contemporary medical literature.
Asunto(s)
Aneurisma de la Aorta Torácica/complicaciones , Rotura de la Aorta/complicaciones , Hemotórax/etiología , Trombosis/etiología , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Causas de Muerte , Hemotórax/diagnóstico por imagen , Humanos , Incidencia , Masculino , Pronóstico , Tasa de Supervivencia , Trombosis/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
Calcium channel antagonists can be quite toxic. In the management of poisoning, early recognition is critical. Calcium channel antagonists are frequently prescribed, and the potential for serious morbidity and mortality with overdosage is significant. Ingestion of these agents should be suspected in any patient who presents in an overdose situation with unexplained hypotension and conduction abnormalities. The potential for toxicity should be noted in patients with underlying hepatic or renal dysfunction who are receiving therapeutic doses. Because there is no specific antidote, decontamination of the gastrointestinal tract is crucial. Intravenous calcium should be administered to symptomatic patients because it is relatively innocuous and may be beneficial. Volume expansion should be the initial approach to hypotension unrelated to bradycardia. Patients who have had a verapamil overdose should be observed in intensive care units where Swan-Ganz catheterization and ventricular pacing are routinely available. The choice of sympathomimetic agents for treatment remains controversial. According to the published literature, isoproterenol, epinephrine, and norepinephrine may be more effective in improving bradycardia and the resultant hypotension than dopamine. However, none of these agents is universally effective. A more logical approach may be to improve cardiac output with agents like amrinone. Bay K 8644 and 4-aminopyridine show promise as potential antidotes but at present are still experimental.
Asunto(s)
Verapamilo/envenenamiento , Adulto , Sobredosis de Droga/terapia , Resultado Fatal , Humanos , Masculino , Resultado del Tratamiento , Verapamilo/farmacocinética , Verapamilo/farmacologíaRESUMEN
The positive effect of family support on the outcome from serious illness that requires intensive care has been recognized by clinicians for decades. We have all seen that family visitation and an intensive care environment more similar to that of a general ward (sunlight, radio, television) can benefit patients with psychosis related to intensive care. The severity of illness of the individual patient exerts a powerful stress on the family unit, but it has been difficult to measure this effect. We used a 40-question family needs survey with a degree of importance scale to compare the intensive care unit (ICU) with the general ward in terms of impact on the family. Five needs were found to discriminate these two environments. The family members of patients in an ICU considered it very important (1) for staff to give directions on what to do at the bedside, (2) to receive more support from their own family unit, (3) to have a place to be alone as a family unit in the hospital, (4) to be informed in advance of any transfer plan, and (5) to have flexibility in the time allowed for visitation. Family members are willing to accept decreased visitation time if the physicians and nurses can equate this decrease with the complexity of care in the ICU. The results of this survey have helped us modify and individualize our approach based on family expectations especially when patients are transferred from the general ward to the ICU or from the ICU to the ward.
Asunto(s)
Familia/psicología , Unidades de Cuidados Intensivos , Relaciones Profesional-Familia , Visitas a Pacientes/psicología , Adulto , Comportamiento del Consumidor/estadística & datos numéricos , Femenino , Georgia , Hospitales con más de 500 Camas , Hospitales de Veteranos , Humanos , Unidades de Cuidados Intensivos/normas , Masculino , Persona de Mediana Edad , Habitaciones de Pacientes/normas , Apoyo Social , Encuestas y CuestionariosRESUMEN
Rhodotorula rubra was recovered in 18 bronchoscopic specimens from 15 patients from May to November 1987. One hundred and twenty-one bronchoscopies were performed during that period by two bronchoscopists (W. W.; R.D.) at Letterman Army Medical Center in San Francisco. Isolation of R rubra occurred in 11 bronchoalveolar lavage (BAL) specimens, four bronchial washes, and three transbronchial biopsies. Clinical infection was not present in any of these patients, although five were immunocompromised hosts. After a stepwise infection control review of the laboratory, the bronchoscopy suite, bronchoscopists, and the fiberoptic bronchoscope failed to recover the organism, a systematic evaluation of the cleaning procedure was undertaken. We discovered that replacement of the suction valve and the rubber biopsy valve on the biopsy channel immediately after cleaning allowed moisture to accumulate in these areas. Removal of both the suction valve and biopsy valve during periods of nonuse resulted in adequate drying of the biopsy channel and eradication of contamination from December 1987 to May 1990 (350 bronchoscopies). Epidemiologic and infection control surveillance is critical for bronchoscopy, especially when possible pathogens are recovered by BAL in the immunocompromised patient.