A Case of Novel Influenza A (H1N1) Virus Pneumonia Complicated Pnemomediastinum and Subcutenous Emphysema / 결핵및호흡기질환

Recently, a novel influenza A (H1N1) has been recognized as the cause of a worldwide respiratory infection outbreak. Although the symptoms of a novel influenza A (H1N1) are usually mild, the disease can cause severe illness and death. A complication of novel influenza A (H1N1) is pneumomediastinum, a rarely reported condition. We report a case of influenza A (H1N1) complicating pneumomediastinum with subcutaneous emphysema, which had initially presented with blood tinged sputum and chest pain. In addition, we demonstrate bronchoalveolar lavage in influenza A (H1N1).

The Characteristics of Eosinophilc Lung Diseases Cause by Toxocara Canis Larval Infestation / 결핵및호흡기질환

BACKGROUND: Toxocariasis is a common cause of eosinophilia and eosinophilic lung disease in Korea. We analyzed the characteristics of eosinophilic lung disease in toxocariasis. METHOD: One hundred and forty one patients with eosinophilia caused by a toxocara larval infection were evaluated from September 1, 2001 through March 30, 2006. The plain chest x-ray, chest CT(computed tomography), and bronchoalveolar larvage(BAL) were examined. A diagnosis of toxocariasis was made by ELISA using that secretory-excretory antigen from the T. canis larvae. RESULTS: Toxocarial eosinophilic lung diseases was diagnosed in 32 out of 141 patients. Ground glass attenuation was the main feature on the CT scans in 23 out of 141 patients (71.9%). Thirteen patients (40.6%) had a random in zonal distribution on CT. Pleural effusion was observed in 9 patients (28.1%). Twenty eight patients (87.5%) complained of respiratory symptoms. Eleven patients (34.4%) had gastrointestinal symptoms and 12 patients (37.5%) had liver infiltration. CONCLUSIONS: The most common findings of the chest CT in patients with toxocariasis was a randomly distributed ground grass attenuation. A toxocara infection should be considered in a differential diagnosis of patients who exhibit pulmonary infiltration with eosinophilia in Korea.

Risk Factors of Extubation Failure and Analysis of Cuff Leak Test as a Predictor for Postextubation Stridor / 결핵및호흡기질환

BACKGROUND: Extubation failure was associated with poor prognosis and high hospital mortality. Cuff leak test (CLT) has been proposed as a relatively simple method for detecting laryngeal obstruction that predispose toward postextubation stridor (PES) and reintubation. We examined the risk factors of extubation failure and evaluated the usefulness and limitation of CLT for predicting PES and reintubation. METHODS: Thirty-four consecutive patients intubated more than 24 hours were examined. The subjects were evaluated daily for extubation readiness, and CLT was performed prior to extubation. Several parameters in the extubation success and failure group were compared. The accuracy and limitation of CLT were evaluated after choosing the thresholds values of the cuff leak volume (CLV) and percentage (CLP). RESULTS: Of the 34 patients studied, 6 (17.6%) developed extubation failure and 3 (8.8%) were accompanied by PES. The patients who had extubation failure were more likely to have a longer duration of intubation and more severe illness. The patients who developed PES had a smaller cuff leak than the others: according to the CLV (22.5+/-23.8 vs 233.3+/-147.1ml, p=0.020) or CLP (6.2+/-7.3 vs 44.3+/-24.7%, p=0.013). The best cut off values for the CLV and CLP were 50ml and 14.7%, respectively. The sensitivity, negative predictive value, and specificity of CLT were relatively high, but the positive predictive value was low. CONCLUSION: The likelihood of developing extubation failure increases with increasing severity of illness and duration of intubation. A low CLV or CLP (<50ml or 14.7%) is useful in identifying patients at risk of PES, but the CLT is not an absolute predictor and should not be used an indicator for delaying extubation.

Particulate Matter from Asian Dust Storms Induces the Expression of Proinflammatory Cytokine in A549 Epithelial Cells / 결핵및호흡기질환

BACKGROUND: PM10(Particulate matter with a diameter < 10micrometer), which is characterized by different environmental conditions, is a complex mixture of organic and inorganic compounds. The Asian dust event caused by meteorological phenomena can also produce unique particulate matter in affected areas. This study investigated the cytokine produced by A549 epithelial cells exposed to particles collected during both the Asian dust pfenomenon and ambient air particles in a non-dusty period. METHOD: Air samples were collected using a high volume air sampler(Sibata Model HV500F) with an air flow at 500l/min for at least 6 hours. The cytokine messenger RNA(mRNA) was measured using a reverse transcriptase polymerase chain reaction(RT-PCR). The A549 cells were exposed to 10 to 500microgram/microliter of a suspension containing PM10 for 24 hours. Each was compared with those in the non-exposed control cells. RESULT: The mRNA levels of interleukin(IL)-1alpha, IL-Ibeta , IL-8, and the granulocyte macrophage colony stimulating factor(GM-CSF) increased after veing exposed to PM10 in the ambient air particles, compared with those in the non-exposed control cells. The increase in IL-1alpha and IL-8 were dose dependent at a PM10 concentration between 100microgram/microliter and 500microgram/microliter. The mRNA level of IL-8 in the A549 epithelial cells was higher during the in the Asian dust period(500microgram/microliter) than during the non dust period. CONCLUSION: A549 cells exposed to the PM10 collected during the Asian dust period produce more proinflammatory cytokine than during non-dusty period. This cytokine enhances the local inflammatory response in the airways and can also contribute to the systemic component of this inflammatory process.

The Expression of MMPs and TIMPs in IPF and NSIP / 결핵및호흡기질환

BACKGROUND: MMPs and TIMPs are important factors for abnormal remodeling the pulmonary parenchyme in idiopathic interstitial pneumonia(IIP) This study evaluated the expression of MMPs and TIMPs in the tissue of IPF, NSIP and normal control subjects. METHOD: The MMP-2 and -9 activity in the lung tissue was studied by gelatin zymography, and the expression of MMP-1, -2 ,-9, TIMP-1 and -2 in the lung tissue was measured by immunohistochemistry. Thirty five patients, who were diagnosed with IIP (UIP ; 22, NSIP ; 13), were enrolled in the immunohistochemical study. Thirteen patients with IIP (UIP ; 9, NSIP ; 4) and five patients with lung cancer were enrolled in the zymographic assay. RESULTS: (1) The immunohistochemistry for MMP-1,-2,-9, TIMP-1 and-2 ; MMP-1,-9 and TIMP-2 were stained stronger in the UIP subjects than NSIP and the normal control. TIMP-2 was strongly stained in the UIP tissue. particularly the fibroblasts in the fibroblastic foci. (2) Zymography for MMP-2 and MMP-9 revealed MMP-2 to have prominent expression in the UIP tissue than in the NSIP tissue. CONCLUSIONS: These results suggest that the overexpression of the TIMPs and gelatinases in UIP might be? important factors in the irreversible fibrosis of the lung parenchyme.

Continuous Positive Airway Pressure during Bronchoalveolar Lavage in Patients with Severe Hypoxemia / 결핵

BACKGROUND: A bronchoalveolar lavage(BAL) is useful in diagnosing the etiology of bilateral pulmonary infiltrations, but may worsen the oxygenation and clinical status in severely hypoxemic patients. This study assessed the safety and efficacy of the continuous positive airway pressure(CPAP) using a conventional mechanical ventilator via a face mask as a tool for maintaining the oxygenation level during BAL. METHODS: Seven consecutive patients with the bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FIO2 ratio

Continuous Positive Airway Pressure during Bronchoalveolar Lavage in Patients with Severe Hypoxemia / 결핵

BACKGROUND: A bronchoalveolar lavage(BAL) is useful in diagnosing the etiology of bilateral pulmonary infiltrations, but may worsen the oxygenation and clinical status in severely hypoxemic patients. This study assessed the safety and efficacy of the continuous positive airway pressure(CPAP) using a conventional mechanical ventilator via a face mask as a tool for maintaining the oxygenation level during BAL. METHODS: Seven consecutive patients with the bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FIO2 ratio

Lymphocyte Proportion and Cytokines from the Bone Marrow of Patients with Far-Advanced Pulmonary Tuberculosis with Peripheral Lymphocytopenia / 결핵

BACKGROUND: The poor prognostic factors of far-advanced pulmonary tuberculosis(FAPTB) are lymphocytopenia in the peripheral blood(PB)( or =65years), cachexia or a low body weight, shock, hematologic diseases, or BM involvement of tuberculosis. The distributions of cells in PB and BM were analyzed and compared to the control group. The interleukin(IL)-2, IL-7, IL-10, TNF-alpha, Interferon-gamma, and TGF-beta levels in the BM were measured by ELISA. RESULTS: Thirteen patients(male : female=9:4) were included and the mean age was 42+/-12years. The proportion and count of the lymphocytes in the PB were significantly lower in the FAPTB group (7.4+/- 3.0%, 694+/-255/mm3 vs. 17.5+/-5.8%, 1,377+/-436/mm3, each p=0.0001 and 0.002). The proportion of immature lymphocyte in the BM showed a decreasing trend in the FAPTB group(9+/-4% vs. 12+/-3%, p=0.138). The IL-2(26.0+/-29.1 vs. 112.2+/-42.4pg/mL, p=0.001) and IL-10(3.4+/-4.7 vs. 12.0+/-8.0pg/mL, p=0.031) levels in the BM were significantly lower in the FAPTB group than those in control. The levels of the other cytokines in FAPTB group and control were similar. CONCLUSION: These results suggest that the cause of lymphocytopenia in PB is associated with a abnormality IL-2 and IL-10 production in the BM. More study will be needed to define the mechanism of a decreased reservoir in BM.

The Relationship of Serum Angiotensin Converting Enzyme (ACE), Angiotensin II and Clinical Markers in the Idiopathic Interstitial Pneumonia / 결핵

BACKGROUND: There have been several studies showing that angiotensin II and the angiotensin convertingenzyme (ACE) contribute to the activation of fibroblast including the pulmonary fibrosis, and apoptosis of the al veolar epithelium in idiopathic intersititial pneumonia. This study was performed to identify the relationship between the serum angiotensin II. ACE and the pulmonary function test (PFT), the dyspnea score, and the cell fraction of the bronchoalveolar lavage fluid (BALF). METHODS: Twenty three patients with idiopathic interstitial pneumonia from March, 1999 to October, 2001 at Gachon medical school were enrolled in this study. They were divided into IPF(UIP) (16) and NSIP (7) group. Twelve of the idiopathic interstitial pneumonia patients (UIP : 5, NSIP: 7) were diagnosed by an open lung biopsy, 11 of IPF patients were diagnosed by the American Thoracic Society (ATS) diagnostic criteria. The PFT values, dyspnea score, serum ACE and angiotensin II were measured, and a bronchoscopy was performed to obtain the BALF. RESULTS: Of all the patients, 7 were in the normal range and 14 showed an increase in the serum level of angiotensin II. In terms of the serum ACE level, 14 patients had an increased level. The DLCO% of the angiotensin II. increased group was significantly lower than the not-increased group (p=0.021). Other factors did not correlate with the serum ACE or the angiotensin II increased group and not-increased group. CONCLUSION: These results suggest that an increased angiotensinII serum level may be associated with in crease in the of alveolar capillary block in the progression of pulmonary fibrosis in idiopathic interstitial pneumonia.

The effectiveness of spiral computed tomography as a diagnostic tool in pulmonary embolism: Comparison of spiral CT with Ventilation-perfusion scan / 결핵

BACKGROUND: With variable symptoms and nonspecific radiographic appearances, pulmonary embolism (PE) is a frequent and often undiagnosed cause of mortality and morbidity. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study suggested that the majority of patients undergoing ventilation-perfusion (V-Q) scan would require additional studies to establish or to exclude the diagnosis of PE. Pulmonary angiography has been regarded as gold standard for diagnosis of PE. However, it is an invasive procedure that may be associated with significant notable mo rbidity and mortality. Thus, availability of an accurate, noninvasive screening examination is highly desirable. METHOD: From October 1994 to February 1997, twenty patients (male 13, female 7, range 23-91 years, median 58 years) who were suspected as pulmonary embolism on the basis of clinical evidence and underwent the spiral volumetric computed tomography (spiral CT), were studied retrospectively to evaluate the effectiveness of spiral CT as a diagnostic tool in PE. RESULTS: PE could be excluded with spiral CT in 4 patients; diagnoses of these patients were lung cancer, pneumonia with lung abscess, bilateral pleural effusion due to congestive heart failure, nonspecific pulmonary abnormality retrospectively. One patient who disclosed high probability in V/Q scan, could be diagnosed as pneumonia with lung abscess and underlying emphysema with spiral CT. Among 4 patients who showed intermediate and low probability in V/Q scan, 3 patients could be confirmed as PE with spiral CT. Spiral CT were helpful in 3 patients, in whom V/Q scan could not be performed due to other reasons (e.g. night time, mechanical ventilation) to confirm the diagnosis of PE. Spiral CT could demonstrate embolus above lobar artery level in 11 patients, and up to segmental artery level in 5 patients. CONCLUSION: This study demonstrated that spiral CT could allow accurate demonstration of thrombotic clots in centrally localized embolism. Spiral CT could be effective, specific, noninvasive and useful diagnostic screening modality for the diagnosis of pulmonary embolism.

The effectiveness of spiral computed tomography as a diagnostic tool in pulmonary embolism: Comparison of spiral CT with Ventilation-perfusion scan / 결핵

BACKGROUND: With variable symptoms and nonspecific radiographic appearances, pulmonary embolism (PE) is a frequent and often undiagnosed cause of mortality and morbidity. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study suggested that the majority of patients undergoing ventilation-perfusion (V-Q) scan would require additional studies to establish or to exclude the diagnosis of PE. Pulmonary angiography has been regarded as gold standard for diagnosis of PE. However, it is an invasive procedure that may be associated with significant notable mo rbidity and mortality. Thus, availability of an accurate, noninvasive screening examination is highly desirable. METHOD: From October 1994 to February 1997, twenty patients (male 13, female 7, range 23-91 years, median 58 years) who were suspected as pulmonary embolism on the basis of clinical evidence and underwent the spiral volumetric computed tomography (spiral CT), were studied retrospectively to evaluate the effectiveness of spiral CT as a diagnostic tool in PE. RESULTS: PE could be excluded with spiral CT in 4 patients; diagnoses of these patients were lung cancer, pneumonia with lung abscess, bilateral pleural effusion due to congestive heart failure, nonspecific pulmonary abnormality retrospectively. One patient who disclosed high probability in V/Q scan, could be diagnosed as pneumonia with lung abscess and underlying emphysema with spiral CT. Among 4 patients who showed intermediate and low probability in V/Q scan, 3 patients could be confirmed as PE with spiral CT. Spiral CT were helpful in 3 patients, in whom V/Q scan could not be performed due to other reasons (e.g. night time, mechanical ventilation) to confirm the diagnosis of PE. Spiral CT could demonstrate embolus above lobar artery level in 11 patients, and up to segmental artery level in 5 patients. CONCLUSION: This study demonstrated that spiral CT could allow accurate demonstration of thrombotic clots in centrally localized embolism. Spiral CT could be effective, specific, noninvasive and useful diagnostic screening modality for the diagnosis of pulmonary embolism.

A Case of Congenital Cystic Adenomatoid Malformation of the Lung Containing Fungal ball-like movable Blood clots in Healthy Young Woman / 결핵

We describe unusual manifestations of congenital cystic adenomatoid malformation ( C.C.A.M.) of the lung, such as movable fungal ball-like intracystic blood clots and hemoptysis, which were detected in previously healthy 23 years-old woman. We identified blood clots only after left upper lobectomy and could not distinguish from fungal ball with radiographic methods. CCAM of the lung, rare and lethal form of congenital pulmonary cystic disease, was initially introduced by Ch'in and Tang in 1949. The histogenesis of this lesion is characterized by polypoid glandular tissue proliferation and overgrowth of mesenchymal elements due to cessation of bronchiolar maturation which occured in after 16weeks intrauterine period. In 80-95% of reported cases, the lesion was confined to a single lobe and there was no lobe and right and left lung predilection. The clinical presentation may be widely variable, ranging from intrauterine fetal death to late discovery in childhood with recurrent pulmonary infection. But there's no reports which were misdiagnosed with intracystic fungal ball. The treatment choice is lobectomy of affected lobe. There's a few case reports with rhabdomyosarcoma, bronchiolar cell carcinoma and myxosarcoma arising in CCAM patients. Therefore, early resection is recommended even if asymtomatic cases. We experienced a rare case of CCAM of the lung in 23 years old female, and there were intracystic fungal ball-like movable blood clots in lower portion of left lung. After left upper lobectomy was performed, now she is discharged and followed up without any complications.

Difference in Patient's Work of Breathing Between Pressure-Controlled Ventilation with Deccelerating Flow and Volume-Controlled Ventilation with Constant Flow during Assited Ventilation / 결핵

BACKGROUND: The patient's work of breathing(WOBp) during assisted ventilation may vary according to many factors including ventilatory demand of the patients and applied ventilatory setting by the physician. Pressure-controlled ventilation(PCV) which delivers gas with decelerating flow may better meet patients' demand to improve patientventilator synchrony compared with volume-controlled ventilation(VCV) with constant flow. This study was conducted to compare the difference in WOBp in two assisted modes of ventilation, PCV and VCV with constant flow. METHODS: Ten patients with respiratory failure were included in this study. Initially, the patients were placed on VCV with constant flow at low tidal volume(VT,LOW)(6-8 ml/kg) or high tidal volume(VT,HIGH)(10-12 ml/kg). After a 15 minute stabilization period, VCV with constant flow was switched to PCV and pressure was adjusted to maintain the same tidal volume(VT) received on VCV. Other ventilator settings were kept constant. Before changing the ventilatory mode, WOBp, VT, minute ventilation(VE), respiratory rate(RR), peak airway pressure (Ppeak), peak inspiratory flow rate(PIFR) and pressure-time product(PTP) were measured. RESULTS: The mean VE and RR were not different between PCV and VCV during study period. The Ppeak was significantly lower in PCV than in VCV during VT,HIGH ventilation(p<0.05). PIFR was significantly higher in PCV than in VCV at both VT (p<0.05). During VT,LOW ventilation, WOBp and PTP in PCV(0.80?0.37 J/min, 164.5?74.4 cmH2O.S) were significantly lower than in VCV(1.06+/-0.39J /min, 256.4+/-107.5 cmH2O.S)(p<0.05). During VT,HIGH ventilation, WOBp and PTP in PCV(0.33+/-0.14 J/min, 65.7+/-26.3 cmH2O.S) were also significantly lower than in VCV(0.40+/-0.14 J/min, 83.4+/-35.1 cmH2O.S)(p<0.05). CONCLUSION: During assisted ventilation, PCV with deccelerating flow was more effective in reducing WOBp than VCV with constant flow. But since individual variability was shown, further studies are needed to confirm these results.