Self-learning experience in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy.

BACKGROUND: Lack of a training program and experience result in underutilized transbronchial needle aspiration (TBNA). Pulmonologists who are not graduated from Europe or the United States might have little chance to learn and gain experience in this procedure. OBJECTIVE: To determine the authors' diagnostic yield from self-learning TBNA in diagnosis of intrathoracic lymphadenopathy. MATERIAL AND METHOD: After reviewing a videotape recorded TBNA procedure repetitively and receiving training in tracheobronchial lung model, the authors performed TBNA according to standard techniques using 21-guage cytology needles connected to a flexible bronchoscope in diagnosis of intrathoracic lymphadenopathy and performed data collection on all TBNA procedures at Ramathibodi Hospital, a tertiary university hospital in Bangkok, Thailand between January 1, 2006 and December 31, 2007. RESULTS: Thirty-eight consecutive patients were examined Twenty-seven nodes (71.1%) were malignancies and II nodes (28.9%) were benign diseases. During the first 6-month, the authors' diagnostic yield and frequency of adequate specimens were low. With some modification of the TBNA technique and learning experience, the frequency of inadequate specimens significant decreased from 36.4% to 0% (p = 0.03). Although the diagnostic yield increased from 45.5% to 84.6%, it did not reach statistical significance (p = 0.09). No complication, in either the patients or the bronchoscopes, was found. CONCLUSION: TBNA is a safe procedure that can be self-mastered by pulmonologists with interest, intent, and who exert themselves. TBNA performance will be improved over time with practice.

Validation of Ramathibodi's acute asthma predictive score.

BACKGROUND: The authors have recently developed Ramathibodi's acute asthma predictive score to help the attending physician decide on a safe discharge of an acute asthmatic patient from the emergency room (ER). However the authors did not validate it in the previous study. OBJECTIVE: To validate the predictive score with a new different population. MATERIAL AND METHOD: The authors conducted a study on acute asthmatic patients, in continuation from our previous study, between September 2005 and September 2007 in the ER of Ramathibodi Hospital. Vital signs, oxygen saturation, and severity factors were recorded. All patients were treated with nebulized salbutamol initially and repeatedly if the peak expiratory flow rates were < 70% predicted or if unfavorable physical signs were seen. The patients who had any of the severity factors were given systemic steroids. Patients were assessed for admission if further treatments were needed after the fourth nebulization. An unfavorable outcome was defined as either hospital admission or relapse within 48 hours of the ER discharge. Then, the authors' predictive score was calculated to give a total score for each patient. Using a cutoff score of 2, the authors calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The area under the receiver operating characteristic (ROC) curve (AUC) was also calculated and compared with that of the development cohort. RESULTS: There were 863 visits from 546 patients and 66.6% had a score of < or = 1 while 33.4% had a score of > or = 2. Using a cutoff score of 2, the acute asthma score exhibited a sensitivity of 60.0%, a specificity of 67.4%, a PPV of 5.7%, and a NPV of 98.1%. The validation group's AUC did not differ from that of the development group. CONCLUSION: Ramathibodi's acute asthma predictive score was found as a valid useful tool for a proper ER discharge of acute asthmatic patients.

A predictive score for unfavorable outcome of acute asthma in the emergency room.

BACKGROUND: It is sometimes difficult to decide on a safe discharge of an acute asthmatic patient from the emergency room (ER). OBJECTIVE: To develop a predictive score for safe discharge of an acute asthmatic patient from the ER. MATERIAL AND METHOD: All adult asthmatic patients who visited the ER at Ramathibodi Hospital from January 2004 to August 2005 were recruited Vital signs, oxygen saturation, and severity factors were recorded. Salbutamol was nebulized initially and repeatedly if the peak expiratory flow rates (PEFR) were < 70% predicted or if unfavorable physical signs were seen. Systemic steroids were administered to those patients whose severity factors had been identified Patients were admitted if further treatments were needed after the 4th nebulization. An unfavorable outcome was defined as either hospital admission or relapse within 48 hours of the ER discharge. Univariate analysis of each variable was performed, followed by multivariate analysis of those with statistical significance. Predictive scores were derived from statistically significant factors at the cutoff point of receiver-operating curve that yielded the best area under the curve. RESULTS: There were 905 visits from 568 patients. Predictive factors included inability to lie down on presentation and wheezing or low PEFR after the last dose of bronchodilator. A comparison of score sensitivity, specificity, and predictive values, across different cutoffs indicated that a score of 2 predicted an unfavorable outcome. CONCLUSION: A predictive score based on three bedside parameters might be used for a safe discharge of asthma patients from the ER.

Percutaneous dilatational tracheostomy with bronchoscopic guidance: Ramathibodi experience.

BACKGROUND: Tracheostomy is considered as the airway management of choice for patients in the ICU who require prolonged mechanical ventilation or airway protection. Percutaneous dilational tracheostomy (PDT) was first described in 1985 and now is a well-established procedure that can be performed at the bedside by a pulmonologist with less surgical equipment required. DESIGN: A retrospective analysis. MATERIAL AND METHOD: Twelve patients underwent PDT because of prolonged endotracheal intubation between March and December 2006. The procedures were done by using bedside percutaneous dilatation tracheostomy with guidewire dilator forceps (GWDF) technique with bronchoscopic guidance under general anesthesia in either the intensive care unit or the intermediate care unit of Department of Medicine, Ramathibodi Hospital. RESULTS: There were seven men and five women with a mean age of 55.0 +/- 11.8 years. Operative mortality was 0%. Procedure related complication was not found Operation time in each case was less than ten minutes. Bronchoscopic examination performed in one of the cases after one month of tracheostomy tube removed showed no scar at the tracheostomy site. CONCLUSION: PDT with bronchoscopic guidance is a safe and easy procedure that can be done by pulmonologist at the bedside setting.

Sarcoidosis presenting as papulonecrotic tuberculid-like lesions: report of a case.

A 50-year-old Thai woman presented with papulonecrotic tuberculid-like eruptions on her back and inframammary area with fever, nonproductive cough and weight loss. Chest radiograph showed diffuse bilateral reticulonodular opacities in both lungs with bilateral hilar lymph node enlargement. High resolution computed tomography (HRCT) of the lungs showed peribronchovascular interstitial thickening with multiple lymph nodes enlargement. Sputum for AFB was negative. Monotest (PPD) was negative. Skin biopsy revealed multiple naked granuloma compatible with sarcoidosis. She was treated with isoniazid, 300 mg/d, rifamipicin, 600 mg/d, ethambutal, 800, mg/d and pyrazinamide, 1000 mg/d for 2 months without improvement of skin and lung lesions. Prednisolone 45 mg/d was then administered adjunctive with isoniazid and rifampicin. After two weeks of treatment with prednisolone, the cutaneous and pulmonary lesions markedly improved Prednisolone was tapered in 6 months. Skin lesions, fever; dry cough disappeared and chest radiograph, HRCT of the chest were markedly improved.