Decision making in the critically ill patient.

In the preceding discussion we have attempted to set forth some realistic guidelines for the primary care physician in the critical care area. We feel that he is of utmost importance in setting the tone for his patient's care. He is the first physician to be called when his patient becomes critically ill. He decides whether or not consultation is needed immediately. He should choose appropriate consultants, trying to provide required expertise and compatible personalities to relate with his patient and the patient's family. His work does not end with establishing roles and delivering care. He is the single most important physician when difficult ethical and medicolegal decisions must be made. He is the physician who knows the patient and the patient's family best. They look to him for guidance and decision making about their health care. He is best able to discuss the wishes and desires of the patient if the patient becomes unable to decide for himself. The primary care physician can be extremely helpful when the appropriate medical decision is to withhold therapy. He can comfort and console the family and help them realize that the proper decisions have been made. His previous close relationship with the patient and family makes difficult decisions much easier to accept. He is also of primary importance when trying to provide care to a patient who ostensibly refuses such care. The trust he has earned in the past because of the care he was provided allows him to be much more forceful than the subspecialist who may have been on the case for 1 or 2 days. He can be the difference between survival and death merely by his presence and advice. Other difficult decisions are always made easier by a primary physician who can relate to the consultants as well as the patient and his family. In conclusion, we feel that the technologic advances of the past 30 years have tended to drive the primary care physician away from the critical care unit. This is mostly because of a need for particular expertise to run the machines of medicine. One cannot be expected to become or remain an expert in primary care and critical care medicine. The primary care physician should not feel or be excluded from the critical care area. His knowledge of general medicine and his expertise in interpersonal and family relationships allow him to provide the much needed "high touch" component of "high tech" critical care medicine.

Difficult nasotracheal intubation: a previously unreported anatomical cause.

Anatomic and congenital abnormalities of the nasal pharynx may make nasotracheal intubation difficult. We present a case of a patient who was comatose from a drug overdose and who required endotracheal intubation. Blind nasotracheal intubation was attempted and was initially unsuccessful due to the presence of a congenital pharyngeal bursa. After the cause of the obstruction was recognized, guided nasotracheal intubation was accomplished without complications. The patient made an uneventful recovery.

Computed tomographic scanning of the brain in initial staging of bronchogenic carcinoma.

Hematogenous dissemination to the brain occurs frequently with bronchogenic carcinoma ( BGCA ). Advocates of computed tomographic (CT) scanning have proposed the use of CT scanning of the brain as a screening procedure to exclude metastasis. To establish CT's appropriate role, we have retrospectively reviewed patients who had CT scanning of the brain during the initial staging and evaluation of BGCA . Clinical factors indicative of metastatic disease, both organ-specific and nonorgan -specific, were extracted from the history, physical, and laboratory data. Eighty-nine patients were studied. Sixteen patients had abnormal CT scans of the brain (18 percent). Only nine of the 16 had evidence of central nervous system (CNS) disease on history or physical examination. All 16 patients had strong clinical indications of disseminated disease. With completely normal clinical examinations, no abnormal CT scans were identified. Among patients with three or more clinical abnormalities present, an abnormal CT scan occurred in 37.5 percent (12 of 32). The clinical examination is a sensitive indicator of metastatic CNS disease as identified by the CT scan. Both organ-specific and nonorgan -specific findings are important indicators of CNS metastatis .

Endobronchial electrocautery. A role in bronchogenic carcinoma?

Progressive respiratory failure due to massive endobronchial involvement causes death in some patients with bronchogenic carcinoma. The absence of satisfactory therapeutic modalities directed specifically at masses of endobronchial tumor has limited our ability to effectively palliate these patients. Electro-cautery is a technique which has the potential for removing large quantities of endobronchial tumor safely, painlessly , and without measurable blood loss. It is especially well suited to the patient requiring local palliation with immediate relief of airway obstruction and without a prolonged hospital stay. The report reviews: a) its use in an individual with tracheal obstruction; b) the effect of electrocautery current changes and probe type on canine trachea; and, c) the technical problems which must be considered in using endobronchial electrocautery. In the individual with tracheal obstruction, large amounts of tumor were cleared with excellent hemostasis. The canine trachea demonstrates that the amount and duration of current used are extremely important. Equipment available of gastrointestinal electrocautery can produce significant tracheal damage and must be used with great caution. Finally, fiberoptic bronchoscopes are not designed for electrocautery work, and care must be employed when performing such procedures through these instruments.

Pseudopneumothorax.

An asymptomatic 18-year-old man presented for treatment of alcohol and substance abuse. He related a history of a recent motor vehicle accident with chest trauma and remote history of colonic interposition for esophageal atresia. Radiographic investigation yielded an interesting set of roentgenograms.

Indications for mediastinal lymph node evaluation.

Successful surgical therapy for bronchogenic carcinoma depends upon an accurate lymph node assessment. Criteria were developed and reported to identify patients who would benefit from mediastinoscopy prior to thoracotomy. This report summarizes the prospective use of the criteria between 1974 and 1977 and the total experience from 1970 to 1977. Selection of patients for prethoracotomy mediastinal evaluation is primarily based on chest roentgenogram and cell type. Left upper lobe lesions meeting the criteria were submitted to mediastinotomy if mediastinoscopy was negative. Eighty-seven potentially resectable lesions were evaluated prospectively, and the total experience included 202 patients. Mediastinal metastasis occurred in 39 patients of the current and 82 patients of the total series. When metastases to the mediastinum were documented, roentgenographic evidence of metastasis was seen in 20 of 39 (51 percent) of the current and 44 of 82 (54 percent) of the total series. There was roentgenographic evidence of metastasis in central lesions, peripheral masses, and small peripheral lesions with mediastinal metastases in 50 percent, 25 percent, and 78 percent of the cases, respectively. Mediastinal metastases were reported 80 percent of the time before thoracotomy using these criteria. The use of mediastinotomy on left upper lobe lesions identified six of seven of the unresectable cases missed by the mediastinoscopy. The criteria will identify patients at high risk for mediastinal metastases who benefit from prethoracotomy surgical evaluation.

Pulmonary metastasis of carcinoma of the cervix: a retrospective study.

The medical records of 243 patients admitted over a five-year period with a diagnosis of carcinoma of the cervix were reviewed to determine (1) the frequency of pulmonary metastasis, (2) the relationship between the stage of the primary lesion and the incidence of pulmonary metastasis, and (3) the relationship between the disease-free interval and the incidence of pulmonary metastasis. We found that pulmonary metastasis had developed in 22 of 243 patients. Pulmonary metastasis occurred in 4.24% of all patients with Stage I carcinoma of the cervix; in 13% of all patients with Stage II; 7.4% of all patients with Stage III; and 57% of all patients with Stage IV disease. The average disease-free interval was 39 months in Stage I disease; 37.3 months in Stage II disease; 18 months in Stage III disease; and less than one month in Stage IV disease. The most common roentgenographic pattern was that of multiple pulmonary nodules (13 of 22 patients). Twenty-five percent (five of 20) of patients with pulmonary metastasis had no evidence of other metastasis.

Immunofluorescence of transbronchial biopsies in Goodpasture's syndrome.

Transbronchial lung biopsies were performed on 6 consecutive patients with presumptive diagnoses of Goodpasture's syndrome. Diagnoses were subsequently confirmed by the typical clinical presentation, circulating antibody to glomerular basement membrane and linear deposition of IgG on renal biopsy. We demonstrated linear deposition of IgG along the alveolar capillary basement membrane in each of the transbronchial lung biopsies. Rapid, meticulous processing allowed us to obtain reproducible results. The routine use of transbronchial lung biopsy with immunofluorescent staining is recommended for all presumptive cases of Goodpasture's syndrome.

Radioisotope scanning in the initial staging of bronchogenic carcinoma.

The use of routine radioisotope scanning to screen for subclinical metastatic disease in the initial staging of bronchogenic carcinoma was studied. To define the value of scans, liver, brain, and bone scans were studied prospectively in 111 patients and retrospectively in 114 patients. Among patients with clinical findings suggesting metastatic disease, 14.4 per cent of the liver scans, 12.3 per cent of the brain scans, and 35.7 per cent of the bone scans were positive. All patients free of clinical findings had negative liver and brain scans. Positive bone scans occurred in 8 per cent of the patients without clinical abnormalities. True-positive bone scans occurred in less than 4 per cent of the patients free of clinical abnormalities. The clinical findings noted in the patients pointed to the organ involved in only 76 per cent of the abnormal liver scans, 62 per cent of the abnormal brain scans, and 75 per cent of the abnormal bone scans. Clinical findings associated with positive liver and brain scans were multiple and significant, whereas findings with the positive bone scans could be few or subtle. Routine scanning failed to identify a significant number of patients with clinically unsuspected metastatic disease. Liver, brain, and bone scanning is indicated only in patients suspected of having metastatic disease.

Pulmonary disease caused by Mycobacterium xenopi:two case reports.

Two cases of pulmonary disease caused by Mycobacterium xenopi are presented. One represents the first case report of Mycobacterium xenopi isolated from surgically resected lung tissue in the United States. The epidemiologic, bacteriologic, and clinical aspects of the disease are presented.

Comprehensive care in chronic obstructive pulmonary disease.

Once a diagnosis of COPD is suspected, history, physical examination, pulmonary function tests, chest roentgenogram, sputum analysis, and so forth, are useful to assess the severity of obstructive airways diseases. A comprehensive program of care is then outlined (Table 2). General measures include avoidance of infection and inhalants, humidification, and proper rest and diet. Appropriate medications may include bronchodilators, antibiotics, corticosteroids, cromolyn sodium, digitalis, and diuretics. Inhalation therapy as aerosols, IPPB, and supplemental oxygen may be indicated. Physical therapy with postural drainage, exercise reconditioning, and occupational therapy deserve attention. The day-to-day care of the vast majority of patients with COPD is managed by primary care physicians. This systematic approach to pulmonary rehabilitation will yield definite rewards. Patients will feel and perform better. They will note an improved exercise tolerance, leading to increased activities of daily living. They will experience reduction in the frequency and duration of hospitalization as well as a decrease in anxiety and depression with an improved quality of life.