Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction.

Cryotherapy is used for endoscopic management of tracheobronchial obstruction (TBO). This study describes the use of a flexible cryoprobe for cryotherapy using nitrous oxide as a cryogen through a fiberoptic bronchoscope. The study group consisted of 22 patients, ages ranging from 28 to 82 years. Twenty patients had malignant TBO and two had bronchial obstruction (BO) following lung transplantation. Benign BO was first dilated with a balloon and followed with cryotherapy. Eighteen of the 20 malignant endobronchial lesions were completely removed. In three of these patients, the airway remained occluded due to extrinsic compression. Cryotherapy offers an alternative to Nd:YAG laser in the management of TBO. Cryotherapy offers other advantages such as being inexpensive, safe for the operator, and safe for other members of the team. Similarly for the patient, there is no danger of bronchial wall perforation or endobronchial fires, cryotherapy can be done under local anesthesia with conscious sedation, and it can be performed in an endoscopy suite.

Enteric neuronal autoantibodies in pseudoobstruction with small-cell lung carcinoma.

Severe gastrointestinal dysmotility is a newly recognized paraneoplastic syndrome that occurs with small-cell lung carcinoma. Thirty-four patients with small-cell carcinoma, of whom 5 had chronic intestinal pseudoobstruction and 29 had no digestive symptoms, were studied serologically. Four of the 5 patients with gut dysmotility had immunoglobulin G antibodies reactive with neurons of the myenteric and submucosal plexuses of jejunum and stomach in an indirect immunofluorescence assay. Antibodies of this type were not found in any of the 29 patients who had no gut dysmotility, nor were they found in patients with chronic idiopathic intestinal pseudoobstruction (n = 8), ovarian cancer (n = 20), or epilepsy (n = 4) or in normal subjects (n = 9). In 4 of the patients with paraneoplastic pseudoobstruction, antibodies in highly diluted serum (1:4000-1:8000) bound selectively to nuclei and cytoplasm of neuronal elements in the gut. This novel autoantibody activity suggests that intestinal pseudoobstruction occurring in patients with small-cell carcinoma may have an autoimmune basis. From a clinical standpoint, serological testing offers a simple means for determining which patients with gut dysmotility syndromes may have associated small-cell carcinoma, thereby enabling earlier diagnosis and treatment of the tumor.

Effects of the methyl xanthine S 9795 on isolated bronchi of the dog.

The xanthine derivative 1-methyl 3-isobutyl 8-(2-ethyl[1-(4-diphenylmethyl piperazinyl)])3, 7-dihydro (1H) purine 2, 6-dione (S 9795) is a potent inhibitor of bronchoconstriction in vivo. The aim of the present study was to analyze the effects of S 9795 in vitro and determine whether S 9795 affects the autonomic nerves, the epithelium or the smooth muscle of the bronchial wall. S 9795 had an inhibitory effect on the contractile responses evoked by acetylcholine and by electrical stimulation of the cholinergic nerves. S 9795 appeared more potent against contractions evoked by nerve stimulation. In addition, S 9795 caused the release of [3H]norepinephrine from the adrenergic nerve endings but did not affect neuronal uptake of the catecholamine. At low concentrations, S 9795 acted as a competitive serotonergic antagonist; at higher concentrations, the compound inhibited noncompetitively the contractions evoked by histamine and acetylcholine. In both second and fourth order bronchi, S 9795 (and theophylline) produced concentration-dependent relaxations that were significantly greater in rings with, compared with rings without, epithelium. The compound also facilitated the epithelium-dependent component of the relaxation response to beta-adrenergic activation. These results suggest that S 9795: 1) causes prejunctional inhibition of the release of acetylcholine, 2) evokes the displacement of stored norepinephrine, 3) exerts a differential inhibitory effect on airway contractions induced by various bronchoconstrictors and 4) augments the release or facilitates the effect of the epithelium-derived relaxing factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Invasive procedures in the diagnosis of pneumonia.

The etiology of respiratory infections can be elusive despite the recent advances in diagnostic technology. Thereby, the clinician needs a systematic approach for a definitive early diagnosis. This review presents the pros and cons of various invasive procedures in order to select the most appropriate diagnostic method. Expectorated sputum, the important initial step in community-acquired pneumonia, is unreliable in complex pneumonias, mainly because of colonization of the oropharynx. Even though blood cultures are frequently negative, they provide a precise diagnosis and should be obtained in undiagnosed pneumonias. Transtracheal needle aspiration has few false-negative results. However, its use has decreased because of the high frequency of false-positive cultures and risk of serious complications. Bronchoscopy provides direct access to both the bronchi and parenchyma for visualization and sampling. Plugged telescoping catheter brush, used safely in different clinical settings, has good sensitivity in identifying the pathogen, but the specificity varies with the underlying status of the patient. Because of upper airway contamination, bronchial washings are only slightly better than expectorated sputum. A newer technique, transbronchial needle aspiration, is, thus far, no improvement over the plugged telescoping catheter brush. In the immunosuppressed patient, bronchoalveolar lavage has excellent diagnostic accuracy for opportunistic infections. The accuracy increases with the addition of transbronchial biopsy. Transthoracic needle aspiration gives decisive information with low false-positive results. With the ultrathin needle, the complications decrease. Renewed interest in thoracoscopy-guided biopsy has demonstrated a high diagnostic accuracy with low complication rate. One procedure, a combination, or improvements of these procedures may reduce the need for open lung biopsy. Nevertheless, an open lung biopsy furnishes the best specimen for making a histological and microbiological diagnosis, although controversy exists regarding any improvement in survival rates.