Prospective randomized trial comparing oxygen administration during nasal flexible bronchoscopy : oral vs nasal delivery.

STUDY OBJECTIVES: To determine the optimal method of delivering supplemental oxygen during flexible bronchoscopy (FB). DESIGN: Prospective study. SETTING: University medical center. PATIENTS: Ninety-seven consecutive patients undergoing outpatient nasal FB during a 7-month period. INTERVENTION: During FB, delivery of oxygen was alternated weekly and administered by nasal cannula either nasally (52 patients) or orally (45 patients). Prior to the procedure, patients completed a questionnaire regarding oral or nasal breathing preferences, history of sinus disease, allergy history, and perceived degree of nasal congestion. RESULTS: Comparison of oxygen delivery groups demonstrated no significant difference in oxygen requirements (4.1 L/min nasal vs 3.8 L/min oral, p = 0.63), overall saturation nadir (90.9% nasal vs 91.4% oral, p = 0.85), or average saturation (95.8% nasal vs 95.7% oral, p = 0.57). No correlation between subjective symptoms or sinus or allergy history was found for oxygen requirements, average saturation, or saturation nadir. CONCLUSIONS: These data suggest that during nasal FB, no discernible difference exists between administration of oxygen using cannulas placed either nasally or orally.

Sleep histories are seldom documented on a general medical service.

BACKGROUND: Sleep disorders are common, but the frequency of sleep history documentation in hospitalized patients is unknown. METHODS: We reviewed 442 initial histories and physical examinations recorded by 122 house officers and 47 medical students in 208 consecutive general medicine ward patients. RESULTS: Any reference to sleep was recorded in only 18 patients (9%), including 12 of 141 (9%) with conditions associated with obstructive sleep apnea. Sleep histories were recorded more often in women (13% vs 4%) and less often than histories of cigarette smoking or alcohol use. Medical students recorded such histories more often than did house officers. Patients with sleep histories more often had pulse oximetry (78% vs 37%), pulmonary function testing (11% vs 1%), arterial blood gas analysis (67% vs 30%), or electrocardiograms (78% vs 49%). CONCLUSIONS: Sleep histories are documented infrequently in hospitalized patients. Patients with a recorded sleep history more often have tests that suggest increased concerns about cardiorespiratory risk and/or a different process of care.

Baseline oxygen saturation predicts exercise desaturation below prescription threshold in patients with chronic obstructive pulmonary disease.

BACKGROUND: Recent studies of exercise-induced hypoxemia in patients with chronic obstructive pulmonary disease (COPD) have shown that oxygen supplementation during exertion increases exercise tolerance and alleviates dyspnea. Although measurements of forced expiratory volume in 1 second and diffusion capacity for carbon monoxide (DLCO) are known to predict exercise-induced desaturation in patients with COPD, baseline oxygen saturation has never been studied as a predictor of exercise-induced desaturation. METHODS: A retrospective analysis was performed of 100 consecutive patients with forced expiratory volume in 1 second-forced vital capacity ratio of 70% or less who underwent exercise testing for desaturation. Any desaturation to 88% or less with exercise was considered significant. Nineteen patients with total lung capacity of 80% or less were excluded to avoid evaluating those with combined obstructive and restrictive defects; 81 patients remained available for study. RESULTS: Nineteen (51%) of 37 patients with resting saturation of 95% or less desaturated with exercise as opposed to 7 (16%) of 44 with resting saturation of 96% or greater (P =.001). The sensitivity and the negative predictive value of baseline saturation of 95% or less as a screening test for exercise desaturation were 73% and 84%, respectively. If all patients with DLCO of 36% or less were excluded, 40 patients were left for study. Eight (40%) of 20 patients with baseline saturation of 95% or less compared with 0 of 20 with resting saturation of 96% or greater desaturated with exercise (P =.006). In this subset, the sensitivity and the negative predictive value of baseline saturation of 95% or less as a screening test for exercise desaturation both improved to 100%. CONCLUSIONS: In patients with COPD, baseline saturation of 95% or less is a good screening test for exercise desaturation, especially in patients with DLCO greater than 36%. This readily available office screening procedure merits further study in larger prospective patient cohorts.

Hemoptysis in patients with renal insufficiency : the role of flexible bronchoscopy.

STUDY OBJECTIVES: To assess the indications, yield, and therapeutic impact of flexible bronchoscopy (FB) in patients with hemoptysis and renal insufficiency. DESIGN: Retrospective cohort analysis. SETTING: Tertiary-care university hospital. PATIENTS: Thirty-four patients over a 7.5-year period who underwent FB to evaluate hemoptysis in the setting of renal insufficiency (ie, serum creatinine level, > 1.5 mg/dL). MEASUREMENTS AND RESULTS: The etiology of hemoptysis was undetermined in 41% of cases. Defined causes of bleeding included infections (29%), pulmonary renal syndromes (15%), airway injury (9%), and pulmonary embolism (6%). No specific bleeding site was identified, but FB lateralized hemorrhaging to one lung in 24% of patients. FB results influenced therapy in 29% of patients overall and in 8% of patients without respiratory tract infection. The hospital survival rate was 47% and did not differ based on the presence or absence (presence vs absence) of the following variables: a defined etiology for hemoptysis (45% vs 50%); lateralized bleeding (38% vs 50%); or management alterations prompted by other FB findings (50% vs 46%). Factors associated with survival included the onset of bleeding prior to hospital admission (80% vs 33%; p = 0.02), the absence of respiratory failure requiring mechanical ventilation at the time of FB (90% vs 29%; p = 0.002), and lack of prohemorrhagic factors (other than uremia) such as disseminated intravascular coagulation, recent treatment with warfarin, heparin, or antiplatelet agents (78% vs 33%; p = 0.05). During the 6 months following hospital discharge, hemoptysis recurred in 14% of patients, and 5 patients died, for an overall mortality rate of 62%. CONCLUSIONS: These data suggest that FB in hospitalized patients with hemoptysis and renal insufficiency, and without radiographic findings suggesting neoplastic disease, has a low yield and limited impact. Whether FB influences outcome in selected patients in this setting requires prospective investigation.

Staging by positron emission tomography predicts survival in patients with non-small cell lung cancer.

BACKGROUND: Positron emission tomography (PET) scanning is used increasingly to detect and stage lung cancer, but the test performance characteristics and relationship of PET to patient outcomes remain undefined. OBJECTIVE: To determine the test performance characteristics and relationship of PET scanning stage to patient outcomes relative to the 1997 International System for the Staging of Lung Cancer. DESIGN: Survival analysis using pathologic staging as the criterion standard for comparison of survival as predicted by staging by PET and CT. SETTING: University-based hospital. PATIENTS: All consecutive patients undergoing PET scanning for the evaluation of possible non-small cell lung cancer (NSCLC) during a 5-year period. MAIN OUTCOME MEASURES: Long-term survival of patients with NSCLC after staging by PET. RESULTS: One hundred fifty-two thoracic PET scans were obtained for the staging of possible NSCLC during a 5-year period. One hundred twenty-three patients (81%) demonstrated increased (18)F-fluorodeoxyglucose uptake. The overall sensitivity and specificity of PET for detecting malignancy were 95% and 67%, respectively, compared with 100% and 27% for chest CT. PET and CT had similar accuracy for staging the overall extent of disease (91% and 89%, respectively). PET stage correlated highly with survival using either nodal location or overall stage (p = 0.003, p = 0.002), as did pathologic staging (p = 0.0001, p = 0.0001). CT scan results did not accurately predict survival (p = 0.608, p = 0.338). CONCLUSION: PET scanning is a highly sensitive technologic advance in detecting and staging of thoracic malignancy and may more accurately predict the likelihood of long-term survival in patients with NSCLC than chest CT does.

Nasal carriage of Staphylococcus aureus among patients receiving allergen-injection immunotherapy: associated factors and quantitative nasal cultures.

OBJECTIVE: To compare the prevalence of nasal Staphylococcus aureus carriage among outpatients receiving allergen-injection immunotherapy with the prevalence among healthy controls and to determine predictors of nasal S. aureus carriage. DESIGN: Survey. SETTING: Allergy clinic of a university hospital. PARTICIPANTS: A volunteer sample consisting of 45 outpatients undergoing desensitization therapy and 84 first- and second-year medical students. RESULTS: The nasal S. aureus carriage rate was significantly higher among patients (46.7%) than among students (26.2%; P=.019). In a multivariate model adjusted for age and gender, the presence of atopic dermatitis or eczema was the only independent predictor of nasal S. aureus carriage (odds ratio [OR], 4.4; 95% confidence interval [CI95], 1.2-16.0; P=.02). The only other participant characteristic associated with nasal S. aureus carriage was immunotherapy with allergen injections (OR, 1.98; CI95, 0.7-6.0), but this association did not reach statistical significance (P=.23). The probability of nasal S. aureus carriage was 88.9% for patients receiving allergen injections and having atopic dermatitis or eczema, and 36.1% for patients receiving allergen injections without atopic dermatitis or eczema. CONCLUSIONS: Patients undergoing desensitization have a higher nasal carriage rate of S. aureus. However, factors other than the regular use of needles, and in particular abnormalities related to the atopic constitution of these patients, may predispose this population for S. aureus carriage.

Anaphylaxis to deer dander in a child: a case report.

BACKGROUND: Hypersensitivity to deer dander is rarely reported, with only 26 cases in the literature. Ours is the youngest reported case and the first reported case of anaphylaxis on exposure to a live deer. OBJECTIVE: Evaluation of a case of anaphylaxis in a young boy upon exposure to a deer. METHODS AND RESULTS: A 4-year-old boy experienced hives, swelling, and shortness of breath requiring epinephrine following a deer exposure. He had one mild reaction 5 days prior to his anaphylaxis with an indirect exposure. A deer dander extract was made from fur supplied by the patient's mother. IgE-mediated reactivity was positive for deer and cattle by both selective skin prick method and RAST results. CONCLUSION: Hypersensitivity to wild animals can lead to life threatening anaphylaxis, even in children. Passive transfer of antigen may occur, but needs further investigation.

The usefulness of positron emission tomography in evaluating patients for pulmonary malignancies.

STUDY OBJECTIVE: Positron emission tomography (PET) can contribute to diagnosing and staging lung cancer, but it has not been determined whether this information influences patient care. DESIGN: We reviewed the effects of thoracic PET scan results during an 11-month period. For each patient, physicians ordering these scans reported how PET specifically altered management, and graded the ease of interpretation and overall usefulness of PET on a 5-point scale. In addition, to appraise general attitudes about PET, we surveyed 488 national American Thoracic Society (ATS) members and 44 physicians at our comprehensive cancer center. RESULTS: One hundred twenty-six questionnaires regarding patients were mailed to 37 ordering physicians, and 98 responses (78%) were returned, primarily by cardiothoracic surgeons (35%) and pulmonologists (47%). Respondents reported that PET provided new information in 83 patients (85%) and altered patient management in 64 cases (65%). Major effects on management included decisions regarding biopsy (n = 16), surgery (n = 16), and palliative treatment (n = 16). Chest clinicians found PET to be more helpful (4.4 vs 3.9, p = 0.007) and easier to interpret (4.2 vs 3.7, p = 0.025) than other specialists. Among 139 ATS members (28%) responding to the general survey, 51 members (39%) had access to PET. PET was more frequently available to university-based (49%) than community-based (27%) physicians (p = 0.016). The majority of physicians without current access to PET (69%) indicated that they would like to have it available. ATS members with access to PET reported that PET results generally affect decisions regarding biopsy or surgery most often, but found the procedure less helpful than physicians at our center (2.77 vs 3. 56, p = 0.003) and ordered it less often for lung cancer staging (60% vs 96%, p = 0.002). CONCLUSION: PET scanning is useful in the management of patients with suspected thoracic malignancies, but impressions about its roles vary, with PET regarded more highly where, as at our center, it is used more often. Whether PET alters patient outcomes requires investigation.

Massive left diaphragmatic separation and rupture due to coughing during an asthma exacerbation.

We report a case of herniation of abdominal contents into the left hemithorax in a patient hospitalized with an acute exacerbation of asthma accompanied by paroxysms of coughing. There was no history of trauma. We believe this is the first reported case of diaphragmatic rupture complicating an asthma exacerbation. We review clinical features, pathophysiology, diagnosis, and treatment of diaphragmatic rupture in its most common setting, trauma, and discuss its occasional "spontaneous" occurrence.

Herpes simplex virus 1 pneumonia: patterns on CT scans and conventional chest radiographs.

PURPOSE: The goal of our study was to describe the herpes simplex virus type 1 (HSV 1) pneumonia patterns on CT scans and chest radiographs. METHOD: We retrospectively reviewed clinical records and chest radiographs of 24 patients with HSV 1 pneumonia and 10 with pneumonia from combined HSV and mixed flora infection. We also reviewed CT scans available for eight patients with HSV pneumonia and four with mixed pneumonia. RESULTS: CT scans of eight patients with HSV pneumonia demonstrated multifocal segmental and subsegmental ground-glass opacities (n = 8), additional focal areas of consolidation (n = 6), scattered distribution (n = 6), and pleural effusions (n = 7). Chest radiographs (23 patients) showed patchy segmental and subsegmental ground-glass opacities and consolidation (n = 23), scattered distribution (n = 20), and pleural effusions (n = 12). Radiographic patterns for isolated HSV pneumonia and mixed flora pneumonia were not significantly different. CONCLUSION: With a growing population of at-risk immunosuppressed patients, it is important to recognize CT and chest radiography patterns consistent with, although nonspecific for, HSV 1 pneumonia.

Fiberoptic bronchoscopy in coronary care unit patients: indications, safety, and clinical implications.

STUDY OBJECTIVES: To evaluate the indications, safety, therapeutic impact, and outcome of fiberoptic bronchoscopy (FOB) in coronary care unit (CCU) patients. DESIGN: Retrospective review of all CCU patients undergoing FOB during a 6-year period. SETTING: Tertiary care university hospital. RESULTS: Among 8,330 patients admitted to the CCU; 40 (0.5%) patients underwent FOB to evaluate pulmonary abnormalities, most often (78%) to appraise clinically suspected pneumonia. Thirty-five (88%) patients were intubated and 21 (53%) had acute myocardial infarction (MI) before FOB. There were two major complications (bleeding, intubation) occurring within 24 h of FOB, one of which appeared due to the procedure. No episodes of chest pain or ischemic events were recorded and no significant increase in major complications was noted in MI patients (3% vs 5%). Patients having FOB within 10 days of MI had higher survival (79%) than those undergoing FOB later (29%) (p = 0.05). Seven different bacterial pathogens were isolated in 6 (15%) patients, probably reflecting prior empiric antibiotics in 32 (80%) patients. Therapy was changed in 64% of patients in whom a potential pathogen was identified. Despite alterations in treatment, patients with clinically suspected pneumonia and any organisms isolated by FOB had greater mortality (79% vs 31%, p = 0.003) than those with sterile FOB cultures. CONCLUSION: FOB may be diagnostically useful in the evaluation of pulmonary abnormalities in selected patients with acute cardiac disease, can be performed safely, and may influence management decisions. Positive bronchoscopy cultures often influence therapy but are associated with higher mortality, suggesting a lethal effect of nosocomial pneumonia in this subset of CCU patients. The risks of FOB must be weighed with the impact of FOB results on patient outcome, and its role requires further investigation.

Sand aspiration with near-drowning. Radiographic and bronchoscopic findings.

Sand and foreign-body aspiration may accompany drowning and near-drowning, but few details regarding such patients are available in the literature. We report a 26-yr-old woman who suffered near-drowning after a motor-vehicle accident. Initial attempts at ventilation were compromised by increased peak airway pressures, which decreased following the removal of large amounts of sand from the patient's endotracheal tube. Chest radiographs and computed tomographic (CT) scans of the patient obtained upon her arrival in the emergency department demonstrated sand bronchograms within the lower lobes of both lungs, and sand within the maxillary sinuses and stomach. We present the radiographic, bronchoscopic, and microbiologic findings within hours after this patient's accident, with a review of the literature and provisional recommendations for the management of such patients.

Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation.

STUDY OBJECTIVE: To determine the impact of fiberoptic bronchoscopy (FOB), including quantitative bacterial cultures obtained by BAL and protected specimen brushing on therapeutic decisions and outcome in bone marrow transplant (BMT) patients. DESIGN: Retrospective review of all BMT patients undergoing FOB during a 4-year period. SETTING: A tertiary care university hospital. RESULTS: Three hundred five patients underwent BMT; 71 (23%) had FOB to assess pulmonary infiltrates. Allogeneic BMT recipients underwent FOB 3.37 times more often than autologous recipients (p < 0.001). Pathogens were identified in 31 (46%) patients undergoing FOB; bacteria were most commonly isolated although 86% of patients had received broad-spectrum empiric antibiotics. Therapy was changed in 20 (65%) patients when a microorganism was identified and in 9 (22%) with nondiagnostic results (p = 0.0026), but isolation of a presumed pathogen had no apparent effect on survival. There were 19 (27%) FOB complications, including bleeding in 8 (11%) patients and death in 2 (3%). Major complications were associated with prolonged prothrombin time (p = 0.006) and were more common (36% vs 14%; p < 0.05) in patients who had protected specimen brushing vs BAL alone. Mortality at 40 months in BMT patients not requiring FOB was 33% compared with 61% mortality in those undergoing FOB (p < 0.001); mortality was 96% in patients with respiratory failure requiring mechanical ventilation. CONCLUSION: FOB is diagnostically useful in the evaluation of some BMT patients with pulmonary complications and often influences therapy, although no impact on survival was clearly demonstrated. FOB should be performed only after benefits of the procedure are weighed carefully against its increased risk in this select population.

Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.

BACKGROUND: Prompt recognition of the reversal of respiratory failure may permit earlier discontinuation of mechanical ventilation, without harm to the patient. METHODS: We conducted a randomized, controlled trial in 300 adult patients receiving mechanical ventilation in medical and coronary intensive care units. In the intervention group, patients underwent daily screening of respiratory function by physicians, respiratory therapists, and nurses to identify those possibly capable of breathing spontaneously; successful tests were followed by two-hour trials of spontaneous breathing in those who met the criteria. Physicians were notified when their patients successfully completed the trials of spontaneous breathing. The control subjects had daily screening but no other interventions. In both groups, all clinical decisions, including the decision to discontinue mechanical ventilation, were made by the attending physicians. RESULTS: Although the 149 patients randomly assigned to the intervention group had more severe disease, they received mechanical ventilation for a median of 4.5 days, as compared with 6 days in the 151 patients in the control group (P=0.003). The median interval between the time a patient met the screening criteria and the discontinuation of mechanical ventilation was one day in the intervention group and three days in the control group (P<0.001). Complications -- removal of the breathing tube by the patient, reintubation, tracheostomy, and mechanical ventilation for more than 21 days -- occurred in 20 percent of the intervention group and 41 percent of the control group (P=0.001). The number of days of intensive care and hospital care was similar in the two groups. Total costs for the intensive care unit were lower in the intervention group (median, $15,740, vs. $20,890 in the controls, P=0.03); hospital costs were lower, though not significantly so (median, $26,229 and $29,048, respectively; P=0.3). CONCLUSIONS: Daily screening of the respiratory function of adults receiving mechanical ventilation, followed by trials of spontaneous breathing in appropriate patients and notification of their physicians when the trials were successful, can reduce the duration of mechanical ventilation and the cost of intensive care and is associated with fewer complications than usual care.