Pulmonary hypertension, hypoxemia, and death in a patient with scleroderma.

Pulmonary hypertension in systemic sclerosis is usually secondary to pulmonary fibrosis or vascular changes. We have described a patient with systemic sclerosis who had pulmonary hypertension as a result of unsuspected thromboembolic disease.

Plasma DNA in the diagnosis of pulmonary embolism.

To assess the diagnostic value of measuring free plasma deoxyribonucleic acid (DNA) in patients suspected of having pulmonary embolism, we prospectively assayed the plasma of 40 consecutive patients who underwent pulmonary angiography for the presence of free plasma DNA. Fifteen of them had angiographic evidence of pulmonary embolism. Of these 15 only two (13%) had a positive result in the test for free double-stranded plasma DNA. We concluded that measuring free double-stranded plasma DNA is of no value in the diagnosis of pulmonary embolism.

Cough caused by exposed endobronchial sutures.

Five patients with histories of resectional lung surgery presented with recurrent or persistent cough. Lobectomy or pneumonectomy had been done for carcinoma (three patients), bronchial adenoma (one patient), and bronchiectasis (one patient). The cough in each case was first interpreted as being due to recurrence of the original disease. Bronchoscopy excluded recurrent disease and led to the discovery of exposed endobronchial sutures. Elimination of the sutures spontaneously in one patient and removal by bronchoscopy in four patients alleviated the cough. Exposed sutures apparently cause cough by producing local irritation, granuloma formation, and infection. This cause should be considered in the differential diagnosis of cough in the post-thoracotomy patient.

Endobronchial metastasis in breast cancer.

Ten patients with endobronchial metastasis from primary breast cancer were found among 1200 fibreoptic bronchoscopies. Six of these patients had radiological signs suggesting bronchial obstruction. The diagnosis was verified in nine cases by means of bronchoscopic biopsy or cytology and in one by thoracotomy. Endobronchial metastasis should be considered when symptoms or chest films suggest endobronchial disease in a patient with a history of breast cancer.

Management of arterial hypoxemia induced by fiberoptic bronchoscopy.

Twenty patients undergoing fiberoptic bronchoscopy (FOB) (bronchofiberscopy) were studied with serial arterial blood gas analyses. Ten patients were managed using a 40 percent Venturi mask with a 2-cm opening cut out for the FOB; there were ten other patients, with this opening modified by a thin rubber diaphragm with a slit for insertion of the FOB. Both masks decreased the extent of hypoxemia after bronchoscopy, but the mask with the diaphragm provided significantly higher PaO2 values. A significantly higher mean FIO2 was found at the carina in the group using the diaphragm-modified mask. This study suggests that declines in PaO2 after bronchoscopy can be avoided in most patients undergoing diagnostic FOB by using a diaphragm-modified 40 percent Venturi mask during and after the procedure. However, patients with a PaO2 below 60 mm Hg before bronchoscopy may require other measure to avoid potentially hazardous degrees of hypoxemia after bronchoscopy.