Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review.

As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.

Temporal changes in lung cancer: a 10-year study in a chest hospital.

BACKGROUND AND AIM: No prospective, wide-scale study on lung cancer (LC) exists in Turkey. We aimed to determine prospectively epidemiologic features, histologic types, stages and temporal changes in LC in the Aegean Region of Turkey. This is the first prospective and largest LC study in Turkey. METHODS: A hospital-based study was conducted on LC cases diagnosed between 1994 and 2004 at a tertiary referral hospital for thoracic medicine and surgery in Izmir, Turkey. The study was divided into two 5-year periods to determine temporal changes. RESULTS: Of 13,344 patients with pathologically confirmed LC, 93.1% was male. The mean age was 61.35 +/- 0.08 (59.5% between 41-65). The majority (82.5%) were smokers or ex-smokers. There was a 13.87% general rise in smoking rate, predominantly in females. LC incidence increased by 38% from 1994-1999 (42%) to 2000-2004 (58%); the contributive increases were 35.5% in males, and 77.5% in females. Frequent types were squamous cell carcinoma (24.7%), small cell carcinoma (SCLC) (14.2%) and adenocarcinoma (13.2%). Adenocarcinoma in the younger group (<40), females or non-smokers, and squamous cell carcinoma in the older group, males or smokers were the leading types. Non-small cell lung carcinoma (NSCLC) was mostly diagnosed at stages IIIB (36.7%) and IV (37%) whereas SCLC at limited stage (59.1%). CONCLUSION: The majority of the LC patients are over 40 years old, current or ex-smokers, or with squamous cell carcinoma. There is a general rise in smoking rate with a female predominance. The most common type is squamous cell carcinoma in males, and adenocarcinoma in females. NSCLC is diagnosed more frequently at advanced stage but SCLC at limited stage.

Combining transbronchial aspiration with endobronchial and transbronchial biopsy in sarcoidosis.

This study was carried out to evaluate the diagnostic yield and safety of flexible transbronchial needle aspiration (TBNA), endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB) combinations in stages I-III sarcoidosis (SA). Between 1989 and 1997, 74 patients suspected of having SA underwent fibreoptic bronchoscopy along with TBNA + EBB + TBLB or EBB + TBLB. During the same fibreoptic bronchoscopy, TBNA (using a 19-gauge histological needle and contrast-enhanced computed tomography (CT) guidance), EBB (from abnormal or normal bronchial mucosa) and TBLB were performed in stages I (n = 33) and II (n = 25), and EBB and TBLB in stage III (n = 16). The diagnosis of SA required the presence of noncaseating granulomas and the absence of "allergic granulomatosis and angiitis with eosinophilic infiltration" or foreign body reaction, with negative Ziehl-Neelson and methenamine silver stains, as well as negative cultures for acid-fast bacilli, fungi and other organisms. TBNA was diagnostic in 20 (61%) and 10 (42%) cases of stages I and II, whereas EBB was diagnostic in 15 (45%), 12 (50%) and seven (58%) cases, of stages I, II and III, respectively, and TBLB in 17 (52%), 15 (63%) and 10 (83%). By means of TBNA, EBB and TBLB alone, the diagnostic yields were nine (27%), four (12%) and six (18%) cases in stage I, two (8%), four (17%) and seven (29%) in stage II, and two (17%) and five (42%) by EBB and TBLB in stage III, respectively. The diagnostic yield of TBNA + EBB + TBLB was 30 (91%) in stage I and 21 (88%) in stage II, and that of EBB + TBLB was 12 (100%) in stage III. Overall, 63 (91%) cases of SA were diagnosed by TBNA + EBB + TBLB and EBB + TBLB. In six of the eleven bronchoscopically-negative cases, mediastinoscopy (four) or thoracotomy (two) established the diagnosis of SA, whereas the remaining five were diagnosed along with non-sarcoidosis diseases (one case in stage II and four in stage III) by various tissue biopsies in the follow-up. The combination of TBNA + EBB + TBLB and EBB + TBLB provided an overall sensitivity and accuracy of 90% and a specificity of 100%. All six (9%) significant complications--pneumothorax (four) and 40-100 mL haemorrhage (two)--were attributable to TBLB. It is, therefore, inferred that the combination of transbronchial needle aspiration, endobronchial biopsy and transbronchial lung biopsy in stages I and II, and that of endobronchial biopsy and transbronchial lung biopsy in stage III, is safe and cost-effective as well as increasing the diagnostic yield, and should therefore be performed routinely in the diagnosis of sarcoidosis.

A case of bronchogenic carcinoma and concomitant Swyer-James syndrome.

A 46-yr-old male patient with the rare concomitance of Swyer-James syndrome in the left lung and small cell lung carcinoma in the right is presented in the light of pertinent literature.

Prednisolone: a beneficial and safe adjunct to antituberculosis treatment? A randomized controlled trial.

SETTING: A referral centre for thoracic diseases in Izmir, Turkey, 1992-1995. OBJECTIVE: To appraise the adjunctive role of prednisolone (PN) in pulmonary tuberculosis (PTB) with toxic reactions. DESIGN: After excluding other febrile causes, and 2 weeks of four/five-drug antituberculosis therapy insufficient to resolve toxic reactions, 178 human immunodeficiency virus (HIV) negative patients with advanced PTB causing persistent high-grade fever (> or =38 degrees C), weight loss (> or =2 kg/week) and/or low serum albumin levels (<3 g/dL) were randomly allocated to receive either a 12-month course of antituberculosis treatment using four first-line drugs and PN (20 mg b.i.d. IV/IM initially, decreasing over 40 days) (91 patients-PN group), or 12 months of antituberculosis treatment only (87 patients-CO group). Twice-weekly sputum bacillary count, temperature recorded every 6 hours, weekly weight, serial albumin level and liver function measurements and chest roentgenograms were used to assess the effects of PN on PTB. RESULTS: Temperature decreased from 39.1+/-0.9 degrees C to 37.9+/-0.7 degrees C (P = 0.0030) within the first 72 (+/-9) hours in those patients on PN treatment, whereas a gradual decline occurred over 22 (+/-3) days in the CO group. In the PN group, patients' weight increased from 49.7+/-4.8 kg to 56.9+/-8.3 kg, compared to 47.1 +/- 6.4 kg to 51.31+/-5.9 kg in the CO group (P = 0.0022). Increases in serum albumin levels in the PN and CO groups were from 2.26+/-0.8 g/dL to 3.32+/-0.6 g/dL and from 2.31+/-0.5 g/dL to 2.90+/-0.7 g/dL, respectively (P = 0.0035). The radiographic regression and drop in bacillary count were more rapid, and the hospital stay shorter (53.4+/-3.1 days vs 71.3+/-5.6 days) in the PN group, although there were no differences in the acid-fast bacilli conversion rates. There were no detrimental side effects and relapses attributable to PN during the 1-3 year follow-up, even in 18 cases with drug resistance. CONCLUSION: Prednosolone is a beneficial and safe adjunct to 12-month antituberculosis treatment in advanced PTB causing toxic reactions, provided that close clinical, radiographic and bacillary monitoring is exercised.

Comparison of rigid and flexible transbronchial needle aspiration in the staging of bronchogenic carcinoma.

In staging bronchogenic carcinoma by transbronchial needle aspiration (TBNA), rigid histology needles are generally preferred to flexible cytology needles owing to the widespread opinion that rigid needles have higher diagnostic yield and less false-positive results. The objective of this study was to compare the efficacy and safety of the rigid and flexible TBNAs in staging bronchogenic carcinoma to establish whether a flexible cytology needle method can replace the rigid needle. A prospective study was conducted in 138 consecutive patients with extra- or endobronchial masses suggestive of bronchogenic carcinoma and amenable to surgical procedures. All 8 mm and larger paratracheal, carinal, hilar and/or main bronchial lymph nodes determined before bronchoscopy by computed tomography (CT) were sampled by successive 18-gauge rigid and 21-gauge flexible TBNAs in the same session. The anatomic landmarks were followed precisely during TBNAs, and a proper technique applied in sampling and specimen processing. Malignant lymph node involvement was specified in 97 (72%) cases of bronchogenic carcinoma by rigid, and in 89 (66%) by flexible TBNA. There were 4 (100%) benign cases (3 with tuberculosis and 1 with sarcoidosis) of 101 (73%) with positive rigid TBNAs (82 with histological and 19 with cytological specimens). TBNAs determined malignant lymph node involvement in a total of 104 (78%) patients. Of 30 TBNA-negative patients, 14 were proven to have false-negative TBNAs by mediastinoscopy/mediastinotomy/minithoracotomy, and 16 to have true-negative TBNAs by thoracotomy. Thoracotomy confirmed true positivity in 52 rigid and 49 flexible TBNAs, and false negativity in 4 rigid and 7 flexible TBNAs. Further staging was confirmed in these 7 cases. Four had proven false-negative results by both methods. The presence of small cell carcinoma (21) or N3 disease (27) presented a contraindication to thoracotomy in 48 TBNA-positive patients. Adequate-quality and malignant lymph node specimens were more frequently obtained by both techniques at advanced tumor and node stages. However, malignant lymph node invasion was significantly more frequent in rigid and flexible TBNA specimens only in the presence of advanced tumor status and abnormal endoscopic appearance. The sensitivities of rigid and flexible TBNAs were 74 and 70%, respectively (p > 0.05), but both had a specificity of 100%. Neither false-positive results nor serious complications other than hemorrhage of 30-100 ml (rigid: 5%, flexible: 2%) were encountered with either technique. These results indicate that in bronchogenic carcinoma, hilar and mediastinal lymph nodes can be staged by 21-gauge flexible TBNA (76%) as accurately as by 18-gauge rigid TBNA (79%) if a proper technique is applied and anatomic landmarks are followed precisely (p > 0.05).

Corynebacterium parvum pleurodesis and survival is not significantly influenced by pleural pH and glucose level.

This study was carried out in the pulmonary department of a referral training hospital for thoracic medicine and surgery, with the aim of assessing the effects of pH and glucose level of a pleural effusion (PE) on survival and the response to pleurodesis (PD) with Corynebacterium parvum. A prospective study was carried out in 204 patients with recurrent, symptomatic PEs (73 benign, 131 malignant). Fifty eight per cent of 204 PEs had low pH (< 7.20; 7.01 +/- 0.14) nd glucose levels (< 60 mg.dL-1; 36 +/- 14 mg.dL-1), whereas the remaining 42% had higher pH (> or = 7.20; 7.36 +/- 0.07 and glucose levels (> or = 60 mg.dL-1; 79 +/- 16 mg.dL-1). PD was attempted twice with 7 mg of C. parvum injected through chest tube in all patients, who were then followed up for the outcome of PD and for survival from the time of PD until death or the closure of the study (August 1996). Of 204 cases, 201 were evaluable for survival and outcome of PD. In 91% of the low-and 82% of the high-pH/glucose benign PEs, complete PD was achieved while the corresponding values for the malignant PEs were 79% and 87%, respectively (p > 0.05). Six per cent of low-and 8% of high-pH benign PEs, and 13% of low- and 9% of high-pH malignant PEs were palliated with partial PD. Failures were 3% and 10% in the low- versus high-pH benign groups, and 8% and 4% in the low- versus high-pH malignancies, respectively. All 201 cases maintained the immediate post-PD outcome throughout the follow-up. Average survival was 21.8 months in high-pH benign PEs versus 21.1 months in low-pH benign PEs, and 9.9 versus 8.7 months, in high- and low-pH malignant PEs, respectively (p > 0.05). We deduce that, regarding survival and the response to pleurodesis with Corynebacterium parvum, there is no significant difference between low- and high-pH/glucose pleural effusions in malignant, or benign cases.

CT bronchus sign-guided bronchoscopic multiple diagnostic procedures in carcinomatous solitary pulmonary nodules and masses.

CT bronchus sign (BS) designates a bronchus leading directly to a peripheral pulmonary lesion. The objective of this investigation is to determine the contribution of BS-guided bronchoscopic multiple diagnostic procedures (BMDPs) to the diagnostic yield of solitary nodules or masses (SPNMs) suspected of pulmonary carcinoma (PC). A prospective study was carried out in 92 patients with a 2-5 cm diameter SPNM at the level of third to fifth bronchial branching and without endobronchial tumors. Within 10 days after 2-mm CT scans were done, in each of 92, bronchial washing (BW), brushing (BR), transbronchial needle aspiration (TBNA) and transbronchial lung biopsy (TBB) were performed respectively, via fiberoptic bronchoscopy (FB) under fluoroscopic guidance. In 40 (82%) of 49 with BS and in 19 (44%) of 43 without BS, FB established the diagnosis (p < 0.01). In 84 cases of PC, BW, BR, TBNA and TBB provided the diagnostic yields of 4% (3), 26% (22), 57% (48) and 49% (41), respectively; the combined yield reached 68% (57). A metastasis and a tuberculoma were diagnosed exclusively by TBB, and TBNA, respectively. All differences of diagnostic yield except that between TBNA and TBB (p > 0.05) were determined to be significant (p < 0.05). Thoracotomy verified diagnosis in 48 of 59 cases diagnosed and 19 of 33 undiagnosed by FB, and various tissue biopsies or clinical follow-up in 11 diagnosed and 14 undiagnosed by FB. The above data suggest that in the diagnosis of PC as a SPNM at the level of third-fifth bronchial branching, combining the guidance of CT BS, and BMDPs under fluoroscopic guidance can increase the yield considerably.

Comparison of endobronchial needle aspiration with forceps and brush biopsies in the diagnosis of endobronchial lung cancer.

Endobronchial forceps biopsy (FB) specimens of lung carcinoma are not uncommonly interpreted as nondiagnostic owing to extensive crush artefact, necrosis, or insufficient tissue. FB cannot be performed in some endobronchial lung cancers (EBLCs) with massive bleeding tendency due to fragility and friability. Cytological studies from the brushings and washings may also be unproductive, increasing the bronchoscopist's frustration. The aim of this study was to compare the diagnostic yield and complications of endobronchial needle aspiration (EBNA) with those of FB and brush biopsy (BB) in EBLCs examined by fibreoptic bronchoscopy. A prospective sequential study was carried out on 151 in-patients with EBLC. Bronchial aspiration (BA), EBNA and BB were performed in the patients with respiratory distress and with accompanying tumours of high bleeding tendency, completely obstructing main bronchi (Group 1: 68 patients). BA, EBNA and FB were performed in those with either central or peripheral EBLCs but without respiratory distress and/or significant bleeding tendency (Group 2: 83 patients). In Group 1, the diagnostic yield of EBNA was found to be 90%, whereas that of BB was 66% (p < 0.05). In the same group, EBNA provided cell types in 95%, compared with 88% by BB (p > 0.05). EBNA was diagnostic in 92% of Group 2 patients, while FB established diagnosis in 78% of patients (p > 0.05). In determining cell type, no significant difference was found between EBNA (95%) and FB (97%) (p > 0.05). Regarding complications (only bleeding), there was no significant difference (p > 0.05) between EBNA (7%) and BB (13%), or between EBNA (4%) and FB (17%). We conclude that in endobronchial lung cancers: 1) the diagnostic yield of endobronchial needle aspiration is higher than brush biopsy; 2) endobronchial needle aspiration increases the yield of brush biopsy when forceps biopsy cannot be performed owing to significant bleeding; 3) endobronchial needle aspiration increases the diagnostic yield when a forceps biopsy specimen is inadequate because of crush artefact, necrosis, or tissue resistance; and 4) endobronchial needle aspiration is as safe as brush biopsy and forceps biopsy.