Revisión de la enfermedad del pulmón de granjero / Farmer's Lung Disease. A Review

La enfermedad del pulmón de granjero (EPG) es una forma de neumonitis por hipersensibilidad (NH) producida por la inhalación de microorganismos procedentes del heno o grano almacenado en condiciones de alta humedad en el ámbito laboral agrícola. Se trata de una enfermedad probablemente infradiagnosticada, sobre todo en el Norte de España, donde las condiciones climáticas son propicias para el desarrollo de la misma. Según estudios previos los antígenos más frecuentes suelen ser hongos y actinomicetos termofílicos. La epidemiología de la enfermedad no es del todo bien conocida, y se basa en estudios realizados por grupos centroeuropeos y asiáticos. La presentación clínica puede ser variada, diferenciándose las formas agudas (tras exposición a elevadas concentraciones del antígeno) y las crónicas (exposición a menores concentraciones del antígeno, pero más prolongada en el tiempo). En estos casos es esencial, en aquellos pacientes con clínica respiratoria durante la exposición laboral agrícola, demostrar una radiología y función pulmonar compatible, así como una sensibilización al antígeno, una linfocitosis en el lavado broncoalveolar en su caso y/o una anatomía patológica concordante. El tratamiento principal es la evitación antigénica, por lo que la educación de los pacientes en las medidas preventivas es fundamental. Por el momento, no existen estudios controlados que permitan evaluar el papel de tratamientos inmunosupresores en esta enfermedad. El tratamiento con corticosteroides solo ha demostrado acelerar la resolución de las formas agudas, pero no hay estudios que demuestren su efectividad a largo plazo, con el fin de evitar la progresión de la enfermedad ni disminuir su mortalidad

Farmer's lung disease (FLD) is a form of hypersensitivity pneumonitis (HP) caused by inhaling microorganisms from hay or grain stored in conditions of high humidity in the agricultural workplace. It is probably underdiagnosed, especially in northern Spain, where climatic conditions favor the development of this disease. According to previous studies, the most common antigens are usually thermophilic actinomycetes and fungi. The epidemiology of the disease is not well known, and is based on studies conducted by Central European and Asian groups. The clinical presentation may vary, differentiating the chronic (exposure to lower concentrations of the antigen over a longer period time) and the acute forms (after exposure to high concentrations of the antigen). In patients with respiratory symptoms and agricultural occupational exposure, radiological, lung function and/or anatomical pathology findings must be compatible with FLD, bronchoalveolar lavage must show lymphocytosis, and tests must find sensitivity to the antigen. The main treatment is avoidance of the antigen, so it is essential to educate patients on preventive measures. To date, no controlled studies have assessed the role of immunosuppressive therapy in this disease. Corticosteroid treatment has only been shown to accelerate resolution of the acute forms, but there is no evidence that it is effective in preventing disease progression in the long-term or reducing mortality

Farmer's Lung Disease. A Review. / Revisión de la enfermedad del pulmón de granjero.

Farmer's lung disease (FLD) is a form of hypersensitivity pneumonitis (HP) caused by inhaling microorganisms from hay or grain stored in conditions of high humidity in the agricultural workplace. It is probably underdiagnosed, especially in northern Spain, where climatic conditions favor the development of this disease. According to previous studies, the most common antigens are usually thermophilic actinomycetes and fungi. The epidemiology of the disease is not well known, and is based on studies conducted by Central European and Asian groups. The clinical presentation may vary, differentiating the chronic (exposure to lower concentrations of the antigen over a longer period time) and the acute forms (after exposure to high concentrations of the antigen). In patients with respiratory symptoms and agricultural occupational exposure, radiological, lung function and/or anatomical pathology findings must be compatible with FLD, bronchoalveolar lavage must show lymphocytosis, and tests must find sensitivity to the antigen. The main treatment is avoidance of the antigen, so it is essential to educate patients on preventive measures. To date, no controlled studies have assessed the role of immunosuppressive therapy in this disease. Corticosteroid treatment has only been shown to accelerate resolution of the acute forms, but there is no evidence that it is effective in preventing disease progression in the long-term or reducing mortality.

Extraction of airway foreign bodies in adults: experience from 1987-2008.

To determine the incidence and the clinical, radiographic, and endoscopic characteristics of adult patients in our area diagnosed with tracheobronchial foreign bodies (FBs), we have performed a descriptive retrospective study analysing rigid and flexible bronchoscopies practised at our department between 1987 and 2008 in patients older than 14 years. Of the 9781 bronchoscopies performed, 32 involved cases of bronchoaspiration of FBs. The mean age of the patients was 43.81 years (S.D. 21.43); 65.6% were male and 34.4% were female. Acute or recurrent infection was the most frequent clinical presentation. Chest radiographs provided data for diagnosis in 68% of the cases. The most common FB aspirated were inorganic (pins and plastic devices 21.4%, respectively). In conclusion, we can state that in our area tracheobronchial aspiration of FBs by adults is not common. The clinical symptoms are highly variable and the FBs are usually lodged in the right bronchial tree.

[Clinical utility of transbronchial needle aspiration of mediastinal lymph nodes in the diagnosis of sarcoidosis in stages I and II]. / Utilidad clínica de la punción transbronquial de adenopatías mediastínicas en el diagnóstico de la sarcoidosis en estadios I y II.

OBJECTIVE: To analyze the individual and combined diagnostic yield and clinical utility of transbronchial needle aspiration and transbronchial biopsy in the histologic diagnosis of sarcoidosis in stages I and II. PATIENTS AND METHODS: We performed a prospective study enrolling all the patients admitted to our hospital between July 2001 and June 2006 with mediastinal lymph nodes of a diameter of over 10 mm and clinical and radiological indication of sarcoidosis. The patients underwent the following tests in the order specified: a transbronchial needle aspiration of 1 or more lymph nodes using a 19-gauge histology needle until 2 satisfactory specimens were obtained, a bronchoalveolar lavage, and 4 to 6 transbronchial biopsies. RESULTS: A total of 32 patients were enrolled during the study period. Of these, 26 were finally diagnosed with sarcoidosis. The mean (SD) age of the patients was 38.9 (10.6) years and there were 13 women (50%). The mean (SD) lymph node diameter was 23.5 (6.5) mm. The most common lymph node aspiration sites were the subcarinal station (9 patients, 34.6%) and a combination of the subcarinal and paratracheal stations (7 patients, 26.9%). Computed tomography scans of the chest revealed parenchymal involvement in 12 (46.2%) patients. Fifteen (57.7%) patients were diagnosed by transbronchial biopsy and 16 (61.5%) by transbronchial needle aspiration. These techniques were used in isolation in 7 (26.9%) and 8 (30.8%) patients, respectively (P>.05). Diagnosis was achieved with the combined results of transbronchial biopsy and needle aspiration in 23 (88.4%) patients. Overall, the diagnostic yield of the combined techniques was significantly higher than that of either one in isolation (P=.01 vs transbronchial biopsy and P=.02 vs needle aspiration). In patients with parenchymal involvement, yield was better for the combined techniques only in comparison with transbronchial biopsy (P=.01). Only 4 (15%) patients developed complications and 20 (76.9%) tolerated the procedures well. CONCLUSIONS: Diagnostic yield was significantly higher when transbronchial biopsy and transbronchial needle aspiration were used in combination than when used alone, particularly in patients without parenchymal involvement. There were few complications and tolerance was good.

Utilidad clínica de la punción transbronquial de adenopatías mediastínicas en el diagnóstico de la sarcoidosis en estadios I y II / Clinical utility of transbronchial needle aspiration of mediastinal lymph nodes in the diagnosis of sarcoidosis in stages I and II

Objetivo: Analizar tanto la rentabilidad individual como La conjunta y la utilidad clínica de la punción transbronquial (PTB) y la biopsia transbronquial (BTB) en el diagnóstico histológico de sarcoidosis en estadios I y II. Pacientes y métodos: Se ha realizado un estudio prospectivo en el que se incluyó a todos los pacientes con adenopatías mediastínicas de diámetro superior a 10 mm y sospecha clinicorradiológica de sarcoidosis, ingresados entre julio de 2001 y junio de 2006. Se realizó a todos, por este orden, PTB con agujas Bard-Wang 319 de una o más adenopatías hasta obtener un mínimo de 2 muestras satisfactorias; lavado broncoalveolar, y 4-6 BTB. Resultados: Se incluyó en el estudio a 32 pacientes, de los que 26 presentaron un diagnóstico final de sarcoidosis. La edad media ± desviación estándar fue de 38,9 ± 10,6 años y 13 (50%) eran mujeres. El diámetro medio de las adenopatías fue de 23,5 ± 6,5 mm. Las estaciones ganglionares más puncionadas fueron la subcarinal, con 9 casos (34,6%), y la combinación subcarinal-paratraqueal derecha, con 7 (26,9%). Se observó afectación parenquimatosa en la tomografía computarizada de tórax en 12 (46,2%). La BTB fue diagnóstica en 15 pacientes (57,7%) y la PTB en 16 (61,5%), y fueron las únicas técnicas diagnósticas en 7 (26,9%) y 8 (30,8%) casos, respectivamente (p > 0,05). La combinación de ambas fue diagnóstica en 23 casos (88,4%), significativamente superior a la BTB (p = 0,01) y a la PTB (p = 0,02) por separado en todos los casos, y sólo a la BTB (p = 0,01) en los casos con afectación parenquimatosa. Únicamente 4 pacientes (15%) presentaron alguna complicación y en 20 (76,9%) la tolerancia fue buena. Conclusiones: La adición de la PTB a la BTB incrementa significativamente el número de diagnósticos de sarcoidosis, sobre todo en pacientes sin afectación parenquimatosa. El número de complicaciones es bajo y la tolerancia, buena

Objective: To analyze the individual and combined diagnostic yield and clinical utility of transbronchial needle aspiration and transbronchial biopsy in the histologic diagnosis of sarcoidosis in stages I and II. Patients and methods: We performed a prospective study enrolling all the patients admitted to our hospital between July 2001 and June 2006 with mediastinal lymph nodes of a diameter of over 10 mm and clinical and radiological indication of sarcoidosis. The patients underwent the following tests in the order specified: a transbronchial needle aspiration of 1 or more lymph nodes using a 19-gauge histology needle until 2 satisfactory specimens were obtained, a bronchoalveolar lavage, and 4 to 6 transbronchial biopsies. Results: A total of 32 patients were enrolled during the study period. Of these, 26 were finally diagnosed with sarcoidosis. The mean (SD) age of the patients was 38.9 (10.6) years and there were 13 women (50%). The mean (SD) lymph node diameter was 23.5 (6.5) mm. The most common lymph node aspiration sites were the subcarinal station (9 patients, 34.6%) and a combination of the subcarinal and paratracheal stations (7 patients, 26.9%). Computed tomography scans of the chest revealed parenchymal involvement in 12 (46.2%) patients. Fifteen (57.7%) patients were diagnosed by transbronchial biopsy and 16 (61.5%) by transbronchial needle aspiration. These techniques were used in isolation in 7 (26.9%) and 8 (30.8%) patients, respectively (P>.05). Diagnosis was achieved with the combined results of transbronchial biopsy and needle aspiration in 23 (88.4%) patients. Overall, the diagnostic yield of the combined techniques was significantly higher than that of either one in isolation (P=.01 vs transbronchial biopsy and P=.02 vs needle aspiration). In patients with parenchymal involvement, yield was better for the combined techniques only in comparison with transbronchial biopsy (P=.01). Only 4 (15%) patients developed complications and 20 (76.9%) tolerated the procedures well. Conclusions: Diagnostic yield was significantly higher when transbronchial biopsy and transbronchial needle aspiration were used in combination than when used alone, particularly in patients without parenchymal involvement. There were few complications and tolerance was good

[Effect of different bronchial washing sequences on diagnostic yield in endoscopically visible lung cancer]. / Influencia en la rentabilidad diagnóstica del momento de realización del aspirado bronquial en los carcinomas broncogénicos endoscópicamente visibles.

OBJECTIVE: Aspiration of bronchial wash fluid is commonly used in conjunction with brushing and forceps biopsy to diagnose endoscopically visible lung cancer. However, the optimal sequence of these procedures is subject to debate. The objective of this study was to determine if the order in which bronchial washing is performed relative to bronchial brushing and forceps biopsy has any effect on the diagnostic yield. PATIENTS AND METHODS: A prospective, cross-sectional study was carried out on patients with endoscopically visible lung cancer who underwent video-assisted fiberoptic bronchoscopy for diagnostic purposes. Aspiration of bronchial wash fluid was performed on all patients both before and after bronchial brushing and forceps biopsy. The results were analyzed separately for each type of endobronchial lesion and for both together. RESULTS: The study included 75 patients, with a mean age of 63.3 years; 81% were men. Bronchoscopy was diagnostic in 71 (94.7%) cases. Findings from bronchial washing fluid were positive in 40 (53.3%) patients when washing was performed prior to brushing and forceps biopsy; when washing was performed after these procedures, findings were positive in 43 (57.3%) patients (P=.6). The combined diagnostic yield of washing before and after brushing and forceps biopsy was 69.3%, a significantly better result than either washing before (P=.001) or after (P=.004) the other sampling techniques. In cases where findings from washing done after brushing and forceps biopsy were negative (14 of 32, 43.7%), blood in the aspirated sample interfered with cytology. In comparison, when washing was performed prior to brushing and biopsy, that problem arose in only 3 of the 35 cases (8.5%) (P=.002). CONCLUSIONS: The order in which bronchial washing is performed in relation to other sampling techniques for diagnosing bronchial tumors does not influence the diagnostic yield. This is probably because the aspirated fluid sample is more likely to contain excessive blood when washing is performed after brushing and forceps biopsy. However, the diagnostic yield can be significantly increased by combining the findings from bronchial washings performed both before and after other sample collection procedures.

Influencia en la rentabilidad diagnóstica del momento de realización del aspirado bronquial en los carcinomas broncogénicos endoscópicamente visibles / Effect of different bronchial washing sequences on diagnostic yield in endoscopically visible lung cancer

Objetivo: Además del cepillado y de la biopsia bronquiales, el aspirado bronquial (AB) es una técnica utilizada habitualmente en el diagnóstico del cáncer de pulmón endoscópicamente visible. Existe controversia sobre el momento adecuado para su realización. El objetivo del presente estudio ha sido evaluar si el momento de la realización del AB puede influir en el rendimiento diagnóstico. Pacientes y métodos: Se ha llevado a cabo un estudio transversal prospectivo, en el que se incluyó a pacientes con carcinomas broncogénicos endoscópicamente visibles a los que se hizo una videofibrobroncoscopia con fines diagnósticos. A todos se les realizaba AB previo y tras el cepillado y la biopsia bronquiales. El resultado se analizó de forma global y para cada tipo de lesión endobronquial. Resultados: Se incluyó a 75 pacientes con una edad media de 63,3 años siendo el 81% varones. La broncoscopia fue diagnóstica en 71 (94,7%). El AB previo fue positivo en 40 pacientes (53,3%) y el posterior en 43 (57,3%) (p = 0,6). La rentabilidad conjunta de ambos fue del 69,3%, significativamente superior a la del AB previo (p = 0,001) y la del AB posterior (p = 0,004) por separado. En el 43,7% de los casos en que el AB posterior fue negativo, la valoración citológica se vio dificultada por ser muy hemática, frente al 8,5% de los AB previos negativos (p = 0,002). Conclusiones: El orden de la realización del AB en el diagnóstico de neoplasias bronquiales no influye en el rendimiento diagnóstico, probablemente por la mayor frecuencia de AB hemorrágicos que se producen cuando el AB se realiza tras el cepillado y la biopsia bronquiales. El estudio conjunto de ambos AB incrementa significativamente el rendimiento diagnóstico de la técnica

Objective: Aspiration of bronchial wash fluid is commonly used in conjunction with brushing and forceps biopsy to diagnose endoscopically visible lung cancer. However, the optimal sequence of these procedures is subject to debate. The objective of this study was to determine if the order in which bronchial washing is performed relative to bronchial brushing and forceps biopsy has any effect on the diagnostic yield. Patients and methods: A prospective, cross-sectional study was carried out on patients with endoscopically visible lung cancer who underwent video-assisted fiberoptic bronchoscopy for diagnostic purposes. Aspiration of bronchial wash fluid was performed on all patients both before and after bronchial brushing and forceps biopsy. The results were analyzed separately for each type of endobronchial lesion and for both together. Results: The study included 75 patients, with a mean age of 63.3 years; 81% were men. Bronchoscopy was diagnostic in 71 (94.7%) cases. Findings from bronchial washing fluid were positive in 40 (53.3%) patients when washing was performed prior to brushing and forceps biopsy; when washing was performed after these procedures, findings were positive in 43 (57.3%) patients (P=.6). The combined diagnostic yield of washing before and after brushing and forceps biopsy was 69.3%, a significantly better result than either washing before (P=.001) or after (P=.004) the other sampling techniques. In cases where findings from washing done after brushing and forceps biopsy were negative (14 of 32, 43.7%), blood in the aspirated sample interfered with cytology. In comparison, when washing was performed prior to brushing and biopsy, that problem arose in only 3 of the 35 cases (8.5%) (P=.002). Conclusions: The order in which bronchial washing is performed in relation to other sampling techniques for diagnosing bronchial tumors does not influence the diagnostic yield. This is probably because the aspirated fluid sample is more likely to contain excessive blood when washing is performed after brushing and forceps biopsy. However, the diagnostic yield can be significantly increased by combining the findings from bronchial washings performed both before and after other sample collection procedures