A proposed classification system of central airway stenosis.

Tracheobronchial stenosis, a serious problem in adults and children, has multiple causes and has been treated in many ways. While developing an international multicentre study to evaluate efficacy of airway stents, it was realised that no adequate description of central airway stenosis regarding type, location and degree has been published. Thus, comparing results of different treatment modalities in different centres has been difficult due to a lack of uniformity of classification. Reports are typically descriptive and precise classification schemes have not adequately addressed either for the trachea or the main bronchi. A standardised classification scheme was proposed with descriptive images and diagrams for rapid and uniform classification of central airway stenosis. The present authors' system divides stenosis into structural and dynamic types and further classifies the disease by degree of stenosis, location and transition zone. Multiple sites can be described and each is transformed into a simple numerical scoring system prompted by a diagram, which can be easily captured for subsequent uniform analysis across sites. A pilot validation of the system, with 18 pulmonologists of varying training background, showed strong precision and agreement between observers. Such a system will enhance the ability to study the effectiveness of treatment modalities for central airway stenosis.

Late mediastinal shift after repeated aspiration of postpneumonectomy seroma.

Development of a postoperative seroma is a frequent complication after muscle-sparing thoracotomy. We describe an unusual case of late mediastinal shift in a patient in whom our original plan to perform a limited muscle-sparing thoracotomy was abandoned. The procedure was converted to a standard posterolateral incision to perform a pneumonectomy for a large central carcinoid tumor with extrabronchial extension. Fluid that accumulated in her pneumonectomy space presumably shifted into the dissected tissues of her chest wall, and was then drained repeatedly by her local physician in the time interval between 2 weeks and 3 months after surgery.

Disseminated coccidioidomycosis. The role of cytology in multidisciplinary clinical approach and diagnosis.

A case of clinically unsuspected disseminated coccidioidomycosis diagnosed by different cytologic approaches and confirmed by mycological culture is reported. An African-American man presented with a clinical picture of pneumonia not responding to antibiotics. He subsequently developed a large neck mass and was found to have mediastinal and hilar adenopathy highly suspicious of a neoplastic process. Fine needle aspiration biopsy of the neck mass, followed by flexible bronchoscopy, was performed. Various cytologic approaches and techniques in rapid diagnosis of suspicious masses are discussed.

A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.

BACKGROUND: The purpose of this study was to compare the effectiveness and safety of a chronic indwelling pleural catheter with doxycycline pleurodesis via tube thoracostomy in the treatment of patients with recurrent symptomatic malignant pleural effusions (MPE). METHODS: In this multi-institutional study conducted between March 1994 and February 1997, 144 patients (61 men and 83 women) were randomized in a 2:1 distribution to either an indwelling pleural catheter or doxycycline pleurodesis. Patients receiving the indwelling catheter drained their effusions via vacuum bottles every other day or as needed for relief of dyspnea. RESULTS: The median hospitalization time was 1.0 day for the catheter group and 6.5 days for the doxycycline group. The degree of symptomatic improvement in dyspnea and the quality of life was comparable in each group. Six of 28 patients who received doxycycline (21%) had a late recurrence of pleural effusion, whereas 12 of 91 patients who had an indwelling catheter (13%) had a late recurrence of their effusions or a blockage of their catheter after the initially successful treatment (P = 0.446). Of the 91 patients sent home with the pleural catheter, 42 (46%) achieved spontaneous pleurodesis at a median of 26.5 days. CONCLUSIONS: A chronic indwelling pleural catheter is an effective treatment for the management of patients with symptomatic, recurrent, malignant pleural effusions. When compared with doxycycline pleurodesis via tube thoracostomy, the pleural catheter requires a shorter hospitalization and can be placed and managed on an outpatient basis.

Massive pleural effusion in systemic lupus erythematosus: thoracoscopic and immunohistological findings.

Small to moderate, bilateral pleural effusions are common during the course of systemic lupus erythematosus (SLE). These are related to several complications, particularly, congestive heart failure, nephrotic syndrome, pulmonary embolism or SLE itself. Thoracoscopy performed for a massive unilateral pleural effusion in a patient with SLE and inferior vena cava thrombosis revealed several small nodules on the visceral pleura. Immunofluorescence studies of biopsy samples showed immunoglobulin deposits confirming the lupus-related origin of the pleuritis.

Acute management of airway compromise in cancer.

Major airway obstruction is a frightening complication of thoracic tumors. Patient presentation may be abrupt. They may experience profound dyspnea, post-obstructive pneumonia, respiratory failure, or progress to death. Immediate relief of obstruction can be accomplished by bronchoscopy with laser or stenting in most patients. Such interventions can improve the quality of life and longevity of these patients and must be considered in the initial treatment of patients with airway obstruction.

Video endoscopy for laser photoresection in tracheobronchial pathology: some considerations after 9 years experience with 2105 treatments.

Between 1984 and 1993 we performed 2105 laser treatments in 1210 patients: 52% of treatments were done for malignant pathology, 45% for benign tracheal stenoses and 3% were in a miscellaneous group. The procedure was carried out with a rigid bronchoscope under general anaesthesia. In patients with malignant tumors, it is a good palliative treatment-safe, well tolerated and with immediate results; it can be repeated as many times as needed with and is well accepted by the patient. In patients without tumors, this method avoids emergency tracheotomies. The long term results are now under evaluation.

Thoracoscopic findings in spontaneous pneumothorax in AIDS.

Six patients with the acquired immunodeficiency syndrome (AIDS) who suffered eight spontaneous pneumothoraces between January 1990 and January 1993 underwent videothoracoscopy. The predominant macroscopic findings, found in four patients on five occasions, were white-yellow nodules dispersed throughout the lung surface. In addition, in one patient, these lesions were associated with multiple small apical bullae and, in another, a large reddish nodule with several smaller white satellite nodules was noted on the parietal pleura. Methenamine silver stain of biopsy samples of both the visceral and parietal nodules in these patients showed the presence of Pneumocystis carinii. May-Grunwald-Giemsa stain of brushing samples of visceral lesions revealed P-carinii in two patients. In one of these patients, previously performed bronchoalveolar lavage (BAL) had not yielded P-carinii. On two occasions, the thoracoscopic findings were unremarkable, although in one of these patients, computed tomography (CT) had shown a large thick-walled cyst near the left hilum and BAL revealed P-carinii. Talc poudrage through the thoracoscopic cannula followed by chest tube drainage was performed in all patients and was successful in treating three of five with proved P-carinii pneumonia-related pneumothorax. The etiology of pneumothorax in AIDS and the diagnostic and therapeutic utility of videothoracoscopy in these patients are discussed.

Endothelium-derived contracting and relaxing factors contribute to hypoxic responses of pulmonary arteries.

The response of porcine pulmonary arteries to hypoxia depended on their location in the vasculature and the degree and duration of the hypoxic challenge. In rings of pulmonary artery suspended for isometric tension recording (37 degrees C, 16% O2 and 5% CO2), moderate hypoxia (10% and 4% O2) caused endothelium-dependent relaxation in distal arteries but transient endothelium-dependent contraction in proximal arteries. In both proximal and distal arteries, the initial response to anoxia (0% O2) was a transient endothelium-dependent contraction. This was followed by a slowly developing, sustained endothelium-dependent contraction in proximal arteries, or by an endothelium-independent relaxation in distal arteries. The endothelium-dependent relaxation to moderate hypoxia in distal arteries was inhibited only by combined inhibition of endothelium-derived relaxing factor (EDRF)-nitric oxide (NO) synthase [N omega-nitro-L-arginine methyl ester (L-NAME)] and cyclooxygenase (indomethacin), suggesting mediation by EDRF-NO and prostacyclin. Transient endothelium-dependent contractions to moderate hypoxia (proximal arteries) or anoxia (all arteries) were abolished by L-NAME, but the late endothelium-dependent anoxic contraction observed in proximal arteries was not reduced by L-NAME and/or indomethacin. Therefore, hypoxia/anoxia may initiate contraction of pulmonary arteries by decreasing the activity of EDRF-NO, but the contractions appear to be maintained by an increased activity of an endothelium-derived contracting factor.

Diagnosis of tracheoesophageal fistula by analysis of gastric air.

Two patients receiving positive pressure ventilation experienced marked gaseous abdominal distension. Analysis of gases from the stomach, ventilator, and room air suggested that the gastric gases came from the ventilator in one patient. The diagnosis of tracheoesophageal fistula was confirmed by esophagoscopy. Analysis of gases in the other patient did not support the suspicion of tracheoesophageal fistula, and no fistula was found at autopsy. The technique of gastric air analysis is presented as a simple supporting tool for the clinical diagnosis of tracheoesophageal fistula in patients receiving positive pressure ventilation.

Multidisciplinary team functioning.

This paper advocates the need to move beyond interdisciplinary team composition as a minimum criterion for multidisciplinary functioning in child abuse treatment. Recent developments within the field reflect the practice of shared professional responsibility for detection, case management and treatment. Adherence to this particular model for intervention requires cooperative service planning and implementation as task related functions. Implicitly, this model also carries the potential to incorporate the supportive functioning essential to effective group process. However, explicit attention to the dynamics and process of small groups has been neglected in prescriptive accounts of multidisciplinary child abuse team organization. The present paper therefore focuses upon the maintenance and enhancement aspects of multidisciplinary group functioning. First, the development and philosophy of service for the Alberta Children's Hospital Child Abuse Program are reviewed. Second, composition of the team, it's mandate for service, and the population it serves are briefly described. Third, the conceptual framework within which the program functions is outlined. Strategies for effective group functioning are presented and the difficulties encountered with this model are highlighted. Finally, recommendations are offered for planning and implementing a multidisciplinary child abuse team and for maintaining its effective group functioning.

Serum levels of type I and III procollagen fragments in Paget's disease of bone.

Patients with Paget's disease of bone were found to have elevated serum levels of type I procollagen carboxyterminal peptide (pColl-I-C) which correlated with other measurements of disease activity. The elevated levels of pColl-I-C decreased within hours after the injection of salmon calcitonin and within weeks after oral dichloromethylene diphosphonate treatment. The decrease in serum pColl-I-C after a single injection of salmon calcitonin was associated with a decrease in urinary hydroxyproline excretion, both of which rose toward pretreatment values within 7 h. The pColl-I-C levels remained normal for months after dichloromethylene diphosphonate therapy was discontinued. Using a RIA for the type III procollagen amino-terminal peptide (pColl-III-N), it was found that serum levels were also elevated in patients with Paget's disease. The levels of pColl-III-N also decreased after the injection of salmon calcitonin, but not to the same extent as those of pColl-I-C. After chronic therapy with dichloromethylene diphosphonate, serum levels of pColl-III-N decreased, but not into the normal range. We postulate that whereas pColl-I-C is derived from synthesis of mineralized bone collagen, pColl-III-N is derived from the loose fibrous stroma replacing marrow in areas closely associated with active Pagetic bone disease.

Hemodynamics in teenagers and asthmatic children during exercise.

Seventeen normal teenagers and eight asthmatic children were studied during submaximal exercise on a bicycle ergometer. A modification of a noninvasive multiple gas rebreathing method was utilized for the estimation of pulmonary capillary blood flow (Qc), diffusing capacity (DL), oxygen consumption (VO2), functional residual capacity (FRC), and pulmonary tissue plus capillary blood volume (VTPC). Significant increases in Qc, DL, VO2, and heart rate occurred in both groups of subjects. Regression equation of Qc equaled 6.0 + 0.0078 VO2 (ml/min) in the teenagers and 3.39 + 0.0082 X VO2 (ml/min) in the asthmatic children. The values of DL as a function of VO2 in both groups were similar to previously reported data. No significant changes in FRC or VTPC occurred in either group during exercise. This method appears to be an acceptable noninvasive way of studying exercise physiology in healthy or sick children.

The effect of nasal decongestant on nasal mucous velocity.

Nasal mucous velocity was measured in 13 healthy nonsmokers before and 10 min after topical application of 2 alpha adrenergic nasal decongestant sprays, phenylephrine and tetrahydrozoline. Phenylephrine increased nasal mucous velocity from 8.4 +/- 2.7 mm per min (mean +/- SD) to 13.7 +/- 4.8 mm per min and tetrahydrozoline from 8.1 +/- 3.8 mm per min (mean +/- SD) to 13.8 +/- 5.1 mm per min. These increases were significant (P less than 0.01) when compared to topical application of phenylephrine and tetrahydrozoline vehicles, normal saline, and sham (empty aerosol container).

A roentgenographic method for measuring nasal mucous velocity.

Nasal mucous velocity was estimated by following the motion of radiopaque discs of Teflon by means of a fluoroscopic image intensifier. From 5 to 10 discs were deposited on the superior surface of the inferior turbinate with a forceps. No local anesthesia was employed and the subjects experienced no discomfort. The linear velocity of the discs was obtained by playing the videotape onto a television monitor, measuring distance with a ruler, and dividing by elapsed time. Duplicate runs of 1-2 min, 15 min apart were very reproducible but runs at 4-h intervals or daily over a 5-day period had a coefficient of variation of 30%. Average nasal velocity for individual ranged from 0 to 22.5 mm/min and group means ranged from 6. 8 to 10.8 mm/min. There was no statistically significant difference in nasal mucous velocity between young and elderly subjects nor was there a sexual difference. The saccharin test of nasal mucous transport was unsatisfactory because of inability to repeat the test more often than 1-2 h and its propensity to produce mild discomfort in a significant number of subjects. Saccharin times did not correlate significantly with values of nasal mucous velocity.