Pulmonary arteriovenous malformation embolization: how we do it.

We report our experience with an embolization technique that allows safe, controllable exclusion of pulmonary arteriovenous malformations using detachable coils, a single venous access site, coaxial catheter guidance, and 1 or 2 microcatheters. This technique is particularly useful when treating central lesions with a short feeding artery and when high flow increases the risk of coil migration and nontarget embolization. It affords precise placement and repositioning of coils prior to detachment. The technique facilitates safe and successful endovascular closure of these challenging lesions.

Assessment of airway caliber and bronchodilator responsiveness in subjects with spinal cord injury.

STUDY OBJECTIVES: Previous spirometric findings among subjects with chronic tetraplegia that reduction in FEV1 and maximal forced expiratory flow, mid-expiratory phase (FEF(25-75%)) correlated with airway hyperresponsiveness to histamine, and that many of these subjects exhibited significant bronchodilator responsiveness, suggested that baseline airway caliber was low in this population. To better evaluate airway dynamics in patients with spinal cord injury, we used body plethysmography to determine specific airway conductance (sGaw), a less effort-dependent and more reflective surrogate marker of airway caliber. DESIGN: Cohort study. SETTING: Veterans Affairs medical center. PARTICIPANTS: Thirty clinically stable subjects with chronic spinal cord injury, including 15 subjects with tetraplegia (injury at C4-C7) and 15 subjects with low paraplegia (injury below T7), participated in the study. Fifteen able-bodied individuals served as a control group. INTERVENTIONS: Subjects underwent baseline assessment of spirometric and body plethysmographic parameters. Repeat measurements were performed among subjects with tetraplegia and paraplegia before and 30 min after receiving aerosolized ipratropium bromide (2.5 mL 0.02% solution; 12 subjects) or normal saline solution (2.5 mL; 6 subjects). MEASUREMENTS AND RESULTS: We found that subjects with tetraplegia had significantly reduced mean values for sGaw (0.16 cm H2O/s), total lung capacity, FVC, FEV1, and FEF(25-75%) compared to subjects in the other two groups. Subjects with tetraplegia who received ipratropium bromide experienced significant increases in sGaw (135%), FEV1 (12%; 260 mL), and FEF(25-75%) (27%). Significant, though far smaller, increases in sGaw (19%) were found among subjects with paraplegia. No discernable change in any pulmonary function parameter was found following the administration of normal saline solution. CONCLUSIONS: Subjects with tetraplegia, as opposed to those with low paraplegia, have reduced baseline airway caliber due to heightened vagomotor airway tone, which we hypothesize is the result of the interruption of sympathetic innervation to the lungs, and/or from low circulating epinephrine levels.

Bronchodilator responses to metaproterenol sulfate among subjects with spinal cord injury.

A previous study using spirometric methods demonstrated that 42% of subjects with tetraplegia experienced significant bronchodilation following inhalation of metaproterenol sulfate (MS). Comparative studies involving subjects with paraplegia were not performed and none has been performed in this population using body plethysmography, a more sensitive method used to assess airway responsiveness. Stable subjects with tetraplegia (n = 5) or paraplegia (n = 5) underwent spirometry and determination of specific airway conductance (sGaw) by body plethysmography at baseline and 30 minutes after nebulization of MS (0.3 mL of a 5% solution). Among subjects with tetraplegia, inhaled MS resulted in significant increases in spirometric indices and sGaw. Among subjects with paraplegia, only sGaw increased significantly, although this increase was considerably less than that seen in subjects with tetraplegia. Our findings indicate that subjects with tetraplegia exhibit greater bronchodilation in response to inhaled MS than do subjects with paraplegia and that sGaw measurements may confer greater sensitivity for assessing bronchodilator responsiveness in tetraplegia.

Sarcoidosis presenting in patients older than 50 years.

BACKGROUND: Sarcoidosis occurs most often between 20 and 40 years of age, but also presents in children and older adults. Newly diagnosed sarcoidosis in older patients has received little attention. In order to characterize sarcoidosis in older patients, the clinical, radiographic and laboratory features of sarcoidosis presenting in patients aged 50 or older were compared to patients whose sarcoidosis was diagnosed at an earlier age. METHODS: The medical records of 181 consecutive patients with sarcoidosis were reviewed. They were divided into 92 patients diagnosed at 50 years of age or older (group A), and 89 whose diagnosis preceded age 50 (group B). RESULTS: Comparison of group A with group B revealed that the two groups were similar with regard to race, gender, smoking habits, common presenting symptoms, organ system involvement, pulmonary function data, radiographic stage, PPD status, and laboratory values. At the time of diagnosis, most patients in both groups presented with either respiratory symptoms or asymptomatic chest roentgenogram abnormalities. The most prevalent pulmonary function abnormality was reduced diffusing capacity in both groups. Most patients exhibited either stage I or II chest roentgenograms. Organ systems most commonly involved included lung, lymph nodes, and skin. CONCLUSION: Sarcoidosis presents with similar clinical features whether diagnosed in young adults or in patients over the age of 50. The diagnosis of sarcoidosis should be considered in patients presenting over age 50 with characteristic signs and symptoms including chest radiographic evidence of mediastinal lymphadenopathy.

Relationship of respiratory symptoms with smoking status and pulmonary function in chronic spinal cord injury.

OBJECTIVE: The relationship of respiratory symptoms to pulmonary function parameters and smoking status was assessed in subjects with chronic (>1 year) spinal cord injury (SCI). METHODS AND PARTICIPANTS: As part of their annual physical examination, subjects were queried regarding respiratory symptoms and underwent pulmonary function studies. The 180 patients who successfully completed pulmonary function testing were evaluated, including 79 subjects with tetraplegia (56 nonsmokers and 23 smokers) and 101 subjects with paraplegia (78 nonsmokers and 23 smokers). FINDINGS: Logistic-regression analysis revealed the following independent predictors of breathlessness: level of injury (tetraplegia, paraplegia, odds ratio = 3.5, P < 0.0015), cough combined with phlegm and/or wheeze (CPWZ, odds ratio = 3.1, P < 0.015), total lung capacity percentage predicted (TLC <60%, odds ratio = 3.9, P < 0.02), and expiratory reserve volume (ERV < 0.6 L, odds ratio = 2.5, P < 0.05). Independent predictors of CPWZ were current smoking (odds ratio = 3.3, P < 0.004), breathlessness (odds ratio = 2.9, P < 0.03), and forced expiratory volume in 1 second (FEV1 <60%, odds ratio = 3.2, P < 0.01). CONCLUSION: Altered respiratory mechanics associated with tetraplegia contribute to breathlessness, restrictive ventilatory impairment (low TLC%), and reduced expiratory muscle strength (low ERV). These factors apparently overshadow adverse effects caused by smoking. Conversely, smoking and reduction of airflow (low FEV1%) were predictive of CPWZ, symptoms commonly associated with cigarette use.

Hemoptysis: diagnosis and management.

Hemoptysis is a frightening and potentially life-threatening symptom. However, most cases can be approached effectively with conservative management. Bronchial artery embolization should be attempted when bleeding is refractory to medical therapy, and surgery may be needed in severe hemorrhage.