The role of closed pleural needle biopsy in the diagnosis of malignant mesothelioma of the pleura.

Malignant mesothelioma of the pleura is a disease that requires a biopsy procedure for a definitive diagnosis. In the past, closed pleural needle biopsy (CPNB) has given poor yields due to the small amount of tissue obtained, and the patient has subsequently been subjected to a diagnostic thoracotomy. In recent years, the availability of more accurate histopathologic tests have enabled the pathologist to make a diagnosis more easily on samples obtained at CPNB. In this retrospective study of 20 consecutive cases of malignant mesothelioma of the pleura diagnosed between 1980 and 1990, we found that a blind CPNB was diagnostic in five of seven procedures and CT-guided CPNB was diagnostic in five of six procedures. An open pleural biopsy (OPB) was diagnostic in ten of ten procedures performed. There were no complications associated with any of the CPNB procedures. We conclude that CPNB is a safe and effective manner of diagnosing malignant mesothelioma of the pleura, and should be attempted prior to OPB.

Pulmonary hyalinizing granuloma presenting as multiple cavitary calcified nodules.

We describe a patient with PHG who presented with multiple cavitary calcified nodules. Laboratory evaluations revealed that she had serum immune abnormalities, and a histoplasmin skin test yielded positive results. Her Histoplasma infection may have produced a hyperimmune reaction that resulted in PHG and the calcified nodules.

Laryngeal spasm mimicking bronchial asthma.

The list of asthma masqueraders grows, emphasizing the need for a careful analysis of the patient suffering from cough, wheezing and/or dyspnea. The present case report describes a 23-year-old patient with spastic vocal cord adduction, initially treated as bronchial asthma. Severe disruption in her arterial blood gases was present. The vocal cord adduction persisted in spite of valium anesthesia. The patient's symptoms and signs were relieved with a tracheostomy. However, the vocal cord spasm persisted.

Pulmonary functions during peritoneal dialysis.

Lung volumes, flows, flow volume loop, diffusing capacity and closing volume were studied in 7 patients (Group I) before, with 2 liter dialyzate in the peritoneal cavity and after 8 hours of peritoneal dialysis. The functional residual capacity, residual volume and the total lung capacity decreased (P less than 0.01, less than 0.05, and less than 0.05 respectively) with 2 liter dialyzate in the peritoneal cavity and returned to baseline after the dialyzate was removed. Arterial blood gas analysis was performed in another 8 patients (Group II) before, with 2 liter dialyzate in the peritoneal cavity, and after the dialyzate had been drained. No significant difference was observed in PaO2, PaCO2 or pHa during any phase of the study. It is concluded that except for a minor decrease in FRC, RV and TLC, there were no deleterious effects with the use of 2 liter dialyzate volume on gas exchange or pulmonary functions during peritoneal dialysis.

Extracorporeal membrane oxygenator support in a case of severe status asthmaticus.

Support with extracorporeal membrane oxygenation (ECMO) can sustain life for a substantial period of time, but the role of long-term ECMO support is limited. The National Institutes of Health ECMO collaborative study revealed no significant reduction in mortality in adults with severe respiratory distress syndrome treated with ECMO. The value of ECMO in the treatment of transient, severe acute respiratory insufficiency has been demonstrated in patients after cardiac operations, in patients with Pneumocystis carinii pneumonia, and in patients following trauma. We present an example of refractory respiratory failure in a young asthmatic with massive atelectasis in whom the institution of ECMO allowed us to perform adequate pulmonary lavage. It resulted in improvement in gas exchange and the patient's survival.

Survival after prolonged submersion in cold water without neurologic sequelae. Report of two cases.

We describe two patients who suffered prolonged (greater than four minutes) submersion in cold water (25 minutes, 32 s, and six minutes, respectively), with complete neurologic recovery. We postulate that hypothermia served to protect the brain from hypoxic injury. These cases also serve to emphasize the need for vigorous one-the-scene resuscitative efforts. We review the problems associated with the treatment of hypothermia and drowning.

The effect of isoproterenol on hypoxia-mediated histamine release.

In 13 guinea pigs the pulmonary circulation was isolated from the systemic circulation and perfused with Tris buffer alone or with isoproterenol. The lungs were initially ventilated with 100% O2 and then switched to 100% N2 to induce alveolar hypoxia. The effluent was collected from the aorta and assayed for histamine. In the control group (n = 7) the histamine levels rose markedly with hypoxia. In the group perfused with Tris buffer and isoproterenol (n = 6) the rise in histamine levels was markedly diminished. Therefore, the authors conclude that isoproterenol, in their in vivo model, had a dramatic effect on hypoxia (non-immunologic) mediated histamine release.

The effect of cromolyn sodium on hypoxia-induced histamine release.

In 16 guinea pigs the pulmonary circulation was isolated from the pulmonary systemic circulation and perfused with Tris buffer or with Tris buffer containing cromolyn sodium. The lungs were first ventilated with 100% O2 and then 100% N2 to induce alveolar hypoxia. The effluent was collected from the aorta and assayed for histamine by the fluorometric method. In all seven animals perfused with Tris alone (no cromolyn) a marked elevation of the effluent histamine was demonstrated. In the group perfused with buffer containing cromolyn there was a substantial diminution in the response to hypoxia. Therefore, cromolyn sodium partially blocked hypoxia-mediated histamine release.

Physiologic consequences of mechanical ventilation.

Mechanical ventilatory support with a variety of devices and techniques has saved many lives; however, it remains the responsibility of those charged with the care of patients suffering from respiratory failure to be thoroughly familiar with these techniques and their complications.

New lung functions and pregnancy.

Newer lung function tests (e.g., flow volume-loops and closing volume), as well as standard pulmonary function tests, were performed on 19 healthy individuals in the third trimester and after delivery. We found that the flow characteristics, manifested in the FVL, and the CV remained unaltered during pregnancy. In regard to the standard pulmonary function tests, we found no statistically significant change except for a decrease in the ERV and in the FRC during pregnancy.

Comparative hemodynamic consequences of inflation hold, PEEP, and interrupted PEEP: an experimental study in normal dogs.

Cardiac output and airway, intrathoracic, arterial, pulmonary artery, left atrial, and central venous pressures were studied in 8 mongrel dogs. They were anesthetized and ventilated with (1) inflation hold of various duration, (2) continuous positive end-expiratory pressure and one breath off). The results indicate a minimal decrease in cardiac output (of approximately 5 per cent) with inflation hold. Diminished cardiac output was noted with increasing levels of continuous PEEP. The severity of the decrease in cardiac output wasproportional to the airway pressure. The higher levels (20 cm H2O) OF PEEP were associated with profound decreases. Utilization of a technique of interrupted PEEP substantially reduced the adverse hemodynamic effects in the dog.

Effect of exercise on lung function tests in hay fever.

The patients in this study were divided into three groups on the basis of V50. Group I included completely normal subjects with normal V50 before and after exercise. Group II showed a normal initial V50 which decreased following exercise. This indicates small airways dysfunction which is exaggerated by exercise. Group II showed abnormal V50 initially which remained unchanged after exercise, suggesting more permanent impairment of the small airways function. Thus significant physiologic abnormalities were identified in patients belonging to Group II and Group III.