A safe high-yield technique for cutting needle biopsy of the lung in patients with diffuse lung disease.

UNLABELLED: The approach to the diagnosis and management of patients with diffuse infiltrative lung disease (DILD) is controversial. The results of transbronchial biopsy are often unsatisfactory. The role of open lung biopsy is highly variable. Percutaneous cutting needle biopsy (CNB) is not recommended because of its reported high morbidity/mortality relative to its low diagnostic yield. We report a technique for CNB with a high diagnostic yield and a low morbidity and no mortality in 228 patients with DILD over the past 23 years. METHODS: The salient features of the technique for CNB are as follows: the anesthetic needle does not enter the pleural space; a Franklin Silverman needle is inserted into the intercostal space posteriorly at outer one-third of chest wall; the biopsy is performed with the breath held at normal end expiration; the plane of pleural space is broken with sudden insertion of needle 8 to 15 cm into lung; and the pathway of the needle is maintained parallel to the lateral chest wall. RESULTS: A diagnosis was established in 129 of 145 biopsies (89%) performed by a trained operator (A.H.N.). There were 36 pneumothoraces (25%), four minimal hemoptyses (3%), and two chest tube placements (1%). There were no deaths (0%). CONCLUSION: With meticulous attention to technique and careful selection of patients, the procedure offers a relatively safe alternative to open lung or thoracoscopic lung biopsy in patients with DILD.

The technique of percutaneous transthoracic needle aspiration biopsy.

Consider percutaneous transthoracic needle aspiration biopsy when specimens of pulmonary malignancies or infections are needed and bronchoscopy is contraindicated or the lesion is in a peripheral location. Percutaneous needle aspiration biopsy can be performed rapidly, and its diagnostic yield is good to excellent. The chief limitation of this procedure is the high incidence of pneumothorax, which makes the technique unsuitable for ventilated patients. A needle is inserted through the chest wall under fluoroscopic or CT guidance; a small sample is then aspirated through the needle. Operator skill and the use of thin needles help reduce the incidence of complications.

Albumin lung/heart ratio change. A simple clinical means of documenting increased pulmonary endothelial permeability to protein.

We investigated a simple method that can be used at the bedside for documenting the net accumulation of albumin in the lung. The technique employs measurement with a computer-linked gamma camera of the activity ratio in an area of the right lung compared with the same-sized area in the heart at 20 minutes and three hours following intravenous injection of technetium Tc 99m albumin. We applied this measurement to three groups of patients: a control group and patients with roentgenographic evidence of edema classified according to clinically available criteria as either hydrostatic edema or permeability edema to see if we could document differences among these groups. In control patients this ratio did not increase by more than seven units between the 20-minute and three-hour measurements. Of 18 patients classified by other routine clinical means as having hydrostatic pulmonary edema, 89% showed no increase in lung albumin accumulation. In 29 patients with permeability edema associated with the so-called adult respiratory distress syndrome, 31% showed evidence of net pulmonary albumin accumulation. These findings suggest that some patients otherwise classified as having hydrostatic edema have concomitant permeability changes in the microvasculature and that permeability edema represents a spectrum of endothelial damage.

Transtracheal aspiration in diagnosis of sputum-smear--negative tuberculosis.

Of 4,200 patients admitted to an acute-care county hospital, 126 (3%) were proved to have pulmonary tuberculosis, among whom 35 (28%) had several sputum smears negative for acid-fast bacilli. On transtracheal aspiration, 31 to 35 had acid-fast bacilli in the aspirate. Eighteen of these 35 (51%) patients had associated infections caused by aerobic or anaerobic bacteria. Tuberculin skin tests were negative in 14 of 35 patients with negative sputum specimens (40%). Ten of 18 patients (56%) with associated bacterial infections had negative skin tests to purified protein derivative. Smear and culture of transtracheal aspirate for tubercle bacilli may be invaluable in establishing the diagnosis when pulmonary tuberculosis is suspected.

67Ga lung scan. An aid in the differential diagnosis of pulmonary embolism and pneumonitis.

Twenty-three patients patients with clinical signs of pulmonary embolic disease and lung infiltrates were studied to determine the value of gallium citrate Ga 67 lung scan in differentiating embolic from inflammatory lung disease. In 11 patients without angiographically proved embolism, only seven had corresponding ventilation-perfusion defects compatible with inflammatory disease. In seven of these 11 patients, the gallium 67 concentration indicated inflammatory disease. In the 12 patients with angiographically proved embolic disease, six had corresponding ventilation-perfusion defects compatible with inflammatory disease. None had an accumulation of 67Ga in the area of pulmonary infiltrate. Thus, ventilation-perfusion lung scans are of limited value when lung infiltrates are present. In contrast, the accumulation of 67Ga in the lung indicates an inflammatory process. Gallium imaging can help select those patients with lung infiltrates who need angiography.

Treatment of anaerobic pulmonary infections; carbenicillin compared to clindamycin and gentamicin.

Twenty-three patients with anaerobic infections of the lung were treated with either two antibiotics, clindamycin and gentamicin (11 patients) or with a single antibiotic, carbenicillin (12 patients). Cultures were obtained prior to therapy, either by transtracheal needle aspiration (17 patients) or thoracocentesis (six patients). Anaerobic bacteria were found in all. Fifteen patients had aerobic and facultative bacteria in addition. The anerobic isolates were peptostreptococci (12), peptococci (12), Bacteroides organisms (eight), clostridia (three), actinomycetes (two), eubacteria (one), and fusobacteria (one). Aerobes included streptococci (nine), enterococci (seven), Neisseria organisms (two), Klebsiella organisms (one), Citrobacter organisms (one), Pseudomonas organisms (one), Mycobacterium tuberculosis (two), and Nocardia (one). The two patients with pulmonary tuberculosis with anaerobic and superinfection received antituberculosis chemotherapy in addition. Therapeutic response was considered excellent in both groups. This suggests that carbenicillin may be used as a single antibiotic in the treatment of anaerobic and mixed infections of the lung.

Bronchiolar and large alveolar cell in pulmonary phospholipid metabolism.

The nonciliated bronchiolar cells (Clara cells) lining the terminal airways actively secrete a phospholipid. In contrast, the large alveolar epithelial cells (type II, granular pneumonocyte) are active phagocytic cells. It is proposed that the Clara cell is the main source of pulmonary phospholipid production (presumably surfactant) while the large alveolar cell is responsible for its subsequent breakdown.