Respiratory failure and cor pulmonale associated with tracheal mucoid accumulation from a SCOOP transtracheal oxygen catheter.

Transtracheal oxygen (TTO) delivery for patients with chronic hypoxemia has been used increasingly since its introduction in 1982. Most complications have been relatively minor and usually occur in conjunction with catheter placement. This report describes two patients with long-term catheter use who developed increasing respiratory failure and cor pulmonale, at least in part, due to a large tracheal mucus plug.

Transbronchial needle aspiration in clinical practice. A five-year experience.

We conducted a five-year review of our use of TBNA during bronchoscopy in our clinical practice. Out of 1,630 bronchoscopic procedures, 633 patients (39 percent) had TBNA performed as part of the initial examination. Mediastinal nodes were sampled in 86 percent of the patients who had TBNA performed, and 127 (23 percent) of 547 of these aspirates were positive. Other areas of mucosal abnormality of the tracheobronchial tree were also sampled by TBNA under direct vision and showed malignant cells in 44 (25 percent) of 176 aspirates. Of 363 patients first diagnosed as having carcinoma of the lung who had TBNA of N2 nodes, 41 (59 percent) of 70 with small-cell tumors were positive, as were 83 (28 percent) of 293 with non-small-cell malignant neoplasms. Comparison of cytologic results obtained by TBNA with histologic material in 109 cases showed an excellent correlation. In 31 cases (4 percent of all TBNA), the aspirate provided the sole means of establishing the diagnosis of cancer. Two patients were thought to have false-positive aspirates. No complications of therapeutic significance were encountered. We believe that TBNA is a safe and effective way to assess mediastinal lymphatic involvement in the staging of lung cancer and that TBNA can be safely performed as part of the initial bronchoscopic examination in patients suspected of having malignant neoplasms of the chest.

Transbronchial needle aspiration in clinical practice.

Transbronchial needle aspiration has recently been adapted for use with the flexible bronchoscope. We studied 108 patients, who had a total of 110 aspirations performed, and diagnosed thoracic cancer in 70 cases. Transbronchial needle aspiration revealed malignant disease in 32 (46%) of these 70 patients. In 12 (17%) patients with cancer this technique provided the sole cytological or histological confirmation of the diagnosis. It gave a positive result in an additional 20 (29%) cases in which the diagnosis was also proved by conventional procedures, and it provided important staging information in these patients. In 20% of patients with cancer transbronchial needle aspiration precluded the need for further diagnostic surgery. There were no complications in this series. This is a safe, useful, and economical technique that can be used in diagnosing and staging patients with carcinoma of the lung.

The preferential deposition of inhaled isoproterenol and propranolol in asthmatic patients.

This study describes the use of central and diffuse airway deposition patterns of isoproterenol and radiotracer aerosol alone, and in the presence of centrally deposited propranolol and radiotracer aerosol, to investigate the distribution of beta 2 adrenoreceptors in six asthmatic patients. The central deposition technique was only partially successful. No definite beta 2 receptor distribution pattern could be interpreted from the airway function responses. It was noted that 3-10 micrograms of isoproterenol in the airways was able to produce 50 percent of the maximum possible flow rate response. Centrally deposited propranolol was an effective antagonist of isoproterenol.

Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis.

The effects of postural drainage, exercise, and cough on mucus clearance were compared in 8 patients with chronic bronchitis. A bolus of 99mTc albumin aerosol was inhaled at a high inspiratory flow rate to enhance proximal deposition. Retention of deposited aerosol in the lung, as a function of time, was quantified using a gamma camera and subsequent computer analysis. Coughing greatly accelerated total lung (P less than 0.005) and peripheral (P less than 0.005) mucus clearance. Exercise resulted in much smaller changes than did cough, but significantly increased total lung clearance (P less than 0.005). Postural drainage in which coughing was prohibited did not alter clearance. These results have therapeutic implications and stress the importance of controlling cough when evaluating therapeutic interventions by these techniques.

A comparison of exercise responses in stairclimbing and cycling.

A free-paced 14.8-m stairclimb was compared to cycle ergometry at equivalent power outputs in six normal subjects. Heart rate (HR), inspiratory flow (VI) andd oxygen saturation in arterial blood (Sao2) were analyzed continuously, carbon dioxide output (Vco2) and oxygen consumption (Vo2) for the duration of exercise, and rebreathing mixed venous carbon dioxide pressure (Pvco2), capillary blood gases, and lactates at the completion of exercise. The average power output was 1,394 kpm/min sustained for 54.8 s. The HR and Vo2 responses were not significantly different between the two forms of exercise. VI was 20.3% less stairclimbing (P smaller than 0.005). A fall in Sao2 of 31.1% +/- 2.7) occurred in stairclimbing compared to 1.2% (+/- 2.1) in cycle ergometry. Differences in Sao2 between stairclimbing and cycling correlated with differences in VI (r = 0.80); falls in Sao2 could be prevented by overbreathing during stairclimbing or induced by controlled underbreathing during cycling. Vco2 and postexercise lactate levels were less stairclimbing (P smaller than 0.005 and P smaller than 0.01), as were Pvco2 measurements. The findings are consistent with a lower CO2 flow to the lung during stairclimbing than in cycling, which results in a lower alveolar ventilation and a consequent fall in Sao2.

Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia.

A thoracoscopic examination was performed in 41 patients under local anesthesia in the lateral decubitus position. Prior thoracocentesis (38 patients) and blind biopsy with an Abrams' needle (32 patients) had been nondiagnostic. The initial nine patients were examined with the flexible fiberoptic bronchoscope, yielding a diagnostic accuracy of 56 percent (five cases). This technique was discontinued when two patients had normal findings on biopsies, despite the visual observation of later diagnosed carcinoma. Subsequent thoracoscopic procedures were performed with a rigid 11-mm single-puncture thoracoscope (Storz), which was diagnostic in 28 (88 percent) of the remaining 32 patients. A hemothorax (400 ml) was the only potentially serious complication. Twelve patients were prospectively monitored during the thoracoscopic procedure for changes in cardiac rhythm and oxygen saturation. Sinus tachycardia was the only arrhythmia observed. The mean fall in oxygen saturation was 1.4 percent. We conclude that thoracoscopic examination with the rigid thoracoscope is diagnostically superior to the fiberoptic bronchoscope and is a safe procedure which can be performed under local anesthesia.

Cerebral dye embolus: a complication of selective bronchography following transbronchial biopsy.

Cerebral embolization of an aqueous solution of propyliodone (Dionosil) occurred during selective bronchographic studies following a fiberoptic bronchoscopic procedure with transbronchial biopsy in a patient undergoing investigation of a pulmonary lesion. The embolization resulted in a grand mal seizure and transient neurologic deficits. This potential complication has not been previously reported. We suggest that selective bronchographic studies be avoided when the transbronchial biopsy is associated with endobronchial bleeding.