Nocturnal hypoxemia is common in primary pulmonary hypertension.

STUDY OBJECTIVE: Unsuspected sleep-related respiratory events are common in patients with severe pulmonary disease. Sleep in patients with primary pulmonary hypertension (PPH) has not been studied (to our knowledge). The purpose of this study was to measure the prevalence of respiratory disturbances and nocturnal hypoxemia during the sleep of patients with PPH. SETTING: Tertiary-care referral hospital. DESIGN: Retrospective review. PATIENTS: Thirteen patients with PPH. MEASUREMENTS: All patients underwent a single-night comprehensive polysomnogram study. Patients who spent > 10% of the total sleep time with oxygen saturation by pulse oximetry (SpO(2)) at < 90% or who needed oxygen to maintain their SpO(2) level at > 90% were classified as nocturnal desaturators. Analysis was performed to determine which clinical variables (ie, demographics, body mass index, spirometry, diffusion capacity, right heart catheterization pressures, 6-min walk test, arterial blood gas levels, resting and walking SpO(2) levels, and polysomnogram variables) would predict nocturnal desaturation. Statistical significance was considered when p values were < 0.05. RESULTS: Of the 13 patients in the study, 10 (77%) were nocturnal desaturators. All patients had normal apnea indexes, but two had mild elevations of the hypopnea index (< 15 episodes per hour). Nocturnal desaturations occurred independently of apneas or hypopneas. Six patients who did not have O(2) titration during sleep spent > 25% of sleep time with SpO(2) < 90%. The mean (+/- SD) variables that were significantly different between desaturators (10 patients) and nondesaturators (3 patients) were FEV(1) (70.1 +/- 9.1% predicted vs 98.1 +/- 15.1% predicted, respectively; p = 0.002), resting PaO(2) (61.8 +/- 16.1 vs 90.3 +/- 2.3 mm Hg, respectively; p = 0.001), alveolar-arterial oxygen pressure difference (P[A-a]O(2)) (40.5 +/- 20.5 vs 12.2 +/- 7.2 mm Hg, respectively; p = 0.048), resting SpO(2) (91.6 +/- 5.4% vs 98.7 +/- 2.3%, respectively; p = 0.038), and walking SpO(2) (83.8 +/- 9.3% vs 95.3 +/- 1.2%, respectively; p = 0.002). The mean hemoglobin level was higher in the group of nocturnal desaturators than in the group of nondesaturators (10.43 +/- 0.31 vs 13.95 +/- 0.98 g/dL, respectively; p < 0.0001). CONCLUSION: Seventy-seven percent of patients with PPH have significant nocturnal hypoxemia that is unrelated to apneas and hypopneas. Nocturnal desaturation occurs more frequently in patients with higher P(A-a)O(2) values and lower FEV(1) values, resting arterial PaO(2) and SpO(2) values, and walking SpO(2) values.

Adult airway foreign body removal. What's new?

Signs and symptoms of adult FB aspiration are most often nonspecific. Misdiagnosis and delay in diagnosis frequently occur. Radiographic evaluation is helpful, but flexible bronchoscopy is the gold standard in the identification and localization of an airway foreign body. With increasing experience and development of better accessories, removal using a flexible bronchoscope under local anesthesia can be performed safely and successfully. Review of large series of FB removal indicates a success rate of 86% in more than 400 procedures with flexible bronchoscopy.

Progressive portopulmonary hypertension after liver transplantation treated with epoprostenol.

Portopulmonary hypertension (PPHTN) is an uncommon complication of advanced liver disease. Epoprostenol has been effective in the treatment of PPHTN and has been used as a bridge to orthotopic liver transplantation (OLT). The role of OLT in the reversal of PPHTN is unclear. We report a case of severe PPHTN (mean pulmonary artery pressure of 45 mm Hg) that progressed after OLT. Acute dosing with epoprostenol improved the pulmonary vascular resistance by 55% and the cardiac index by 134%. Hemodynamic and symptomatic improvements were maintained after 18 months of long-term treatment with epoprostenol. This is the first reported case of a successful favorable outcome after treatment for progressive PPHTN after OLT. Our case report complements previous reports by highlighting the potential effective use of epoprostenol as a definitive treatment for PPHTN.

Head computed tomography in medical intensive care unit patients: clinical indications.

OBJECTIVE: To assess whether clinical variables might be useful in selecting patients who will have an acute intracranial abnormality seen in head computed tomographic scans (HCT). DESIGN: Retrospective study. SETTING: Medical intensive care unit (MICU) in a tertiary teaching hospital. MEASUREMENTS: Medical records of patients admitted to the MICU who underwent HCT between January 1, 1994, and December 31, 1995, were reviewed. Patients with acute intracranial abnormalities (HCT-positive) and those without new acute findings (HCT-negative) were compared on various clinical variables, including demographics, indications for obtaining the HCT (mental status change, neurologic deficit, fever, seizures), coagulation profiles, when the HCT was performed (at admission or after admission), and ordering physician. MAIN RESULTS: Of 297 HCTs obtained in 230 patients, 37% (109/297) were positive. When the clinical variables were examined univariately, only the presence of a neurologic deficit (70% vs. 37%; difference, 33%; p < .001) differed significantly between positive and negative HCTs. Multivariate analysis confirmed that only the frequency of a new neurologic deficit differed significantly in the two groups (p < .001; odds ratio, 3.9; 95% confidence interval, 2.3-6.4). In patients without neurologic deficits, only the presence of seizures was associated with a positive HCT (p < .01: logistic regression). The presence of either neurologic deficit or seizures best predicted a positive HCT: sensitivity 0.81, specificity 0.53, positive predictive value 0.50, and negative predictive value 0.83. CONCLUSION: Among MICU patients, the presence of either neurologic deficit or seizures is associated with the presence of an acute intracranial abnormality seen in HCT, but the association is not powerful enough to reliably depend on these clinical variables to select patients for HCTs in the MICU.

Stenting of the tracheobronchial tree.

Endoscopic treatment of endobronchial obstructions is becoming increasingly important. Tracheobronchial stents often are needed in the treatment of obstructions from submucosal or extrabronchial lesions. Tube stents have been available since the early 1960s but are underused because their insertion requires the use of a rigid bronchoscope. With the recent development of metallic stents, interventional radiologists increasingly are involved in the treatment of tracheobronchial obstructions. Metallic stents, easily placed with flexible bronchoscopy, are growing in popularity. All available tracheobronchial stents have been shown in various clinical series to be able to achieve immediate resolution of respiratory symptoms from various tracheobronchial obstructions. A stent's performance, however, should not be based solely on short-term response. Presently, there is no ideal stent because none is free of complications and none are able to consistently maintain life-long patency. Gianturco stents are associated with serious major complications (bronchial perforations and strut fractures) and are no longer recommended for use in the tracheobronchial tree. The Palmaz stent has also fallen into disfavor, because a strong external force, such as a vigorous cough, can recompress it. The Strecker stent can only be used in smaller airways, but may be useful in the accurate stenting of short segment stenoses because it does not foreshorten on deployment. The Wallstent and Ultraflex are our present metallic stents of choice. Both are easy to deploy, available in covered forms, exert adequate radial force, remain relatively stable in position, and have good longitudinal flexibility for use in tortuous airways. Disadvantages include excessive granulation tissue formation and difficulty of removal once the stent has been epithelialized. Metallic stents should be chosen very carefully for use in benign lesions with ongoing active local inflammation or when temporary stenting is needed. In the absence of an ideal stent, technologic advancements will continue. Potential developments include removable metallic stents, biodegradable stents, and chemically and radioactively coated stents. Unquestionably, the expanding stent market will drive scientific research toward the development of the ideal stent. Clearly, physicians need to be ready to assess these technologic advancements.

Role of bronchoscopy in lung cancer.

Advancements in technology and experience have pushed forth the bronchoscope's increasing role in the struggle against lung cancer. The bronchoscope is useful in the following situations: diagnosis, staging, treatment of endobronchial lesions for palliation or cure, early detection of lung cancer, and research. In this article, we provide a concise overview of several endoscopic modalities (i.e., transbronchial needle aspiration, laser photoresection, photodynamic therapy, electrocautery, cryotherapy, brachytherapy, stents, autofluorescence bronchoscopy, and gene therapy). Basic principles, technique, indications, outcome data, and associated complications of each modality are discussed.

Coronary spasm and cardiac arrest from carcinoid crisis during laser bronchoscopy.

Bronchoscopic manipulation of an endobronchial carcinoid can precipitate a carcinoid crisis. Coronary artery spasm is an uncommon manifestation of carcinoid crisis, and has never been reported as a complication of flexible bronchoscopy. We report a case of a 10-year-old girl who developed coronary artery spasm and cardiac arrest during neodymiumyttrium aluminum garnet (Nd-YAG) laser photoresection of an endobronchial carcinoid. Recognition of this unusual presentation of a carcinoid crisis is important as the treatment approach differs from standard resuscitation protocols.

Pneumocystis carinii pneumonia diagnosed by non-induced sputum stained with a direct fluorescent antibody.

Non-induced expectorated sputum (NIS) stained with tinctorial stains is not considered useful in the diagnosis of Pneumocystis carinii pneumonia (PCP). The diagnostic yield of NIS was evaluated in human immunodeficiency virus (HIV)-infected patients, when stained with a more sensitive direct fluorescent antibody for PCP-direct fluorescent antibody (PC-DFA). A retrospective analysis was carried out on fifty-five HIV-infected patients with PCP, who had NIS submitted for staining with PC-DFA. Thirty had positive NIS with PC-DFA and all had clinical courses consistent with PCP. Twenty-five had negative NIS with PC-DFA and were diagnosed as having PCP, by autopsy (n = 2), by a positive bronchoalveolar lavage (n = 10), or by having a clinical course consistent with PCP (n = 13). Thus, the sensitivity of NIS stained with PC-DFA was 55 percent (30/55). This is within the range reported in the literature for induced sputum for the diagnosis of PCP. Non-induced sputum stained with PC-DFA can be useful for the diagnosis of PCP in HIV-infected patients.

Retrospective analysis: are fever and altered mental status indications for lumbar puncture in a hospitalized patient who has not undergone neurosurgery?

Although nosocomial meningitis is rare in nonsurgical patients, lumbar punctures are frequently performed on hospitalized medical patients who develop delirium and/or fever. A retrospective review was undertaken to determine the yield of lumbar puncture in this setting and to compare it with the yield for suspected community-acquired meningitis. Of 232 lumbar punctures studied, 51 (22%) were performed to rule out nosocomial meningitis, while 181 (78%) were done to rule out community-acquired meningitis. No lumbar puncture performed for suspected nosocomial meningitis was positive, while results of 26 (14%) of those done for suspected community-acquired meningitis were abnormal (P < .01). Patients whose lumbar punctures were positive more often had headache or meningeal signs than those whose lumbar punctures were negative, and only 11 patients (22%) who had lumbar punctures performed for suspected nosocomial meningitis had headache or meningeal signs. We conclude that lumbar punctures performed for suspected nosocomial meningitis in nonsurgical patients have a low yield and that in some low-risk patients without headache or meningeal signs, lumbar puncture may be unnecessary.