Combined aztreonam and gentamicin therapy for pseudomonal lower respiratory tract infections.

A multicenter, open-label study was performed to assess the efficacy and safety of aztreonam plus gentamicin in the treatment of lower respiratory tract infections due to Pseudomonas aeruginosa. Patients with documented P aeruginosa infections were given aztreonam 2 g every 8 hours (q8h) plus gentamicin 3 to 5 mg/kg per day in three equal doses. Clindamycin, 600 mg q8h, was added to the regimen for patients with infections also involving gram-positive and/or anaerobic bacteria. Therapy was continued for at least 5 days or until obvious failure to respond to treatment. Of 64 patients with suspected P aeruginosa infections, 57 were eligible for clinical evaluation and 51 for microbiologic evaluation. At entry, impaired host defense was present in 35% of patients, and chronic obstructive pulmonary disease in 28%, in addition to other predisposing conditions such as emphysema, history of tuberculosis, and pneumothorax. The clinical response rate for the combination regimen was 48/57 (84%), which included 27 (47%) cures and 21 (37%) partial responses. The microbiologic response rate was 35/51 (69%), of which 25 (49%) outcomes were classified as eradication and 10 (20%) as eradication with relapse. Superinfection was observed in 3 (6%) patients. The combination of aztreonam and gentamicin was synergistic in the initial isolates obtained from 33 (72%) patients. A total of 16 patients died of pulmonary or other underlying disease, for a mortality rate of 28%. The monobactam-aminoglycoside combination was generally well tolerated. Two other patients were withdrawn because rashes emerged on treatment. This study demonstrates that aztreonam can be administered as one component of a synergistic monobactam-aminoglycoside therapy in the treatment of nosocomial lower respiratory tract infections involving P aeruginosa.

Positive end-expiratory pressure in the management of lobar atelectasis.

Positive end-expiratory pressure (PEEP) has been extensively utilized in the treatment of severe hypoxemia from noncardiogenic pulmonary edema. The usefulness of therapy with PEEP in the management of lobar atelectasis has not been previously stressed. Recently, we observed four patients with lobar atelectasis who failed to respond to the usual conservative measures of endotracheal suctioning and thoracic physiotherapy. Atelectasis was confirmed by physical examination and chest x-ray films, and three of the four patients subsequently underwent fiberoptic bronchoscopic examination. Endobronchial obstruction was not found, and despite extensive irrigation and suctioning, the atelectasis failed to resolve. Therapy with PEEP was then added, with pressures of 5 to 15 cm H2O. Serial chest x-ray films disclosed resolution of the atelectasis within 4 1/2 hours in two patients, within 14 hours in one patient, and within 24 hours in the remaining patient.

Endobronchial metastasis from prostatic cancer in patient with renal cell carcinoma.

A patient was seen with a right upper lobe endobronchial mass initially thought to be brochogenic carcinoma. There was a history of prostatic carcinoma, and subsequent investigation demonstrated a hypernephroma. Thoracotomy and special studies proved the endobronchial metastasis to be prostatic in origin, a rare cause of endobronchial metastasis.

False-positive cytological diagnosis of lung carcinoma in patients with pulmonary infarcts.

Cytological examination of specimens obtained from the tracheobronchial tree has become an integral part of the evaluation of pulmonary lesions. Cytological criteria for the diagnosis of carcinoma exist and are well defined. Certain benign processes, however, may possess features strongly suggestive of carcinoma of the lung. We report 3 patients in whom a positive cytological diagnosis of carcinoma of the lung was made by an experienced cytopathologist. At operation each patient was found to have pulmonary infarct and no evidence of carcinoma. Review of this experience has disclosed cytological and clinical features that should alert the clinician to the possibility that the cytological diagnosis of lung cancer may be misleading in certain nonmalignant diseases.

Subclavian placement of flow-directed thermodilution catheters. A rapid and safe technic.

A rapid and safe method for the placement of No 7 French flow-directed thermodilution catheters via an infraclavicular subclavian approach is described.

Transvenous pulmonary embolectomy for acute massive pulmonary embolism.

Transvenous pulmonary embolectomy employing a vacuum-cupped directionally controlled catheter is a relatively new technique used in the management of major pulmonary embolism. We present the findings in a patient with acute massive pulmonary embolism who underwent transvenous pulmonary embolectomy, with immediate and marked improvement in hemodynamic function and survival. Insertion of a new intracaval filter at the same time provided protection against recurrent thromboembolism.