Effectiveness of medical thoracoscopy and thoracoscopic talc poudrage in patients with exudative pleural effusion.

INTRODUCTION: This study aimed to assess the effectiveness of medical thoracoscopy (MT) and thoracoscopic talc poudrage (TTP) in patients with exudative pleural effusion. METHODS: We evaluated the diagnostic yields, complications and outcomes of MT and TTP in 41 consecutive patients with symptomatic pleural effusions who were planned to undergo both procedures from 1 December 2011 to 30 November 2012. Data was reviewed retrospectively and prospectively up to March 2013. RESULTS: Among the 41 patients, 36 underwent MT with the intent of biopsy and talc pleurodesis, 2 underwent MT for pleurodesis only and 3 had failed MT. Aetiologies of pleural effusion included lung cancer (n = 14), tuberculosis (n = 9), breast cancer (n = 7), ovarian cancer (n = 2), malignant mesothelioma (n = 1), congestive cardiac failure (n = 1), peritoneal dialysis (n = 1) and hepatic hydrothorax (n = 1); pleural effusion was undiagnosed in five patients. The overall diagnostic yield of MT, and the yield in tubercular and malignant pleural effusions were 77.8%, 100.0% and 82.6%, respectively; it was inconclusive in 22.2%. Complications that occurred were self-limiting, with no procedure-related mortality. The 30-day mortality rate was 17.1%. A total of 15 patients underwent TTP. The 30-, 60- and 90-day success rates were 77.8%, 80.0% and 80.0%, respectively, with one patient having complications (i.e. empyema). The 30-day mortality was 40.0%. CONCLUSION: MT is a safe procedure with high diagnostic yields in undiagnosed pleural effusions. TTP is an effective method to stop recurrence of pleural effusions.

Overlap syndrome between chronic obstructive pulmonary disease and obstructive sleep apnoea in a Southeast Asian teaching hospital.

INTRODUCTION: Overlap syndrome between obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is important but under-recognised. We aimed to determine the prevalence of overlap syndrome and the predictors of OSA in patients with COPD. METHODS: Patients aged ≥ 40 years were recruited from a dedicated COPD clinic and underwent overnight polysomnography. A diagnosis of OSA was made when apnoea-hypopnoea index (AHI) was ≥ 5. RESULTS: In all, 22 patients (aged 71 ± 9 years), predominantly men, were recruited. Mean values recorded were: predicted forced expiratory volume in the first second percentage 55 ± 15; body mass index 23.7 ± 6.5 kg/m2; Epworth Sleepiness Scale score 5.6 ± 5.8; and AHI 15.8 ± 18.6. Among the 14 patients with OSA (prevalence of overlap syndrome at 63.6%), the mean number of hospital visits for COPD exacerbations in the preceding one year was 0.5 ± 0.7. Patients with overlap syndrome had worse modified Medical Research Council dyspnoea scale scores and a lower percentage of rapid eye movement (REM) sleep than patients without. There were no other statistical differences in lung function or sleep study indices between the two patient groups. CONCLUSION: The majority of our patients had overlap syndrome and minimal exacerbations, and were not obese or sleepy. Significant differences between patients with and without overlap syndrome were seen in two aspects - the former was more dyspnoeic and had less REM sleep. Our findings suggest that standard clinical predictors cannot be used for patients with overlap syndrome, and therefore, a high index of suspicion is needed.

The prevalence of syndrome Z (the interaction of obstructive sleep apnoea with the metabolic syndrome) in a teaching hospital in Singapore.

BACKGROUND: Syndrome Z describes the interaction of obstructive sleep apnoea (OSA) with the metabolic syndrome. PURPOSE OF STUDY: A pilot study to determine the prevalence of syndrome Z in a teaching hospital in Singapore. METHODS: Patients (age > or =18 years) recruited for this prospective study had to satisfy three of the following five inclusion criteria: fasting glucose >6.1 mmol/l, blood pressure >/=130/85 mm Hg, HDL cholesterol <1.04 mmol/l in men and <1.2 mmol/l in women, triglycerides > or =1.7 mmol/l, and a waist circumference >102 cm in men and >88 cm in women. All subjects underwent standard overnight polysomnography. Overnight fasting glucose and lipid levels were measured and baseline anthropometric data recorded. All sleep studies were scored and reported by a sleep physician. OSA was deemed to be present if the respiratory disturbance index (RDI) was > or =5, with mild, moderate and severe categories classified according to the Chicago criteria. RESULTS: There were 24 patients (19 males and five females) of whom 10 were Chinese, eight Malay and five of Indian origin, with one other. Mean age was 48+/-13.5 years, mean body mass index was 34.9+/-6.1 kg/m2 and mean waist circumference was 111.3+/-15.7 cm. 23 (95.8%) of the patients had OSA with a mean RDI of 39.6+/-22.4 events/h with 15 patients (62.5%) in the severe category. The five patients who fulfilled all five criteria for diagnosis of the metabolic syndrome had severe OSA. CONCLUSION: The prevalence of OSA in our studied population exhibiting the metabolic syndrome is very high. Therefore, a polysomnogram should always be considered for this subset of patients.