Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care.

The aim of the present study was to establish the agreement between two recommended definitions of airflow obstruction in symptomatic adults referred for spirometry by their general practitioner, and investigate how rates of airflow obstruction change when pre-bronchodilator instead of post-bronchodilator spirometry is performed. The diagnostic spirometric results of 14,056 adults with respiratory obstruction were analysed. Differences in interpretation between a fixed 0.70 forced expiratory volume in one second (FEV(1))/forced vital capacity (FVC) cut-off point and a sex- and age-specific lower limit of normal cut-off point for this ratio were investigated. Of the subjects, 53% were female and 69% were current or ex-smokers. The mean post-bronchodilator FEV(1)/FVC was 0.73 in males and 0.78 in females. The sensitivity of the fixed relative to the lower limit of normal cut-off point definition was 97.9%, with a specificity of 91.2%, positive predictive value of 72.0% and negative predictive value of 99.5%. For the subgroup of current or ex-smokers aged > or =50 yrs, these values were 100, 82.0, 69.2 and 100%, respectively. The proportion of false positive diagnoses using the fixed cut-off point increased with age. The positive predictive value of pre-bronchodilator airflow obstruction was 74.7% among current or ex-smokers aged > or =50 yrs. The current clinical guideline-recommended fixed 0.70 forced expiratory volume in one second/forced vital capacity cut-off point leads to substantial overdiagnosis of obstruction in middle-aged and elderly patients in primary care. Using pre-bronchodilator spirometry leads to a high rate of false positive interpretations of obstruction in primary care.

Exercise-induced spontaneous hemothorax insinuates trauma; yet unmasks a lament disorder.

The investigation for a plausible explanation of the development of massive spontaneous hemothorax during exercise in two patients led to the disclosure of two different malignancies. The first patient (pleural fibrosarcoma) passed away shortly after diagnosis. The second patient is alive without signs of disease (peripheral neuro-ectodermal tumor, PNET) since the diagnosis was made 3 years before. Spontaneous hemothorax (SH) arising during exercise does not exclusively designate trauma and full search for anatomical abnormality is warranted.

Bronchial intraepithelial neoplastic lesions in head and neck cancer patients: results of autofluorescence bronchoscopy.

To determine the efficacy of autofluorescence bronchoscopy for detection of bronchial intraepithelial neoplastic lesions in head and neck cancer patients, we analyzed data from head and neck cancer patients who underwent both white light bronchoscopy and autofluorescence bronchoscopy for the rates of detection of intraepithelial neoplastic lesions. The results of the histopathologic examination were compared with the bronchoscopic findings. The sensitivity for detection of intraepithelial neoplastic lesions was calculated. Eleven moderate dysplasias and 3 severe dysplasias were detected during 8 of the 42 bronchoscopic examinations (19%) in 6 of the 24 patients (25%). The sensitivities for white light bronchoscopy alone and for white light bronchoscopy combined with autofluorescence bronchoscopy for detection of intraepithelial neoplastic lesions were, respectively, 21% (3 of 14) and 57% (8 of 14). In short, bronchial intraepithelial neoplastic lesions were found in a considerable percentage of head and neck cancer patients. Use of autofluorescence bronchoscopy improved the detection of these lesions.

Outcome of bronchial carcinoma in situ.

INTRODUCTION: The proportion of patients with carcinoma in situ in whom invasive cancer will develop is not known. It is important for clinical decision making to know the outcome of these lesions. The same applies for studies assessing the effectiveness of chemoprevention treatment or endobronchial therapy. METHODS: The records of patients with a bronchial carcinoma in situ who had undergone autofluorescence bronchoscopic examinations at regular intervals during a follow-up period for at least 6 months were reviewed. Data were examined for the outcome of carcinoma in situ, and for the detection, course, and bronchoscopic findings of neoplastic lesions at other bronchial sites. RESULTS: Progression to carcinoma occurred in five of nine patients (56%) with a carcinoma in situ. Eight neoplastic lesions were detected at other sites in four of the nine patients (44%). In earlier biopsy specimens of two sites that later showed a severe dysplasia and a carcinoma, only normal epithelium was found. Biopsies had been performed at these sites because they were assessed as suspicious during autofluorescence bronchoscopy. CONCLUSION: The majority of sites showing a carcinoma in situ progressed to invasive carcinoma. A considerable portion of the patients had neoplastic lesions at other bronchial sites. The fluorescence pattern of the bronchial mucosa may reflect early changes that are not found at histopathologic examination, but which may progress to neoplastic growth.

Tissue effects of bronchoscopic electrocautery: bronchoscopic appearance and histologic changes of bronchial wall after electrocautery.

STUDY OBJECTIVES: To study tissue effects of bronchoscopic electrocautery (BE). DESIGN: In six patients with non-small cell lung cancer, a BE procedure was performed immediately before surgery. After patients were placed on ventilation, normal mucosa on different carinae was treated with a cautery probe (2-mm(2) surface area) at a power setting of 30 W with a variable time of application of 1 to 5 s. Bronchoscopic appearance of the treated area was documented photographically, and histologic changes of the bronchial wall were examined. SETTING: Bronchoscopy unit of a university hospital. MEASUREMENTS AND RESULTS: BE resulted bronchoscopically in whitening of the bronchial mucosa with crater-shaped lesions. After longer duration of BE application, deeper craters with more profound charring were seen. Histologic changes of the lesions showed craters containing a variable amount of necrotic tissue. In one case, thin subsegmental carinae were coagulated and measurements could not be performed. In the remaining five cases, microscopic findings revealed 0.2 +/- 0.1-mm necrosis after 1 s; 0.4 +/- 0.2-mm necrosis after 2 s; 0.9 +/- 0.5-mm necrosis after 3 s; and 1.9 +/- 0.8-mm necrosis after 5 s. A variable degree of tissue damage surrounding the necrotic tissue area was found. In one case, cartilage damage appeared after 3 s of coagulation, and extensive damage of the underlying cartilage was seen in four cases after 5 s of application. CONCLUSIONS: Superficial damage was obtained by short duration of BE (< or = 2 s), and longer duration of coagulation (3 s or 5 s) caused damage to the underlying cartilage. Bronchoscopic appearance after endobronchial electrocautery corresponded with the histologic changes.

High-resolution CT in patients with intraluminal typical bronchial carcinoid tumors treated with bronchoscopic therapy.

STUDY OBJECTIVE: To evaluate the extent to which high-resolution CT (HRCT) can predict the clinical outcome of bronchoscopic treatment with curative intent in patients with intraluminal typical bronchial carcinoid tumors. DESIGN: An observational study. SETTING: Bronchoscopy unit and radiology department of a university hospital. PATIENTS AND INTERVENTIONS: Eighteen patients with intraluminal typical bronchial carcinoid tumors in the absence of nodal and distant disease were treated with bronchoscopic electrocautery or Nd-YAG laser as an alternative to surgical resection. Prior to treatment, HRCT was performed. RESULTS: In 10 patients, HRCT showed no peribronchial tumor extension, and 9 of these patients were found to be tumor free after bronchoscopic treatment. So far during follow-up, none of these patients has had a recurrence of the tumor. The median duration of follow-up was 33 months (range, 13 to 68 months). In five patients, HRCT showed signs of peribronchial tumor extension. In three of these patients, specimens taken from biopsies performed after bronchoscopic treatment showed residual tumors, and salvage surgery was carried out. In three patients, HRCT was unable to assess peribronchial tumor extension: in two because of insufficient connective tissue contrast between the hilar structures and in one patient because of suboptimal scan technique. CONCLUSION: HRCT findings were complementary but not conclusive in patients with intraluminal typical bronchial carcinoid tumors treated with bronchoscopic therapy. However, in a category of patients in whom HRCT showed strictly intraluminal tumors, bronchoscopic resection as an alternative for surgical resection seems justified.

Assessment of sleep complaints and sleep-disordered breathing in a consecutive series of obese patients.

BACKGROUND/OBJECTIVE: The prevalence of sleep-related complaints (SRC) and the frequency of sleep-disordered breathing (SDB) in obese patients has not been studied extensively. We investigated SRC and SDB in a group of obese persons as part of a preoperative workup for weight reduction (bariatric) surgery. METHODS: All consecutive patients attending a weight-loss clinic for evaluation for bariatric surgery were asked to complete a questionnaire. The questionnaire consisted of a section on SRC and a validated general sleep questionnaire (Sleep Wake Experience List). The patients underwent sleep studies in which an Edentrace recorder registered heart rate, chest wall movements by impedance, airflow and oxygen saturation. RESULTS: Fifty-one patients (14 men, 37 women) were evaluated. Mean body mass index (BMI) was 45 kg/m2 (range 33-61). Eighteen patients (35%) demonstrated SDB, defined as (a) an apnea/hypopnea index 5, and/or (b) more than 2% of registration time with an oxygen saturation below 90%. There was no difference between these 18 patients and patients who did not exhibit SDB in age, sex, BMI or SRC. Seven patients had SDB of a severity warranting closer investigation and perioperative monitoring. CONCLUSION: Both SRC and SDB are common in obese patients. Limited nocturnal respiratory monitoring is indicated as part of the preoperative workup for weight reduction surgery.

Prevalence and severity of sleep disordered breathing in a group of morbidly obese patients.

BACKGROUND: Obesity may be complicated by sleep disordered breathing (SDB). The presence of SDB is associated with increased morbidity and mortality. Patient characteristics, pulmonary function tests and daytime arterial blood gas analyses may help to identify patients with SDB. These variables and the prevalence and severity of sleep disordered breathing were studied in a group morbidly obese patients. METHODS: Forty-eight patients, 19 men and 29 women who were referred to our clinic of internal medicine because of their obesity were included. Characteristics, pulmonary function tests and daytime arterial blood gas analyses of groups with different grades of SDB were compared. RESULTS: Male subjects had significantly more apnoeas/hypopnoeas per hour (AHI) (18.4 +/- 20.9 versus 4.8 +/- 9.4) with more desaturation, a lower mean saturation (92.6 +/- 4.1 versus 96.1 +/- 1.6) and a lower saturation nadir (73.8 +/- 12.0 versus 83.1 +/- 6.7). Five (26%) of the male subjects and none of the female subjects had severe SDB (AHI > or = 25). Subjects were divided into three groups according to the severity of their SDB: twenty-nine subjects (23 women and 6 men) with AHI < 5, 14 subjects (6 women and 8 men) with AHI > or = 5 and < 25 and 5 subjects, all men, with AHI > or = 25. Except for gender no significant differences were found between the three groups. CONCLUSION: Our study confirms the findings that morbidity obese men have SDB more frequently and more severely than obese women. Patient characteristics other than gender, pulmonary function tests and daytime blood gas analyses have no predictive value.

Results of two years expenience with fluorescence bronchoscopy in detection of preinvasive bronchial neoplasia.

The aim of the study was to determine whether use of fluorescence bronchoscopy improves the detection of preinvasive neoplastic bronchial lesions. The data of all patients who underwent fluorescence bronchoscopy and in whom bronchial biopsies were taken, were analyzed. Most patients were at risk for preinvasive lesions. A total of 174 bronchoscopies were performed in 95 patients. Of the 681 representative biopsies, 31 were found to be moderate dysplastic, 39 were found to be severe dysplastic and 9 exhibited carcinoma in situ. These 79 preinvasive lesions were found in 34 patients. The respective results of fluorescence bronchoscopy in addition to conventional bronchoscopy and of conventional bronchoscopy alone for detection of preinvasive lesions were: sensitivity 85% (67/79) and 59% (47/79); specificity 60% (351/581) and 85% (493/581); positive predictive values of 23% (67/297) and 35% (47/135); negative predictive values of 97% (351/363) and 94% (493/525). A separate analysis of only the first bronchoscopy of each patient showed similar results. Results of fluoresence bronchoscopy were better in the second part of the patient group. We conclude that after a learning period fluorescence bronchoscopy can increase the yield of finding preinvasive neoplastic lesions when used in addition to conventional bronchoscopy.

Bronchoscopic treatment of intraluminal typical carcinoid: a pilot study.

OBJECTIVE: The curative potential of various bronchoscopic treatments such as Nd:YAG laser, photodynamic therapy, and brachytherapy for the treatment of intraluminal tumor has been reported previously. Bronchoscopic treatment can be used to treat small intraluminal tumor with curative intent, such as in patients with roentgenologically occult squamous cell cancer. In a retrospective study, we showed that bronchoscopic treatment provided excellent local control with surgical proof of cure in 6 of 11 patients with intraluminal typical bronchial carcinoid. METHODS: In a prospective study, 19 patients (8 women and 11 men) with resectable intraluminal typical bronchial carcinoid have undergone bronchoscopic treatment under general anesthesia. Median age was 44 years (range, 20-74 years). If tumor persisted after 2 bronchoscopic treatment sessions, surgery was performed within 4 months after the treatment. RESULTS: Bronchoscopic treatment was able to completely eradicate tumor in 14 of the 19 patients (complete response rate 73%, 95% CI: 49%-91%). Median follow-up of these patients is 29 months (range, 8-62 months). One patient had severe cicatricial stenosis after bronchoscopic treatment, and sleeve lobectomy was necessary. No residual carcinoid was found in the resected specimen. In the remaining 5 patients, bronchoscopic treatment did not result in a complete response and radical surgical resection was performed afterward with confirmation of residual carcinoid in the resected specimen. Median follow-up of the surgical group is 34 months (range, 12-62 months). CONCLUSIONS: Current data suggest that bronchoscopic treatment may be an effective alternative to surgical resection in a subgroup of patients with resectable intraluminal typical bronchial carcinoid. It alleviated the necessity of surgical resection in 68% (95% CI: 43%-87%) of the patients.

Radiographically occult lung cancer treated with fibreoptic bronchoscopic electrocautery: a pilot study of a simple and inexpensive technique.

The curative potential of bronchoscopic intervention, e.g. photodynamic therapy (PDT) and brachytherapy, for resectable radiographically occult lung cancer has been reported previously. Bronchoscopic electrocautery is currently feasible using an insulated flexible bronchoscope to coagulate and vaporize tumour tissue. Since the lesions are usually small, noninvasive bronchoscopic electrocautery may be able to eradicate radiographically occult lung cancer completely. In a prospective study, 13 patients with 15 radiographically occult lung cancer lesions were treated with bronchoscopic electrocautery. The duration of follow-up was > or = 16 months. The median age of the patients was 69 yrs (range 48-79 yrs). Fibreoptic bronchoscopy under local anaesthesia was used to coagulate the occult lung cancer. Approximately 30 W of energy was applied until visible necrosis of the tumour area became apparent. There were no immediate complications. In 10 patients with 12 lesions, a complete response (CR) was obtained (CR rate 80%; 95% confidence interval (95% CI) 52-96%). Median duration of follow-up was 21 months (range 16-43 months). Bronchoscopic electrocautery did not obtain a CR in the remaining three patients, but PDT also failed to achieve CR. Two patients underwent radical resection, and the tumours were histologically confirmed to be more invasive. One patient received external radiotherapy. Three patients with a CR died during follow-up, two as a result of myocardial infarction and apoplexy, and one because of metastasis from his previously resected T3N1 primary large cell cancer. Current data show bronchoscopic electrocautery to be equally effective and potentially as curative as photodynamic therapy for treating patients with radiographically occult lung cancer. Obvious advantages are that it is an inexpensive and simple procedure, which does not cause photosensitivity.