A middle-aged woman with chronic productive cough diagnosed using sputum wet mount examination.
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Aspergillosis, Allergic Bronchopulmonary↗
Biomedical subjects
K G Torrington
Publications and source records attributed to K G Torrington.
Serum angiotensin converting enzyme does not correlate with radiographic stage at initial diagnosis of sarcoidosis.
Serum levels of angiotension converting enzyme (ACE) are elevated in many patients who suffer from sarcoidosis. Few studies have correlated ACE levels at diagnosis with the radiographic stage of the disease. The present authors reviewed the charts of all patients who had the diagnosis of sarcoidosis made between 1990 and 1995, and correlated ACE level at diagnosis with radiographic stage. Only patients with biopsy-proven sarcoid were included. One hundred and sixteen cases were identified, and complete data were available for 104 individuals. Serum ACE levels were increased in approximately 63.5% of the study population. The relationships between both stage and ACE level, and stage and percentage of individuals with elevated ACE levels within that stage were not statistically significant (P > 0.05). This large, retrospective study of patients with histologic evidence of sarcoidosis demonstrated no association between serum ACE level and radiographic stage.
Biomarkers↗
Endobronchial disease and racial differences in pulmonary sarcoidosis.
In a retrospective review of 7 years of Walter Reed Army Medical Center fiberoptic bronchoscopy records, 154 patients with biopsy specimen proved (122) and clinically diagnosed (32) sarcoidosis were identified. Endobronchial mucosal appearance was normal in only 70 (45%). Abnormal mucosal findings included erythema (29 patients), nodules (13), plaques (13), and cobblestoning (29). Fifty-nine patients were evaluated with endobronchial biopsies (EBBX), and non-necrotizing granulomata diagnostic of sarcoidosis were found in 42 (71%). The diagnostic yield from endobronchial biopsies was similar regardless of the type of mucosal abnormality. EBBX specimens were diagnostic in 85% of black patients and 38% of white patients (p = 0.00081), but diagnostic yield did not correlate with patient's sex, symptoms, radiographic stage of disease, or extent of physiologic abnormalities. Four patients with normal-appearing bronchial mucosa underwent EBBX, and sarcoidosis was diagnosed in two. Transbronchial lung biopsy (TBBX) specimens were diagnostic of sarcoidosis in 61 of 82 (74%) black and 28 of 56 (50%) white patients (p = 0.0038). We conclude that the bronchial mucosa appears abnormal in the majority (55%) of patients with sarcoidosis. EBBX specimens will diagnose sarcoidosis in a high percentage of such patients and should be performed routinely. EBBX may be preferable to TBBX because of its greater safety profile. In our patients, the yield of both EBBX and TBBX was significantly greater in African-Americans than white Americans.
Adolescent↗
Do-not-resuscitate decisions in the medical ICU: comparing physician and nurse opinions.
STUDY OBJECTIVE: To determine how soon after admission to a medical ICU physicians and nurses decide that attempts at resuscitation are inappropriate and how frequently physicians and nurses disagree about do-not-resuscitate (DNR) decisions. DESIGN: Prospective, opinion survey of care providers. SETTING: Ten-bed adult medical ICU in a university-affiliated tertiary care referral hospital. PATIENTS: Consecutive adult medical ICU admissions. INTERVENTIONS: Over 10 months, physicians and nurses were surveyed independently every day regarding their opinions about DNR issues on each patient in the ICU. MEASUREMENTS: ICU day when DNR order was deemed appropriate by either physicians or nurses. RESULTS: Of 368 consecutive admissions, 84 (23%) patients were designated DNR during their ICU stay. In 6 of these 84 cases (7%), the responsible nurse did not agree that DNR orders were appropriate. In the remaining 78 patients designated DNR, the median time for physicians to recommend DNR (median, 1 day; range, 0 to 22 days) was not significantly different from the median time for nurses (median, 1 day; range, 0 to 13 days); (p=0.45). For the 284 patients not designated DNR, physicians and nurses both believed DNR was appropriate in 14 cases (5%), but a DNR order was not written five times (2%) because there was not time to do so and nine times (3%) because patient or family did not concur. Physicians and nurses disagreed about a DNR recommendation in 33 of the 284 patients not designated DNR (12%). Physicians were more likely to believe that DNR was appropriate than were nurses (p<0.0005), with physicians alone recommending DNR 29 times (10%) and nurses alone favoring DNR in four cases (1%). CONCLUSIONS: At our institution, recognition of DNR appropriateness by nurses and physicians occurs over a similar time frame. However, physicians are more likely to recommend DNR in cases of disagreement between nurses and physicians.
Aged↗
Necessity of routine chest roentgenography after thoracentesis.
OBJECTIVE: To determine the necessity of posteroanterior chest roentgenography for the identification of pneumothorax and other complications after thoracentesis. DESIGN: Prospective cohort study. SETTING: Tertiary care teaching hospital. PATIENTS: 67 men and 43 women (mean age +/- SD, 62.4 +/- 13.2 years). Exclusion criteria included age younger than 18 years, concurrent pleural biopsy, ultrasound guidance, and use of mechanical ventilation. MEASUREMENTS: 174 thoracenteses done between March 1991 and June 1993. RESULTS: 2 hemothoraces (1.2%) occurred, and 8 patients had a total of 9 pneumothoraces (5.2%). The roentgenograms obtained immediately after the procedures identified 8 pneumothoraces; the other pneumothorax was seen incidentally on a delayed roentgenogram obtained 3 days later. Pneumothorax was suspected in 5 of the 8 cases, and tube thoracostomy was done in 4 of these 5 cases. Patients with unsuspected pneumothorax identified on the roentgenogram obtained immediately after the procedure did not receive treatment for their pneumothoraces. Univariate analysis showed that the variables that correlated significantly with pneumothorax were aspiration of air during the procedure (relative risk ratio, 12.3; 95% CI, 3.7 to 41.4), number of passes with the thoracentesis needle (relative risk ratio, 6.1; CI, 1.6 to 23.3), history of thoracic radiation therapy (relative risk ratio, 10.5; CI, 2.5 to 44.4), and operator suspicion of pneumothorax (relative risk ratio, 25.9; CI, 8.6 to 78.5). CONCLUSION: Among hospitalized patients with pleural effusions, we identified subgroup of patients in whom the risk for pneumothorax is low enough (approximately 1%) with sufficiently minimal clinical consequences to justify the avoidance of about 60% of chest roentgenograms obtained after thoracentesis. These patients are clinically stable, have not previously received chest irradiation, had only one pass at thoracentesis attempted without the aspiration of any air, and give no other indication of pneumothorax.
Aged↗
Postoperative pulmonary changes after laparoscopic cholecystectomy.
Laparoscopic cholecystectomy (LC) has been widely used in recent years because of short postoperative hospital stays and low morbidity. In this study, 24 patients were prospectively evaluated with preoperative and postoperative spirometry, arterial blood gas determinations, and chest radiographs to quantitate the magnitude of postoperative pulmonary changes after LC. Statistically significant reductions were noted in forced vital capacity (FVC) (mean decrease, 810 mL) and forced expired volume in 1 second (FEV1) (mean decrease, 420 mL). Clinically important changes in arterial blood gas values did not occur. Of 20 postoperative chest films, 7 showed the development of atelectasis or effusion and 9 showed persistence of subdiaphragmatic free air 24 hours after LC. In summary, LC caused mean decreases of 23% in FVC and 16% in FEV1 24 hours after surgery. The physiologic derangements that follow LC are sufficiently small that all but the most severely impaired patients with pulmonary disease should be able to tolerate this operation.
Blood Gas Analysis↗
Protocol-driven respiratory therapy. Closing in on appropriate utilization at comparable cost and patient outcomes.
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Adult↗
Pulse oximetry correction for smoking exposure.
Pulse oximetry oxygen saturation (SpO2) does not distinguish carboxyhemoglobin (COHb) from oxyhemoglobin (O2Hb), giving a false impression of the apparent degree of oxyhemoglobin saturation in smokers who have elevated levels of COHb. We questioned whether accounting for smoking exposure history could improve description of pulse oximetry by correcting for COHb levels. We evaluated smoking history and %SpO2 as predictors of %O2Hb and %COHb by CO-oximetry of arterial blood in 18 actively smoking and 18 age-matched nonsmoking patients in a clinical pilot study. The difference between %SpO2 and %O2Hb was significantly greater (p < 0.001) in the smokers (5.6 +/- 3.1) than the nonsmokers (2.1 +/- 2.1). This difference correlated with %COHb (rp = 0.789; p < 0.001) and the smoking exposure score (SES, rp = 0.621; p < 0.001), a six-point index we developed based on whether patients were active smokers, refrained from smoking prior to testing, or were exposed to passive smoking in the home or workplace. The following formula summarizes the correction: %O2Hb = 0.882[%SpO2] - 0.968[SES] + 9.245 (rp = 0.841; SES = 2.478; p < 0.001). This pilot study suggests that smoking exposure history correlates with COHb levels and that correction for smoking exposure improves the accuracy of pulse oximetry.
Carboxyhemoglobin↗
Small volume bronchoalveolar lavage used in diagnosing Pneumocystis carinii pneumonia in HIV-infected patients.
To determine the volume of bronchoalveolar lavage (BAL) fluid necessary to diagnose Pneumocystis carinii pneumonia (PCP) in immunocompromised patients, specimens from 25 patients were evaluated. Twenty-one patients were HIV infected. BAL was performed using three to four 60-mL aliquots of room temperature, sterile, saline solution. Each syringe of BAL effluent was numbered and its volume was measured. Immunofluorescent stains were performed on about 8-mL aliquots of the initial, final, and aggregate BAL specimens, and a modified Giemsa stain was also performed on a 0.4-mL aliquot of the aggregate specimen. Of 25 patients, Pneumocystis carinii organisms were identified in 9 with HIV infection, in whom all BAL specimens were positive with both immunofluorescence and Giemsa stains. In 16 patients, BAL specimens were negative for P carinii on both immunofluorescent and modified Giemsa testing. Both staining methods were 100% specific (95% confidence interval [CI], 83 to 100%) and 100% sensitive (95% CI, 72 to 100%). The volume of BAL effluent in the initial specimens positive for P carinii ranged from 15 to 25 mL. We conclude that in this small group of patients, PCP was accurately diagnosed from a single 60-mL BAL specimen stained with immunofluorescence methods.
AIDS-Related Opportunistic Infections↗
Exploratory thoracotomy for nonresectable lung cancer.
We sought to evaluate the effect of new diagnostic modalities on patients explored surgically for inoperable lung cancer. From July 1983 to February 1992, 335 patients underwent thoracotomy for lung cancer. Thirty-three of the 35 patients with nonresectable disease had sufficient data for analysis and underwent chest radiography (CXR), CT scan, and bronchoscopy. The study was terminated when video-assisted thoracoscopy (VAT) was introduced at the institution. Causes of nonresectability included significant N2 disease not diagnosed preoperatively (n = 11), tumor invasion of contiguous mediastinal structures (n = 8), and insufficient pulmonary function (n = 4). Four patients were left with unresected disease because of thoracic metastasis. Two patients had technically unresectable disease; three patients were explored surgically because diagnoses could be obtained by no other means. One patient was found to have small cell cancer. Data analysis demonstrated that 19 of 33 thoracotomies could potentially have been avoided or resulted in resection with current techniques. Refinement of imaging criteria, a judicious surgical approach to N2 disease, and VAT may significantly reduce thoracotomies for nonresectable lung cancer.
Aged↗
Adherence to established guidelines for preoperative pulmonary function testing.
Guidelines for ordering preoperative spirometry have been proposed by GM Tisi (1979) and more recently by the American College of Physicians (ACP). Requests for preoperative spirometries represent a significant portion of all requests for screening spirometry at our institution and utilize significant man-hours of technician time. We determined the percentage of these requests that did not meet the ACP guidelines and characterized why these requests were being generated. We sampled 441 screening spirometries performed by the Walter Reed Pulmonary Function Laboratory over a 4-week period. One hundred thirty-eight (31%) of these were done preoperatively and complete data were available in 135 cases. Patients in the analyzed group had a mean age of 59 years (+/- 14 years), ranging from 20 to 84 years of age. Fifty-two (39%) requests did not meet ACP guidelines. Most of these requests were associated with either normal spirometry (n = 34) or only mild spirometric abnormalities (n = 14). Spirometry revealed severe obstruction in only one case when the request was not indicated. No cases of moderate obstruction, severe restrictive pattern, or possible upper airway obstruction were found in the group of requests in which spirometry was not indicated. Of the requests that did not meet ACP guidelines, 21 met Tisi's broader guidelines. Most of these requests were found exclusively in patients older than 70 years of age (n = 13) and the morbidly obese (n = 4). Of the 31 studies that did not meet either set of guidelines, 25 occurred in asymptomatic, current, or prior smokers. In conclusion, during a 4-week study period at our institution, 39% of preoperative spirometry requests did not meet ACP guidelines. Most of the patients had been referred because of age greater than 70 years, morbid obesity, and a current/prior history of smoking. However, the literature does not support obtaining preoperative spirometry in such patients except for those undergoing only lung resection. We recommend stricter adherence to the ACP guidelines as a means of decreasing the number and cost of unnecessary spirometries being performed.
Adult↗
Fiberoptic bronchoscopy in the evaluation of newly diagnosed esophageal carcinoma.
To determine the diagnostic utility of fiberoptic bronchoscopy (FB) in the evaluation of patients with newly diagnosed esophageal carcinoma (EC) and whether FB findings impact therapy and survival, we retrospectively reviewed 2,832 FB records (1984 through 1992). Twenty-two cases were identified in which FB was performed to evaluate pulmonary involvement in patients with newly diagnosed EC. Two cases were eliminated due to data unavailability. Seventeen of 20 patients had no pulmonary symptoms and most of them (15/17) had normal chest radiographs. All three patients with pulmonary symptoms (cough, hemoptysis, dyspnea) had significant radiographic abnormalities. In the asymptomatic group, FB findings were normal in nine, showed extrinsic compression of the trachea and/or bronchi in seven, and demonstrated a submucosal tumor nodule in one. The pathologic diagnosis of malignant airway involvement was not made in any asymptomatic patient. In the three symptomatic patients, extensive endobronchial abnormalities were present. Therapy with surgery, radiation, and/or chemotherapy did not differ among patients with extrinsic compression compared to patients with normal FB. Average survival in the patients with normal endobronchial anatomy was 20.5 months, in the group with extrinsic compression 12.2 months, and in the group with marked endobronchial abnormalities, less than 1 month. Statistical analysis of our findings suggest that FB is a low-yield procedure in the evaluation of patients with EC unless pulmonary symptoms of cough and/or hemoptysis or chest radiographic abnormalities are present.
Bronchial Neoplasms↗
Sarcoidosis complicated by chylothorax.
Chylothorax is a rare complication of sarcoidosis; only one well-documented case has been described previously. Before chylothorax is diagnosed in a patient with sarcoidosis, infection and malignancy need to be aggressively excluded as possible diagnoses. We report the case of a 34-year-old black woman with sarcoidosis confirmed by lung, pleural, and mediastinal lymph node biopsies whose clinical course was complicated by chylothorax. Oral corticosteroid treatment resulted in prompt resolution of the chylothorax.
Adult↗
Fiberoptic bronchoscopy in the evaluation of carcinoma metastatic to the lung.
To determine the clinical presentation of patients with malignancies metastatic to the lung, the diagnostic utility of fiberoptic bronchoscopy (FB), and the primary site of malignancies metastasizing endobronchially, we retrospectively reviewed 1,853 FB records (1987 to 1991) and selected 111 cases for review. Cases were divided on the basis of FB findings into abnormal (44 patients) and normal (67 patients). Pulmonary symptoms (cough, hemoptysis, and chest pain) prompted referral significantly more often in the abnormal FB group (34/44) than in the normal FB group (24/67). The finding of atelectasis on chest radiograph occurred more frequently in patients with endobronchial abnormalities. The spectrum of extrapulmonary malignancies that metastasize endobronchially has changed during the AIDS epidemic. Our study shows the most frequent causes of endobronchial mass lesions were Kaposi's sarcoma and the lymphoma group (Hodgkin's disease, nonHodgkin's lymphoma, chronic lymphocytic leukemia) and the most common malignancies causing submucosal metastases were breast and the lymphoma group. In summary, the highest yield from FB can be expected in patients experiencing symptoms of cough or hemoptysis and/or having radiographic evidence of atelectasis. We propose a new mnemonic "KLAS" (Kaposi's sarcoma, Lymphoma, Adenocarcinoma, Sarcoma) to describe the malignancies most likely to metastasize endobronchially in the 1990s.
Biopsy↗
Right upper lobe pulmonary edema caused by acute mitral regurgitation. Diagnosis by transesophageal echocardiography.
Unilateral pulmonary edema is a distinctly unusual clinical entity, often misdiagnosed initially as one of the more common causes of focal lung disease. Predominantly lobar pulmonary edema is rarer still. We report a case of right upper lobe pulmonary edema caused by the acute onset of severe mitral regurgitation. In addition, we briefly review the other causes of unilateral pulmonary edema, focusing on the cases that have been reported in association with heart failure and valvular heart disease. The majority of cases of right upper lobe pulmonary edema have been associated with mitral regurgitation. In addition to confirming the presence of mitral regurgitation, transesophageal echocardiography proved useful in delineating the mechanism for edema formation. It detected differential gradients between the right and left pulmonary venous systems and documented the direction of the regurgitant flow.
Acute Disease↗
The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule.
To determine the value of routine, preoperative, fiberoptic bronchoscopy (FB) for diagnosing and treating patients (pts) with solitary pulmonary nodules (SPNs), we retrospectively reviewed the records of all pts with SPNs undergoing FB at Walter Reed Army Medical Center between January 1986 and December 1989. We defined SPNs radiographically as < or = 6 cm peripheral pulmonary lesions completely surrounded by pulmonary parenchyma. Of 191 charts reviewed, 91 (72 bronchogenic carcinomas [BC], 7 carcinoid tumors, 12 benign) constitute the study population. Fifty-four charts were eliminated because preoperative, clinical-radiologic staging revealed advanced (greater than stage I) BC or extrathoracic malignancy metastatic to the lung (44), the clinicians suspected benign disease and elected medical followup (3), the pt had medically inoperable disease (3), or the pt refused surgery (4). Forty-six charts were incomplete or unavailable. Fiberoptic bronchoscopy revealed one unsuspected vocal cord carcinoma and no occult synchronous BCs. Five pts had submucosal or endobronchial tumors and biopsy specimens showed BC in four of five tumors from which specimens were taken. Four of 66 (6 percent) cytologic evaluations of bronchial brushings or washings diagnosed BC. In pts shown at surgery to have BC, 9 of 30 transbronchial lung biopsy (TBBx) specimens showed BC. Diagnostic yield of TBBx specimens was not improved in the pts who underwent biopsies under fluoroscopic guidance. The 16 FB specimens positive for BC concurred 100 percent with the surgical specimens. The FB findings did not obviate the need for surgery nor alter the surgical stage of BC. A preoperative diagnosis of malignancy did not affect operative time or operative procedure, because many pts required frozen-section biopsy of mediastinal lymph nodes prior to lung resection. At our institution, routine, preoperative FB did not measurably benefit pts with SPNs.
Bronchoscopy↗
Utility of repeated fiberoptic bronchoscopy for suspected malignancy.
We retrospectively evaluated records of 1598 fiberoptic bronchoscopies (FBs) performed on 1,391 patients (PTs) between Jan 1, 1986 and Dec 31, 1990. We found a progressive increase from 11 percent to 20 percent in the use of repeated fiberoptic bronchoscopy (RFB). Of the 254 RFBs, 151 were done in PTs with known or suspected intrathoracic malignant neoplasms. The 78 (of 151) RFBs performed in PTs with previously diagnosed malignant neoplasms were used to guide additional therapy. The other major indication for RFB (67 of 151) was to evaluate new suspicious lesions that had not been diagnosed on the initial FB. RFB specimens were positive in 36, false-negative in 24, and true-negative in 7 PTs. For some PTs, RFB could probably have been avoided if at initial FB physicians had (1) used fluoroscopy to direct transbronchial lung biopsies in PTs expected to have normal airways, (2) performed transbronchial needle aspiration in all PTs with extraluminal disease or mediastinal adenopathy, and (3) obtained bronchial biopsy specimens from all PTs with endobronchial lesions. In PTs whose initial FB specimens were nondiagnostic despite visualization of endobronchial or extraluminal abnormalities, RFB was associated with a significant diagnostic yield and obviated the need for more morbid, surgical staging procedures.
Bronchoscopy↗
Patient-induced pulmonary embolism.
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Aged↗