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PubMed1983

Clinical studies of measuring extravascular lung water by the thermal dye technique in critically ill patients.

We measured extravascular lung water (EVLW) by the thermal-dye technique in a broad group of critically ill patients who had either acute cardiac or noncardiac illnesses. A portable AP supine chest roentgenogram, reviewed blindly, was used to classify patients as to the presence or absence of pulmonary edema; by clinical history we categorized patients into either a cardiac or noncardiac (ie, ARDS) group. With a normal chest roentgenogram, the mean EVLW was 5.6 +/- 1.8 ml/kg, and the pulmonary capillary wedge pressure (PCWP) was 11.3 +/- 5.3 mm Hg (mean +/- SD). In contrast, patients with pulmonary edema on a cardiac basis had a mean EVLW of 10.2 +/- 3.1 ml/kg (mean PCWP, 20.5 +/- 8.2 mm Hg), while patients with clinically defined noncardiac pulmonary edema and a normal PCWP (11.6 +/- 5.7 mm Hg) had a mean EVLW of 15.8 +/- 4.6 ml/kg, significantly higher than in the cardiac group (p less than 0.001). On a severity system of 014, the EVLW increased in parallel to the severity of the chest radiologic appearance of edema in both the cardiac (r2 = .44; p less than 0.001) and noncardiac (r2 = .59; p less than 0.001) patients. This study defined a normal range of thermal-dye EVLW in critically ill patients without radiologic evidence of pulmonary edema. We further demonstrated the increased pulmonary microvascular permeability of noncardiac pulmonary edema compared with cardiac edema by the greater EVLW at normal microvascular hydrostatic pressures in the former group.

Adult↗
PubMed1984

Radiographic recognition of chest tube malposition in the major fissure.

Twelve patients with a chest tube positioned in the major fissure of either lung were collected prospectively in a two-year period. In eight of these 12, there was evidence of chest tube malfunction, with poor drainage of pleural air or fluid collections; in six of these eight, placement of additional tubes or tube repositioning resulted in improved pleural drainage. In all 12, the tube had been placed through the lateral chest wall. Although tube placement in the major fissure can sometimes be suspected on the anteroposterior portable chest roentgenogram because of the tube's characteristic course, in such cases a lateral roentgenogram is not usually obtained for confirmation of location unless there is evidence of tube malfunction.

Adult↗
PubMed1984

Radionuclide localization of massive pulmonary hemorrhage.

Lung scans with technetium sulfur colloid were performed in ten patients with life-threatening hemoptysis and nondiagnostic chest roentgenograms. Localized deposition of radionuclide was demonstrated in five of the six patients who were studied during active bleeding. These abnormalities were confirmed bronchoscopically in four patients, and lung scans provided clinically useful information regarding the bleeding site that had not been available from the medical history, physical examination, or chest roentgenogram. Evaluation with radionuclide scanning may complement bronchoscopic and roentgenographic studies in selected patients with massive pulmonary hemorrhage.

Adult↗
PubMed1984

Epidemic of pulmonary blastomycosis (Namekagon fever) in Wisconsin canoeists.

Epidemics of pulmonary blastomycosis have rarely been reported. The following epidemic occurred in a Minnesota family and several of their acquaintances after a canoeing trip in northwestern Wisconsin. The common exposure area was most likely a campsite, located along the upper reaches of the Namekagon River. The Namekagon River Valley is a known endemic area of Namekagon fever (blastomycosis) in dogs. Approximately one month after returning home, five of the eight members of the group had positive direct microscopic examinations and cultures of Blastomyces dermatitidis from their sputa, as well as abnormalities on their chest roentgenograms. Among these five patients, four were symptomatic, with fever, cough, and pleuritic chest pain. Of the three others, one had pleuritic chest pain with a transient lung infiltrate, the second was asymptomatic with a transient lung infiltrate, and the third was asymptomatic with a normal chest roentgenogram. Results of acute serologic tests (complement fixation and immunodiffusion) were negative in all five patients evaluated. None of the patients received antifungal therapy. Follow-up five years after the epidemic revealed that all eight were in excellent health, and none had evidence of continuing pulmonary or extrapulmonary disease.

Adult↗
PubMed1985

Sensitivity, specificity, and predictive values of bronchoscopy in neoplasm metastatic to lung.

Bronchoscopic examination to diagnose lung metastases has not been as rewarding as in primary lung cancer. Despite a lower expected yield, we believe the procedure has value in certain patients, ie, those with clinical findings of endobronchial disease. To determine better the value of bronchoscopy in this population, we retrospectively reviewed records of patients at five community teaching hospitals over a 66-month period. These patients all underwent fiberoptic bronchoscopy. They had a history of prior nonpulmonary malignancy and an abnormal chest roentgenogram suspicious for recurrent malignant disease, or they presented with abnormal chest roentgenographic findings and further evaluation showed the lung disease to be metastatic. Bronchoscopy for metastatic lung disease was most likely diagnostic in patients with primary colorectal cancer (79 percent) and breast cancer (57 percent), and least likely in patients with genitourinary tract cancer (33 percent). Hemoptysis, signs of local airway obstruction, or a roentgenogram showing either atelectasis or diffuse lung disease especially favored a positive biopsy. Bronchoscopy is a valuable diagnostic procedure in selected patients with metastatic lung disease.

Adolescent↗
PubMed1986

Initial roentgenographic manifestations of bacteriologically proven Mycobacterium tuberculosis. Typical or atypical?

Admission chest roentgenograms were reviewed of all patients diagnosed with pulmonary and extrapulmonary tuberculosis (TB) at the Medical College of Georgia--Eugene Talmadge Memorial Hospital (MCG-ETMH) during a five-year period from 1979 to 1983. Of 75 patients included, 51 had pulmonary TB, whereas 24 had extrapulmonary infection. Cavitary disease was common (28 of 51 patients with pulmonary TB). Forty-four of 51 patients with pulmonary TB had involvement of apical and/or posterior segments of the upper lobes with cavitation or infiltrates. Pleural effusion, parenchymal nodules, lymphadenopathy, and lower lung field disease were uncommon. Thirteen of 24 patients with extrapulmonary TB had abnormal admission chest roentgenograms, suggesting the possibility of Mycobacterium tuberculosis infection. Despite recent studies suggesting that TB presents with atypical roentgenographic features more commonly than reported in the past, the roentgenographic manifestations of TB in our series were typical of those previously described as pathognomonic for the disease.

Adolescent↗
PubMed1986

Endobronchial tuberculosis revisited.

Analysis was made of 20 patients with endobronchial tuberculosis proven by fiberoptic bronchoscopy and bronchial biopsy. Unlike prechemotherapy reports, the disease affects the older age group and more men. Only one half of the patients had fever, and the characteristic localized wheeze was found in 15 percent of cases. Chest roentgenogram showed typical collapse-consolidation in most cases; however, it was clear in 20 percent of patients. Sputum/smear was negative for AFB in 85 percent of patients. When the gelatinous granulation tissue was not found during bronchoscopy, a diagnosis of bronchogenic carcinoma was made incorrectly in 30 percent of patients. At a mean period of 27 months postchemotherapy, all 12 patients recalled for study developed bronchostenosis proven by bronchoscopy/bronchography except one. Noninvasive methods such as chest roentgenogram and flow-volume loops were insensitive for detection of stenosis. Steroid therapy probably did not influence outcome of tuberculous endobronchitis.

Adolescent↗
PubMed1986

Pulmonary function in Pi M and MZ grainworkers.

Twenty-eight men with the Pi MZ phenotype who have been employed in the Saskatchewan country grain elevators and thus regularly exposed to high levels of grain dust, were case matched for age, years of employment, employment status, smoking status, and smoking history with grainworkers of type Pi M. Individuals answered a questionnaire, had a chest roentgenogram, skin tests, and performed a battery of pulmonary function tests. There were no differences between the two groups in prevalence of symptoms or atopy. Although not statistically significant, the MZ group had three times as many individuals with abnormal roentgenograms suggestive of COPD as the M group. The Pi MZ grainworkers had consistently poorer mean results for the pulmonary function tests with significantly lower mean values for FEV1, FEV1/FVC, MMFR, and Vmax50, leading us to suggest that Pi MZ individuals may be at higher risk of COPD than Pi M individuals, but only in the presence of other risk factors such as grain dust exposure.

Adult↗
PubMed1986

Increased vascular pedicle width preceding burn-related pulmonary edema.

Widening of the vascular pedicle on the chest roentgenogram is a recently identified sign of increased circulating blood volume. To determine whether vascular pedicle enlargement can be detected during the initial day of burn resuscitation and whether this change correlates with the early development of pulmonary edema, we reviewed the serial chest roentgenograms of 42 patients with cutaneous burns and risk factors for inhalation injury. Although no patient had pulmonary edema at the time of vascular pedicle measurements, 18 (42.9 percent) developed this complication during the 3.3 +/- 1.5 days after injury. These patients were significantly older (p less than 0.025) and had received more resuscitative fluid (P less than 0.005) than those without pulmonary edema. Initial vascular pedicle width was similar in both groups (5.9 +/- 0.9 vs 6.0 +/- 1.0 cm) and did not change in patients without pulmonary edema (5.8 +/- 0.7 cm). Vascular pedicle width increased (6.9 +/- 1.2 cm, p less than 0.01) in patients who subsequently developed pulmonary edema, and 12 of the 13 patients who had changes exceeding +1.0 cm had this problem. Enlargement of the vascular pedicle is associated with early burn-related pulmonary edema and might provide a clinically useful predictor of this cardiopulmonary complication.

Adult↗
PubMed1987

Computed chest tomography in the evaluation of hemoptysis. Impact on diagnosis and treatment.

The results of computed chest tomograms (CT) and chest roentgenograms (CR) were compared in 32 patients who presented with hemoptysis. The CT demonstrated roentgenographic abnormalities more often than CR (p less than 0.01), providing new diagnostic information in 15 patients (46.9 percent), and clarifying CR abnormalities in five (15.6 percent) others. In addition, CT correctly localized sources of bleeding in 23 (88.5 percent) of the 26 patients in whom a site was identified at bronchoscopy, while CR localization was correct in 17 (65.4 percent) (p less than 0.05). Despite this augmentation of roentgenographic yield, information derived from CT scans influenced the management of only six patients, did not obviate the need for bronchoscopy, and supplemented the combined diagnostic yield of CR and bronchoscopy in only two. Outcome was changed in one patient in whom CT had demonstrated an otherwise unrecognized malignant solitary pulmonary nodule. The chest roentgenogram and fiberoptic bronchoscopy provided all the information essential for diagnosis and therapeutic recommendations in 93.7 percent of these patients. Although the CT provided additional information in over one half of our patients, its overall impact on clinical management was small and does not support routine use of this imaging procedure in evaluation of hemoptysis. The possible role of chest CT in evaluating carefully selected patients with hemoptysis requires further study.

Bronchitis↗
PubMed1987

Interobserver variance in clinical scoring for cystic fibrosis.

Multicenter clinical research would benefit from a simple, reliable scoring system for comparison of the clinical status of patients at different centers. In this study, five physicians performed simultaneous, independent scoring of 41 individuals with cystic fibrosis using the Doershuk modification of the Shwachman-Kulczycki scoring system for history, physical examination, and nutrition, and the Birmingham scoring system for chest roentgenograms. These were added together to obtain a clinical score. Interobserver variance of the scores was calculated. Mean individual observer variance from the consensus mean was 1.6-2.9 score points of a possible 25 for each category, 4.5-6.0 of a possible 100 for the total score. Coefficient of variance about the mean was approximately 10 percent for the individual categories, 6.7 percent for the total score. We concluded that the interobserver variance of this scoring system is within acceptable limit for most clinical studies. The total consensus score correlated with the NIH clinical score, chest roentgenogram score alone, and predicted values for forced vital capacity and FEV1 with a high degree of confidence.

Activities of Daily Living↗
PubMed1987

Ring-calcification of coronary artery aneurysms in an adolescent.

A 17-year-old asymptomatic boy with a history of Kawasaki disease in infancy was found to have an abnormal ring-calcification as seen in the chest roentgenogram and the electrocardiographic evidence of anteroseptal myocardial infarction. Coronary angiogram revealed aneurysms associated with ring-calcifications in the right coronary artery and subtotal obstruction of the left anterior descending coronary artery. A plain chest roentgenogram may, at times, be useful for identifying coronary aneurysms in patients with a possible history of Kawasaki disease.

Adolescent↗
PubMed1988

Roentgenographic underestimation of early asbestosis by International Labor Organization classification. Analysis of data and probabilities.

We analyzed the limitations of the International Labor Organization (ILO) classification of chest roentgenograms in predicting the presence of histologically determined early asbestosis. The ILO system is arbitrary, without histologic correlates, and does not consider the asbestos exposure history or clinical and laboratory information. We present data from the literature and our own work which demonstrate that the application of the ILO classification to an asbestos-exposed individual can result in a 10 to 20 percent probability of a "normal" roentgenographic interpretation in the presence of significant asbestosis at the histologic level, leading to an inappropriate conclusion regarding the presence of asbestosis. In view of the data and statistical analysis presented, we suggest that sole reliance upon the ILO classified chest roentgenogram for determination of the presence of early pulmonary asbestosis in individual cases is inappropriate.

Asbestosis↗
PubMed1988

Posterior mediastinal mass with intraspinous extension.

The differential diagnosis of masses in the posterior mediastinum includes neurogenic neoplasms, cysts, esophageal tumors, infectious processes including abscesses, and disorders of the thoracic spine. Nonoperative procedures, including transcutaneous and transbronchial biopsies and thoracoscopy, may not lead to a definitive diagnosis. We present two cases in which a neurogenic tumor, with and without significant spinal canal involvement, was diagnosed at thoracotomy after several nondiagnostic procedures. The appearance of the mass on chest roentgenogram can be used to narrow the preoperative differential diagnosis between ganglion-series and nerve-sheath tumors. The utility of computerized tomography of the chest, in addition to the chest roentgenogram, in assessing the bony involvement of the thoracic tumor is illustrated. The role of magnetic resonance imaging is yet to be fully defined in this entity. These lesions may be approached by separate thoracic and neurosurgical approaches, or by a combined, single-staged procedure. These cases and a review of the literature support the use of the single-staged approach.

Diagnosis, Differential↗
PubMed1988

Haziness of the right hemithorax in a newborn.

We describe a neonate with an accessory diaphragm, a rare congenital anomaly. It almost always occurs in the right hemithorax, which appears diffusely hazy on the anterior chest roentgenogram. The lateral chest roentgenogram is essential in the diagnosis of this condition.

Diaphragm↗
PubMed1989

Open lung biopsy in patients with non-Hodgkin's lymphoma and pulmonary infiltrates.

Patients with non-Hodgkin's lymphoma (NHL) are at increased risk for pulmonary infection with opportunistic pathogens associated with diminished cell mediated immunity. Open lung biopsy (OLB) frequently is recommended for diagnosis of pulmonary infiltrates in patients with NHL, but its usefulness for patient management and outcome has not been evaluated for patients with NHL. We reviewed the results of 20 consecutive OLB in 19 patients with previously diagnosed non-Hodgkin's lymphoma at Stanford University Medical Center during a nine-year period. Fifteen patients had known active lymphoma at time of OLB, and no patient had granulocytopenia. Ten of the 20 OLBs yielded specific diagnoses. A greater proportion of patients with stage I or II disease had specific diagnoses than patients with more advanced NHL. Five of 14 patients considered to have had a life threatening illness at the time of OLB had specific diagnoses from OLB vs five of six patients considered clinically stable. Chest roentgenograms that had discrete masses or nodules correlated with ability to establish a specific diagnosis by OLB. For patients in whom the results of OLB were nonspecific, management appeared unaffected by the OLB. The OLB in NHL appeared most useful for detecting recurrent NHL in clinically stable patients with discrete nodules or masses on chest roentgenogram. Pneumocystis pneumonia was the only infection identified by OLB.

Biopsy↗
PubMed1989

Kaposi's sarcoma. CT-radiographic correlation.

The role of CT in the diagnosis of intrathoracic Kaposi's sarcoma (KS) was evaluated retrospectively in 24 patients, in the absence of coexistent opportunistic infections. In all cases the diagnosis of KS was initially established by histologic evaluation of extrathoracic disease: 15 patients had verified parenchymal KS and nine patients endobronchial KS. (Chest roentgenograms were analyzed separately for each group: in 14 patients serial films were available for review. The predominant radiographic findings was the presence of nonspecific, bilateral, perihilar infiltrates in 22 of 24 cases (92 percent). Corresponding CT scans documented the presence of abnormal hilar densities characteristically extending into the adjacent pulmonary parenchyma along distinctly perivascular and peribronchial pathways. Discrete, poorly marginated nodules were identified radiographically in ten cases (42 percent); these proved to be randomly distributed throughout the parenchyma on CT. Radiographic evidence of mediastinal adenopathy was distinctly unusual, seen in only two cases (8 percent). While CT typically demonstrated shotty adenopathy, significantly enlarged nodes (greater than 1 cm) were rarely identified. We concluded that CT is more specific than routine roentgenograms for identifying pulmonary KS. While not pathognomonic, peribronchial and perivascular disease is sufficiently characteristic to obviate more invasive diagnostic procedures, especially in patients with established KS.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Pulmonary non-Hodgkin's lymphoma in AIDS.

Whereas extralymphatic involvement is common in lymphomas associated with HIV infection, there have been few reports of pulmonary lymphoma. In 648 cases of AIDS reported in Colorado, 40 have had non-Hodgkin's lymphoma. Of these, four have had documented pulmonary involvement and are reported in detail. Clinical manifestations were nonspecific and included fever, weight loss, generalized lymphadenopathy, dyspnea, chest pain and cough. Chest roentgenograms revealed multiple nodules or interstitial infiltrates. Transbronchial biopsy failed to establish the diagnosis in all cases. Three of four patients died four to five months after appearance of pulmonary nodules; one patient with stage IE disease showed slow radiographic progression over 16 months following radiation and chemotherapy and died 18 months after appearance of pulmonary nodules. Pulmonary involvement with lymphoma should be considered in patients with HIV infection, especially if multiple nodules are seen on chest roentgenograms.

Acquired Immunodeficiency Syndrome↗