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Topics: atrium
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Chest. 1995;108(6):1495-1498. doi:10.1378/chest.108.6.1495

Study objective: To determine and correct cause of high incidence of intra-aortic balloon leaks (ruptures).

Design: Epidemiologic investigation of factors associated with intra-aortic balloon leak, and sequential application of corrective measures evaluated by continued concurrent data collection.

Setting: Thirty-four-bed ICU in 598-bed tertiary care medical center.

Interventions: Procedure changed to place smaller balloons (34 mL instead of 40 mL) in patients less than 163 cm in height.

Measurements and results: Demographic and clinical data on all patients showed no change after initial interventions, followed by significant drop (8 to 2%) in incidence of balloon leak when smaller, shorter balloons were placed in shorter patients.

Conclusions: Placement of larger, longer balloons in patients increases risk of perforation of balloon by calcific plaque in the distal thoracic and abdominal aorta.

Chest. 1995;108(6):1499-1501. doi:10.1378/chest.108.6.1499

Recurrent pericardial effusion or tamponade can complicate malignant disease. The medical approach with pharmacologic agents has a high recurrence rate. Balloon pericardiotomy (BP) may provide a less invasive alternative to surgery. We performed BP in ten high-risk patients with malignant pericardial tamponade (MPT). BP was performed with aseptic technique under fluoroscopic and echocardiographic guidance. We used a percutaneous subxiphoid approach. A 20-to-25-mm-wide and 4-cm-long balloon was introduced over a stiff guide wire, positioned across the parietal pericardium, and manually inflated until the waisting disappeared. Echocardiographic study and chest radiograph were taken before, immediately after the procedure, and during follow-up. The procedure was successful and well tolerated in all patients. There were no immediate or late complications. No patients developed recurrence of pericardial effusion at up to 10 months' follow-up. In conclusion, BP can be performed in patients with MPT with high rate of procedural success. It may become the preferred treatment to avoid a more invasive procedure in these critically ill patients.

Chest. 1995;108(6):1502-1509. doi:10.1378/chest.108.6.1502

Study objective: To find an accurate algorithm for the diagnosis of acute myocardial infarction in nontraumatic chest pain patients on presentation to the emergency department.

Design: In a prospective clinical study, we compared the diagnostic performances of clinical symptoms, presenting ECG, creatine kinase, creatine kinase MB activity and mass concentration, myoglobin, and cardiac troponin T test results of hospital admission blood samples. By classification and regression trees, a decision tree for the diagnosis of acute myocardial infarction was developed.

Setting: Emergency room of a Department of Internal Medicine (University Hospital).

Patients: One hundred fourteen nontraumatic chest pain patients (median delay from onset of chest pain to hospital admission, 3 h; range, 0.33 to 22): 26 Q-wave and 19 non-Q-wave myocardial infarctions, 49 patients with unstable angina pectoris, and 20 patients with chest pain caused by other diseases.

Measurements and results: Of each parameter taken by itself, the ECG was tendentiously most informative (areas under receiver operating characteristic plots: 0.87±0.04 [ECG], 0.80±0.08 [myoglobin], 0.80±0.04 [creatine kinase MB mass], 0.77±0.04 [creatine kinase activity], 0.69±0.06 [clinical symptoms], 0.67±0.06 [creatine kinase MB activity], 0.67±0.05 [troponin T]). In patients presenting 3 h or less after the onset of chest pain, ECG signs of acute transmural myocardial ischemia were the best discriminator between patients with and without myocardial infarction. In patients presenting more than 3 h, however, creatine kinase MB mass concentrations (discriminator value, 6.7 µg/L) were superior to the ECG, clinical symptoms, and all other biochemical markers tested. This algorithm for diagnosing acute myocardial infarction was superior to each parameter by itself and was characterized by 0.91 sensitivity, a 0.90 specificity, a 0.90 positive and negative predictive value, and a 0.90 efficiency.

Conclusions: We found an algorithm that could accurately separate the myocardial infarction patients from the others on admission to the emergency department. Therefore, this classifier could be a valuable diagnostic aid for rapid confirmation of a suspected myocardial infarction.

Chest. 1995;108(6):1510-1513. doi:10.1378/chest.108.6.1510

Background: Women undergo evaluation and treatment for cardiac diseases less frequently than men with similar symptoms. The purpose of this study was to determine what differences exist in clinical evaluation and treatment between men and women presenting with coronary heart disease that may indicate a gender bias.

Methods: A single hospital retrospective review of patients admitted with the diagnosis of cardiac ischemic syndrome, undergoing stress testing, coronary arteriography, percutaneous interventional procedure, or coronary bypass surgery was performed, including an evaluation by gender of the demographic, clinical, and angiographic parameters of 1 year of patients undergoing hospital admission, evaluation, or revascularization therapy for coronary heart disease in a single university hospital.

Results: Women admitted to the coronary care unit with a coronary diagnosis were less likely to undergo coronary arteriography than men. Women having a positive stress test result were as likely to undergo coronary arteriography as men with similar findings. Women undergoing coronary arteriography were as likely as men to undergo percutaneous transluminal coronary angioplasty, but less likely to undergo coronary artery bypass surgery.

Conclusions: A gender-based selection bias exists in choosing patients to undergo coronary arteriography and coronary artery bypass grafting.

Chest. 1995;108(6):1514-1519. doi:10.1378/chest.108.6.1514

Since there is experimental evidence that insulin promotes atherosclerosis, we tested the hypothesis that insulin levels are higher in patients with diffuse atherosclerotic coronary artery disease by measuring insulin levels in 46 nondiabetic patients with angiographically defined diffuse coronary artery disease and 46 normal controls with angiographically normal coronary arteries. Fasting insulin levels were similar in both groups of patients: 7.70±5.77 µU/mL in those with diffuse coronary disease versus 7.39±5.01 µU/mL in controls. Also, insulin levels drawn 1 and 2 h after oral glucose challenge were not significantly different in patients with diffuse disease (48.78±32.46 µU/mL and 42.26±32.38 µU/mL, respectively) compared with patients with normal coronary arteries (51.03±28.01 µU/mL and 43.79±31.62 µU/mL, respectively). We conclude that insulin probably does not promote clinical atherosclerosis in nondiabetics.

Chest. 1995;108(6):1520-1523. doi:10.1378/chest.108.6.1520

Thrombolytic therapy salvages ischemic myocardium by rapidly reestablishing coronary artery patency in acute myocardial infarction. One of its major limitations is the complication of hemorrhage. A retrospective study of myocardial infarction patients who received thrombolytic therapy was performed to determine risk factors associated with a hemorrhagic event. Three hundred fifty patients were enrolled, and 20 (5.7%) had a bleeding complication, including four patients (1.1%) who had an intracranial hemorrhage. The factors associated with an increased risk for a significant hemorrhagic event were age (>65 years) and female gender. Factors associated with an intracranial hemorrhage were age (>65 years) and a history of hypertension.

Chest. 1995;108(6):1524-1532. doi:10.1378/chest.108.6.1524

Study objectives: We measured the individual and combined effects of the β-agonist dobutamine and the phosphodiesterase inhibitor enoximone both in vitro and in vivo in the failing human heart.

Design: This was an unblinded, prospective study.

Setting and patients: The in vitro measurements were performed on 20 hearts obtained from subjects with end-stage biventricular failure and from seven normal hearts. The in vivo measurements were performed in eight subjects with class IV heart failure.

Interventions and measurements: The in vitro measurements of enoximone, dobutamine, and the combination of these agents were phosphodiesterase activity using a sarcoplasmic reticulum-enriched preparation, cyclic adenosine monophosphate (cAMP) accumulation using particulate fractions, and tension response using isolated right ventricular trabeculae. The dose response to dobutamine, the combination of enoximone and dobutamine, and the combination of nitroprusside and dobutamine were measured in vivo using invasive hemodynamic monitoring.

Results: In vitro, enoximone exhibited dose-dependent inhibition of phosphodiesterase activity. The addition of enoximone to dobutamine resulted in an upward and leftward shift of the dobutamine dose-response curve for both cAMP production and contractile response. In vivo, enoximone significantly shifted the dobutamine dose-response curves for cardiac index, left ventricular stroke work index, and heart rate upward and to the left; and shifted the dobutamine dose-response curves for right atrial, pulmonary arterial, and pulmonary wedge pressures downward and to the right.

Conclusions: Enoximone exerts favorable effects on cardiac performance that are additive to those produced by dobutamine. These effects are mediated by increasing cellular cAMP concentrations through independent, additive mechanisms.

Chest. 1995;108(6):1533-1540. doi:10.1378/chest.108.6.1533

Study objective: To assess possible effects of systemic sclerosis on ventricular function.

Design: Retrospective analysis of patients referred for echocardiographic examination to assess ventricular function.

Setting: Tertiary referral center for cardiac and chest diseases equipped with invasive and noninvasive facilities.

Patients: Thirty-four patients with clinical diagnosis of systemic sclerosis, aged 49±12 years; 24 had pulmonary fibrosis and 10 did not. There were 21 normal controls of similar age.

Measurements: Two-dimensional guided M-mode echocardiographic recordings of the left ventricular minor and long axis at the left and septal sites and right ventricle were obtained. Transmitral and transtricuspid Doppler flow velocities were also obtained with ECG and phonocardiogram.

Results: In 24 patients with pulmonary fibrosis, long-axis excursion was reduced 2.1±0.5 vs 2.7±0.4 cm/s as was peak rate of shortening and lengthening, 8.5±3.3 vs 10.8±2.4 cm/s and 7.5±2.5 vs 12±3.6 cm/s, respectively (p<0.001), at the right side compared with 10 patients without. The onset of right long-axis shortening and lengthening was delayed with respect to the Q wave of the ECG and P2 of the phonocardiogram (p<0.001 in both vs controls). The onset of tricuspid forward flow from the second heart sound was also delayed in the two groups, 110±15 ms and 100±20 ms vs 80±15 ms, respectively (p<0.001). Right ventricular late diastolic filling velocities were increased 35±15 and 35±12 cm/s vs 20±10 cm/s in both groups (p<0.01), and hence E:A ratio reduced 1.25±0.5 and 1.4±0.3 vs 1.9±0.4, respectively (p<0.001). Pulmonary flow acceleration time was reduced only in patients with pulmonary fibrosis, 105±30 ms vs 125±30 ms (p<0.001). At the left side, total long-axis excursion was reduced only in patients with pulmonary fibrosis (p<0.01), while peak shortening and lengthening rates were reduced in both groups (p<0.05). The onset of shortening from the Q wave and lengthening from the second heart sound were both delayed in the two groups with the latter greatly delayed in patients with pulmonary fibrosis (p<0.05).

Conclusions: Right and left ventricular long-axis function is frequently abnormal in patients with systemic sclerosis. Abnormalities are more profound in patients with CT evidence of pulmonary fibrosis than in those without. We suggest that these disturbances are due to myocardial fibrosis which, from the anatomic distribution of longitudinally directed fibers, is likely to have been subendocardial.

Chest. 1995;108(6):1541-1545. doi:10.1378/chest.108.6.1541

Study objective: To determine if temperature during cardiopulmonary bypass (CPB) has an effect on perioperative and postoperative thyroid function.

Design: Prospective study comparing thyroid function during and after hypothermic and normothermic CPB.

Setting: Cardiac surgical unit at a university-affiliated hospital.

Patients: Twelve patients scheduled to undergo cardiac operations with normothermic (n=6) or hypothermic (n=6) CPB.

Interventions: Blood was analyzed for serum concentration of total thyroxine (TT4), total triiodothyronine (TT3), free T3 (fT3), reverse T3 (rT3), and thyroid stimulating hormone (TSH) preoperatively, 60 min after CPB was initiated, 30 min after discontinuing CPB, and on postoperative days (POD) 1, 3, and 5.

Measurements and results: Patients who underwent either cold (26°±5°C) or warm (35°±1°C) CPB were comparable with regard to age, body weight, duration of CPB, cross-clamp time, use of inotropes, total heparin dose, and length of hospital stay. Incidence of postoperative myocardial infarction, congestive heart failure, and death were similar. In both groups, TT4 and TT3 were reduced below baseline values beginning with CPB and persisting for up to 5 days after CPB (p<0.05), free T3 was reduced for up to 3 days after CPB (p<0.05), mean serum rT3 was elevated on POD 1 and POD 3 (p<0.05), and TSH remained unchanged.

Conclusion: The results of this study suggest that normothermic CPB does not prevent the development of the "euthyroid sick syndrome" during and after CPB. Despite these changes in thyroid function, most patients in both groups had a normal postoperative recovery.

Chest. 1995;108(6):1546-1550. doi:10.1378/chest.108.6.1546

Study objective: The objective of the present study was to evaluate medium- and long-term results of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction (LVD).

Design: Prospective evaluation (clinical follow-up and equilibrium radionuclide angiography scan) of all the patients with severe LVD who underwent CABG from November 1986 to November 1991 at the Tel Aviv Medical Center and were referred to the Post Cardiac Surgery Follow-up Clinic at this institution.

Patients: Seventy-four consecutive patients (65 men, 9 women, aged 43 to 82 years; mean age, 68.2 years) with left ventricular ejection fraction (LVEF) of 30% or less who underwent isolated CABG (without automatic implantable cardioverter-defibrillator implantation, aneurysmectomy, valve replacement, or other open heart procedures) during a 5-year period and were discharged from hospitalization were prospectively evaluated. Preoperatively, 62% of patients had angina, 65% had congestive heart failure (CHF), and the LVEF ranged from 10 to 30%. The mean number of grafts was 2.98 per patient; the internal mammary artery (IMA) was used in 54 patients. The patients were followed up 4 to 96 months (mean, 64.9 months) postsurgery for survival, clinical status, and left ventricular function.

Results: Survival was 96%, 93.2%, 91.9%, 87.8%, 86.5%, 83.8%, and 83.8%, at 1, 2, 3, 4, 5, 6, and 7 years, respectively. Postoperatively, mean angina class improved from 2.9 to 1.4 (p<0.0001) and mean CHF class improved from 2.7 to 1.8 (p<0.0001). Mean LVEF improved from 23.5% preoperatively to 35.7% postoperatively (p<0.0001).

Conclusions: The following occur in patients with coronary artery disease and severe LVD undergoing CABG: (1) good medium- and long-term survival is attained; (2) angina class improves; (3) CHF class improves; (4) LVEF objectively improves; and (5). IMA can be used safely as a conduit.

Chest. 1995;108(6):1551-1556. doi:10.1378/chest.108.6.1551

To test the hypothesis that acute lung injury during cardiopulmonary bypass (CPB) is related to the activation of neutrophils and the body temperature during bypass, we determined the differential WBC count, plasma elastase concentrations, and lung function before, during, and after CPB in 38 patients undergoing elective coronary artery bypass surgery. The patients were randomly assigned to receive either normothermic (n=19, rectal temperature: 35.9±0.1°C, mean±SE) or hypothermic (n=19, 29.2±0.5°C) CPB. The cellular response to the extracorporeal circulation was significantly delayed in the hypothermic group with a later onset of neutrophilia and a later increase in plasma elastase levels during bypass. Lung function deteriorated significantly after CPB as assessed by respiratory index, alveolar-arterial oxygen gradient, and intrapulmonary shunt, independent of bypass temperature. There was a positive correlation between peak elastase concentrations and postoperative respiratory index as well as intrapulmonary shunt (R2=0.5, p=0.002 and R2=0.45, p=0.003, respectively). Besides peak plasma elastase levels, multiple regression revealed no significant influence of other independent factors on postoperative lung dysfunction in our patients.

Chest. 1995;108(6):1557-1561. doi:10.1378/chest.108.6.1557

Study objective: To examine the relation of smoking habits and development of asthma in a large cohort of US women.

Design: Prospective cohort study.

Participants: Among 74,072 women, 34 to 68 years of age, who were free of major diseases, we documented 671 incident asthma eases and 798 incident cases of chronic bronchitis during 10 years of follow-up.

Methods: Age-adjusted relative risk estimates for smoking categories were calculated separately for chronic bronchitis and asthma.

Results: Risk of chronic bronchitis was significantly higher in current smokers than in never smokers (relative risk [RR]=2.85; 95% confidence interval [CI]=2.45 to 3.32) and increased with the number of cigarettes smoked per day (p for trend <0.0001). Approximately 5 years after quitting, chronic bronchitis risk in past smokers approached that in never smokers. In contrast, current smokers were at significantly lower risk for asthma than women who never smoked (RR=0.57; 95% CI=0.46 to 0.71) and women who quit (RR=0.50; 95% CI=0.40 to 0.62), possibly because individuals with sensitive airways are less likely to become regular smokers, and smokers who develop respiratory symptoms of any etiology tend to quit. Asthma risk in past smokers initially increased compared with that in never smokers, possibly because of quitting prior to diagnosis in response to symptoms of any etiology, but decreased with time since quitting (p for trend=0.007); within approximately 5 years, the risk did not differ between past and never smokers.

Conclusion: These data suggest that smoking in adults may not be an independent cause of asthma but could exacerbate or be perceived as exacerbating asthma symptoms in susceptible individuals.

Chest. 1995;108(6):1562-1567. doi:10.1378/chest.108.6.1562

Pentoxifylline has been reported previously in an unblinded study to improve oxygen saturation, treadmill walk time, and resting diffusion of carbon monoxide (Dco) in patients with COPD. We recruited 12 patients with moderate to severe COPD whose exercise capacity was limited by ventilation or who developed hypoxemia with exercise. Patients were randomized to receive pentoxifylline or placebo, each for a 12-week period in a prospective, double-blind, crossover design study, to assess the effects of pentoxifylline on oxygenation, resting Dco, and exercise tolerance using arterial blood gas analysis. Eleven patients with a mean FEV1 of 0.94 L and a mean Dco of 9.85 mL/min/mm Hg completed the study. One patient withdrew from the study after developing pneumonia. There were no significant differences in resting oxygenation, resting Dco, or spirometry after 12 weeks of pentoxifylline relative to placebo. The 12-min walk test and dyspnea index for activities of daily living were also not significantly different while taking pentoxifylline. Finally, at maximal exercise, there were no differences in workload attained, exercise duration, oxygen consumption, carbon dioxide production, minute ventilation, oxygen saturation, Po2, alveolar-arterial oxygen pressure difference, or Borg score while taking pentoxifylline relative to placebo. We conclude that pentoxifylline does not improve oxygenation, resting Dco, exercise tolerance, or dyspnea in patients with moderate to severe COPD.

Chest. 1995;108(6):1568-1571. doi:10.1378/chest.108.6.1568

A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled β2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 µg/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled β2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to β2-agonist," there was a significant improvement in the FEV1 (defined as ≥20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to β2-agonist," there was no significant improvement in the mean FEV1 (1.41±0.1 L before, and 1.61±0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar β2-agonist consumption (4.8±0.2 and 5.0±0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of β2-agonist inhalations (2.4±0.1 in the budesonide period as compared with 5.3±0.1 in the placebo period; p<0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled β2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to β2-agonist inhalation.

Chest. 1995;108(6):1572-1576. doi:10.1378/chest.108.6.1572

Study objective: To assess the usefulness of noninvasive nasal mask ventilation (NMV) in the treatment of an exacerbation of chronic respiratory insufficiency in patients stable enough to be admitted to a non-ICU ward.

Design: A prospective study in which the beneficial effect of NMV was compared with conservative treatment.

Setting: A ward of respiratory medicine of a tertiary-referral teaching hospital.

Patients: The study group included 15 patients with acute respiratory acidosis. These patients had pH less than 7.35 and PaCO2 more than 60 mm Hg, respiratory rate of 30 breaths or less per minute, hemodynamic stability, and alertness and willingness of cooperation with the NMV treatment. The control group consisted of 16 patients who fulfilled the same arterial blood gas requirements, retrospectively selected from the discharge forms of the ward of respiratory medicine for the year 1993.

Interventions: Patients underwent NMV for two sessions per day (one in the morning and one in the afternoon), each session lasting 4 h. A volumetric respirator (Monnal D; Taema; Paris, France) was used in four patients with restrictive disease. A positive-pressure ventilator (DP90; Taema; Paris, France) was used in 11 patients with obstructive disease. Control patients received standard medical, oxygen, and chest physical therapy.

Results: As compared with pre-NMV values, mean pH was significantly higher at 4 h of NMV after the patient's ventilatory adaptation (t=8.814, p<0.001) and at the end of NMV (t=12.06, p<0.001). Ventilatory support also produced a significant improvement in hypercapnia (pre-NMV vs NMV after the patient's ventilatory adaptation, t=6.675, p<0.001; pre-NMV vs post-NMV, t=6.976, p<0.001). Posttreatment pH and PaCO2 values were significantly higher and lower, respectively, in NMV-treated patients than in controls. At the end of treatment, a significantly higher PaO2 FIo2 ratio was documented in the study group than in controls (post-NMV vs posttreatment, t=2.846, p<0.01).

Conclusions: NMV associated with standard treatment may be more beneficial than conservative treatment alone for improving blood gas exchange in patients with chronic respiratory insufficiency admitted to the hospital (but not the ICU) for an episode of acute decompensation and respiratory acidosis.

Chest. 1995;108(6):1577-1580. doi:10.1378/chest.108.6.1577

Study rationale and objective: Sleep-disordered breathing is commonly treated with nasally applied continuous positive airway pressure (CPAP). Typically, pressures are titrated to pneumatically splint the airway to prevent its collapse in response to negative inspiratory pressure. This investigation was prompted by several patient complaints of sleep-related breathing difficulty associated with travel to high altitudes. CPAP devices create pressure with fan-generated airflow; therefore, CPAP performance should behave according to collective fan laws.

Measurements and results: In the present study, we examined the effect of simulated altitude change on four commercially available CPAP machines. Machines were tested using anatomic airway mannequins in an altitude chamber. We made three simulated ascents to 12,000 feet with machines set at 5, 10, and 12 cm H2O sea level pressure equivalents. We measured pressure using water manometers at 2,000-foot increments during ascent and descent. Mask pressures varied systematically with changing altitude in three machines. One machine, equipped with a pressure regulation feature, maintained pressure within 1 mm H2O at all pressure and altitude combinations.

Conclusions: Altitude significantly alters delivered pressure according to predictions made by the fan laws, unless a unit has pressure-compensating features. Clinicians should consider this factor when CPAP is prescribed for patients who live or travel to places located at significantly higher or lower elevations than the titration site.

Chest. 1995;108(6):1581-1586. doi:10.1378/chest.108.6.1581

Although the number of users of home mechanical ventilation (HMV) is increasing, information regarding the users' perceptions of the impact of HMV on their lives is incomplete. We administered an openended questionnaire to 98 (48 male, 50 female) HMV users aged (mean±SD) 47.4±19.5 years with COPD (9%), thoracic restrictive disease (43%), and neuromuscular disease (48%). At the time of survey, subjects had received HMV for 59.5±58.3 months. Fifty-three percent were ventilated electively. Ventilator use was continuous (18%), at night only (37%), or at night with occasional daytime use (45%). Twenty-seven (28%) individuals identified themselves as being totally independent while 32 (33%) rated themselves as partially dependent on caregiver assistance for daily activities. Only 37 (38%) considered that they had made an informed choice when first starting HMV whereas 54 (55%) did not. The impact of using a mechanical ventilator was believed to be overwhelmingly positive (87%). Positive comments regarding the impact of the ventilator on lifestyle were grouped in the following categories: life sustaining, facilitating mobility, and improving physical symptoms. Negative comments were grouped in the following categories: limiting mobility, equipment issues, and social implications. HMV users with a tracheostomy volunteered significantly fewer positive statements than those ventilated noninvasively (p<0.05). Whereas 52 (53%) of users indicated that they had experienced initial difficulties in coping with the ventilator, only 11 (11%) identified difficulties at the time of the survey.

Chest. 1995;108(6):1587-1593. doi:10.1378/chest.108.6.1587

Study objective: Health status and quality of life (QOL) in lung transplant candidates and recipients were compared to determine the impact of transplantation, and whether recipients experience continued improvements in the years after transplant surgery.

Design: Two patient groups, adult lung transplant candidates (n=44) and adult lung transplant recipients (n=54), completed self-report QOL questionnaires. Eighteen of the 54 recipients completed QOL questionnaires on two occasions, about 18 months apart, after lung transplant. The questionnaire included the Medical Outcome Study Health Survey (MOS 20) that assesses six dimensions of health-related QOL: physical, role and social function, mental health, health perceptions and bodily pain, as well as a self-report Karnofsky Index and other indicators of QOL.

Setting: University medical center transplant service.

Results: Compared with candidates, recipients reported higher levels of happiness and more satisfaction with their life and their health. They also reported better function on the Karnofsky Index and in every MOS 20 dimension (p<0.0001), except pain. No significant differences were found in comparisons among recipients, grouped by the time since their transplant. Eighteen recipients completed two QOL questionnaires after transplant. No significant differences were found between the earlier (median, 11 months) and later (median, 29 months) QOL responses for this group overall. However, recipients (n=5) who developed obliterative bronchiolitis between assessments showed decrements in their health-related QOL. Dimensions particularly affected were physical and social functioning and bodily pain.

Conclusions: Dramatic improvements in health status and QOL occur after successful lung transplant and remain stable over time. Obliterative bronchiolitis results in notable QOL reductions.

Chest. 1995;108(6):1594-1601. doi:10.1378/chest.108.6.1594

Objective: Lung transplantation is one of the fastest-growing solid organ transplant procedures in the world, yet its cost-effectiveness is unknown. We compared the costs and outcomes of the first 25 patients who received lung transplants at the University of Washington with 24 patients currently on the lung transplant waiting list.

Design: Inpatient and outpatient charges were obtained from the hospital billing service and home health agencies. Quality-adjusted life year scores (QALYs) were computed from the following: (1) utility scores obtained through standard gamble interviews, and (2) published survival data from an international lung transplant registry and from studies of patients on lung transplant waiting lists.

Results: Transplantation charges averaged $164,989 (median, $152,071). Average monthly charges posttransplant were $11,917 in year 1 and $4,525 thereafter, vs $3,395 for waiting-list patients. Posttransplant utility scores were significantly higher than waiting-list scores (0.80 vs 0.68; p<0.001). Life expectancy was not greater for lung transplant vs waiting-list patients (5.89 vs 5.32 years; p>0.05), although quality-adjusted life expectancy did improve significantly. After converting charges to costs, the incremental cost per QALY gained for posttransplant compared with waiting-list patients was $176,817.

Conclusions: Lung transplantation is very expensive, although it can substantially improve quality of life. Two-thirds of care costs are incurred after transplantation. The principal barriers to cost-effectiveness at present are the high cost of postrecovery care and marginal gains in life expectancy compared with conservative care.

Chest. 1995;108(6):1602-1607. doi:10.1378/chest.108.6.1602

Background: We observed an unexpectedly high incidence of postoperative gastroparesis among lung and heart-lung transplant recipients.

Purpose: To identify the incidence of GI complications and to describe the clinical profiles of patients who developed symptomatic gastroparesis after lung transplantation.

Patients and methods: Retrospective study of GI symptoms and complications identified during 3 years of follow-up of 38 adult lung and heart-lung transplant recipients.

Results: Sixteen of 38 patients (42%) reported one or more GI complaint and received a specific GI diagnosis. Nine of 38 patients (24%) complained of early satiety, epigastric fullness, anorexia, nausea, or vomiting. Gastroparesis was suspected when endoscopic evaluation revealed undigested food in the stomach after overnight fast and symptoms could not be attributed to peptic disease or cytomegalovirus gastritis. Delayed gastric emptying was confirmed by gastric scintigraphy. Mean gastric emptying (t½) was 263±115 min (normal <95 min). Gastroparesis occurred in 4 of 13 right lung, 2 of 12 left lung, 1 of 9 bilateral single lung, and 2 of 4 heart-lung recipients (p=NS). Patients responded partially to metoclopramide or cisapride, with the exception of two patients who required placement of jejunal feeding tubes secondary to severe symptoms. In long-term follow-up, symptoms resolved in all patients and treatment with medications or mechanical intervention was successfully discontinued. Four of nine patients (44%) suffering from gastroparesis developed obliterative bronchiolitis (OB). Food particles were discovered in the BAL fluid of two such symptomatic patients. In contrast, only 6 of 29 (21%) nonsymptomatic patients developed OB (p=0.16).

Conclusion: Symptomatic gastroparesis is a frequent complication of lung or heart-lung transplantation that may promote microaspiration into the lung allograft.

Chest. 1995;108(6):1608-1613. doi:10.1378/chest.108.6.1608

We reviewed our experience with bacteremic pneumococcal pneumonia (BPP) over a 1-year period at a 600-bed community teaching hospital; 26 cases were identified. The mean age was 57.5 years and there were 12 male and 14 female subjects. Cough, sputum production, fever, and mental status changes were the most frequent symptoms. Risk factors included drug abuse in 10, HIV in 4, current smoking in 7, diabetes in 3, and cancer in 3. The mean PaO2 FIo2 ratio was 274. Radiographic features included a consolidation pattern in 7, bronchopneumonia in 15, combined in 1, and an initial normal film in 3. Average length of stay (LOS) was 11 days with an overall mortality of 11.5%. Four patients required mechanical ventilation, two meeting the criteria for ARDS (if this group were eliminated, LOS would be 8.4 days). Three of these survived. Four patients had organisms resistant to penicillin and all survived. We conclude that (1) BPP remains a serious but treatable infection particularly when utilizing full supportive care; (2) the bronchopneumonia x-ray film pattern was associated with all the mortality; and (3) the occurrence of penicillin resistance did not contribute to the mortality, since early recognition and the use of appropriate antibiotics saved all of these patients.

Chest. 1995;108(6):1614-1616. doi:10.1378/chest.108.6.1614

Introduction: CD14 is a cell surface glycoprotein expressed mainly on mature monocytes and macrophages. Soluble CD14 (sCD14) is present in normal plasma and is found increased in serum of patients with septicemia, polytrauma, and sarcoidosis. In active sarcoidosis, increased levels of sCD14 in BAL supernatant have been demonstrated.

Study objective: To investigate sCD14 levels in BAL of pulmonary tuberculosis (PTB), another inflammatory disease characterized by granuloma formation.

Methods: BAL was performed in 12 patients with active but untreated PTB and 12 healthy persons. Cytologic and immunocytologic characteristics were determined. sCD14 was measured by a sandwich enzyme-linked immunosorbent assay.

Results: The level of sCD14 in patients with PTB was increased compared with controls (mean±SEM: 34.4±9.6 ng/mL vs 11.5±2.2 ng/mL; p=0.02). No correlation was found between sCD14 levels and BAL cell differentials or lymphocyte surface markers.

Conclusion: Similar to sarcoidosis, increased levels of sCD14 are found in BAL supernatant of PTB patients.

Chest. 1995;108(6):1617-1621. doi:10.1378/chest.108.6.1617

Purpose: To assess the role of positron emission tomographic (PET) imaging with 18-fluoro-2-deoxyglucose (18FDG) in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma.

Materials and methods: Over a 2-year period, any patient presenting to our institution with newly diagnosed bronchogenic carcinoma who was to have thoracic nodes sampled was considered eligible. All PET studies were performed prior to nodal sampling and areas of increased uptake were mapped according to the American Thoracic Society classification. Studies were correlated with CT and pathology. Sensitivity and specificity for predicting nodal metastases was calculated.

Results: Forty-two patients had 62 nodal stations (40 hilar/lobar, 22 mediastinal) sampled. The sensitivity and specificity for hilar/lobar lymph node station metastases using PET imaging was 73% and 76%, respectively. With CT, the sensitivity and specificity were 27% and 86%. The sensitivity and specificity using PET imaging for mediastinal node station metastases was 92% and 100%, respectively, while with CT the figures were 58% and 80%. The sensitivity and specificity for combined thoracic nodal station metastases using PET imaging was 83% and 82%, respectively, while with CT it was 43% and 85%. There was a strong statistical relationship between positive PET imaging and lymph node abnormalities.

Conclusions:18FDG-PET imaging is accurate in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma. Normal results of PET studies virtually preclude the need for mediastinal nodal sampling prior to surgery, whereas abnormal results of studies most likely represent mediastinal metastases. Treatment can be based on the extent of disease suggested by PET imaging.

Chest. 1995;108(6):1622-1626. doi:10.1378/chest.108.6.1622

Aim: To describe the thin CT scans findings in AIDS patients with intrathoracic Kaposi's sarcoma (KS).

Material and methods: Fifty-three CT scans of patients with KS were retrospectively reviewed. The diagnosis of intrathoracic KS was established histologically (n=17) or on the association of skin KS and the visualization of characteristic endobronchial lesions (n=36). CT scans were performed with thin slices (2 mm) obtained at 10-mm intervals, and a 512x512 reconstruction matrix. No patients had Pneumocystis carinii pneumonia within the 3 months preceding the CT scan examination.

Results: Numerous nodules (n=42), tumoral masses (n=28), bronchovascular pathways thickening (n=35), and pleural effusions (n=28) were the most frequent patterns. Septal lines (n=15), ground-glass opacities (n=3), and mediastinal adenopathies (n=8) were not frequent.

Conclusion: Numerous nodules, tumoral masses, bronchovascular pathways thickening, and bilateral pleural effusions were the main signs of intrathoracic KS; their association (66%) is very characteristic. An opportunistic infection or mycobacteriosis must be sought if the thin CT scans reveal ground-glass opacities and/or mediastinal adenopathies.

Topics: kaposi sarcoma
Chest. 1995;108(6):1627-1631. doi:10.1378/chest.108.6.1627

Study objective: Prader-Willi syndrome (PWS) is characterized by a number of abnormalities of hypothalamic function, such as hyperphagia, short stature, temperature instability, hypogonadotropic hypogonadism, and neurosecretory growth hormone deficiency. Patients with PWS are reported to have sleep-disordered breathing and have blunted hypercapnic ventilatory responses secondary to abnormal peripheral chemoreceptor function. Thus, we hypothesized that hypercapnic arousal responses would be abnormal in PWS.

Design: Hypercapnic arousal responses were tested in ten nonobese children and adults with PWS, aged 17.7±2.5 (SEM) years, 70% female, and nine control subjects, aged 14.2±2.6 years, 67% female. Hypercapnic challenges were performed during stage ¾ nonrapid eye movement sleep.

Results: The PWS subjects had a significantly higher arousal threshold to hypercapnia compared with the controls (53±1.0 vs 46±1.7mm Hg; p<0.01). The PWS subjects had significantly higher baseline end-tidal CO2 levels (42±0.8 vs 38±1.1 mm Hg; p<0.01) and more central apneas greater than 15 s/h of sleep (1.5±0.3 vs 0.1±0.1; p<0.01).

Conclusions: Elevated hypercapnic arousal thresholds during sleep are found in PWS subjects; these may be a manifestation of abnormal peripheral chemoreceptor function and may further contribute to sleep-disordered breathing in PWS patients.

Chest. 1995;108(6):1632-1639. doi:10.1378/chest.108.6.1632

Background: The thresholds of the diagnostic procedures performed to diagnose ICU-acquired pneumonia (IAP) are either speculated or incompletely tested.

Purpose: To evaluate the best threshold of protected specimen brush (PSB), plugged telescoping catheter (PTC), BAL culture (BAL C), and direct examination of cytocentrifugated lavage fluid (BAL D) to diagnose IAP. Each mechanically ventilated patient with suspected IAP underwent bronchoscopy successivelywith PSB, PTC, and BAL in the lung segment identified radiographically.

Population: One hundred twenty-two episodes of suspected IAP (occurring in 26% of all mechanically ventilated patients) were studied. Forty-five patients had definite IAP, and 58 had no IAP. Diagnosis was uncertain in 19 cases.

Results: Using the classic thresholds, sensitivity was 67% for PSB, 54% for PTC, 59% for BAL D, and 77% for BAL C. Specificity was 88% for PSB, 77% for PTC, 98% for BAL D, and 77% for BAL C. We used receiver operating characteristics methods to reappraise thresholds. Decreasing the thresholds to 500 cfu/mL for PSB, 102 cfu/mL for PTC, 2% cells containing bacteria for BAL D, 4x103 cfu/mL for BAL C increased the sensitivities (plus 14%, 23%, 25%, 10%, respectively) and moderately decreased the specificities (minus 4%, 9%, 2%, 4%, respectively) of the four examinations. The association of PSB with a 500 cfu/mL threshold and BAL D with a 2% threshold recovered all but one episode of pneumonia (SE 96±4%) with a 84±10% specificity. For a similar ICU population, these "best" thresholds increased negative predictive value with a minimal decrease of positive predictive value. They need to be confirmed in multiple ICU settings in prospective fashion.

Chest. 1995;108(6):1640-1647. doi:10.1378/chest.108.6.1640

Objective: To assess the incidence, clinical characteristics, management, and outcome of epiglottitis in a defined population over an 18-year period.

Design: Case series.

Setting: The state of Rhode Island, 1975 through 1992.

Patients or other participants: Cases who met predetermined criteria for acute epiglottitis identified from hospital discharges and the State Medical Examiner's log of prehospitalization deaths.

Main outcome measures: Incidence by year and age, clinical presentation, results of diagnostic evaluations, management, and outcome.

Results: Four hundred seven cases were identified, 134 in children and 273 in adults. Incidence in children dropped from 38 cases in the first 3 years of the study to 1 case in the last 3 years (p<0.001). Adult cases increased from 17 in the first 3 years to 69 in the last 3 years (p<0.001). Seventy-nine percent of adults and 32% of children were treated without an artificial airway. Factors associated with airway obstruction included symptomatic respiratory difficulty, stridor, drooling, shorter duration of symptoms, enlarged epiglottis on radiograph, and Haemophilus influenzae bacteremia (p<0.001 for each). Twelve patients died (3 children and 9 adults), with all cases of fatal respiratory obstruction occurring within 12 h of presentation.

Conclusions: There have been significant changes in the clinical epidemiology of epiglottitis, which now occurs almost exclusively in adults, often with less severe symptoms and a lower incidence of H influenzae infection. While careful observation is indicated for all patients, the data suggest that those with certain clinical characteristics can be treated safely without an immediate artificial airway.

Chest. 1995;108(6):1648-1654. doi:10.1378/chest.108.6.1648

Study objective: To assess the effect of low dose dopexamine and dopamine on splanchnic blood flow as measured by gastric intramucosal pH, hepatic metabolism of lidocaine (lignocaine) to monoethylglycinexylidide (MEGX), and plasma disappearance rate of indocyanine green (ICG).

Design: Single-blind randomization of patients with a gastric intramucosal acidosis to receive dopexamine (ten patients), dopamine (ten patients), or saline solution (five control patients) for 2 h.

Setting: All 25 patients were in the ICU of Guys' Hospital.

Patients: All patients met the criteria for the diagnosis of the systemic inflammatory response syndrome, were mechanically ventilated, and had pulmonary artery catheters placed. All had a low gastric intramucosal pH and had a median first 24-h acute physiology and chronic health evaluation (II) score of 22 (range, 7 to 40).

Measurements and interventions: Baseline measurements of gastric intramucosal pH, MEGX formation from lidocaine, ICG plasma disappearance rate, heart rate, mean arterial pressure, pulmonary artery occlusion pressure, cardiac index, oxygen delivery index, oxygen uptake index, systemic vascular resistance, and arterialpHwere taken. Dopexamine (1 mg·kg−1·min−1), dopamine (2.5 mg·kg−1·min−1), or 0.9% saline solution was then infused for 2 h, after which a repeated set of the measurements was taken.

Results: Dopexamine at a low dose had no effect on any of the systemic measurements. The median intramucosal pH rose from 7.23 to 7.35 (p<0.005), the median ICG plasma disappearance rate from 7.6 to 11.3%·min−1 (p<0.02), and the median MEGX concentration from 4 to 10.2 ng·mL−1 (p<0.005). Dopamine had no effect on any of the measured variables. There were no changes in the control group.

Conclusions: Low-dose dopexamine increases splanchnic blood flow as measured by gastric intramucosal pH, MEGX formation from lidocaine, and ICG clearance. The lack of any change in the systemic measurements suggests that these effects are the result of a selective vasodilatation of the splanchnic vessels. At the dose used in this study, dopamine had no effect on splanchnic blood flow. Dopexamine may be useful in the management of splanchnic ischemia in the critically ill.

Topics: vascular flow
Chest. 1995;108(6):1655-1662. doi:10.1378/chest.108.6.1655

Study objective: To determine whether the development of late-onset ventilator-associated pneumonia (VAP) is associated with an increased risk of hospital mortality.

Design: Prospective cohort study. Setting: ICUs of two university-affiliated teaching hospitals.

Patients: Three hundred fourteen patients admitted to an ICU who required mechanical ventilation for greater than 5 days.

Interventions: Prospective patient surveillance and data collection.

Measurements: The primary outcome measures were the development of late-onset VAP (ie, occurring >96 h after intubation) and hospital mortality.

Results: Late-onset VAP was observed in 87 patients (27.7%). Thirty-four (39.1%) patients with late-onset VAP died during hospitalization compared with 85 patients (37.4%) without late-onset VAP (relative risk, 1.04; 95% confidence interval [CI], 0.76 to 1.43). Twenty patients (6.4%) developed late-onset VAP due to a "high-risk" pathogen (ie, Pseudomonas aeruginosa, Acinetobacter sp, Xanthomonas maltophilia) with an associated mortality rate of 65%. Stepwise logistic regression analysis identified five variables as independent risk factors for hospital mortality (p<0.05): an organ system failure index of 3 or greater (adjusted odds ratio [AOR], 3.4; 95% CI, 2.0 to 5.8; p<0.001), having a nonsurgical diagnosis (AOR, 2.1; 95% CI, 1.3 to 3.6; p=0.002), a premorbid lifestyle score of 2 or greater (AOR, 1.8; 95% CI, 1.1 to 2.9; p=0.015), acquiring late-onset VAP due to a "high-risk" pathogen (AOR, 3.4; 95% CI, 1.2 to 10.0; p=0.025), and having received antacids or histamine type-2 receptor antagonists (AOR, 1.7; 95% CI, 1.0 to 2.9; p=0.034). Additionally, we found the occurrence of late-onset VAP due to high-risk pathogens to be the most important predictor of hospital mortality among patients developing VAP (AOR, 5.4; 95% CI, 2.8 to 10.3; p=0.009).

Conclusions: Nosocomial pneumonia due to certain high-risk microorganisms is an independent risk factor for hospital mortality among patients requiring prolonged mechanical ventilation. We suggest that future investigations of late-onset VAP stratify patient outcomes according to the distribution of high-risk pathogens when reporting their results.

Chest. 1995;108(6):1663-1667. doi:10.1378/chest.108.6.1663

Background: Experimental studies recently demonstrated that positive pressure ventilation may not be essential for initial cardiopulmonary resuscitation. Nevertheless, oxygen enrichment of inspired gas mixtures and spontaneous gasping were associated with increased resuscitability and survival after cardiac arrest. However, as yet unresolved is the benefit of early airway control under conditions simulating "sudden death" due to ventricular fibrillation.

Methods: Twenty adult, male Sprague-Dawley rats were randomly assigned to one of two groups in which the airway was unprotected or protected by an oropharyngeal airway of our design. Cardiac arrest was induced by an alternating current delivered to the right ventricular endocardium. Oxygen was delivered to a hood that was loosely applied over the head of the each animal at a flow rate of 1 L/min. Precordial compression was initiated after 4 min of untreated ventricular fibrillation and defibrillation was attempted 6 min later. After spontaneous circulation had been restored, a tracheostomy was performed and the animals were mechanically ventilated with 100% oxygen for an additional interval of 1 h. Animals were then returned to their cages and observed for an additional 24 h.

Results: Spontaneous circulation was restored in each of the animals who had an oropharyngeal airway and nine of ten animals in the absence of an artificial airway. In each group, seven animals survived for more than 24 h. Animals in which the airway had been protected had significantly greater frequency of spontaneous gasping (28±13/min vs 13±9/min; p<0.05) and significantly higher arterial oxygen saturation (77± 19% vs 55±25%; p<0.05).

Conclusion: In the setting of experimental cardiac resuscitation, the insertion of an artificial airway increased the frequency of spontaneous gasping and arterial oxygenation. Nevertheless, no significant differences in resuscitability or postresuscitation survival were associated with insertion of the artificial airway.

Chest. 1995;108(6):1668-1672. doi:10.1378/chest.108.6.1668

Study objectives: To determine (1) whether metered-dose inhaler (MDI) salbutamol administered at the elbow connector of the anesthetic circuit produced tracheal epithelial lesions in intubated rabbits, and (2) the time course for resolution of tracheal lesions produced by MDI salbutamol through an intratracheal catheter.

Design: Prospective, randomized, controlled trial.

Setting: University-affiliated animal research laboratory.

Participants: Thirty-nine adult New Zealand white rabbits.

Interventions: (1) Twenty-one intubated rabbits received 0,5, or 20 puffs of MDI salbutamol delivered at the elbow connector of the anesthetic circuit. (2) Eighteen intubated rabbits received five puffs of MDI salbutamol through an intratracheal catheter and were killed 1 h, 24 h, or 1 week later.

Measurements: Samples of trachea, bronchi, and lungs were examined by light microscopy, and the degree of epithelial injury was assessed semiquantitatively.

Results: MDI salbutamol (5 or 20 puffs) administered at the elbow did not induce tracheal epithelial injury. When administered through an intratracheal catheter, MDI salbutamol (five puffs) produced moderate or severe tracheal epithelial injury in those killed 1 h after the study. Evidence of epithelial regeneration was observed 24 h after the injury and recovery was virtually complete by 1 week.

Conclusion: Epithelial lesions do not occur when the MDI salbutamol (5 or 20 puffs) is administered at the elbow connector of the ventilation circuit. Tracheal epithelial lesions produced by MDI salbutamol (five puffs) administered through an intratracheal catheter resolve within 1 week of the injury.

Chest. 1995;108(6):1690-1710. doi:10.1378/chest.108.6.1690
Chest. 1995;108(6):1711-1717. doi:10.1378/chest.108.6.1711
Chest. 1995;108(6):1718-1723. doi:10.1378/chest.108.6.1718

Continuous extrapleural intercostal block (EPIB) with bupivacaine has been reported to be an effective analgesic technique in patients after thoracotomy. We report a retrospective study of EPIB using a continuous infusion of 1% lidocaine hydrochloride at a dose of 1 mg/kg/h. A posterior parietal pleural pocket was created and cannulated with a 16-g polyethylene catheter. Lidocaine was perfused over a 3-day period following surgery. Patients also had access to morphine sulfate via patient-controlled analgesia. Eighteen consecutive posterolateral thoracotomies (in 17 patients) performed during a 6-month period were reviewed. Serum lidocaine exceeded the toxic level of 5 µg/mL in only one patient, a 104.5-kg man who had a level of 5.9 µg/mL on postoperative day 2 but experienced no clinical toxicity. Pain was evaluated by verbal analog scores (0=no pain and 10=worst pain), which averaged 3.02, 3.14, and 2.8 in the 3 days following surgery. Mean total daily MS doses were 24.3, 37.75, and 34.32 mg (range, 0 to 94 mg). Sedation was scored on a 1 to 5 scale. Mean scores were 2.78, 2.56, and 2.6. No patient died or had a major respiratory complication. Continuous EPIB with lidocaine appears to he a promising adjuvant technique in the management of postthoracotomy pain. Effectiveness needs to be confirmed in a prospective randomized study.

Chest. 1995;108(6):1724-1727. doi:10.1378/chest.108.6.1724

A 45-year-old woman was admitted to the hospital with a brain abscess due to asymptomatic pulmonary arteriovenous malformation (PAVM). The brain abscess was removed by craniotomy and excision following antibiotic therapy. The stapled wedge excision of the lung with the PAVM was successful under video-assisted thoracoscopic surgery.

Chest. 1995;108(6):1728-1730. doi:10.1378/chest.108.6.1728

The advent in video-assisted thoracic surgery has rendered us to rely more and more on mechanical devices. We prospectively studied staple formation on resected lung specimen by radiography and attempted to correlate this with the clinical outcome. From February 1994 to January 1995, 36 consecutive pulmonary wedges (23 apical bullae, 12 pulmonary metastases, 1 tuberculoma) from 31 patients who had undergone resection by endoscopic staple-cutter (Endo GIA30, USSC) were examined by two-plane radiography for staple alignment and closure. Imperfect staple formation was found in 21 (58%) of resected specimens. The median size of the resected bullae is 4.2 mL (range, 2.0 to 58.8 mL) compared with 36 mL (range, 1.2 to 222.8 mL) in the resected metastases and tuberculoma specimen. Despite detecting more imperfect staples in the metastases group (77% vs 57%), there was little difference in the two groups with respect to postoperative chest drainage duration (median, 3 vs 2 days) or hospital stay (median, 2 vs 2 days). We conclude that the currently available endoscopic staplers are by no means perfect, especially for resection of larger specimens, even though this maynot be apparent clinically. A continuous search for improvement in endoscopic staplers designed specifically for lung resection is needed.

Chest. 1995;108(6):1731-1734. doi:10.1378/chest.108.6.1731
Topics: tachycardia
Chest. 1995;108(6):1735-1736. doi:10.1378/chest.108.6.1735
Chest. 1995;108(6):1737-1738. doi:10.1378/chest.108.6.1737
Topics: lung , brain mass
Chest. 1995;108(6):1739-1741. doi:10.1378/chest.108.6.1739
Chest. 1995;108(6):1742-1743. doi:10.1378/chest.108.6.1742

A 56-year-old man presented with a sternotomy wound infection 6 months after coronary artery bypass grafting. The organism responsible was group B betahemolytic Streptococcus. This organism was simultaneously cultured from an infected diabetic ulcer on the patient's foot as well as from a total knee prosthesis. The Streptococcus apparently spread hematogenously to the sternum, an extremely rare cause of sternotomy wound infection.

Chest. 1995;108(6):1743-1745. doi:10.1378/chest.108.6.1743

A case of a rare partial anomalous pulmonary venous return of the right upper lobe into the superior vena cava is reported. Multiple three-dimensional image reconstructions in association with spiral CT are used in the aim of clarifying this abnormality of pulmonary venous drainage.

Chest. 1995;108(6):1745-1746. doi:10.1378/chest.108.6.1745

Congestive heart failure and emphysema are common diseases in western society. The presence of these diseases in a single patient can lead to diagnostic uncertainty. A case of congestive heart failure presenting as multiple air fluid levels within lung bullae is reported.

Chest. 1995;108(6):1747-1748. doi:10.1378/chest.108.6.1747

Delayed traumatic pericardial syndromes are well recognized. We describe a case in which a patient presented 3 years after an initial trauma with manifestations of constrictive pericarditis. The etiology in this report is attributable to a large intrapericardial hematoma, which is rarely described. This article also illustrates the complimentary nature of magnetic imaging and Doppler echocardiography in the evaluation of pericardial disease.

Topics: ascites , hematoma , abdomen
Chest. 1995;108(6):1748-1751. doi:10.1378/chest.108.6.1748

Cardiac complications can occur long after chest radiotherapy. We describe a patient who developed both valve disease and complete heart block at different intervals following radiotherapy for Hodgkin's disease. The combined presentation of these two very rare cardiac complications and surgery for radiation-induced tricuspid valve disease have not been described before.

Chest. 1995;108(6):1751-1752. doi:10.1378/chest.108.6.1751

Clubbing of the fingers is commonly associated with interstitial lung diseases (ILDs). Although ILD occurs in as many as 40% of patients with polymyositis/dermatomyositis (PM/DM), clubbing of the digits has never been reported to occur in patients with PM/DM and ILD. We report the first case of clubbing associated with PM/DM and ILD.

Chest. 1995;108(6):1752-1754. doi:10.1378/chest.108.6.1752

Cysticercosis can affect any organ of the body although central nervous system manifestations are the most common. Cysticercosis involving the myocardium is extremely rare and is usually diagnosed postmortem. We report a case of cysticercosis involving the myocardium diagnosed antemortem using ultrafast CT.

Chest. 1995;108(6):1754-1756. doi:10.1378/chest.108.6.1754

Continuous-infusion prostacyclin improves symptom scores and decreases mortality in patients with primary pulmonary hypertension, but use of prostacyclin in patients with pulmonary veno-occlusive disease may precipitate pulmonary edema. A patient with pulmonary veno-occlusive disease received a graduated intravenous infusion of prostacyclin and pulmonary capillary pressures were calculated during prostacyclin dose ranging. Calculated capillary pressure increased with low-dose prostacyclin (≤6 ng/kg/min) but decreased with higher doses. These data suggest that the post-capillary pulmonary venules in our patient had reversible vasomotor tone, but required a higher dose of prostacyclin to vasodilate than did the precapillary arterioles.

Chest. 1995;108(6):1756-1758. doi:10.1378/chest.108.6.1756

We describe the first case, to our knowledge, of usual interstitial pneumonia (UIP) as the pulmonary manifestation in primary Sjögren's syndrome (SjS). A 45-year-old woman was admitted to our hospital because of a dry cough and an interstitial shadow on a chest roentgenogram. Labial biopsy and sialogram confirmed a diagnosis of SjS. BAL fluid analysis revealed lymphocytosis with a decreased CD4/CD8 ratio compatible with bronchiolitis obliterans organizing pneumonia or lymphoid interstitial pneumonia. Open-lung biopsy specimen, however, showed evidence of UIP. Open-lung biopsy was a useful and necessary examination to determine the nature of the pulmonary complication in primary SjS. Conservative treatment without corticosteroids maintained a stable condition for a follow-up period of 3 years.

Chest. 1995;108(6):1758-1762. doi:10.1378/chest.108.6.1758

Acute aortic dissection has been reported with the use of cocaine. We report a case of intermittent cocaine use spanning nearly 5 years and leading to recurrent dissection and extension of the false lumen. The patient repeatedly declined surgical correction. Management involved aggressive pharmacologic blood pressure control, close monitoring, and encouragement to enter drug rehabilitation.

Chest. 1995;108(6):1763-1764. doi:10.1378/chest.108.6.1763

A liver transplant recipient in cardiogenic shock from an acute myocardial infarction and failed coronary angioplasty underwent successful emergency coronary artery bypass graft surgery. Our case is only the fourth documented report of a coronary artery bypass graft in a liver transplant patient and the first conducted on an emergency basis in a patient in cardiogenic shock. Preservation of both cardiac and liver function has been evident in all cases. Based on these findings, liver transplantation should not be a deterrent or contraindication to coronary artery bypass or cardiac surgery.

Chest. 1995;108(6):1776. doi:

In the Special Report (CHEST 1995; 108:865-67), entitled "About Egophony," by Dr. Joseph D. Sapira, the second sentence of the abstract should read, "It is due to a decrease in the amplitude and an increase in the frequency of the second formant, produced by ...."

Chest. 1995;108(6):1776. doi:10.1378/chest.108.6.1776

In the editorial entitled "Steering Clear of Automobile Accidents in Patients With Sleep Disorders" by Dr. Nancy A. Collop and which appeared in the October issue (CHEST 1995; 108:889), the following final paragraph was omitted: "Obviously, further testing of Steer Clear is necessary before this could be routinely recommended. I congratulate Dr. Findley on his work concerning this very important issue and encourage him and others in the sleep medicine field to continue working to make our roads safer."

Chest. 1995;108(6):1776. doi:10.1378/chest.108.6.1776-b

In the article by Enright et al, entitled "Spirometry and Maximal Respiratory Pressure References From Healthy Minnesota 65- to 85-Year Old Women and Men," published in the September issue (CHEST 1995; 108:663-69), the first two column headings of Table 3 were inadvertently shifted rightward. This table gives regression equations for spirometry variables. For example, the first equation of Table 3 should be correctly interpreted as follows: The FEV1 for men equals (0.066xht)-(0.37xage)+ 1.05, with the height in inches. Table 5 gives regression equations for maximal respiratory pressures and its first equation should be read as follows: MIP for men equals 149-(1.00xage)+(0.10xwt), with the body weight in pounds. The first author apologizes for the difficulties in interpreting these tables as printed.


Chest. 1995;108(6):1673-1677. doi:10.1378/chest.108.6.1673
Chest. 1995;108(6):1678-1682. doi:10.1378/chest.108.6.1678
Chest. 1995;108(6):1683-1689. doi:10.1378/chest.108.6.1683

Thrombosis of left-sided prosthetic valves is an uncommon yet potentially serious complication. Thrombolytic therapy has been proposed as an alternative to surgical methods in treating this condition. We sought to determine from a review of the literature what outcomes may be expected subsequent to thrombolytic administration and what groups may be at risk or benefit from this approach. We searched for studies including two or more patients treated with thrombolytic agents. Ten studies were reviewed. We describe and include two patients with valve thrombosis treated at our institution. A total of 182 episodes of prosthetic valve thrombosis in 162 patients were examined. Clinical success was achieved in 72.0% of cases and there was a mortality risk of 9.9%. Clinical success from thrombolysis was significantly related to the degree of heart failure at presentation and aortic valve position. Clinical success was not related to the duration of symptoms, time from valve replacement to obstruction, or valve type. Rethrombosis of successfully treated valve occurred subsequently in 19.5% of cases. Repeated thrombolytic administration in these patients was associated with similar rates of success as those treated for their initial episode of prosthetic valve thrombosis. Candidates for thrombolytic therapy include patients with obstructive valve thrombosis with or without congestive heart failure who are hemodynamically stable. Duration of time since valve replacement or symptom onset does not limit successful outcome. Close observation and aggressive maintenance of anticoagulation after therapy is suggested.

Communications to the Editor

Chest. 1995;108(6):1765. doi:10.1378/chest.108.6.1765
Chest. 1995;108(6):1765-1766. doi:10.1378/chest.108.6.1765-a
Chest. 1995;108(6):1766. doi:10.1378/chest.108.6.1766
Chest. 1995;108(6):1767. doi:10.1378/chest.108.6.1767
Chest. 1995;108(6):1767-1768. doi:10.1378/chest.108.6.1767-a
Chest. 1995;108(6):1768. doi:10.1378/chest.108.6.1768
Chest. 1995;108(6):1768. doi:10.1378/chest.108.6.1768
Chest. 1995;108(6):1768-1769. doi:10.1378/chest.108.6.1768-b

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