Advances in diagnostic interventional pulmonology

The recent advances in diagnostic pulmonary procedures have revolutionized the evaluation of abnormal thoracic findings including lung nodules and masses, mediastinal lymphadenopathy, and pleural diseases. Bronchoscopies with endobronchial ultrasonography and electromagnetic navigation are examples of new technology that has significantly improved the specificity and sensitivity of these procedures in diagnosis and staging of lung cancer without the need for more invasive procedures. This report describes the different diagnostic pulmonary interventions providing a description of the procedures, their indications, diagnostic yield and drawback.

The outcome of acute respiratory distress syndrome in relation to body mass index and diabetes mellitus

OBJECTIVE

To determine the 28 day mortality of patients with ARDS in relation to body mass index (BMI) and presence diabetes mellitus (DM).

DESIGN

Retrospective cohort study of patients enrolled in the ARDS Network randomized controlled trials.

RESULTS

2914 patients were enrolled in these trials. 112 patients were underweight (BMI < 18.5), 948 patients were normal range (18.5 ≤ BMI < 25.0), 801 patients were overweight (25.0 ≤ BMI < 30.0), 687 patients were obese (30.0 ≤ BMI < 40.0), and 175 patients were severely obese (BMI ≥ 40.0). 469 patients had DM. There was no significant difference in the 28 day mortality in relation to BMI or presence of DM (underweight adjusted OR, 1.217; 95% CI, 0.749-1.979; overweight adjusted OR, 0.887; 95% CI, 0.696-1.131; obese adjusted OR, 0.812; 95% CI, 0.624-1.056; severely obese adjusted OR, 1.102; 95% CI, 0.716-1.695; and DM adjusted OR, 0.938; 95% CI, 0.728-1.208).

CONCLUSIONS

The short term mortality in patients with ARDS is not affected by BMI or the presence of DM.

Coil embolization of pulmonary arteries as a palliative treatment of diffuse type I hepatopulmonary syndrome

Hepatopulmonary syndrome is a serious complication of liver disease. Type I hepatopulmonary syndrome is associated with diffuse dilatation of the pulmonary vasculature, leading to severe hypoxemia. Liver transplantation is the treatment of choice for this condition. There are limited options for those who are not candidates for liver transplantation. We present the case of a patient who presented with severe hypoxemia requiring FIO2 of 0.95 with PaO2 of 59 mm Hg. Workup revealed 33% intrapulmonary right-to-left shunt. A pulmonary angiogram showed diffuse dilatation of the pulmonary arteries, especially in the lower lobes. The patient was diagnosed with type I hepatopulmonary syndrome. He was not a candidate for liver transplantation. The patient underwent sequential coil embolizations of the lower lobe pulmonary arteries. He was discharged home on 2 L of supplemental oxygen. This case demonstrates that coil embolization of dilated pulmonary arteries is a potential palliative treatment for patients with diffuse type I hepatopulmonary syndrome.

Azithromycin improves lung function in patients with post-lung transplant bronchiolitis obliterans syndrome: a meta-analysis

INTRODUCTION

Azithromycin has been shown to reverse or halt the decline of forced expiratory volume in one s (FEV1) in patients with bronchiolitis obliterans (BOS) syndrome following lung transplant. The overall effect of azithromycin on the absolute values of FEV1 has not been compared between reported studies. We studied the effects of azithromycin on lung function in patients with post-lung transplant BOS syndrome.

METHODS

A meta-analysis was performed using studies identified following an extensive database search. To be included, studies were published in English or French and explicitly reported percentage change in FEV1 or hazard ratios.

RESULTS

A total of 10 studies were included in this review. One hundred and forty patients were evaluated after treatment with azithromycin for an average follow-up period of seven months. The mean percentage increase in FEV1 was 8.8 (CI 5.1-12.47) p < 0.001. The pooled hazard ratio was 0.25 (CI 0.06-0.56) p = 0.041 for a mean follow-up period of 2.9 yr.

CONCLUSION

This study demonstrated a significant improvement in lung function in patients with BOS syndrome following lung transplant after seven months of treatment. It remains uncertain whether this improvement stays after seven months. We also found that patients on azithromycin were less likely to die from BOS syndrome compared with patients who were not on azithromycin.

Lung transplantation following hematopoietic stem cell transplantation: report of two cases and systematic review of literature

BACKGROUND

Non-infectious pulmonary complications following hematopoietic stem cell transplantation (HSCT) are major cause of morbidity and mortality with limited treatment options. Lung transplantation (LT) has been rarely reported as a treatment option for selected HSCT recipients with these problems.

OBJECTIVE

Describe the outcome of HSCT recipients who underwent LT.

METHODS

Two cases of LT following HSCT from our institution are presented. Cases reported in literature were identified using English language PubMed/MEDLINE with keywords hematopoietic stem cell transplantation, bone marrow transplantation, or bronchiolitis obliterans cross-referenced with lung transplantation. We extracted data on baseline characteristics and survival data following LT.

RESULTS

Total of 84 patients are analyzed. Age at time of LT was median of 22 yr (range 1-66). Seventy-nine patients were recipients of allogeneic HSCT. The indications for LT were bronchiolitis obliterans syndrome (BOS; 63 patients), pulmonary fibrosis (13 patients), BOS/pulmonary fibrosis (five patients), and graft-versus-host-disease (GVHD) of lung (three patients). The median time between HSCT and LT was 52.3 months (range 6-240). The median follow-up after LT was 36 months (range 0-168). During this time, BOS was documented in 25 patients. Relapse of hematological malignancy was reported in two patients, and new malignancy developed in four patients. At the end of follow-up, 60 patients were alive and 24 patients died. The probability of survival following LT at 24 and 36 months was 0.88 (95% CI 0.78-0.93) and 0.79 (95% CI 0.67-0.87), respectively.

CONCLUSION

LT is a potential therapeutic option in selected patients with severe chronic pulmonary disease following HSCT. Further studies are needed to determine the appropriate timing and the outcome of this approach.

An update on pulmonary complications of hematopoietic stem cell transplantation

The indications for hematopoietic stem cell transplantation (HSCT) continue to expand. However, the risk for pulmonary complications post-HSCT continues to be high. Early recognition and treatment of pulmonary complications may improve outcomes. This is an overview of diagnosis, manifestations, and treatment of the most common infectious and noninfectious pulmonary complications post-HSCT. Knowing the patient's timeframe post-HSCT (preengraftment, postengraftment, late), type of HSCT (allogeneic vs autologous), radiographic findings, and clinical presentation can help to differentiate between the many pulmonary complications. This article will also address pretransplantation evaluation and infectious and noninfectious complications in the patient post-HSCT. While mortality post-HSCT continues to improve, respiratory failure continues to be the leading cause of ICU admissions for patients who have undergone HSCT. Mechanical ventilation is a predictor of poor outcomes in these patients, and further research is needed regarding their critical care management, treatment options for noninfectious pulmonary complications, and mortality prediction models posttransplantation.

Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest

PURPOSE

To determine the effects of anticoagulation with intravenous unfractionated heparin (IVUH) during therapeutic hypothermia (TH) post-cardiac arrest.

METHODS

Single-center, retrospective, observational trial in the intensive care units of two hospitals within the Detroit Medical Center. Unresponsive survivors of cardiac arrest, receiving treatment doses of IVUH during TH were included. Patients were required to have at least 1 measured activated partial thromboplastin time (aPTT) during TH. Coagulation parameters were collected at 3 distinct temperature phases: baseline, TH, and post-re-warming (±37 °C) target aPTT defined as 1.5-2 times baseline.

RESULTS

Forty-six patients received IVUH during TH, with 211 aPTTs. Heparin starting rate was 13±4 units/kg/h. Average baseline, TH and post-TH aPTT were 34±12, 142±48, and 56±17 s, respectively. Using standard dosing strategies, initial aPTT was above the target range in 89% of patients. After re-warming, aPTT significantly decreased (142±48s vs. 56±17 s, p=0.005), and heparin dose significantly increased (7.9±3 vs. 9±4 units/kg/h, p<0.001). There was a significant difference between aPTT among all three groups, and heparin dose between TH and post-TH even after correcting for age, sex, body mass index, heparin rate, and APACHE II score (p<0.001). Three patients experienced a major bleeding event.

CONCLUSIONS

Current dosing protocols for IVUH should not be utilized during TH. Heparin requirements are drastically reduced during TH and prolonged interruptions may be required to allow for adequate clearance of UH.

An update on the evaluation and management of small pulmonary nodules

The widespread utilization of chest CT scans has increased the importance of the proper evaluation of incidentally found lung nodules. The primary goal in the evaluation of these nodules is to determine whether they are malignant or benign. Clinical factors such as older age, tobacco smoking, and current or remote history of malignancy increase the pretest likelihood of malignancy. Radiological features of these nodules are important in differentiating benign from malignant lesions. However, the etiology of the lung nodules frequently remains indeterminate and requires further evaluation. The approach to the management of indeterminate lung nodules ranges between observation with repeat chest CT scan, further diagnostic studies such as PET scan or invasive procedures to obtain tissue diagnosis. This article reviews the importance of the different radiological features of lung nodules. This is followed by an update on the approach to the management of the different types of small lung nodules.

Modifiable factors associated with severe asthma exacerbations in urban patients

BACKGROUND

Rates of asthma morbidity, mortality, and resource use are highest among African American individuals residing in inner-city locations, yet factors associated with adverse outcomes are not well established.

OBJECTIVE

To identify modifiable factors associated with asthma exacerbations.

METHODS

A total of 104 adult patients who presented to an inner-city hospital or emergency department (ED) with an asthma exacerbation from October 1, 2009, through June 31, 2010, completed surveys of clinical status, acute events, sociodemographic characteristics, current asthma knowledge, self-efficacy, attitudes toward asthma self-management, and perceived barriers to asthma care questionnaires. Associations with asthma hospitalizations and ED visits were assessed.

RESULTS

The mean age of the patients was 42 years, 91% were African American, 33% were insured, 57% were taking a controller medication, and 63% had an income level below the federal poverty line. On bivariate analysis, males, years of asthma, history of smoking, self-classification of asthma severity, history of admission to intensive care unit or intubation, use of peak flow meter or asthma action plan, controller medication use, and history of oral corticosteroid bursts were positively associated, whereas self-efficacy was negatively associated with number of ED visits or hospitalizations. No association was found for asthma knowledge, perceived barriers to care, or attitudes toward asthma management. On multivariate analysis, low self-efficacy remained associated with both asthma hospitalizations and ED visits.

CONCLUSION

Short-term use of health services for asthma is negatively associated with asthma self-efficacy. Self-management programs that enhance self-efficacy, rather than those that focus on knowledge or attitudes, may be effective in reducing adverse asthma outcomes for inner-city, predominantly African American populations.

Pulmonary aspergillosis: a clinical review

Aspergillus is a mould which may lead to a variety of infectious, allergic diseases depending on the host's immune status or pulmonary structure. Invasive pulmonary aspergillosis occurs primarily in patients with severe immunodeficiency. The significance of this infection has dramatically increased with growing numbers of patients with impaired immune state associated with the management of malignancy, organ transplantation, autoimmune and inflammatory conditions; critically ill patients and those with chronic obstructive pulmonary disease appear to be at an increased risk. The introduction of new noninvasive tests, combined with more effective and better-tolerated antifungal agents, has resulted in lower mortality rates associated with this infection. Chronic necrotising aspergillosis is a locally invasive disease described in patients with chronic lung disease or mild immunodeficiency. Aspergilloma is usually found in patients with previously formed cavities in the lung, whereas allergic bronchopulmonary aspergillosis, a hypersensitivity reaction to Aspergillus antigens, is generally seen in patients with atopy, asthma or cystic fibrosis. This review provides an update on the evolving epidemiology and risk factors of the major manifestations of Aspergillus lung disease and the clinical manifestations that should prompt the clinician to consider these conditions. Current approaches for the diagnosis and management of these syndromes are discussed.

The relationship between chronic obstructive pulmonary disease and lung cancer in African American patients

RATIONALE

Airflow obstruction and/or emphysema have been associated with lung cancer risk; however, this relationship and the joint occurrence of these conditions are not well studied in the African American population

OBJECTIVE

To describe the prevalence of airflow obstruction and/or emphysema in African Americans with lung cancer and to evaluate their impact on the management and outcome of lung cancer.

METHODS

Medical records of 114 African Americans who had participated in population-based case-control studies of lung cancer and who sought medical care at the Karmanos Cancer Center in Detroit, Michigan, were reviewed. The medical records of these patients were reviewed for demographics, type and stage of lung cancer, spirometry, treatment, and outcome. Computed tomographies (CT) of the chest about the time of the diagnosis of lung cancer were reviewed by a radiologist for evidence of emphysema. COPD was diagnosed when there were changes consistent with emphysema on CTs and/or airflow obstruction by spirometry.

RESULTS

There were no differences by sex for age at lung cancer diagnosis (P = .78) and tumor histology (P = .43). The men were more likely to present at a later stage of lung cancer diagnosis compared with the women (P = .04), and the women were more likely to have surgery than the men (P = .03). Overall, 94% of the men and 78% of the women in this population had spirometry and/or CT evidence of COPD. The men were somewhat more likely to have COPD diagnosed by either CT or spirometry than were the women (P = .06), but the Global Obstructive Lung Disease Classification scores did not differ by sex among those with spirometry-diagnosed COPD (P = .34). Seventy-eight percent of individuals who did not report a previous diagnosis of COPD had clinical evidence of COPD, whereas 94% of individuals who reported a previous diagnosis of COPD also had clinical evidence of COPD (P = .03). Among individuals who had both spirometry and CT data available, 29% had CT evidence of emphysema but normal spirometry. No differences in COPD diagnosis (P = .82) or emphysema diagnosis (P = .51) were noted by tumor histology. Stage at diagnosis also did not differ by COPD or emphysema diagnosis (P = .30 and P = .06, respectively), nor did treatment modality (P = .54 and P = .10, respectively). Patients with lung cancer and with COPD, diagnosed either via spirometry or CT, did not show an increased risk of death compared with patients with lung cancer and without COPD after adjusting for age at diagnosis, sex, and stage (hazard ratio, 1.31 [95% CI, 0.68-2.53]).

CONCLUSION

There is a high incidence of COPD, emphysema in particular, in a selected group of African American patients with lung cancer. A significant number of these patients were not aware that they had COPD. There was no significant difference in the outcome of lung cancer in relation to the presence or absence of COPD.

Non-caseating granulomas in patients after the diagnosis of cancer: clinical characteristics and outcome

BACKGROUND

The association between cancer and non-caseating granulomas is controversial. The aim of this study is to describe the clinical characteristics and outcome of a cohort of patients found to have non-caseating granulomas following the diagnosis of cancer.

METHODS

Retrospective review of medical records.

RESULTS

There were 30 patients with non-caseating granulomas following the diagnosis of cancer. There were 21 females and 14 patients were African Americans. Breast, lung, and head and neck cancers were the most common malignancies. The time between the diagnosis of cancer and non-caseating granulomas was a mean of 27.6 months (range 3 to 245 months). New mediastinal lymphadenopathy were present in 29 patients and pulmonary infiltrates or nodules were detected in 15 patients. All patients who underwent FDG-PET scan (n=18) had FDG avid findings with a mean SUV of 6.8 (range 2.8-19.4). Non-caseating granulomas were diagnosed by mediastinoscopy (12 patients), EBUS-FNA (6 patients), surgical thoracic biopsy (3 patients), transbronchial biopsy (2 patients), and other biopsies (7 patients). Patients were followed for a mean of 32.7 months (range 6-98 months) and 3 patients developed recurrence of the primary cancer.

CONCLUSION

Non-caseating granulomas should be considered in patients with cancer who develop lymphadenopathy or pulmonary nodules. Recurrence of cancer should not always be assumed, and tissue diagnosis is essential.

Frequency and type of epidermal growth factor receptor mutations in African Americans with non-small cell lung cancer

BACKGROUND

Epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer (NSCLC) predict response to tyrosine kinase inhibitors. Mutations occur more commonly in never smokers and East Asians, but there are conflicting reports on the frequency of EGFR mutations in tumors from African Americans.

METHODS

Tumors from 67 African American and 77 white participants in previous case-control studies of lung cancer were selected to determine EGFR mutational status. Mutation analysis was performed using the Sequenom mass array analyzer (Sequenom, San Diego, CA).

RESULTS

Overall, 13.9% of the study population carried an EGFR mutation. EGFR mutations occurred in 11.9% of tumors from African Americans compared with 15.6% in whites (p = 0.53). All mutations found in African Americans were deletions in exon 19. The majority of mutations were found in nonsmokers among both African Americans (7/8) and whites (8/12).

CONCLUSION

These results indicate that African Americans with NSCLC harbor somatic EGFR mutations at a frequency similar to whites with NSCLC. Thus, clinicians should not use race as a clinical decision parameter for the use of EGFR-tyrosine kinase inhibitors.

Lumbar puncture for suspected meningitis after intensive care unit admission is likely to change management

PURPOSE

The aim of this study was to determine the outcome of lumbar punctures (LPs) in critically ill medical patients and how likely the results were to change case management.

MATERIALS AND METHODS

A retrospective review was conducted on the medical records of all 168 patients who underwent LP during their medical intensive care unit (MICU) admission at a university hospital during a 4.5-year period beginning in January 2000.

RESULTS

Lumbar puncture was performed a mean of 2.8 days after MICU admission. The most common symptoms that prompted LP were changes in mental status and fever. Seventy-four percent of patients were on antibiotics at the time of LP, and 98% of patients had a computed tomography scan of the head performed before the procedure. Lumbar puncture confirmed meningitis in 47 (30%) patients and provided a specific bacteriologic diagnosis in 5 (3%) patients. The results of the procedure led to a change in management in 50 (30%) patients. The presence of meningeal signs and use of antibiotics at the time of the procedure were the factors that predicted change in management.

CONCLUSION

Although the likelihood that LP will yield a specific bacteriologic diagnosis in critically ill patients is low, the procedure frequently provides important information that can lead to a change in case management, most commonly de-escalation of antibiotic therapy.

Aspergillus lung disease in patients with sarcoidosis: a case series and review of the literature

Chronic cavitary pulmonary aspergillosis (CCPA) has been associated with advanced lung diseases. Pulmonary sarcoidosis, a granulomatous inflammatory disorder, is associated with CCPA. We identified CCPA in 2% of cases in a large cohort of sarcoidosis patients. We found a lack of response to medical treatment and poor outcome in this subgroup.

The natural tumor suppressor protein maspin and potential application in non small cell lung cancer

The grim prognosis of lung cancer, that has an overall 10-15% survival at 5 years, remains in the US the leading cause of cancer mortality, provides a compelling rationale for studying the molecular basis of this malignancy. Surmising the common, general association with smoking, lung cancers differ at the microscopic, anatomical, epidemiological and clinical level and harbor complex genetic and epigenetic alterations. Currently, lung cancer is divided into small cell lung carcinoma (SCLC) and non small cell lung carcinoma (NSCLC) for the purpose of clinical management. (NSCLC) constitutes 80-85% of lung cancers and is further divided into histological subtypes such as adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, etc. The ultimate goal for lung cancer research is to develop a strategy to block the tumor progression and improve the prognosis of lung cancer. This goal can realistically be achieved only when the biological complexity of this disease is taken into account. To this end, identification and understanding of molecular markers that are mechanistically involved in tumor progression is needed. Our recent studies suggest histological subtype-dependent distinct correlations between the expression and/or subcellular localization of tumor suppressive maspin with the progression and prognosis of NSCLC. Maspin is an epithelial specific member of the serine protease inhibitor (serpin) superfamily but recently identified as an endogenous inhibitor of histone deacetylase 1 (HDAC1). This novel biochemical activity coincides with a consensus emerged recently from the evidence that nuclear maspin confers better differentiated epithelial phenotypes, decreased tumor angiogenesis, increased tumor sensitivity to drug-induced apoptosis, and a more favorable prognosis. In the current review, we discuss the evidence that maspin may be a marker that stratifies the progression and prognosis of different subtypes of NSCLC.