Clinical features and outcome in patients with acute asthma presenting with hypercapnia

To determine the clinical features and outcome of patients with hypercapnia from acute asthma, we examined 229 (62 men, 167 women) consecutive episodes of acute asthma over a 6-yr period. Sixty-one episodes were associated with hypercapnia at presentation (PaCO2 greater than 38 mm Hg). Men more commonly presented with hypercapnia: 31 of 62 (50%) men with acute asthma had hypercapnia compared with only 30 of 167 (18%) women (p less than 0.001). Patients with hypercapnia had a longer duration of chronic asthma and were more likely to be steroid-dependent. Hypercapnic patients had greater airway obstruction, respiratory rate, and pulsus paradoxus than did nonhypercapnic patients. Findings of a quiet chest on auscultation, inability to talk, and cyanosis also suggested the presence of hypercapnia. Five hypercapnic patients required mechanical ventilation, but hypercapnia did not prolong hospitalization. In nonventilated patients, hypercapnia resolved in a mean time of 5.9 h; 50% of hypercapnic episodes resolved by 4 h, and all resolved by 16 h. No patient presenting with normocapnia progressed to hypercapnia with therapy, and there were no deaths in either the hypercapnic group or the nonhypercapnic group. In patients with more than one admission, the PaCO2 of one episode correlated with the PaCO2 on a subsequent admission, suggesting a role for individual variation in ventilatory control. With appropriate medical therapy, most patients with hypercapnia from acute asthma have rapid reversibility, and mechanical ventilation usually can be avoided. However, these patients require close inhospital observation until it is certain that the acute asthmatic episode has resolved.

The impact of respiratory failure on the diagnosis of tuberculosis

Six patients with hypoxic respiratory failure (arterial PO2/alveolar PO2 less than 0.50) resulting from active tuberculosis were evaluated to assess the impact of respiratory failure on the diagnosis of the underlying tuberculosis. All patients demonstrated anemia (hematocrit [mean +/- SEM], 0.29 +/- 0.01 [29.0% +/- 1.0%]) and hypoalbuminemia (serum albumin, 22 +/- 2 g/L [2.2 +/- 0.2 g/dL]) and noted an illness longer than one week. Findings on chest roentgenograms varied from a miliary pattern, misinterpreted as congestive heart failure, to cavitary and noncavitary alveolar infiltrates, misdiagnosed as bacterial pneumonia. Tuberculosis was not considered as a diagnostic possibility on admission in any patient. The mean time from admission until consideration of tuberculosis was 4.7 +/- 1.0 days and the time to diagnosis was 7.2 +/- 1.7 days. In contrast, tuberculosis was considered on admission in 12 patients presenting with undiagnosed active tuberculosis without respiratory failure. We conclude that respiratory failure delays the diagnosis of active tuberculosis by suggesting nontuberculous pneumonia.

Biliopleural fistula as a complication of percutaneous biliary drainage: experimental evidence for pleural inflammation

We describe 3 patients in whom biliopleural fistulae complicated percutaneous biliary drainage. All patients had complete obstruction of their biliary tree because of malignancy. Biliopleural fistulae developed as a complication of inadvertent catheter removal in 2 patients and of catheter dysfunction in the third. Early reinstitution of biliary drainage and successful drainage of the pleural space led to complete recovery in all patients. An animal model to evaluate the effects of bile in the pleural space in normal rabbits revealed rapid absorption of bilirubin, the production of a polymorphonuclear-predominant exudative effusion with extremely high LDH levels, and resolution with a macrophage influx. We conclude that biliopleural fistulae are heterogeneous in their presentation, depending upon the persistence of biliary drainage into the pleural space, the volume of exudative effusion, and the presence of suppurative complications.

Pleural fluid pH in malignant effusions. Diagnostic, prognostic, and therapeutic implications

STUDY OBJECTIVE

To determine whether the measurement of pleural fluid pH in malignant effusions has diagnostic use, predicts survival, and has therapeutic implications.

DESIGN

A prospective comparison of cytologic examinations and pleural biopsy results, survival, and response to chemical pleurodesis with tetracycline in patients with normal-pH (7.30 or greater) and low-pH (less than 7.30) malignant pleural effusions.

SETTING

Academic medical center, university referral hospital, city hospital, and Veterans Administration hospital.

PATIENTS

Sixty patients with malignant pleural effusions, proven at either initial thoracentesis by cytologic examination or within 4 months of initial thoracentesis by repeat thoracentesis, thoracotomy, or autopsy, were followed until death.

INTERVENTION

Twenty-one patients, 12 with normal pleural fluid pH and 9 with low pleural fluid pH, were treated with tube thoracostomy and intrapleural tetracycline for symptomatic, recurrent pleural effusions.

MAIN RESULTS

The 20 patients with low-pH malignant effusions had a significantly greater positivity on initial pleural fluid cytologic evaluation, a shorter mean survival, and a poorer response to tetracycline pleurodesis compared with 40 patients with normal-pH malignant effusions.

CONCLUSIONS

Determination of pleural fluid pH in malignant effusions provides a rational approach to further diagnostic testing, prognostic information, and a rationale for palliative treatment.

Effect of patient positioning on distribution of tetracycline in the pleural space during pleurodesis

Thoracostomy tube drainage with tetracycline (TCN) instillation is an effective technique for management of recurrent, symptomatic, malignant pleural effusions. Although patient rotation through various positions after instillation of TCN has been advocated empirically, it has not been shown scientifically to be necessary and is often uncomfortable for the patient and time-consuming for personnel. Five patients with symptomatic, malignant pleural effusions were studied during pleurodesis using radiolabelled TCN. Scintigraphic imaging was done immediately after TCN instillation prior to patient rotation. Patients were rotated through six positions and multiple images were obtained at 30 and 120 minutes. Tetracycline dispersed throughout the pleural space within seconds. Patient positioning had no effect on the intrapleural distribution of TCN in four of the five patients. In one patient with loculated hydropneumothorax and trapped lung, rotation minimally improved distribution of TCN to the apex. Rotation during pleurodesis does not appear to be necessary in patients with a relatively normal pleural space. However, patient rotation enhances distribution of TCN when the lung is separated substantially from the chest wall, as with trapped lung. Possibly, in this situation the properties of fluid mechanics and capillary action no longer apply.

Protected transbronchial needle aspiration and protected specimen brush in the diagnosis of pneumonia

Protected transbronchial needle aspiration (PTBNA) of pneumonic lung theoretically could bypass dislodged upper respiratory tract flora, a potential source of contamination of protected specimen brush (PSB) cultures. To evaluate the usefulness of PSB and PTBNA in establishing the etiology of pneumonia, we prospectively studied 20 patients with acute bacterial pneumonia not receiving antibiotics. After informed consent, patients had fiberoptic bronchoscopy under fluoroscopy to localize the pneumonia, and specimens were obtained by the PSB. The protective plug of a specially devised needle for PTBNA was pneumatically dislodged and aspiration was performed within the infiltrate under fluoroscopy. Quantitative cultures were plated immediately for aerobes, anaerobes, and Legionella. Greater than 4 X 10(3) organisms/brush or 1 X 10(4) organisms/ml needle aspirate were considered to be consistent with infection. The results using PSB and PTBNA were compared in 15 of 20 patients in whom a definitive diagnosis (positive blood or pleural fluid culture) or presumptive diagnosis (expectorated sputum culture, clinical characteristics, and response to specific therapy) was established. The PSB and PTBNA cultures on uninfected control subjects (n = 5) being bronchoscoped for other reasons were negative. The PSB and PTBNA were each diagnostic in 2 of the 5 patients with definitive diagnoses. In the group with a presumptive diagnosis (n = 10), PSB was diagnostic in 7 of 10 and PTBNA in 9 of 10. The overall (definitive plus presumptive) diagnostic yield was 60% for PSB and 73% for PTBNA. Multiple organisms were isolated in high concentrations in 53% of the patients. The most common organisms recovered in addition to the primary pathogen was alpha hemolytic streptococci.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspergilloma in sarcoid and tuberculosis

The presentation, treatment, and outcome of 28 patients with aspergilloma and cavitary tuberculosis (14) and sarcoidosis (14) were compared. Patients with tuberculosis had localized disease (12 of 14, 86 percent), whereas patients with sarcoidosis had diffuse disease (1 of 14, 7 percent localized). Results indicated that patients with either sarcoid or tuberculosis who developed an aspergilloma had a poor prognosis over the next decade. Patients with sarcoid appeared to have a worse short-term prognosis; surgical resection in the tuberculosis patients may have contributed to their better short-term survival.

Pulmonary hemorrhage and air embolism complicating transbronchial biopsy in pulmonary amyloidosis

We describe a fatal complication of transbronchial biopsy in a patient with pulmonary parenchymal amyloidosis. Hemorrhage after biopsy required intubation and positive-pressure ventilation that resulted in massive arterial air embolism. Postmortem findings suggested that the bleeding and air embolism were related to persistent patency of biopsied blood vessels infiltrated with amyloid. Patients with pulmonary amyloidosis may be at increased risk of major complications after transbronchial biopsy.

Thoracocentesis. Clinical value, complications, technical problems, and patient experience

A prospective study of 129 consecutive thoracocentesis in 86 patients at a university medical center evaluated the clinical value, complications, and patient experience with thoracocentesis. Pleural fluid analysis in conjunction with the clinical presentation placed 78 pleural fluids into diagnostic categories: definitive 14 (18 percent), presumptive 44 (56 percent), and nondiagnostic 20 (26 percent). Fourteen of 78 (18 percent) of the nondiagnostic fluids were useful, while only six (8 percent) were not useful clinically; therefore, 92 percent of thoracocentesis provided clinically useful information. Using sequential data analysis, initial diagnostic categorizations of eight of 78 patients were upgraded from presumptive or nondiagnostic to definitive based on data available 24 hours following thoracocentesis. Thus, 70 patients were categorized based on the pleural fluid data obtained within the first 24 hours of thoracocentesis. Thirty-four objective complications occurred in 26 of 129 (20 percent) thoracocentesis. The most common complications were pneumothorax, 15 of 129 (12 percent), and cough, 12 of 129 (9 percent). Sixty-five subjective complications occurred in 56 of 123 (46 percent) thoracocentesis. Anxiety, 26 of 123 (21 percent), and site pain, 24 of 123 (20 percent), were the most common subjective complications noted. Thirty technical problems occurred in 129 (23 percent) thoracocentesis with blood contamination, 14 of 129 (11 percent), and dry tap, nine of 129 (7 percent), being the most common. We conclude that diagnostic thoracocentesis is a clinically valuable procedure if used in conjunction with the patient presentation with an understanding of its limitations for providing a specific etiologic diagnosis. When performed by physicians in training, the number of complications are substantial and the operator often underestimates the degree of patient discomfort. Awareness of the clinical value and complications of thoracocentesis should lead to improved use and safety of this procedure.

Post-extubation pulmonary edema following anesthesia induced by upper airway obstruction. Are certain patients at increased risk?

Pulmonary edema due to upper airway obstruction can be observed in a variety of clinical situations. The predominant mechanism is increased negative intrathoracic pressure, although hypoxia and cardiac and neurologic factors may contribute. Laryngospasm associated with intubation and general anesthesia is a common cause of pulmonary edema in children. However, only seven cases of pulmonary edema presumably due to laryngospasm have been reported in adolescents and adults. Five of the seven had other risk factors for upper airway obstruction, and in four, the diagnosis of "laryngospasm" could be explained by other factors. Patients with underlying risk factors for upper airway obstruction, such as a forme fruste of sleep apnea or nasopharyngeal abnormalities, appear to be at increased risk for the development of pulmonary edema in the setting of intubation and anesthesia. This form of pulmonary edema usually resolves rapidly without the need for aggressive therapy or invasive monitoring.

Mycosis fungoides presenting as ARDS and diagnosed by bronchoalveolar lavage. Radiographic and pathologic pulmonary manifestations

A patient with mycosis fungoides involving the lung, presenting with ARDS, and diagnosed by bronchoalveolar lavage, is described. A review and correlation of chest radiographic manifestations and pathologic observations are presented. We stress the importance of obtaining a specific diagnosis in light of the tenuous radiographic-pathologic correlation and discuss procedures for diagnosis and the inclusion of bronchoalveolar lavage as a previously undescribed diagnostic modality. The dismal prognosis of these patients, once pulmonary involvement is diagnosed, is noted.

Bacillus Calmette-Guérin-stimulated neutrophils release chemotaxins for monocytes in rabbit pleural spaces and in vitro

Neutrophils are often seen first at sites of granulomatous inflammation but their contribution to monocyte recruitment and granuloma formation is unknown. We tested the hypothesis that neutrophils release chemotaxins which attract monocytes. We found that rapid accumulations of fluid and influxes of neutrophils followed by monocytes occurred in bacillus Calmette--Guérin (BCG)-sensitized rabbits given BCG intrapleurally but did not occur in nitrogen mustard-treated (neutropenic) BCG-sensitized rabbits given BCG intrapleurally--unless the rabbits were also given intrapleural injections of neutrophils. We also found monocyte chemotaxins in pleural spaces of control and neutrophil-reconstituted neutropenic but not in neutropenic rabbits given BCG intrapleurally. Moreover, pleural fluid monocyte chemotaxins had molecular weights (12,000-15,000 and 1,000) that were similar to molecular weights of monocyte chemotaxins present in supernatants from mixtures of neutrophils and BCG in vitro. In addition, intrapleural injection of neutrophils and BCG or supernatants from in vitro mixtures of neutrophils and BCG (but not neutrophils or BCG alone) increased the numbers of monocytes and 3H cell pellet activity in pleural fluids from untreated neutropenic rabbits or neutropenic rabbits previously injected intravenously with 3[H]methyl thymidine-labeled monocytes. Furthermore, fewer BCG were recovered from pleural fluids of BCG-sensitized control compared to neutropenic rabbits given BCG, and at autopsy 10 d after instillation of BCG, control but not neutropenic rabbits had well-defined granulomas without adhesions on their pleural surfaces. Our results suggest that BCG stimulates neutrophils to release chemotaxins that recruit monocytes, and that these responses might contribute to granuloma formation in tuberculous pleurisy.

Reactivation of bleomycin lung toxicity following oxygen administration. A second response to corticosteroids

We report a patient who had two episodes of bleomycin lung toxicity with a good clinical response following corticosteroid therapy. The first episode followed treatment with 120 units of bleomycin and was characterized by cough and dyspnea. The second resulted in ARDS following a surgical procedure that used an FIO2 level of 0.33.

Pleuropulmonary complications of enteral tube feedings. Two reports, review of the literature, and recommendations

Enteral tube feeding is an attractive alternative to intravenous alimentation for nutritional support. As previously used nasogastric tubes have been replaced with narrow-bore nasogastric tubes, the spectrum of complications seen with these devices has changed. We report a previously undescribed event associated with narrow-bore nasogastric tube feeding, review the literature, noting predisposing factors and complications, and suggest guidelines to avoid pitfalls of insertion and the ensuing adverse effects.

The pathogenesis of low glucose, low pH malignant effusions

Possible mechanisms to explain the finding of a low pH, low glucose, malignant pleural effusion include: use of glucose and acid production by pleural fluid constituents including leukocytes and free malignant cells; pleural membrane metabolism, especially by malignant cells; abnormal transfer of glucose, carbon dioxide, and hydrogen ion across a diseased pleural membrane. To determine the pathogenesis of low glucose, low pH effusions, we performed incubation and glucose and gas transport studies in 5 patients with malignant effusions, 3 with a low pH (less than 7.30) and 2 with a pH greater than 7.30 (control patients). After 24 h of incubation, there was no significant difference in the metabolic activity of pleural fluid between low pH fluids and control fluids. Transport studies confirmed impaired glucose transfer both into and out of the pleural space and impaired efflux of CO2 from the pleural space in patients with low pH effusions, whereas control patients demonstrated free transfer across the pleural membrane. It appears that an abnormal pleural membrane (tumor or fibrosis), rather than increased acid production, results in a low glucose concentration from impaired glucose transfer from blood to pleural fluid and a low pH from impaired hydrogen ion efflux in some malignant effusions.

Immunologic diseases of the pleura

This heterogeneous group of immunologic causes of pleural effusions includes connective tissue diseases, a syndrome related to tissue injury (postcardiac injury syndrome), a disease of unknown etiology (sarcoidosis), a malignancy, and adverse reactions to drugs. Except in rheumatoid pleurisy and lupus pleuritis, the pleural fluid findings are either nonspecific or have not been characterized fully. The clinical presentation is essential in the presumptive diagnosis of these causes of pleural effusions.

Malignant pleural effusions

Various diseases of the gastrointestinal tract at times are accompanied by an exudative pleural effusion. The exudative pleural effusions resulting from esophageal perforation, pancreatic disease, subphrenic abscess, intrahepatic abscess, splenic abscess, abdominal operations, and diaphragmatic hernia are discussed in this article.