[Pulmonary sequestration]

The author discusses pulmonary sequestration which is a rare developmental anomaly difficult for diagnosis. Eleven patients were under observation and underwent operation for pulmonary sequestration (8 with intralobar and 3 with extralobar) which accounted for 2.4% of patients with congenital developmental anomalies of the lungs and for 0.48% of those with chronic unspecific disease of the lung. Complete clinical radiological examination, including aortography, made it possible to recognize the anomaly before the operation in 6 patients. In the remaining patients sequestration of the pulmonary tissue was an operative finding. Preoperative functional study of pulmonary circulation revealed a marked left-to-right shunt of the blood, increased oxygenation of blood in the superior vena cava and saturation of arterial and venous blood with oxygen (to 94 and 91%, respectively, on the average). Analysis of clinical, radiological, and morphological data allowed three main forms of pulmonary sequestration to be distinguished: cystic-abscessed, pseudotumorous, and fibrous-atelectatic.

Respiratory changes after open-heart surgery

Breathing pattern was studied non-invasively in 20 coronary artery bypass surgery patients before the operation and post-operatively after weaning from mechanical ventilation. Post-operatively minute ventilation (VE), breathing frequency (Fr) and mean inspiratory flow (VT/TI) increased (28%, 42%, 27%; p less than 0.01, p less than 0.001, p less than 0.01, respectively), while tidal volume (VT) decreased (15%, p less than 0.025). CO2 production (VCO2) and oxygen consumption (VO2) increased postoperatively (p less than 0.001 for both), contributing to the increase in ventilatory demand. Reduced variation of VT and Fr (p less than 0.001, p less than 0.01, respectively) and number of sighs (p less than 0.001) were characteristic of the post-operative breathing pattern. Post-operatively an increase in the contribution of rib cage (%RC) to tidal volume in the supine position was observed suggesting reduced motion of the diaphragm. All patients had atelectasis, 17 had pleural fluid and only 6 normal vascularity post-operatively. The shallow breathing in combination with increased ventilatory demand, impaired gas exchange and the surgical trauma of the thorax predispose to postoperative respiratory complications.

[Radiologic follow-up of the thoracic organs in intensive care patients. The value of the thoracic picture correlated with the clinical and biochemical findings]

Correlation between chest radiographs and clinical indicators was studied in 212 patients in intensive care. 1. There was good correlation between raised pulmonary artery pressure and radiological signs of left heart insufficiency, but not with the value of central venous pressure. 2. Fever and leukocytosis nearly always precede radiological evidence of pneumonia; their persistence does not necessarily indicate persistent pneumonia. 3. Pneumonias, effusions, atelectases and emboli are more common on the right. 4. More than 70% of central venous catheters were incorrectly placed; most commonly, the catheter was placed too low. Life-threatening complications occurred in 1.3%.

Differentiation of bronchogenic carcinoma from postobstructive pneumonitis by magnetic resonance imaging: histopathologic correlation

Obstructive pneumonitis frequently occurs distal to hilar bronchogenic carcinomas or in lung adjacent to peripheral tumors. The article evaluates the role of MRI in the differentiation of tumor from pneumonitis. Twelve patients underwent MRI of the thorax before surgery. T1-weighted (SE 310/20) and T2-weighted (SE 2000/60-120) images were obtained through the tumor and presumed areas of pneumonitis. Five histologic types of pneumonitis were identified on pathologic examination of the 12 specimens. Cholesterol pneumonitis, found in 7 patients, was the most common type. Organizing pneumonitis, bronchiectasis with mucus plugs, atelectasis, and abscess were found in 3, 4, 2, and 1 patients, respectively. MRI was able to differentiate tumor from pneumonitis in 5 of 6 patients with a hilar mass and in 5 of 6 patients with a peripheral tumor. This was achieved by a visual difference in signal intensity on heavily T2-weighted (SE 2000/120) images. Cholesterol pneumonitis and bronchiectasis with mucus plugs were always hyperintense relative to tumor, and organizing pneumonitis and atelectasis were isointense and indistinguishable from tumor. MRI can differentiate tumor from pneumonitis provided that pneumonitis is of the cholesterol type or if there are mucus plugs in the collapsed lung.

[Lobar emphysema. Important differential diagnosis of obstructive lung diseases in childhood]

The lobar emphysema is characterised by a lobe-restricted overinflation combined with dislocation of the neighbouring organs. Surgical treatment is indicated because of the high mortality by waiting and conservative treatment. Differential diagnosis has to exclude other causes for overinflation as atelectasis with compensated emphysema, diaphragmatic hernia, and stenotic changing of the tracheobronchial tree and others. In the course of a retrospective study of 6350 thoracotomies (1978-1988) out of 198 patients with congenital malformations of the lungs 5 (2.5%) children less than 5 years were found to have undergone surgical therapy because of lobar emphysema. Five patients were found with additional malformations in four patients this was held to be the cause. All patients were dyspnoeic at the time of operation. The most important diagnostic procedure was the routine x-ray of the chest and fluoroscopic examination. In 4 patients surgical treatment consisted in lobectomy, in one patient segmental resection was sufficient. There was no 30-day-mortality, postoperative recovery was uneventful in all patients.

[Respiratory failure in patients with severe craniocerebral trauma]

To study the pathogenesis of respiratory insufficiency in a severe craniocerebral injury the authors examined 120 patients. The results showed bronchospasm, diffuse collapse of alveoli, and the occurrence of atelectasis to be the underlying factors of respiratory insufficiency in severe craniocerebral injury. The effect of analgesics, neuroplegics, barbiturates, and heliox on this condition was studied.

Pitfalls in the diagnosis of thoracic aortic aneurysm by transesophageal echocardiography

A 74-year-old man underwent transesophageal echocardiography to evaluate the possibility of dissection of the descending aorta. The study demonstrated a round lumen that contained an echogenic mass mimicking aortic aneurysm with thrombus. However, computerized tomographic scanning identified the lumen as the pleural cavity containing a collapsed lung. The esophagus was on the right side of the spine, and the transesophageal technique could not visualize the descending aorta.

Cross-sectional echocardiographic characterization of atelectatic lung segments. Differentiation from extracardiac tumors

This report describes a unique series of patients who, during routine cross-sectional echocardiographic examination, were each noted to have a large echo-dense extracardiac mass adherent to the lateral aspect of the left ventricle. While this echo-dense mass was considered initially to represent an extracardiac tumor, this mass was shown subsequently to be an atelectatic segment of the left lower lobe of the lung. The salient echocardiographic findings that were considered to be helpful in terms of differentiating these adherent pulmonary atelectatic lung segments were that the lung segments always occurred in the presence of a moderate to large left pleural effusion; in real-time examination, the atelectatic lung masses generally appeared solid, as opposed to cystic, with a characteristic brightly reflective ground-glass appearance; there was never any evidence of extrinsic compression of the heart by the lung mass.

[Evaluation of the risk of pulmonary complications after abdominal surgery]

Pulmonary complications are frequent after abdominal surgery. The object of this study was to evaluate the incidence and the predisposing factors of the postoperative pulmonary complications with a particular attention to their definitions. It included 146 patients. The respiratory complications were separated into clinical complications (bronchitis), radiological complications (atelectasis) and hypoxaemia (PaO2 less than 70 mmHg). Clinical complications (23%) were correlated neither with radiological complications (57%) nor hypoxaemia (46%). They particularly occurred in patients with a preoperative history of respiratory disease. Preoperative risk factors were males, low PaO2 and decreased FEV1. Radiological complications were strongly correlated with postoperative hypoxaemia. Their incidence was not affected by a previous history of respiratory disease. Both radiological complications and hypoxaemia were predicted by age.

[Theoretical basis and clinical assessment of fluid evacuation from the lungs during bronchoalveolar lavage in children]

The authors discuss the theoretical aspects of the process of lavage fluid absorption from bronchial and alveolar spaces during broncho-alveolar lavage. It is shown that pressure in the vessels of pulmonary circulation, the blood colloid osmotic pressure, and permeability of the alveolar-capillary barrier play an important role in the dynamics of changes of the absorption process. Methods for correcting the intensity of absorption (use of solutions of different osmotic force for lavage) are suggested. Data gained in observation over the use of therapeutic lavage in children confirm the theoretical conclusions and demonstrate the favourable results of lavage in children with atelectases.

Early diagnosis of postoperative pneumonia following upper abdominal surgery. A study in patients without cardiopulmonary disorder at operation

In 130 patients with no cardiac or pulmonary disease at the time of elective upper abdominal surgery, chest radiography was performed 2 and 4 days postoperatively. The sputum was examined and the patients were monitored with measurement of body temperature, arterial oxygen tension and white blood counts. Pneumonic infiltrates appeared in 8.4% of the patients and atelectasis in 68.5%. Most of the patients had elevated body temperature, raised white blood count and reduced arterial oxygen tension postoperatively. None of these commonly employed clinical or laboratory findings, singly or in combination, proved adequate for diagnosis of postoperative pneumonia.

Pericardial pseudotumor. Echocardiographic observation of juxtacardiac pulmonary collapse

Despite its value in the diagnosis of pericardial disease, two-dimensional echocardiography also is known to produce confounding results. Ten patients had juxtacardiac masses simulating pericardial tumor implants on echocardiographic examination ("pericardial pseudotumor") caused by juxtacardiac pulmonary atelectasis or lobar collapse. The atelectatic nature of these masses was based on echocardiographic delineation of pericardial and pleural anatomy, combined with ancillary radiographic and CT studies. Drainage of pleural fluid also led to disappearance of the masses on echocardiographic examination, suggesting that the masses were an ultrasonic manifestation of pulmonary atelectasis resulting from surrounding compressive effusive fluid. Finally, clinical follow-up failed to show development of malignant disease in any patient. The possibility of pericardial pseudotumor should be considered when ultrasound studies show juxtacardiac masses within large collections of pleural fluid, especially in the clinical absence of malignant disease.

Tracheobronchopathia osteochondroplastica presenting as right middle lobe collapse. Diagnosis by bronchoscopy and computerized tomography

Tracheobronchopathia osteochondroplastica (TO) is a rarely described disorder which historically has not been frequently recognized antemortem. Studies by computerized tomography (CT) and bronchoscopy now permit a definitive antemortem diagnosis and can obviate a more invasive diagnostic evaluation. We describe two cases of TO presenting as right middle lobe collapse, discuss the clinical and pathologic features, and outline an approach to its evaluation using CT and bronchoscopic study.

Tracheal plugs in oligohydramnios

Obstruction of the tracheobronchial tree in the fetus-newborn is well recognized with meconium-stained amniotic fluid, but this problem is not usually considered in the absence of meconium. In the case reported here, airway obstruction by a large mucous-like plug apparently developed in the context of severe oligohydramnios and fetal distress. The infant required resuscitation but it was initially impossible to expand the chest despite endotracheal intubation and positive pressure ventilation. The lung compliance changed abruptly at 6 minutes of age and breath sounds were audible unilaterally on the left. A chest radiograph confirmed an atelectatic right lung. After aspiration of a large plug, both lungs became normally aerated. Airway obstruction must be included in the differential diagnosis of respiratory distress occurring in the context of severe oligohydramnios.

Lung cancer: differentiation of tumor, necrosis, and atelectasis by means of T1 and T2 values measured in vitro

In vitro measurements of T1 and T2 values were performed in surgical specimens from 15 patients with lung cancer. Correlation between histologic results and measured values revealed that different pathologic tissues can be characterized by means of T1 and T2 values. The transverse magnetization decay curve of the lung tissue was multiexponential, which can be explained by two different relaxation times, fast T2 and slow T2. The signal intensity of pathologic lung tissues at different pulse sequences was simulated on a signal intensity gradient graph based on measured values of T1, fast T2, slow T2, and water content. The results showed that T2-weighted sequences were more valuable in discriminating viable lung cancer from necrotic tumor and collapsed lung lesions.

Diagnostic accuracy of fever as a measure of postoperative pulmonary complications

Various prevalence rates have been estimated for pulmonary complications after abdominal surgery, and fever has been thought to be a diagnostic indicator. This study quantifies the diagnostic accuracy of fever as a measure of postoperative pulmonary complications and includes the sensitivity, specificity, and positive and negative predictive values. Assessments using fever and chest x-ray film were determined for 270 patients after elective intra-abdominal surgery in three hospitals with six practicing surgeons in a Southern Ontario city. With use of reliable chest x-ray reports indicating lung pathologic findings as positive for pulmonary complication, the prevalence of a positive finding was 57%. The prevalence of a fever (temperature greater than or equal to 38 degrees C) was 40%. The sensitivity and negative predictive value of fever were slightly below 50%, and the specificity and positive predictive value of fever was 68% and 66% respectively. Fever was an accurate indicator of x-ray evidence of atelectasis in only 56% of the subjects. Therefore, neither the presence nor the absence of fever can assure clinicians of the presence or absence of a postoperative pathologic pulmonary complication such as atelectasis.

[Pulmonary atelectasis and massive pleural effusion. Echocardiography]

Pulmonary atelectasis can be detected by Two Dimensional Echocardiography (2D-E) when massive pleural effusion is present. A triangular mass, base toward the mediastinum and apex moving freely in the pleural cavity, is shown by 2D-E either in an apical modified view in left pleural effusions or in a subcostal modified view in right pleural effusions. The texture of the mass is liver-like. Three cases are reported by way of example. Differential diagnosis with other masses, such as pleural or pericardial metastasis, is discussed.

Differentiation of proximal bronchogenic carcinoma from postobstructive lobar collapse by magnetic resonance imaging. Comparison with computed tomography

MRI and CT studies in 18 patients with proximal bronchogenic carcinoma and postobstructive lobar collapse were analyzed retrospectively. The relative abilities of these imaging techniques to identify central tumor by a contour abnormality and to distinguish tumor mass from collapsed lung by CT attenuation values and MRI signal intensities were compared. MRI and CT were equivalent in their ability to identify a contour abnormality, both succeeding in 13 of 18 (72%) patients. CT was more successful than MRI in differentiating tumor mass from collapsed lung. Dynamic computed tomography scanning differentiated tumor from collapsed lung in eight of ten (80%) patients. MRI demonstrated different signal intensities of tumor and collapsed lung in 8 of 18 (44%) patients. T2-weighted images more often separated tumor from collapsed lung than other imaging sequences.