Contribution of four common pulmonary function tests to diagnosis of patients with respiratory symptoms: a prospective cohort study.

BACKGROUND: Few studies of the diagnostic value of pulmonary function testing are available. We assessed the diagnostic contribution of four basic pulmonary function tests: spirometry, lung volume, airway resistance, and diffusing capacity. METHODS: In this prospective cohort study, we enrolled patients presenting to a pulmonologist with respiratory symptoms but no clear diagnosis from 33 hospitals in Belgium. Each patient had spirometry, lung volume, airway resistance, and diffusing capacity testing and all other tests necessary for a definitive diagnosis. Clinical history and pulmonary function data were presented to local focus groups, who established differential diagnoses and a preferred diagnosis after each test-the focus groups were masked to additional investigations. The final diagnosis was established by the attending physician on the basis of all the investigations done, and validated as the gold standard diagnosis by the local focus group. The primary outcome was a score calculated by 1/number of differential diagnoses, corrected for the accuracy of the diagnosis. Secondary outcomes were the number of differential diagnoses for patients with a correct preferred diagnosis and the proportion of preferred diagnoses that were correct. The study is registered at ClinicalTrials.gov, number NCT01297881. FINDINGS: We screened 1285 people, of whom 1023 were enrolled and 979 analysed. The primary outcome score was 0·226 after spirometry, increasing to 0·296 after measurement of lung volume, 0·373 after airway resistance test, and 0·540 after measurement of diffusing capacity (p<0·0001 for each step). The number of differential diagnoses decreased after each step (4·2, 3·4, 3·0, and 2·4; p<0·0001 for each step) and the proportion of correct preferred diagnoses increased (61%, 65%, 70%, and 77%; p<0·0001 for each step). INTERPRETATION: The increase in scores shows a progressive reduction of the number of differential diagnoses and an increased accuracy of the preferred diagnosis. Each of the four classic pulmonary function tests contributes significantly and independently to the final diagnosis in new patients with respiratory symptoms seen by pulmonologists. Thus, funding of these tests is justified in that setting. FUNDING: Belgian Society of Pneumology.

Hemoptysis and pulmonary edema in a scuba diver using diclofenac.

Hemoptysis and pulmonary edema associated with nonsteroidal anti-inflammatory drug use is a known condition, but is probably underreported. The mechanisms of induction of pulmonary toxicity are still not well understood. We describe a case of hemoptysis and dyspnea in a scuba diver who was taking diclofenac.

The wrong stent at the wrong time: a cautionary tale.

Self-expandable metallic stents have been promoted for a multitude of indications because of their easy insertion and convenience. This may lead to inappropriate use. We report two patients in whom self-expandable metallic stents led to severe early or late complications. The correct choice of the type of a stent demands expertise with consideration and anticipation of late side effects especially in benign stenosis.