[Mechanical ventilation in a respiratory ward. Evolution from 1994 to 2000]. / Ventilación mecánica en hospitalización neumológica. Evolución en el período 1994-2000.

OBJECTIVE: To investigate the absolute and relative frequency of mechanical ventilation in the management of patients on a respiratory medicine ward between 1994 and 2000. To describe reasons for admission, mean hospital stay and outcomes. SETTING: A tertiary-care university hospital. METHODS: Observational, descriptive study of a case series. RESULTS: During the study period, 257 admissions involved mechanical ventilation of 132 patients. During that time, there was a progressive increase in the total number of ventilated patients as well as in the relative frequency, such that ventilated patients eventually accounted for 6.1% of all admissions for respiratory care in 2000. Nearly 80% of admissions were related to the service's home mechanical ventilation program, either to initiate and adapt ventilation for new patients or to treat exacerbations or diagnose and treat other medical or surgical problems in already-ventilated patients. Patients transferred from the intensive care unit (ICU) because of weaning difficulties (median ventilation, 31 days) had the highest mean stay. Nine of the 132 patients had to be transferred to the ICU and 18 died while hospitalized (7% of admissions and 13.6% of patients). The patients who died were those who were more acutely and severely ill (acute exacerbation in home-ventilated patients, patients with acute respiratory failure treated initially with non-invasive ventilation and patients transferred from the ICU due to weaning difficulties). CONCLUSIONS: Admissions requiring mechanical ventilation have increased and most are related to the home mechanical ventilation program. The mean stay and the mortality rate were related to the reason for admission.

[Prospective study of 1,000 consecutive patients with pleural effusion. Etiology of the effusion and characteristics of the patients]. / Estudio prospectivo de 1.000 pacientes consecutivos con derrame pleural. Etiología del derrame y características de los pacientes.

OBJECTIVE: To describe the characteristics of patients with pleural effusion (PE) and the causes of PE in a prospective, consecutive series of patients. SETTING: A tertiary care hospital associated with the Universidad Complutense de Madrid (Spain). PATIENTS: One thousand consecutive patients with PE for whom clinical signs indicated the need for diagnostic thoracocentesis were studied prospectively in our service from December 1991 to July 2000. RESULTS: The most common cause of PE was neoplasm (n = 364 patients). The most common place of origin of the tumor was the lung (n = 125), followed by the pleura (mesothelioma, n = 48). The most common histologic type was adenocarcinoma (n = 128). Tuberculosis was the second most common cause of PE (n = 155). PE was transudate in 118 patients, mainly secondary to heart failure. Among the 42 patients who were positive for human immunodeficiency virus (HIV), the most common cause of PE was tuberculosis. Tuberculosis was also the most likely cause of PE in patients under 40 years of age. CONCLUSIONS: The most common causes of PE were neoplasm and tuberculosis. Tuberculosis was the most common cause in patients under 40 years of age and in those infected by HIV.

Measurement of pleural pressure during therapeutic thoracentesis.

The aim of therapeutic thoracentesis (TT) is to aspirate as much pleural fluid as possible. Monitoring pleural pressure (PlP) during TT has been proposed to avoid the adverse effects due to an unintended sharp drop in PlP. The objectives of this study are to ascertain the diagnostic value of the PlP measurement, to find a predictive variable of the amount of fluid that can be removed, to obtain insight into the characteristics of the PlP curve and pleural elastance (PE) during TT, and to describe the complications of TT. Sixty-one unselected patients were studied. Only the four patients with suspected trapped lung had an initial PlP lower than -4 cm H(2)O and a PE higher than 33 cm H(2)O/L. There was a weak correlation (r = 0.52) between PE during the first 0.5 L aspirated and the total amount of fluid aspirated. Partial PE values were 10, 7.5, and 14 cm H(2)O/L at the early, intermediate, and late phases of TT. No complications were found except for nine pneumothoraces. In conclusion, the technique was clinically helpful because large amounts of pleural fluid could be aspirated with few and mild complications, and because it allows clinicians to support the preliminary diagnosis of trapped lung. None of the studied variables was found to predict the suitability of aspirating more than 1.5 L. Rather than being monotonically descendent, the PlP curve shows a three-part line with the deepest slopes at the first and last phases of the thoracentesis.

[Compliance with inhalation treatment of patients with chronic obstructive pulmonary disease]. / Estudio de cumplimiento del tratamiento por vía inhalatoria en pacientes con enfermedad pulmonar obstructiva crónica.

OBJECTIVES: To evaluate patient compliance with inhaled medication therapy in chronic obstructive pulmonary disease (COPD), to identify determining factors and to propose corrective measures to improve compliance. METHODS: This was an open, observational, cross-sectional, non-comparative, single-measurement, non-random study. The inhalers were the Serevent Accuhaler, the Serevent Inhalador and the Flixotide Inhaler. Compliance was measured in four ways: a) difference in weight at the beginning and end of the study for all devices; b) dose counter reading for the Accuhaler; c) information from patient diaries (by days and by applications); and d) information from patient interviews using the Morinsky-Green Test. Compliance was rated as follows: poor: < 50%, fair 51%-79%, good 80%-119%, or "hypercompliant" > 120%. RESULTS: Seventy-two patients (mean age 65 years) were enrolled. Compliance measured by weight was good in 77.1%, fair in 11.5%, poor in 1.4% and hypercompliant in 10%. Compliance was good for the Accuhaler according to both weight (75%) and counted doses (83.3%). According to patient diaries, compliance was good when assessed by applications (98.8%) and by days (98.3%). According to the Morinksky-Green test, compliance was good for 87.9%. CONCLUSIONS: Compliance was good as assessed by the methods used in this study. Patients who live in families, who enjoy a high socioeconomic level, have simple therapeutic regimens and have a good understanding of their disease and inhaler tend to have good compliance. Careful patient follow-up and good patient-physician communication has improved compliance. However, follow-up studies are needed to check these results.

[High prevalence of long-term domiciliary oxygen therapy with a low percentage of inappropriate prescription in the Madrid health care area. Evaluation of the correct use]. / Alta prevalencia de oxigenoterapia crónica domiciliaria, con bajo porcentaje de indicación incorrecta en un área de salud de Madrid. Valoración del uso correcto.

UNLABELLED: The efficacy of long-term domiciliary oxygen therapy (DOT) has been confirmed in patients who comply with guidelines; however, the prevalence in different populations varies greatly although no satisfactory explanation has been found for this. OBJECTIVES: To assess the prevalence of inappropriate use of DOT in the health care area of the Community of Madrid, where demographic and health care features are well-defined. MATERIAL AND METHODS: Descriptive, transversal population study enrolling all patients with DOT in our health care area over a period of one year (May 1995 to Mayo 1995). Inappropriate use was defined as characterized by at least one of the following conditions: inappropriate prescription, poor compliance or continued smoking. RESULTS: The total number of patients was 860, the prevalence of DOT use being 178.3 per 100,000 inhabitants for the period. Ninety-three refused to participate. Nearly half the patients ha been using oxygen therapy for over two years. Seventy percent were followed by pneumologists. Seventy-four percent were men, with a mean age of 70 +/- 9 yr. Criteria for prescription were not followed in 9.7% of the cases. Chronic obstructive pulmonary disease was the reason for prescribing DOT in 59.7%. Use was appropriate in 719 cases. Use was inappropriate in 337 (46.9%), related to poor compliance in 60.5%, current smoking in 11%, and inappropriate prescription in 5.6% and for more than one criterion in 22.8%. CONCLUSIONS: The prevalence of DOT use in our health care area is very high. The percentage of inappropriate use is high, although similar to that of other populations, and highly related to poor compliance. The percentage of inappropriate prescription is low. Possible reasons for the high prevalence are discussed.

Treatment of chronic ventilatory failure using a diaphragmatic pacemaker.

We present our series of patients with chronic ventilatory failure treated with electrophrenic respiration: 13 males and nine females with a mean age of 12 +/- 11.5 years. The etiology was, 13 tetraplegia, five sequelae of surgical treatment of intracranial lesions, and four central alveolar hypoventilation. The mean duration of the conditioning period were 3-4 months. Eighteen patients (81.8%) achieved permanent, diaphragmatically-paced breathing with bilateral stimulation and in four (18.2%) patients, pacing was only during sleep. Five patients died (22.7%): two during the hospital stay and three at home; two deaths had unknown cause and three were due respectively to, lack of at-home care, recurrence of an epidermoid tumor, and sequelae of accidental disconnection of the mechanical ventilation before beginning the conditioning period. Two cases were considered failures: One patient had transitory neurapraxia lasting 80 days, and the other had an ischemic spinal cord syndrome with progressive deterioration of the left-side response to stimulation. One patient had right phrenic nerve entrapment by scar tissue and four suffered infections. The follow-up periods since pacemaker implantation are currently: 1, 11 years; 4, 10 years, and 17, less than 5 years. The results of our experience demonstrate that complete stable ventilation can be achieved using diaphragmatic pacing and that it improves the prognosis and life quality of patients with severe chronic respiratory failure.

[Tracheobronchial granular-cell tumors. A report of 8 cases]. / Tumores de células granulares traqueobronquiales. Presentación de 8 casos.

To describe the clinical and radiologic signs, evolution and response to treatment of patients diagnosed of tracheobronchial granular cell tumors (GCT) in our practice. Retrospective computerized review of all bronchoscopic procedures performed in our hospital from January 1974 through November 1996. Patients with GCT were identified and their case histories reviewed. Eight male patients with 9 GCT were identified. Mean age was 55 years. Only one was symptomatic (hemoptysis) and only one had radiologic signs (solitary pulmonary node). Six patients were diagnosed of tumors in other organs. With the exception of one GCT located in the trachea, all were found in the right bronchial system. Endoscopy revealed mucosal abnormalities in six patients and nodes in three. Treatment was conservative in four patients, endoscopic in three (2 mechanical endoscopic resections and one laser Nd-YAG resection in a patient with two tumors), and surgical in one. Disease evolution as treated was favorable during the observation period. Tracheobronchial GCT are rare tumors. Most patients were between 50 and 70 years old, were often asymptomatic and had few radiologic manifestations. They suffered accompanying neoplasia in other organs. GCT were located in central and segmentary bronchial and nodes or abnormal mucosa could be seen endoscopically. Treatment was conservative, endoscopic or surgical, depending on tumor size and patient characteristics.

[Ambulatory diagnosis of patients requiring a pleural biopsy. Study of 100 consecutive cases]. / Diagnóstico ambulatorio de los pacientes que precisan biopsia pleural. Estudio de 100 casos consecutivos.

Our aim was to describe our experience with outpatients requiring pleural biopsy. The first 100 patients with pleural exudate from whom at least one pleural biopsy specimen was taken on an outpatient basis at our hospital since January 1993. Clinical and radiological signs were recorded for all patients. We also analyzed complications, frequency of use of other diagnostic test and time required for diagnosis. The mean age of the 100 patients (64 men) was 56 years. Outpatient study of these patients was not prevented by the advanced age on the sample (with 35 patients older than 79), the size of the pleural effusions (23 of which were large), or the diagnosis of diseases with poor prognoses (with 43 effusions diagnosed as neoplastic). Complications encountered in taking the biopsy specimens were similar to those reported for other series. The mean time until diagnosis was 7.4 days. Biopsies can often be obtained from patients with pleural effusion on an outpatient basis, even when clinical symptoms vary widely, without increasing the number of complications and within a reasonable period of time.

Interferon-gamma in 388 immunocompromised and immunocompetent patients for diagnosing pleural tuberculosis.

The level of interferon-gamma (IFN-gamma) in pleural fluid has been reported to be increased in pleural tuberculosis. Nevertheless, its diagnostic value has not yet been well-established, and immunocompromised patients have not previously been evaluated. The aim of this study was to determine the value of the IFN-gamma level in pleural fluid for diagnosing tuberculous pleurisy in immunocompetent and immunocompromised patients. Three hundred and eighty eight consecutive patients were studied prospectively (73 with tuberculous pleural effusions, including nine with concurrent human immunodeficiency virus (HIV) infection and one after liver transplantation, and 315 with nontuberculous effusions). IFN-gamma was measured by radioimmunoassay. The sensitivity of the test, using a 3.7 U.mL-1 cut-off point, was 0.99 (95% confidence interval (95% CI) 0.93-1.00) and the specificity was 0.98 (95% CI 0.96-1.00). The sensitivity of the test did not differ in HIV-positive and HIV-negative patients. Patients with lymphoma, vasculitis or vascular connective tissue disease did not have abnormal IFN-gamma values. In conclusion, the level of interferon-gamma in pleural fluid is a very good diagnostic marker of tuberculous pleural effusion, even in immunocompromised patients.

Diagnostic value of CA 72-4, carcinoembryonic antigen, CA 15-3, and CA 19-9 assay in pleural fluid. A study of 207 patients.

BACKGROUND: The differential diagnosis of pleural effusion is a frequent clinical problem. Several tumor markers have been evaluated in pleural fluid, but the value of CA 72-4 assay and of combinations of tumor marker assays has not been firmly established. To find a minimally invasive tool for differentiating between pleural effusions of malignant or benign origin, the authors assessed the diagnostic value of CA 72-4, carcinoembryonic antigen (CEA), CA 15-3, and CA 19-9 assays in pleural fluid individually and in combination. METHODS: The authors prospectively studied 207 patients with pleural effusion (65 malignant, 48 tuberculous, 24 parapneumonic, 26 transudates, 14 miscellaneous, and 30 of unknown nonneoplastic origin). The levels of CA 72-4, CEA, CA 15-3, and CA 19-9 were measured in pleural fluid by radioimmunoassay. RESULTS: CA 72-4 assay in pleural fluid had an acceptable sensitivity and very good specificity for diagnosing malignant pleural effusion. The combination of CA 72-4 plus CEA plus CA 15-3 yielded the best accuracy, 0.90 (95% confidence interval [CI] 0.85-0.94), with a sensitivity of 0.78 (95% CI, 0.67-0.88), specificity of 0.95 (95% CI, 0.90-0.98), positive predictive value of 0.88 (95% CI, 0.77-0.95), and negative predictive value of 0.91 (range, 0.85-0.94). A good clinical strategy may be to begin with a CEA assay (specificity of I) and then, if it is negative, to add CA 15-3 or even CA 72-4 assays to improve sensitivity. The diagnosis of mesothelioma is more likely with a high CA 15-3 level and normal CEA and CA 19-9 levels. CONCLUSIONS: Assays of CEA, CA 72-4, and CA 15-3 in pleural fluid, or the combination of CEA with CA 15-3 and CA 72-4, was useful in differentiating between pleural effusion of malignant and benign origin.

Transdiaphragmatic pressure in quadriplegic individuals ventilated by diaphragmatic pacemaker.

BACKGROUND: Electrophrenic pacing can be used in the management of ventilatory failure in quadriplegic patients. A study was undertaken to determine the pattern of transdiaphragmatic pressure (PDI) during the conditioning phase of electrophrenic pacing to see if it had a possible role in optimising the process of conditioning. METHODS: The tidal volume (TV) and PDI were measured in a group of six quadriplegic patients commencing ventilation by low frequency pulse stimulation (7-10 Hz) and low respiratory rate stimulation (< 10 breaths/min). RESULTS: Tidal volume increased between baseline and month 1 (4.33 ml/kg, p < 0.001) and between months 1 and 2 (3.00 ml/kg, p < 0.05) and then stabilised. PDI was higher during bilateral diaphragmatic pacing (mean (SD) 1.73 (0.30) kPa) than with either left (1.15 (0.34) kPa) or right (0.86 (0.37) kPa) unilateral pacing. PDI varied throughout the observation period, probably by interaction between recovery of the diaphragmatic fibres and the pacing regimen. CONCLUSIONS: Patients with quadriplegia due to high spinal injury can be maintained with ventilation by continuous electrophrenic pacing. The control criteria used in this study for pacing were tidal volume and the patient's tolerance, and the PDI measurement did not contribute any additional information to help with managing the conditioning process.

[Diseases diagnosed at a pneumology unit integrated with its health area. Comparison with historical controls]. / Patología diagnosticada en una unidad neumológica integrada con su área de salud. Comparación con controles históricos.

An understanding of changes in pulmonology disease patterns observed at a general hospital before and after implantation of a population-based model of health care not only provides useful insight into the diseases treated but also aids adjustment of health care service organization. The aim of this study was to compare data collected after 1992 (when the new system was established) with records kept by the same pulmonology group in earlier years (1974-1986). Data after 1992 described patients attended in Health District 11 by the newly organized pneumologists. For the two periods the most common pneumological diagnoses were chronic air flow obstruction and chronic hypersecretory bronchitis. The most common non pneumological diagnoses were systemic arterial hypertension, obesity, diabetes, liver disease and hiatus hernia/gastroesophageal reflux. The prospective study covered a larger population and was closer to primary care, including as it did patients at clinics unattached to hospitals. In the earlier hospital-based experience the most common diagnoses were acute respiratory infection, chronic air flow obstruction and asthma, apart from those patients referred in whom no respiratory disease was found. With the organizational integration of hospital and health district pulmonology service, contact between patients and specialists has increased. Record systems have been established for a well-defined population to permit better forecasting at less cost and facilitate contact with primary care givers and epidemiological studies.

Chylothorax and chylous ascites due to heart failure.

Chylous ascites and chylothorax have rarely been reported as a consequence of severe right heart failure. To our knowledge, this is the first case report of both disorders occurring as a result of ischaemic cardiomyopathy. The autopsy findings and possible mechanisms of production are discussed.

Determination of tissue polypeptide-specific antigen in pleural fluid and serum from patients with pleural effusion.

As a tool for differentiating malignant and benign pleural effusions, we evaluated the diagnostic value of the assay of tissue polypeptide-specific antigen (TPS) in pleural fluid and serum, and of the pleural fluid TPS/serum TPS ratio in patients with pleural effusion. We studied prospectively 147 consecutive patients who had pleural effusions: 43 malignant pleural effusions and 104 benign pleural effusions. TPS levels were measured by RIA. The sensitivity and specificity of these measurements were: TPS in pleural fluid (cutoff 20,000 U/L): 0.21 and 0.98; TPS in serum (cutoff 300 U/L); 0.31 and 0.96; pleural fluid TPS/serum TPS ratio (cutoff 1200): 0.07 and 0.99. All these values enhanced the sensitivity of cytologic analysis of pleural fluid. However, we conclude that TPS assay in pleural fluid and serum, and the pleural fluid TPS/serum TPS ratio have limited diagnostic value in patients with pleural effusion.